Columbia Banibergitp intf)eCitpofi^eto|9orfe College of ^Jjps^tciang anb ^urgeong <@iben bp ©r. CtibJin p. Cragin 1859-1918 .^ (^'^'tC^DiA^nt Corpus Iiiteum of pregnancy : i, ovary of woman two days after menstruation, showing earliest stages of transformation of a ruptured and bloody Graafian follicle into a corpus luteum ; 2, ovary of woman nine days after menstruation: the dark spot is the cicatrix; the surrounding yellow circle is the corpus luteum shining through the transparent tissue; 3, ovary of woman at term of pregnancy, showing corpus luteum with firm white central clot; 4, ovary of woman twenty days after menstruation : besides large fresh corpus luteum are seen two smaller old ones, and Graafian follicles of different sizes (Dalton). A M A N UAL OF OBSTKTRICS BY W. A. NEWMAN BORLAND, A. M., M. D. Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Instructor in Gynecology in the Philadelphia Polyclinic ; one of the Consulting Obstet- ricians to the Southeastern Dispensary for Women ; Fellow of the American Academy of Medicine. WITH 163 ILLUSTRATIONS IN THE TEXT, AND 6 FULL-PAGE PLATES PHILADELPHIA W. B. SAUNDERS 925 Walnut Street 1896 Copyright, 1896, by W. B. SAUNDERS. ELECTBOTYHEO BY pBESS OF KESTCOTT & THOMSON, PHILADA, „. a SAUNDERS, PHILAOA. THIS VOLUME RESPECTFULLY INSCRIBED PROFESSOR BARTON COOKE HIRST, UNIVERSITY OF PENNSYLVANIA. Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofobstetriOOdorl PREFACE. In the preparation of this manual the primary object has been a systematic and rational presentation of the subject of Obstetrics as recognized by the leading teachers of the day. As most conducive to this end, it has been deemed expedient to adopt a combined clinical, physiologic, and pathologic basis upon which to work. Thus, clinically, the vast majority of pregnancies and labors are normal in almost every respect, and physiologic obstetrics should most appro- priately first command the attention of the accoucheur. Accordingly, a normal pregnancy and labor in a normal woman are depicted from the time of conception to the weaning of the child, at which period the patients naturally pass from the hands of the obstetrician to those of the general physician. In the development of such a history a chronologic sequence of events has been followed as closely as possible, so that the various phases of ovulation, insemination, conception, embryologic and fetal growth and development, maternal alterations and manifestations, the signs and stages of labor, the birth of the child, the retro- grade processes of involution, and the establishment of the mammary function, follow each other in a smooth and natural order, as is most desirable in actual practice, and 7 8 PREFACE. necessary to ensure a comprehensive review of the per- formance from a literary point of view. Unfortunately, however, there is an immense variety of pathologic possibilities that may mar the features of this physiologic process at its successive stages, and these con- ditions, under the caption of pathologic obstetrics, are pre- sented, also in their usual chronologic sequence, in the second and larger portion of the book. Thus, in the various stages of ovular, embryonic, and fetal development, abnor- mal conditions of the growing structures may be engen- dered, and either prematurely terminate gestation or be productive of other evident chnical manifestations; the profound alterations in the maternal metabolism conse- quent upon the unusual condition may readily result in a disturbance of the normal equilibrium of health, and some of the diseases of pregnancy appear, or a grave form of dystocia be developed ; the proper disposition of the retro- grade substances of involution may fail, or adverse external influences be brought to bear upon the woman during this critical period of her life, and the serious pathologic condi- tions of the puerperium result ; and, finally, the new-born child may present any one of a vast number of morbid conditions requiring active treatment on the part of the accoucheur. In the evolution of the foregoing system of obstetrics every measure has been adopted that will facilitate the aims of the student of medicine or the busy obstetrician. To ensure ease of reference, a sy.stcm of paragraphing, italiciz- ing, and numbering has been followed ; all unnecessary divisions into chapters and artificial sections have been dis- carded, and wherever possible carefully selected diagrams and illustrations, many of them new, have been inserted to PREFACE. g still further elucidate the text. All measurements have been given in the metric system, with the English equiva- lents in parentheses. A large number of diagnostic tables have been formulated and introduced in their proper places, and these constitute a prominent feature of the book ; by their aid the various diagnoses may be made with unusual facility, and a comprehension of the stages of the mechan- isms of labor becomes a matter of ease. The recent rapid strides in the knowledge of the path- ology of the many morbid states encountered in obstetrics have rendered possible a more scientific classification of these conditions. In this respect especial care has been taken in the preparation of the book. Preeminent among these innovations stands the classification of puerperal sepsis, than which there is no more complicated or obscure subject in obstetrics. Through the labors of the pathologist and bacteriologist a wider knowledge of this disease is now entertained, and there has been offered a classification of the varieties of sepsis based upon their clinical manifestations and pathologic features. Mention should also be made of the grouping of the hemorrhages of pregnancy, of those of the puerperium, and of those of the newborn, as well as of the presentation of puerperal eclampsia, contracted pelvis, and extrauterine pregnancy, in all of which departments espe- cial progress has been made within recent years. In pur- suance of the general plan of the book, a rational sequence of the abnormal mechanisms of labor has been adopted, and every possible complication of labor has been noted in its appropriate place. Finally, a complete index with numerous cross-references, and a comprehensive table of contents, add materially to the efficiency of the book. The author desires to return his most cordial thanks to lO PREFACE. Dr. Robert N. Willson for valuable assistance rendered in the reading of the proof-sheets, and to the publisher, Mr. W. B. Saunders, for the care bestowed upon the many details of the publication of the work. 1 20 South Seventeenth Street, Philadelphia, May, i8g6. CONTENTS. PART I.— PHYSIOLOGIC OBSTETRICS. PAGE I. The Generative Organs and the Parturient Canal 17 Introductory, 17. — The Generative Organs, 18. — The Ovaries, 18. — The Oviducts or Fallopian Tubes, 18. — The Uterus or Womb, 19. — The Pa7-turient Canal, 22. — The Vagina, 22. — The Vulva, 23. — The Labia Majora and Minora, 23. — The Clitoris, 24. — The Vestibule, 24. — The Fossa Navicularis, 24. — The Mons Veneris, 24. — The Bony Pelvis, 24. — The True Pelvis, 25. — The Pelvis in Life, 28. — Pelvimetry, 30. — The Male and the Female Pelvis com- pared, 37. II. Puberty and its Manifestations 38 The Ovisacs or Graafian Follicles, 38. — The Ovum, 39. — Ovula- tion, 39. — The Corpus Luteum, 41. — Menstruation, 41. — The Meno- pause, 42. III. Pregnancy or Gestation 43 Inse??tination ; Conception ; Embryologic and Fetal Development, 43. — The Semen, 44. — Fecundation, 45. — Method of Impregnation, 46. — Changes in the Ovum Prior to its Lodgement in the Uterus, 47. — The Fetal Appendages and Membranes, 50. — The Deciduge, 50. — The Amnion, 51. — The Liquor Amnii or " Waters," 52. — The Um- bilical Vesicle, 58. — The Allantois, 54. — The Chorion, 54. — The Placenta or After-birth, 55. — The Umbilical Cord or Funis, 58. IV. The Physiology of Pregnancy 59 I. Fetal Physiology, 59. — Fetal Nutrition, 59. — Fetal Respiration, 61. — Fetal Circulation, 62. — Fetal Secretions and Excretions, 65. — Fetal Innervation, 66. — Fetal Development at the Successive Months of Gestation, with Correlated Clinical Manifestations and Path- ologic Conditions, 68. — 2. Maternal Physiology, 72. — Alterations in the Genitalia, 72. — Abdominal Walls, 75. — Pelvic Articulations, 76. — Pelvic Contents, 76. — General Alterations, 76. 11 12 CONTENTS. PAGH V. The Clinical Manifestations, the Differential Diagnosis, AND THE Hygiene of Pregnancy 78 The Signs of Pregnancy, 79. — Uterine Symptoms, 78. — Abdominal Signs, 83. — Pressure-symptoms, 85. — Vaginal Signs, 87. — Cutaneous Manifestations, 91. — Sympathetic and Reflex Manifestations, 92. — Mammary Changes, 94. — Fetal Symptoms, 96. — The Diagnosis of Pregnancy, lOO. — Differential Diagnosis, 103. — The Hygiene and Managemefit of Pregnancy, 106. — Diet, 107. — Clothing, 107. — Ex- ercise, 107. — Sexual Intercourse, 108. — Bathing and Douching, 108. — The Kidneys, 108. — Constipation, 108. — Mental Occupation, 109. — The Mammary Glands, 109. VI. EuTociA, or Normal Labor 109 The Duration of Pregnancy, no. — Methods of Determining the Date of Confinement, no. — Labor, 115.— Causes of Normal Labor, 115. — Phenomena of Normal Labor, 117. — Stages of Normal Labor, 120. — Duration of Normal Labor, 127. — Mechanism of Normal Labor, 127. — Positions and Presentations of the Fetus, 130. — Vertex Presentations, 136. — Pelvic Presentations, 146. — Prognosis of Normal Labor, 157. — Management of Normal Labor, 158. — Management of Vertex Presentations, 164. — Management of Pelvic Presentations, 173. VII. The Puerperium. — Lactation .181 Physiology of the Puerperium, 181. — Changes in the Genitalia, 181. — Changes in the General System, 184. — Management of the Puerperium, 187. — Diagnosis of the Puerperal State, 196. — Lacta- tion, 196. — Anatomy of the Mammary Glands, Mammae, or Breasts, 196. — Milk, 197. VIII. The Physiology and Management of the New-born . . . 200 Inmiediate Attention, 200. — The Physiology of the New-born, 201. — The Cleansing and Bath, 205. — The Care of the Cord, 206. — Dressing of the Infant, 207. — The Caput Succedaneum, or " Acces- sory Head," 208. — Moulding of the Head, 208. — The Nursing, 208. — Growth and Development of the Child, 210. — Weaning, or Ab- lactation, 211. — The Bal)y's Outing, 213. PART II.— PATHOLOGIC OBSTETRICS. Diseases of the Ovum and the Fetal Appendages 215 I. Diseases of the Membranes, 215. — Pathologic Conditions of the Deciduae, 215. — Pathologic Conditions of the Chorion, 222. — Path- ologic Conditions of the Amnion, 227. — 2. Diseases and Anomalies of the Placenta, 235. — Placentitis, 235. — Placental Apoplexy, 238.— CONTENTS. 1 3 PAGE Edema of the Placenta, 240. — Degenerations of the Placenta, 240. — Tumors of the Placenta, 242. — Anomalies of the Placenta, 243. — 3. Diseases and Anomalies of the Umbilical Cord, 244. — Disease of the Umbilical Vessels, 244. — Cysts of the Cord, 245. — Hernia of the Cord, 245. — Anomalies of the Cord, 246. — 4. Pathology of the Ovum in its Entirety, 250. — Premature Discharge of the Ovum, 250. — In- duction of Premature Expulsion of the Ovum, 265. — Missed Abor- tion, 272. — Extrauterine Pregnancy, 274. — Cornual Pregnancy, 296. — Missed Labor, 297. II. Pathologic Conditions of the Fetus 298 I. Eetal Malformations and Monstrosities, 299. — Hemiterata, 299. — Heterotaxis, 301. — Teratism, 302. — 2. Fetal Disease, 302. — General Diseases, 303. — Diseases of the Digestive System, 309. — Diseases of the Respiratory System, 310. — Diseases of the Circula- tory System, 310. — Diseases of the Nervous System, 310. — Diseases of the Genitourinary System, 314. — Diseases of the Cutaneous Sys- tem, 314. — 3. Fetal Traiwiatism, 316. — 4. Fetal Death, 316. III. The Pathology of Pregnancy 320 I . General Diseases, 320. — The Zymotic Diseases, 320. — 2. Diseases of the Digestive Tract, 323. — Gingivitis, 323. — Dental Caries, 323. — Salivation or Ptyalism of Pregnancy, 323. — Anorexia, 324. — Pica (Malacia), 324. — Indigestion, Gastric and Intestinal, 325. — Pernicious Vomiting of Pregnancy, 325. — Constipation, 330. — Diarrhea, 331. — Hemorrhoids, 331. — Jaundice, 331. — 3. Diseases of the Respiratory Tract, 332.— Hyperosmia, 332. — Dyspnea of Pregnancy, 332. — Nervous or Spasmodic Cough, 333. — Emphysema, 333. — Croupous Pneumonia, 333. — Pulmonary Tuberculosis, 334. — 4. Diseases of the Circulatory System, 335.— Cardiac Palpitation, 335. — Syncope, 335. — Hydremia, 335. — Pernicious or Progressive Anemia of Pregnancy, 338. — Endocarditis, 339. — Varicose Veins, 341. — Aneurysm, 344. — The Hemorrhages of Pregnancy, 344. — Placenta Praevia, 345. — Pre- mature Detachment of the Placenta, 356. — Affections of the Thyroid Gland, 362. — 5. Diseases of the Genitoicrinary Tract, 363. — Affec- tions of the Kidneys, 363. — Nephritis, 363. — Renal Insufficiency, 364. — Puerperal Eclampsia, 367.- — Affections of the Bladder and Pathologic States of the Urine, 381. — Pathologic Conditions of the Uterus, 384. — Diseases of the Vulva and Vagina, 400. — Pathologic States of the Mammas, 404. — 6. Diseases of the Ney-vous System, 404. — Gestational Insanity, 404. — Insomnia, 404. — Vertigo and Syncope, 404. — The Neuralgias of Pregnancy, 405. — Gestational Paralysis, 406. — The Neuroses complicating Pregnancy, 407. — 7. Diseases of the Osseous System, 408. — Relaxation of the Pelvic Articulations, 408. — Inflammation of the Pelvic Joints, 409. — Osteomalacia, 409. — 14 CONTENTS. \. Diseases of the Cutaneous System, 410. — Increased Pigmentation, .10. — Pruritus, 410. — Herpes Gestationis, 411. — Impetigo Herpeti- armis, 411. — Purpura HsemoiThagica, 411. IV. Dystocia 412 I. Fetal Dystocia, ^i2.~Dysfoeia due to Malpositions and Mal- presentations of the Fetus, 412. — Backward Rotation of the Occiput in Vertex Presentations, 412. — Transverse Engagement of the Occiput, 418. — Transverse Position of the Head at the Inferior Strait, 419. — Other Anomalies in the Mechanism of Vertex Pres- entations, 421. — Impacted Breech, 422. — Extension of the Arms in Breech Presentations, 425. — Nuchal or Dorsal Position of the Arm, 426. — Backward Rotation of the Occiput in Breech Presenta- tions, 427. — Malpresentations due to Imperfect Flexion of the Head, 428. — Presentation of the Bregma, 428. — Presentation of the Brow, 430. — Craniotomy and Cranioclasm, 438. — Presentation of the Face, 443. — Transverse or Preternatural Presentation : Presentation of the Trunk, or Cross-birth, 457. — Version, or Turning, 466. — Embry- otomy, 475. — Complex, Compound, or Complicated Presentations, 478. — Superimpregnatiou : Multiple or Plural Pregnancy ; Plural Births, 478. — Dystocia due to Malformations and Diseases of the Fetus, 491. — Over-size of the Fetus, 491. — Premature Ossification of the Fetal Skull, 492. — Fetal Malformations and Monstrosities, 492. — Pathologic Over-size of the Fetal Head, 493. — Tumors of the Fetal Trunk, 496. — Fetal Death and Subsequent Rigor Mortis, 497. — Dystocia due to Abnortnalities in the Fetal Appendages, 497. — Dystocia due to Abnormalities in the Membranes, 497. — Dystocia due to Abnormalities in the Funis, 497. — Dystocia due to Placental Abnormalities, 498. — Dystocia due to Fetal Accidents, 500. — Funic Presentation, 500. — Rupture of the Funis, 504. — Decapitation of the Fetus, 505. — Avulsion of the Fetal Extremities, 505. — 2. MATERNAL Dystocia, 505. — Precipitate Labor, 505. — Protracted or Retarded Labor, 509. — Uterine and Abdominal Inertia, 51 1. — The Obstetric Forceps, 516. — Obstructed I^abor, 530. — Pelvic Contraction, 532. — Pubic Symphysiotomy, or Sigault's Operation, 556. — Cesarean Sec- tion, 561. — Malformations of the Uterus, 571. — Uterine Displace- ments, 572. — Tumors, Uterine, Cervical, Pelvic, and Vaginal, 573. — Rigidity or Atresia of the Soft Structures of the Parturient Canal, 578. — Maternal Accidents, 582. — Rupture of the Birth-canal, 582. — Vaginal and Vulvar Thrombosis, 597. — Inversion of the Uterus, 599. — Diastasis of the Pelvic Joints, 603. — F"racture of the Pelvic Bones, 604. — Subcutaneous Emphysema of the Head and Neck, 605. — Rupture of a Blood-vessel, 606. — Sudden Maternal Death during Parturition, 606. CONTENTS. 1 5 PAGE V. Pathology of the Puerperium . . • 608 I. The Hemorrhages of the Puerperium, 609. — Postpartum Hem- orrhage, 609. — Puerperal Hemorrhage Proper, or Secondary Post- partum Hemorrhage, 619. — 2. Puerperal Thrombosis and Embolis^n, 621. — 3. Puerperal Anemia, 623. — 4. Puerperal Sepsis, 624. — Puerperal Septicemia, 629. — Puerperal Phlebitis, 643. — Puerperal Erythema, 656. — Puerperal Infectious Pemphigus, 657. — Puerperal Tetanus, 657. — Puerperal Neuritis, 659. — Puerperal Metritis, 661. — Puerperal Pelvic Cellulitis, 663. — Puerperal Peritonitis, Pelvic and General, 667. — Vulvitis, 670. — Endokolpitis, 671. — Endometritis, 672. — Endosalpingitis, 675. — Puerperal (Septic) Urethritis, Cystitis, Ureteritis, and Pyelitis, 676. — Puerperal (Septic) Proctitis, 678. — Autogenetic Puerperal Sepsis (Autoirifection), 679. — 5. Puerperal Insanity, 680, — 6. Subinvolution of the Uterus, 682. — 7- Superin- volution [Hyperinvolution) of the Uterus, 685. — 8. Intestinal Ab- normalities, 685.- — Constipation, 685. — Acute Tympanites, 686. — Hemorrhoids, 686. — 9. Incontinence of Urine, 687. — 10. Retention of Urine, 688. — 1 1 . Pathology of the Mammce, 688. — Inversion of the Nipple, 688. — Fissured Nipples, 689. — Mastitis, 690.— Oligo- galactia ; Agalactia, 695. — Artificial Feeding, 696. — Polygalactia; Galactorrhea, 699. — Galactocele, 700. — Tabes Lactealis, 700. VI. Pathology of the New-born 701 I. Preinaturity , 701. — 2. Asphyxia Neonatortim, 706. — 3. Trau- matisms of the Infant, ']\T). — Caput Succedaneum, 713. — Cephalo- hematoma, 714.— Caput Obstipum, 715. — Fractures, 716. — Perfora- tions of the Body, 716. — Paralyses, 717. — 4. Affectiotts of the Respi- ratory Systein, 717. — Atelectasis, 717. — Catarrhal Pneumonia, 717. — Coryza, 719. — 5. Affections of the Digestive System, 719. — Stomatitis, 719. — Vomiting, 720. — Colic, 721. — Icterus Neonatorum, 721. — Marasmus, 721. — Constipation, 722. — Diarrhea, 722. — 6. Affections of the Circulatory System, 723. — The Hemorrhages of Infancy, 723. — CEdema Neonatorum, 726. — Cyanosis Neonatorum, 726. — 7. Affections of the Cutaneous System, 727. — Strophulus, 727. — Ritter's Disease, 727. — Pemphigus Neonatorum, 728. — 8. Ophthalmia Neo- natorum, 728. — 9. Mastitis, 729. — 10. Convulsions, 730. — 11.. Sep- tic Infection, 730. — 12. Congenital Syphilis, 732. — 13. Congenital Defects, 733. — Tongue-tie, 733. — Hare-hp, 733. — Cleft Palate, 733. — Supernumerary Digits, 734. — Phimosis, 734. — Imperforate Rectum, 734. — Spina Bifida, 734. — Umbilical Hernia, 736. A Manual of Obstetrics. PART I. PHYSIOLOGIC OBSTETRICS. I. THE GENERATIVE ORGANS AND THE PAR- TURIENT CANAL. Introductory. — The science of obstetrics or midwifery may be defined as that branch of the study of medicine pertaining to the care of women in pregnancy, childbirth, and the puerperal state. Destined as woman has been from the foundation of the world to pass through this period of reproduction and parturition in order to the natural propagation of the race, childbirth should be regarded as an absolutely normal process, as much so as is menstruation or the menopause. It is a function for which she has been especially designed anatomically and physiologically. Her peculiar pelvic con- formation, her special and highly functionized generative organs, the provision allotted her for the maintenance of her offspring after birth, and the mental states and emotions that constitute her characteristic maternal instincts, — all unmistakably indicate the noble purpose for which she was created. To the pernicious influences of civilization upon the development of the sexual apparatus and desires alone must be ascribed all those abnormalities of parturition that have done so much to render childbearing an object of terror to womankind, and the subject of obstetrics, and especially of dystocia, one of such uncertainty and appre- 2 17 1 8 A MANUAL OF OBSTETRICS. hension to the medical attendant. An investigation of the causes that have led to this deplorable state of affairs, how- ever interesting such a study must be, would far exceed the limits of a volume of these proportions. There are some preliminary considerations, however, that are essential to a thorough comprehension of the physiologic processes concerned in gestation and parturition, and foremost among these stands a knowledge of the anatomic peculiarities of the female genitals. A brief description of these organs will therefore be in order. The Generative Organs. The female genitalia include those organs that are con- cerned in the production and development of the ovum. These have from time immemorial been conveniently divided into (i) the true or internal goiitals, including {a) the ovaries (the organs of ovulation) and their ducts (the oviducts or Fallopian tubes), {li) the uterus (the organ of development and expulsion), and (6 in.) thick. Its weight is Anatomically considered, it may be divided into two main portions, the body and the cervix. arous adult in.) broad, about 31 grams (7 drams). 20 A MANUAL OF OBSTETRICS. the constricted portion between the two being the isthmus. The upper portion of the body, that above the point of entrance of the Fallopian tubes, is the fiuidiis uteri ; the portion between the tubes and the internal os is the body proper; and that between the internal and the external os is the cervix. The anterior surface of the uterus is markedly flattened, and, save at the extreme upper portion, is in close juxtaposition with the bladder ; the posterior surface is more convex, and is separated from the rectum by a fold of peri- FiG. 2. — View of the pelvis and its organs: b, bladder; u, uterus (drawn down by loop i); V, Fallopian tubes ; o, ovaries ; L, round ligaments ; g, ureter ; a, ovarian vessels, often prominent luider their peritoneal covering. toneum constituting Douglas's pouch or cul-de-sac. At the superior angles or cornua of the body the Fallopian tubes are g^ched. The cavity o^h^utcrus measures about 6}^ cm. (23^ in.); it is covered witl^^ pale mucosa lined with cylindric ciliated epithelium.*'*irfee main bullc of the uterus is composed of unstriped muscular tissue disposed in three layers. It is lined within by the mucous coat, and GENERATIVE ORGANS AND PARTURIENT CANAL. 21 without by the serous or peritoneal coat. Of the three layers of muscular tissue, the inner is mainly sphincteric in nature ; it is largely disposed in the vicinity of the internal OS and around the orifices of the Fallopian tubes. The fibers of the outer layer extend longitudinally, and in labor assist materially in dilating the cervix and retracting it over the fetal presentation. The middle layer of obliquely-dis- posed fibers constitutes the main bulk of the muscle and is the most active portion in parturition. From an obstetric point of view the uterus may be divided into the upper and lower segments, separated by the con- Liower nteriiio seg^ineut Internal os. (Miiller's ring.) External os Internal os {or Ringof Bandl). (Braun's isthmus.) External os. Fig. 3. — Diagram illustrating the two teachings concerning the lower uterine segment and the cervix. On the left side an internal os has been added for the sake of clearness, al- though in the frozen sections of women with full dilatation it is rarely apparent macroscopi- cally (one-third natural size). traction-ring of Bandl, and the cervix. The nppcr uterine segment embraces all that portion of the uterus that be- comes actively engaged in the expulsion of the fetus. It is limited below by Bandl's ring, which in pregnancy at A MANUAL OF OBSTETRICS. term is approximately about 12 to 15 cm. (5 or 6 in.) above the internal os, or about the point of attachment of the peritoneum to the uterus, and holds a position at a level with the pelvic brim. The lower uterine segment (Fig. 3) is that portion of the uterus that remains passive during labor and undergoes dilatation. It extends between Bandl's ring above and the. upper portion of the cervix below. The Parturient Canal (Fig. 4). — The passage-way- through which the fetus, mature or immature, makes its entrance into the world. It includes: i. The lower uterine segment ; 2. The vagina ; 3. The pelvis. It termi- nates below in the vulva. TJic vagina, or sJicath, confined entirely within the true pelvis, is the or- gan of copulation, and is the passage extending ob- liquely upward, at about an angle of 60° to the horizon, from the vesti- bule of the vulva below to the cervix above; the latter protrudes into the lumen of the vagina for a short distance. The space in front of the cervix is called the anterior vagi- nal ininlt ; that behind the cervix, the posterior vaginal vault. The vagina is composed of two walls, anterior and posterior, which are normally in contact; the anterior wall is about 6_J^ to 7 cm. (2.5590 to 2.7559 in.) long, the posterior 7^ cm. (3.0018 in.). The mucous surface of the vagina is thrown into pronounced transverse folds or ruga;, which are most marked in virgins. During labor the vagina dilates to permit of the passage of Fig. 4. — General axis of the parturient canal, including the uterine cavity and the soft parts : A, center of superior strait ; B, center of inferior strait ; C, center of the pelvic cavity. GENERATIVE ORGANS AND PARTURIENT CANAL. 23 J^ ^4 the fetus. The hymen is a fold of the vaginal mucosa guarding its lower orifice, the introitiis vagincs. The Vulva. — The external genitals, or vulva (Fig. 5], comprise the labia majora and minora, the clitoris, the vesti- bule, the fossa navicularis, and the mons veneris. The labia majora, the ana- logue of the scrotum in the male, consist of two thick folds \ of integument extending for about 7^ cm. (3.0018 in.) from the symphysis pubis above to their junction below — \}:iQ poste- rior commissure, or fourchet — about 2^ cm. (i in.) in front of the anus. In structure they are composed of adipose tissue, blood-vessels, and nerves, with an internal mucous and an exter- nal cutaneous surface, the latter being clothed with short, crisp hairs. Bartholiid's glands, or the glands of Duverney or of Hu- guier, one on either side, are imbedded in the lower third of the labia majora. The rima pudenda?, the fissure separating the labia. The fourchet is torn in the majority of labors occurring in primiparae. The labia ndnora, or nymphce, are two small mucous folds situated within the greater lips, and uniting above to form the prepuce of the clitoris. They extend downward to about the middle of the labia majora, where they merge into the latter. A large number of sebaceous glands are found on their surfaces. Fig 5 — Virginal vulva- i, labia ma- jora; 2, fourchet; 3, labia minora; 4, glans clitoridis ; 5, meatus urinarius; 6, vestibule ; 7, entrance to the vagina ; 8, hymen ; 9, orifice of Bartholini's gland ; 10, anterior commissure of labia majora ; 11, anus; 12, blind recess; 13, fossa na- vicularis; 14, body of clitoris (modified from Tarnier). 24 J MANUAL OF OBSTETRICS. The clitoris is the analogue of the penis in the male. Like the latter, it is composed of two corpora cavernosa, which end distally in a rounded extremity, the glans clito- ridis. It is situated about i^ cm. (0.492125 in.) below the union of the labia majora above. From its large nerve- supply it is believed to be the seat of sensual pleasure. The vestibule is the triangular space bounded above by the clitoris, laterally by the labia minora, and below by the orifice of the vagina. The urethra and a number of mucous glands open into this space. The fossa navicularis is the triangular space seen when the labia majora are separated below. It is bounded above by the vaginal ori- fice, below by the fourchet, and later- ally by the labia majora. The mons veneris isan eminenceabove the symphysis pubis composed mainly of adipose tissue and skin. It serves as a cushion during copulation. The Bony Pel- vis. — The pelvis is a basin-shaped bony canal situated at the base of the trunk of the body ; it rests upon the fe m o ra and supports the vertebral column. It is composed of four bones — the two innominate or hip-bones, the sacrum, and the coccyx. It is divided by the iliopectineal lines into an upper and a lower portion, known respectively as the false ^S^-^-W /; B 01 'E Fig. 6. — Axes of the pelvis : P, promontory of the sa- crum ; C, coccyx ; .S", symphysis pubis; /, umbilicus; P S, plane of the superior strait ; C L, plane of the inferior strait; H H' , line of the horizon; I M A, axis of the su- perior strait ; A R, axis of inferior strait ; MAR, curve of Carus ; P B L, obliquity of superior strait ; C L H, ob- liquity of the inferior strait. GENERATIVE ORGANS AND PARTURIENT CANAL. 25 and the true pelvis. The relationship which the pelvis holds to the trunk above and to the extremities below is known as its position or obliquity (Fig. 6) ; thus, the angle formed by the plane of the superior strait with the horizon varies from 50° to 60°, and that formed by the plane of the inferior strait and the horizon is about 10°. This obliquity is not a fixed factor, but varies with the position of the patient : it is almost entirely obliterated when the sitting or stooping posture is assumed. The parturient canal is somewhat shortened in this position ; hence the advantage of having the patient draw up the limbs during labor. The false pelvis obstetrically has no function other than that of favoring the engagement of the fetus in the superior strait. It provides the inclined plane, directed mainly from behind forward, down which the fetus will descend under the impulse of the uterine contractions. The True Pelvis. — Laterally the two iliopectineal lines, and posteriorly the base of the sacrum, form the upper limit of the true pelvis (Fig. 7). This cordate margin is termed Fig. 7. — Female pelvis, one-third natural size, showing form and diameter of brim or inlet: ab, anteroposterior or conjugate diameter; cd, transverse diameter; ef, right oblique diameter ; gh, left oblique diameter. the i7ilet or superior strait. Its most important measurement is the anteroposterior, conjugate, or sacroptibic diameter, ^- 26 A MANUAL OF OBSTETRICS. extending between the central points of the upper margin of the symphysis pubis and the promontory of the sacrum . - (' T ^m QX-Jr ^},^ ii * ) . The transverse or bisiliac diameter ^ joins the central points of the two iliopectineal lines; it ZT>^ measures 13;^ cm. (5.3150 in.). The oblique diameters C'^'^'^ measured from either iliopectineal eminence to the opposite sacroiliac synchondrosis are each 12^ cm. (5.0196 in.) in ^^-J^^ length. Accurately, the right oblique diameter (that ex- V tending from the left iliopectineal eminence to the right sacroiliac synchondrosis, and corresponding to the right hand of the obstetrician when he faces the patient) is a trifle longer than the left, even in the dried pelvis. The circum- ference of the brim is about 40 cm. (15.7480 in.). Its axis, or an imaginary line drawn perpendicular to the center of the strait, if extended would pass through the umbilicus above and the tip of the coccyx below. The cavity of the pelvis is the space between the superior and inferior straits. It is larger above than below, thus con- tinuing the downward inclination begun above in the false pelvis. By the jutting outward of the two ischial spines, one on either side, there are formed two general inclined planes, an anterior and a posterior, the latter being more Ca'^^\- prominent. By this arrangement the presenting fetal part is by some supposed to be directed forward toward the vulvar orifice by a process of internal rotation. The depth of the pelvis anteriorly through the symphysis pubis is 4 to 43^ cm. (1.5748 to 1.7716 in.); laterally from the iliopectineal line to the ischial tuberosities, 9 to 91^ cm. (3.5433 to 3.7401 in.) ; and posteriorly down the sacrum and coccyx 12^ cm. (4.9869 in.). The axis of the pelvic cavity or ■canal, also termed the curve or circle of Carus, is an im- aginary line extending from the middle point of the plane of the superior strait downward to the middle point of the plane of the inferior strait, at all points being equidistant from the pelvic walls. The intensity of this curve depends upon the degree of curvature of the sacrum. This line GENERATIVE ORGANS AND PARTURIENT CANAL. 2/ represents the path followed by the fetus during parturi- tion (see Fig. 6). The inferior strait or outlet (Fig. 8) of the pelvis is like- wise cordate in shape, but this is subject to variation, owing Fig. 8. — Diameters of the pelvic outlet (Dickinson) to the niovability of the coccyx, so that during labor it be- ^' comes almost circular. Its boundaries are the pubes, the /^*ax> rami of the pubes and ischium, the tuberosities of the f» ischium, the sacro-sciatic ligaments, and the coccyx. The diameters of this strait are — the anteroposterior, conjugate, or coccypiibic, measured from a line dropped perpendicularly from the lower border of the symphysis pubis to the tip of the coccyx, 9^ cm. (3.7401 in.), increasing to 11 cm. (4.3307 in.) in labor, the coccyx being displaced backward i^ cm. (.5906 in.); the transverse or bisiscJiiac, extending between the inner borders of the tuberosities of the ischia, 1 1 cm. (4.3307 in.) ; and the oblique, measured from the junction of the descending pubic ramus and ascending ischial ramus of one side to the center of the greater sacro- 28 A MANUAL OF OBSTETRICS. sciatic ligament of the opposite side, 12^ cm. (5.0196 in.). The axis of the outlet, if extended, would pass through the promontory of the sacrum above. The Pelvis in Life. — The space within the bony pelvis is considerably diminished by the disposition of the soft structures found therein. These consist of ligaments, fascia, muscles, bowel, bladder, vessels, and nerves, and upon their presence depend many of the phenomena of the mechanism of labor. The ligaments of the pelvis (Fig. 9) are as follows: i. Those joining the sacrum with the iliac bones, the anterior Fig. 9. — Front view of the pelvis, with its ligaments : a, anterior sacroiliac ligament; b, iliofemoral ligament; c, obturator membrane; d, symphysis pubis; e, sacrosciatic liga- ment. and posterior sacroiliac ligajuents, two of each ; 2. Those connecting the sacrum and the coccyx, the anterior, pos- terior, and lateral sacrococcygeal ligaments ; 3. Those join- ing the two pubic bones, the anterior, posterior, and superior pubic and the subpubic ligaments ; 4. Those connecting the sacrum and the coccyx with the ilia and the ischia, the two greater and two lesser sacrosciatic ligaments, the greater ex- GENERATIVE ORGANS AND PARTURIENT CANAL. 29 tending from the tubercles of the sacrum to the tuberosity of the ischium, and the ksscr from the lateral margin of the sacrum to the same point. These ligaments are important as still further modifying the shape of the pelvis and the direction of its axis, and, in labor, as serving as buffers for the fetal presentation. The muscles of the pelvis include those of the canal and those of the pelvic floor, and these have somewhat distinct Fig. 10.— The levator ani muscle as seen from above, with the tendinous arch that spans the obturator muscle. obstetric functions. Those of the canal, including the coc- cygeus, pyriformis, and iliopsoas posteriorly and the obtu- rator internus anteriorly, serve to turn the presenting part into the mo.st favorable diameter for its expulsion, and also act as cushions upon which the fetus may rest and escape injury from undue pressure. Owing to the presence of these muscles (the iliopsoas in particular), the transverse diameter of the superior strait becomes smaller than the oblique ; hence the frequency of oblique fetal positions whatever the presentation. It has been ascertained that these muscles diminish the transverse diameter by about i^ cm. (0.5906 in.), and the congugate by i cm. (0.3937 30 A MANUAL OF OBSTETRICS. in.). The muscles of the pelvic floor are, from without inward, the transversus perinei, the ischiocavernosus, the sphincter ani, the sphincter vaginae, the coccygeus, and the levator ani (Fig. lo). Their functions are primarily to support the pelvic viscera, and obstetrically to complete the direction of the pelvic canal, and to direct, by the pressure they exert, the fetal presentation toward the vulvar orifice. The most important muscle of the pelvic floyr is the levator ani, a powerful structure extending backward and inward from its origin on the body of the pubis near the symphysis, and sending off branches behind the vagina and around the rectum. In difficult labor or when the perineum is unduly rigid this muscle is torn through, and the condition known as a lacerated perineum results. The pelvic fascia is in direct communication with the fasciae of the thighs and perineum and with the abdominal subcutaneous tissue. It may therefore serve as an avenue for peritoneal infection following lesions of these external surfaces, the morbific agent infecting rapidly the lymphatic tissue in the course of the fascia. Thus, the septic process beginning in the vagina, urethra, or rectum may extend to the peritoneum by direct continuity of tissue, and the patient be exposed to the dangers of puerperal pelvic cellu- litis or peritonitis. The very rich vascular and lymphatic supply of the pelvis renders all such septic processes excep- tionally virulent. Hemorrhages into the interstitial spaces also follow the distribution of the pelvic fascia. Tile situation of the rectum to the left side of the pelvis is an imjoortant determining factor in the position of the presenting part. By its presence the left oblique diameter of the superior strait is still further impinged upon, and the presenting fetal part is compelled to find the necessary room in the right oblique diameter ; hence another cause for the frequency of oblique presentations. Pelvimetry. — As some of the most serious forms of dys- GENERATIVE ORGANS AND PARTURIENT CANAL. 3 1 tocia arise from irregularities in the pelvic conformation, it becomes essential to determine what are the normal pelvic re- lations and measure- ments. Hence has arisen the science of pelvimetry , or the measurement of the pelvis in the living woman. These meas- ,. „ 1 Fig. II. — Baudelocque's pelvimeter. urements are secured ^ ^ by means of a special instrument, the pelvimeter, or by the fingers (when the process is termed digital pelvinictr)'), cer- tain fixed points of the bony pelvis being taken as the guiding-points. The pelvimeter in its common form re- sembles a pair of calipers to which is attached a scale graduated according to the metric system. The instru- ments of Baudelocque (Fig. 11) and Duncan are probably the most familiar. The measurements may be made exter- nally and internally, or by the combined method ; the exter- nal measurements, however, are but approximately accurate on account of the varying degrees of stoutness and osseous development. Estimation of the Pelvic Inlet. — The four fixed points of the pelvic inlet — namely, the two iliopectineal emi- nences anteriorly, and the two sacroiliac synchondroses posteriorly — are essential elements in the estimation of the' size of the upper pelvic diameters, and also in determining the position of the fetal presentation. They have been termed the cardinal points of Capnron. The most import- ant diameter of the pelvic inlet is the anteroposterior or con- jugate {conjugata vera), for the reason that it is this diameter that is most commonly shortened in deviations from the normal in the contour of the pelvis. The size of this diam- eter may be estimated by taking three measurements, two 32 A MANUAL OF OBSTETRICS. internally and one externally. The external measurement is taken by placing one arm of the pelvimeter upon the upper edge of the symphysis pubis, and the other arm upon the Fig. 12. — Baudelocque's pelvimeter ; method of taking the external conjugate diameter of the inlet. nJLpriiA. ' .ion unHf:r tho spine of the last lumbar vertebra (Fig. 12), about 2^ cm. (0.98425 in.) above the transverse line joining the posterior superior iliac spines, the patient resting upon her side. This diameter, which is called the external co)iju(!^ate, or the diameter of Dandelocque, measures normally . ^o)^ Qx\\. (7.9724 in.), which is 95^ cm. (3.6417 in.) more than the true conjugate diameter of the pelvis. Hardie's measure- ment is also made externally, but is not practical on account of its inaccuracy and the limited period of gestation (the first GENERATIVE ORGANS AND PARTURIENT CANAL. 33 trimester only) during which it can be employed; it can only be taken in women who are not obese. The patient resting in the lithotomy position, the fingers are placed about 2]/^ cm. (.98425 in.) below the umbilicus, and pressure backward is made until the sacral promontory may be felt; the dis- tance from the promontory to the top of the symphysis is measured, and an approximate idea of the size of the pelvic inlet is obtained. The internal vieasiircincnts are the sacrocotyloid diameter, extending from a point immediately above the center of the acetabulum to the promontory of the sacrum (9^ cm. or 3.6417 in.), and the internal ox indirect conjugate diagonal. The latter measurement is taken by the hand in the vagina (Fig. 13), the tip of the middle finger resting against the Promontonj Fig. 13. — Manual method of measuring the diagonal conjugate. promontory of the sacrum ; the distance between the tip of this finger and the point on the radial border of the hand in 3 34 A MANUAL OF OBSTETRICS. contact with the under surface of the symphysis, the sub- pubic Hgament, is the conjugate diagonal (i2%! cm. or 5.0196 in.); it is i^ cm. (0.691475 in.) greater than the true conjugate. To avoid the errors in this measurement consequent upon the variations in the length of the sym- physis and the size of the conjugatosymphyseal angle (that between the top of the symphysis and the true conjugate of the superior strait), a better and more direct method is that recently suggested by Professor Barton Cooke Hirst of the University of Pennsylvania. This consists in measuring from the promontory of the sacrum to the upper outer edge of the symphysis pubis (Fig. 14); the thickness of the symphysis Fig. 14. — Measuring tlic true conjugate plus tl kucss of tlic sympliysis (Dickinson). alone must then be deducted in order to ascertain the true conjugate diameter (Fig. 15). For this purpose Dr. Hirst has devised a special form of pelvimeter modelled after the instrument of Skutsch, but considerably improved. The transverse diameter of the inlet may be estimated by one internal and four external measurements. The external GENERATIVE ORGANS AND PARTURIENT CANAI. 35 measurements are the anterior intcrspinoits diameter, or the distance between the anterior superior ihac spinous processes Fig. 15. — Measuring the thickness of the symphysis (Dickinson). (26 cm. or 10.2362 in.), the posterior interspinmis diameter, or the distance between the posterior superior iliac spinous processes {Zyi to 9 cm. or 3.35745 to 3.5433 in.), the inter- cristal diameter, or the dis- tance between the middle points of the iliac crests (29 cm. or 1 1.4173 in.), and the intertroclianteric diameter, or the distance between the two major trochanters (31 cm. or 12.2047 in.). The internal measurement is Lbhleiiis, or the so-called internal ascending obliqne diameter, which is of but minor importance in the estimation of the pelvic diameter ; it is the distance from the central point of the subpubic Fig. 16. — Ch.intreuil's method of pelvic measurement. ^6 A MANUAL OF OBSTETRICS. ligament to the upper and anterior margin of the great sacrosciatic foramen ; this is 2 cm. (0.7874 in.) shorter than the transverse diameter. The oblique or diagonal diameters of the pelvis measure 22 cm. (8.6614 in.). They are inght Male pelvis seen from the front (Dickinson) and left, and extend from one anterior superior spinous pro- cess of the ilium to the opposite posterior superior spinous process, which may be recognized by the distinct indentation overlying it. This measurement is taken with the patient resting upon her side. .The circumference of the pelvis at the upper margin is 90 cm. (35.4330 in.). Estimation of the Pelvic Outlet. — Only in one common variety of pelvic deformity is this portion of the pelvis con- tracted — namely, in the kyphotic pelvis. Therefore but slight import is attached to the measurements here. In the normal pelvis the transverse or bisischiac diameter — the most important, pathologically considered — measures 1 1 cm. (4.3307 in.), and it may be determined by the metJiod of GENERATIVE ORGANS AND PARTURIENT CANAL. 37 Chantreiiil (Fig. 16), in which, the patient resting upon her knees and elbows or in the hthotomy position, the thumbs are placed upon the ischial tuberosities and the intervening distance is accurately measured by an assistant. Fig. 18. — Female pelvis seen from the front, one-third natural size (Dickinson). The Male and the Female Pelvis Compared. — When a male pelvis (Fig. 17) and a female pelvis (Fig. 18) are viewed together, some striking points of difference may be recognized. These rest upon modifications in the female pel- vis dependent upon the generative function. In the following table are grouped the most prominent points of distinction : Points of Difference between the Male and the Female Pelvis. Female. Structure is light. Cavity is shallow, but roomy ; iliac bones are widely separated. Sacrum is wide and deeply curved ; there is moderate projection of the prominence. Ischial tuberosities are widely separated. Subpubic angle ranges from 90° to 100°. Pelvic brim is elliptic or cordate. There is great pelvic inclination. Thyroid foramen is triangular. Male. Structure is heavier. Cavity is deep and contracted; iliac bones are closer together. Sacrum is narrow and slightly curved ; there is deep projection of the prominence. Tuberosities are more closely approximated. Subpubic angle ranges from 75° to 80°. Pelvic brim is triangular. There is slight pelvic inclination. Thyroid foramen is oval. 38 A MANUAL OF OBSTETRICS. II. PUBERTY AND ITS MANIFESTATIONS. Having described the ovary anatomically, it remains, before entering into a study of gestation and its phe- nomena, to elucidate the egg-bearing function of this organ, known technically as ovulation. The Ovisacs, or Graafian Follicles (Fig. 19). — Scattered thickly throughout the oophoron, or active ovarian stroma, may be noted numerous small round vesicles in various stages of development, known as the Graafian follicles. They number many thousands in each ovary ; as they mature they increase in size and approach the surface Fig. 19. — Section of the ovary of a cat, enlarged six times : i, outer covering and free border of the ovary (epithelium and albuginea) ; i', attached border; 2, vascular zone, or medullary substance ; 3, parenchymatous zone, or cortical substance; 5, Graafian follicles in their earliest stages, lying near the surface ; 6, 7, 8, more advanced follicles, im- bedded more deeply in the stroma ; 9, an almost mature follicle, containing the ovum in its fleepest part ; 9', a follicle from which the ovum has accidentally escaped ; 10, corpus luteum (Schron). of the ovary, where they rujiturc and discharge their con- tents. The adopted theory of the formation of the ovisacs is that of Pfliiger and other German writers : it is that there occurs in fetal life an invagination of portions of the epi- thelial covering of the ovary in long processes known as egg-cords, or the cords or loops of Pfiugcr, and the epithe- PUBERTY AND ITS MANIFESTATIONS. 39 lial cells thus invaginated undergo extreme specialization and develop into the ovisacs, each of which contains an ovum. Anatomically, a Graafian follicle is composed of the following elements : Externally is the tunica fibrosa or vascidosa, a fibrous membrane composed mainly of vascular connective tissue ; next, the tunica propria, composed of simple connective tissue, lined by the membrana granulosa, which consists of columnar nucleated cells. At the point of attachment of the ovum to the membrana granulosa there is an accumulation of the cells of the latter structure, forming the discus or cumulus proligerus. The cavity of the ovisac contains the ovum and a transparent viscid fluid, the liquor follicidi. The Ovum. — The vital element or reproductive cell of the female, varying in size from y^ to -^-^ of an inch, is termed the ovum. It consists of a protoplasmic yelk or vitcllus and a nucleus or gcrmi}ial vesicle {z'csicida ger- minativd) enclosed within a hyaline covering, the zona pel- lucida or vitelline membrane. An examination of the vitellus reveals two constituents — namely, a solid substance, the spongioplasm, existing as a delicate reticulum, in the meshes of which is a more fluid substance, the hyaloplasm. Within the germinal vesicle, either centrally or peripherally situated, is a minute dark point known as the gernnnal spot [jnacida genninativci), which is the active generative portion of the ovum. It is surrounded by the nuclear fluid. Ovulation. — By this term is meant, in its fullest sense, the formation, development, and discharge of a mature ovum from the ovary. Until puberty the Graafian fol- licles remain in a state of quiescence. Upon the establish- ment of puberty, however, certain of the follicles assume extraordinary growth and rapidly approach the ovarian surface. One of these follicles reaches its full maturity about the time of a menstrual epoch, and under the impulse of certain determining causes it ruptures and discharges its 40 A MANUAL OF OBSTETRICS. contents — namely, an ovum, with the Hquor folliculi and a few cells of the discus proligerus. Causes of RtLpturc of the Follicle. — Nothing positive is known as to just why a mature follicle ruptures. Certain plausible theories have been suggested, as follows : i. Absorption and attenuation of the theca folliculi, due to increased intrafollicular pres- sure from accumulation of fluid within the follicle ; 2. Extravasation of blood into the sac ; 3. Exaggerated growth of the membrana granulosa, with liquefactive changes in its cells, resulting in undue softening thereof; 4. Periodic contraction of the ovarian stroma; 5. The ex- citement and local congestion consequent upon coition. Relationship existing betiveen Ovulation and Menstruation. — The exact time of the discharge of the ovum — that is, whether it takes place before, during, or after the appear- ance of the menstrual discharge — is still sub jjidice ; it is quite generally believed, however, that ovulation occurring at the menstrual period takes place just prior to the onset of the menstrual flux. While usually coexistent, ovulation and menstruation may occur independently of one another, an ovum being discharged midway between two menstrual epochs. Ultimate Disposition of the Ovum. — The escaped ovum being received into the Fallopian tube either by direct introduction at the time of rupture or by suction, according to Henle's theory, it is carried into the uterine cavity by the action of the ciliated epithelium of the tube. Here it is lost in the menstrual flux, or, having become impregnated, finds lodgement and develops into the product of conception. This change in location is known as the migration of the ovum. It is probable that in many instances the ova fail to gain entrance into the oviduct, and are lost in the peritoneal cavity, where they become absorbed. Curious instances are on record in which an ovum, escaping from a given ovary, has failed to enter the corresponding Fallopian tube, probably on account of some diseased condition of the latter , but, crossing the uterine PUBERTY AND ITS MANIFESTATIONS. 4 1 fundus, has gained admission into the opposite tube, and thence proceeded into the uterus. This is known as external migration of the ovum. The Corpus Luteum. — The ruptured folhcle after the dis- charge of the ovum undergoes a series of retrograde changes, resulting in the formation of a scar known as the corpus hi- t€?nn or yellow body (see Frontispiece). The cavity fills with blood, which in time undergoes organization, becoming yel- lowish in color, and finally being transformed into true fibrous tissue. This contracts and a permanent cicatrix results. The size of this cicatrix and the time required for its formation vary according to the degree of congestion of the ovary. Should pregnancy result or should there exist some pathologic condition, as a chronic ovaritis, a septic pelvic peritonitis, or marked uterine disease {e. g. the presence of uterine fibroids), the corpus luteum will be increased in its dimensions, and before complete cicatrization can be ac- complished three or four months may elapse instead of the whole process being completed in as many weeks. The former belief in the medico-legal value of the size of the corpus luteum in the determination of the existence of pregnancy has been proved fallacious. Puberty. — Puberty is the period of sexual maturity in a child, at which time, in the female, fecundation becomes pos- sible. The age at which puberty takes place is governed by several well-recognized determining factors. These are race, social development, climatic influences, and family pre- disposition. In this country the average age is about the fourteenth year, while in warmer climates puberty may occur much earlier. The signs of pjibej'ty in the female are — i. The appearance of hair upon the pubes ; 2. The development of the breasts ; 3. The establishment of the function of ovulation ; 4. The appearance of menstruation ; 5. The widening of the pelvis ; 6. The growth of the sexual sense. Menstruation. — Menstruation is that periodic series of 42 A MANUAL OF OBSTETRICS. phenomena occurring normally every twenty-eight days in the non-pregnant female from puberty to the menopause, and consisting principally in a congested state of the uterine and tubal mucosae, which is attended by sundry systemic and psychic manifestations and is followed by a discharge of a sero-sanguinolent fluid from the genital canal, known as the menses, floiu, or nienstnial flux. This fluid is com- posed mainly of altered blood containing portions of des- quamated mucosal cells mixed with the normal uterine and vaginal secretions ; it is alkaline in reaction, with a faint, peculiar and somewhat disagreeable odor, and, because of its admixture with mucus, does not undergo coagula- tion. It is derived from the congested mucosae of the tubes and uterus, the distended vessels permitting a leak- ing of the blood through their attenuated walls, according to the view advanced by Leopold. The usual duration of the menstrual flux is three or four days, and the total amount normally lost is from 148 to 295.73 c.cm. (5 to 10 ounces) ; this may be estimated by the number of napkins soiled, usually two or three daily. The symptoms attend- ant upon the appearance of menstruation are termed the menstrual inoliniina. They include pelvic congestion, as manifested by vague pains and a sense of discomfort in the back and lower abdominal region ; pigmentation of the skin, especially noted around the eyes ; swelling of the breasts with milk-formation; frequent pulse-rate; and enlargement of the tonsils and other glandular structures of the neck, often producing a huskiness of the voice. It is believed that the object of the menstrual flow is to make ready a nidus for the impregnated ovum. The menopause, cliuiaeteric, or change of life occurs about the middle of the fifth decade, and consists in a gradual diminution in the frequency and amount of the menstrual flow, and ultimately in a complete cessation. This, as has been said, usually occurs about the forty-fifth year, but may be delayed much longer, even beyond the PREGNANCY OR GESTATION. 43 sixty-fifth year ; or it may appear sooner, the menstrual function being, in certain recorded cases, abohshed as early as the twenty-fifth year. Thirty years of sexual activity is considered the normal duration. There are some marked changes consequent upon the arrest of this ph)-si- ologic process. Not only do all the genitalia undergo an atrophic change, but nervous manifestations appear, and the woman for a period of some months will suffer from the characteristic flasJics of /icat, together with alterations, slight or pronounced, in disposition and physical constitu- tion. There is a more or less constant tendency to obesity at this time. III. PREGNANCY OR GESTATION. Insemination ; Conception ; Embryologic and Fetal Development. In order that there may be a propagation of the race it is necessary that there be brought about a union of the vital elements of the two sexes. This is accomplished by means of coition or copulation. During sexual intercourse there is deposited by the male organ within the vagina a peculiar fluid, the scnicn, containing the vitalizing element. This act is termed insemination. Now, insemination is not necessarily followed by impregnation. In order that the woman shall conceive there must be a meeting and amal- gamation of the male and female elements. When such an amalgamation occurs the ovum is said to be fertilised or fecundated ; the woman conceives or is impregnated, and enters upon the period o^ pregnancy or gestation. A nullip- aroiis woman, or a nullipara, is one who has never borne a child, and this condition of non-productiveness is termed nulliparity. Parity is the condition of being able to bear children, and when a woman becomes pregnant for the first time she enters the state of priniiparity, and is termed a 44 A MANUAL OF OBSTETRICS. primiparous woman, a primipara, or a primigravida ; in subsequent pregnancies she is said to be in the state of dihI- tiparity, and is termed a vmltiparoiis woman, a multipara, or a vuiltigravida. It has hitherto been the custom to desig- nate the different degrees of parity by Roman numerals : thus, a primipara has been designated Ipara ; a woman in her second pregnancy, Ilpara ; one in her third gestation, Illpara; and so on. Recently Dr. George M. Gould of Philadelphia has very appropriately suggested substituting for these " unpronounceable monstrosities " the following terms : For a woman in her second pregnancy, dnipara {deiitipara or secundipara) ; in the third, tripara (or tcrtip- ara) ; in the iQx\\\.\\, quadr ipara ; in the fifth, qinntipara ; in the sixth, sextipara ; in the seventh, siptipara ; in the QX^Wx, octipara ; in the xixViCci, nonipara ; in the tenth, ^r- cipara, and so on. This terminology will be employed throughout this work. The Semen. — The semen is a thick, viscid, yellowish or opalescent fluid, with a faint, characteristic, lime-like odor, discharged by the male at the height of the orgasm. It is the secretion of the testicles in combination with the secretions of the prostate and Cowper's glands. It is composed mainly of the liquor seminis, the seminal gran- ules, and the spermatozoa or vital elements. The liqjior sciiwiis is a highly albuminous fluid holding in solution an odoriferous, mucilaginous body, spennatin, together with phosphates, chlorids, and other in- organic substances. Its most important Fig. 2o.-spermatozoa : constitucuts arc thc spcrmatozoa (Fig. 20). h, apparent nucleus ; /', t., . • i. j 1 i-i L !• body ;/, tail. 1 hcsc are microscopic, tadpolc-1 iKC bodics present in immense numbers, and derived from thc .sperm-cells of the seminal tubules of the testicles ; they are about jj-^ of an inch in length. Each spermatozoon consists of a flat, oval head, a small body, and an immensely PREGNANCY OR GESTATION. 45 elongated and tapering tail or flagellum, which, in the living spermatozoon, is in constant motion, and which imparts mo- tility to the entire organism. When this faculty of locomo- tion is lost the spermatozoid no longer possesses the vitaliz- ing power. The length of time that vitality is retained de- pends largely upon the environment. The spermatozoa may still possess full fertilizing power within the female genitalia a week after insemination. An excessively acid or alkaline leukorrhea will destroy them, as will also exposure to ex- treme degrees of heat and cold. They show a marked aver- sion to the action of mercuric chlorid, very weak solutions of which (i : 10,000) will render them inert. The amount of semen deposited in sexual congress varies, but is on an average about 3.7 cubic centimeters (i dram). When much in excess of this amount the condition is known as poly- spermism, while if the quantity is markedly deficient it con- stitutes the pathologic condition of oligospermism. The orgasm is the crisis of the venereal passion. Nor- mally it should take place simultaneously in the male and the female, and when such coincidence occurs conception is more probable. This is, however, not absolutely essential to fecundation, for the orgasm may be entirely absent in the woman and impregnation follow. This has been noted in cases of sexual apathy, or when intercourse has been in- dulged in while the woman was intoxicated, unconscious, asleep, or under the narcotic influence of some drug. During the orgasm in the female there is said to be a slight descent of the uterus accompanied by a contraction of its muscular fibers, resulting in a suction-process in the cervix, the external os rapidly opening and closing, and thus afford- ing ready entrance to the fertilizing fluid. Fecundation. — The spermatozoa, being thus received within the uterine cavity, take up their journey to meet the ovum. The rate at which they travel upward in the uterus is, according to Henle's observations, about an inch in a little over seven minutes. This is accomplished by means 46 A MA A' UAL OF OBSTETRICS. of the vibrations of the tail-Hke appendage. There is still considerable uncertainty as to just where impregnation takes place. The consensus of opinion, however, favors the tubes, or even the ovarian surface, as the meeting-place, and this view is substantiated by the fact that unless impregnated very shortly after its discharge from the Graafian follicle the ovum becomes incapable of fertilization. The time when impregnation is most prone to follow intercourse has been generally stated as being from the first to the tenth day after menstruation, the ovum being discharged immedi- ately upon full establishment of the menstrual flow, and the vital elements, male and female, being brought into immediate proximity. The periods of comparative (but not absolute) immunity are the second week before the expected appearance of the flow, and the first four months of lacta- tion ; statistics show that insemination occurring during these periods is likely to be fruitless. Method of Impregnation. — This question is now posi- tively determined. There is beyond doubt an actual pene- tration by the spermatozoids of the vitelline membrane of the ovum (Fig. 2i), and this penetration probably takes place through a minute open- ing, the micropyle. At least this is true of invertebrates, and probably of the rabbit, and, inferentially, the exist- ence of such an entrance in all ova may be assumed. As to the cause of the mutual attraction of ovum and sper- matozoid little is known. It is probable that but one spermatozoid finds entrance into the ovum, and that this accomplishes the work of fertiliza- tion. The ovum, being thus fecundated, proceeds on its Fig. 21. — Ovum of the Nephelis vulgaris, showing retraction of vitcllus and the pene- tration of the spermatozoa through the vitel- line membrane ; X 300. PREGNANCY OR GESTATION. 47 way to the uterus, where it finds permanent lodgement at about the tenth to the twelfth day after impregnation. Its point of attachment is generally high up on the posterior uterine wall near the orifice of one of the Fallopian tubes. F.V^~, ,.\-M.PN. F.I'N.- FiG. 22. — Fertilizalion of the ovum of a moUusk (Elysia viridis) : A, ovum sending up a protuberance to meet the spermatozoon (5) ; £, approach of male pronucleus {M. PN.) to meet the female pronucleus [F. PN.). Chang-es in the Ovum Prior to its Lodg-ement in the Uterus. — An interesting series of phenomena occur within the ovum immediately subsequent to impregnation. Shortly after penetration of the ovum the vibratile extremity of the spermatozoid is absorbed, leaving the head only,/ which is known as the male promiclais (Fig. 22). This unites with the female pronu cleus to form the •~ &&spCT^n -t fi' "MrrsWSpiiTT. THe female pro- nucleus is formed in the fol- lowing manner: Within a few hours after impregnation the protoplasmic yelk undergoes a process of shrinkage, so that a transparent space is seen to exist between it and the vitel- line membrane. Simultaneously with this process there occurs a disappearance of the germ- inal vesicle and spot, and two protrusions of granular material, -Jr-^^Sigft, -i Fig 23 — formation of the "polar globule ' I, zona pellucida, containing spermatozoa; 2, yelk; 3, 4, germinal ves- icle ; 5, the polar globulci 48 A MANUAL OF OBSTETRICS. the polar globules (Fig. 23), take place from the contracted yelk into the clear space beneath the vitelline membrane. A new nucleus now appears from the debris of the faded germinal vesicle, and to it has been given the name of the female pronucleus. In the center of the contracted yelk a clear vesicle appears, known as the vitelline nucleus, and this is regarded as the first sign of impregnation. The changes in the oosperm or blastosphere consist pri- marily in a division of the vitelline nucleus, followed by Fig. 24. — Formation of the blastodermic membrane from the cells of the muriform body : i, layer of albuminous material sunounding 2, the zom pellucida (after Joulin). segmentation of the vitellus. This process of division and subdivision proceeds rapidly until the morula, muriform body, or mulberry mass, as it is variously termed, is formed. Within the center of this morula there appears an accumu- lation of a transparent fluid, which by its pressure crowds the morula, in the form of a thin layer of cell-like struc- tures, against the vitelline membrane. To this cellular layer has been assigned the name of the blastoderm or blastodermic membrane (Fig. 24), and from it arc developed [J(jlyU*y\^ PREGNAV OR GESTATION. 49 the various fetal portioiW \ The entire ovum at this stage is termed the blastodcruitK vesicle The blastoderm undergoes a rapid series of changes. Three layer^ may be disfting^ished, the outer of which is the ^iikktSL, the middle tl li ypobhift ^ Each of these lay^ the development of the fetus. iei,ottasr, and the inner the Jias its special function in Thus Ifam-tfee 3piMi i j^ are derived the dermis and its appendages, the organs of special sense, the central nervous system, and the amniotic mem- brane ; from the incso'mvm^^xsQ the osseous, muscular, vas- cular, and genito-urinary systen^ajid the connective tissue of the body ; and from the igj^^fflSSrtre^erived the epithe- lial lining of the alimentary and respiratory tracts, the um- bilical vesicle, and a portion of the allantois. An aggregation of the hypoblastic cells now occurs, resulting in the production of a small elevated spot known as the germinal or embryonic area. In the center of this area appears a dark line, which is the first indication of the coming fetus, and is termed the primitive trace or groove or the embryonic line. It is sur- rounded by a translucent space, the area pelhicida (Fig. 25). About this time the fetal ellipse begins to make its appearance. It is formed by a rolling in of the two extremities of the primitive trace, resulting in the forma- tion of two folds known as the anterior, cephalic, or head fold and the posterior, cau- dal, or tail fold. At the same time lateral folds develop on either side and in front of the primitive groove ; these are termed the medullary folds, and they include between them a furrow known as the medtdlary groove. The caudal portion of the lateral 4 Fig. 25. — Lliagram of the area germina- tiva, showing the primitive trace and the area pellucida. 50 .4 MANUAL OF OBSTETRICS. folds springing from the sides of the primitive trace are named the dorsal plates, ^nd they ultimately form the spinal canal ; they include the chorda dorsalis or notocliord, the primitive vertebral column. From their bases spring two other folds, the lateral ox abdominal plates, which enclose the future abdominal cavity. The Fetal Appendages and Membranes. — While these processes of development have been going on in the fecun- dated ovum corresponding changes have been in progress for the reception, nourishment, and development of the little embryo. The uterus has assumed an unwonted growth, and a receptacle has been provided to accommo- date the fetus up to the full term of normal gestation, together with the proper means of best furnishing it nutri- ment during the different periods of its growth ; thus the various membranes, fetal and maternal, and the organs of nutrition and respiration — the umbilical vesicle, the allan- tois, the umbilical cord, and the placenta — have been called into existence to meet the various indications. The Membranes. — The membranes are three in number, the amnion, the chorion, and the decidua, the latter only being maternal in origin. As the decidua claims priority in formation, it will be considered first. TJie Decidua;. — The hypertrophied uterine mucosa form- ing the outermost or containing membrane of the product of conception is known as the decidua or cadiica. Origin. — Immediately after conception there ensues an extreme vascularity of the lining membrane of the uterus, and this results in a very short space of time in an immense hyper- trophy and proliferation of the connective-tissue cells lying between the utricular glands. In consequence of this exag- gerated growth of embryonic cells — the so-called "decidual cells " — the uterine mucosa is thrown into very decided con- volutions, that fill the entire uterine cavity and form a soft, pulpy investment for the impregnated ovum, which is com- pletely buried in the meshes so produced (Fig. 26). The PREGNANCY OR GESTATION. 51 deepest layer of this decidua is composed of interlacing fibers with blood-vessels and the blind extremities of the utricular glands. It is termed the spongy layer of the decidua, or the postage- stamp layer (Berry Hart). For convenience the de- cidua has been divided into three portions — the decidua vera, or that lining the entire uterine cavity ; the decidua reflexa, or the portion that is reflected or thrown over the ovum ; it eventually — during the fourth month — comes in contact with the decidua vera, with which it forms an intimate union, the two eventually becoming one membrane ; until this union takes place the space be- tween the two is filled with Jiydroperione, a mucous fluid somewhat resembling the liquor amnii. The de- cidua serotina is the area of the decidua vera occupied by the ovum, and which ultimately becomes the placental site. Ultimate Disposition. — During the latter months of preg- nancy the decidua undergoes a fatty degeneration that tends to loosen its attachment to the uterus. The bulk of this degenerated membrane is thrown off at parturition; the bal- ance is discharged in the lochia, with the exception of a small portion that assists in the formation of a new uterine mucosa. The Amiuon. — The amnion (Fig. 27) is a smooth, very tough, fibrous structure, the innermost of the fetal mem- 4 5 Fig. 26. — Diagrams representing the rela- tionship of the decidua to the ovum at dif- ferent periods. The deciduae are colored black, and the ovum is shaded transversely. In 4 and 5 the vascular processes of the chorion are figured, i, ovum entering the congested mucous membrane of the fundus — decidua sero- tina ; 2, decidua reflexa growing around the ovum ; 3, completion of the decidua around the ovum ; 4, general growth of villi of the chorion ; 5, special growth of villi at placental attach- ment, and atrophy of the rest (Dalton). 52 A MANUAL OF OBSTETRICS. Fig. 27. — Diagram showing completion of the amnion and formation of the chorion : A, am- nion ; I, zona pellucida ; 2, outer lamina of the epiblast after closure of the amniotic folds ; P, allantois ; U, umbilical vesicle. branes, surrounding the fetus and continuous with it at the umbihcus ; it secretes and encloses the Hquor amnii. It also contributes the sheath or outer covering of the umbil- ical cord. Origin. — This structure is a double mem- brane derived from the epiblast and mesoblast at an early period in fetal de- velopment. The enclosed space is the true anmiotic sac or cavity, and in this is contained the liquor amnii. The space between the folds of the outer layer of the amnion — which is me- soblastic in origin, the inner being epiblastic — and the chorion is termed the false amniotic cavity. It contains the allantois, the umbilical vesicle, and, at times, a mucous fluid closely resembling the liquor amnii, the hydroperione, previously mentioned. At birth the amnion in conjunction with a portion of the chorion forms the so-called " bag of waters." The Liquor Amnii or " Waters^ — Within the cavity of the amnion is an alkaline fluid amounting at term to about a quart, and containing albumin, urea, creatin, epithelial cells, the chlorids, phosphates, and other salts, sebaceous material, and various other constituents, and having a light specific gravity — about 1005. ^^s color is usually an opaque white, although it may be variously colored by accidental ingre- dients, and its odor is heav}' and characteristic. Its origin is a matter of dispute. It is probable that at first it is derived mainly from the amniotic cells, but that during the latter half of pregnancy this fluid is increased in amount by the accumulation in it of the fetal urine, which is voided at PREGNANCY OR GESTATION. 53 irregular intervals. Thcfunctioji of the liquor amnii during pregnancy is mainly protective to both mother and child. By distending the uterus it prevents undue pressure of the uterine walls upon the fetus, thus admitting of unrestricted growth and free fetal movements, and thereby preventing the development of monstrosities ; it also saves the uterus from injury due to the fetal movements; it maintains around the fetus an equable temperature, receives and dilutes its excre- tions, and, since it is a well-recognized fact that the fetus will at times swallow the amniotic fluid, by some it is sup- posed, probably without foundation, to afford a certain amount of nourishment to the child. During labor a very valuable function is its hydraulic action. Driven downward by the uterine contractions, it dilates as a wedge the circu- lar fibers of the os uteri, and also lubricates the tissues to a limited extent. The Umbilical Vesicle and the Allaiitois.-^'SN \i\\m the false amniotic cavity are found two important nutritive structures of the fetus — namely, the umbilical vesicle and the allan- tois — which must now be described. The Jiinbilical vesicle is a temporary spheroid structure formed from the hypoblast by the union of a caudal and a cephalic projection from the embryo. As these two pro- jections approach one another on the anterior surface of the embryo they divide the protoplasmic yelk into a larger and a smaller portion ; the latter becomes eventually the intestinal canal of the fetus, while the larger is termed the umbilical vesicle, vitelline sac, or navel sac. The constricted portion joining the intestine and the umbilical vesicle is termed the vitelline, vitellointestinal, or omphalic dnct, and it is through this duct that nutriment is carried from the umbilical vesicle to the intestinal tract of the embryo prior to the formation of the placenta. After the fourth week of gestation the umbilical vesicle undergoes an atrophic process, and by the eighth week it has disappeared, its function then being assumed by the placenta. 54 ^ MANUAL OF OBSTETRICS. The allantois is a small, pear-shaped vesicular structure developing from the lower portion of the embryonic aliment- ary canal at an early period of intrauterine life — about the twentieth day. It is composed of two layers, derived re- spectively from the mesoblast and the hypoblast. The meso- blastic layer is the vascular element of the allantois, and in it are soon formed four vessels — two arteries and two veins. A smaller portion of the intestinal diverticulum from which the allantois is developed enters into the construction of the urinary bladder. Owing to its rapid growth, the allan- tois in the third week is brought into contact with the inner surface of the chorion, with which it forms intimate connec- tions. From its pedicle are developed ultimately the um- bilical cord and the iiraclms, or allantoic stalk, the latter in the adult being a remnant of fetal life acting as one of the ligaments of the bladder. The point of entrance of the allantoic vessels into the chorion becomes eventually the placental site. "Wi^ function of the allantois is, primarily, to remove the excrementitious matter of the fetus, and second- arily and more important, to carry the nutritive vessels, the umbilical arteries and veins, from the fetal intestine to the chorion. Tlie Chorion. — The chorion is the external fetal mem- brane lying between the amnion and the decidua. It is the vascular organ of the embryo, and is epiblastic in origin. Its characteristic anatomic feature is the development over its outer surface of a great number of minute and branching projections known as the chorionic villi, which give a peculiar shaggy appearance to this side of the mem- brane ; these villi in the second or third month are received into corresponding depressions in the decidua, and serve in the early weeks of pregnancy as a means of attachment for the ovum, retaining it in position in the upper portion of the uterus. Each villus is hollow and contains, within a short time after its development, an arterial and a venous loop ; it is lined within by a delicate epithelium called the PREGNANCY OR GESTATION. 55 endochorion, and without by another, the cxocliorion (Fig. 28). The inner surface of the chorion is smooth and glossy. The primitive chorion is reinforced in the third week by the union with the allantois, and the resulting structure is designated as the true or complete chorioji. During the sec- ond month of ges- tation a curious change takes place in the outer surface of the chorion. The villi covering that portion attached to the decidua reflexa lose their vascular- ity and undergo an atrophic process, while those covering the portion of the chorion over the decidua serotina assume a corre- spondingly rapid in- crease in size and vascularity. As a ^ „ r>i . 1 -n .1 -a a 1 -' Fig. 28. — Placental villus, greatly magnified: i, 2, pla- COnSeOUence the cental vessels, forming terminal loops ; 3, chorion tissue, 1 • , ,11 formins; external walls of villus ; 4, tissue surrounding chorion by the be- vessels (after Joulm). ginning of the ninth week becomes divided into two portions — namely, a larger smooth portion, the chorion Icbvc, comprising about two- thirds of its surface, the function of which is to surround and protect the embryo, and a smaller, shaggy or villous portion, the cJiorion frondosiiin^vA\\z\\ develops into the fetal portion of that important nutritive organ, the placenta. The Placenta, or After-birth. — The placenta (Figs. 29, 30) is the essential nutritive and respiratory organ of 56 A MANUAL OF OBSTETRICS. the fetus. Formation. — During the rapid development of the chorion frondosum a corresponding change takes place in the decidua serotina ; its tissues hypertrophy and become thick, spongy, and very vascular. The chorionic villi sink deeply into this pulpy mass and become intimately con- FiG. 29. — Human placenta, uterine surface (Tarnier). nected with it, so that separation can only be accomplished by actual tearing of the decidual substance. By the end of the third month the placenta is fully formed and is able to assume the functions for which it is destined. These fimctions diVC the supplying of nourishment from the mother to the fetus, the oxygenation of the impure fetal blood, and the excretion of the effete products from the fetus. It is probable that the placenta also possesses to a certain extent a glycogenic function. Any disturbance of these functions will result in disease or death of the fetus. The Placenta at Term. — When fully developed the placenta is a flat, circular, spongy structure from 15 to 23 cm. (5.9055 to 9.0551 in.) in diameter, \y^ to 2yi cm. (0.492125 to 0.98425 in.) thick at the central point, and weighing usually slightly over a PREGNANCY OR GESTATION. 57 pound. It presents two surfaces — a smooth internal or fetal surface, clothed with the fetal membranes, and to the center of which is generally attached the umbilical cord ; and a dark-red, granular, lobulated external or maternal surface, by which it is attached to the decidua. Its usual Fig. 30. — Human placenta, fetal surface. The amnion is dissected off one side to show the vessels (Tarnier). point of attachment is the upper posterior uterine wall near one or the other tubal orifice, and it generally faces the ventral surface of the fetus. It is possible, however, for it to be attached to any portion of the surface of the uterine cavity. In structure it is both fetal and maternal, though mainly the former ; it is composed of from fifteen to twenty tufts of chorionic villi, together with the immensely hj^per- trophied connective tissue of the uterine mucosa {clecidna scrotina). Ultimate Disposal. — Shortly before the termina- tion of pregnancy a partial fatty degeneration occurs in the maternal portion of the placenta; in this way the separation of the organ at parturition is facilitated. Should this process be carried too far, fetal death may result from asphyxiation, 58 A MANUAL OF OBSTETRICS. either from premature separation of the placenta or from interference with the placental respiratory function. The Umbilical Cord, or Funis. — This is a cord-like structure, also called the navel-string or funicle, extending from the umbilicus of the fetus to the placenta. The line of demarcation separating the cord from the skin is termed the navel ring. Origin. — The funis is developed from the pedicle of the allantois at about the fourth week of preg- nancy. When fully formed it is composed of two umbili- cal arteries, which are provided with circular valves having central perforations, one umbilical vein having semicircular valves, the vitelline duct, the pedicle of the allantois (at the fetal extremity of the cord), the remains of the umbilical vesicle (at the distal extremity), the whole being surrounded by a varying amount of transparent gelatinous substance known as Wharton's jelly or gelatin (which protects the important funic structures from injurious pressure), and an outer sheath or covering of amnion. In length the cord nor- mally measures about 50 cm. (19.6850 in.); it is from ^ to i^^ cm. (0.295275 to 0.492125 in.) in thickness. The vessels are coiled from right to left, the arteries being external and surrounding the veins ; hence their pulsation — the funic pulse — can readily be detected. There are generally about ten or twelve of such twists. Frequently dis- tinct knots are found in the cord, which, however, do not as a rule interfere with the vitality of the child. The placental implanta- tion of the cord, while most fre- quently median, maybe marginal, when the interesting condition known as battledore placenta (Fig. 31) results. Function of the Cord. — The funis is the medium of communication be- Fir,. 31. — Battledore placenta, oval (Auvard). THE PHYSIOLOGY OF PREGNANCY. 59 tvveen the mother and the fetus, conveying nourishment from the mother to the child and excrementitious matter from the fetus to the placenta. Its function is, therefore, duplex. IV. THE PHYSIOLOGY OF PREGNANCY. I. Fetal Physiology. During the rapid development of the embryo its vital functions have been assumed one by one, until it practically carries on an existence very similar to that of the individual ex 7itero, but with notable modifications dependent upon its peculiar environment. Fetal Nutrition. — Pre-eminent among these changes are to be noted the various methods by which the requisite nourishment is obtained during the successive stages of gestation. It is impossible in a manual of the present dimensions to dwell largely upon the interesting changes observed in fetal alimentation and assimilation. A mere outline must be sufficient to portray the successive stages in fetal nourishment from the ovum to the fully-developed product of conception. This subject may be studied at four different periods — namely, the tubal, the vitelline, the allantoic, and the placental. Tubal Nutrition. — The method by which the fecundated ovum obtains its nourishment during the short period of migration through the Fallopian tube into the uterine cavity is still a matter of conjecture. There can be no doubt that the nutritive material is introduced into the ovular substance by a process of endosmosis, but as to the source of this pabulum nothing positive is known. In the first few days of fecundation it is probable that the cells of the discus proligerus themselves nourish the ovum, and that the material thus furnished is supplemented by an absorption of the albuminous matter that coats the ovum 6o A MANUAL OF OBSTETRICS. while in the tube. Whether or not there is an actual secre- tion of a nutritive liquid by the mucosa of the Fallopian tube, as has been claimed by some, is not known. Vitelline Nutrition. — From the time of entrance into the uterine cavity until the formation of the allantois the grow- ing embryo absorbs its nutrition from the umbilical vesicle through the agency of the omphalo-mesenteric vessels. The omphalo-mesenteric artery is a direct branch of the primitive aorta, and as such carries to the developing ovum the richest of pabulum. This vessel subsequently becomes the umbilical artery. The vitelline stage of nutrition covers the period up to the beginning of the fourth week of gesta- tion, by which time the allantois is formed and has assumed the nutritive function. Allantoic Nutrition. — The period of allantoic nutrition covers the space of two months, or until the formation of the placenta at the end of the third month. The allan- tois, being intimately connected with the chorion, receives the nutritious substance absorbed by the chorionic villi from the maternal tissues and transmits this through its vessels to the fetal intestine. This is the beginning of nourishment through the agency of a vascular system. As the placenta is formed the allantois relinquishes to this organ its function, loses one of its veins, and gradually assumes the secondary role of the means of communication between the active absorbing agent and the fetus ; in other words, it develops into the umbilical cord. Placental Nutrition. — Contrary to that which might be expected, the closing stage in fetal nutrition is not well understood. The most generally accepted hypothesis is that which assumes the existence of a system of sinuses in the maternal placenta, accommodating corresponding cho- rionic digitations. The terminal capillaries of the umbilical vessels form loop-like projections which are continued in the chorionic villi, one in each ramification of a villus. The maternal portion of the placenta is composed of a mesh- THE PHYSIOLOGY OF PREGNANCY. 6 1 work of decidual tissue enclosing a vast number of spaces or lacunae that communicate directly with the terminal branches of the uterine arteries, and are therefore, in reality, immensely dilated capillaries. Into each lacuna one of the chorionic villi dips and is continually bathed in the slowly- flowing maternal fluid. There is thus no direct communica- tion between the fetal and maternal circulations, the inter- change of nutritious and excrementitious matter being accomplished altogether by an osmotic process. According to some authorities (Ercolani, Haller), each villus is lined by a peculiar glandular structure of maternal origin whose function it is to elaborate from the maternal blood a highly nutritious, albuminous, saline, and fatty sub- stance called uterine milk; this, these writers claim, is absorbed by the capillaries of the villi and enters the fetal circulation. This view has not been substantiated by more recent investigators, notably Werth. It is probable, there- fore, that the preceding view of direct osmotic interchange is the correct one. Fetal Respiration. — The respiratory function of the fetus is established when the fully-formed placenta assumes the work previously carried on by the allantois. The method by which the oxygenation of the blood is accomplished prior to this time remains undetermined. Respiration in the fetus after the formation of the placenta is piscine in nature, the gaseous interchange being accomplished through the medium of a fluid, the maternal blood. The fetal blood, contaminated by an absorption of carbonic-acid gas during its passage through the fetal structures, finally reaches the chorion, where it is exposed, over the widely-extended sur- face afforded by the chorionic villi, to the revivifying action of the maternal blood. The carbonic dioxid is abstracted, its place is supplied by fresh oxygen from the maternal blood, and the bright-red blood thus produced, enriched by the further absorption of the nutritious pabulum, re-enters the fetal circulation. 62 A MANUAL OF OBSTETRICS. Fetal Circulation (Fig. 32). — In order that the pabu- lum and oxygen supplied at the placental site shall gain R.Ccm.CmeUol ' L Com CuYOUcL R Suhtlo' SuJiei-ioT Vena Cavot - -J- '~ -r UmbiUcu Placenta, KiG. 32.— Diagrammatic view of the fetal circulation. access to the various fetal tissues, it becomes necessary that they be distributed throughout the body through the agency of the vascular system. Owing to the non-activity of the THE PHYSIOLOGY OF PREGNANCY. 63 respiratory and digestive systems there is evolved a com- plex method of circulation, varying very radically from that which takes place in the individual ex utcro. The center from which the blood is derived, and to which it is impelled by the action of the fetal heart, is the placenta ; here it is that the impure venous blood is depleted and the rich red arterial blood is elaborated, and hence it is here that a sys- tematic study of the fetal circulation should begin. Surcharged with its vital constituents, the blood collects from the venous radicles in the chorionic villi and finds its way into the large umbilical vein. This passes down the umbilical cord to the navel, and thence is carried to the under surface of the liver. Here it divides into ,a large and a small branch, the latter of which, the ductus venostis or dtict of Arantius, situated posteriorly, passes directly across to the ascending vena cava. The greater portion of the blood, however, empties into the portal vein and is carried into the right hepatic lobe. Passing through the liver, in the substance of which it probably undergoes some metabolic changes, the blood re-collects in the hepatic vein, through which it passes to the ascending vena cava. Here it joins the blood that pours in from the ductus venosus, together with the vitiated blood coming up in the ascending cava from the inferior extremities, and the mixed current thus formed ascends to the right auricle of the heart. The fetal heart differs very materially from that of the adult individual. In the first place, there is a free com- munication between the right and left hearts by means of the foramen ovale. This is a small oval aperture in the interauricular septum, provided with a valve or dupli- cature of the endocardium that opens into the left auricle and permits a flow of blood only from the right side to the left. The opening of the inferior vena cava into the right auricle is guarded by a duplicature of the lining membrane of that sac, known as the EustacJdan valve, a semilunar structure situated in the lower and posterior portion of the 64 A MANUAL OF OBSTETRICS. auricle, between the anterior margin of the inferior vena cava and the auriculo-ventricular orifice. It directs the current from the ascending cava across the right auricle and through the foramen ovale into the left auricle. To prevent an undue congestion of the lungs, which are functionally in abeyance, a large communicating vessel is provided, running from the point of bifurcation of the pul- monary artery to the descending portion of the arch of the aorta. This vessel is known as the ductus arteriosus or diict of Botal (or Botallo) ; its function is to convey a large por- tion of the blood, which otherwise would dangerously engorge the pulmonary tissues, directly into the aorta. With this knowledge of the peculiarities of the anatomy of the fetal heart a clear understanding of the course of the fetal circulation may be obtained. Having found its way through the hepatic tissue into the ascending cava, the blood is carried upward to the floor of the right auricle, where it is directed by the Eustachian valve across the cavity of the auricle through the foramen ovale into the left auricle. It then passes through the left auriculo-ventricular orifice into the left ventricle, which, by its contraction, drives it out into the aorta. The large ves- sels to the head and upper extremities being given off by the aorta shortly after its emergence from the heart, most of the blood-current is carried upward through these large branches, only a small portion passing on to enter the descending aorta. The blood supplied to the upper portion of the fetal body finds its way eventually through the venous radicles into the descending vena cava. Originally this vessel is known as the right duct of Cuvicr, formed by the union of a supe- rior vein (the primitive jugular) and an inferior vein. The left duct disappears during the process of development. This cava communicates with the upper portion of the right auricle, and its current, passing down in front of the current of the ascending cava, enters the right ventricle through the THE PHYSIOLOGY OF PREGNANCY. 65 right auriculoventricular orifice. Here it is driven out into the puhnonary artery, and the greater volume of it passes directly into the descending aorta through the ductus arte- riosus; enough enters the pulmonary tissue to supply thereto the necessary nutriment. The vitiated blood in the aorta is now carried down to the division of that large trunk into the two iliac arteries, and thence through the hypogastric arteries (branches of the internal iliac artery), which ultimately become the umbilical arteries ; the latter continue up the cord to the placenta, thus completing the cycle of the fetal circulation. The fetal circulation, as depicted in the foregoing para- graphs, is modified somewhat toward the close of the period of gestation by the partial atrophy of the Eustachian valve which occurs at that time. By its loss of substance a par- tial mingling of placental and vitiated blood is permitted in the right auricle of the heart, and this mixed blood is car- ried down into the right ventricle, and thence through the ductus arteriosus and aorta to the lower portions of the body, which thus receive a higher grade of nutrition than in the earlier months. This accounts for the more rapid development of the lower extremities immediately prior to the onset of labor. Petal Secretions and Excretions. — As pregnancy ad- vances and the metabolic changes in its organism become more marked the emunctory organs of the fetus begin to manifest their activity. The following changes may be noted : (i) The Kidneys. — These organs begin to form at about the seventh week, and communicate at first by means of their ducts with the cavity of the allantois, but as the bladder is developed from this structure the ureters make their exit eventually into the latter viscus. Sooner or later urine is excreted to a limited extent, and is voided in small quantities at irregular intervals into the amniotic sac, as is demonstrated by the presence of traces of urea in the liquor amnii. There is also an escape of urine from the 66 A MANUAL OF OBSTETRICS. bladder immediately after birth, thus proving the activity of the fetal kidneys. Fetal urine always contains more or less albumin. An interesting point of medico-legal value is the formation of dark-yellow infarcts of urates within the kidneys of infants that have breathed, even though it be but slightly, before death. The cause of these infarcts is not known. (2) The Skin. — It is not until the latter part of the fifth month that the skin commences to show glandular activity. At that time the sebaceous glands throw out a greasy, unctuous substance, which when mixed with desquamated epithelial cells constitutes the so-called vciiiix cascosa or " cliccsy varnisliy This is more abundant upon some fetuses than upon others, and is most marked upon the back and in the axillae, groins, and other cutaneous folds. Its function is to prevent maceration of the fetus by the action of the liquor amnii, and probably also it acts, to a certain extent, as a lubricant during parturition. (3) The Bozvcls. — These are inactive throughout intra- uterine life ; during the latter half of pregnancy they contain the meconium, which, however, is not discharged except in pathologic conditions. The nicconiinn is a dark-green, viscid liquid composed of intestinal mucus, bile, lanugo, and exfo- liated epithelium from the mucosa of the bowel. (4) The Liver. — This organ does not functionate until about the fifth month of gestation. From that time on it secretes the bile which is stored up in the intestines and gall-bladder. As to its other functions there is nothing positively known. Bernard has attributed to it the produc- tion of the glycogen that is present in large quantities in the fetal tissues, but this has not been absolutely demon- strated. It is probable from the disproportionate size of the fetal liver that it has assigned to it some important action or function that is as yet unrecognized. Fetal Innervation. — The question as to whether or not the fetus is capable of intelligent or voluntary nervous action THE PHYSIOLOGY OF PREGNANCY. 67 68 A MANUAL OF OBSTETRICS. is Still sub jiidicc ; it is probable, however, that such volition does not exist, but that the fetus can respond only to reflex impulses originating in some form of irritation, such as the action of cold or of an external force. Fetal Development at the Successive Months of Ges- tation, with Correlated Clinical Manifestations and Path- ologic Conditions (Fig. 33). — From the Tcntli to the Twelfth Day (the time of entrance into the uterine cavity). In this period the embryo exists merely as the disk-like embryonic spot. The dorsal or abdominal plates may be seen. Size of the ovum, 7^ cm. (0.26246 in.); of the embryo, % cm. (0.098425 in.). First MoiitJi. — The amnion and umbilical vesicle are fully formed ; the allantois is present, but is not united with the chorion ; the visceral arches are distinct ; the spinal canal is closed. The fetal organs that may be distinguished are the heart, primitive traces of the liver and kidneys, the eyes, and the intestine with anal and oral orifices ; the ex- tremities are rudimentary. The length of the fetus is i cm. (•3937 '"•)• Clinical Manifestations. — Suppression of men- struation ; enlargement and bogginess of the uterus ; soft- ness of the cervix ; enlargement and tingling of the breasts ; frequent micturition. Malformations and Diseases. — Spina bifida (from failure of the spinal canal to close) ; abortion. Second Month. — The embryo is the size of a pigeon's egg. The amnion is distended with fluid and is in contact with the chorion. The umbilical vesicle is small ; the um- bilical cord is distinct. The visceral clefts, with the excep- tion of the first, are closed ; the eyes, nose, and ears are distinguishable ; there are primitive traces of the hands and feet, which are webbed; the vertebrae are present; there is beginning formation of the external genitals, although sex is not to be differentiated ; there is a beginning of the ossi- fication of the lower jaw and clavicle ; the circulatory system is forming; the Wolffian bodies are present; the kidneys and suprarenal capsules are forming. The length of the THE PHYSIOLOGY OF PREGNANCY. 69 fetus is 4 cm. (1.5748 in.); its weight is 4 grams (61.729 grains). Cli)iical Ahmifcstatioiis. — The same as the pre- ceding ; in addition, there are nausea and vomiting (from the sixth or seventh week) and Rasch's sign. Malfor- mations and Diseases. — Arrest of development results in hare-lip, umbilical hernia, exomphalos. The maternal path- ology includes abortion, apoplexy of the decidua, uterine prolapse, herpes gestationis, rupture of an extrauterine preg- nancy, hemorrhage from placenta przevia (central variety). Third Month. — The embryo has attained the size of a goose-egg; there is now nourishment by means of maternal blood; the chorionic villi are lost; the placenta is formed, but is small ; the decidua reflexa and decidua vera come in contact; the digits become distinct (they are not webbed and show membranous nails) ; the neck is distinguishable ; the ribs are formed ; the uterus appears, thus distinguishing the sex; the integument is forming; points of ossification are present in most of the bones. The length of the fetus is 9 cm. (3.5433 in.) ; its weight is 30 grams (463 grains). Clinical Manifestations. — The same as the preceding ; in addition, Hegar's sign is present ; the fundus of the uterus is just above the pubes. Diseases. — Rupture of an extra- uterine pregnancy may occur; apoplexy of the decidua; hydramnios ; cystic degeneration of the chorionic villi ; odontalgia (which may occur at any time during the first half of pregnancy). Fourth Month. — There is a formation of Wharton's jelly in the cord ; the latter is two or three times the length of the fetal body ; there is the formation of hair upon the scalp, and of lanugo upon the body ; there is a develop- ment of the convolutions of the brain and a formation of the muscles; the intestines contain meconium ; the sex is well defined ; ossification begins in the frontal and occipital bones. The length of the fetus is 16 cm. (6.2992 in.) ; its weight is 55 grams (848.76 grain.s). Clinical JSTanifesta- tions. — The same as the preceding. In addition may be yo A MANUAL OF OBSTETRICS. noted Braxton Hicks' sign; quickening (four and one-half months) ; ballottement ; Jacquemin's sign ; uterine souffle ; beginning abdominal enlargement ; the fundus of the uterus is midway between the umbilicus and the symphysis. Dis- eases. — Miscarriage ; hydramnios ; cystic degeneration of the chorionic villi ; incarceration of a retroflexed uterus ; true nephritis is apt to manifest itself. Fifth Mouth. — -The hair and nails are fully formed ; the vernix caseosa appears ; the face is wrinkled and senile ; the eyelids begin to open ; ossification commences in the ischium. The length of the fetus is 25 cm. (9.8425 in.); its weight is 273 grams (10. 8 ounces). Clinical Manifesta- tions. — The same as the preceding. In addition, the fetal heart-sounds may be heard. Diseases. — Miscarriage; ne- phritic. Sixth Montli. — There is a beginning deposition of fat in the subcutaneous cellular tissue; there is increased growth of hair, and the appearance of eyebrows and eyelashes ; the membrana pupillaris is present ; the testicles commence to descend toward the inguinal rings ; there is beginning ossi- fication of the pubic bones. The length of the fetus is 30 cm. (11. 8 1 10 in.); its weight is 715 grams (23 ounces). Clinical Manifestations. — The same as the preceding. In addition, the umbilicus is on a level with the abdominal wall ; the fundus of the uterus is on a level with the umbil- icus. Diseases. — Kidney of pregnancy (albuminuria) ; hy- drorrhoea gravidarum; impetigo herpetiformis, occurring at any time during the second half of pregnancy. Seventh Month. — The skin is still wrinkled and reddish, and is covered with vernix caseosa ; the eyelids are open ; the membrana pupillaris disappears ; the testicles are at or in the inguinal canal. The dccidua reflexa and decidua vera have now thoroughly merged into one. The length of the fetus is 35 cm. (13.7795 '"•) ; ^^^ weight is 1213 grams (39 ounces). Clinical Manifestatio)is. — The same as the pre- ceding. In addition, the outlines of the fetal body may be THE PHYSIOLOGY OF PREGNANCY. 7 1 felt on abdominal palpation, and the presenting part may be distinguished on vaginal examination ; the fundus of the uterus is midway between the umbilicus and the ensiform cartilage. Diseases. — Hydrorrhoea gravidarum; recurrent vomiting of pregnancy from renal insufficiency. Eighth MojitJi. — The lanugo begins to disappear from the face ; the nails are harder, but do not project beyond the finger-tips ; the left testicle is in the scrotum ; ossifi- cation begins in the lower epiphysis of the femur. The length of the fetus is 40 cm. (15.7480 in.); its weight is 161 7 grams (4^ pounds). Clinical Manifestations. — The same as the preceding ; the fundus of the uterus is now at the ensiform cartilage. Diseases. — The same as the preceding. Ninth Month. — There is a great increase in the amount of subcutaneous fat ; the face loses its wrinkled and senile appearance; the lanugo begins to disappear from the body; both testicles are in the scrotum ; all the diameters of the fetal head are about i cm. (0.3937 in.) smaller than at term. The length of the fetus is 45 cm. (17.7165 in.) ; its weight is 1990 grams (5}^ pounds). Clinical Manifesta- tions. — The same as the preceding ; the fundus of the uterus has fallen to about the same point that it occupied at the seventh month. Diseases. — Hydrorrhoea gravidarum and any of the diseases of the preceding months. The Fetus at Term. — The body of the fetus at full ma- turity is well rounded; the lanugo has disappeared ; the skin is rosy ; the nails project beyond the finger-tips ; the eyes are open ; the cuboid bone is beginning to ossify. The length of the foot is 8 cm. (3.1496 in.) ; this is regarded by many as an important proof of fetal maturity. The length of the fetus is 50 cm. (19.6850 in.) ; its weight is 2737 grams (7^ pounds). Delaboiifs Ride. — Delabout has formulated a rule for ascertaining approximately the age of a fetus by its length. It is worded as follows : " For the first six months of intra- 72 A MANUAL OF OBSTETRICS. Uterine life the length, at different ages, is indicated in centimeters by the square of the numerical figure of the corresponding month." II. Maternal Physiology. As a result of the foregoing remarkable and rapid changes occurring within the woman's uterine cavity corresponding alterations are taking place in the maternal organs and tissues. These changes, as might be expected, are most pronounced in the generative organs, and especially in the uterus. Alterations in the Genitalia. — The Uterus (Figs. 34, 35). — Following the increased vascularity of the uterus there is a general hypertrophy of all the uterine tissues. Fir.. 34. — Longitudin.il section uf a niilliparoiis (a) .Tnd of a multiparoiis (li) uterus : A, cavity of tlic cervix anil arbor vit;c; T, cavity of the body; O, constriction between body an-< « 4^ HH HH^^ -1^ "-f^ od^ NO 4^ NO 4>> HH HI 4- " -f>- i-i ta to '-n. to <-n to Cn to en HH HH en to en vo en HH en en to ea to en M ON U> On M U> ON H-l U) ON 00 ON to On OJ ON ON HH On HH M ON OJ ON OJ On U) •-* l-H t-l -^^ -^•^ HH VO en en to HH en to HH tj en to HH to en to ON Oj On to 11 OJ ON to HH U) On OJ On to HH to ON to HH Oj On to HH ON M HH HH ON to HH HH 0^ to HH OJ ON to HH Oj On to i-i to M to HH to HH 4^ ^ to 1 0- ^ to ** to HH HH ^J K> HH to ^ to HH to *-4 to HH 4^ ^ to HH 4^>vi +» 00 to w ^J\ 00 to "H tyi 00 to HI tn 00 en 00 to HH -t^ 00 to HH en 00 to HI to 00 to H. OJ CO to HH Oj 00 to HH en 00 Ivl HH en 00 to l-l ON NO to 11 On NO to HH ON NO M HH ON NO to HH en NO to HH On NO to HH OJ NO to HH 4^ vo to HH 4^ NO to HH ON NO to HH On NO N (0 OnO to to ^ to to ^ to to ^ to to ^ to to On to to •V] to to 4^ to to en to to en to to -J to to ^ to to to to 00 l-l to to 00 11 to to 00 HH to to 00 1 to to •' 00 to ^ 00 to -f>- 00 to N 00 to 00 tJ en CO to 4^ CO to to tn NO to to On NO to en NO to en NO to en vo to en \o to 00 NO to OJ NO to en vo OnO 00 OnO OnO ^ OJ ON OJ OnO ON OJ ONO OJ -^ OJ 4^ OJ c^ Co ^4 >^ OJ ^J HH eo ^J HH OJ ^1 HH eo (_n HH OJ ^1 HH 03 > C <-1 1— 1 c a 2 > H1_ fD (— 1 3 n :3 < 114 A MANUAL OF OBSTETRICS. Nine Calendar Months. January i . February i March i . . April I . . May I . . . June I . . July I . . . August I September i October i . November i December i To September 30 October 31 . November 30 December 31 January 31 . February 28 March 31 April 30 May 31 . June 30 . July 31 . August 31 Days. 273 =73 275 275 276 273 274 273 273 273 273 274 Ten Lunar Months. To October 7 . . November 7 December 5 . January 5 . . February 4 . March 7 . . April 6 . . . May 7 ■ ■ - June 7 . . . July 7 . . . August 7 . . September 6 Days. 280 280 280 280 280 280 280 280 280 280 280 280 In order to estimate the duration of a pregnancy be- ginning on any given day between the first and last of any given month, all that is necessary is to add to the date corresponding to the termination of a pregnancy beginning on the first of the month in which menstruation ceased a number of days corresponding to the date of cessation of Fig. 50. — Schultze's circle. menstruation. Thus, a woman ceased to menstruate on April 17 ; she will be confined at some time between Janu- ary 17 and 22, which dates are obtained by adding seven- EUTOCIA, OR NORMAL LABOR. II5 teen days to the dates of termination of pregnancy as given in the table — namely, December 31 and January 5. ScJmlt.'^cs Circle (Fig. 50). — In order to estimate the date of confinement, count back according to Naegele's method, and add to the date thus obtained the number of days indi- cated within the section under the month designated, thus making 280 days. In leap-years the figure within the brackets is to be added. Labor. Labor is that natural process by which a pregnant woman expels the product of conception at the full expiration of the period of pregnancy, 280 days after conception. Causes of Normal Labor. — Although it is not exactly known why normal labor should occur when it does, there are certain predisposing factors that may have a bearing upon it. None of them are entirely satisfactory in their explanation of the phenomenon, and it may be that there is no one absolute determining cause, but that the combined action of all of these factors exerted at the proper time is necessary, in conjunction with some slight exciting cause, to precipitate the onset of the labor- pains. Some of the views that have been advanced are incapable of substantiation, although eminently rational in their suggestion. The determining or predisposing causes of labor may be grouped as follows: (i) Hcj'edity. — It is probable that the habit of womankind, contracted through numberless gen- erations, of falling into labor at the expiration of ten lunar months is a very powerful determining factor in the produc- tion of labor. With this strong tendency existing any trivial exciting cause will suffice to initiate the process. {2) Period- icity. — Sinitlis {Tyler) Theory. — This view of the causation of labor claims that at the regular monthly periods an ova- rian congestion is present, and that this becomes extremely pronounced at the tenth menstrual epoch following concep- Il6 A MANUAL OF OBSTETRICS. tion, resulting in the precipitation of labor-pains. Asso- ciated with this is an increased uterine irritability at these epochs, rendering the uterus more susceptible to the influ- ence of external agencies. (3) Reflex Contraction from Ovcr- distention of the Uterus. — This is evidently a false view, for in certain pathologic conditions — e, g. hydramnios — there oc- curs extreme distention of the uterus without the production of uterine pains. (4) Fatty Degeneration of the Decidiia. — Simpson's Theory. — Fatty changes undoubtedly take place in the tissues of the decidua toward the end of pregnancy, and Simpson claimed that these changes favor a separation of the mature product of conception from its uterine attach- ment, it then becoming a foreign body and exciting ute- rine contraction. (5) Fatty Degeneration of the Placenta. — Corresponding changes also take place in the placenta asso- ciated with the formation of peculiar polynucleated giant- cells, and, according to this view, from these changes there results an accumulation of carbonic-acid gas in the uterine sinuses ; the uterus is thus stimulated to contract. (6) Poldmans Theory. — A very ingenious and rational theory, somewhat resembling Simpson's theory, but not taking into consideration any degenerative tissue-metamorphosis, has recently been suggested to me by Professor Pohlman of the Buffalo University. He believes that so long as the fetus is in the process of development it constitutes in effect, if not in reality, a portion of the mother's organism, but as soon as full maturity is reached the fetus becomes a foreign body, and as such is extruded from the body by means of uterine contractions, as all foreign bodies, wherever they may be located, are cast off by nature. The exciting or efficient causes of labor are any slight ex- ertion over the normal — excessive exercise, mental excite- ment, the use of a cathartic, slight trauma, as a fall or a jar, the jolting of a carriage, or other similar trivial agency. These, acting upon the preexisting determining causes, re- sult in a stimulation of the uterine muscles to contract. EUTOCIA, OR NORMAL LABOR. WJ Phenomena of Normal Labor. — The onset of labor is manifested by certain cHnical phenomena that are unmis- takable. When these are present the speedy expulsion of the product of conception may be anticipated. These phe- nomena of labor are as follows : (i) Lightening, Subsidence of the Uterus, or the so-called " Falling of the IVomd." — At a variable period before labor — ten days or two weeks in multiparae and three or four weeks in primiparae — there is a subjective premonitory sign of labor. The woman finds that she is able to breathe with greater ease, and she has a sense of lightness and decrease in the amount of abdominal distention. This sensation is produced by a descent of the uterus into the pelvic cavity, with accommodation of the size and shape of the fetal head to the pelvic inlet — the first step in the mechanism of labor ; this occurs sooner in primiparae on account of the greater irritability of the uterine muscles and their consequent resentment of over-distention. The relief of the dyspnea of pregnancy is, however, gener- ally accompanied by an aggravation of the pressure-symp- toms. The bladder immediately becomes more irritable than before, and frequent micturition is the rule, together with increased constipation, the formation of hemorrhoids, excessive leukorrhea, and edema of the vulva and extremi- ties. Failure of lightening to occur is frequently indicative of some obstetric complication, such as a degree of con- tracted pelvis, the presence of a neoplasm, or some fetal malposition, and as such must be regarded with consider- able apprehension. (2) The " Pains," or Uterine Contractions. — These are in- voluntary and painful contractions of the uterine muscles occurring intermittently and with increasing severity. They are, in reality, an exaggeration of the rhythmic uterine con- tractions that have occurred throughout the last months of pregnancy (Braxton Hicks' sign). Time of the Commence- ment of Labor. — In the vast majority of cases the initial pain occurs during the first half of the night, generally between Il8 A MANUAL OF OBSTETRICS. ten and twelve o'clock. This is a curious fact that has as yet evaded explanation. Their Course. — Opinions vary as to the starting-point of the pains, whether at the fundus or in the cervix, but fPoni a resume of the views advanced the consensus of belief seems to favor the fundal origin. The pains may follow one of two courses : {a) Usually they are first felt over the small of the back, and from this point pass around the abdomen and even at times down the thighs; {b) They may reverse this direction, and, commencing at the um- bilicus, pass backward to the sacrum. They are cumulative in nature, beginning as a slight colicky pain, and increasing in intensity until they assume the proportions of a severe cramp, after which they slowly die away. They are not all of equal intensity, the first pains being slight, but the others progressively becoming more severe and more effective until the birth of the child is accomplished. Their frequency also varies: at first they may occur but once in a half or three-quarters of an hour; as labor advances and the os dilates they occur with increasing frequency, and toward the close of labor there may be a pain every one and a half to two minutes. The duration of each pain is from a half to one min- ute. Mental emotion of any kind will temporarily diminish their intensity or even absolutely suppress them ; the entrance of the physician into the lying-in room may have the same effect. The object of the pains is to forcibly drive the liquor amnii against the cervical tissues, and by means of the hy- draulic pressure thus exerted to secure ultimate dilatation of the OS. Their character varies in the different stages of labor. At first acute, colicky, and cramp-like, after thorough dilata- tion of the OS has been accomplished they acquire a "bear- ing-down " quality, and then become effective in expelling the fetus. Not all women suffer alike during the process of parturition, the amount of suffering being influenced largely by the nervous development of the patient. The pains are more likely to be severe in ])rimipar<'e who arc very young or who are advanced in years. Tlie intermittent quality is EUTOCIA, OR NORMAL LABOR. 119 nature's provision to prevent maternal exhaustion and fetal death : were it not for this interval of relaxation, not even the strongest woman could survive the anguish of parturi- tion, and every fetus would be destroyed by asphyxiation from interference with the placental circulation or from cerebral compression. Effects of the Pains. — Under the influence of a pain the uterine muscle becomes hard and rigid, and in shape the uterus is altered from an ovoid to a globular body (Figs, 51, 52); the area of the intrauterine Fig. 51. — Diagram illustrating the alteration in the shape of a cross-sec- tion of a uterus during its contractions. The heavy line represents the non-con- tracted, the dotted line the contracted, uterus (compare Fig. 52). Fig. 52. — Diagram illustrating the alteration in the shape of a sagittal section of the uterus during its contractions. The heavy line repre- sents the non-contracted, the dotted line the contracted, uterus. space is also diminished and the contents are driven toward the expanding os. There is a marked rise in the arterial tension of the mother's blood-vessels and an acceleration of the pulse-rate, the beats falling again to the normal as the uterus relaxes. The uterine souffle becomes more distinct ; there is a slight elevation of the body-temperature, and a slowing of the respiration during, with rapid respiration be- tween, the pains. There is also a slowing of the fetal heart. Cause of iJie Pains. — In the early stages of labor it is prob- able that the suffering results, in part, from compression of the terminal nerve-filaments of the uterus by the contract- ing muscular fibers. Werth suggests that to this is added 120 A MANUAL OF OBSTETRICS. a spinal neuralgia from anemia of the lower portion of the cord and its meninges. In the late stages of labor the pain is increased by pressure on the pelvic nerve-plexuses by the enlarged uterus, and upon the vaginal nerves by the de- scending fetal presentation, and also by cramp-like contrac- tions of the abdominal muscles. False or Premonitory Pains {Dolores Presagientes). — These are peculiar painless or slightly, and at times decidedly, painful irregular uterine contractions occurring shortly be- fore the advent of labor, and not resulting in the dilatation of the OS nor in the production of the " show." They are most common in multiparze, and occur usually in the first hours of the night. Location. — They are most frequently felt in the fore part of the abdomen, and result as a rule from constipation. (3) The " S/io2i>." — This is a discharge of a small amount of blood-stained, stringy mucus characteristic of progressing labor. The plug of mucus has persisted in the cervical canal throughout the latter months of pregnancy, and as the os dilates it is loosened and finds its way into the vagina ; it is tinged by the blood coming from the lacerated cervical vessels. (4) Dilatation of the Os, witJi Effacenient of the Cciincal Canal. — This maybe regarded as the most important of the signs of beginning labor, although simple dilatation without effacenient is not absolutely incompatible with a continuation of pregnancy. Cases are on record in which dilatation to the extent of an inch or more has been noted, followed by a par- tial retraction and the postponement of labor for several days or weeks. Stages of Normal Labor. — For convenience of descrip- tion labor has been divided into three stages — namely, the stage of dilatation and cffacement, the stage of expulsion, and the placental stage or stage of the after-birth. (i) Tlie Stage of Dilatation and Effacenient. — This covers the period from the first true pain until full dilatation of EUTOCIA, OR NORMAL LABOR. 121 the OS has been accomplished ; its average duration is, in primipara;, ten or twelve hours, and in multiparae six or eight hours. The pains during this stage are in- voluntary ; they are acute and cramp-like, and grad- ually increase in severity, frequency, and duration. The character of the cry produced is rather that of a high-pitched whine, and is not modified by voluntary expulsive ef- forts. There is but a slight degree of exhaus- tion attendant upon this stage, and what little there is results largely from interference with sleep and rest. Vaginal examination reveals a patulous condition of the external os, through which the protruding bag of waters (Fig. 53) may be felt as an elastic membrane ; as the labor progresses the* OS becomes more dilated and the cervix thinner, until finally the latter feels like a ring of tissue-paper, which becomes hard and rigid during a pain. The fetal presentation may be distinguished through the lax membranes in the intervals between the pains, but during a pain the liquor amnii is driven downward and the membranes bulge, giving the feel of a tense cushion. With the progressive dilatation reflex nausea and vomiting are very commonly present, and occasionally an uncontrollable nervous shivering is noted. As a rule, rupture of the membranes does not occur until toward the close of this stage ; in exceptional cases, how- ever, the liquor amnii may be discharged almost with the first pain, and in this case the delivery, which is generally Fig. 53. — The bag of waters. 122 • A MANUAL OF OBSTETRICS. much protracted, is termed a '^ dry labor T In other and still rarer cases rupture may be delayed until after the birth of the fetus, when the child is said to be born with a caul. Some cases are even recorded in which there has been the delivery of the entire product of conception, pla- centa, membranes, and fetus, without escape of the liquor amnii ; when this occurs it is usually an accompaniment of premature and precipitate labor with an undersize of the fetus. Such a case occurred during the writer's term of service as resident physician in the Philadelphia Hospital, the patient being a syphilitic primipara in labor at six and one-half months. Dr. Joseph Forman ' has reported the expulsion of a complete ovum at the seventh month, the membranes intact and the child living. The patient was a duipara suf- fering with pleuropneumonia. Such an occurrence may be the result of a short cord, as when the funis encircles the neck or other portion of the fetal body, or it may be due to a premature fatty degeneration of the placental attachment, to extreme tenacity of the membranes, or to undue laxity or over-size of the parturient canal. There is usually a tem- porary diminution in the severity of the pains immediately after rupture occurs. The posUire to be assumed by the patient during this stage of labor is usually left to her own volition. She should be permitted to stand erect, walk around the room, or sit down as she chooses and on no account should she endeavor to assist the labor-pains ; such efforts are valueless and exhausting. (2) TJie Stage of Expiilsion. — This stage covers the period from the time of full dilatation of the os until the birth of the child; its average duration is, in primiparse, two or three hours, and in multiparae from one to two hours. The pains now are completely altered in character ; they are much more intense, have assumed a bearing-down quality, and are associated with voluntary efforts on the part of the patient, the abdominal muscles and the diaphragm being ' Jour, lie Mht. de Paris, \\>x\\ 9, 1895. EUTOCIA, OR NORMAL LABOR. 123 brought into play. As the pain comes on the woman takes a long breath, grasps whatever object may be within reach, and strains as in difficult defecation. This is often ac- companfcd by a grunting sound as a quick inspiration is taken and the bearing-down efforts are renewed. The effect Fig. 54. — Bulging of the perineum. of the pains is very apparent. Passing through the fully- dilated cervix, with each pain the presenting part is driven down the vagina, which dilates to receive it. Finally the pelvic floor is reached, and the firm but elastic perineal structures direct the advancing part upward and forward 124 ^ MANUAL OF OBSTETRICS. toward the vulvar orifice. The passage through the vagina is facilitated by a profuse secretion of glairy mucus that thoroughly anoints the presenting part and the vaginal tract. In the intervals between the pains the resisting soft struc- tures press back the fetus, so that there is a marked reces- sion until the head becomes too firmly fixed under the sym- physis pubis for this phenomenon to occur. The perineun now bulges during the pains (Fig. 54) ; the anus opens and the bowel protrudes ; the vulvar orifice dilates, and the pre- senting part may be seen as the woman bears down, again disappearing as the pain dies away. This alternate advance- ment and recession gradually distends the perineum and prevents laceration, which otherwise would inevitably occur in every case. During this process the woman complains of an irresistible desire to micturate and defecate, due to the pressure upon the bladder and rectum exerted by the ad- vancing fetus, and frequently there is an escape of both urine and feces. Finally, under the impulse of one supreme effort, the presenting part emerges from beneath the sym- physis, the thinned perineum retracting below. With the birth of the head the fundus uteri rapidly sinks, the uterine walls and the fetal body remaining in close apposition. Much has been written of the physiologic cry that accompanies the birth of the first portion of the fetus. It has been said that as the woman shrieks all volition is removed and the ute- rine contractions alone accomplish the delivery of the child, thus to a large degree preventing perineal lacerations. This is true as far as it goes, and were it inevitably the case that the woman emitted a shriek just as the fetus was born, doubtless numerous perinei would escape extensive injury. In point of fact, however, in many instances there is no out- cry whatever, the fetus being driven irresistibly onward through the vulvar orifice, while the patient strains in her expulsive efforts with clenched hands and closed mouth and firmly-contracted abdominal muscles. The effect thus produced is tremendous, and extensive laceration seems EUTOCIA, OR NORMAL LABOR. 12$ inevitable. In such cases it is only by stern commands to the patient to cease her bearing-down efforts and to open her mouth that the voluntary force can be abolished and the perineum protected. Immediately succeeding the birth of the head there is again a temporary cessation of the pains, which, however, soon return, and the entire body is expelled together with a gush of blood-stained liquor amnii, thus terminating the second stage of labor. ^\iQ. posture occupied by the woman during these succes- sive changes varies. In every instance she should be con- fined to the bed as soon as cervical dilatation is completed. In the early portion of this second stage of labor, if left to herself, she will toss from side to side, and finally, as the head descends, will almost invariably turn upon her back with the thighs drawn up and the legs flexed, and while she is in this position the child will be born. It has been found, however, that labor may be facilitated by super- intending the movements of the patient. Thus, in the first half of the expulsive stage the semi-recumbent position is the best, with the feet well supported and the hands grasp- ing a puller fastened to the foot of the bed. In this way the pelvic obliquity is lessened and the voluntary forces may be best employed. As the head descends the position must be changed. The patient should then turn upon that side toward which the fetal back presents — generally the left — in order to secure perfect flexion of the head, and, still maintaining the squatting position of the body, she should continue her traction upon the puller during the uterine contractions, ceasing her voluntary efforts, however, when commanded to do so. (3) Tlic Placental Stage, or Stage of the After-birth. — This stage covers the period from the birth of the child until the delivery of the secundines (placenta and membranes) ; its average duration is, in primiparae, fifteen or twenty minutes, and in multiparae from five to fifteen minutes. Immediately following the delivery of the child there succeeds a short 126 A MANUAL OF OBSTETRICS. period of calm and restfulness. The patient lies quietly or expresses her satisfaction at the termination of her suffer- ings. In some cases there is a feeling of faintness due to the sudden emptying of the uterus ; in others there may supervene a sensation of chilliness, or an absolute rigor may occur, the patient shaking violently and her teeth chatter- ing. This, the postpartum chill, as it is termed, is purely nervous in origin, and is by no means indicative of a begin- ning pathologic process. An examination of the abdomen at this time will reveal a hard and knotted condition of the uterus, which organ will extend upward to a point a little above the umbilicus. Palpation is productive of pain, and the patient will bitterly resent any abdominal manipu- lation. Auscultation of the abdominal surface immediately over the uterine tumor may at this time elicit Caillanfs sign, which may be mentioned here not as being of any diagnos- tic value, but merely as of interest in the study of labor. It consists in a peculiar scratching sound heard after the birth of the child, during the process of delivery of the placenta, and is believed to be produced by the tearing away of the placenta from the tissues of the uterine wall. It cannot always be detected. The finger in the vagina may follow the cord upward to the mouth of the uterus, which is now considerably contracted, and just above, as a rule, the pla- centa may be felt resting apparently within the lower uterine segment. In the space of a few minutes — from ten to twenty — there is a return of the labor-pains, though to a greatly diminished degree, and the placenta and attached membranes will be protruded from the vulvar orifice together with gushes of liquid and clotted blood. The uterus rapidly contracts upon the advancing sccundines and postpartum hemorrhage is prevented. During this process the cord may be held taut, without, however, any traction being made. The expulsion by the uterine contraction is aided by the voluntary contraction of the abdominal and perineal muscles. The posture of the woman during and imme- EUTOCIA, OR NORMAL LABOR. 1 27 diately following this stage should be the flat dorsal, with the limbs flexed and the head low. Duration of Normal Labor. — This is dependent upon various determining factors, most essential of which is the number of the pregnancy. It has been found that in prim- iparse the average duration of labor is from twelve to fifteen hours, and in multiparae from eight to ten hours. The age of the patient also influences the duration, and an elderly prim- ipara will usually have a protracted or tedious labor. The change produced in the physical constitution of the woman by her environment and mode of living will exert a very powerful influence upon her ease of procreating. Thus, as a rule, labor is more tedious and difficult among civilized people than among savages. Indeed, painless parturition is said to be the rule among the barbarous and semi-barbarous nations. The time at which the majority of births take place is during the latter half of the night. Mechanism of Normal Labor. — By the mechanism of labor is meant the manner in which the fetus and secundines pass through the parturient canal and are expelled. This subject comprises the recognition of the part of the fetus that is presenting, the position it holds, and the mechanical forces by which it is expelled from the uterus and is caused to pass through the vagina and vulva. These points may be determined by palpation of the abdomen and by vaginal examination. By \\\Q presentation is meant that portion of the fetal body which is detected by the examining finger introduced to the center of the plane of the superior strait of the maternal pelvis. The possible varieties of presentations are — i. Cephalic, or Head, including {a) Vertex, ijy) Face, (r) Bregma or Anterior Fontanel, {d^ Brow, {e) Ear, (/) .Parietal Eminence; 2. Pelvic, including {a) Breech or Coc- cygeal, {8) Knee, {c) Foot or Footling ; 3. Transverse or Trunk, including presentation of the abdomen, arm, shoul- der, back, breast, neck, and side. Of these varieties but 128 A MANUAL OF OBSTETRICS. two may be regarded as normal presentations — namely, those of the vertex and the pelvic varieties. These alone will be considered under the normal mechanism of labor, the others being treated among the causes of dystocia. The term position has a twofold signification in the subject of the mechanism of labor. As generally accepted it means the varying relationship borne by the most prominent point of the presenting part of the fetus to the cardinal points of Capuron, According to the position occupied by the pre- senting part will be determined in any case the possibility or impossibility of a normal mechanism. The term position may also indicate the relationship existing between the long axis of the fetus and that of the uterus. Thus, a fetus may occupy a longitudinal or a transverse position in the uterine cavity according as to whether its long axis corresponds with or is at right angles to the long axis of the uterus. The most common position of the fetus with reference to the uterus is the longitudinal, about 99^ per cent, of all fetuses holding this position ; it includes all of the cephalic and pelvic presentations. Of the two varieties of longitudinal presentations, the cephalic is by far the more frequent, it occurring in about 95^ per cent, of all cases, and for very obvious reasons. These are as follows: i. Because of the peculiar shapes of the uterus and of the fetal ellipse ; 2. Because it is most conducive to the comfort of the fetus and to the furtherance of its growth and development; 3. Because of the situation of the fetal center of gravity, which lies near the head. In order to comprehend the first of these causes of cephalic presentation it will be necessary to refer for a moment to the shape of the uterus and that of the fetus. By the term fetal ellipse, so designated because of its peculiar elliptic shape (Fig. 55), is meant the attitude of the full-term child in ntero. There is an arching forward of the body, with flexion of the head upon the chest and of the thighs upon the pelvis ; the arms are closely pressed EUTOCIA, OK NORMAL LABOR. 129 against the thoracic walls, and the forearms are flexed upon the arms and crossed upon the chest ; the legs are flexed upon the thighs ; the feet are laterally inverted with the toes turned in, and are crossed upon each ■ other. The pelvic portion of the fetal ellipse is larger than the cephalic, and therefore finds more room in the upper and larger portion of the pear-shaped uterus, while the head is better adapted to the smaller lower uterine segment. Pajots lazv of accoviviodatioii admirably expresses this most probable mechanical reason for the frjsquency of head presen- tations of the fetus. It has been thus worded : " When one solid body is con- tained in another, and if the latter be alternately in a state of motion and of repose, and if the surfaces are rounded and smooth, the included body con- stantly tends to accommodate its shape and dimensions to the shape and capacity of the containing body." In the appended table ^ (pages 130, 131) will be found a grouping of the various fetal positions and presentations, with their respective points of diagnosis. The vertex is the most common of the cephalic presenta- tions. This results from the mechanical relationship exist- ing between the axis of the spinal column and the axis of the fetal head. As may be seen by reference to Figure 55, the vertebral axis does not bisect the cephalic axis at its middle point, but at a point nearer the posterior portion of the head. Now, the force exerted equally upon all portions of the fetal head will result in greater flexion of the longer bar, according to a well-known rule of physics, 1 Prepared originally by the writer for Gould's Dictionary, and altered therefrom. Fig. 55. — Diagram show- ing fetal ellipse ; also the head lever (Dickinson). I30 A MANUAL OF OBSTETRICS. <0 ^ V o-go •I^jaj > o.g V V — > CL C O 0.0 ^ i-H §^ i:_ § « ^ ~ o 5 rt •go.S c "~ 1) c E c rt = O 2 ■^■^~ o i^-SCi c u E2 Pi »5 u!J2 3 n o MX o o « o o D j;;3 u rt E:= u u o — - - "^ oj: S §3^ „ " c c iS " _2 '-'""'< r*i It •- !2 j._jj_^i.u.^« •.••tJ!)H£'"i!-'ra~i' -gcx D^ wo i.— be- 3 rt: o ^ij-:- !i^-S:2:,^~^«^f,lJo^^s^s^ Soil's ::Ss u_„^_S«i"o3i,'''.^nCi '5«2^ 3 u u j: 2.S„-g2.= j23 2e-i;iic-i:Ji-^ •G :2 ^ c -5 = « .£?-5 -^ = i -5 -S c i .S o .5? E .£ o 3 iJ .5 ^ .S? S c .= 3 2 OOOOUUUU JO Xsusubsjj} •|0qiuj?s 'X3U3nb3j,j iiopcjuaSDJjj c rt S J ►J « Pi fa ^ Oi Pi 1-1 •- ■it ■0% .'°.5 E E •3.S E (/I "! J S E^ S E .tl n: ,3S^ re_o"-a" L.'3 3 t 3 3 .2.0-0- ii33 i!-3"S .. D U UX2 42 c u 3 -3 6 ■it lA ha S-Q ^^^^-■= c« ■~" — tjiJ ssi2e --2 E "> " S-a .5 ?■; ^ ,-S " c ■" ° ii " L' ^ « S ■- ^i^ rt^ e^ "^ - 3 a- 3 C ^ ^ c-S ^■C re rtij2"'" — if ox^^ c i-'h- .. e's'j^s 3 •-' n *-» 3 V ^ ■" =3 M c " c_5^ c Ctt! = c "" f,Z2" si 3T3 4J il '■' re u u QJ _. 3 3 c ESS g ° E S ^^S 2.2 ?c 4J 0*5 rt3 i-^"^ Si-s> 1 ill 2.2 2 033 .r-i PQ PQ p. (U c (u 'C 0-2x1 -a T3 re 2rtT3T3"lHOO re re W CO '72 § E c leg 13 , >> C U 8* ^ %% E ^8e 1) 3 a ti < Ph f^l < < fc Ph' u :-! P. 0. . u tn . J-I c u re C **" it L* ■a I. T3 in in u IT. . c . i- re .2 It 1) C i •0 C 0) <-• If II .2 0) *^ '0 II re c "".2 "*- ii hJ ^ s hJ J Pi Pi ►J ►j" Pi p« J u, V- u- u •^ re ui u c 3 u c a ^~ D- " O.VU. re ^ iR i "3 si xi en n 132 A MANUAL OF OBSTETRICS. and consequently the anterior portion of the head, repre- senting the longer bar, will be flexed upon the chest, while the vertex, or shorter bar, will present at the middle of the plane of the superior strait. 'Y.\iQ forces concerned in labor are of two kinds — namely, the positive or expulsive and the negative or resistant. The former include the strongly-contracting upper uterine seg- ment and the abdominal muscles. The action of these two elements of propulsion is identical. The uterine muscle by its contraction expels the contents of the uterine cavity by causing a diminution in the area of this cavity, while the abdominal muscles by diminishing the area of the intraabdominal cavity strongly supplement the expulsive action of the contracting uterus by displacing that organ downward and causing it to drag upon its ligamentous attachments. The ligaments themselves contract and help to fix the uterus at the brim of the pelvis. The difference between the two forces is that the one, the uterine element, is persistent throughout labor and is involuntary in its pro- duction, while the other, the abdominal element, is almost entirely voluntary and is only of service during the active second and third stages of labor. By the combined action of these two forces, which has been variously estimated as equivalent to from seventeen to sixty pounds, the liquor amnii and fetal body are displaced downward, the lower uterine segment is thinned and distended to a remarkable degree, and the vagina is dilated. This dilatation is favored by the softened and edematous condition of the cervical and vaginal tissues, together with the upward traction exerted by the longitudinal layer of muscular fibers in the uterine walls. By this latter action the uterine muscle is largely massed above the contraction-ring of Bandl, while the fibers of the lower segment are separated and stretched to an enormous extent. The negative forces of resistance are, in function, entirely conservative. They are intended to prevent too precipitate EUTOCIA, OR NORMAL LABOR. 1 33 expulsion of the fetus and to favor the proper mechanism of the various positions. These forces include the resistance offered (i) by the soft parts of the parturient canal (the lower uterine segment, the cervix, the vagina, and the vulva), (2) by the bony pelvis, and (3) by the fetal body. The most im- portant of these factors are the actions of the pelvis and of the fetal body. In the normal pelvis sufficient resistance only is afforded by the rigid walls to secure proper moulding and rotation of the advancing part, and to give to the softer structures time enough to dilate sufficiently to prevent lace- ration and excessive bruising. While the pelvis thus acts mainly as a resistant force, certain changes occur in its artic- ulations during labor that facilitate the progress of the ad- vancing part. Thus, the symphysis pubis separates slightly, and the sacrococcygeal joint permits of backward displace- ment of the coccyx to the extent of 2}4 cm. (0.98425 in.). The sacrum varies in its position at the beginning and end- ing of labor. In the first stage its base is rotated backward slightly, and the entrance of the fetal head into the pelvic inlet is in this way facilitated ; toward the close of labor, when the head strikes the pelvic floor, the lower portion of the sacrum rotates backward to permit of an increase in the diameters of the pelvic outlet, so that the advancing fetus may find room for its proper egress. Fctovictry. — Very essential as a resistant factor is the fetus itself, and especially on account of its bony structure does the fetal head play an important role in the mechanism of labor. By fctomctry is meant the measurement of the various fetal diameters and parts. The most important of these measurements are given in the following pages. The Fetal Skull at Term (Fig. 56).— A knowledge of the diameters and salient points of the fetal cranium is essential to a comprehension of the various cephalic presentations. The skull of the fetus at term is oval in shape, and is com- posed of a lower firmly-ossified portion, comprising the base of the skull and the face, and an upper yielding por- 134 A MANUAL OF OBSTETRICS. tion, composed of seven bones that are united by mem- branous tissue, thus permitting of a certain amount of com- pressibiHty and over- lapping. These Hnes of membranous j unc- tion are termed su- tures, and receive their names accord- ing to the bones they unite and the posi- tion they hold, as fol- lows : The frontal, joining the two fron- tal bones; the coro- nal ox frontoparietal, joining the two frontal and the two parietal bones ; the great, sagittal, or biparietal, joining the two parietal bones; a n d t h e lavibdoid or occipi- toparietal, joining the occipital and the two parietal bones. There are two others, the tonporal or squamous sutures, which cannot be felt in labor and are unessential to its mechanism. In addi- tion to these sutures, there are two other features of the fetal skull that play an important part in the mechanism of labor. These are the two membranous spaces in the cranial vault known 'A9, fontanels (Fig. 56). The anterior or larger fontanel, also known as the bregma and occasionally as the sinciput, is a diamond-shaped space left at the point of juncture of the frontal, coronal, and sagittal sutures. It persists as a space' throughout labor, although somewhat diminished in area by the approximation of the cranial bones. The posterior or Fig, 56.- -Fetal skull at term, showing anterior and pos- terior fontanels (Dickinson). EUTOCIA, OR NORMAL LABOR. ' Plate i. > « Fetal skull seen from in front (i) and from the side (2), showing sutures, fontanels, and diameters. C4U. ij^i^^tiifh Q^fu^Jic «^» /^.3a EUTOCIA, OR NORMAL LABOR. 1 35 smaller fontanel is situated at the point of juncture of the lambdoid and sagittal sutures, and is triangular in shape. It ceases to be a space during labor, owing to the over- lapping of the depressed occiput by the two parietal bones. The diameters of the fetal skull (see Plate i) may be divided into three sets, the transverse, the longitudinal, and the vertical. The transverse diameters are as follows : (i) The bitemporal, joining the extremities of the coronal suture, 8 cm. (3.1496 in.) in length; (2) The biparietal, joining the two parietal eminences, 9^ cm. (3.6417 in.) in length : this is the greatest possible transverse diameter of the fetal skull ; (3) The bimastoid, joining the two mastoid processes, 7^ cm. (3.0018 in.) in length: this is the smallest diameter of the fetal skull. The longitudinal diameters are — (i) The occipitofrontal, extending from the root of the nose to the external occipital protuberance, and measuring i \y^ cm. (4.6259 in.) in length ; (2) The occipito- mental, extending from the external occipital protuberance to the point of the chin : it measures 131^ cm. (5.3150 in.), and is the largest diameter of the fetal skull ; (3) The siib- occipitobregmatic , extending from the central point of the bregma to a point midway between the occipital protuber- ance and the foramen magnum : it measures 9^ cm. (3.8386 in.) in length. The vertical diameters are — (i) The fronto- mental, extending from the top of the forehead to the point of the chin, and measuring 8 cm. (3.1496 in.) in length; (2) The trachelobregmatic , extending from the central point of the bregma to the anterior part of the foramen magnum : it measures 9^ cm. (3.7401 in.) in length ; (3) The mcnto- bregmatic or cervicobregmatic , extending from the central point of the bregma to the junction of the chin with the neck, and measuring 9^ cm. (3.6417 in.) in length. Other fetal measurements worthy of remembrance are the circumference of the skull through the occipitofrontal diam- eter, which measures 34^ cm. (13.5827 in.) ; the bisacromial diameter, that joining the two acromial processes, and 136 A MANUAL OF OBSTETRICS. measuring 12 cm. (4.7244 in.) in length; the bisiliac diam- eter, the greatest transverse diameter of the fetal pelvis measured from crest to crest — from 9^ to 10 cm. (3.7401 to 39370 in.); the intcrtvocluDitcric diameter, that joining the two greater trochanters, and measuring 9 cm. (3.5433 in.); and the average length of a child at term — namely, 50 cm. (19.6850 in.). Having now disposed of the preliminary matters in the subject of the mechanism of labor, we may take up in order the steps and peculiarities in the various normal mechanisms. (i) Vertex Presentations. — The vertex is that conical portion of the fetal skull the apex of which is situated at the posterior fontanel ; its almost circular base is the plane formed by the bisection of the biparietal and trachelo- bregmatic diameters. There are four possible positions for the vertex to hold after engagement in the superior pelvic strait — namely, the head occupying the right or left oblique diameter of the pelvis, with the occiput either ante- rior or posterior. Most commonly it is the right oblique diameter that is involved, and generally the occiput is ante- rior. The transverse diameter of the superior strait being the largest, Spiegelberg has found that in 81.4 per cent, of all vertex presentations the head enters the strait in this diameter, but that under the action of the resistant pelvic walls it soon comes to occupy one or other of the four positions of the vertex. In the balance of the cases the entrance into the pelvis will be primarily in one of the ob- lique diameters ; this position is termed Solayre's obliquity of the head. The positions of the vertex are as follows : (i) The occiput anterior and to the left — left occipito- anterior; symbol, L. O. A.; (2) the occiput anterior and to the right — right occipitoanterior; symbol, R. O. A. ; (3) the occiput posterior and to the right — right occipitoposterior ; symbol, R. O. P. ; (4) the occiput posterior and to the left — left occipitoposterior ; symbol, L. O. P. EUTOCIA, OR NORMAL LABOR. 137 Mechanism of the First Position. — Left occipitoanterior — L. O. A. (Fig. 57). — About 70 per cent, of all vertex cases present in this position. Cause. — The reason for this great frequency may be found, in the first place, in the position of the rectum to the left side of the pelvis; this, by cutting off a portion of the left oblique diam- eter of the pelvis, makes it smaller than the right, in which diameter the fetus accordingly finds more room for growth and descent. In the sec- ond place, the prominence afforded by the anterior curvature of the ma- ternal spinal column renders an ante- rior position of the rigid fetal back more conducive to the comfort of the fetus. Diagnosis. — Vaginal examina- tion shows that the depressed occiput and smaller fontanel are anterior and pointing toward the left iliopectineal eminence. The sagittal suture runs from the small fontanel obliquely backward and to the right in the line of the right oblique diameter. The head holding a position in this diameter, the shoulders must of necessity occupy the left oblique diameter. Examination of the abdomen reveals the firm fetal back to the left side, with the extremities above and inclined to the right side. The fetal heart-sounds may be heard midway between the umbilicus and the left anterior superior spinous process of the ilium. Fetal Diameters In- volved. — Before flexion the occipitofrontal, ii^ cm. (4.6259 in.), and the biparietal, 934^ cm. (3.6417 in.), present; after flexion, the ^-"^/-f^A^Z/rrrTriTiVi-^ 9^ cm. (3.7401 in.), is sub- stituted for tUe occipitofrontal, making a diminution of 2 V cm. (0.885 8/in.). Steps of the Mechanism. — The mechanism Fig. 57. — Vertex presentation, first position, L. O. A. : S, sym- physis pubis ; E, left iliopecti- neal eminence ; S', sacrum. i3« A MANUAL OF OBSTETRICS. of this, as of all presentations, may be said to consist of three processes — namely, adaptation of the fetal presenting por- tion to the pelvic canal, preparation of the canal for the descent of the fetal presentation, and, finally, its descent and delivery, i. The adaptation of the fetal presenta- tion comprises three steps of the mechanism, as follows : (i) Preliminary flexion and vioulding to accommodate the size and shape of the fetal skull to the pelvic inlet. This occurs shortly before the onset of labor, and is the cause of the phenomenon known as " lightening." (2) With the first labor -pain the head is more thoroughly adapted to the pelvic in- let — /. c. more completely flexed and moulded by the downward impulse im- parted to it by the uterine contraction. The extreme flexion of the head upon the trunk is termed Roe- dercrs obliquity of the fetal head. (3) NaegcWs oh- liqidty (Fig. 58), or lateral inclination of the fetal head toward the maternal sacrum. This is produced by a crowding of the fun- dus uteri firmly against the spinal column. As a result the fetal trunk becomes convex anteriorly, and the left car is pressed against the left shoulder, the right parietal bone presenting. The sagittal suture is directed, now, more posteriorly, and the examining finger must be passed farther back in order to find the vertex. According to many observers, there is some doubt as to the occurrence of this obliquity, but a careful study of the mechanical relation existing between the pres- FiG. 58. — Naegele's obIioer cent, solution of cocain, i ounce ; 5 per cent, car- boliz«K^aselin, 2 ounces ; a solution of creolin of such strength n^t I dram to i pint of water will make a 2 per cent. solutiori)S^bottle of iodoform-gauze ; a small roll of absorbent cotton ;^^«^f Barnes' dilators ; a set of Hegar's dilators ; chloroform, 5 oi?l*8^s; Monsel's solution, 2 ounces ; a small faradic battery ; a stetluJ^a^De ; pure carbolic acid, 6 ounces ; a solution of chloral hydral^^N^^grains to the dram, 2 ounces. (3) TJic Use of Antisepsis. — The imperative necessity of an antiseptic management of labor is now universally recog- nized, and the following rules and suggestions should be strictly adhered to, in order to ensure safety for the patient during the lying-in period. There is probably no condi- tion in which a patient is more susceptible to the action of pathogenic germs than after labor; she has gone through a siege of suffering and bodily toil that has ex- hausted all of her surplus vitality and resisting powers ; there are numerous abrasions and lacerations throughout the genital tract to which the germs of putrefaction find ready access, and there is no better culture-medium than blood-serum. Having once found entrance into the nidus thus prepared by labor, these infective microorganisms generate organic products of extreme virulence known as ptoniains, and these when absorbed into the system give rise to the symptoms of puerperal sepsis. It becomes, therefore, a question of the utmost importance to the ob- stetrician in attendance upon a given case of labor how best to avoid the possibility of septic infection of his patient dur- ing and after the process of parturition. From nymerous experiments madt in the large ma)fernity insti^tions in this country anar abroad it has be^ found i\\3.j ereo/in, di coal-tar produjn deprived of its carbolic acid :\r^ possessed of highly anpseptic properties, \/ in the strenaffh of a 2 per cent, sol ut/on, most effective nC destroying Jme pathogenic germs, ami is the safest of t^e germicides because of its EUTOCIA, OR NORMAL LABOR. l6l nontoxicity. Other antiseptic agents that may be em- ployed, although some of them are of rather inferior value, are boiling water, mercuric chlorid and biniodid (i : 4000 to I : 2000), and salicylic and carbolic acids. By the use of such agents and the observance of other proper precau- tions to secure thorough asepsis, the mortality of labor may be reduced to its minimum and the greater comfort and happiness of the patient be assured. [a) The Room. — In choosing a room for the confinement, one that is large, with plenty of air and light, sufficiently heated, and not in close proximity to a bath-room or a water-closet, should be preferred. An open fireplace is a valuable means of ventilation, and, if possible, a room with such a convenience should be selected. All unnecessary furniture, hangings, and bric-a-brac should be temporarily removed, and the room rendered as cleanly and aseptic as possible. {8) Disi7ifection of the Physician and the Nurse. — One of the commonest methods by which a puerperal patient may become infected is through the improperly or imperfectly disinfected hands of her medical attendants. It is unfor- tunate that the introduction of the fingers into the genital tract of a woman in labor is necessary, but, this being the case, it is most essential to submit the examining hands to such recognized precautionary antiseptic measures as will best ensure the patient's safety from germ-infection. Indeed, some of the leading obstetricians, notably Leopold and Sporlin ^ of Germany, have recently advocated limiting examinations made in the course of ordinary labor to the external parts, thereby avoiding the danger of infecting the membranes : they claim that the position and presentation of the fetus may be recognized by external manipulation alone, and vaginal exploration need only be made to deter- mine the presence of pathologic conditions of the birth-canal. There are in vogue a number of special methods of ren- ^ ArcJiiv f. Gynalc, Band xlv. Heft 2. 11 l62 A MANUAL OF OBSTETRICS. dering the hands aseptic, best known among which are Kelly's or the permanganate method and Fiirbringer's method. Kelly s mctliod is as follows: i. The hands and nails (closely pared) are scrubbed for ten minutes in water, frequently changed, at about 40° C. (104° F.), a sterilized brush being used ; 2. The hands and forearms are then immersed in a solution of potassium permanganate (made by adding an excess of the salt to boiling distilled water) until stained a deep mahogany-red ; 3. They are then im- mersed in a saturated solution of oxalic acid until com- pletely decolorized ; 4. After this they are cleansed in warm sterilized water. Furbriuger's method is as follows: i. The pared nails are cleaned with a pointed steel ; 2. The hands and forearms are scrubbed for from one to three minutes with soap and hot water and a sterilized brush ; 3. The soap is removed by immersing in clean hot water ; 4. The hands and arms are then immersed in 95 per cent, alcohol for one minute; 5. Still wet with the alcohol, they are immersed for one minute in a freshly-prepared men curic-chlorid solution (i : 500 or I : icx)o). The finger, sten ilized by one of the foregoing methods, should be lubri-i catcd with a 5 per cent, carbolized vaselin and the exami- nation proceeded with. The hands of the nurse should pass through the same cleansing process. The clothing of the physician should be freed from the dust of infec- tious diseases, and his linen should be fresh and clean. The nurse's clothes are to be thoroughly washed in car- bolized or mercurial solution and freshly donned for the occasion. (r) Disinfection of the Patient. — As soon as labor-pains begin to manifest themselves the patient should be given a full bath and the external genitalia cleansed with green- soap and alcohol, and this followed by an application of mercuric chlorid (i : looo). A vaginal douche should not be given before labor, to avoid the introduction of germs with the nozzle of the syringo. The clothing should be changed EUTOCIA, OR NORMAL LABOR. 1 63 completely. After the pains have become well established an enema of a pint of soapsuds with i dram of turpentine may be administered, after which the parts should be again disinfected by the mercuric-chlorid solution. (<-/) Preparation and Disinfection of the Bed. — The bed should not be excessively low, and should be placed in the center of the room, so as to be easy of access ; it should contain a hair- or spring-mattress, and over this should be placed a rubber blanket for the protection of the latter. A sheet is spread above this. The linen used should be abso- lutely clean and wolL ■otoriliood 4 n mcicuiic diluiid. Over the sheet should be placed the special coverings that are to be removed at the termination of labor. These, as adopted now almost universally, consist, from below upward, of a rubber blanket, a sterilized sheet, and a large pad to receive the discharges of labor ; the latter is preferably made of oakum, or, if this cannot be secured, of a sterilized piece of blanket, and this covered with a layer of soft flannel. [e] Disinfectio7i of the Instruments. — Occasionally it will become necessary to employ other means of assistance than the attendant's hands : when this is the case all instruments so employed must undergo a process of thorough steriliza- tion ; the danger of sepsis increases with the number of instruments introduced into the vagina. Iif uf jjtttlT'Lhey s lrould b(J platLd bLfuiL usiiiulu a pilchei o f boiling water ^ and left there untt^equired ; if of iWd rubb^^ me^uric- chlorh^olution (i Tra^o) or a solutioiN^^ carbo^l*^ aci^(5 per cen^^imist be used. (4) T/ie Examination. — The object of the examination is to determine the position and presentation of the child, its condition, the progress of the labor, the size of the maternal pelvis, and the condition of the soft structures of the par- turient canal. The examination should be made after thor- ough disinfection of the hands, and should consist first in palpation and auscultation of the abdomen, and, secondly, in a vaginal exploration. While palpating the abdomen the 164 A MANUAL OF OBSTETRICS. patient should lie upon her back with the shoulders slightly levated and t^ie thighs partly flexed upon the abdomen ^(Fig. 74). Th ^ known as the obi h\ posjiw^ for tl>ei^aginal£;i4minations- is Fig. 74. — Dorsal posture. ure; the p' lose to the right slightly ?hile exploring ed with his face e left side w-ilh the b bsxrawn toward byth le patient's head t IG 75 — Lett I itcral ri.i,uiiibeiit posture. 'well in making the vaginal examination to keep the finger in contact with the membranes before and during one of the pains in order to ascertain the strength and effectiveness of he uterine contractions. During the process of examination third person, preferably the nurse or the husband, should c present, not only for the satisfaction of the patient, but also for the protection of the physician. All other persons should be strictly forbidden the room during the progress of labor and for the first few days of the puerperium. Matiagcincnt of Vertex Presentations. — First Stage. — In a perfectly normal presentation of the vertex there is but little to be done by the accoucheur. The patient's spirits should EUTOCIA, OR NORMAL LABOR. 1 65 be stimulated by words of encouragement, and her mind diverted from her condition as far as is possible. She should be permitted to walk around the room or sit in an easy-chair, and to occupy her time in reading or sewing, or doing nothing, as she prefers. A vaginal examina- tion should be made not oftener than once in an hour or two, and while she is being prepared for this purpose the physician should pass into an adjoining room. When the dilatation of the os has progressed to 4 or 5 cm. (1.5745 to 1.9685 in.) the patient should be confined to her bed to avoid any risk of a precipitate expulsion of the fetus. The physician should see that the bowels are well emptied and that the urine has been properly voided. If the pains are rather severe and cause bitter complaining on the part of the patient, Playfair's treatment may be of service, espe- cially in those cases in which there exists a considerable rigidity of the cervical and vaginal tissues : this consists in the administration of chloral hydrate in i5-grain doses repeated once or twice at intervals of from fifteen to thirty minutes. The chloral may also be given per rectum in 30- grain doses, suspended in mucilage of acacia or in milk and the white of an Q^^. It should not be used when there is grave organic heart-disease. This drug quiets the patient, induces drowsiness, regulates and strengthens the pains, and relaxes the soft structures of the partu- rient canal. Should this stage be protracted, the pa- tient will require some nourishment ; this may consist of a small amount of beef-tea, a cup of sherry, or a glass of milk, and a cracker or two. If the abdominal walls should be found to be relaxed, as is often the case in multipara;, the effectiveness of the pains may be materially increased by the application of an abdominal support. Second Stage. — (i) Delivery of the Head. — Labor having progressed until complete dilatation of the os has been effected, vaginal examinations should then be made -eveuji* J e tW ui ' l TffggTriwp wulajj * M lIil miLmbi i anciu Imiir tured spoijtaneously by the time dila^tion ofir the os if completed, it becomes the physician's duty, in the case of multiparae only, to artificially cause their rupture. This may be accomplished preferably by the finger-nail or by a hair-pin or a match-stick, pressure being exerted upon the membranes while not tense as during the presence of a pain. Care must be observed that it is not the scalp or the attenuated lower uterine segment that is perforated in mistake for the smooth membranes. This can generally be decided by waiting for a pain, when, if it be the mem- branes covering the presenting part, they will be noticed to become tense and to bulge through the os to a greater or less extent ; the scalp, on the contrary, during the height of a pain becomes corrugated, so that there should be no difficulty in recognizing it. Before the escape of the liquor amnii it is well to have the patient's garments well drawn up above her hips and secured there, in order to avoid soiling. Preservation of the Peritieuin. — The pains now become straining in character, and during their presence the woman should be encouraged to bear down ; she may also make traction upon a puller, so as to contribute to the uterine action the support of the abdominal muscles ; this may be continued until the perineum becomes well dis- tended, when all voluntary efforts should cease. The aim of the physician should then be to preserve the integrity of the perineum as far as it is possible for him to do so. The fourchet will be torn in over 60 per cent, of primiparae, while there will occur a laceration of the perineum to a greater or less extent in about 35 per cent, of primiparai and in 10 per cent, of multiparcTe; extensive laceration of the perineum, however, and especially those tears involving the rectovaginal septum, are to a large degree avoidable. The common causes of perineal laceration are — (i) precipi- tate expulsion of the fetus ; (2) large size of the fetal head .or under-size of the vulvar outlet; (3) rigidity of the peri- neum ; (4) faulty mechanism, as wh<*n there is failure of the EUTOC/A, OR NORMAL LABOR. 167 head to extend or when the head is expelled in an oblique diameter, as in case of contraction of the pubic arch; (5) improper management of the delivery of the shoulders. Pre- ventive Treatjuent of Laceration. — Efforts directed toward the preservation of the maternal soft structures may be made as follows : (i) Retardation of the Expulsion of the Head. — This may be accomplished in the following ways : {a) By Hold's Method (Fig. 76), which consists in applying resistance to the Fig. 76. — Hohl's method of preventing laceration of the perineum. head by pressing the thumb against the occiput above and the index and middle fingers posteriorly against that portion of the head nearest the fourchet ; in this way absolute con- trol may be had over the advancing head, {b) By Fasbender s Method. — The patient resting upon her left side, the physi- cian stands behind her and applies the index and middle fingers of the right hand to the occiput while he inserts the thumb as far up into the rectum as is possible. The move- ments of the head are thus under thorough control ; during a pain it may be retarded, and in the interval it may be helped onward, {c) By the use of the forceps, which may be applied and the head held back during the height of a pain, and gently assisted downward in the intervals. (2) i68 A MANUAL OF OBSTETRICS. Efforts at Effecting Perineal Relaxation. — {a) Goodell's Method. — The thumb of the left hand is pressed against the advancing occiput, while the middle and index fingers of the same hand are inserted into the rectum and caused to drag forward and upward the distended perineum during a pain, {b) Playfaifs Method. — The thumb and forefinger of the right hand are placed on either side of the head upon the distended perineum, and the latter is gently pushed for- ward over the head during the pain, {c) Merkerttschiantz' s Method. — Bilateral Pressure. — The patient resting in the dorsal po- sition, the thumb and fingers of both hands are pressed against the distended perineum on both sides, and during a pain the tissues thus grasped are pushed to- ward the central line ; as the head begins to emerge the left hand is placed above with the ulnar border in appo- sition with the mons veneris and the mid- dle and index fingers about an inch from the thin border pressing the upper portion of V\i.. 1-j. — I)nul)lL- episintomy (skctrli, just nftcr dc- . livery, from nature, by R. L. Dickinson) : A, direction tllC penUeUm tOWard of incision faulty, pointing toward the posterior vaRinal .1 rnFvrlJnn Wnp ( i1\ wall ; B, correct line of incision, running parallel with '"'J^ UlCUlclIl lUlt,. \ll ) the axil of the vulvar opening. Tlu USe of^eVieStJieticS, prcferablyT^lICl''" \e) Episiotoniy (Fig. JJ^. — This operation consists in the mak- ing of a lateral incision of the vulva for the purpose of .,.^'cKi«jsi.- 'A ^v s ■ A»jjij^ ^r / )V-^ ^nS^F •>^-^ EVTOCTA, OR NORMAL LABOR. 169 relieving vulvar and perineal tension. During the height of a pain the incisions are made upon the mucosa just within the vulvar opening, about ^ an inch upon the vagi- nal walls; they should be from ^ to ^ of an inch long, and not more than y^ of an inch in depth, and should be closed immediately after labor. This operation is not recommended, as a simple laceration of the perineum involves less destruction of tissue than a laceration on either side of the vulva, and can be more readily repaired' than the latter. (3) Effoi'ts at Elevating the Head. — [d] Ritgen's Method. — The tips of the fingers of the right hand are placed upon the perineum back of the anus and close"" to the point of the coccyx, and pressure upward and for- ward is made between the pains upon the frontal bone of the fetal head, {b^ Olslianseiis Method. — Rectal Expres- sion. — The index and middle fingers of the right hand are passed into the rectum and pushed through the rectovaginal septum into the mouth or beneath the chin of the child ; between the pains the head is pressed upward and forward. (2) Delivery of the Shoulders. — The head of the child having now passed through the vulvar orifice, and this oc- curring preferably after the pain has passed away, for a few moments there is a cessation of the uterine contractions. During this time it is the duty of the physician to support the head in the right hand, and at the same time to pass the fingers of the left hand over the neck in order to ascertain whether or not the cord is coiled around it: if it be found, it should be loosened as far as is possible, or, if there are two or three coils, it then becomes necessary to ligate the funis in two places and divide it between the ligatures, at the same time hastening the delivery of the body of the child by pressure upon the fundus of the uterus in order to stimulate the latter to contract. This pressure may best be made by an assistant, the physician devoting his energies for the time being to the care of the child. The vaginal secretions should be cleansed from the eyes and face, and 1/0 A MANUAL OF OBSTETRICS. by the time this is accomphshed the next pain, which is to dehver the shoulders, will probably occur. Should there be any delay at this stage of labor and the child seem to be in danger of death from rupture of a cerebral vessel, the head should be grasped by both hands placed on the lateral aspects and carried first down and backward toward the sacrum, then up again toward the symphysis, gentle out- ward traction being made, and finally down again ; the ante- rior shoulder being extracted in this manner, the rest of the body is rapidly delivered. This method will generally an- swer ; but should it not succeed, a finger should be passed through the posterior axilla and gentle traction made, the head being lifted and the assistant making friction over the fundus of the uterus. As the shoulders and body slip out of the vulvar orifice in quick succession, the hand of the assistant follows the contracting uterus to prevent relaxation and postpartum hemorrhage. Respiration is established, the child cries, the heart's action becomes regular, and in a few moments the cord ceases to beat. (3) Ligation of the Cord. — The cord should be ligated only after the pulsations have entirely ceased ; immediate ligation after birth is said to deprive the fetal circulation of at least three ounces of blood — a considerable loss in weak and anemic children. The most desirable ligature is a small-sized tape which will not cut through the structures of the cord. The liga- tion is made at a point about two inches from the umbilicus, and again about an inch farther from the navel, a sur- FiG. 78. — Fetus at term, showing method of tying 1 1 „^4. v.'^„ ^.^ the cord. geons knot being em- ployed for the proximal ligature (Fig. 78) ; the cord is then divided midway between the two ligatures, care being taken not to injure the child itself EUTOCIA, OR NORMAL LABOR. 17I in the process. To avoid this danger it is best to cut the cord while it is held in the hollow of the hand, the dorsum of the hand being directed toward the child's abdomen. The object of the double ligation is manifold : in the first place, it prevents unnecessary soiling of the bed by arresting the escape of blood from the placenta during the time that must elapse between division of the cord and expulsion of the secundines ; secondly, in case of twin-pregnancy, death of the second child from hemorrhage is prevented. The cord being severed and the non-existence of a twin-pregnancy being assured, the second ligature may be removed and the free blood contained within the placental tissue be allowed to drain into a vessel ; the bulk of the placenta is thereby considerably lessened and its early and easy expulsion from the uterus and vagina facilitated. Nguyen Khac Can ^ makes the ingenious suggestion that the rapid diminution in the size of the placenta, due to the free escape of the in- traplacental blood, favors retroplacental hemorrhage and consequent complete separation of the placenta. While this suggestion has not been confirmed by further observation, it is interesting to note that out of 68 cases of labor in Can's care, in which double ligature of the cord was practised, there were 4 cases of adherence of the placenta, while in 146 cases with single ligature there occurred but 2 cases of adherent placenta. The duration of the third stage of labor is also considerably lessened when but a single ligature is applied to the cord. In case of unusual thickness of the cord, due to the presence of an excessive amount of Wharton's jelly, strip- ping may be indicated. This consists in placing the finst or placental ligature, and then in severing the cord on the umbilical side of the ligature, the cord being held firmly at the umbilicus between the thumb and the index finger. This grasp being maintained, the excess of jelly is squeezed out of the end of the funis by pressure with the ' Boston Med. and Surg, your., March I, 1894. 172 A MANUAL OF OBSTETRICS. fingers of the other hand, and a second ligature is then placed near the extremity of the cord. The object of this process is to favor rapid desiccation. Stephen'' s Method. — Laceration of the Cord. — This method consists in wrapping the cord around the index finger of each hand and tearing it asunder; the vessels retract beneath the torn edges and hemorrhage does not follow. We cannot see that this method is in any respect superior to that generally employed. (4) The Use of Anesthetics. — Occasionally in the second stage of labor, owing to the severity of the pains or to the hypersensitiveness of the patient, or in order to avoid severe perineal laceration or to arrest eclamptic seizures, the use of an anesthetic is required. Either chloroform or^ther may be employed, but preferably the latt e wM^'oViS puer ipgfi4w6fi]nniynia. Proper precautions must Be observed in the use of the anesthetic, and grave cardiac or pulmonary afifections will be an absolute contraindication to its admin- istration. The method of administering the anesthetic varies somewhat from that employed in an ordinary surgi- cal operation. The most acceptable mode consists in laying a towel over the mouth and nose and pouring upon it, when the pain is coming on, three or four drops of ether or one or two drops of chloroform at each respiration. This will suffice to dull the pain ; the anesthetic may be withdrawn during the intervals. Advantages of an Anes- thetic. — It cannot be denied that certain advantages attend the use of the anesthetic. Thus, (l) it greatly diminishes the intensity of the patient's suffering ; (2) it relaxes the soft structures, and facilitates in this way expulsion of the child. There are to be noted, however, certain disadvan- tages, as follows: (i) It diminishes the efficiency of the uterine contractions to an appreciable extent ; (2) if admin- istered in too large quantity, it is followed by the usual after-effects — nausea, vomiting, and headache ; (3) it pre- dispo.ses to postpartum hemorrhage from non-contraction of the uterus. EUTOCIA, OR NORMAL LABOR. 1 73 Bedford Brown of Alexandria, Va., has employed chloro- form in over fifteen hundred cases of labor without any ill results. It is very evident that pregnant and parturient women show a remarkable immunity to the toxic action of chloroform, and Brown claims that its employment is justi- fiable in every case in which, in the second stage of labor, the woman shows any tendency to nerve-exhaustion. Managcuicnt of Pelvic Presentations. — {a) Before Labor. — On account of the high fetal mortality — 30 per cent. — at- tendant upon presentation of the pelvic extremity it is ad- visable in every case in which the diagnosis of breech pres- entation is made prior to the onset of labor to attempt to convert the presentation into that of the cephalic extremity by means of external bimanual manipulation. The proper performance of this maneuver requires experience on the part of the operator, the presence of a sufficient amount of liquor amnii, and the absence of excessive irritability of the abdominal and uterine muscles. If it cannot be accom- plished or if the case be seen after labor has begun, the treatment then consists in a careful supervision of the normal mechanism of the presentation, {f) First Stage of Labor. — Absolute inaction on the part of the accoucheur, other than a close watch over the progress of the case, is all that is required during the process of uterine dilatation. Particular care must be taken to preserve the membranes as long as possible, even until their appearance at the vulvar outlet, since they serve as a better dilator than does the soft breech, and by their presence the uterus is stimulated to more powerful contraction, (r) Second Stage of Labor. — The inaction observed during the first stage of the mechan- ism should continue until the breech has passed through the vulvar orifice ; care must be taken at that time to guard the perineum as in ordinary vertex presentations. The patient should be brought to the edge of the bed and made to assume the dorsal decubitus as soon as the breech has begun to distend the vulva, and every arrangement 1/4 ^ MANUAL OF OBSTETRICS. must be made to facilitate the birth of the upper portion of the trunk and the head. As the breech is expelled it is supported by the hands of the physician, while an assistant makes gentle pressure upon the fundus uteri ; no traction should be made, in order that the normal relationship of the arms to the thorax shall not be disturbed. The cord will appear as soon as the umbilicus of the child emerges from the parturient canal, and attention must at once be directed to it ; if the pulsations be normal, the funis should be placed in the angle corresponding to the sacroiliac .syn- chondrosis of the diameter opposite to that occupied by the fetal head, where it will be least impinged upon. There are now but a few minutes in which to deliver the child to avoid asphyxiation. Firm pressure must be exerted upon the fundus uteri, and the woman should be encouraged to bear down ; the body of the child must be supported, and even lifted somewhat, in order to favor descent and delivery of the posterior shoulder. If traction has not been made, the arms will slip out flexed upon the chest and the shoulders will emerge ; the body of the child will now occupy a transverse position, with the abdomen directed downward. Delivery of the After-coming Head. — Pulsations in the cord now probably cease from compression of the funis above against the pelvic wall by the advancing head, and fetal life cannot be maintained under these circum- stances for a period longer than five minutes. Immediate delivery must therefore be accomplished through manual efforts on the part of the physician himself There are various methods by which the after-coming head may be delivered. These, in the order of their application, are as follows: (i) The Wicgaiid-Martin Mctliod. — The child is laid astride the left arm, while the fingers of the corre- sponding hand are introduced into the vagina beneath the fetal body ; the index finger of this hand is passed into the child's mouth, and gentle traction is made in order to se- cure and maintain complete flexion of the head (Fig. 79). EUrOCIA, OR NORMAL LABOR. 175 The fingers of the right hand are then placed upon the occi- put through the abdominal walls just above the symphysis pubis, and by combined pressure above (backward, down- ward, and forward) and traction below the head is delivered ; Fig. 79. — Delivery of the after-coming head by flexion through seizure of lower jaw, and extrusion by means of pressure in axis of brim (Dickinson). as it emerges from the vulvar orifice the left arm should be elevated, so that the fetal back is directed toward the mother's abdomen; this movement prevents undue disten- tion, with laceration, of the perineum. (2) The Mcmriccaii or Vcit-Sincllie Method. — This is the same as the preceding as regards the disposal of the left hand. Instead, however, of indirect pressure upon the fetal head through the abdom- inal wall, the fingers of the right hand are passed into the vagina above the child, the middle finger extending up the 1/6 A MANUAL OF OBSTETRICS. neck until the external occipital protuberance is felt, upon which direct pressure is exerted ; the index and ring fingers grasp the clavicles, and traction is made by both hands downward, outward, and upward, following the course of the parturient canal. If it be desired, an assistant may aid in this movement by suprapubic pressure upon the descend- ing head. (3) The Prague Method (Fig. 80), also called Fig. 80. — Prague method of extracting the after-coming head, superior strait (Dickinson). PiigJis Method. — The right hand firmly grasps the child's ankles, the heels fitting into the palm of the hand, the mid- dle finger just above the internal malleoli, and the index and ring fingers above the external malleoli ; the index finger of the left hand is then passed over the right clavicle from above, and the remaining fingers of this hand over the left clavicle, and combined traction with the two hands is made downward and outward until the head well distends the perineum; the right hand now grasps the legs just below the knees in the same manner as before, the toes, however, resting upon the back of the hand; with this hand the body is forcibly lifted upward and carried over the mother's abdomen, toward which the back of the child is directed, while the left hand remains firmly fixed at the symphysis as a fulcrum beneath which the head rotates on its outward way over the perineum. Unless this maneuver be performed with great care the fetal neck may be dislocated or fractured, or the child even be EUrOCIA, OR NORMAL LABOR. 177 decapitated. (4) The Dcvciitcr lilctliod (Fig. 81). — This method should be employed only in cases in which very rapid delivery is required and in which no pelvic or other deformity exists. The mother being placed with the hips extending well beyond the edge of the bed, the child is grasped as in the Prague method, and is carried downward Fig. 81. — Deventei's method of extraction of the after-coming head ami arms (Dicl J rounds. iVx 2 9^ 3 II 4 i^i^ 5 14 6 15 Month. Weight in Pounds. 7 16 8 17 9 18 In size a healthy child should grow nearly three-quarters of an inch for each month during the first year of life, and during the second year about half an inch per month. ■Weaning, or Ablactation. — By this term is meant the ending of the nursing-period and the transference of the child from mother's milk to other food. Usually a child should be weaned not earlier than the ninth month and not later than the twelfth month ; occasionally weaning may be accomplished as early as the sixth month. Weaning should not take place during excessively warm weather or while the child is suffering from any attack of illness not dependent upon deficiency in its original food-supply, bi- dications for Weaning. — The indications for weaning are as follows: I. Any disagreement of the maternal milk with 212 A MANUAL OF OBSTETRICS. the digestive function of the child ; 2. The presence in the mother's system of some grave systemic poisoning develop- ing late in lactation, such as syphilis or tuberculosis ; 3, The advancing age of the child, with the appearance of the teeth ; as a rule, the child should not be completely weaned until six or more teeth have appeared, by which time the power to digest stronger food will be present ; 4. A grow- ing dislike on the part of the child for the mother's milk ; 5. An insufficiency or total absence of milk in the breasts. Method of Weajting. — It is, as a rule, not safe to wean a baby suddenly. The proper method is to give daily for a couple of weeks one artificial meal of cracker and milk or beef-tea, or thin chicken-broth containing barley, rice, or bread-crumbs. If this meal be found to be well borne, an additional meal may then be given, and the child thus ac- customed gradually to the taking of table-food. In pro- portion as this is increased, the breast-milk may be di- minished until the child is completely weaned. It is proper to teach every infant over six months of age to drink milk from a cup. Malted milk, condensed milk, and some of the better prepared foods are sometimes of service as the child approaches the period of weaning. An egg or the white of an tgg, beaten up with milk or in a delicate broth, may occasionally be given ; with proper supervision the child may be allowed to suck a piece of steak or to gnaw on chicken-bones. A common error, and one that results fatally in many instances, is to allow the child to advance too rapidly to a diet of vegetables and fruits. It should be remembered that at birth the infant is purely carnivorous, and that it requires the lapse of months before its digestive organs become able to cope with vegetable food. Drying 1/p of the Breasts after Weaning. — The secretion of milk will often continue for some time after the child has been weaned, and its presence may be a source of considerable discomfort to the woman, so much so as to call for interfer- ence on the part of the medical adviser. In such cases the PHYSIOL OGY AND MANA CEMENT OF NE VV-BORN. 2 1 3 use of saline aperients will exert a powerful depletive effect, and their action should be supplemented by the ingestion of as little fluid as possible and the administration of certain drugs, such as potassium iodid in large doses — from 25 to 30 grains three times daily. Locally, applications of warm lead-water and laudanum or lint saturated with warm cologne-water will relieve the distention, together with the use of gentle massage and the careful and judicious em- ployment of the breast-pump. Cocain, also, in weak solu- tion, applied locally, has been claimed to promptly reduce the production of milk. Belladonna-ointment or a glycerol, of belladonna (made by rubbing a dram of the extract of belladonna with an ounce of glycerin) applied to the surface of the breast may be a valuable adjuvant in arresting the secretion of milk. The Baby's Outing. — Merely a word will suffice as to this point in the proper management of an infant. There is no fixed law upon the subject, but it is generally thought best by well-regulated families not to permit the child to leave the house in winter until it has attained the age of three months, and then it is to be taken out only on a clear day and just before the noon hour. In summer, if desired, the child may be taken into the yard after the second week, and after it is two months old it may spend most of its time in the coach out of doors, avoiding, of course, an excess of sunshine or prolonged exposure to strong winds. PART II.— PATHOLOGIC OBSTETRICS. INTRODUCTION. Hitherto we liave been dealing only with the normal state of a woman during the time that must elapse from conception to the weaning of the child. While it is possible for such a condition of eucrasia to exist that the mother and her offspring will pass through this critical period without falling victims to any of the numerous diseases and mishaps that thickly beset the childbearing era, such an immunity is exceedingly rare. In the vast majority of cases there will be manifested at some time and to a greater or less degree one or more of the pathologic states that are familiar to an obstetrician of any experience whatever. The physical imperfections of parents and ancestors, perhaps latent and obscure hitherto, will reveal themselves in se- rious and often fatal form in the unfortunate offspring ; the pernicious influence of years of improper hygienic environ- ment resulting in faulty and imperfect bodily development will be manifested in pregnancy in exaggerated and patho- logic reflex neuroses, and in labor in a grave and complicated form of dystocia ; want of proper antiseptic precautions on the part of physician or nurse, or irremediable non-hy- gienic surroundings exerting a pernicious influence not- withstanding the best of such precautions, will result in grave puerperal complications ; through some unexpected and unavoidable combination of circumstances the normal management of the new-born infant must be widely de- viated from, and the risks and often serious consequences of such deviation to both mother and child must be com- bated. With such grave possibilities menacing each and 214 DISEASES OF THE MEMBRANES. 21$ every stage of this eventful period it is no wonder that it is exceptional for a woman to pass through it unscathed from beginning to end. In order to the clearer and more systematic presentation of these manifold pathologic conditions, and in accordance with the system adopted in the foregoing portion of this book, a chronologic sequence has been selected as the most satisfactory and rational method of dealing with the subject. Treated in this manner, the following natural subdivisions present themselves for consideration : I. Diseases of the Ovum and the Fetal Appendages. II. Pathologic Conditions of the Fetus. III. The Pathology of Pregnancy. IV. Dystocia, or Difficult Labor. V. The Pathology of the Puerperium. VI. The Pathology of the New-born. I. DISEASES OF THE OVUM AND THE FETAL APPENDAGES. I. Diseases of the Membranes. (a) Pathologic Conditions of the Deciduee. — Diseases of the maternal membranes are the most frequent pathologic processes of intrauterine life, and because of their great frequency and their grave sequelae, the most common of which is abortion, they well deserve early mention in the pathology of obstetrics. (i) Deciduitis, or inflammation of the decidual tissue, is in reality an endometritis modified by the peculiar changes wrought in the uterine mucosa by pregnancy. The disease may be either acjifc or clwonic. Acute deciduitis is very rare. It may result from trauma, filth, or certain infectious diseases, and occurs in three well-marked forms — namely, the infectious or exanthematous, the hemorrhagic, and the purulent, {a) Infectious or exaiitlieuiatous deciduitis is that form accompanying the development of the exanthema- 2l6 A MANUAL OF OBSTETRICS. tous diseases during pregnancy. It is a well-known fact that the mucosje of the body participate in the eruption of these diseases, and it is probable that when such a disease attacks a pregnant woman the hypertrophied uterine mucosa, because of its extreme vascularity, becomes intensely in- flamed and covered with the eruption. The almost inevi- table result is abortion, the discharge of the ovum taking place just as the efflorescence appears upon the skin. The maternal mortality in this variety is high, {b) Hemorrhagic deciduitis is a very rare form accompanying acute infectious diseases such as Asiatic cholera. It is destructive to the product of conception, and likewise is generally fatal to the mother, (r) Piir'ident deciduitis is a septic and often rapidly fatal form characterized by the presence of an offensive and purulent discharge. It is usually a sequel of attempts at criminal abortion, but it may follow other traumatisms. Treatment of Acjite Deciduitis. — The management of the acute inflammations of the decidua consists merely in at- tention to the complications as they arise, the prevention of excessive hemorrhage, and the favoring of the abor- tion should the signs of a discharge of the ovum appear. Efforts to arrest the threatened escape of the ovum would be misdirected. Chronic Deciduitis. — Chronic inflammation of the decidua is a very common affection, and is probably the predis- posing cause of the vast majority of early abortions. As to its precise etiology there is much conjecture, though but little is actually known. It is probable that the follow- ing may act as causative factors in many cases: (i) A pre- existing neglected endometritis which, under the stimulus of gestation, assumes renewed activity; (2) Syphilis; (3) Death of the fetus, with the production of irritating retro- grade products that act locally upon the decidua; (4) Ovcr-excrtion and excessive work; (5) General systemic dyscrasia. There are described four clearly-defined forms of this disease — namely, the diffuse hyperplastic, the tuber- DISEASES OF THE MEMBRANES. 2iy ous or polypoid, the cystic, and the catarrhal, [a) Chronic Diffuse Hyperplastic Deciduitis {Endometritis decidua chronica diffusa vel Endometritis gravidantni Jiyperplastica). — As the name indicates, the pathology of this disease consists essentially in an inflammatory overgrowth of the deciduae, especially of the decidua vera, with the production of a firm sarcous mass. This disease is a common one, and generally occurs secondarily to a preexisting endometritis. If it develop early in pregnancy, as is usual, there can be but one result — namely, decidual apoplexy with abortion and the discharge of a piece of meat-like substance, a so-called yfrj-Zy/ mole. Occasionally these fleshy masses may be retained in jitero for months and undergo partial organization. In the rarer cases in which the development of the disease occurs late in pregnancy the fetal growth may not be interrupted and gestation may proceed to term ; there then follows the formation of extensive adhesions resulting in that serious complication of labor, adherent placenta with retention of portions of the decidua vera, {b) Chronic Tuberous ox Poly- poid Deciduitis {Endometritis decidua tuberosa et polyposa vel Endometritis gravidariim polyposa). — This is a rare vari- ety of the preceding condition, and consists in a localization of the inflammatory process in scattered areas of the de- cidua ; at these foci of inflammation excessive overgrowth of the decidual tissue occurs, with the formation of polyp- like growths that are most frequently located upon the anterior or posterior uterine walls as determined by the position of the ovum, the growths directly facing the site of the latter. The polyps may attain a considerable size (from ^ to ^ of an inch in length) and are exceedingly vascular. The inevitable result of this affection is early abortion (from the second to the fourth month) from fatty degeneration and decidual apoplexy, {c) Chronic Cystic Deciduitis [Endometritis gravidarum cystica). — A variety of the hyperplastic deciduitis in which not only is there an over- growth of the decidual connective tissue, but also an occlu- 2l8 A MANUAL OF OBSTETRICS. sion of the ducts of the utricular glands, with hypersecretion and accumulation of the mucus, forming large-sized reten- tion-cysts. If spontaneous cure or abortion does not take place, a variety of hydrorrhea results, {d) Chronic Catarrhal Deciduitis {Endometritis gravidarum catarr ha/is vel Endo- metritis dccidua catarrlialis). This is an interesting form of deciduitis, of less severity than the others, and characterized mainly by excessive activity of the glandular elements of the endometrium ; there is associated to a certain degree a hyper- plasia of the constituent elements of the decidua. This con- dition is most common in multiparous women, and occurs generally after the sixth month of gestation, although it has been noted as early as the third month. When occurring early in pregnancy the fluid escapes gradually and only in small amounts ; at times, however, the adhesions between the reflected layer of the decidua and the decidua vera prevent its escape in this way, and an accumulation of the secretion occurs, often to a remarkable degree ; instances are reported where a pound or more of the fluid has been stored up in the uterine cavity. As a result of the immense pressure exerted by this large collection of fluid the adhesions be- tween the deciduje are torn apart and the water escapes in a gush — the so-called Jiydrorrha\i gravidarum {Jiydrorrha-a decidualis), or "false waters," closely resembling the escape of the liquor amnii when the membranes are ruptured. This discharge may take place without any premonitory symptoms, and may not be accompanied by other clinical manifestations ; occasionally, however, there are present triv- ial pains due to slight uterine contractions. Cause. — There is considerable obscurity as to the exact etiology and pa- thology of decidual hydrorrhea. Thus, Braun emphasizes the precxistcnce of an endometritis with resulting exudation. Hegar considers the pathologic process to be of the nature of a decidual hypertrophy especially involving the glandular substance. Scanzoni, Zini, and Chazan refer it to the con- dition of the blood, Scanzoni believing that the disease DISEASES OF THE MEMBRANES. 219 results from a transudation of serum from the watery blood, Zini regarding the fluid as an extravasation resulting from the hyperemia of the uterine mucosa, and Chazan referring it to the periodic congestion of the genital organs that occurs during pregnancy. Source of the Fluid. — Just as an uncer- tainty exists as to the etiology of the disease, so various theories are advanced as to the source of the fluid. It is probable that there is no one constant source, but that the fluid may accumulate as a result of pathologic processes located in various structures of the developing ovum. With- out a doubt in some cases there exists a true edema or se- rous infiltration of the uterine wall, resulting in an accumu- lation of fluid between this and the membranes. In other cases Kaltenbach and others claim that the fluid collects between the opposed surfaces of the decidua vera and de- cidua reflexa in the space that normally exists between these membranes during the early period of pregnancy (the first three months). There are two facts that would seem to demonstrate the probability of such an origin — namely, the frequent development of the malady during these months of gestation, and the fact that occasionally in this disease the immensely thickened vera has been separately expelled after the placenta, thus proving absence of union between the deciduse vera and reflexa. It is the belief of Hennig and Schroeder that the accumulation of the fluid occurs between the chorion and the decidua, while Duges and Jorg assert that a persistence of the allantoic sac may produce a hydror- rhea. They claim that in many instances the amnion and chorion, instead of being glued together by an amorphous tissue, are separated by a collection of fluid, so that two sacs are present in the after-birth ; it maybe that these so-called ''false ^caters" may escape during pregnancy in the form of a hydrorrhea, although this is incapable of actual demon- stration because of the inability to chemically distinguish the fluid from the true liquor amnii (Doderlein). Intensely inter- esting as the subject is, the etiology and pathology remain 220 A MANUAL OF OBSTETRICS. as yet largely matters of conjecture, awaiting the results of further research. Character of the Fluid. — The fluid that is discharged in true hydrorrhoea gravidarum is clear, thin, watery or mucopurulent (occasionally serosanguinolent), of a pale-yellow or slightly reddish tinge, highly albuminous, and with a peculiar spermatic odor. Repeated gushes may occur at irregular intervals when the patient is on her feet or while she is resting in bed. Diagnosis. — So closely does this condition of hydrorrhea resemble the escape of the liquor amnii that some points of differentiation should be indicated in order that a correct diagnosis may be made. Ilydrorrhcea Gravida nif)i. Discharge of the Liquor Amnii. The discharge may occur days or even The discharge immediately precedes de- weeks before labor. livery. Usually there are no premonitory symp- Usually labor-pains or the premonitory and toms. other signs of labor have been present for some minutes or hours. The flow occurs at intervals. The discharge occurs but once. The OS uteri is closed. The os uteri is patulous. Ballottement may be elicited, proving the Ballottement cannot be elicited. presence of the liquor amnii. The fluid is highly albuminous and contains The liquor amnii contains only a trace of al- mucin. bumin, but considerable amounts of urea and urates. (This is the main test in the diagnosis of those rare cases of amniotic hydrorrhea.) Treatment of CJironic Deciduitis. — For the first three vari- eties of deciduitis no management other than symptomatic treatment is required. When abortion is threatened efforts should be made to preserve the product of conception, and if these efforts prove futile, danger from hemorrhage and sepsis should be averted, and the patient subsequently treated as a puerperal woman. In the case of hydrorrhea generally no treatment is indicated ; if it be accompanied by painful uterine contractions, rest in bed with the administration of opium by the mouth or per rectum will suffice. (2) Hemori'hage from the Decidna, or Decidual Apoplexy. — Owing to the extreme vascularity of the deciduae, and the rapid growth and distention of their blood-vessels and cap- DISEASES OF THE MEMBRANES. 221 illaries, the latter manifest a peculiar tendency to rupture, with the production of an effusion of blood into and between the membranes. This is most common during the first two months of gestation, and the usual result is abortion. If this follow immediately after the effusion of blood,- the expelled mass is termed a blood or sanguineous mole [inola sanguined) ; if the discharge be postponed for some weeks, a certain amount of organization of the blood-clots takes place, and the mass when finally expelled presents a peculiar meat-like appearance and is termed a carneous or fleshy mole {inola carnosd) ; in exceptional cases a deposit of lime-salts may take place in these organized clots, and the mass, which is hard and stony, is then termed a calcareous or stone mole ; a gestation thus prematurely ended is termed di false or molar pregnancy, and the product a blighted ovum. The etiology of apoplexy of the decidua embraces traumatism of various kinds (including too frequent coitus) and chronic nephritis, the decidua sharing in the general tendency to apoplexy manifested by this disease. The treatment is that of abortion. (3) Atrophy of the Decidua. — In some rare cases the ute- rine mucosa fails to undergo the development that normally takes place during pregnancy. As a consequence of this atrophic condition of the decidua the impregnated ovum does not find sufificient lodging- place in the fundus uteri; it remains at its normal site until its increasing weight be- comes too great for the decidual adhesions, which it gradu- ally stretches into the form of an elongated pedicle. It finally lodges within the cervix, and there it continues to develop until by its growth reflex contraction of the cervix is produced and the ovum is expelled. This condition is termed a cervical pregnancy and is most common in prim- iparae. The treatment is that of abortion. (4) Tumors of the Decidual. — Neoplasms of the deciduae are very rare. Two varieties have been recognized, {a) Dcciduonia. — This is a non-malignant growth composed of decidual relics that have undergone hyperplasia. The 222 A MANUAL OF OBSTETRICS. symptoms produced by this tumor are hemorrhage more or less severe, a fetid and profuse leukorrhea with possibly the occasional discharge of fragments of decidual tissue, and a certain degree of blood-poisoning as evidenced by elevation of temperature, prostration, and chilly sensations. The deciduoma is but slightly attached to the uterine wall. The only treatment of this growth consists in its complete removal by the curet under antiseptic precautions, followed by the introduction of an iodoform-tampon. Internally, quinin and stimulants are indicated. {U) Dccidiiosarconia, ]\Ialignant Deciduoma. — This is a malignant degeneration of retained decidual debris characterized by a tendency to the formation of metastatic deposits throughout the body, and rapidly proving fatal in from five to six months after delivery. It may follow cystic disease of the chorion. The treatment is hysterectomy. The curet and iodoform-gauze may be employed, but generally the neoplasm promptly returns. {I}) Pathologic Conditions of the Chorion. — (i) Cliorion- itis, or inflammation of the chorion. In common v/ith other vascular tissues the chorion is subject to slow forms of in- flammation that result in the production of more or less dense bands of adhesion between it and the amnion and decidua. This inflammation may be, and very frequently is, syphilitic in origin, or the chorion may participate in an inflamed condition of the decidua secondary to a preexisting endometritis. If the process become well marked, abortion is apt to follow. The treatment is purely symptomatic. (2) Cystic Disease of the Chorion. — Synoiiyms. — Hydatidi- form, Hydatiform, Hydatoid, Cystic, Placental, or Vesicular Mole ; Hydatidiform or Myxomatous Degeneration of the Chorion ; Dropsy of the Villi of the Chorion ; Cystic De- generation of the Villi of the Chorion ; Cystic Disease of the Ovum ; Uterine Hydatids ; Molar Pregnancy. — This is a rare affection of the chorion consisting in a proliferative de- generation of the chorionic villi, with the production of a mass DISEASES OF THE MEMBRANES. 223 of grape-like vesicles attached to the placenta and known as placental moles (Fig. 87) ; these vesicles vary in size from that of a pin's head to a walnut or larger, and they contain a trans- parent fluid closely resembling the liquor amnii. The disease is an exceedingly rare one, statistics showing that it occurs but once in about two thousand cases of preg- nancy. A curious feature of the affection is the tendency it shows to recur in successive pregnancies in a given individual, one patient, reported by Mayer, suffering with the disease eleven times. The Fig. 87. — Hydatiform mole: a, number of cysts may be very vast, deddua; b, chorion and amnion; even five thousand or more, each '^.;^^seis;..,/, vesicles of differ- ' ent size and form. cyst having a pedicle which is attached to another cyst and not to a common stalk ; the entire mass of diseased villi may attain the size of a fetal head or in rare instances occupy a bulk equal to that of a fetus at term or even larger, and weigh several pounds. Time of Developvient. — Most commonly, accord- ing to Bloch, Louis Meyer, Schroeder, and Kehrer, the disease originates during the latter part of the childbearing period, 22 per cent, occurring in the fourth and fifth decen- nia; it usually appears during the first month of gesta- tion, and when it occurs thus early the fetus quickly dies and may be entirely absorbed. If the disease de- velop later, in the second or third month, while fetal death may result, provided sufficient of the membranes and placenta be involved, it is possible for the life of the fetus to be preserved. In case of fetal death at this period of gestation complete absorption does not generally take place. Causes. — The true etiology is obscure, but among the probable causes may be enumerated the following : 224 '^ MANUAL OF OBSTETRICS. (i) Preexisting endometritis or metritis; (2) the presence of uterine fibroids ; (3) a chronic deciduitis ; (4) some grave maternal dyscrasia, such as syphiHs or carcinoma (Vir- chow) ; {5) abnormal allantoic development, such as absence or deficiency of the vessels (Spiegelberg) ; (6) some obscure fetal disease (probably syphilis) ; (7) fetal death (Graily Hewitt, Greise). An interesting and as yet unanswered question is, " Is the disease primarily embryonic or maternal in origin ? " In other words, is embryonic death the cause or the outcome of the pathologic process in the chorion ? While no definite answer can be given, it is probable that in some instances, it may be in the majority of the cases, the disease follows a pathologic process in the embryo, resulting in its death, while in other cases death of the embryo is a direct outcome of interference with the func- tion of the chorion, the result of the dropsical condition of the villi. In either case, the disease occurring within the early weeks of pregnancy, entire absorption of the embryo may follow. Pathology. — The first portion of the chorion to participate in the degenerative process is the epithelium of the villi. The connective-tissue cells undergo an immense proliferation, and the fibrous tissue thus formed is grouped in small areas ; the remainder of the villus is unchanged. By the growth of these elements each villus becomes distended, and many of the epithelial cells undergo a liquefactive pro- cess ; the fluid thus produced separates the connective tis- sue and forms a reticulated mesh within the interior of the villus. These membranous tufts maintain the same form as the normal chorionic tufts of the first two months. There are formed in this manner the characteristic grape-like bodies. The vascular supply of the diseased tissue is de- rived from the connections of the chorion with the decidua, and the tufts consist of living, growing tissue-elements. Varieties of Hydatidiforvi Moles. — Vesicular moles are, ac- cording to Kehrer, observed in four different forms : i. Mola hydatidosa incipiens. — In this variety a cyst is formed, about DISEASES OF THE MEMBRANES. 22$ the size of an ovum of the third or fourth month of gestation, consisting- of an amnion and a chorion, upon the surface of which there are numerous vesicles. The embryo is either entirely absent or some of its fragments float in the liquor amnii. The umbilical cord may be present or absent. 2. Mola Jiydatidosa partialis. — In these cases the fetal mem- branes and the placenta are normally developed, but some of the placental villi are surmounted by vesicles, or parts of the placenta are changed into bands or plaques of vesi- cles. The branches of the umbilical artery leading to these degenerated villi are obliterated. The fetus is often living, sometimes normally developed, sometimes stunted in its growth. 3. Mola Jiydatidosa totalis. — The ovum is a mass of vesicles surrounded by a decidua perforated in numerous places. Remnants of fetal membranes are sometimes found in the midst of the vesicles. Of the fetus no trace is left. 4. Those cases in which a twin-pregnancy exists. One ovum is normally developed, the other one is a shapeless mass of myxomatous villi. Twelve cases are reported in medical literature, one by Kehrer.^ Clinical Manifesta- tions. — There are three very characteristic symptoms of this curious disease — viz. sudden or rapid increase in the size of the uterus much beyond that corresponding to the period of pregnancy; irregular uterine hemorrhages vary- ing in duration from a few hours to several weeks, and in amount from a moderate to an excessive flow; these hemorrhages become more frequent and severe with the growth of the vesicles into the decidua ; and the dis- charge of a serosanguineous fluid containing the peculiar vesicular growths. While the disease may have existed from the first month of gestation, the excessive increase in size is usually not noted until the third or fourth month. At this time palpation of the large and often irregular uterine tumor will reveal a peculiar doughy sensation, with inability to distinguish the outlines of the fetal tumor ' A)-chiv f, Gyndk., Band xlv. Heft 3. 15 226 A MANUAL OF OBSTETRICS. through the walls of the uterine mass, and there is an absence of the fetal heart-sounds. The hemorrhages may be frequent in occurrence and very profuse, or there may be but one hemorrhage rapidly proving fatal. The cysts, upon finding which in the discharge an absolute diag- nosis may be made, are of a whitish, sago-like appearance, and are generally surrounded by small clots of blood. According to McClintock, these cysts may be retained in iitcro for months and even years, a few being expelled at varying intervals. Associated with the enlargement of the abdomen are aggravated reflex manifestations, such as excessive nausea and vomiting, a feeling of faintness often aggravated to syncope, and abdominal (in 50 per cent, of the cases), lumbar, or sacral pains ; extreme exhaustion may be noted. It is probable that the abdominal pains are caused by the penetration of the villi into the uterine sub- stance. Renal insufficiency with albuminuria and edema of the feet is frequent. A serious complication exists when the cystic change extends through the decidual tissue and in- volves the uterine wall itself; the disease then assumes a semi- malignant type, and death may result from uterine perfora- tion with septic peritonitis. Diagnosis. — The diagnosis will be more or less obscure until the vesicular growths are dis- covered in the discharge ; an absolute diagnosis may then be made. In some cases it may be possible by introducing the finger through the os uteri to distinguish the character- istic grape-like masses. Prognosis. — As regards the fetus the prognosis is very grave ; usually the ovum is destroyed and in many instances entirely absorbed. The fetal risk is di- rectly proportionate to the extent of villous involvement. The maternal prognosis is by no means good. Over 13 per cent, of women afflicted with this disease will lose their lives. The causes of maternal death are exhaustion from hemorrhage, septic infection, and uterine perforation with peritonitis. The disease terminates usually in the fourth or fifth month of gestation, a premature expulsion of the DISEASES OF THE MEMBRANES. 22/ diseased ovum being favored by the excessive growth and consequent over-distention of the uterus and by the irritation produced by the penetration of the vesicles into the uterine substance. Treatment. — Immediate evacua- tion of the uterine contents is the proper course to pursue. The woman being anesthetized, after thorough disinfection of the vulva and vagina the os may be stretched by Hegar's dilators or Barnes's bags, and when sufficient dilatation has been effected the diseased product of conception should be removed by the finger or the placental forceps ; the curet should not be used for fear of the possible involvement of the uterine wall with resulting danger of perforation. After the contents have been evacuated an intrauterine douche should be given and an iodoform- tampon introduced into the uterus ; the woman may then be treated as a puerperal patient. Full doses of ergot may be exhibited for some days after the removal of the mole. If the only symptom presented be hemorrhage, it should be controlled by the use of tampons, rest, and opiates. If the lochia become fetid intrauterine antiseptic douches will be required. (3) Fibromyxomatous Degeneration of the CJiorion, or Myxoma fibrosiim. — This is a still rarer affection of the chorion than the preceding, limited usually to the placental portion, and occurring in the later stages of gestation. It consists in a fibroid degeneration of the connective-tissue portion of the chorion situated over the placental site, with the formation of small-sized tumors that ultimately take on a myxomatous change. Those portions that undergo the mucous change have a soft, gelatinous feel. Owing to the late development of this disease, fetal life may not be de- stroyed. The symptoms are obscure, and the diagnosis may not be made until after labor. The treatment is symptomatic. [c] Pathologic Conditions of the Amnion. — (i) Atn- niotitis {Amniotis). — This is a plastic inflammation of the 228 A MANUAL OF OBSTETRICS. amnion, characterized by the exudation of a soft, but- tery material which, on hardening, causes adhesions between the amnion and certain fetal portions, constituting what are termed the fctomnniotic bands. For these adhe- sions to take place the inflammation must occur early in pregnancy, before there has been a considerable formation of liquor amnii, and while the fetus and its membranes are still in close juxtaposition. Two serious conse- quences may follow extensive amniotic adhesions — viz. premature detachment of the placenta from traction caused by the fetus during expulsive uterine efforts, and resulting in fetal death and serious maternal hemorrhage ; and, secondly, there may be produced the so-called spoiitaneojts or intrauterine amputations of fetal parts (Fig. 88). A dense band or fold of the amnion may be thrown over a limb of the fetus, and by con- stricting the circulation may arrest the growth and de- velopment of the distal portion, which may be either com- pletely separated or only retarded in its growth and caused to undergo an atrophic process. In case complete amputa- tion is effected the severed member will probably be entirely absorbed if the accident has happened prior to the third month of gestation; if amputation has occurred later in pregnancy, the separated portion may be expelled at the time of labor subsequent to the birth of the child. The theory ascribing intrauterine amputation to constriction produced by twisting of the cord around the fetal limbs is erroneous ; such constriction would result in fetal death, from asphyxiation due to interference with the circulation in the cord, long before amputation had been accomplished. (2) Rupture of the Amnion. — In rare instances the Fig. 88. — Ectromelus (intraulerine amputation). DISEASES OF THE MEMBRANES. 229 amnion, for unknown reasons, will become excessively attenuated, so that it will resemble tissue-paper. Any additional stretching will inevitably result in a rupture of the delicate structure, and the over-distended mem- brane will then retract in bands or strings that may en- circle some fetal portion and give rise to intrauterine con- strictions or amputations. In other cases, without this pre- existing tenuity rupture of the amnion may take place, with escape of the contained liquor amnii. If the solution of continuity occur low down, in the usual situation, the uterine contents will generally be evacuated ; occasionally, however, the rupture takes place at some point near the attachment of the amnion to the placenta, and then, instead of one quick gush of fluid, the liquor amnii will drain away in small quantities from time to time for a period of weeks or months. This constitutes the condition known as am- niotic liydrorrhea, which must be diagnosed from the ordinary hydrorrhea of pregnancy. Generally, the treat- ment of this condition is inaction, unless abortion be threat- ened, when measures must be taken to preserve the product of conception ; if this be impossible, the usual treatment of abortion must be instituted. (3) Oligoliydrainnios is an abnormal deficiency in the amount of liquor amnii secreted. This condition is ex- tremely rare, probably not occurring more frequently than once in 3500 cases, and is of pathologic import- ance only when it is marked in the early months of intra- uterine life ; it may then result in fetal deformities, such as talipes or bowing of the limbs (due to interference with the growth of the fetus from compression by the uterine walls), or in intrauterine amputations from the formation of feto- amniotic bands with ultimate constriction of one or more parts. If present late in pregnancy, the fetal movements will be more or less painful to the mother, and the labor will be prolonged and difficult on account of the absence of the amniotic fluid. V 230 A MANUAL OF OBSTETRICS. (4) Hydramnios, Polyhydramnios, or Dropsy of the Am- nion. — This is an excessive secretion of the liquor amnii, a much more common condition than its converse, oHgohy- dramnios ; it is said to occur about once in 300 cases of labor. For the sake of convenience in determining when this affection exists an accumulation of two quarts or more of the fluid has been accepted as constituting a true hydramnios. At times the amount of fluid stored up in the amniotic cavity has been very large, as much as six or seven gallons being on record. The disease may be encoun- tered in one of two forms. In rare instances it maybe acntc, the excessive secretion taking place in from one to a i&w days ; more common is the chronic form, in which there is a steady accumulation of fluid during a period of several months. Etiology. — As to what is the actual cause of this interesting malady no positive statement can be made. It is probable, however, that it most often results from a path- ologic state of the fetus, generally syphilis, manifesting itself in some obstruction to the fetal circulation, the obstruction being usually located in the liver or the heart. In consequence of this obstruction there is a great rise in the pressure of the blood in the umbilical veins, the fetal portion of the placenta becomes highly edematous, and through osmotic action the excess of fluid accumulates in the cavity of the amnion. Other theories that have been advanced in an effort to elucidate the matter are these : (i) An excessive secretion of urine on the part of the fetus ; (2) pressure upon the umbilical or other veins by a large fetal abdominal tumor; (3) exudation from the fetal skin when the latter is the seat of some pathologic affection, such as nevus or elephantiasis congenita cystica ; (4) amniotitis (often the cause of acute hydramnios); (5) deciduitis; (6) multiple pregnancy, resulting in interference with the circulation of the weaker fetus, and consequent hydramnios from placental edema : a fact worthy of note is that occasionally hydram- nios is associated with, and perhaps caused by, hypertrophy DISEASES OF THE MEMBRANES. 23 1 of the placenta, the latter attaining a size considerably above the normal; (7) general maternal anasarca, the gravid uterus participating in the condition ; (8) exaggerated maternal hydremia; (9) multiparity (according to McClintock hy- dramnois occurs more frequently in multiparae than in primiparae in the proportion of 23 : 5). Symptoms. — In the acute form the symptoms may be quite marked ; there is more or less pain, which often becomes intense ; extreme and rapid distention of the abdomen ; a moderate rise of temperature, resulting from the acute inflammatory action that is taking place upon the amniotic surface ; inability of the woman to assume the recumbent posture; vomiting that may become incessant ; profound disturbance of respiration, often amounting to orthopnea, and then accompanied by symptoms of asphyxiation — viz. lividity of the face and irregularity of the pulse and respiration. In the chronic form of hydramnios the accumulation of fluid is much less rapid, and is, consequently, unattended by the foregoing severe symptoms. The distention is most commonly noticed about the third or fourth month, and is steadily progressive, giving rise, as a rule, to but little discom- fort to the mother. There is a slight disturbance of the general health, the patient feeling somewhat depressed ; there is more or less insomnia, resulting probably from the sense of weight — rarely amounting to actual pain — in the pelvic region ; associated with these general mani- festations are the most important symptoms of the disease — namely, those resulting from pressure. Impeded respiration and palpitation of the heart from upward displacement of the diaphragm; neuralgia of the abdominal walls, pelvis, and lower extremities from pressure upon the pelvic and sacral plexuses of nerves ; edema of the genitalia and limbs from interference with the pelvic circulation ; the voiding of scanty and albuminous urine from obstruction of the renal circulation ; derangements of digestion resulting reflexly from the extreme uterine distention or directly 232 A MANUAL OF OBSTETRICS. from pressure exerted upon the abdominal viscera; occa- sionally the production of ascites from pressure upon the portal vein — all of these troublesome symptoms may occur as a direct result of the great over-size of the uterine tumor. Physical Signs. — Inspection shows extreme distention of the abdomen. Palpation reveals an immensely enlarged uterus with tense and somewhat elastic walls, while a vague sense of fluctuation may be noticed. The fetus may be readily displaced from one position to another or even completely inverted. On auscultation there is either total absence of the fetal heart-sounds, or they are much diminished in intensity by their transmission through the excessive amount of liquor amnii. Vaginal examination reveals a high position of the OS, with more or less obliteration of the cervical canal ; the lower uterine segment is tense, elastic, and at times dis- tinctly fluctuating, while the presenting fetal part can be distinguished with difficulty. Diagnosis. — In pronounced cases of hydramnios the correct diagnostication of the con- dition is by no means a simple matter. It becomes imper- ative to distinguish between that condition and the presence of ascites during pregnancy, ovarian cystoma, and multiple pregnancy. In the following tables may be found the main points of differentiation — From ascites : Hydramnios. Ascites. The uterus may be readily detected as a The contour of the uterus is recognized with round, almost spheric mass. difficulty. Percussion gives an area of dulness corrc- The patient occupying the dorsal position, sponding to the contour of the uterus, with dulness will be found in the flanks as well a tympanitic note in the flanks. as over the pregnant uterus. Change of position has no eflfect upon the The area of dulness varies with a change in area of dulness. the position of the patient. There is no effusion of liquid elsewhere. There is usually the coexistence of dropsical effusions in other parts of the body. The urine is not much decreased in amount, The urine is diminished in quantity and is but may contain traces of albumin, whitish and turbid. There is little or no thirst. There is constant and great thirst. Distention occurs mainly in the median line. The hypochondria are much distended. In hydramnios rapidly developing at the In extreme ascites the umbilicus is mark- fifth or sixth month (usual time) the um- edly protuberant. bilicus rarely protrudes. DISEASES OF THE MEMBRANES. 233 From ovarian cystoma (very difficult) : Hydramnios. Ovarian Cystoma. The uterine tumor is drawn up, and is felt The uterus is low down in the pelvis, even with difficulty by vaginal examination. though pregnancy coexist (Kidd). Other signs of pregnancy coexist. In uncomplicated cases these are absent. There is a history of pregnancy, with the There is a history of gradual and slow de- rapid development of the uterine disten- velopment of the growth covering a period tion during its progress. of months. The characteristic blotches of pregnancy The characteristic ovarian facies is present are seen upon the face. in advanced cases. Usually the patient is not much emaciated. The patient ultimately emaciates. From imdtiple pregnancy (often difficult) : Hydi-atnnios. Multiple Pregnancy. The uterine tumor is more distinctly tense. The uterine walls are not so uniformly dis- tended and tense. Fluctuation may be elicited. Fluctuation is absent. There is inability to palpate the fetal limbs. A number of fetal limbs may be palpated. The lower uterine segment is unusually dis- There is no undue distention of the lower tended, tense, and elastic; the presenting uterine segment; the presenting part of fetal part is recognized with difficulty. a fetus may be readily detected. The fetal heart-sounds are faint or altogether The fetal heart-sounds are distinct ; heart- absent, sounds of diffi:rent rates, corresponding to the two fetuses, may be heard. Prognosis. — The maternal prognosis, while not grave, is not good ; there is manifested a great tendency for the ges- tation to suffer an early termination from excessive uterine distention, from fetal death, or from premature detachment of the placenta, thus exposing the patient to all the risks of an abortion ; the extreme distention to which the uterine walls have been subjected is apt to result in weak and ineffectual labor-pains, thereby causing a prolongation of labor, with subsequent decided inclination to postpartum hemorrhage ; the uterus is slow to recover from the effects of the disease, and involution consequently is retarded or perhaps is not fully completed. Death may even supervene from exhaustion, especially in the more acute variety of the disease. The coexistent pathologic condition of the fetus and its appendages predisposes to the development of puerperal sepsis. The fetal prognosis is bad, fully 25 per cent, of the children losing their lives. Many of the fetuses are diseased, and present after labor various path- 234 A MANUAL OF OBSTETRICS. ologic conditions, such as hydrocephalus, syphiHs, or ele- phantiasis. Death in iitero is a frequent cause of the ter- mination of pregnancy. In addition to the great prevalence of fetal disease in cases of hydramnios, the high mortality is essentially increased by the notable frequency of funic prolapse and of malpresentations complicating labor and producing death of the fetus. Treatment. — Acute hydram- nios as soon as diagnosed should be treated by immediate evacuation of the uterine contents. This may be accom- plished by perforation of the membranes after dilatation of the OS. The danger of the other course suggested by various authors — namely, aspiration of the fluid through the uterine walls — is patent, and the method is to be con- demned. Sudden discharge of the fluid should be pre- vented, and the administration of ergot hypodermically or by the mouth, together with other measures to prevent hemorrhage, should be instituted. Chronic hydramnios in the majority of cases requires no treatment other than the application of an abdominal binder and the enforcement of absolute quiet upon the part of the patient in the hope of saving the fetus. Should respiratory or cardiac symp- toms appear, or should the patient manifest signs of ex- haustion, the pregnancy must be terminated by rupture of the membranes after dilatation of the os. The patient is to be placed upon her back with her hips elevated, and the membranes punctured in the absence of uterine con- traction ; the fluid should be allowed to flow slowly through the hand of the operator in order to avoid the danger of funic prolapse, syncope from sudden escape of so large a bulk of water, and hemorrhage from premature placental detachment. Every precaution to secure firm uterine con- traction and to prevent postpartum hemorrhage must be observed. (5) Putrefaction of the liquor ainnii is a rare condition in which there is more or less discoloration of the liquid (from brown to black), associated with an extremely often- DISEASES OF THE PLACENTA. 235 sive odor resembling that of putrefaction. This is generally an accompaniment of fetal death with decomposition, and in such cases there is also present to a limited degree the formation of gaseous products of putrefaction, constituting a true physometra. It is possible, however, in exceptional cases for this condition to be present and the child still be viable. The cause under these circumstances is unknown, and the condition is only found upon rupture of the mem- branes during labor. 2. Diseases and Anomalies of the Placenta. (i) Placentitis, or inflammation of the placental tissue, may occur in two forms, the acute and the chronic, the latter including the simple, the syphilitic, and the tubercu- lous varieties. Acute placentitis is an exceedingly rare affec- tion, and is usually a result of septic infection secondary to attempts at criminal abortion, or follows the escape into the uterine cavity of pus from an old pyosalpinx. It is at- tended with pain, fever, chilly sensations, and more or less prostration, and is, as a rule, soon followed by discharge of the embryo and its appendages, the result of abscess-forma- tion and apoplexies. Of more frequent occurrence is the cJironic form of the disease. Simple chronic placentitis is most commonly the result of chronic inflammation of the decidual cells, and is then termed placentitis decidnalis ; in other cases it appears as a form of arteritis beginning in the larger arteries of the fetal portion of the organ and gradu- ally involving the entire placental structure. As it pro- gresses the inflamed tissues become indurated and undergo fibrous changes, dense adhesions forming between the pla- centa and uterine walls {adherent placentci). The organ is undersized and atrophic in appearance. Abscess-formation is exceedingly rare in simple chronic inflammation of the placenta. Syphilitic placentitis, or syphilis of the placenta, is, perhaps, the most prolific cause of fetal death. That it is a true inflammatory condition partaking of the gen- 236 A MANUAL OF OBSTETRICS. eral nature of syphilis in other organs and tissues — namely, a slow inflammation with connective-tissue formation — is a thoroughly rational view to adopt, notwithstanding the theories of Whittaker and others to the contrary. It is an extremely common and interesting condition, and the placenta will present a varying pathology according to the source of the specific infection (whether maternal or paternal) and the time of implantation of the disease. As a whole, the organ is generally much increased in size and thickness for the period of pregnancy at which it is ex- pelled ; it is pale red and anemic in appearance, and its sur- face is mottled with the yellowish-white patches of diseased tissue. There is an irregular hyperplasia of the connective tissue of the organ, resulting in the formation here and there of dense, though friable, areas. If the disease has had its origin in a syphilitic spermatozoid, it localizes itself es- pecially in the chorionic villi ; these become immensely hy- pertrophied and the seat of cloudy swelling, and are highly infiltrated with granulation-cells that show the peculiar syphilitic predilection for the immediate vicinity of the blood-vessels : as a result of the organization of these cells into fibrous connective tissue the lumen of the blood-ves- sels becomes obliterated, and the fetus perishes from as- phyxiation or malnutrition. If the mother be infected at the same time, the decidua joins in the inflammatory pro- cess, and becomes excessively thickened from hyperplasia of the connective tissue ; dense adhesions are formed be- tween the placenta and uterus, and these fail to be dissolved by the uterine contractions in labor. If the conception occur in a woman already syphilitic, tertiary manifestations of the disease will be present in the placenta in the form of wedge-shaped gummatous nodules, with their bases situated in the decidu?E and their edges fading ofif into the fetal por- tion of the organ. These gummata vary in size from a millet-seed to a walnut, and possess the characteristic structure of gummata elsewhere ; they are formed of con- DISEASES OF THE PLACENTA. 237 centric lamellae surrounding a central zone of soft, yellow- ish or reddish cheesy degeneration, or an actual abscess- cavity with fatty, pus-secreting walls. They are frequently the seat of fatty and calcareous changes. According to Frankel, infection of a woman with the syphilitic virus after conception has occurred has generally no effect upon the placenta, which, to all appearances, is normal : this, how- ever, is not an invariable rule. Prognosis. — Syphilis of the placenta offers a fatal prognosis for the fetus and a bad one for the mother. The fetus, as a rule, quickly dies of mal- nutrition from obliteration of the blood-channels. The risk to the mother is greatest at the time of labor ; she is then exposed to the dangers of adherent placenta — viz. post- partum hemorrhage and inversion of the uterus from exces- sive traction on the fundus, together with subsequent septic processes originating in decomposition of retained placental debris. Treatment. — If syphilitic infection be suspected during pregnancy, the woman should immediately be placed upon antisyphilitic treatment ; especially is the so-called mixed treatment of service in controlling the tertiary man- ifestations that may be present. If the patient abort not- withstanding these conservative efforts, thorough evacuation of the uterine contents should be effected and attention directed to the avoidance of hemorrhage and other un- toward sequelae. The specific treatment should be con- tinued throughout the puerperium and for some time subsequently. Chronic tnbcrcnlous placentitis, or plithisical placenta, is a form of chronic inflammation of the placenta characterized by the presence of a cellular exudate (miliary tubercles) in the placental lacunae, the exudate probably coming from the chorionic villi. This material undergoes a peculiar cheesy change closely resembling that which takes place in tuberculous glands or organs, and tubercle bacilli have been detected in it. The vessels of the tuber- culous villi are filled with h}'aline thrombi, and there occurs a hyperplasia of the endothelium. -0' A MANUAL OF OBSTETRICS. (2) Placental apoplexy is an effusion of blood behind and within the placental tissue — a very common occurrence in early pregnancy, and the most frequent cause of abortion. Varieties. — If the hemorrhage take place before the third month, it will not be confined to the limits of the placenta, but, owing to the lack of union between the chorion and decidua, may force itself between these tissues and spread in the form of an immense clot over the entire outer surface of the chorion. This is termed a uteroplacental hemorrhage, and may be recognized after abortion by the peculiar fleshy appearance of the ovum, which is of a dark bluish-black color with a smooth, somewhat polished surface ; section of the aborted ovum shows that the amnion and chorion are intact, and the embryo may or may not be found floating in the liquor amnii, according to the period of time that has elapsed between its death and the expulsion of the product of con- ception : if this be considerable, complete absorption may have occurred. If the decidua has been removed during the process of expulsion, the aborted ovum closely resem- bles a blood-clot. After the third or fourth month the chorion and decidua have become firmly united, and any effusion of blood now taking place into the placental site is limited by its borders : to this variety of placental hemor- rhage Cruveilhier has given the name oi placental apoplexy. This accident increases in gravity the later it occurs in pregnancy, and in the latter months of gestation it may be attended with a high maternal mortality. Three well- defined forms of placental apoplexy have been described by Jacquemin, as follows: [a) The effusion takes place directly into the tissues of one or more of the placental lobes, with the formation here and there of small currant-jelly clots ; {b) the effusion occupies irregular cavities throughout the placental structure: these are more numerous near the margin of the organ and arc surrounded for some distance by an infiltrated and reddened area ; (r) the effusion occu- pies a number of regular and clearly-defined cavities of DISEASES OF THE PLACENTA. 239 varying size (from that of a millet-seed to that of a pigeon's ^Sto) '^ot surrounded by areas of infiltration. In course of time these hemorrhagic effusions lose their color and organ- ize into yellowish-white fibrous masses. Causes of Placental Apoplexy. — Most commonly does the rupture take place in the maternal portion of the placental tissue, and this is due to some pathologic condition of the mother, such as chronic nephritis, which causes increased arterial tension with congestion of the venous system ; under any undue excitement or exertion the weakened venous walls yield and the placental apoplexy is produced. Traumatism, such as a kick or a blow upon the abdomen, may be a cause, and in very rare instances the apoplexy is secondary to some fetal disease, with rupture of one or more of the branches of the umbilical vessels ; in the latter case the fetus may become exsanguinated and perish. Results of Placental Apoplexy. — The results of apoplexy of the placenta vary according to the size and extent of the hemorrhage, (i) If the effusion be large, the placenta may to a considerable extent be detached ; embryonic life is then destroyed and the ovum aborts ; (2) if the effusion be extensive, but still not sufficient to cause considerable detachment of the placenta, the embryo will suffer from interference with placental function, and will manifest at birth the signs of malnutrition; (3) if the apoplexy consist only in minute and isolated hemorrhagic exudations, the placental function is unimpaired and gesta- tion proceeds without any alteration in its normal course. The small effusions may undergo fatty, fibrous, or calcareous changes. Symptoms. — There are no characteristic clinical manifestations of this interesting pathologic condition : if the effusion be sudden and excessive, there may be present the symptoms of internal hemorrhage — shock ; small, feeble pulse; cold, clammy skin; a tendency to syncope; pallor; uterine pain — followed by abortion. Examination of the discharged ovum will then reveal the cause. -Treatment. — The treatment is that of ordinary abortion. If excessive 240 A MANUAL OF OBSTETRICS. hemorrhage has not occurred, and the condition be sus- pected merely from its previous occurrence in the patient during former gestations, prophylactic measures may be in- stituted. These will include the observance of absolute rest with limited diet, and efforts at venous depletion, such as the administration of concentrated saline mixtures or, in plethoric patients, the careful performance of venesection. (3) Edema of the placenta is a not infrequent condition dependent upon some interference with the fetal or placental circulation, and consisting pathologically in a serous effusion in and around the chorionic villi, with the formation of small cysts. The placental function is not interfered with by this effusion, and the condition is recognized only upon the discharge of the organ, which is large and friable, of a pale- red color, and soft and juicy on pressure. Placental edema usually follows syphilitic stenosis of the umbilical vein, but may accompany hydramnios or general anasarca in either fetus or mother. There are no clinical manifestations, and consequently therapeutic measures cannot be instituted. (4) Degenerations of the Placenta. — The placenta is subject to various forms of degeneration as follows : [a) Hyaline Degeneration. — An affection of the maternal portion of the placenta originating in the decidua and extending to the intervillous spaces. It is exceedingly common, nearly every placenta showing some of the white spots of degeneration termed white infarctions ; these vary in color from grayish-white to yellowish-red, and are circumscribed and firmer than the surrounding tissue, and may reach the size of an English walnut. If present in large numbers or if of excessive size, they may result in fetal death from interference with the placental functions. {!>) Fatty degeneration is a change of a por- tion — one or more lobes — of the placenta into tissue of a ycllowisli-white color, friable and greasy to the touch, some- what denser than the surrounding tissues, and leaving a fatty stain upon whatever it is laid. It results from some DISEASES OF THE PLACENTA. 24 1 interference with the circulation of the affected part, and is therefore a sequel of placental apoplexy or localized chronic placentitis. Dependent upon the amount of placental tissue involved will be the effect upon the fetus ; if moderate in extent, it will manifest itself in a proportionate amount of fetal malnutrition, while, if extensive, fetal death may result. ic) Fibrous degeneration may follow a fatty change in the placenta, the diseased tissues forming dense adhesions with the uterine walls. When a large amount of both fibrous and fatty tissue is present this condition is termed a fibro- lipomatous degeneration of the placenta. Syphilitic gum- mata may undergo a similar change, or a fibrous placenta may develop from an extensive chronic placentitis of what- ever origin. The danger arising from this degeneration is the production of an adherent placenta with probable postpartum hemorrhage. {d~) Calcareous Degeneration. — Stone placenta is a not uncommon condition characterized by the presence of sabulous particles in the placenta, in either the fetal or maternal portion, but usually in the latter. The degeneration is frequently localized in the vicinity of the blood-vessels, especially in placentae affected with syphilis. Stony plates or scales, or even more exten- sive formations, may be seen in placentse that have been retained in ntcro for weeks or months after fetal death has occurred. In the usual form occurring during fetal life the placental function remains unaffected, {e) Myxomatous de- generation or fibrous myxoma of the placenta (Virchow) is a change in the placenta characterized by the formation of vascular mucous and fibrous tissue scattered throughout the organ in the form of small neoplasmata. It usually occurs late in pregnancy, and is not necessarily destructive to the fetus. (/) Cystic Degeneration. — Cysts are of fre- quent occurrence in the placenta, and are formed either from old placental apoplexies, the solid constituents of the blood being absorbed and nothing but the aqueous portion remaining, or they are the result of inflamma- 16 242 A MANUAL OF OBSTETRICS. tion of the chorionic villi, with effusion of liquid around them ; or they may follow a mucoid degeneration of the placenta. They are most common near the central portion of the placenta, never attain any considerable size, and are of no pathologic significance. (^) Pigmentation of the Pla- centa. — Very often small areas of pigmentation may be observed scattered throughout the substance of a placenta ; these generally result from old placental apoplexies, and are due to the absorption by the surrounding tissues of the hemoglobin of the exuded blood. They have no path- ologic significance. (5) Tumors of the Placenta. — Two varieties of placen- tal neoplasmata are noted : {a) Placentonia, or placental polyp, is a hyperplasia of a portion of placental tissue retained subsequent to an abortion. It very frequently happens that portions of the placenta are left in the uterine cavity after abortion, and this persistence has been explained by Pilliet in the following manner: At term the blood- sinuses of the uterine tissue have widened and coalesced so as to form a single layer of blood between the maternal and fetal structures, hence complete detachment of the pla- centa is readily effected ; in abortion the foregoing condition has not developed, and in proportion to its non-development does detachment become more difficult. These retained fragments may either derive nourishment from the uterine vessels and take on renewed growth, or they may gather around them fibrin and blood-clots, which become organized and form large polypoid tumors that have been termed placcntoniata. These give rise to repeated uterine hemor- rhages, profuse, mucosanguinolent, and often exceedingly offensive leukorrhea, and attacks of uterine colic. The uterus is large and subinvoluted, and boggy to the touch. The treatment consists in thorough uterine curetment and tamponade of the uterine cavity with iodoform-gauze. (/;) Destructive placental polyp is a malignant growth of one or more of the placental villi, showing a tendency to perforate DISEASES OF THE PLACENTA. 243 the uterine wall and even to project into the abdominal cavity. This quickly proves fatal, either from exhaustion, from hemorrhage, or from peritonitis. (6) Anomalies of the Placenta. — Curious anomalous conditions of the placenta have been described. These may be grouped as follows : {a) Anomaly of Size. — Placenta vienibranacea, a malformation of the placenta resulting from failure of the chorionic villi to atrophy. As a con- sequence of this defect the placenta forms over the entire chorionic surface as a thin, broad, membranous structure intimately connected with the deciduae. Such a placenta is frequently adherent, {li) Anomalies of Shape. — (i) Horse- shoe placenta, a crescentic form frequently seen when the placenta forms around the internal os, as in placenta praevia, and a common occurrence in twin pregnancy, in which the two placentae are united by a strip of placental tissue. (2) Placenta inarginata, a form in which the normal placenta is surrounded by a rim or collar of placental tissue. (3) Bat- tledore placenta, one in which there is a marginal, instead of a central, implantation of the cord, whereby the organ assumes somewhat the shape of a battledore or a tennis- racket. (4) Annular placenta, one that extends around the interior of the uterus in the form of a belt. (5) Placenta fenestrata, one in which there is an absence of the true placental tissue in one or more places, at which points the chorion laeve appears as a transparent membrane, if) An- omalies of Number. — (i) Placenta duplex or bipartita, a mal- formation of the placenta in which it is divided into two portions. (2) Placenta tripartita, a malformation in which there are three distinct portions of the organ more or less intimately united. (3) Occasionally, in addition to the usual placental mass, there will be found one or more distinct and separate placental lobes ; these are termed subsidiary pla- centas i^placentcB succenturiatce). If they do not act as true placental tissue — that is, have no relation to the nourish- ment of the fetus — they are ttrtn^d placoitcz spuria;, or false 244 ^ MANUAL OF OBSTETRICS. placentas. The danger to be feared under these circum- stances is the retention of these accessory growths after labor, with resultant hemorrhage or sepsis, {d) Anojiialy of Position. — Placenta p7'(Evia, a term applied to that condi- tion in which the placenta is fixed to the portion of the uterine wall that undergoes dilatation as labor advances (the lower uterine segment), so that the placenta precedes the advance of the presenting part of the fetus. 3. Diseases and Anomalies of the Umbilical Cord. (i) Disease of the Umbilical Vessels. — Certain path- ologic conditions of the vein and arteries of the cord maybe encountered, giving rise to more or less serious interference with fetal nutrition. Thus, there have been noted : {a) Ste- nosis. — There may be a congenital narrowing of the lumen of the vessels of the cord, or they may become obstructed as a result of syphilis or other inflammatory disease. The fetus suffers in proportion to the amount of stenosis, and may present an emaciated appearance at birth, or fetal life may even be destroyed. If the vein alone be involved, the placenta becomes hypertrophied, congested, and edematous; if the arteries share in the condition, the fetal circulation will be impeded and the fetus itself will become more or less edematous. {6) Atheroma quite frequently occurs, but generally does not exert a pernicious effect on the fetus. At times, however, it becomes excessive, and then may give rise to more or less stenosis with resulting thrombosis. The atheromatous condition, which is generally syphilitic in origin, never extends beyond the cord into the fetal body. {c) Arteritis and phlebitis luith cirrhosis of the blood-vessels invariably result in stenosis, and are always sequels of fetal syphilis. This condition is characterized by an excessive hyperplasia of the connective tissue in and around the blood-vessels, and is one of the main causes of fetal death. {d) Varicosities of the Cord. — This is generally an unimportant condition characterized by the formation of lumps or protru- DISEASES OF THE UMBILICAL CORD. 245 sions in the course of the vessels. It sometimes happens that one of these varicose veins will rupture, usually close to the placenta, and a large-sized hematoma will form ; in some cases the bleeding will be so excessive as to destroy the fetus. {/) HypertropJiy of the valves is a rare condition, probably syphilitic in origin, resulting in obstruction to the lumen of the vessels. When well marked, nodules of con- siderable size may indicate the site of the valves. (2) Cysts of the Cord. — Cystic degeneration of the cord may result from interference with its circulation, with a resultant effusion of serum into the spaces beneath the amniotic sheath and in the allantoic tissue ; it may be due to a liquefaction of Wharton's jelly, with an accumulation of the fluid in more or less circumscribed sacs ; or it may be a sequel of apoplexies in the cord. It is of no clinical importance. (3) Hernia of the Cord. — This consists in a protrusion of a loop of bowel, or in more aggravated cases of one or more of the abdominal viscera, at the point of insertion of the umbilical cord in the abdominal wall. The extruded viscera are included in a dilatation of the sheath of the cord. The condition may result from one of two causes : {a) There may be a failure of the fetal intestine to retract into the ab- dominal cavity during the process of fetal development ; {p) the abdominal walls (lateral plates) fail to unite after visceral retraction has been accomplished. In the latter case, as the cord increases in length the intestines are progressively drawn farther out of the abdominal cavity until quite exten- sive hernise may be produced. In the majority of cases there is associated with this condition other manifestations of imperfect fetal development, especially of the limbs or lower abdominal regions, and in many instances the fetus is stillborn. The treatment, should fetal life be preserved, consists in protection of the protruding viscera by properly- fitted shields or bandages until appropriate operative pro- cedures may be instituted. 246 A MANUAL OF OBSTETRICS. Anomalies of the Cord. — Various abnormalities of the cord may be noted. These consist in : (a) Torsion. — A cer- tain amount of rotation of the arteries around the umbiHcal vein (ten to twelve twists) is normal, and the fetus is not thereby incommoded. If the torsion should become exces- sive, however, the umbilical vessels must necessarily become obstructed to a varying degree, and even to the point of causing fetal death. In order to permit this extreme torsion of the cord great mobility of the fetus is necessary, and this can result only from undue length of the funis associated with undersize of the fetus, or from a lax condition of the uterine walls and excessive dilatation of the uterine cavity. From the latter condition may be explained the relatively greater frequency of the complication in multipar^e than in primiparse. It is the generally accepted view that instances of excessive torsion are found only after fetal death has oc- curred, and that the torsion itself, induced by active fetal movements, is not the primary condition. The degree to which the twisting may take place under these circumstances is remarkable : the cord may be reduced to the thickness of a strand of ordinary sewing-thread, and the twists may num- ber three hundred or more. It would be impossible for this large number of twists to have occurred during the life of the fetus, as the obstruction produced by one or two twists would have resulted in fetal death long before others had formed (Schauta). A curious fact is the greater frequency of torsion in the cords of male fetuses. When present in a minor degree, the twists are located most commonly in the immediate vicinity of the umbilicus. (/;) Knotting. — In rare instances true knots arc found in the cord ; usually these are merely loose loops rather than tightly-drawn knots. They arc produced by the passage of the child, either before or during parturition, through a loop encircling its bod)', and are not of much clinical importance; if they should occur during pregnancy, they may become tightly drawn, and death will follow from obstruction of the circulation with DISEASES OF THE UMBILICAL CORD. 247 resulting asphyxiation. Occasionally a true surgeon's knot may be found, {c) Coiling. — It not infrequently hap- pens that during the growth of the fetus its neck or one or more portions of its body will become completely encircled by the cord (Figs. 89-94). This condition was referred to Figs. 89-94.— Anomalies of the umbilical cord (McGillicuddy). by the older writers under the caption of suicidium fcctus in ntcro. This will or will not result disastrously to the fetus according as to whether or not the constriction is tight enough to cause circulatory obstruction or to interfere in any way with the vital functions of the fetus. The coilings never give rise to intrauterine amputations, as was formerly 248 A MANUAL OF OBSTETRICS. believed ; before such a result could be accomplished the encircling coil would itself undergo such compression that the lumen of the vessels would be obliterated and the fetus perish. A common position for the coils to occupy is around the neck, as many as nine in one case being on record, while one to three coils are of common occurrence; statistics show that coiling around the neck occurs in at least 25 per cent, of all births. Under these circumstances the fetal life is jeopardized during labor, death from strangulation resulting if the coils be not speedily loosened. A shoulder or one or more limbs may be encircled, and the cord be so reduced in length as to cause considerable obstruction to labor. Thus the advance of the child may be hindered, a malposition or malpresentation be produced, or the placenta be prematurely detached and dangerous hemorrhage follow. The treatment consists in efforts at relaxation as soon as discovered. This may be accomplished in the majority of cases by gentle traction upon the yielding extremity of the cord ; the relaxed loop should then be slipped over the encircled portion. If efforts at relaxation fail and strangulation seem inevitable, a double ligature must be applied and the cord severed be- tween, after which speedy delivery must be accomplished. {d) Tangling. — In multiple pregnancies it occasionally hap- pens that the cords become twisted or even knotted together; in case of such an accident the almost inevitable result is the destruction of both fetuses from asphyxiation, with ultimate expulsion of the product of conception, {e) Anomalies of Size. — It is quite a common event to find the cord consid- erably increased in length, even reaching the size of from 180 to 210 cm. (70.8660 to 82.6770 in.) ; one in.stance is re- corded in which it attained the length of 9 feet. The dan- gers attendant upon increase in length arc the production of coils and knots and funic prolapse at the time of rupture of the membranes. More rare is decrease in the length, al- though cases have been recorded in which the cord has been extremely short, and even in a few instances practically DISEASES OF THE UMBILICAL CORD. 249 absent, as when, for instance, it has measured but i cm. (0.3937 in.) in length. The dangers associated with this condition are obstruction to labor from failure of the fetus to descend, and premature detachment of the placenta with resultant hemorrhage. Variations in the thickness of the cord have been noted, due to an increase or decrease in the quantity of the jelly of Wharton. In some cases the cord may be found half as thick as a man's wrist. This condi- tion is a matter of scientific interest only, and not of clinical importance. (/) Vascular Anomalies. — The vascular elements of the cord are subject to great variations both in the num- ber of the vessels and in their distribution. Instead of there being, as normally, two arteries and one vein, the order may be reversed, and there may be two veins with one artery, or in other instances only one of each — of scientific interest rather than of pathologic import. Of more importance are the alterations in placental attachment. Three distinct variations from the normal central implantation of the cord have been noted. In the marginal or battledore placenta the vessels enter the margin of that organ to be ultimately distributed throughout its structure. The cord is said to 3ff^ 4 Fig. 95. — Placenta with velamentous attachment of cord (Ribemont-Lepage). have a vclamentons insertion [ijisertio vclamentosa, Fig. 95) when the vessels pass for some distance between the chorion and amnion before finally entering the placental structure. 250 A MANUAL OF OBSTETRICS. This is a condition fraught with considerable danger to the fetus, for the vessels are exposed in their unnatural position to traumatism, and rupture may be followed by serious or even fatal hemorrhage before the delivery of the fetus can be accomplished. An analogous condition is that in which there exists what has been termed, from its resemblance to the suspensory structures of the kidney, rectum, or colon, the mesocoi'd ; in this anomaly the cord, instead of being directly inserted into the placenta, is received into a fold of the amnion, which it first traverses. This condition does not in any way interfere with the health of the fetus. 4. Pathology of the Ovum in its Entirety. (i) Premature Discharge of the Ovum. — In the pre- ceding pages repeated mention has been made of the un- timely termination of pregnancy as directly associated with, or the outcome of, diverse morbid states of the ovum and its appendages. This phenomenon is by far the most com- mon pathologic feature of the childbearing era. No accu- rate statistics as to the frequency of its occurrence can be offered, but it is a well-recognized fact that the vast major- ity of married women have once, and in many instances re- peatedly, lost an ovum before the full completion of the term of pregnancy. It is also known that one abortion predisposes to others in subsequent pregnancies, and thus the deplorable condition of habitual abortion may be inau- gurated, the woman showing an apparent inability to carry the fecundated ovum to term. Laying aside the fact that immense numbers of fetal lives are thus annually lost, the subject is one of vital importance on account of the direful maternal sequelae. The wreck of many a woman's consti- tution may be directly traced to one, or repeated, abortions, and it behooves him who would successfully combat this accident of pregnancy and avert its unhappy effects to closely investigate the causes, remote or immediate, of any given case, with an aim to their removal, if this be possible. PATHOLOGY OF THE OVUM. 2$ I and to fully equip himself for the proper management of the condition. A well-conducted case of spontaneous abortion may be made to redound tenfold more to the credit of the attending accoucheur than can a dozen cases of simple labor at term. For accuracy of classification of this vast subject it has been found convenient by writers to divide the cases into three distinct groups according to the period of gestation at which they occur. Thus, expulsion of the ovum during the first trimester of pregnancy — that is, before the forma- tion of the placenta, the most common period — is termed abortion ; taking place at this time, but little material is retained in the uterine cavity, the ovum generally being expelled entire. If the product of conception be lost at any time in the second trimester, the fourth, fifth, or sixth month — that is, up to the period of fetal viability — the acci- dent is termed a miscarriage ; in this class of cases the ovum is generally expelled first, and the placenta or por- tions of it subsequently, and hence arises the danger of sepsis and protracted uterine hemorrhages so constantly encountered at this time. Finally, loss of the ovum after viability of the fetus and at any time prior to its full ma- turity is termed premature labor. Causes of Abortion. — Numerous as are the causes of abor- tion, they may all be grouped under two main headings — namely, the pathologic and the incidental. The former in- cludes all diseased conditions of the parents or of the product of conception that result in its untimely expulsion, while under the latter heading may be classed those acci- dental or peculiar circumstances that in any given case will bring to a termination a pregnancy that has apparently been until then absolutely normal. Among i\\Q pat/iologic causes of abortion may be included — (i) Certain morbid states of the ovum and fetus, as apoplexies of the ovum occurring early in the course of gestation ; disease of the umbilical vesicle ; any inflammation or other abnormal condition of 252 A MANUAL OF OBSTETRICS. the deciduae and other membranes (deciduitis, the various forms of degeneration, atrophy of the decidua, cystic dis- ease of the chorion, dropsy of the chorion, hydramnios) ; placentitis, placental apoplexy, and the various forms of degeneration of the placental tissue ; certain malpositions of the placenta, especially placenta praevia ; various abnor- malities of the funis, as extreme degrees of torsion or knotting, with stenosis of the vessels ; later in pregnancy various diseased conditions of the fetus, as- hydrocephalus or syphilis (and here it may be stated that syphilis is re- sponsible for by far the great majority of premature expul- sions of the ovum, operating as it does through both father and mother) ; finally, death of the fetus from any of the foregoing causes, the dead product of conception then act- ing as a foreign body in iitero, although a dead embryo may be retained for an indefinite period, even up to or beyond term, as in that rare condition, missed labor. (2) Certain paternal causes, most prominent among which should be mentioned syphilis, resulting in the discharge of syphilitic spermatozoa; constitutional exhaustion from venereal excesses and masturbation, resulting in the pro- duction of degenerated, illy-formed, and unhealthy sperma- tozoa ; extreme youth or advanced age, in either instance the spermatozoa lacking virility. (3) Certain maternal dis- eases, including any acute, infectious malady, such as small- pox, typhoid fever, the exanthemata, and certain acute cutaneous diseases ; contagious abortion (a form of septic infection resulting in discharge of the ovum — a frequent occurrence in preantiseptic days, but now rarely encount- ered) ; sudden and extreme elevation of temperature, as in certain fevers ; various pathologic states resulting in interference with the circulatory exchange of the respira- tory gases, as grave valvular lesions of the heart, em- physema, pneumonia, in all of which carbonic-acid gas accumulates in the system and acts as a stimulant to ute- rine contraction ; certain convulsive affections in which the PATHOLOGY OF THE OVUM. 253 uterus participates, such as chorea, epilepsy, hysteria, tetany, cholemia associated with renal insufficiency, uremic eclampsia ; the systemic action of certain poisons, as mala- ria — which is especially prone to prematurely terminate pregnancy — sewer-gas, lead, mercury, alcohol, and other drugs ; certain alterations in the nutritive functions of the body, as obesity (in which condition the great bulk of the maternal body deprives the developing ovum of the blood that should be devoted to its nutrition, and it, in con- sequence, perishes) or leukocythemia or anemia from the ingestion of insufficient food, subsequent to profuse hemor- rhage, or resulting from sedentary life and lack of proper exercise, the fetus perishing from malnutrition or asphyxia- tion ; certain pathologic conditions of the internal genitalia, including malformations of the uterus, metritis and peri- metritis with adherent uterus, excessive rigidity of the uterine fibers (especially noted in old primiparae), undue laxity of the cervical tissues, uterine displacements (espe- cially retroflexion and prolapsus), excessive hyperemia of the uterus and pelvic organs from any cause whatever, severe cervical laceration, exaggerated ulceration and ero- sion of the cervix, certain tumors of the uterus (fibroids and mucous polyps), diseases of the uterine appendages, such as salpingitis (rupture of a pus-tube is very prone to occur during pregnancy, and may result not only in abortion, but also in the production of a septic peritonitis), ovaritis or ova- rian cyst, and inflammation of adjacent organs (proctitis, cys- titis, and appendicitis). The incidental causes of abortion are also very numerous, and include — (i) All forms of trauma- tism, such as blows or falls, the lifting of heavy weights, the wearing of tight clothing, tight lacing, the injudicious pass- age of a uterine sound during a gynecologic examination, excessive and uncontrollable action of the abdominal mus- cles, as in severe and persistent vomiting, hiccoughing, coughing, or sneezing, excessive laughing, any form of violent exercise, local medication of the cervix uteri, or 254 ^ MANUAL OF OBSTETRICS. excessive coitus. (2) The acquired habit of aborting {liabit- iial abortion), in which, when a woman reaches a certain stage in the period of gestation, she manifests a strong tendency to fall into labor-pains and expel the product of conception. (3) Various reflex causes, such as severe men- tal shock, violent emotions (fear, joy, sorrow) ; any irritation of the mammary glands, as during excessive lactation ; the irritating action of intestinal worms ; the performance of minor surgical operations upon any portion of the body ; multiple pregnancy, causing reflex contraction of the uterus from over-distention of its walls ; any trivial exertion acting upon an exceedingly neurotic disposition, as manifested by a marked tendency of the uterus to contract under the slightest stimuli (the so-called uritable uterus): in women of such a neurotic disposition the action of a simple laxative or purgative drug, the jolting of a carriage or a railway-car, the taking of a long walk, sea-bathing, or the advent of a menstrual epoch may initiate uterine contractions of suf- ficient magnitude to cause expulsion of the product of con- ception. (4) Finally, under this heading must be placed the various forms of criminal abortion as produced by the use of instruments passed through the cervix, or by the inges- tion of certain drugs, such as ergot, ustilago, savin, penny- royal, or tansy. Symptoms of Abortion. — The symptoms vary according to the stage to which gestation has advanced, (i) Early abor- tion, also called ovular abortion (Guillemot), occurring within the first three weeks of gestation, is characterized by a flow of blood attended with little or no pain. The history of an absence of the catamenial flow at the preceding menstrual epoch, together with the simultaneous appearance of some of the signs of pregnane}', is strongly presumptive evidence of the existence of gestation ; if after this suppres.sion of from five to six or seven weeks there is a return of the dis- charge with greatly increased flow lasting for some days over the normal duration of the menstruation, and acconi- PATHOLOGY OF THE OVUM. 255 paniecl by the escape of numbers of dark clots of varying size and consistence, a diagnosis of abortion may be safely made. In these early abortions the ovum may frequently escape detection owing to its extremely small size. The pain is very slight, probably not more than a backache such as would attend a menstruation ; it does not assume the characteristic bearing-down quality of labor-pains of a later period of gestation, and is dependent upon the pass- age of blood-clots through a contracted cervix. (2) The clinical phenomena of abortion at a more ad- vanced stage — that is, occurring during the second and third months, embryonic abortion (Guillemot) — are more marked ; they may be classed as prodromal, active, and physical. The prodromal symptoms are at the best vague and unreliable : they consist in a sense of discomfort or fulness in the pelvis and about the thighs ; sacral pains ; a feeling of malaise; anorexia; considerable thirst; headache; a tendency to frequent micturition with vesical tenesmus; possibly a desire to defecate ; increased leukorrhea ; de- pression of spirits; coldness of the extremities; chilly sen- sations ; pallor of the face ; and at times a slight rise of temperature. The active symptoms are hemorrhage, steadily increasing in amount; uterine contractions; and, finally, expulsion of a part or the whole of the product of concep- tion. The physical signs are very important, and vary with the degree to which the abortion has advanced: (i) If the clinical manifestations have just begun to show themselves, the cervix, upon vaginal examination, will be found to be soft and patulous, and possibly the entire cervical canal will be somewhat dilated ; the body of the uterus will be felt as an enlarged mass in the anterior portion of the pelvis just behind the symphysis pubis. (2) If the abortion has been in progress for some hours and the clinical phenomena have been steadily progressing in intensity, there will be found a considerable dilatation of the os ; Tarnier's sign of inevita- ble abortion will be present, and probably the finger may 256 A MANUAL OF OBSTETRICS. detect the advancing ovum. Tarnier's sign — namely, com- plete effacement of the angle of anteflexion that in preg- nancy normally exists between the upper and lower ute- rine segments — is produced by the descent of the ovum, which in its course from the fundus to the os straightens the anterior uterine wall. In order to determine whether or not that which the finger detects is an ovum or a blood-clot, Hoirs signs may be borne in mind. These are as follows : {a) During a uterine pain an ovum becomes tense and smooth, increases in volume, and advances, while a blood-clot does not become tense and is compressed with- out advancing ; (/;) an ovum offers a rounded, elastic ex- tremity, while the blood-clot is non-elastic, solid, and cone- shaped, with the apex below ; (<:") on pressure upon the fundus uteri in case of an ovum the motion is not commu- nicated to the product of conception en masse, on account of its elasticity, while a blood-clot, being more solid, would be displaced bodily by such pressure ; (3) If the product of conception have escaped before the arrival of the medi- cal attendant, the physical signs in conjunction with an ex- amination of the expelled material will determine whether or not the abortion has been complete or incomplete. In case of incomplete abortion the body of the uterus will be large, soft, and boggy ; the cervical canal will be found to be quite patulous, permitting the introduction of the finger even into the uterine cavity, while clots, fragments of mem- brane, or soft, pulpy placental tissue will be detected within the uterus ; there will also be present considerable sero- sanguinolent discharge containing dark clots and shreds of tissue, while, if much time have elapsed since the first por- tion of the ovum was expelled, the discharge will be of a peculiar brownish appearance and will probably emit an extremely fetid odor. In case there has been a complete abortion, the body of the uterus will be found to be large, but firmly contracted ; the os will be closed, and it will be impossible to introduce the finger through the ccrvi- PATHOLOGY OF THE OVUM. 257 cal canal into the uterine cavity; there will also be pre- sent the normal lochial discharge. An examination of the expelled substance — which should always be retained for the physician's personal inspection — may be made by placing it in a vessel containing clear water and removing, in this way, adherent clots and blood. If complete, the deciduae will be found closely investing the mass, separation having taken place in the spong}'- or deepest layer of the decidua ; in other cases the completeness or incompleteness of the membranes may be demonstrated by floating them upon the water, when any imperfection will be noted. (3) The clinical manifestations of discharge of the ovum between the fourth and sixth months inclusive {iniscarriage) are more pronounced. There is now an exaggeration of all the foregoing symptoms, an increased flow of blood, severe bearing-down pains, and more decided uterine contractions. There is a considerable secretion of liquor amnii by this time, and during one of the uterine contractions the mem- branes may yield and a gush of water follow. The ex- amining finger may also detect the advancing fetal part. In other instances the entire product of conception — em- bryo, membranes intact, contained liquor amnii, and pla- centa — may be expelled en masse. More usually there is apt to be retention of some of the placenta, with profuse hemorrhage and increased danger of septic processes from decomposition of the retained masses, or ultimate develop- ment of placentomata. (4) The clinical phenomena of premature labor are in every respect identical with those of labor at term. Duration of Abortion. — The time consumed in an abor- tion varies considerably in different women. If, as occa- sionally happens, the entire product of conception escape upon the first appearance of the clinical phenomena, as following a severe jar or fall, this is termed an instan- taneous abortion; in other cases, and much more fre- quently, there is a gradual discharge of the ovum and its 17 258 A MANUAL OF OBSTETRICS. appendages, covering a period of days, weeks, or even months, until, in some instances, the patient becomes almost exsanguinated ; such a state of affairs should be arrested by mechanical interference on the part of the accoucheur. On the whole, it may be said that the aver- age duration of abortion, as commonly met with, is from twenty-four to thirty-six hours. Diagnosis of Preniahire Expulsion of the Ovum. — (i) Of Abortion. — A sudden uterine hemorrhage, attended or not with pain according to the stage to which gestation has advanced, and following suppression of menstruation for a variable period, during which time there have been present one or more of the recognized early signs of pregnancy, is sufficient ground upon which to base a diagnosis of threatened abortion. When, however, on being called in to see a patient presenting such a history, or who states that there has been in addition the discharge of clotted mate- rial in a small or considerable amount, quite another and exceedingly delicate question of diagnosis is involved. It then becomes incumbent upon the medical attendant to determine by physical investigation of his patient, together with careful examination of the expelled masses, whether he has on his hands merely a threatened abortion with every possibility of saving the product of conception, or an abortion so far advanced that it is inevitably bound to continue notwithstanding the most conservative efforts on his part; or, on the other hand, whether there has already occurred a complete or partial expulsion of the ovum. In the following table the main characteristic features of these different forms or periods of abortion are delineated : Threatened Aboi-- Inevitable Abor- Incomplete Abor- Complete Abor- tion, tion. tion. tion. Hemorrhage is free, Hemorrhage is per- There are repeated There is a complete bright-red, persist- sistent, increasing attaclcs of hemor- arrest of hemor- ent, and free from in amount and con- rhage, at times rhage. clots. taining clots and profuse; often fragments of the dark, grumous, ovum. and very offensive. PATHOLOGY OF THE OVUM. 259 Threatened Abor- tion. Pain is slight or en- tirely absent. Discharge consists only of pure blood. Os is somewhat di- lated, but not freely patulous. Uterus is soft, large, boggy, anteflexed ; vaginal vault is tense. Signs of pregnancy, other than sup- pression, are pres- ent. Inevitable Abor- tion. Pain progressively in- creases in severity. Discharge consists of blood and por- tions of the ovum. Os is well dilated and admits the finger, which may feel the advancing ovum. Uterus is anterior, but shows Tar- nier's sign. There is an arrest of the signs of pregnancy. Jncoiiiplete Abor- tion. Occasional attacks of uterine colic. Examination of the expelled material shows imperfec- tions in the mem- branes. Os is quite patulous ; the finger detects shreds of mem- brane, masses of placenta, and blood-clots. Uterus is persistent- ly large and soft, and is not under- going involution. Subsidence of all the signs of pregnancy other than enlarge- ment of the uterus. Cotnplete Abor- tion. Absence of pain. Discharge is the nor- mal lochia, grad- ually terminating in a leukorrhea. Os is closed. Uterus is hard, en- larged, but firmly contracted ; invo- lution is normal. Subsidence of all the signs of preg- nancy. (2) The diagnosis of miscarriage may be made by a history of the case showing that the pregnancy had ad- vanced to or beyond the fourth month, by the presence of the hquor amnii, by the possibihty of recognizing the advancing fetal part, by the greater severity of the symp- toms, by arrest of the signs of pregnancy, and possibly by the development of the mammary secretion. Prognosis of Premature Expulsion of the Oinini. — The maternal prognosis is a matter of grave import and em- braces a number of possibilities. In spontaneous abor- tion the mortality is very low ; the dangers consist in hem- orrhage, peritonitis from extension of inflammation from the uterus, and sepsis from retention of portions of the ovum. The immediate hemorrhage is not likely to result fatally, but the patient very frequently suffers from its re- mote effects: she remains weak and anemic, and even forms of pernicious anemia resulting fatally have been known to follow. Secondly, a woman having once aborted there is manifested a peculiar tendency to a repetition of the act in a subsequent pregnancy, and the habit of abortion may be formed. According to Napier of London, at least 18.6 per 260 A MANUAL OF OBSTETRICS.' cent, of the women who miscarry are habitual aborters. Kortright says that " repeated abortions occur commonly either at the beginning or at the end of the childbearing period. When occurring soon after marriage they indicate lack of development of the sexual organs. When occurring late in life they indicate exhaustion of the power of repro- duction."^ Again, Napier declares that of loo women that miscarry, 22 will remain sterile, and of these 14 will have painful and incurable pelvic disease, and 8 will not suffer, but will be barren. Finally, there may be retained in the uterine cavity fragments of placental tissue which, becoming organized or receiving upon their surfaces large deposits of blood-fibrin, develop gradually into placentomata or pla- cental polypi of various forms, flat or acuminate, that give rise to severe endometritis, subinvolution, and profuse hem- orrhages; the health of the woman then becomes impaired or even permanently lost. Trcaiviciit of Aboj'tion and Miscarriage. — This may be divided into prophylaxis, the treatment of threatened abor- tion or miscarriage, the treatment of the inevitable form, and the after-treatment. (i) PropJiy lactic Treatment. — If, for any reason, premature expulsion of the ovum is to be feared, as when the mother is the subject of some systemic disease such as syphilis, or when there exists a chronic form of local disease, as an aggravated endometritis, or when there has been manifested a tendency to habitual abortion, strenuous measures must be adopted to conserve the product of conception. In all such cases the patient should be instructed to observe es- pecial precautions, such as the avoidance of over-exer- tion, as the lifting of heavy weights or the reaching for objects above her head, especially at the time when the menstrual epochs would occur did pregnancy not exist, or at the period of gestation at which previous abortions have taken place; the taking daily of several hours of rest in the * Brooklyn Med. Jour., Sept., 1894. PATHOLOGY OF THE OVVM. 26 1 prone position ; the avoidance of sexual intercourse or other causes of pelvic congestion, and of the various dis- orders of digestion ; and the importance of properly regu- lating the bowels without resort to purgative medicine. It is well during the time for the menstrual epoch for the woman to remain in bed for five or six days. In addition to these measures, which it becomes the special duty of the patient herself to institute, there are various prophylactic measures that the physician should take pains to put into operation. Thus, a retrodisplaced uterus must be replaced and held in position by a properly-fitting pessary until the natural growth of the organ will carry it above the promon- tory of the sacrum. If there be known to exist an endo- metritis or a severe laceration of the cervix, appropriate treatment should be instituted in the period prior to im- pregnation, in order to bring the organ into as perfect a condition as possible for the subsequent pregnancy. A woman affected with syphilis should be placed upon a strong course of mercurials, or preferably the mixed treat- ment, before and during the continuance of her pregnancy. Mercuric protiodid may be given in from gV to ^ of a grain thrice daily in association with potassium iodid in from 10- to 30-grain doses, or the potassium salt may be adminis- tered internally in conjunction with inunctions of mercurial ointment or of mercuric oleate. (2) Tj-catincnt of Tlireatcncd Abortion. — If there be every reason to believe that the ovum is in a healthy condition and that the threatened discharge is due to some one of the incidental causes of abortion, a conservative line of treat- ment must be instituted. If, however, the woman be suf- fering from one of the acute infectious diseases, the abortion must be regarded as nature's effort to throw off a portion of the disease, and steps must be taken to empty the uterus as rapidly as possible. The same line of treatment should also be pursued if the fetus be known to be dead, as when there is associated with the hemorrhage a grumous and 262 A MANUAL OF OBSTETRICS. offensive discharge. Efforts to arrest a threatened abortion consist in absolute quiet and rest in bed in a darkened room with the head lowered. Nerve-sedatives should be administered in large doses — preferably opium, or chloral, potassium or sodium bromid, and the fluid extract of viburnum prunifolium. Opium should invariably be ad- ministered, either in the form of laudanum in from 15- to 20-drop doses, or chlorodyn in doses of 10 minims, or better by suppository containing I grain of the aqueous extract morning and evening, or by hypodermic injec- tions in the abdomen of from 3-^2" ^^ -| of a grain of mor- phin. Its action may be supplemented by the use of large doses of the fluid extract of viburnum prunifolium — i dram four times daily (Jenks, Hirst). If the threatened abortion be due to an accumulation of carbonic-acid gas in the maternal blood, inhalations of oxygen may be given with excellent results, or oxygenation of the blood may be secured by the administration of large doses of potassium chlorate — 20 grains thrice daily (Lusk, Fordyce Barker, Sir J. Y. Simpson, R. A. F. Penrose). After the bleeding has been arrested the patient should be confined to bed for a week or two in order to secure absolute rest and quiet. (3) Trcatiuciit of Inevitable Abortion. — When, after such a course of treatment as the foregoing, the .symptoms steadily grow worse and portions of the decidua or other tissues are cast off, it may be decided conclusively that an inevi- table abortion is to be dealt with, and a corresponding plan of treatment must be adopted. In the management of this condition one of two methods may be followed. The first and better method is that known as the active treatineut, which consists in immediate evacuation of the uterine con- tents ; while the other is the expectant plan, and consists in the repeated use of vaginal tampons in combination with the internal administration of ergot, in the hope that Nature herself may throw off the product of conception. The steps of the active treatment of inevitable abortion may be PATHOLOGY OF THE OVUM. 263 stated as follows: (i) TJie introduction of a vaginal tampon to control the bleeding and to favor dilatation of the os and expulsion of the ovum. The tampon should consist of small pieces of antiseptic wool or sterilized cotton, or of strips of iodoform-gauze introduced through a vaginal speculum ; it should be carried well back of and packed tightly around the cervix ; the entire vagina must be filled with the tampon and a T-bandage then applied. If the bleeding be very excessive and fears be entertained for the safety of the patient, a strip of iodoform-gauze or a number (from twenty to twenty-five) of small balls of iodoform-cotton the size of the end of the little finger may be introduced into the ute- rine cavity. In some instances the ovum may be discharged without rupture of the fetal membrane having occurred, and in such cases the hemorrhage is so slight that a vaginal tampon is not required. (2) Removal of the tampon at the expiration of from eight to ten hours and the introductio7t of a second tampon, if this be necessary. One tampon may suffice to accomplish the expulsion of the ovum, and, if so, all further active treatment will be unnecessary. If a second tampon be required, a vaginal douche of mercuric chlorid (1:4000) must be given, and the tampon introduced as before and allowed to remain for a second period of from eight to ten hours. If on the removal of this tampon there be still no sign of the discharge of the ovum, more vigorous measures to secure its expulsion must be adopted. It is at this point that the expectant plan of treatment is recommended by some obstetricians, who claim that all manual interference should be avoided, so that, if pos- sible, the membranes may escape rupture, and hemor- rhage thus be prevented, and that final expulsion of the product of conception should be accomplished by admin- istering internally repeated doses of the fluid extract of ergot, while successive tampons are applied in the vagina ; the patient under this treatment should be strictly confined to bed, and occasional antiseptic vaginal douches given. 264 A MANUAL OF OBSTETRICS. careful watch being maintained for the sh'ghtest sign of sepsis. In case this should appear or should the hemor- rhage become very severe, steps may then be taken to empty the uterus. The objections to this expectant plan of treatment are — {a) The length of time that may elapse before expulsion of the ovum, thus considerably augmenting the risk of sepsis, and imposing upon the patient a long and tedious course of vaginal manipulations ; {p) the strain upon the physical and mental powers consequent upon a prolongation of the clinical phenomena ; [c) the danger of the production of irregular uterine contraction from the ad- ministration of the ergot, with retention of a portion of the uterine contents. In all cases in which, after the intro- duction of the second tampon, there is still a retention of the ovum, it is infinitely better to at once proceed to en- ergetic measures to empty the uterus. The succeeding steps of the active treatment will then be as follows : (3) etherization of the patient ; (4) dilatatioii of the os by means of Hegar's dilators ; (5) removal of the retained ovum by one of the following methods in the order given : {a) Intro- duction of the right forefinger into the uterine cavity, the hand being inserted into the vagina, with counter-pressure by the left hand placed upon the abdominal wall immediately over the symphysis pubis. This method requires considerable time and patience for its successful performance, but is probably the best that can be adopted ; {p) the placental forceps (Thomas's) ; (r) tlie uteri)ie curet, which should be employed with extreme care, in order to avoid perforation of the spongy uterine wall ; {d) Hoening's Method of Ex- pression. — This is a modification of Crede's method of extraction of the placenta, and is performed thus: With the anesthetized patient resting in the dorsal position, two fingers of the left hand are carried to the cervix and vaginal vault, while the fingers of the right hand grasp the uterus through the abdominal walls and squeeze out its contents by strongly compressing the fundus. The INDUCTION OF ABORTION. 26$ advantage of this maneuver, if it can be successfully man- aged, lies in the fact that there is no manipulation of the interior of the uterus ; it is painful and difficult to per- form, however, and a considerable portion of the decidua is likely to be retained even after thorough compression. The method cannot be strongly recommended; (6) thoroiigJi flushing of the uterine cavity with warm sterilized water to remove fragments and debris ; (7) tJie application of CJiurchiWs tincture of iodin to the 7iterine cavity ; (8) tlie introduction of a strip of iodoform-gause to the fundus uteri, and vaginal tamponade, which should be removed at the expiration of from ten to fifteen hours. (4) After-treatment. — The subsequent treatment of abor- tion is in every respect the same as that following normal labor. Immediately after the operation hot bottles should be applied to the feet and limbs of the patient, and the head kept low until reaction takes place. After the re- moval of the gauze further tamponade is generally un- necessary. If the patient have lost sufficient blood to cause pronounced anemia, hot drinks and small amounts of alcoholic stimulants will be indicated. Later, to coun- teract the constitutional debility, a nutritious diet, with the addition of tonics such as iron, quinin, and strychnin, will be beneficial. Involution may be favored by rest in bed for two or three weeks, together with small doses of ergot — lO drops thrice daily — and retrodisplacement of the enlarged uterus guarded against by avoidance of prolonged dorsal decubitus. During convalescence a change of air will be exceedingly beneficial. Treatment of Miscarriage. — This is in every respect iden- tical with the treatment of labor at term. The Induction of Premature Expulsion of the Ovum. — It occasionally devolves upon the obstetrician, because of various pathologic states of the mother or fetus inimical to their existence, to prematurely terminate the progress of a gestation. Such a proceeding, involving as it frequently 266 A MANUAL OF OBSTETRICS. does the destruction of human life, is necessarily one of extreme gravity, and should be entered upon only after the most judicious thought and counsel. The principle em- bodied in this serious operation, however paradoxical it may at first sight seem, is one of conservatism : the lesser of two evils is chosen, and the more unimportant life sac- rificed for the more important. The supreme law of operative obstetrics is preservation of the maternal life at all hazards, if need be by destruction of the fetus itself; this procedure, however, must ever be regarded as the operation en reserve, only to be resorted to when it becomes patent that other methods would be futile or even reprehensible. Here, again, arises the question as to just when it becomes proper to take the initiative. While it is probable that many fetal lives are unnecessarily destroyed by a too precipitate adop- tion of extreme measures, it is just as evident that a cer- tain proportion of women annually perish from an un- warrantable delay in the institution of an energetic course of treatment. There are some cases in which the pregnancy must be terminated so early in its course — prior to the period of fetal viability — that all thought of preservation of fetal life is excluded ; the line of treatment to be pursued in these cases is plain, and the termination of the gestation during this period — before the seventh month — is termed the in- duction of abortion. When it becomes imperative to end the pregnancy after fetal viability and before the normal term of fetal maturity, two lives are to be taken into consid- eration, the question becomes more complex and serious, and the operation is termed the induction of premature labor. It is in this latter period that the danger of a too protracted delay in the adoption of operative procedures is to be anticipated. The most common time for the induction of premature labor is from four to eight weeks before term, at which time all the diameters of the fetal skull are about I cm. (0.3937 in.) shorter tJian at term. According to the investigations of Budin, Ahlfeld, Stolz, Tarnier, and others, INDUCTION OF ABORTION 267 the most important diameter of the fetal head — the bipari- etal — presents the following measurements during the last trimester of pregnancy : At the seventh month, 7 cm. (2.75 59 in.); at seven and a half months, 7}^ cm. (2.95275 in.); at eight months, 8)^ cm. (3.248025 in.); at eight and a half months, 8^ cm. (3.444875 in.); and at nine months, 914^ cm. (3.6417 in.). The advantage to be derived by the in- duction of a premature labor in certain degrees of pelvic contraction becomes evident from a study of these figures. Indications for the Induction of Premature Expidsion of the Ovnni. — (i) Of Abortion. — The induction of abortion is indicated when maternal life is menaced by some grave pathologic state of the fetus or of the mother. The fetal indications are — [a) Cei'tain grave affections of tJie fetal ap- pendages^ as cystic disease of the chorion and the acute form of hydramnios ; {6) embryoidc death, as evidenced by an arrest of the signs of pregnancy and a cessation of, or a decrease in, abdominal distention. More numerous are the maternal indications. These include — {a) certain pathologic conditions of the genitalia, as the presence early in pregnancy of large tumors in the uterus or pelvic cavity ; incarceration of a retroflexed or prolapsed uterus ; undilatable cicatricial atresia of the cervix or vagina ; irreducible hernia of the gravid uterus ; advanced cervical carcinoma ; extreme pelvic contraction (6 cm. — 2.3622 in. — or under); {B) certain grave general pathologic conditions, as pernicious anemia, perni- cious vomiting, progressively increasing albuminuria, chronic nephritis with or without albuminuria, the major form of chorea, certain forms of insanity, as acute mania and pro- nounced melancholia. (2) Of Premature Labor. — -The in- dications for the induction of premature labor include all conditions menacing fetal or maternal life, as well as those pathologic states of either mother or child that will, if the pregnancy be allowed to continue to term, be pro- ductive of grave degrees of dystocia. Again, adopting the foregoing classification, \X\q fetal indications are — {ci) Habit- 268 A MANUAL OF OBSTETRICS. ual oversize or premature ossification of the upper portion of the fetal skull, as evidenced by previous pregnancies ; acute hydramnios occurring late in pregnancy ; {U) habitual death of the fetus during the last days or weeks of pregnancy, and usually due to placental degeneration (nonsyphilitic) ; {c) fetal death from any cause. The matenial indications are — {a) Certain pelvic deformities that would prevent normal de- livery at term, as minor degrees of contracted pelvis (from 9^ to 8 cm. — 3.7401 to 3.1496 in.) ; {h) placental anomalies, as placenta przevia ; [c) grave systemic disease, as pernicious vomiting, pernicious anemia, increasing albuminuria, eclamp- sia, dyspnea from extreme ascites, grave valvular disease of the heart, advanced pulmonary tuberculosis, tumors in the pelvic canal. MetJiods of Inducing Abortion and Premature Labor. — (i) Abortion. — Various methods have been suggested for emp- tying the uterine cavity during the early (first four) months of pregnancy. Those that have met with more or less uni- versal favor are the following : {a) Cervical and vaginal tamponade. — This consists in the following steps : i. Thor- ougJi asepsis of the vaginal tract by means of a douche of hot water followed by one of mercuric chlorid (i : 2000) ; 2. Partial dilatation of the cervical canal : this is accom- plished by Hegar's or Ellinger's dilators, dilatation proceed- ing until the canal will admit the index finger: during this procedure the patient may lie in the lithotomy or the Sims posture ; 3. Tamponade of the cervix and vagina. There is introduced into the cervix, past the internal os, a strip of iodoform-gauze ; this should be from 2 to 3 feet long and about I inch wide ; it should be tightly packed into the cer- vix, and the vagina filled with another strip of gauze or with antiseptic wool ; 4. Removal of tlie gauze at the expiration of from twelve to twenty-four hours. If necessary, after an antiseptic vaginal douche, a small piece of the decidua may be torn away by the placental forceps and another tampon introduced and left /;/ situ for from eight to ten hours ; if at INDUCTION OF PREMATURE LABOR. 269 the expiration of this time the ovum has not been dis- charged, the following method must be adopted : ib) Rapid dilatation of the cervix and immediate removal of the ovum by the placental forceps and curet. This method may be employed in preference to the preceding in cases of great urgency ; it is possible thus to empty the uterus in from fif- teen to twenty minutes. The steps of the method are as follows : I. Thorough asepsis of the vagina; 2. Rapid dilata- tio)i by means of the Goodell dilator to an extent of from 2 to 2^ cm. (0.7874 to 0.98425 in.) ; 3. Removal of the bulk of the ovum and membranes by tJie placental forceps ; 4. Thor- ougJi citrettage of the uterine cavity. After-treatment of In- duced Abortion. — The after-treatment varies but slightly from that of an ordinary labor. It includes — i. Douching of the uterine cavity with hot sterilized water; 2. Intro- duction to the uterine fundus of a strip of iodoform-gauze, to be removed in from twenty-four to forty-eight hours, when a vaginal douche should be given; 3. Confinement, of the patient to bed for the normal period after childbirth, with the usual puerperal diet. (2) Premature Labor. — The induction of premature labor may be accomplished by one of several methods, as follows : {a) Simpson's or Krause' s Method — Catheterism of the Uterus. — The steps of this method, which acts by causing a partial separation of the membranes from the uterine wall, are as follows : I. Thorough asepsis of the vagina by a douche of mercuric chlorid (i : looo or 2000). 2. The patient, if a primipara, should be placed in the lithotomy position ; if she be a multipara, the Sims posture is preferable ; the hips should extend well over the edge of the bed or table. 3. Introduction of a sterilised bougie, preferably of hard rubber and in size No. 17 of the French or No. 12 of the American scale, in the following manner : The index finger of the left hand is introduced into the vagina and made to impinge upon the mouth of the cervix ; the bougie, well oiled, is passed along the finger through the cervix and into 270 A MANUAL OF OBSTETRICS. the uterine cavity for a distance of from 15 to 20^ cm. (5.9055 to 8.07085 in.); in its upward course it passes be- tween the deciduae vera and reflexa, and if introduced upon the side of the uterus opposite to that upon which is situated the placenta, hemorrhage from detachment of the latter will not occur. The balance of the bougie is bent upon itself in the vagina and held in position by means of a tampon of iodoform-gauze. 4. If labor-pains have not supervened at the expiration of twelve hours, a second bougie may be introduced beside the first, after removal of the tampon and the administration of a vaginal douche. Usually labor will be established in from twenty-four to thirty-six hours. 5. Artificial Dilatation of the Os by Barnes' Bags. — At the expiration of thirty-six hours the cervical tissues will have been materially softened. The bougies may then be removed and Barnes' bags in successive sizes introduced as follows : The smallest bag of the series (Fig. 96) should be well oiled, doub- led laterally upon itself, and introduced into the cervix -Barnes' bag. ^ , . by means 01 dressmg- forceps, the patient occupying the lithotomy position at the side of the bed ; by means of an ordinary household or Davidson syringe the bag may be fully distended with warm water, and allowed to remain i^i situ for from one to three hours, when it may be replaced by the next larger size. To prevent accidental rupture of the bag, with con- sequent severe or even fatal shock to the patient, she should remain in the dorsal position while the bags are retained in the cervical canal. 6. Introduction of the hand and the per- formance of version. {b) The Expectant Plan. — This consists in sterilization of the vaginal tract, followed by cervical and vaginal tampon- ade with iodoform-gauze. The tampon must be renewed daily until labor-pains appear. INDUCTION OF PREMATURE LABOR. 27 1 {c) The Rapid Method. — This method may be employed in cases of urgent necessity. It embraces the following steps : I. Rupture of the membranes ; 2. Rapid dilatation of the cervix by means of Hegar's dilators, then by Barnes' or Champetier's bags, allowing each of the former to remain /;/ situ not more than from ten to fifteen minutes. The bag of Champetier de Ribes is a nonelastic structure of water- proof silk, shaped like an ear-trumpet, and having a capacity of about 17 ounces. By it a dilatation of about 9 cm. (3.5433 in.) can be secured. It is expelled when complete dilatation is accomplished. This bag is superior to Barnes' bags in that it is more readily introduced, but one is re- quired, and it accomplishes a complete cervical dilatation. 3. Introduction of the hand and the performance of version and rapid extraction of the child, or delivery by means of the forceps. If desired, first one finger and then the others in rapid succession may be introduced into the cer- vix until the entire hand enters the uterine cavity, when version may be performed and the child rapidly delivered. This method is of service in cases of placenta prsevia. id) Pelzer's Method — Intrauterine Injection of Sterilized {boiled) Glycerin. — Recently Pelzer has suggested the em- ployment of intrauterine injections for the establishment of labor-pains. . The following are the steps of this method : I. Thorough vaginal asepsis; 2. The patient is placed in the Sims posture with the Sims speculum introduced ; 3. The cervix is held with a volsellum forceps, and 2 ounces of sterilized glycerin are slowly injected high up toward the fundus uteri between the deciduae vera and reflexa. The instrument used for this purpose is an ordinary Davidson syringe with a No. 10 English catheter (Jewett); 4. Reten- tion of the patient in the Sims posture for at least thirty minutes to prevent discharge of the glycerin. There are two serious objections to the employment of this method — namely, the danger of occasioning fatal glycerin-poisoning (characterized by extreme renal irritation), and the possi- 2/2 A MANUAL OF OBSTETRICS. bility of the introduction of air into the circulatory system. Especially is this method not to be employed in cases of preexisting nephritis. {c) Dcnman's Method — Puncture of the Membranes. — This is a dangerous method, only to be employed in uterine apathy or before fetal viability. The steps are — i. Vaginal asepsis; 2. Introduction of the index finger of the left hand to the cervix ; 3. The passage of a uterine sound or other dull-pointed instrument into the os and through the membranes ; the liquor amnii must escape slowly. The objections to this method, according to Playfair, are — i. Labor frequently does not ensue for some hours or days ; 2. Fetal life is greatly imperilled by the direct pressure exerted upon the child by the contracting uterine walls ; 3. It does away with the hydraulic action of the liquor amnii. (/) KiwiscJis Method — Vagi) ml Douches of Cold or Warm Water. — This requires a number of days for its successful performance, and is also objectionable on account of the danger of inducing fatal shock from entrance of the stream of water into the uterine cavity ; it cannot therefore be recommended. {g) Bayer's Method — Galvanization. — Bayer employs the constant galvanic current, the positive electrode being placed upon the abdomen over the fundus uteri, and the negative electrode being introduced into the cervix. This method, while probably inducing true labor-pains, does so only after repeated applications of the current, and requires so much time for its performance that it is applicable to but a few cases in which there exists no indication for rapid delivery. In certain other instances two or three applications may be of service in hastening cervical softening, other and more rapid methods being employed after the softening of the tissues has been accomplished. (2) Missed Abortion. — " Missed abortion " is a term ap- plied to that condition in which death of the ovum takes place at some time during the early weeks or MISSED ABORTION. 273 months of gestation, shortly followed by the symptoms of a threatened abortion, which, however, gradually subside without expulsion of the dead product of conception ; the latter is retained in the uterine cavity for varying periods of time, even amounting to eight or nine months (McClin- tock). There may be no clinical manifestations attendant upon this retention of the embryo in titcro, while, on the other hand, vague symptoms of septic changes may be noted, with general malaise, irregular uterine hemorrhages, and more or less leukorrheal discharge. In addition, there is entire subsidence of all the preexisting signs of preg- nancy. The changes that the retained ovum undergoes are interesting to note. If there be rupture of the membranes with access of air, there will sooner or later be produced decomposition of the blighted ovum, with the production of a fetid leukorrhea and some symptoms of septicemia. If, however, rupture have not occurred, the ovum is apt to disappear by absorption, if death take place before the third month ; if death have occurred later than the third month, various forms of the so-called true moles result, which are in the course of a few weeks or months expelled with all the symptoms of an ordinary abortion, except to a lesser degree. This expulsion usually takes place about the fourth or fifth month, and the mole by that time has probably attained the size of an average orange. Varieties of True Moles. — True moles are always the result of conception, and must be distin- guished from the so-called false moles, which are nothing more than masses of coagulated blood and exfoliated vaginal mucosa occasionally discharged in the course of a membran- ous dysmenorrhea, and not resulting from the retention of a deceased product of conception. The following varieties of true moles have been described: (i) Ova moles, or blighted ova, in which the true ova have been dissolved, and merely a bloody mass containing chorionic villi and other membra- nous and fatty debris remains ; (2) flcsJiy moles, or retained products that have died at an early stage of gestation and 18 274 ^ MANUAL OF OBSTETRICS. have undergone more or less organization into carneous tissue ; (3) placental moles, consisting mainly of masses of placental tissue (see also Cystic Disease of the Chorion) ; (4) decidual tnoles, formed entirely of decidual tissue; (5) vesicular moles, due to cystic disease of the chorionic villi {g. v.). Diagnosis. — The diagnosis of this interesting condi- tion can be made only upon the discharge of the mole, to- gether with reference to the history of the appearance of the early signs of pregnancy, the onset of the symptoms of a threatened abortion, and their subsidence, with arrest of the signs of gestation. The prognosis is good, and the treatment is that of an ordinary abortion. (3) Extrauterine Pregnancy. — This is a generic term indicating that rather frequent and extremely interest- ing condition, also known as ectopic gestation or extra- uterine fetation, in which there is a development of an ovum at any point without the cavity of the uterus. Frequency. — It has only been within the last few years that ectopic gesta- tion has come to be recognized as of frequent occurrence, although just what proportion it bears to normal gestation cannot yet be accurately stated. Probably it occurs about once in from four to five hundred cases, but, owing to the lack of general information on the subject, many cases escape detection altogether, and many others are treated and reported as instances of so-called pelvic hematocele, which in almost half of the reported cases is nothing more nor less than a collection of blood in the pelvic cavity coming from a ruptured extrauterine pregnancy. Varieties. — Not- withstanding the fact that some of the leading gynecologists of the day (Lawson Tait, Bland Sutton, and others) advance the theory of the tubal origin of all forms of extrauterine pregnancy, such a view cannot as yet be accepted as a clearly demonstrated truth. Indeed, the accurate record of a few cases of undoubted ovarian and abdominal preg- nancies that have occurred in this and other lands would seem to disprove such a sweeping statement, but the EXTRAUTERINE PREGNANCY. 275 clinical history of this interesting pathologic condition is so undetermined that any dogmatic statement upon these mooted questions would be unbecoming. It would seem better, therefore, to accept the following classijfication of extrauterine pregnancy, which is that generally adopted, as best expressing the present status of our information upon the subject: i. Tubal pregnancy /nxcXvidLWx^ — (i) Inter- stitial, imiral, or tiiboutcrine pregnancy; (2) ///^«/ pregnancy proper, the most common variety, including the intraperi- toneal, intraligamentous, and extraperitoneal forms ; and (3) tuboovarian pregnancy ; 2. Ovarian pregnancy (exceed- ingly rare) ; 3. Abdominal pregnancy, including — (i) the primary (exceedingly rare) and (2) the secondary form, the latter resulting either from a ruptured tubal {tnboabdominal pregnancy) or more rarely from a ruptured interstitial preg- nancy [liter o abdominal pregnancy). In rare instances there may be present at one and the same time both an intra- uterine and an extrauterine pregnancy ; in other cases an extrauterine pregnancy in one tube may in a very short space of time be followed by a similar condition in the opposite tube. Very exceptionally there has been noted a plural (twin) pregnancy in one of the Fallopian tubes, and one case is reported (Bloom) of a simultaneous tubal pregnancy on both sides. These are all to be regarded as pathologic curiosities, so great is their rarity. Etiol- ogy s — ^^The true causation of extrauterine pregnancy is still a matter of uncertainty. Owing to its almost constant occur- rence in a certain class of women there have been described as predisposing factors in 'its development age and sterility. The condition is generally encountered in women who are between twenty and thirty years of age, and who present the history of a protracted period of sterility following one or more pregnancies. It is probable that the sterility is itself not the cause of the extrauterine pregnancy, but that both conditions result from the same cause located in the Fallopian tubes, and that this cause, whatever it may 2/6 A MANUAL OF OBSTETRICS. be, is most prone to manifest itself at the stated age. From a careful physical and microscopic examination of a large number of tubes removed for this condition it is now gen- erally conceded that some pathologic state of that struc- ture has preceded the obstetric condition probably for months or years, causing an insurmountable obstacle to the passage of the fecundated ovum : these abnormal conditions, which may be regarded as the true etiologic factors in the production of ectopic pregnane)^, may be grouped under two main classes — namely, pathologic condi- tions of the tube and malformations of the tube. The former class includes all such inflammatory conditions as will, from the resulting hyperplasia or neoplasmic growth, result in occlusion, more or less complete, of the lumen of the organ. Most commonly this is some form of salpingitis, especially the catarrhal and gonorrheal forms, which by causing an exfoliation of the ciliated epithelium and a cellular infiltra- tion of the remaining tissues of the tube — the latter result- ing in a lack of the normal peristaltic motion — prevent the proper transmission of the ovum to the uterine cavity. Not infrequently, however, small mucous polypi block up the channel, or bands of peritoneal adhesions consequent upon perimetritic inflammation so constrict and distort the yielding structure as to totally obstruct its lumen or form pocket-like dilatations, into one of which the ovum drops. Any abdominal tumor, as a uterine fibroid, an ovarian cystoma, or a renal neoplasm, may so compress the tube in its growth as also to occlude its lumen to an extent suffi- cient for the production of this disease. The possible participation of emotions, fright, or shock in the produc- tion of extrauterine pregnancy by inducing a temporary spasmodic stricture of the tube is suggested by some writers, but nothing positive is known in regard to this. Under such circumstances as the foregoing it will be im- possible for the ovum, already fecundated, to find its way to its normal nidus^ and it lodges where first it encounters EXTRAUTERINE PREGNANCY. 2'J'J the obstruction. Various tubal vialforinations , as con- genital stenosis or the existence of diverticula, or even of blind accessory tubal canals, may also very readily result in an ectopic pregnancy. As to what is the cause of the rare forms of the disease, the ovarian and primary abdominal, absolutely nothing positive is known. Pathology of the Various Forms of Extrauterine Pregnancy. — (i) Tiibal Pregnancy (Fig. 97). — In this, which is by far ./■"^... Fig. 97.— Ruptured left tubal pregnancy, fetus still attached and lying within the pelvis. Hydrosalpinx and adhesions on the right side. Uterus displaced toward the right by the sac : u is the fundus uteri ; R, the rectum ; T, the right closed tube ; f, the fetus ; and s, the ruptured extrauterine sac. the most common variety, there is a development of the ovum at some point within the lumen of the tube; in the great majority of instances it is located at about the junc- tion of the middle and outer thirds of the oviduct. Here it begins to develop, as in a normal gestation, but soon en- counters resistance from the limited space in which it is confined. The tube dilates to accommodate the growing ovum, and there occurs simultaneously an hypertrophy of its walls from an increase in the size of the individual mus- 278 A MANUAL OF OBSTETRICS. cular fibers. This causes the organ to assume a character- istic spindle shape. The hypertrophy, however, is not symmetric at all portions of the tube-walls, and, indeed, there may be at certain points a thinning, rather, of the tissue; it is at one of these attenuated points, usually upon the upper or posterior surface of the tube, that rupture sooner or later occurs. Immediately around the ovum are formed the amnion and chorion, the latter containing the villi as usual. The thickened walls of the dilated tube constitute the so-called decidua, although no true decidual tissue is formed around the fetus. This tubal decidua is an hyper- plasia of the tubal mucosa, together with some proliferation of the fibrous and muscular tissue below it into which the thickened mucosa dips ; it assumes the functions of a pla- centa to a limited extent, although generally no true placenta is found. Direction of Groivtli. — The development of the ovum may take place in one of two directions: (i) Most commonly it grows upward into the abdominal cavity. Usually this results in an early rupture of the gestation-sac ; more rarely this may not occur, and the growth upward may continue until late in pregnancy, forming a peduncu- lated tumor attached to the uterus and broad ligament below and extending upward into the abdominal cavity, where it may be detected on palpation, while the uterus is found to be displaced laterally or even retroverted. This is termed the iiitrapcritotical form of tubal pregnancy. (2) More rarely its growth is downward, separating the folds of the broad ligament. This is the so-called i)itraliganicn- tous or siibpcritoiicopdvic variety of extrauterine pregnancy. Rupture may occur early in this form, but, owing to the additional support afforded by the substance of the broad ligament, it is possible for gestation to be carried to term. The growth in this case does not reach upward into the abdominal cavity, but fills the pelvic space and lies in close proximity to the uterus, which is generally displaced up- ward and forward. In exceptional instances the downward EXTRAUTERINE PREGNANCY. 279 growth between the layers of the broad ligament may be continued until the pelvic floor is reached; the mass is then directed backward and upward, lifting as it advances the posterior deflection of the peritoneum, behind which it con- tinues to develop until it attains its full size at term. This has been termed the extraperitoneal or siibperitoiicoabdoniinal variety of extrauterine pregnancy (Hart and Carter). In all of these varieties extensive adhesions to the peritoneum and adjacent viscera are formed, resulting frequently in serious complications, such as intestinal strangulation, rupture and dislocation of the bladder, or perforation of a bowel, the patient dying of shock, hemorrhage, or septic infection. (2) Interstitial Pregnancy. — That variety of extrauterine pregnancy in which the ovum develops in the portion of the oviduct that passes through the uterine wall is termed an interstitial or intramural pregnancy. Here much latitude of growth is prevented by the greater resistance of the tissues that form the walls of the gestation-sac. As the ovum develops, a tumor-like projection appears upon the upper and lateral wall of the uterus, and this projection at first consists largely in an hypertrophy of the muscular tissue of the uterus, with the broad ligament and Fallopian tube covering its outer surface. The growth of the ovum, however, soon becomes so excessive that the uterine muscle fails to con- tain it, and early rupture into the peritoneal cavity ends the gestation. If the direction of growth be toward the uterine cavity, rupture may take place at this point, and the con- tents be expelled through the normal channel with all the symptoms of an ordinary abortion. In such instances the patient generally recovers without any disastrous sequelae. This exceedingly rare occurrence may be termed an inter- stitial or intramural abortion. (3) Tuboovarian Pregnancy . — A tuboovarian pregnancy (Fig. 98) is that form of extrauterine pregnancy in which the ovum is attached to bath the oviduct and the ovary in the space between the tubal fimbriae. The usual fetal mem- 28o A MANUAL OF OBSTETRICS. branes are developed in this variety, but the outer wall of the gestation-sac is formed in part by the tube and in part by the ovary. Owing to the insecure position of the ovum and the lack of sufficient tissue in the wall of the sac, early rupture is the usual termination. Occasionally the growth Fig. 98. — Tuboovarian pregnancy : a, ruptured Graafian follicle; b, uterine end of tube; r, Fallopian tube ; d, ovary ; c, fetal sac opened ; /;, wall of sac formed by ovary ; i, pla- cental tissue : /, gestation-sac. may be directed downward, as in the intraligamentous form, and the ovum may then develop within the meshes of the broad ligament, the pregnancy even advancing to term. (4) Ovarian Prcgnaucj. — An ovarian pregnancy {internal ovarian pregnancy), so called, is that extremely rare variety of extrauterine pregnancy in which the fecundation and growth of the ovum take place within the ovisac itself Just how this occurs is not definitely known, but its occa- sional existence may be said to have been absolutely demonstrated (Patenko, Paltauf, Hirst, Kiwisch, Puech, Hecker, Coste). Whether it result from penetration by the spermatozoid of an unruptured ovisac or whether impreg- nation take place in a ruptured ovisac without escape of the ovum, the sac closing after fecundation of the latter, is a matter of speculation only. Impregnated in whatever manner, the ovum commences to develop, and EXTRAUTERINE PREGNANCY. 28 1 may even reach full maturity, as in an undoubted instance recorded in the Transactions of the Philadelphia Obstetrical Society. More probable is termination by early rupture accompanied by dangerous hemorrhage, or death of the embryo followed by its absorption — if this take place be- fore the third month — and conversion of the gestation- sac into a cystic tumor; in case of fetal death subsequent to the third month the cyst may contain fetal portions. The fetal membranes are well marked in this variety of extrauterine gestation, but the decidua, if such it may be called, is but poorly formed, although affording a certain amount of nutrition and protection to the ovum. (5 ) Abdomi?ial Pregnancy. — By primary abdominal preg- nancy is meant that exceedingly rare form of extrauterine fetation in which the ovum, having escaped from the ovisac, becomes impregnated in the peritoneal cavity, probably while still in contact with the ovary {external ovarian preg- nancy), and, not finding a place for suitable attachment, drops to the floor of the abdominal cavity, where it becomes fixed in either one or the other iliac fossa, in Douglas's pouch, or higher up among the intestines, and there con- tinues its process of development. The fetal structures under these circumstances are well formed, including the placenta, which is attached to the peritoneum covering the pelvic walls, the intestines, or other viscera, and the preg- nancy may go to term without interruption. The peritoneum underlying the ovum becomes hyperplastic and intensely congested. The inflammatory action induced gives rise to an exudate that surrounds the ovum, and thus forms a more or less complete cyst-wall containing newly-formed blood- vessels ; this structure assumes the function of the decidua. The uterus becomes slightly enlarged from the formation of a true decidua, and the pregnancy may continue to term without interruption. By secondary abdominal pregnancy {metacyesis) is meant the more frequently encountered con- 282 A MANUAL OF OBSTETRICS. clition in which, after the escape of the ovum into the ab- dominal cavity from a ruptured tubal {tuboabdomiiial) or interstitial or true intrauterine {iiteroabdoniinal') pregnancy, the embryo lodges somewhere among the abdominal con- tents and continues its growth and development. In these cases the fetal membranes encircle the displaced ovum, while the placenta may or may not still be retained at the original site of ovular implantation (in the tube, uterine wall, or uterine cavity), communication between the two being maintained through the agency of the umbilical cord. In those cases in which the pregnancy originally was intrauterine the rupture is probably dependent upon and occurs at the site of some previous solution of continuity in the uterine wall, as from a former Cesarean section or rupture. Usually death of the embryo speedily follows the rupture, but in rare instances life may be .preserved and the pregnancy continue to term. In case death occur at a subsequent period, but prior to full maturity, the liquor amnii will become absorbed and the fetus be left in situ ; the latter may then pass through a series of retrograde changes. In those rare cases in which an abdominal preg- nancy advances to term, fetal death usually occurs at the time of the labor, probably as a result of placental detach- ment induced by the labor-pains. Symptoms of Extrauterine Pregnancy. — It is mainly owing to the peculiarly vague character of the symptoms of this disease that it remained for so long a time shrouded in mystery even to the most experienced obstetricians. The clinical manifestations may be grouped under those that are common to all forms of extrauterine gestation and those few symptoms that may result from the peculiar location of the respective varieties. Symptoms of all Varieties in Com- mon. — In all cases of gestation occurring without the ute- rine cavity there are developed the same reflex manifesta- tions that are present in normal pregnancy. These gener- ally appear, however, subsequent to a protracted period of EXTRAUTERINE PREGNANCY. 283 sterility which has often been attended by one or more of the symptoms of an endometritis. The reflex nausea and vomiting of pregnancy are, as a rule, very pronounced, and begin quite early after conception. There is noted gener- ally an arrest of menstruation, at least for one or two pe- riods, possibly with the exception of a primary abdominal pregnancy, in which case menstruation may not be dis- turbed at all and may even continue regular to the full expiration of pregnancy. This is not absolutely true, for the only disturbance in the menstrual function may be a decrease in the amount of the discharge or the occurrence of an irregularity in the time of the flow ; in other instances there may be no cessation at all, but, on the contrary, a constant escape of a serosanguinolent discharge which, just before rupture takes place, may contain small shreds of ex- foliated decidual tissue that upon microscopic examination will be found to contain no chorionic villi. Usually the re- turn of the menstrual discharge indicates embryonic death and predicates early rupture of the sac. The mammary changes are the same, as are also the nervous manifesta- tions. There is the same frequency of micturition, or there may be noted an actual dysuria. Vaginal pulsation is generally present. Very often the patient is unable to lie upon the affected side. There is the usual constipation of pregnancy, increasing in intensity as the gestation ad- vances, and there is often an annoying rectal tenesmus, arising from the pressure exerted upon the bowel by the adventitious gestation-sac, the patients often com- plaining bitterly of it. As the case progresses pressure- symptoms are especially prone to develop upon the side on which the abnormal gestation is located, and at a much earlier period than in normal pregnancy ; these include edema of the limb of the affected side, together with lan- cinating, cramp-like pains originating in the vicinity of the gestation-sac and radiating down the limb and to the sacral region. This prominence of pain should be especially 284 A MANUAL OF OBSTETRICS. noted as one of the most decided symptoms of an extraute- rine gestation. There may be in association with it an elevation of temperature : this may often be noted as early as the fourth week, and is usually slight — 99° or 99.5° F. ; at times it may rise to a considerable height, even reaching 105° F., but only in hyperesthetic indi- viduals : with this there may be some impairment of the general health — anorexia, malaise, or more or less nervous exhaustion. At the time of rupture there is very often an acute elevation of temperature. In connection with a history of symptoms like the foregoing, which are pre- sented in common by all the varieties of ectopic gestation, a physical examination of the patient must be made* and it is here that slight shades of difference may be detected between the various forms of the disease. Physical Signs. — Alterations in the Genitalia. — The changes that take place in the uterus and vagina are the same for all the varieties, and are about identical with those that occur in an ordinary intrauterine pregnancy. The vaginal walls are hyperemic, relaxed, edematous, hyper- trophied, and pigmented {Jacquemin s sign) ; there is more or less of a leukorrheal discharge ; the cervix uteri is soft, and the external os may be somewhat patulous, although the mucous plug that is usually present in pregnancy fills the cervical canal ; the uterus is enlarged, but not to an extent proportionate to the duration of the pregnancy, and, instead of being strongly anteflexed, as in a normal preg- nancy, it is more often laterally disposed, being carried to the side of the pelvis opposite to that in which the ectopic gestation is developing. The uterine enlargement is due to the formation within the organ of a decidua which is almost identical in histologic structure with that developed in a normal gestation. In very rare cases, however, the uterus may be scarcely altered in size and no decidual membrane be formed. If the condition be one of tubal gestation, there will be detected on the affected side, on a line with EXTRAUTERINE PREGNANCY. 285 or behind the uterus, or more rarely anterior to that organ — which will be displaced accordingly — a very sen- sitive rounded tumor, it may be about the size of a small orange, fixed in its position and giving a peculiar elastic or semi-fluctuating sensation as well as a distinct and often well-marked pulsation ; in many cases ballottement may be detected at an early date. The only distinguishing point of interstitial pregnancy is an increased size of the uterus — that is, to a greater extent than in simple tubal pregnancy — with a less marked line of demarcation between the uterus and the gestation-sac. There are no distinctions to be drawn between the physical signs elicited in an ovarian and a tubal pregnancy: abdominal section alone will reveal the true state of affairs. In case of abdominal pregnancy the uterus will be but slightly enlarged above the normal ; the cervix will show the peculiar softness of pregnancy ; a large tumor will be found at some point in immediate prox- imity to the uterus, varying in shape, often having its long axis in a transverse direction, and not corresponding to the rounded or oval tumor of a normal pregnancy ; in ad- vanced cases the fetal parts may be very readily palpated through the abdominal walls, or through Douglas's cul-de- sac should the ovum be behind the uterus, while the heart- sounds will be heard with unusual distinctness. Diagnosis of Extrauterine Pregnancy. — It is patent that the making of a positive diagnosis prior to the occurrence of rupture of the gestation-sac, although quite possible in view of the advanced knowledge of the disease, must always be a matter of considerable difficulty. That some patho- logic condition exists is a self-evident fact, but in many in- stances the correct state of affairs can be recognized only after the exploratory incision has been made. There are several factors which when taken in conjunction render it possible to make a fairly strong presumptive diagnosis of the obstetric condition, and these are the history of the signs of an early pregnancy accompanied by a rapid development 286 A MANUAL OF OBSTETRICS. of the reflex symptoms in an aggravated form ; the early ap- pearance of abdominal pain, exceedingly sharp and cramp- like and steadily increasing in severity ; the presence of a sensitive tumor to one or the other side of the uterus; and the non-development of the uterus as in a normal preg- nancy. In no instance is it justifiable to resort to the use of the uterine sound to solve the question. The occurrence of rupture will greatly facilitate the diagnosis, and in those rare cases in which pregnancy is well advanced or even reaches term no difficulty should be experienced in arriving at a positive conclusion. It is only in the early weeks that the diagnosis is shrouded in uncertainty, but, unfortunately, this is the period in which it is most im- portant for a positive knowledge of the condition to be entertained in order that a fatal termination from rupture may be avoided. There are certain pathologic states that closely simulate ectopic pregnancy, the most important of which are cornual pregnancy, pyosalpinx associated with an uncertain history of gestation, normal pregnancy compli- cated with the development of a fibroid tumor in one of the lateral walls of the uterus, and extreme lateral flexion of a pregnant uterus. Some of the points to be borne in mind in studying cases representing the respective conditions arc presented in the following tablcsrvvhich are not to be accepted as conclusively determining the diagnosis in any given case, but are to be looked for as probable points of difference that, in combination with the history of the case, will assist in arriving at a presumptive diagnosis : From cornual pregnancy : Extrauterine Pregnancy. Cornual Pregnancy. Rupture is most prone to take place at some Rupture usually occurs between llic third period during the first three months. and sixth months. The tumor exists to one or the other side of There may be but one tumor, this being the uterus, and is usually distinct. dependent upon the degree of bifurcation. The tumor is exceedingly sensitive and The tumor is not so sensitive, and presents semi-elastic. the characteristics of a uterine tumor. 'rhe round ligament may be felt attached to The round ligament is displaced outward the uterus on the inner or uterine side of and is attached to the external side of the the gestation-sac. gestation-sac. EXTRA UTERINE PRE GNANC Y. 287 Extrauterine Pregnancy. Examination of the removed specimen shows an absence of true decidual tissue. In interstitial pregnancy the gestation-sac communicates with the uterine cavity by the orifice of the Fallopian tube. From pyosalpinx : Extrauterine Pregnancy. The uterus is enlarged, with a soft cervix and the peculiar softening of the body that is present in pregnancy. There is a history of sterility, with the signs of endometritis or salpingitis. The tumor is small, exceedingly sensitive, but, as a rule, not firmly bound down in the pelvic cavity. Rupture is likely to occur at some time dur- ing the first three months. The usual clinical manifestations of preg- nancy will be present. Cormial Pregnancy. True decidual tissue will be found surround- ing the fetal membranes. The two halves of the uterus are united by a muscular band. Pyosalpinx with Indistinct History of Pregnancy. The uterus is probably not enlarged, the cervix is not soft, and there is not the elas- tic feel that is present in pregnancy. There is a history of acute attacks of peri- tonitis occurring at intervals after an at- tack of gonorrhea. The tumor is large, moderately sensitive, firmly bound down in the pelvis, and sur- rounded by a mass of exuded lymph. The history may have covered a period of months without the symptoms of rupture. The clinical manifestations of pregnancy are absent or very indistinct. From intrauterine pregnancy zvitJi fibroid tumor : Extratiterine Pregnancy ( Tubal Variety) . There is discovered to one side of the uterus a mass, rounded, exceedingly sensitive, and elastic or semi-fluctuating. The uterus is enlarged, but not to a size pro- portionate to the period of gestation. The menstrual history is irregular, and there may be an early return of the show. Rupture occurs at the usual time. Pain is an early and prominent symptom. From lateral flexion of a pr Extratiterine Pregnancy. The body and cervix of the enlarged uterus are generally in a straight vertical line. The extrauterine gestation-sac is in close proximity to the body of the uterus. Anesthetization reveals the mass closely at- tached to the fundus and readily outlined. The size of the uterus is much below that in- dicated by the duration of the pregnancy. The menstrual history is irregular. There is a history of severe abdominal pain and rectal tenesmus. Intrauterine Pregnancy complicated ■with Fibroid Tumor. The mass may be rounded ; more often it is nodulated, very hard, non-elastic, and non- fluctuating, and not sensitive to the touch. The size of the uterus corresponds to, or is even in excess of, the time of gestation. Menstruation is likely to be suppressed. No signs of rupture follow. Pain develops only after the tumor has reached sufficient size to press upon the surrounding structures. egnant utei'us : Intrauterine Preg7iancy with Lateral Flexion of the Uterzis. The fundus lies to one side of the pelvis, with the cervi.x carried to the opposite side. A deep sulcus may be felt between the fun- dus and the cervix. Anesthetization reveals a normal condition of the appendage. The size of the uterus corresponds to the period of the gestation. Menstruation is suppressed. Usually there is no pain other than a back- ache; there is no rectal tenesmus. 288 A MANUAL OF OBSTETRICS. Prognosis. — Of the many obstetric complications to which woman is heir, extrauterine pregnancy must be classed as one of the most serious. It is universally recognized that hemorrhage is the great danger to be feared. Not only is this likely to occur from rupture of one of the enlarged vessels in the Fallopian tube and broad ligament, but there is reason to believe that a peculiar hemorrhagic tendency exists in this condition whereby serious or even fatal bleeding may occur from vessels or structures more or less remote from the gestation-sac. Thus, Drs. J. L. Mitchell and W. C. Goodell recently reported a case of fatal hemorrhage occurring from one of the splenic veins without appreciable cause. This is a possible contingency that would add materially to the gravity of the prognosis. If left to nature, the mortality of extrauterine pregnancy is about 6673 per cent., the remaining 33^ per cent, recovering by the so-called spontaneous cure brought about by death of the ovum with absorption of the contents of the gestation-sac. If an appropriate course of treatment be instituted, either before or immediately after rupture has occurred, the mortality may be reduced to less than 5 per cent. As to the ulti- mate effect upon the woman's general health, the prognosis is also doubtful. Those who survive the immediate conse- quences of the disease often linger through protracted periods of invalidism consequent upon the shock and ex- cessive hemorrhage coincident with rupture of the gesta- tion-sac. In other instances troublesome and dangerous, or even fatal, sequelae are recorded, such as ulceration with pelvic or abdominal abscess-formation in cases of retained products of conception ; ulceration and perforation of the intestines, bladder, or abdominal walls consequent upon pressure exerted by retained fetal parts ; or intestinal ob- .struction from ultimate contraction of inflammatory bands of lymph formed during the gestation. The methods by which nature unaided terminates an EXTRAUTERINE PREGNANCY. 289 ectopic pregnancy are but three. Taken in the order of their frequency, they may be stated as fohows : (i) RiLptiire with hemorrhage and frequentlj'- death. This occurs in tubal pregnancy when the tube has been stretched to its fullest extent, and takes place generally during the third month of gestation, although it has been noted as early as the fourth week and as late as the sixth month. The usual site of mptiLve in tubal pregnancy is in the upper and posterior portion of the tube, and the hemorrhage then takes place directly into the abdominal cavity; hence it is unlimited. In rarer instances the rupture will occur in the lower portion of the tube, and the blood, to a much smaller amount, will then be poured into the meshes of the broad ligament. In the ovarian and abdominal varieties the rupture, when it occurs, takes place directly into the abdominal cavity, while in interstitial pregnancy it may occur either into the abdom- inal cavity, into the layers of the broad ligament, or very rarely into the uterine cavity. The amount of blood effused is very generally excessive, but is quite independent of the size of the gestation-sac or the period to which the preg- nancy has advanced ; considerable blood may be lost by the rupture of a small sac, and vice versa. At times, espe- cially when there have been repeated hemorrhages, so con- siderable may have been the loss that the woman will be almost completely exsanguinated, and the incision made through the abdominal wall at the time of operation may be absolutely bloodless, the tissues cutting like so much compact suet. At other times the hemorrhage may be controlled by bands of adhesion, clots, fetal portions, or the layers of the broad ligament. It is possible in excessive hemorrhage to detect the soft, boggy masses through the posterior vaginal fornix or even on palpation of the abdom- inal walls. Upon the amount of blood exuded will depend the length of time that a woman may survive the rupture of the sac ; in the average case death will supervene in 19 290 A MANUAL OF OBSTETRICS. from eight to twenty hours, although it has followed in two hours, or has been postponed for days or even weeks. As to the dctcriiii)ii)ig cause of rupture very little that is positive can be said. The sac-walls yield when they have reached their utmost degree of distention, and it will at this time need but a trivial exciting cause to deter- mine the rupture. In th'e majority of instances this is so obscure as to altogether escape the notice of the patient. Often rupture has occurred while she was at rest in bed or while sitting in her chair; it has followed straining at stool, some sudden shock, mental emotion, or physical strain, sexual intercourse, a hasty and it may be rough manipulation during a gynecologic examination, or some minor operative procedure upon the genitalia, as a rapid dilatation or a uterine curetment. The attendant symp- toms are sudden and very characteristic. There may have been noticed for a few days preceding a gradually in- creasing sang'uinolent discharge from the vagina contain- ing granular debris or shreds of dark decidual tissue which probably indicate death of the embryo. Exceedingly se- vere cramp-like pains in the iliac region of the affected side, at times sufficient to cause the woman to drop to the floor in collapse, attend the rupture of the sac-wall ; they are accompanied by all the symptoms of concealed hemor- rhage — extreme pallor of the surface, feeble running pulse, the so-called ''air-hunger'' (audible yawning), moist, clammy skin, coldness of the extremities, profound shock, vomiting, and at times coma with perhaps varying degrees of abdom- inal distention; the vaginal discharge increases, and now may contain large masses of decidual tissue or even com- plete casts of the uterine cavity, the dccidua coming away en masse. If the amount of hemorrhage be considerable and death do not promptly supervene, the woman will, if unattended, shortly present the symptoms of a rapidly developing peritonitis. The varieties of tubal rupture that have been noted, as EXTRAUTERINE PREGNANCY. 29 1 well as the ultimate results, may be grouped into two main classes — namely, (i) external rupture, including those in which there is complete rupture of the tubal walls as well as of the walls of the gestation-sac ; and (2) internal rnptnre, including those in which there is apparently rupture of the walls of the gestation-sac only without coincident rup- ture of the tubal walls. Under the first heading, external riLptiire, may be mentioned the following distinct subdivis- ions, enumerated in about the order of the frequency of their occurrence : {a) Rupture of the sac-zvall, xvith profuse henior- rhage into the abdominal cavity, and death. This is by far the most common form, and may occur in any of the varieties of extrauterine gestation ; the hemorrhage is unlimited, {b) Rupture of the sac-wall, ivitli limited effiision of blood into circumscribed spaces betiveen bands of inflammatory lymph, producing the so-called pelvic or abdominal hematoceles. For many years these limited effusions of blood were unrecog- nized as having any relationship to a preceding ectopic gestation, and it has only been within the past decade or two that this truth has been positively demonstrated. The most common situation in which the hematocele is found is Douglas's cul-de-sac, where it constitutes the so-called retrouterine hematocele ; if, as rarely occurs, the blood accu- mulate in the vesicouterine pouch, the condition is termed an anteuterine hematocele. Other hemorrhagic accumula- tions have been noted in the immediate vicinity of the broad ligaments or wherever inflammatory adhesions may have formed between the pelvic or abdominal viscera, [c) Rupture of tJie sac-zvall, zvitli effusion of blood into the meshes of the broad ligament. This constitutes what has been termed hematoma of the broad ligament. The hemorrhage in this case is necessarily limited — that is, as long as the distended tissues of the broad ligament maintain their integrity. In many cases the pressure from the accumu- lated blood is so great that the thin layer of peritoneum yields, and the confined fluid finds vent into the abdom- 292 A MANUAL OF OBSTETRICS. inal cavity (secondary abdominal hemorrhage) ; a fatal result often follows this accident. In the second group, internal rnpture, are likewise found a number of sub- divisions that are also presented in about the order of their frequency. These are as follows : {a) Rupture of a large vessel in the sac-zvall, zuith profuse hemorrhage into the gestation-sac itself, and death of the embryo. This condition is described by some writers under the term hematoma of the sac. Such an accident need not necessarily result fatally to the woman, but always results in the death of the prod- uct of conception. Usually it occurs early in the gesta- tion, and is, as a rule, followed by absorption of the ovum. ill) Rupture of the outer or pelvic wall of the gestation-sac zvitJiout coincident rupture of the tubal tvall, ivith profuse discharge of blood into the abdominal cavity through the fimbriated extrcjnity of the tube. This rather rare termi- nation of tubal pregnancy has been very appropriately termed by Bland Sutton tubal abortion. The hemorrhage may be excessive, and may be repeated at varying inter- vals of time until the excision of the tube, {c) Rupture of a large vessel, with effusion of blood into the sac-walls themselves, without penetration into the abdominal cavity or into the meshes of the broad ligament. This condition is known as hematoma of the tube, and is not, as a rule, accom- panied by a profuse loss of blood. The ovum dies and undergoes a process of atrophy and partial absorption. id) Rupture of the inner or uterine sac-wall, with discharge of the contents of the gestation-sac into the uterine cavity, whence they are expelled as in an ordinaiy abortion. This, the opposite of tubal abortion, which may be termed inter- stitial or intramural abortion (since it is possible for it to occur only in cases of the so-called interstitial preg- nancy), is an exceedingly rare termination of tubal gesta- tion, and is even claimed by many writers never to occur. (2) Death of the Product of Conception. — This event will be followed by varying results according to the time at EXTRAUTERINE PREGNANCY. 293 which embryonic death occurs. If this happen prior to the third month of gestation, there follows complete cessa- tion of the signs of pregnancy, with subsidence of any and all the symptoms of the abnormal condition that may have been present. The ovum undergoes a process of absorption, and it and the gestation-sac may be entirely removed, so that no trace of either as, such, can be found. There re- mains, however, a chronically diseased and distorted con- dition of the tube. This termination constitutes the so-called spontaneous cure of tubal gestation that is thought to occur in about one-third of the cases of this interesting condition. Should embryonic death occur subsequent to the third month of gestation, as is the case usually in ovarian or abdominal pregnancy, such a termination as the preceding could not be expected. Under these circumstances there will follow an absorption of the liquor amnii with partial atrophy of the gestation-sac, while various changes, as maceration, calcification, mummification, adipoceration, or putrefaction, may take place in the fetus itself The entire gestation-sac may be converted into an abscess-cavity, which may rupture into the peritoneal cavity, the bowel, the blad- der, or through the abdominal wall, subjecting the woman to all the risks of septic peritonitis, septicemia, and exhaus- tion from fecal and other fistulse. (3) Contimiance of the Pregnancy to Term. — This, when it occurs, usually takes place in an abdominal or ovarian pregnancy, although it is quite possible for a tubal preg- nancy to be carried to term, the walls of the tube undergo- ing an enormous dilatation. Necessarily, this is an exceed- ingly rare termination of ectopic gestation. In these cases the woman falls into labor at the normal time, but owing to the abnormal circumstances the pains are ineffectual, gradu- ally pass away, and a variety of missed labor results, the fetus generally perishing from placental separation. As a resume of the foregoing these terminations of extra- uterine pregnancy may be tabulated as follows : 294 "-^ MANUAL OF OBSTETRICS. I. Rupture. 1. External : (i) Into the free abdominal cavity. (2) Into the abdominal cavity between bands of ad- hesions {^pelvic or abdominal hematocele). (3) Hematoma of the broad ligament. 2. Internal: (i) Hematoma of the sac. (2) Tubal abortion. (3) Hematoma of the tube. (4) Interstitial or intramural abortion. II. Death of the product of conception. (i) Before the third month {spontaneous cure). (2) After the third month. III. Continuance of the pregnancy to term. Treatment. — There is no more important matter than the proper management of an extrauterine pregnancy. This may conveniently be disposed of under the two captions of early and advanced gestation. (i) Early Gestation. — Any attempt to palliate in a condition of such gravity as that under consideration should not be countenanced. As soon as a suspicion of the existence of an ectopic pregnancy is entertained energetic measures must be taken to con- firm, if possible, or to disprove, the diagnosis. If an abso- lute decision cannot be reached and the patient can be kept under constant surveillance, the physician may be justified in waiting until the symptoms of rupture indicate active in- terference : it may be that the fortunate termination by spontaneous cure may ensue, and the patient thus escape the dangers of rupture or of an exploratory abdominal in- cision. Under no circumstances should attempts to destroy the life of the product of conception be made. The use of the electric current, either faradic or galvanic, and Joulin's method of injections of strychnin or mor[)hin into the sac, have in repeated instances signally failed to accomplish the object in view, and when successfully employed the EXTRAUTERINE PREGNANCY. 295 patient has been exposed to the imminent danger of peri- tonitis or of septicemia consequent upon putrefaction or suppurative changes in the deceased embryo. In those cases in which the medical attendant feels justified in making an absolute diagnosis, or whenever symptoms of rupture have supervened, but one course of treatment is indicated — namely, immediate abdominal section with re- moval of the gestation-sac. Efforts to determine whether or not the effusion of blood is circumscribed are futile, and valuable lives may be lost by the delay thus im- posed. The steps of the operation are — {a) The observ- ance of absolute antisepsis ; {li) a median abdominal in- cision ; {c) the evacuation of clots and free blood that will be contained within the abdominal and pelvic cavities subsequent to rupture ; {d) the separation of any adhesions that may exist ; {e) the ligation and extirpation of the af- fected tube ; (/) irrigation of the peritoneal cavity with hot water; {^g) closure of the abdominal incision; the subsequent treatment the same as in an uncomplicated ovariotomy. (2) Advanced Gestation. — After passing through a period of controversy that was ably carried on by the advocates of the radical methods of treatment, and those of the con- servative measures that were employed in the hope of sav- ing the fetal life when this was clearly demonstrated to ex- ist, the method of immediate removal of the gestation-sac subsequent to the making of the diagnosis is now coming into very general favor as affording to the patient the best chances of recovery. The steps of the operation under these circumstances are essentially the same as in the ear- lier operation, modified, however, b}^ the greater frequency of complications dependent upon the presence of extensive inflammatory adhesions. When possible, complete extirpa- tion of the sac should be made, and if this can be accom- plished the subsequent treatment is the same as that for an ordinary abdominal section. If, however, it be found neces- sary to leave behind a portion of the sac or the placenta — 296 A MANUAL OF OBSTETRICS. and in these advanced cases attempts at removal of the pla- centa will almost invariably result fatally — after ligation and removal of as much as can be secured the edges of the re- tained portion should be stitched to the margins of the ab- dominal incision, the sac thoroughly irrigated, and a pack- ing of iodoform-gauze introduced. This is necessarily followed by a prolonged convalescence while the retained portions are undergoing the process of disintegration and discharge, and necessitates on the part of the medical at- tendant the adoption of stringent measures to prevent the development of septic processes during this period. (4) Cornual Pregnancy. — Cornual pregnancy, or preg- nancy taking place in one of the rudimentary horns of a bicornate uterus, is of exceedingly rare occurrence. Clini- cally, it so closely simulates tubogestation that it is almost impossible to draw any line of distinction between the two. The main diagnostic point lies in the relation existing between the gestation-sac and the round liga- ment. In cornual pregnancy the latter may be traced from the pelvic brim to the outer aspect of the gestation-sac, while in tubal pregnancy it holds a position to the inner side of the sac. In addition to this, at the time of rupture of a cornual pregnancy true decidual tissue will be found in intimate connection with the fetal structures. The course of the two conditions is the same, with the exception that the uterine tissues will permit of greater distention than will the tubal walls; hence rupture will occur at a more advanced period of gestation, usually between the third and sixth months. The site of the niptiire is generally the upper border of the cornu ; the hemorrhage may be excessive and prove rapidly fatal. Other possible terminations are rupture into the uterine canal with expulsion of the product of con- ception, as in ordinary abortion, or, more rarely, develop- ment of the fetus to term, the condition ending in a natural labor. The treatment consists in abdominal section, with excision of the entire uterus accordincr to the Porro method. MISSED LABOR. 297 (5) Missed Labor. — This is a rare occurrence, in which at the time of full maturity of the fetus the woman falls into labor, experiences a few ineffectual labor-pains that grad- ually pass away without the appearance of the remaining signs of labor, and the product of conception is retained i)i iitcro for an indefinite period covering months or even years. In rarer instances there is merely a prolongation of preg- nancy without the occurrence of any pains whatever. Causes. — The etiology of this accident is obscure. It generally results from some form of obstruction, as a fibroid tumor of the uterus, an ovarian cystoma, an exos- tosis or sarcoma of one of the pelvic bones, a sarcoma of the uterus, cervical carcinoma, or cicatricial bands of ad- hesions in the cervix or vagina. In other cases it may be an extrauterine pregnancy that has advanced to term, or there may be an abnormal absence of uterine irritability, so that the patient will not fall into labor. Results. — Invariably the fetus dies and undergoes some process of katabolism. Usually the soft tissues become macerated and are dis- charged in portions, while the bones are retained to under- go disintegration at a later period, with ultimate discharge through the cervix ; if this be impossible, they may ulcer- ate their way through the uterus into the vagina, rectum, or abdominal cavity, with escape through the anterior abdommal wall in the latter instance. Septic metritis, septic peritonitis, or septicemia may result during this process, and the patient lose her life in consequence. Other possible changes are mummification, calcification, adipoceration, and putrefaction. Treatmeiit. — If the patient be known to have gone at least two weeks beyond the normal period of pregnancy, labor should be induced at once, otherwise the excessive growth of the fetus may give rise to complications at the time of delivery. In the rare cases in which weeks or months have elapsed and fetal death has followed, with maceration or putrefaction, the cavity of the uterus must be emptied manually with every antiseptic precaution, the patient being 298 A MANUAL OF OBSTETRICS. anesthetized. When a septic metritis has developed, or in case of ulceration with perforation of the uterine wall, an abdominal section is indicated, with removal of the fetal portions, and, if need be, a hysterectomy may be done to prevent the development of a general septicemia. II. PATHOLOGIC CONDITIONS OF THE FETUS. During its process of evolution in iitcro the embryo and fetus leads a precarious existence. Not only is it exposed to the dangers of the development of inherent defects and pathologic states the result of congenital infection derived from either the male or the female pronucleus, but morbific processes in its autosite, the mother, may very readily react disastrously upon the sensitive and growing organism with- in her womb. Thus, from the very moment of inception to the hour of parturition not a day passes in which some new peril does not menace embryonic and fetal life. Some mis- placement of embryonic tissue, some profound mental im- pression made upon the mother during her pregnancy, the occult influence of the imperfectly comprehended laws of telegony, or some inflammatory processes occurring in the fetal investments, — any or all of these may so alter or divert the normal process of development and maturation as to lead to the production of a fetal teratism ; the implantation within the ovular structures of a profound dyscrasia may engender such perverted tissue-metabolism as to result in the formation of a puny and imperfectly elaborated organism at term, or even destroy the vitality of the product of con- ception before the period of maturity ; and, finally, through the invasion of the maternal system by pathogenic germs of extreme virulence the fetus itself may become infected, and, in miniature, pass through the various stadia of the disease. The .study of fetal pathology, therefore, becomes no trivial matter. Unfortunately, because of its esoteric processes, as FETAL MALFORMATIONS AND MONSTROSITIES. 299 yet but comparatively little is known of it. Owing to the unflagging efforts of such men as Graetzer, and more re- cently Ballantyne of Edinburgh, its mysteries are now be- coming somewhat better understood, and it is beginning to assume its proper importance in the science of obstetrics. Again pursuing a rational plan of treatment, attention will first be directed to that interesting department of fetal pathology known as teratology, or the science pertaining to malformations and monstrosities, and then to the various diseases and accidents to which the fetus may be liable. T. Fetal Malformations and Monstrosities. The variations in the fetal form and structure consequent upon abnormal conditions during the process of develop- ment are numerous and interesting, and form, when exag- gerated, some of the most important elements in the pro- duction of fetal dystocia hereafter to be considered. The exact etiology of these monstrosities is unknown. It is probable, however, that in many instances maternal psychic impressions — anxiety, grief, fear — play a prominent causa- tive role. Also, any cause tending to produce a partial detachment of the fecundated ovule from the decidua, such as deciduitis or attempts at abortion, may be operative in producing fetal teratosis. Syphilis has been suggested as a cause, and hydramnios is at least a frequent concomi- tant. The classification of these abnormalities as made by Geoffroy Saint-Hilaire had long been adopted by the medi- cal profession as the standard treatise on the subject, and this is essentially true to-day, although through the labors of Professors Hirst and Piersol his grouping has been somewhat modified and perfected in the lines of progress that have followed more thorough information on the sub- ject. According to this revised classification, fetal abnor- malities are grouped into three main classes as follows : (l) Hemiterata, a class of malformations including all fetal bodies presenting any abnormality of development not 300 A MANUAL OF OBSTETRICS. grave enough to be called monstrous nor of the specific character to be classed as heterotaxic or hermaphroditic. In "this class are included all those numerous abnormalities of volume, form, color, structure, and number which, while striking enough to form distinct variations from the normal, do not in any way gravely modify the existence of the creature or interfere with the functions of life. Here are to be placed the changes in stature, including delayed growth with general diminution in size, as in dwarfs, and excessive development with general increase in size, as in giants. Instead of being general, this variation in develop- ment may be localized in some one portion of the body ; thus there may be deficient or excessive development of a part, as an atrophy of one limb or an overgrowth of the cranial vault; there may be excessive development of a certain system or element of the body, as when there is a superabundance of fatty tissue ; or, on the other hand, there may be imperfect development of a system or an element, as when there is a marked arrest of growth in the muscular tissue of the body ; certain organs may be under-sized or over-sized, as in macroviazia (hypertrophy of the mammse), or its converse, micromania (abnormal smallness of these glands). In a second group of fetal malformations the anomaly may consist in a misshape of a certain organ or part, as when there is a deformity of the pelvis or when there is a peculiarly formed head, stomach, or other part or viscus. A third group includes those fetuses in which the parts, organs, or systems are perfectly developed, but in which there is a defect in the pigment of the body — either a deficiency or an absence, constituting a partial or complete albinism, an excess, resulting in a partial or complete melan- ism, or an abnormal coloration of a certain part, as in a pink tint of the irides. In a fourth group of cases of hemitcrata the formation and development may be normal, but the structure of a certain part or system may be radically altered ; thus, there may be a lack of ossification in the FETAL MALFORMATIONS AND MONSTROSITIES. 3OI osseous system, the bones retaining their fetal cartilaginous condition, or there may be a deposit of the lime-salts in a part normally free from such elements, as when there occurs a more or less complete ossification of the muscular or fibrous tissues of the body. A fifth group includes those fetuses in which there appear either more or less than the usual number of parts or organs : here may be included the instances of supernumerary digits, double or bicornate uterus, double vagina, polymastia, polychiria, an excessive number of teeth, a deficiency in the number of teeth, ribs, vertebrae, and muscles, or absence of an organ or a part. (2) Heterotaxis, a class of fetal malformations including the anomalous disposition or transposition of parts or inter- nal organs without interference with nutrition or function. Here may be grouped the curious cases of splanchnic inversion, as when there is an anomalous position of the heart or stomach, the various forms of visceral hernia, or exstrophy of an organ, as the bladder. In rare cases these inversions may be general, and all the organs of the body be located upon the opposite side of the trunk, or the ab- dominal viscera occupy the position usually held by the thoracic viscera, and vice versa. The other tissues may join in this displacement, and then are noted anomalies in the position of certain blood-vessels, of the molar teeth, or of other parts or structures. In another group of cases normal parts are developed in abnormal relations, as when teeth appear out of the regular line of the gum-margin, or when a false joint exists, or muscles or ligaments are attached to structures other than in the normal individ- ual ; when unusual branches arise from a nervous or arterial trunk ; or when abnormal openings exist in the body, as of the rectum or urethra into the vagina. In another group of cases there are anomalous im perforations, as of the rectum, vagina, mouth, or esophagus, while in still another group are classed anomalous perforations, as when there is a per- sistence of certain fetal structures, such as the foramen 302 A MANUAL OF OBSTETRICS. ovale, the urachus, the ductus venosus, or the ductus arteri- osus. In this same class may be grouped those instances of anomalous divisions of parts normally united, such as congenital splits and fissures (hare-lip, cleft palate, hypo- spadias, fissured cheek, fissured tongue, coloboma). An- other group embraces all instances of congenital union of organs, such as the horseshoe kidney, webbed fingers or toes, tongue-tie, adhesion of the tongue to the palate, the union of teeth or of the testicles. To this same class of heterotaxis also belongs the interesting condition of her- maphrodism, either true or false. (3) Teratism, or the development of monsters or mon- strosities. By a monster or monstrosity is meant a fetus exhibiting some abnormal development, some superfluity or deficiency of parts, or some vice of conformation. Mon- sters may be single or composite according as to whether they are composed of the parts of one or of two or more fetuses, and antositic or ompJialositic (parasitic) according as to whether they are capable of self-existence or derive their being through nourishment taken from another fetus, the autosite. A vast variety of these malformations have been described, and a classification suggested by Saint-Hilaire has been generally adopted, reference to which must be had elsewhere. 2. Fetal Disease. During the process of development the fetus is subject to numerous diseases that may seriously interfere with its vital functions, and which in many instances succeed in destroying the fetal life at varying stages in its growth. Unfortunately, but little is known of the changes that take place during these pathologic processes, how or when they are acquired, what are their clinical manifestations — if they have any — or what their terminations other than the most constant one, fetal death. Considered systematically, our knowledge of this very imperfectly known subject may be grouped as follows : FETAL DISEASE. 303 I. General Diseases. — (c?) TJie Infections Diseases. — The fetus /;/ ntero is prone to develop any of the zymoses or exanthemata upon exposure of the mother to the specific germs of these diseases. As to just how the germs find access to the fetal system nothing definite can be stated ; it is probable, however, that the transmission from mother to child is accomphshed entirely through the agency of the placental circulation. The fetus shows an unequal aptitude for the acquirement of these diseases, readily yielding, for example, to invasion by the germs of variola, measles, and typhoid fever, while very persistently resisting encroach- ment by those of tuberculosis and malaria. In the case of small-pox, fetal inoculation, while very general, is not always the rule, and the child may even escape altogether while the mother experiences a sharp attack of the disease ; in some instances the disease manifests itself in the infant only after birth, although the mother suffered from an attack at some comparatively remote period of the preg- nancy. In other cases, while the mother's immunity is complete, the fetus may acquire small-pox and pass through a pronounced attack with ultimate recovery, or more gen- erally the pregnancy be terminated prematurely. The disease usually assumes the discrete form in the fetus. Measles, while rarely affecting the fetus, almost invariably results in abortion when it has once invaded the fetal sys- tem ; the same may be said of scarlatina, typlioid, typhus, and relapsing fevers, which, while occasionally encountered, are rare, and usually result in abortion ; especially is this true of typhoid and relapsing fevers. Ver)' rarely does malaria terminate a pregnancy, although this has been known to occur, and the fetus has shown evidences of the disease in a splenic enlargement and in the presence of the pigment-granules in the blood and tissues. Asiatic cholera may attack the fetus and destroy it by asphyxiation, the result of changes in the maternal blood. Acute lobar pneu- monia frequently causes termination of pregnancy from fetal 304 A MA A' UAL OF OBSTETRICS. death due to hyperpyrexia or asphyxiation from imperfect oxygenation of the maternal blood. Other infectious dis- eases that have been noted as affecting the fetus in iitero, though rarely, are anthrax, yellow and recurrent fevers, leprosy, and erysipelas, all generally terminating in abortion. (/;) Congenital Rachitis. — Fetal rickets is a common con- dition, and may, in pronounced cases, be a cause of marked fetal dystocia. The disease is not manifested during intra- uterine existence, but may very readily be recognized at birth. The signs are to be found in the osseous system only, and are as follows : The characteristic square-cut head with prominence of the frontal and parietal bosses ; craniotabes; at times lateral inclination of the head upon the spinal axis ; extreme prominence of the articulations of the body ; varying degrees of spinal curvature ; fre- quently marked prominence of the sternum, constituting the s,o-c3.\\td pigco7i-breast ; the presence of the "beading of the ribs " {rachitic rosary, rachitic rose-garland), a suc- cession of visible and palpable nodosities at the points of junction of the ribs and costal cartilages; curving of the long bones of the body, or even the so-called spontaneous imiltiple fracture of these bones, due to their excessive fra- gility. The treatment of this condition, if it be suspected, consists in supplying the mother with a rich and nutritious diet and the administration of the hypophosphites and the salts of lime in suitable amounts. {c) Fetal or Congenital Syphilis. — Of all the diseases of the developing embryo, syphilitic infection is the most com- mon and probably the most serious ; if it do not result in early abortion, it will very frequently terminate fetal life at a late stage in pregnancy, or in less virulent cases seriously affect fetal health. The infection may take place directly through the mother, or it may be purely paternal in origin, the mother becoming infected from her syphilitic fetus, and manifesting the secondary symptoms of the disease without primary lesion. The woman may infect her offspring in one FETAL DISEASE. 305 of two ways — namely, either at the time of conception, the malady being present in her system prior to that occurrence, and consequently the ovum itself being the seat of the dis- ease before its meeting with the male element ; or she may infect the embryo or fetus at any time during pregnancy through the placental circulation. The most common method of fetal infection is through the medium of a syph- ilitic ovum ; the next in frequency is through the agency of a syphilitic spermatozoid ; and, finally, though rarely, through late infection of the mother, with transmission of the specific taint through the agency of the placental circu- lation. In some cases the disease is transmitted in a very virulent form to the embryo by both parents, in which case early abortion is generally the result. The intensity of the fetal manifestations also depends upon the length of time the disease has existed in the parent transmitting it, as well as upon the amount of treatment that has been instituted before conception. Clinical Manifestations. — Appreciable symptoms are absent, as a rule, prior to those of abortion. In the infrequent cases in which the fetus becomes in- fected late in pregnancy the patient may not miscarry, and the only signs that may lead to the suspicion of the trans- mission of the disease to the product of conception may be a gradual weakening of the fetal heart-sounds and move- ments, with sudden death of the offspring shortly before the onset of labor. As a rule, however, the development of such fetuses is to all intents undisturbed, and gestation is carried to full term, when there ensues the birth of an ap- parently healthy child, the specific disease only manifesting itself some weeks or months subsequent to labor. Ulti- mate Results. — In the vast majority of instances of congeni- tal syphilis the fetus is either still-born, prematurely dis- charged, or the pregnancy is terminated by an early abor- tion. In the comparatively few cases that arrive at term with symptoms of the disease well advanced, fetal death usually follows within a few weeks. The cause of the prem- 20 306 A MANUAL OF OBSTETRICS. ature discharge of the ovum is a fatty change in the pla- cental tissues consequent upon the syphilitic inflammation of those structures. Pathology. — As in syphilis in the adult, the pathologic processes are to be found more or less marked in all the tissues of the body ; the changes wrought by the disease are those of a chronic inflammation — namely, cellular infiltration with hyperplasia of the connective tis- sues wherever found. The placenta will present the charac- teristic signs already described (see page 235), and the um- bilical cord will show degrees of stenosis of the vessels con- sequent upon the same hyperplasia of the connective-tissue element. The vascular system throughout the body also shares in this process. The fetus is small for the period to which the pregnancy has advanced, is exceedingly ema- ciated, and the skin is shrivelled and yellowish in color, giving the body a peculiar old and wrinkled aspect. Upon the palms of the hands and soles of the feet are very com- monly developed large pemphigoid bulls, and this is an absolutely positive sign of fetal syphilis, for the lesions of the ordinary nonspecific pemphigus never occur in these regions, although present upon any other portion of the body ; at times these bullae may have ruptured, and then they appear as slightly elevated erosions. The glandular structures of the body are all notably increased in size and weight, especially the spleen and the thymus gland ; if the latter organ be cut into and its tissues compressed, it yields a milky, puruloid fluid that is very characteristic. The liver is exceedingly large, and often fills the entire abdomi- nal cavity, displacing upward and downward the other vis- cera : on section of this organ large patches of hyperplastic connective tissue may be noted surrounding areas of indu- rated and bile-stained hepatic tissue, the whole being im- bedded in normal liver-cells ; the same serous fluid exudes when the organ is subjected to pressure. In the lungs may be found varying pathologic features according to the de- gree to which the specific changes have advanced ; usually FETAL DISEASE. 307 there is found a condition of fibroid pneumonia character- ized by an induration of the lung not dependent upon an ex- udation of cells, but upon a hyperplasia of the pulmonary connective tissue. In other cases, and more rarely than the preceding, the lung presents a condition known as the ca~ tarrhal or white piicmnojiia o{ {Qtdi\ syphilis ; this is charac- terized by a fatty degeneration of the lung-tissue due to extreme proliferation of the cells of the air-vesicles, which, crowding upon one another and impinging upon the sur- rounding lung-substance, cause the death of the latter ; the lung presents an opaque-white appearance, is dense and edematous, and is marked with the imprint of the ribs with which it has come in contact. In still other cases the lunofs will be found to be studded with gummata, that appear as indurated nodules having the density of hepatic tissue, of varying size and yellowish in color ; at times these break down at their central points and give rise to semi-purulent collections that may be found on making sections of differ- ent portions of the lungs, A very characteristic change, that may be considered as diagnostic of fetal syphilis, is that to be noted on making longitudinal sections of the long bones. The general tendency to connective-tissue prolif- eration is manifested here at the lines of junction between the diaphyses and epiphyses ; the embryonic tissue thus formed fails to derive sufficient nutrition, undergoes a pro- cess of retrograde metamorphosis with fatty changes, and manifests itself in irregular yellow lines separating the epiphyses from the diaphyses. Diagnosis. — Before the dis- charge of the product of conception the condition can only be suspected. After the birth of the fetus the diagnosis may be made by attention to the pathologic changes as just noted. The prognosis is grave for fetal life. Treatment. — For evident hygienic reasons syphilitic individuals should not marry until the specific taint is entirely eradicated from their systems, if this be possible ; even then, after concep- tion, the mother should be placed upon the mixed treat- 308 A MANUAL OF OBSTETRICS. ment (protiodid and mercuric potassium iodid), and this continued throughout gestation ; the fetus thus receives .medication through absorption from the maternal blood, and the course of the disease in it is modified. After the birth of the child, should any of the manifestations of the disease be noted, mercurial inunctions should be made at suitable intervals. {d) Fetal Tiijuors. — Malignant growths of the fetus, while rare, have been noted. They may be situated in any of the viscera, notably the liver, spleen, and kidney, but rarely reach any considerable size, although they may attain suf- ficient bulk to cause appreciable obstruction at the time of labor. Growths that have been noted elsewhere are unusual size of the thymus and thyroid glands {congenital goiter), and tumors situated in the trunk-walls, in the axillae, or in the posterior cervical region. These may be either cystic, fatty, bony, cartilaginous, vascular, or carcinomatous, and are most commonly found over the region of the sacrum or in the perineum ; here they may attain remarkable size, even that of the fetal head at term, and may produce a considerable degree of dystocia. These neoplasmata can- not be recognized before labor has begun. {e) Conditions Secondary to Maternal Disease. — Any alter- ation in the state of the maternal health will speedily mani- fest itself in the sensitive organism of the fetus, and to a degree proportionate to .the gravity of the maternal condi- tion and the refinement of the nervous organization of the child. Thus, chronic systemic disease of the mother will become to a certain extent indelibly impressed upon the fetal constitution, while any incidental indisposition will awaken a quick response on the part of the fetus. It is owing to this peculiar and intimate relationship existing between mother and child that has arisen the custom of administering remedies to the woman in order to correct certain fetal disorders. Profound alterations in the mater- nal nutrition inducing varying degrees of anemia, or cer- FETAL DISEASE. ' 309 tain forms of systemic poisoning, such as that generated in the course of a chronic nephritis or consequent upon the introduction into the system of the salts of lead or mercury, likewise producing anemia, will react unfavorably upon the fetal nutrition or even result in fetal death, with subsequent abortion. Abrupt elevations of temperature, as in the grave fevers — typhoid and pneumonia — may very speedily result in fetal death, while temperatures equally as high, but attained by gradual stages, may be borne for a limited period with impunity. Closely allied to the effect produced by these physical conditions is the influence exerted upon the fetus by mental states and emotions in the mother. How these violent mental changes react upon the fetal con- stitution is somewhat of a mystery, but the result, as has been suggested, is probably the outcome of sudden altera- tions in the placental circulation produced by variations in the maternal blood-pressure : the shock to the fetus may be so extreme as to induce grave systemic manifestations or even entire suspension of the vital functions. Death of the mother will usually be followed by fetal death in from fifteen to twenty minutes, although one or two instances of undoubted veracity (Tarnier) are on record in which the fetus has continued to live for from one to two hours sub- sequent to the maternal death. 2. Diseases of the Digestive System. — Pancreatic en- largement, due either to some form of new growth or to a chronic, it may be specific, inflammatory process, has been noted. Peritonitis may be present in the fetus or may appear shortly after birth ; it is consequent upon syphilitic infection or blows upon the abdomen, or may follow mater- nal peritonitis, the action of cold, or over-exertion upon the part of the mother. It is often accompanied by a limited amount of ascites that rarely causes sufficient abdominal distention to give rise to any difficulty at the time of labor. Certain degenerations or neoplasms of the liver may produce abdominal distention in the fetus. Very rarely Jaundice 310 A MANUAL OF OBSTETRICS. associated with maternal jaundice has been noted. Patho- logic conditions of the alimentary canal, if ever encoun- tered, must be of exceedingly rare occurrence. 3. Diseases of the Respiratory System. — Owing to the inaction of the pulmonary organs during intrauterine existence pathologic states of these structures are rare. Syphilitic disease of the lungs has been described under fetal syphilis. HydrotJiorax, usually associated with serous effusions elsewhere, may be occasionally found : if con- siderable, it may constitute one form of fetal dystocia. 4. Diseases of the Circulatory System, — Vakndar dis- ease of tJie heart and pericardial effusions of varying size have been noted, and are usually fatal. General anasarca, when present, is dependent upon stenosis of the umbilical vessels or some variety of obstruction to the placental cir- culation, generally of syphilitic origin ; the bulk of the fetal body may be so augmented as to present a moderate degree of obstruction to labor. Enlargement of the spleen may be found, either of malarial origin or consequent upon some circulatory impediment or a tumor in the organ. 5. Diseases of the Nervous System. — [a) Maternal impressions, or peculiarities in the mental or physical for- mation of the offspring dependent upon some mental shock or impression made upon the mother during pregnancy, are interesting phenomena that are not infrequently en- countered. They are probably most common in the chil- dren of women whose nervous organisms are highly devel- oped, but the exact nature of their production has not as yet been clearly demonstrated. The phenomena as noted in the fetus are generally referred by the family to some unplea.sant occurrence, such as an encounter by the preg- nant woman with some gruesome object or person, the hearing of some startling piece of news, or the seeing of some tragedy ; but as to how far the fetal condition is due to the maternal impression received at the stated time is a mooted question. While the mode of transmission of FETAL DISEASE. 3II the impression to the fetal organism is obscure, it is un- doubtedly true that curious coincidences of the kind have been noted by men whose standing is such as to add much weight to their statements, and that go to prove the exist- ence of an occult influence between the nervous organiza- tion of the mother and the developing mental and phys- ical organisms of the fetus. Clinically, the effects of such so-called impressions upon the fetus may be manifested in two distinct ways : in the one case there results a lack of physical, and in the other a lack of mental, development, although these two are frequently combined in one indi- vidual. As illustrations of the first class there may be noted, according to the varying degree of intensity of the impression made upon the fetal system from the lesser to the greater, the presence of nevi or mother's marks ; the existence of malformations, such as the absence of members or the presence of supernumerary parts ; and, finally, the production of monstrosities ; in the second class the child may manifest strange physical or mental pecu- liarities corresponding to peculiarities in the person or object that originated the maternal impression : it may be afflicted with convulsions and other evidences of brain-irri- tation, or, finally, there may be an entire arrest of all mental functions and an idiotic offspring result. During the siege of Paris it is well authenticated that many pregnant women, terrified by the harrowing scenes and experiences of that time, ultimately gave birth to feeble-minded children. At best, the subject, though intensely interesting, is still largely within the realm of speculation, and nothing beyond the facts as just presented can be stated with any degree of authority. It has been suggested that the fetus may pos- sess capacities that it subsequently loses in the normal course of development, just as it possesses organs that subsequently undergo a process of atrophy, and that the capacity to receive nervous impressions by induction may come under this category. The literature of this subject 312 A MANUAL OF OBSTETRICS. is deplorably poor, and it would be well were every case of supposed maternal impression accurately reported, the statement to include not only the exact anatomic facts, but also whatever family history of heredity, maternal or paternal, might exist. (/;) Intracranial diseases, including pathologic altera- tions in the brain-substance, such as the development of brain-tumors or the occurrence of sclerotic changes, have been noted and are incompatible with fetal life. Congenital cnceplialocele, or a hernia of the brain-substance through a cranial fissure, together with an accumulation of cephalic fluid, is often encountered in connection with fetal monstrosi- ties, and may from its bulk constitute an important form of fetal dystocia. A cerebral meningocele is a protrusion at any point through the cranial vault of a portion of the cerebral meninges containing more or less fluid ; it is usually cov- ered by skin or a portion of the scalp. A Jiyciroencepha- locele is a congenital brain-tumor protruding through some portion of the calvarium and containing meninges, brain- substance, and fluid ; it constitutes the true encephalocele. In size an encephalocele varies from a minute bulging to a tumor as large as or larger than the fetal head at term ; it is soft and fluctuating, and generally more or less peduncu- lated. It may be situated at any point upon the skull, but is especially found between the eyes or in the occipital region. The exact cause of the condition is not known ; it may be due to some defect of development, to an attenu- ation of the cranial bones the result of internal hydro- cephalus, or it may follow an intracranial inflammation with the formation of bands of adhesion. Communication may or may not exist between the encephalocele and the cranial cavity through its pedicle. Hydroccphahis (Fig. 99), a collection of serous fluid at some point within the cere- bral substance {internal JiydrocepJiahis) or outside the brain- substance {external hydroceplialns), preventing closure of the fontanels and causing enlargement of the skull, is not as FETAL DISEASE. 313 frequent a prenatal as it is a postnatal disease ; it occurs once in about two thousand pregnancies. When it does occur during intrauterine life it constitutes an important variety of fetal dysto- cia. Nothing definite is known as to its eti- ology, although it is probably a sequel of some obscure form of inflammation of the cerebral meninges. According to some authorities, an inti- mate relationship ex- ists between hydro- cephalus and mater- nal ill health, and Herrgott claims an invariable association between hydroceph- alus and cretinism. Whatever its origin, the fluid slowly accu- mulates within the cavities, and in order to provide room for itself distends the cra- nial vault, often to an immense degree, so that the bones of the skull may attain a parchment-like thinness ; not infre- quently do encephaloceles of varying size result as a direct consequence of this attenuation. The quantity of fluid that is present may amount to several pints. The deformity thus produced is very characteristic : the head is wedge-shaped with the base upward, and the face and lower Fig. 99. -Hydrocephalus distending lower uterine segment (Varnier). 314 ^ MANUAL OF OBSTETRICS. portion of the skull, retaining their normal size, present a startling degree of disproportion when compared to the immensely distended vault above ; the eyes are set far in under the protruding forehead, and have their axes directed obliquely inward, so that they present a crossed appear- ance ; the fontanels and sutures are widely distended ; the remaining portions of the fetus may be well developed, but the body often presents a wrinkled and emaciated appear- ance. The prognosis is grave for the fetus, because of the difficulty experienced at the time of labor and because of the primary brain-lesion. Spina bifida may also be men- tioned here, but it will be treated of under the pathology of the new-born infant. 6. Diseases of the Genitourinary System. — Various pathologic conditions of the kidneys and bladder have been noted as developing during intrauterine life. Among these may be mentioned hydronephrosis, cystic degenera- tion of the kidneys, dilatation of the ureters, extreme dis- tention of the bladder, and exstrophy of that organ. These vary in their gravity according to the extent of the lesion and the amount of difficulty they produce at labor. 7. Diseases of the Cutaneous System. — Of the various forms of congenital skin-disease, probably the most interest- ing, though but rarely encountered, is that known as scbor- rh(£a squamosa [seu sicca) neonatorum, intrauterine ichthyosis, ichthyosis cojigcnita, or fetal ichthyosis ; this is characterized by a coating of the entire surface of the fetus with thick, fatty, epidermic plates, firmly adherent to the skin, and sep- arated by deep rhagades extending down into the corium. These plates vary considerably in size and shape, and give rise to the popular terms of " alligator boy " and " collodion fetus." Owing to the stiffiiess and contraction of the skin, the eyes cannot be completely opened or closed, the lips are retracted, the nose and cars are atrophied or even entirely absent, and the fingers and toes contracted and cramped, producing the condition known as o)iycJiogrypJiosis, while FETAL DISEASE. 315 the hands and feet are frequently clubbed. The color of the skin varies from a dirty-white to a yellowish-brown, while the rhagades present a more or less livid appearance ; the skin is dense and hard and to the touch, and is commonly colder than normal. If not still-born, the infant soon suc- cumbs from starvation and depression of temperature. Our knowledge of the etiology of this grave condition is deplor- ably deficient. As suggested by Ballantyne, there seems to, be exhibited a strong family tendency to the disease ; parental consanguinity also may exercise a causal action. The disease usually originates at some time toward the close of the third or during the fourth month of pregnancy. The treatment, which is applicable only to the milder grades of the disease, should consist in the removal of the scales by warm baths, followed by applications of bland substances, such as ichthyol, green-soap, and lanolin or vaselin. Artificial feeding by the spoon or per rectum is necessary. The grave cases usually terminate fatally within a few hours or days after birth. Chronic cystic elephantiasis, characterized by marked induration and the formation of multiple cystic tumors throughout the derm, is a rare congenital disease of the skin. It is very generally associated with vascular and lymphatic lesions. Fetal keratolysis (Ballantyne), also designated under the terms excoriatio fceiiis or congenital desquamation, is a rare congenital disease of the skin, characterized by a condition of "abnormal looseness of attachment or of actual desquamation of the epidermis of the living fetus." This pathologic state may be universal or may be confined to special regions, as the hands, feet, or scrotum. The etiology of this curious disease is un- known. Ballantyne suggests that it may be entirely the result of fetal exanthematous disease (measles, scarlatina) or of erysipelas, syphilis, or pemphigus. Others suggest that it is the result of deficient nutritive power in the epidermic vessels. The denuded areas are usually of a pale salmon tint, in strong contradistinction to the bright- 3l6 A MANUAL OF OBSTETRICS. red areas that are characteristic of postmortem maceration ; this, however, is not absolute. The condition is a grave one, but not necessarily fatal. It is best treated by the application of bland unguents, as lanolin or vaselin, and careful and nutritious feeding. 3. Fetal Traumatism. Curious instances of injuries to the fetus resulting from external violence to the mother during gestation have been noted. Fractures of one or more of the bones are not in- frequent after severe blows upon the abdomen of the preg- nant woman, and even lacerated and contused wounds of the soft parts have been observed, either shortly after the mjury has been inflicted or weeks afterward, the only visible manifestations of the accident being the presence of well-formed cicatrices. Spontaneous amputation of fetal parts has been considered under the subject of Aniniotitis (page 228). 4. Fetal Death. Owing to the precarious existence through which the delicate embryo must pass for days and weeks subsequent to conception, as already noted, death of the developing ovum is of very frequent occurrence. There are numerous causes to which fetal death may be ascribed, and preeminent among these stands syphilis, which not only destroys thou- sands of ova during the early stages of gestation, but is also the cause in very many instances of death of the fetus shortly before the onset of labor. Another very prolific cause is apoplexy of the placenta, membranes, or ovum itself, dependent upon some form of inflammation of these structures, a preexisting endometritis, maternal anemia or plethora, chronic nephritis, or other chronic maternal dis- ease. It may follow various forms of systemic poisoning, as that due to lead, mercury, or tobacco; it may result from paternal disease, from alcoholism, or from extreme age or youth of the father ; while in a certain number of cases no FETAL DEATH. 317 assignable cause may be found other than habit, the mother losing her children in successive pregnancies at about the same period of gestation. The signs of fetal death are inconstant and deceptive : often it is impossible to state accurately whether or not the fetus still lives at any given time. A number of tests by which the occurrence of fetal death maybe recognized have been offered, none of which are, however, absolutely positive, although when taken in conjunction they are strongly pre- sumptive evidence of such an event. In about their order of value these maybe named as follows: i. Cessation of abdominal and uterine growth, followed by subsidence in the size. In ascertaining this decrease in size the following measurements should be taken : {a) The girth of the ab- domen over the most prominent portion of the bulk ante- riorly and in the hollow of the waist posteriorly ; {b) the distance from the symphysis to the umbilicus ; {c) the dis- tance from the umbilicus to the xiphoid cartilage ; 2. Sub- sidence of the signs of pregnancy; 3. Absence of the fetal heart-sounds and fetal movements; 4. Absence of pulsation in the umbilical cord or fetal precordium, as ascertained by the introduction of the hand within the uterus; 5. Decrease in the cervical temperature, which in pregnancy is normally about one degree above that of the body-temperature ; 6. Occasionally the appearance of milk in the breasts, which at the same time become flaccid ; 7. Some disturbance of the renal action, with, possibly, the presence of peptone in the urine ; 8. Cranial crepitus, only to be found in cases in which the fetus has been dead for a considerable period and the head has undergone a certain amount of maceration, so that the bones are loosely fastened together ; 9. Stoltd's sign — a peculiar rustling sound, of doubtful existence, said to be heard in case of fetal death, and supposed by Stoltz to be due to gaseous decomposition of the liquor amnii. Postmortein Changes in the Fetus. — According to the period at which fetal death has occurred, the length of 3l8 A MANUAL OF OBSTETRICS. time during which the deceased product is retained in the body, and as to whether or not there is access of air to the gestation-sac, will depend the retrograde changes that take place in the fetal structures after death. The following changes, in about the order of frequency in which they are encountered, have been noted: (i) Maceration, occurring only when the membranes have not been ruptured, is a softening and nonputrefactive decomposition of the fetus resulting from the action of the liquor amnii upon the skin primarily, and subsequently upon the deeper tissues, the protective influence of the vernix caseosa no longer being exerted. A fetus that has undergone this change is desig- nated as a foetus saiigiiinolentJis, and presents a very cha- racteristic appearance. Owing to the absorption by the amniotic fluid of the coloring-matter of the blood and the products of tissue-decomposition, this fluid is greatly dis- colored, being reddish, greenish, or brownish in color, and at times somewhat offensive in odor. The surface of the fetus is softened and wrinkled, and may present the charac- teristic appearance of the washerwoman's hand ; scattered over the body are patches of varying size of a glistening red appearance, produced by the desquamation of the epidermis at these points ; they are most marked upon the abdomen and extremities; the deeper tissues are soft, flabby, and edematous, and easily displaced from the bony struc- tures ; the articulations are loose and the extremities may be readily disjointed ; the internal organs are infiltrated, edematous, and friable, the cranial bones widely separated and very mobile ; the cord is rounded, soft, and spongy, without exhibiting any of the normal coiling ; and the placenta and membranes are pulpy and edematous. (2) Absorption. — This is the so-called spontaneous cure of extrauterine pregnancy, but it is also known to occur after early fetal death in intrauterine pregnancy. It can only take place before the third month of gestation, and consists in a maceration and ultimate complete absorption of the FETAL DEATH. 319 fetal parts by the liquor amnii, so that not a trace of them can be found ; the only peculiarity consists in a thick and gummy condition of the amniotic fluid. (3) Mummifica- tion, a change only possible before rupture of the membrane has occurred, and occasionally noted when fetal death has followed a slow process of inanition, especially after the fourth or fifth month of gestation. A mummified fetus presents a shrunken, shrivelled, and dried-up appearance, and is of a deep-yellow color and leathery consistence : if it occur in a twin pregnancy, the mummified fetus is usually flattened by pressure from the growing fetus ; there is a notable absence of areolar tissue throughout the body ; the fetal appendages are dried and tough and show traces of fatty degeneration. (4) Putrefaction, due to the entrance of air carrying with it the germs of decomposition. There results the condition known as physometra or tympanites uteri, on account of the tympanitic note elicited when percussion is made over the gaseous uterine tumor. The soft structures are removed by the process of disintegration, and the bones are retained, to eventually ulcerate their way through the wall of the gestation-sac, or are removed by operative procedure. (5) Adipoceration and saponification, varying degrees of one and the same condition, in which the fetal structures undergo a fatty or soapy change, and acquire a peculiar greasy feel from a deposit within them of cholesterin and sodium, potassium, and calcium mar- garates. (6) Calcification, or the deposit of lime-salts in the tissues, producing a hard and stony condition ; such a cal- cified fetus is termed a lithopedioti or " stone child." Treatment. — In any case in which there has been reten- tion of the deceased fetus, with the supervention of one or other of the foregoing changes, treatment consists in the induction of abortion or premature labor with removal of the contents of the uterus. If it be a case of extrauterine gestation, the treatment is abdominal section with removal of the gestation- sac under antiseptic precautions. 320 A MANUAL OF OBSTETRICS. III. THE PATHOLOGY OF PREGNANCY. So manifold are the pathologic possibilities to which the pregnant woman is exposed that few pass through the period of gestation without experiencing some one or more of the troublesome complications now to be enumerated. Many of these are of no significance as concerns risk to mother or child, while others are of the gravest import and may determine fetal or maternal death, or both. The entire organism of the woman sympathizes with the un- usual state of the organs of generation, and to the undue sensitiveness thus engendered may be ascribed the many reflex pathologic manifestations and neuroses that beset the childbearing period. To the affections thus reflexly brought about must be added the various accidental complications of pregnancy that exert a more or less baleful influence upon the gestation or are themselves modified in their clinical phenomena by the coexisting physiologic condition. I. General Diseases. (i) The Zymotic Diseases. — The zymoses, while not exhibiting any marked predilection for the period of preg- nancy, may all complicate gestation, and be modified by it in such a manner as to assume in many instances almost a malignant type. Generally they run an exceedingly acute course and terminate the pregnancy prematurely. In many instances they react so severely upon the maternal system as to induce rapid dissolution either from excessive systemic poisoning, profound shock, or the attendant accidents of the abortion. The discharge of the ovum should, however, be regarded as a beneficent measure intended by nature to assist in eradicating from the maternal .sy.stem a portion of the morbific substance, and, as such, prophylactic meas- ures should not be instituted. Some of the zymotic diseases are more prone to attack a pregnant woman, and are more GENERAL MATERNAL DISEASES. 32 1 radically altered thereby in their clinical course, than are others. Among the eruptive fevers, variola assumes pre- eminence in this respect ; it is the one most commonly encountered in the pregnant woman, and may be regarded as the most virulent ; it generally results speedily in both fetal and maternal death. Should pregnancy not be termi- nated prematurely and the mother survive, the fetus upon birth will generally show marks of the ravages of the dis- ease. The prognosis will depend upon the period of preg- nancy at which the complication occurs and the type of the disease ; it is much more grave when occurring near term and when the disease assumes the confluent form. Scarla- tina is of much less frequency in pregnancy than is variola, but, like it, is exceedingly virulent ; as a rule, early abortion with maternal death from profound intoxication ensues. The disease most commonly attacks primiparae, and much more frequently in the puerperal than during the gestational period. The most prominent symptoms are fever, erup- tion, vomiting, diarrhea, and albuminuria. The treatment should be mainly antipyretic and sustaining. Measles usually assumes a very severe type when occurring under these circumstances ; abortion is the rule, and the patient manifests a marked tendency to the development of pneu- monia and puerperal hemorrhage ; death occurs in a con- siderable proportion of the cases. The treatment should be supporting and antipyretic, and special attention should be paid to the pulmonary condition. Ty pi loid fever is most common in the earlier months of pregnancy, and very gen- erally results in abortion ; the nature of the disease is not materially altered by the physiologic condition. Typhus fever is rarely seen, and does not often assume an aggra- vated form nor does it tend to terminate pregnancy. (2) Among the other specific diseases that may complicate pregnancy must be mentioned Asiatic cholera, influenza, intermittent and relapsing fevers, and syphilis. Cholera is not a frequent complication of pregnancy, but when it does 21 322 A MANUAL OF OBSTETRICS. occur it is apt to result in premature expulsion of the ovum and frequently in the death of both mother and child, the latter from asphyxiation ; it is most common in the later months of pregnancy. Influenza usually results in abortion, either directly from the action of the specific poison or indirectly from the spasmodic action consequent upon the violent coughing. Intermittent fever is of rather infrequent occurrence in pregnant women, and rarely ter- minates pregnancy prematurely ; its course is atypical ; the treatment is the same as under other circumstances, save that the quinin must be administered in larger doses. Relap- sing fever has been noted ; it is rare, however, and is most frequently encountered during the early months of gesta- tion. Syphilis may be contracted by the mother prior to, at the time of, or subsequent to conception, and according to the time of infection will depend the effect upon the fetus ; in case of the contraction of the disease during pregnancy the fetus may or may not inherit the malady. A healthy mother may acquire the disease in its secondary form from a fetus that has become infected through a dis- eased spermatozoid. In all cases in which syphilis compli- cates pregnancy there is manifested a marked tendency to abortion ; in fact, an exceedingly large percentage of abor- tions may be traced to this disease. A curious feature of syphilis contracted at the time of conception is the extreme virulence of the initial lesion and the remarkable mildness of the later lesions ; the disease seems almost to exhaust itself in the virulence of its primary manifestations; these assume a phagedenic character, and may spread over a large surface of the vulva, vagina, thighs, and buttocks. The treatment of this condition should be both local and constitutional. The mixed treatment must be pushed to the point of salivation, and, locally, drying and sedative applications should be continued until the lesions disap- pear ; tonics and nutrients are always indicated. DISEASES OF THE DIGESTIVE TRACT. 323 2. Diseases of the Digestive Tract. (i) Gingivitis, the inflammation of the gums that is occasionally encountered in pregnancy, is a curious condi- tion and one that is very rebellious to treatment. The gums are swollen and spongy, painful to the touch, readily bleed, and are at times ulcerated ; usually there is a foul odor to the breath. In aggravated cases the ulceration may extend to the other structures of the mouth or even down the esophagus to the stomach. Generally the con- dition disappears upon the birth of a child, but in excep- tional cases it may be protracted thoughout the period of lactation. The treatment consists in the employment of tonics internally, and astringent mouth-washes, as listerin and tincture of myrrh. (2) Dental Caries. — During the progress of gestation there is frequently developed a rapidly progressive caries of teeth that had previously shown no signs of decay; this may or may not be accompanied by severe toothache. It is especially prone to occur in women of the higher social ranks, and its cause is believed by some to be an acidity of the secretions of the mouth consequent upon the acid dyspepsia that is so common in pregnancy. If it develop late in gestation, nothing in the line of treatment should be done until after parturition, for fear of the induc- tion of abortion, unless the suffering becomes severe, when the decayed tooth may be removed or the cavity treated. Should it appear early in pregnancy, supervision by a dentist becomes imperative. (3) Salivation or ptyalism of pregnancy is a curious neurotic condition occasionally noted during the course of a gestation and characterized by a hypersecretion of saliva, the amount expectorated amounting even to two or more quarts in the twenty-four hours. There is a constant drib- bling from the mouth, to the great annoyance of the patient, and the drain upon the system may be so severe as 324 A MANUAL OF OBSTETRICS. to cause a rapid decline in the general health. The affec- tion is most commonly observed early in pregnancy, and disappears as gestation advances, usually not persisting longer than from eight to ten weeks.. Occasionally it may be protracted to term, and the condition of the patient then becomes truly pitiable. Some women develop this condi- tion with each pregnancy. Trcatmoit is at the best unsat- isfactory. The best results may be obtained from the use of nerve-sedatives, as the bromids and chloral. Ergot has been employed, as have also astringent gargles and lozenges, atropin in doses of y^ of a grain, belladonna, minute doses of pilocarpin, the fluid extract of viburnum prunifolium, galvanism of the parotids, and blisters and other forms of counter-irritation over the regions of the salivary glands. None of these remedies will answer in every instance, but the combined use of two or more may succeed when one has failed. (4) Anorexia. — It is very common for a pregnant woman to exhibit more or less loathing for special forms, or even in rarer cases for all forms, of food. This has been espe- cially noted at the beginning and toward the close of preg- nancy, when the neurotic element in the patient is most prone to manifest itself In some cases it may take the form of an intense disgust for meats of all kinds, while in other cases meats alone can be tolerated. There is no spe- cial mode of treatmefit that can be suggested to meet this condition ; in each instance it is wise, as a rule, to permit the patient to select the food that is most to her liking. If the loss of appetite be due to gastric, hepatic, or intestinal torpidity, appropriate remedies in the form of tonics, chola- gogues, or laxatives may be given with beneficial effect. (5) Pica (Malacia). — A craving for unnatural and strange articles of food, a peculiar perversion of taste, is frequently encountered in pregnancy, and is then popularly known as "longings" or "pining." In exceptional cases this may amount to a true form of insanity, the most disgusting or DISEASES OF THE DIGESTIVE TRACT. 325 even injurious substances being devoured with avidity. Moral suasion, with mental diversion and regulation of the diet and the alimentary tract, is all that can be attempted in the line of treatment. The condition disappears with the termination of the pregnancy. (6) Indigestion, Gastric and Intestinal. — Very gener- ally, and particularly in primiparae, there will be manifested during the childbearing period more or less gastric and in- testinal derangement. Pyrosis or heartburn, with acid eructations, most marked late in pregnancy, is the main characteristic of gastric, while enteralgia in varying de- grees characterizes intestinal, indigestion. The treatment consists in the administration of pepsin, magnesia, sodium bicarbonate, aromatic spirits of ammonia, powdered ca- lumba, and alkaline waters such as Vichy, an occasional laxative, and regulation of the bowels. (7) Pernicious Vomiting of Pregnancy (Hyperenaesis gravidarum). — Of extreme importance and gravity is the condition recognized as an exaggeration of the physiologic nausea and vomiting of pregnancy : so long as it consti- tutes merely an exaggeration of the symptom of gestation, assuming unusual prominence without materially affecting the health of the patient, it need not excite apprehension. Unfortunately, however, it occasionally exceeds this limit, and then assumes such a degree of gravity as even to menace life. The physiologic symptom, which, as a rule, begins shortly after conception, has generally subsided by the time quickening has occurred ; in the exceptional cases now under consideration it may be protracted long beyond this period, with continued duration assuming increasing severity. Etiology. — There are many factors that may contribute to the development of this condition, although just what is the cause in any given case cannot always be definitely stated. Taken in about the order of frequency, these causes may be grouped as follows : {a) A reflex neur- osis resultine from excessive distention of the uterine walls 326 A MANUAL OF OBSTETRICS. with irritation of the peripheral nerve-endings therein con- tained. Naturally, one would expect to find, as is the case, the condition more common in primiparae, in whom disten- tion of the womb is accomplished with greater difficulty on account of the greater tonicity of the muscular fibers, and in multiple pregnancy, in which condition the distention must proceed at a more rapid pace and to a more consider- able extent; {l?) Chronic preexisting disease of the uterus, as a cervical or corporeal endometritis, a chronic metritis, or some form of uterine displacement ; (r) Preexisting or coexisting pelvic disease, as a salpingitis, a pyosalpinx, an ovaritis, or an appendicitis ; [d) Some pathologic state of the alimentary canal, as dyspepsia, chronic gastritis, and, more rarely, gastric ulcer; and intestinal disease, as mucous polyps, or stenosis from inflammatory adhesions without the canal, all of which would be aggravated by the neurotic element that assumes prominence during gestation. {/) Too frequent sexual intercourse ; (/) Profound emotion ; {g) When the disease manifests itself late in pregnancy (after the sixth or seventh month) it is very generally due to nephritic trouble with uremic manifestations ; this is termed the recur- rent vomiting of pregnancy. Symptoms. — The disease, which commences as the ordinary morning sickness, steadily in- creases in severity until there is an almost continuous retching and vomiting of a bile-stained, often blood-streaked and intensely acid mucus ; the mere sight of food or a change in the position of the patient may be sufficient to induce emesis ; the patient grows extremely weak and is subject to attacks of syncope ; her lips become fissured and covered with sordes ; she rapidly emaciates ; and there are variations in the temperature, which maybe either slightly elevated or subnormal ; the skin becomes harsh and shrivelled ; intes- tinal and gastric pains are common ; there is epigastric ten- derness ; salivation has been noted, and constipation is the rule ; the gums are swollen and the teeth coated with sordes ; there are intense thirst, a dry and coated tongue, DISEASES OF THE DIGESTIVE TRACT. 327 and a foul odor to the breath ; the pulse is soft and rapid ; the respiration is accelerated; there is increasing restlessness with insomnia ; and the extremities are cold and clammy ; the urine is scanty, highly colored, albuminous, and fre- quently contains casts. The patient steadily grows worse ; toward the end the face becomes pinched and blue, the eyes sunken, the vomiting ceases, severe neuralgic pains develop, delirium often supervenes, subjective sensations as of unpleasant odors or strange sounds may be complained of (Horwitz), and the woman dies in a comatose condition of profound inanition. In some cases the violent expulsive efforts associated with the vomiting are sufficient to pro- duce abortion, whereupon the unpleasant gastric symptoms promptly subside. The diagnosis of the condition is easy; the prognosis is grave, the mortality being high. Treatment. — The treatment may be hygienic, medicinal, and operative. The hygienic treatment consists in ascertaining and re- moving any known or probable cause, and the regula- tion of the diet and of the general mode of living. A simple change of scene may work a cure. Should there be found to be present a catarrhal condition of the cervical canal, appropriate treatment would consist in the applica- tion of ichthyol, hydrogen peroxid, Churchill's tincture of iodin (Routh's method), or a weak solution of silver nitrate (from 10 to 30 grains to the ounce) ; if the vagina and cer- vix be hypersensitive, this may be overcome by judiciously applying a solution of cocain of from 10 to 15 per cent, strength. Sexual intercourse must be strictly prohibited ; the bowels must be kept patulous ; all odors of cooking should be prevented from gaining access to the patient; any articles of diet to which she has taken an especial aver- sion should be banished from the diet-list, while if there be any suitable article of diet for which is developed a long- ing, it may be supplied. The patient may be instructed to sip a glass of sherry-wine, iced milk with lime-water, ice-cold koumiss, iced champagne, or strong coffee before 328 A MANUAL OF OBSTETRICS. rising. She should be instructed to take as much rest as possible. The tJicrapciitic measures that have been recom- mended in the management of the condition are many, and their very number proves their generally unsatisfactory ac- tion. Probably the best that may be used are — cocain (a i or 2 per cent, solution), applied locally to the throat or in small doses (from -| to ^ of a grain) internally each hour until from ^ to I grain has been taken ; menthol, \ gr. each hour; nerve-spdatives, as from 5 to lo grains of chloral by the mouth or from 20 to 30 grains per rectum, and sodium or potassium bromid in lO-grain doses three or four times daily; dilute hydrocyanic acid, in 3- to 5- minim doses; ingluvin, in from 10- to 15-grain doses; silver nitrate, in from \- to ^- grain doses four times daily ; tincture of nux vomica, from 5 to 10 minims; creasote, from i to 2 minims daily; oxalate of cerium, 10 grains three to four times daily; antipyrin, in from 5- to lO-grain doses; wine of ipecac or Fowler's solution, in from \- to i -minim doses; and strychnin sulphate, gr. -^^ to -^-^ twice or thrice daily. Hypodermically may be given hyoscin hydrobromate ^\^ grain, or morphin sulphate gr. \ to \. Various local applica- tions maybe tried, prominent among which maybe mentioned a laudanum-poultice or an ether-spray to the epigastrium, faradism of the stomach, ice to the posterior cervical re- gion, or a few leeches to the epigastrium. Some accou- cheurs advocate very highly vesication over the fourth and fifth dorsal vertebrc-e, claiming that a single application is sufficient to terminate the vomiting. Inhalations of oxygen may be beneficial in some cases. If the patient grow steadily wor.se notwithstanding these hygienic and thera- peutic measures, it will then become necessary to abstain from all food by the mouth and to resort to rectal ali- mentation. y\ nutritive enema containing some predi- gested food may be given three or four times daily, the bowel being thoroughly washed out immediately before introducing the enema. Suitable materials for this pur- DISEASES OF THE DIGESTIVE TRACT 329 pose are pancreatized milk, partially digested meat or eggs, liquid peptonoids, beef-serum, defibrinated blood, or one of the following special formulae : i. Rcnnie's Formula. — Add to a bowl of good beef-tea \ pound of lean raw beefsteak pulled into shreds ; at 99° F. add i dram of fresh pepsin and \ dram of dilute HCl ; place the mixture before the fire and let it remain for four hours, stirring frequently; the heat must not be too great or the artificial digestive process will be stopped altogether; it is better to have the mixture too cold than too hot; if alcohol is to be given, it should be added at the last moment; eggs may also be added, but should be previously well beaten. 2. Lenbe's Paiicveatic-meat Ennilsion. — Chop five ounces of finely- scraped meat still finer, add to it \\ ounces of finely- chopped pancreas, free from fat, and then 3 ounces of luke- warm water; stir to the consistence of a thick pulp; give at one time, care being taken to wash out the rectum with water about an hour before. 3. Marefs Forumla. — Fresh ox-pancreas 150 to 200 grams; lean meat 400 'to 500 grams ; bruise the pancreas in a mortar with water at a temperature of 37° C, and strain through a cloth ; chop the meat and mix thoroughly with the strained fluid, after separating all the fat and tendinous portions ; add the yolk of one ^%^\ allow to stand for two hours, and administer at the same temperature, after having cleansed the rectum with an injection of oil ; this quantity is sufficient for twenty- four hours' nourishment, and should be administered in two doses. 4. Peaslees Fonmila. — Crush or grind a pound of beef-muscle fine; then add a pint of cold water; allow it to macerate for forty minutes, and then gradually raise it to the boiling-point ; allow it to boil for two minutes and then strain. 5. Flint's Mixtiire. — Milk 2 ounces, whisky \ ounce, to which add half an o.^^. The amount administered by rectum at any one time should not exceed from 4 to 6 ounces. Generally under this treatment the patient will commence to improve and slowly recover. It 330 A MANUAL OF OBSTETRICS. occasionally happens, however, that even these energetic measures fail, and all that is then left is the so-called ope- rative U'eatment, embracing Copeman's method of cervical dilatation, and finally the induction of abortion. The former consists in carefully dilating the cervix under anti- septic precautions, either with the finger slowly introduced up to or slightly within the internal os, or with an instru- ment judiciously used, not exceeding half an inch of dila- tation. This maneuver has been successful in a large number of cases, and should be employed before the fetal life be sacrificed. If this should fail, there remains but the one course — namely, the induction of abortion according the method already given. (8) Constipation. — The normal intestinal torpidity of women is very generally aggravated by gestation. This has a duplex cause : it may be partly mechanical from occlusion of the bowel by the enlarged and growing uterus, and it may result in part from impaired peristalsis due to alteration in the innervation of the bowel. If untreated, the degree of torpidity may become excessive: women have been known to pass from seven to ten days or more without def- ecation, vast fecal accumulations taking place in the mean time. There is frequently associated with this intestinal inactivity more or less of the symptoms of copremia — head- ache, fulness of the veins, giddiness, and retarded cerebra- tion. The prophylactic treatment should consist in the proper use of laxative food-stuffs to overcome the natural tendency in this direction. When fully developed, laxative remedies, such as the pill of aloin, .strychnin {^ gr.), and belladonna at bedtime, the extract of cascara sagrada (^ gr.), compound licorice-powder, cascara cordial, Hunyadi or Friedrichshalle water, inspissated ox-gall, i to 2 grains in combination with the extract of belladonna {\ gr.), or rectal cnemata of soap- suds must be employed. In extreme cases of fecal impac- tion it may become necessary to empty the rectum by means of a spoon or spatula, following this by an enema DISEASES OF THE DIGESTIVE TRACT 33 1 to remove the material from the upper portion of the colon. (9) Diarrhea is much rarer than the preceding, and is usually due to dietetic errors, although irritability of the bowel from mechanical pressure of the pregnant uterus may result in hyperperistalsis, with the discharge of the watery constituents of the canal. If unchecked, it may excite uterine contraction and result in premature discharge of the ovum. The treatment consists in the administration of astringents, as chlorodyne, chalk-mixture, and aromatic sulphuric acid, and in cases in which there is a strong nervous element the nerve-sedatives and the bromids. (10) Hemorrhoids constitute a not-infrequent complica- tion of pregnancy and a source of untold suffering to the patient. The condition is in part due to the consti- pation and in part to mechanical obstruction to the pelvic circulation from pressure of the gravid uterus upon the hy- pogastric and hemorrhoidal veins. The treatment consists in the employment of mild laxatives to relieve pelvic con- gestion, preferably a sulphur pill or a pill containing aloin and extract of belladonna, and local astringent remedies in the form of suppositories ; one that has been of much service contains tannic acid from 5 to 10 grains, extract of bella- donna ^ of a grain, and aqueous extract of opium ^ grain. (11) Jaundice (Icterus gravidarum). — Jaundice, though rarely complicating pregnancy, may occur in one of two forms. It may manifest itself as a simple discoloration of no significance other than indicating a catarrhal con- dition of the biliary passages or a slight obstruction to the hepatic circulation and flow of bile from mechanical inter- ference with the vessels and ducts ; or it may assume malig- nant qualities dependent upon an acute yellow atrophy of the hepatic cells, and in this case rapidly terminate fatally. The former condition is prone to develop into the latter when occurring during pregnancy, for several reasons, which, according to Davidson, may be stated as follows: 332 A MANUAL OF OBSTETRICS. [a) Retention of the bile-acids and other effete products in the blood as a result of impaired renal activity, with fatty- degeneration of the liver-cells due to their presence ; (/i) impairment of the resisting powers of the body due to the impoverished condition of the blood; (c) impeded car- diac action from vasomotor spasm produced by the toxic material in the blood, with consequent- ill-nutrition of the liver-substance ; [d) over-activity of the hepatic cells, re- sulting in rapid degeneration of the substance. The condi- tion may develop from a variety of causes, physical and mental, as grief, fear, the ingestion of indigestible sub- stances, the action of miasmata, and exposure to a high temperature. It may result in a certain proportion of cases from direct mechanical pressure by the gravid uterus or by the overloaded transverse colon upon the ductus com- munis choledochus. Not uncommonly abortion follows an acute attack of jaundice, and in some cases malignant .symp- toms rapidly develop upon the discharge of the ovum. The treatment of the catarrhal form is largely hygienic, together with the administration of calomel, podophyllin, and other cholagogic remedies ; nothing can be done in the malignant form, which invariably terminates fatally. 3. Diseases of the Respiratory Tract. (i) Hyperosmia. — A morbid acuteness of the sense of smell may be developed during gestation, especially in women of a strong neurotic tendency. In some instances it may become so pronounced as to constitute an etiologic factor in the production of the hyperemesis of pregnancy. In such cases strongly odoriferous substances that are ac- ceptable to the patient .should be kept in her vicinity to destroy the unpleasant odors and thereby prevent the development of the grave gastric condition. (2) Dyspnea of pregnancy (asthma gravidarum) is a neurotic condition most commonly encountered early in pregnancy and in women with a highly-developed neurotic DISEASES OF THE RESPIRATORY TRACT 333 tendency. It is very intractable to treatment, and may only disappear at the termination of gestation. The symptoms are those of severe spasmodic asthma. The treatuiciit con- sists in the administration of nerve-sedatives (chloral and the bromids) in full doses. Mechanical dyspnea, resulting from impeded action of the lungs and heart due to upward displacement of the diaphragm, is a late symptom of preg- nancy, and continues until " lightening " occurs. Light regimen, the wearing of loose clothing, and the avoidance of constipation will ameliorate the symptom. (3) Nervous or spasmodic cough is a term applied to a reflex nervous manifestation, without associated lar- yngeal or bronchial disease, very frequently developed in neurotic women, and often the source of considerable dis- comfort to them and of anxiety to the family. There are no attendant symptoms. The paroxysms of coughing may, if severe, induce an abortion. Like the other nervous mani-. festations of pregnancy, this condition is intractable to treat- ment. The only remedies of service are the antispasmodics and nerve-sedatives — the bromids, chloral hydrate, hydro- cyanic acid, valerian, and asafetida. (4) Emphysema is very commonly encountered in preg- nancy, and, in consequence of the hydremia and mechanical interference with respiration, is prone to assume an aggra- vated form. The associated cardiac dilatation adds to the gravity of the case, and the condition may become so threat- ening that the induction of abortion alone will relieve the patient. It is not uncommon for spontaneous abortion to follow the exaggerated efforts at respiration. Cardiac and respiratory stimulants and the inhalation of oxygen may alleviate the suffering to a certain extent. (5) Croupous pneumonia when developed during the course of a pregnancy constitutes a grave complication. Not only are its symptoms aggravated by the physiologic condition, but in return it reacts unfavorably upon the ges- tation, and not infrequently terminates it prematurely. It 334 ^ MANUAL OF OBSTETRICS. is said that 60 per cent, of these patients will die, probably from pulmonary edema secondary to acute heart-failure or from hyperpyrexia. Should the disease occur late in ges- tation and labor supervene, excessive stimulation of the patient will be required to counteract the extreme tend- ency to collapse that will be manifested. For this purpose whisky or brandy in large amounts, tincture of digitalis in full doses, tincture of strophanthus, quinin, aromatic spirit of ammonia, or ammonium carbonate may be exhibited. When full dilatation of the os has occurred, rapid instru- mental delivery must be performed to avoid further ex- haustion from voluntary expulsive efforts. (6) Pulmonary Tuberculosis. — While this disease, ex- cept in the advanced stages, does not exert any specially baleful influence upon gestation, it is itself very unfavorably influenced by the physiologic state. There is frequently an arrest of the pulmonary symptoms during the period of gestation, consequent upon the plethora that very gene- rally is present at that time ; in many instances, however, not only does this amelioration of the symptoms fail to occur, but there is even in those already suffering from the disease an aggravation of the pulmonary conditions, and a rapid decline in strength and health in those affected with latent tuberculosis or who inherit a pronounced tendency to the affection. After the birth of the child there invariably occurs a rapid progress of the disease with early fatal termination. Acute miliary tuberculosis is always rapidly fatal. In all instances of su.spected or latent tuberculosis marriage should be strongly discountenanced : if pregnancy ensue, super- alimentation and the administration of tonics (iron, quinin, arsenic) and cod-liver oil will constitute the treatment. Lactation should not be permitted, as well for the safety of the child as with the object in view of husbanding the strength of the mother. DISEASES OF THE CIRCULATORY SYSTEM. 335 4. Diseases of the Circulatory System. (i) Cardiac palpitation is a functional disorder of the heart of slight significance, dependent generally upon a neurotic habit, exaggerated, it may be, by some gastric or gastrointestinal disturbance, but occasionally due to me- chanical interference with the heart's action from the over- distended abdomen. It is not serious in its consequences, but may give rise to much discomfort to the patient. Nerve-sedatives and antispasmodics will largely control it. (2) Ssnicope is an hysteric manifestation in eminently neurotic women, and is most marked in those patients who do not present other and more common reflex phenomena. Such women are apt to develop fainting-fits at any time throughout the course of pregnancy, but especially so at or near the time of quickening; these spells are pseudofainting fits — that is, there is generally not a complete loss of con- sciousness. Owing to their evident neurotic origin, the administration of such remedies as valerian, asafetida, sum- bul, chloral, and the bromids will most promptly control the attacks ; these measures may be supplemented by the use of tonics and a nutritious regimen. (3) Hydremia (serous cachexia, serous plethora) is a watery condition of the blood characterized by a consid- erable increase in the fluid constituents without decided decrease in the solid components. A certain amount of hydremia in pregnancy is physiologic, but in many instances this becomes exaggerated to such an extent as to constitute a true pathologic condition. Owing to the large amount of fluid circulating in the vessels, hydremia was formerly looked upon as a variety of plethora, and this view was sustained by the great similarity of some of the clinical manifestations of the two affections ; as, for instance, the full, bounding, and frequent pulse, the ringing in the ears, vertigo, and local flushings, which are as pronounced in hydremia as in true plethora. An examination of the blood. 336 A MANUAL OF OBSTETRICS. however, reveals the correct state of affairs : it is found to contain an excess of serum with a diminished number of corpuscles, associated with a lessened amount of albumin and of iron and an increased amount of fibrin. When with- drawn from the vessels, such blood forms a small and im- perfect clot surrounded by a large amount of pure serum. The physical condition of the blood, therefore, closely sim- ulates the state of the blood in chlorosis. The total amount of fluid present is very frequently much increased above the normal. The causes of this hydremia lie in the alterations in the metabolism of the body, in derangements of the alimentary canal, and in the presence in the blood of effete products from both mother and child. The symptoms are a sense of fulness in the vessels ; marked pulsation of the arteries, especially those of the neck and head, of which the woman may complain very bitterly ; a sensation of heaviness in the head ; occasional vertigo and ringing in the ears ; flashes of heat over the body, and especially in the head; imperfect vision ; drowsiness; cephalalgia and varying degrees of dyspnea, most marked upon exertion. There are associated nervous phenomena, as attacks of syncope, neur- algias in various portions of the body, and alterations in taste and manners ; the appetite is impaired and capricious, the digestion imperfect, the bowels constipated. The local flushings that are so marked in the cephalic region may also be manifested in other parts of the body ; thus there may be phenomena localized in the pelvis and abdomen — tension and swelling of the abdomen, a sense of pelvic weight, dull aching pains in the sacral region, in the groins, and in the upper portion of the thighs, increased leukor- rhea, and a diminution in the fetal movements, probably consequent upon alterations in the placental circulation ; in addition, localized congestions of various organs may result in some of the accidental hemorrhages that have been noted in these cases, such as hemoptysis, hematemesis, epistaxis, or placental apoplexy : should there be developed a certain DISEASES OF THE CIRCULATORY SYSTEM. 337 amount of renal inactivit)', some uremic manifestations may be noted. A somewhat frequent late complication of hy- dremia, usually appearing after the sixth month of gestation, is the effusion of a serous fluid into the cellular tissue of the body or into the body-cavities, or both, constituting a general anasarca. Very often this is confined entirely to the lower portions of the limbs, but in many cases it will slowly extend from below upward to the external genitalia, to the trunk and arms, and even to the face. At first the edema disappears during recumbency, but it becomes persistent if the hydremic condition be very pronounced. In the advanced cases there are occasionally noted effusions into the peritoneal and pleural sacs, and also into the fetal mem- branes, constituting a form of hydramnios. The degree of ascites present may be extreme, even sufficient to mask the uterus, and by adding to the dyspnea natural to pregnancy may greatly inconvenience the patient. Various reasons have been advanced to account for the production of the serous infiltrations of hydremia ; the most probable, as stated by Tarnier, are a diminution in the albuminous con- stituents of the blood, an increase in the serous portion {serous plethora), and, locally, obstruction of the circulation from mechanical pressure by the gravid uterus. The diag- nosis of this condition is plain if the history of the patient be considered, and this supplemented by a careful analysis of the blood. The prognosis is good, as a rule. The symptoms very quickly subside upon the termination of pregnancy, and the edema is rapidly removed. In excep- tional cases, in which the serous effusions occur early, it may become necessary to end the gestation prematurely in order to save the maternal life. The treatment is essen- tially that of anemia: it consists in a rich and nutritious diet, largely of milk ; the administration of iron, quinin, and arsenic; and, to overcome local congestions, the judicious employment of local bloodletting (dry or wet cups ; over the back sinapisms or blisters) ; for the edema 22 338 A MANUAL OF OBSTETRICS. (local or general) will be indicated diuretics, mild laxatives, and diaphoretics, the recumbent posture with the limbs elevated, and small incisions or punctures to permit of the escape of the fluid from the distended cellular tissues of the limbs : if the ascites be extreme and dyspnea pronounced, some of the fluid may be withdrawn by means of an aspi- rator, the patient being warned of the possibility of abortion or peritonitis following. Thoracentesis may be required for large pleuritic eff"usions. (4) Pernicious or Progressive Anemia of Pregnancy. — This is a profoundly anemic condition, fortunately but rarely developing in the pregnant woman, but when once established steadily progressing with the gestation until death from inanition be imminent or actually occur. This grave disease differs from the preceding in not being asso- ciated with the serous plethora of that condition, nor with the production of serous effusions in the tissues or cavities of the body beyond a slight amount of edema of the lower extremities. An examination of the blood reveals a mod- erate degree of hydremia, a diminution in the amount of the albumin, and a marked decrease in the number of the red blood-corpuscles. The causes, though often obscure, may be a preexisting anemia or chlorosis, resulting cither from systemic poisoning (such as follows long-continued malarial intoxication), from hemorrhage, from rapidly recur- ring pregnancies, or from insufficient alimentation. Symp- toms. — The disease is steadily progressive ; there is increas- ing pallor and loss of strength ; the skin is yellowish and transparent ; anorexia is more or less complete ; there is fatigue on slight exertion ; the nervous system is excitable ; hemorrhages may occur from the mucous surfaces ; the gums arc spongy and red ; the breath is foul, and the tongue coated. Various neuralgias, including headache and tic douloureux, may develop ; fainting-spells and car- diac palpitation are not uncommon ; a loud systolic mur- mur may be heard over the heart and in the great vessels ; DISEASES OF THE CIRCULATORY SYSTEM. 339 in some cases there is marked a considerable degree of som- nolence, in others more or less insomnia ; vertigo and loss of memory have been noted ; toward the close emaciation may be extreme, edema of the extremities develop, and the patient die, comatose, of profound inanition, which may or may not be preceded by premature discharge of the ovum. The disease may cover a period of months. The diagnosis is easy ; the prognosis is anxious. The treatment must be largely hygienic, including a light but nutritious diet, regu- lation of the bowels, change of scene, and mental and phys- ical rest. Internally, iron must be administered in some form, together with Fowler's solution of arsenic; preferably should be given Blaud's pill thrice daily, the albuminate of iron in from 5- to lO-grain doses, or the arsenate, ^Ig- of a grain three times daily. If the disease continue, the induction of abor- tion may become necessary. (5) Endocarditis. — Disease of the cardiac valves (mitral stenosis and aortic insufficiency) is a serious complication of pregnancy; not only does it exert a harmful influence upon the gestation, but the disease itself under these cir- cumstances is prone to assume an unwonted gravity. Owing to the impeded action of the heart, there invariably results a certain degree of pulmonary congestion ; there is thus produced considerable dyspnea, even amounting to orthopnea ; more or less edema of the lungs follows, the blood is crowded back upon the weakened heart, and sud- den cardiac failure with fatal syncope ensues. This accident is more prone to occur during or directly after the birth of the child than at any period during pregnancy, and results then from the additional strain thrown upon the heart by the reflux of blood from the pelvic organs, where it is no longer needed. The blood.-pressure is considerably elevated as a result of the uterine contractions, which narrow the lumen of the uterine sinuses. In addition, Phillips (yTlie Practitioner, London, June, 1895) remarks that "owing to the forced expiratory position of the thorax during the throes 340 A MANUAL OF OBSTETRICS. of labor the usual sucking up of the venous blood into the right heart does not take place regularly, and, as a conse- quence, more or less cyanosis of the face and fulness of the veins of the neck are noticed. After the birth of the child the abdominal pressure sinks almost immediately, and at the same time a number of large vessels are very suddenly cut off from the general circulation by the uterine contraction. As a result of this sinking of abdominal pressure there is an overfilling of the right heart, requiring considerable expendi- ture of force to overcome it." The overtaxed heart cannot accomplish this, and a fatal syncope ensues. Fritsch, on the other hand, suggests that as a usual result of the reduced abdominal pressure the blood remains accumulated in the large abdominal veins, and the right heart, instead of being engorged, is anemic : this view is probably incorrect. Syn- cope may largely be avoided by favoring free bleeding at the time of the separation of the placenta, by lacerating the cervix during the delivery of the child, or by performing phlebotomy and removing a few ounces (from lo to i6) of blood if placental separation prove comparatively bloodless. The effect upon the gestation is likewise disastrous: the high arterial tension consequent upon the impeded circula- tion, with accumulation within the vessels of large amounts of carbon dioxid, frequently give rise to fetal death from rupture of the placental vessels (placental apoplexy). The prognosis must, therefore, be looked upon as grave. One- fourth of the fetuses will perish by abortion, while the maternal mortality varies up to 50 per cent, in chronic and severe cases. The danger of sudden fatal syncope is just as great after a premature labor as it is at term ; hence, should it become necessary to artificially terminate the pregnancy, every precaution must be observed to avoid reflux of blood to the heart. TrcatiiicJit. — The usual heart-stimulants should be administered while pregnancy lasts : if the symptoms assume such gravity as to indicate maternal danger, the pregnancy must be terminated ; free bleeding at this time DISEASES OF THE CIRCULATORY SYSTEM. 34 1 must be allowed, and sudden syncope from rapid diminution in the intraabdominal pressure guarded against by the pre- vious application of the binder, which must be tightened as tlie uterine contents are evacuated. Owing to the extreme dyspnea the sitting posture is more comfortable to the patient. Inhalations of nitrite of amyl, the use of nitro- glycerin hypodermically, and excessive stimulation of the heart by the exhibition of caffein, strophanthus, digitalis, alcohol, and strychnin during the delivery of the child are demanded ; if labor take place at term, forceps must be applied just before full dilatation of the os is secured, or the child delivered by the feet should the breech present. Ergot in these cases is strongly contraindicated, since by contracting the peripheral arterioles it increases the resist- ance the heart is compelled to overcome. (6) Varicose Veins. — Varicosities constitute a very com- mon accompaniment of the late stages of pregnancy, par- ticularly in multiparas. The distended veins are most commonly those of the thigh, leg, and rectum, but there may be an involvement of the vessels of the vulva, vagina, bladder, and broad ligaments. According to Bloom, they are very frequently most pronounced upon the left limb. The condition is either a direct result of circulatory obstruc- tion from pressure by the gravid uterus, or it may be a sequel of the physiologic alterations that take place in the blood itself or in the vessel-walls. Thus, the increased quantity of the blood and its altered composition, together with the high vascular tension, may very readily result in the formation of varices, especially should the muscular coats of the veins be weakened by the degenerative changes, fatty or atheromatous, that are peculiar to pregnancy, and that are often produced secondarily to renal lethargy. The veins appear as prominent tortuous structures, dark blue in color, ominously jutting out from the surface of the limb, and showing distinctly by their knotted appearance the valvular arrangement of the vessels. The distention may 342 A MANUAL OF OBSTETRICS. become so extreme as to present an alarming appearance ; the patient will experience more or less pain in the limb according as to whether or not the deeper veins are involved, and there is frequently a sensation of tingling and burning in the vicinity of the varicosities. When the vulvar and vaginal veins are enlarged there will be a sense of vaginal heat and discomfort, increased leukorrhea, and some inter- ference with locomotion. Usually the vaginal hemorrhoids are situated in the lower third of the canal and are of but small size. The vulva may be immensely swollen and dis- torted by the enlarged veins, and masses of intricate and tortuous varicosities larger than a man's fist may hang as a pendulous tumor from one or the other labium. Vesical hemorrhoids will produce a degree of vesical irritation, and should rupture occur will be followed by hematuria, it may be to an alarming degree. Dilatation of the hemorrhoidal veins results in the formation of hemorrhoids. That the venous structures of the broad ligaments and other pelvic organs share in the varicose condition has been amply demonstrated by operative pro- cedures, as Cesarean section ; the danger of rupture is im- minent, and many of the instances of pelvic hematocele and hematoma of the broad ligaments have their origin in this condition. In many cases the patients, though suffering from varicose veins of immense size, may pass entirely through pregnancy and parturition without any complica- tion occurring. There are, however, a number of possible accidents that must constantly be borne in mind under these conditions. First of these in the order of 'frequency and gravity is niptiirc. This may follow the most trivial traumatism, as a slight jar or fall, scratching of the irritated skin, or prolonged standing, or it may appear without any apparent cause; the ensuing hemorrhage may prove fatal within a few moments, or rupture may occur subcutaneously, and large extravasations of blood into the subcutaneous cellular tissue take place without fatal issue. If the DISEASES OF THE CIRCULATORY SYSTEM. 343 rupture occur in the vulva or vagina, as not infrequently happens during labor, a large hematoma or thrombus may- be formed, more or less occluding the passageway, and constituting an obstruction to the escape of the child : such a hematoma, if large, may be the cause of fatal septicemia from suppuration of the exuded blood with absorption of the toxic principles. Another possible accident is the clot- ting of the blood in the dilated veins, consequent upon its sluggish flow, and resulting in irritation of the vessel-walls ; a true phlegmasia alba dolens may thus develop in preg- nancy, and the thrombi either undergo suppuration with the production of septic infection, or emboli may be carried to different portions of the body, possibly with disastrous effects. Finally, in rare cases the cutaneous irritation asso- ciated with the disease of the vessels may develop into a true erysipelas, or into an eczematous affection, as a result of the constant scratching that is excited by the annoying pruritus. The prognosis of varicose veins is good ; the pos- sible accidents, however, must be guarded against. The treatment is mainly protective. The vessels, if on the limbs, must be supported by elastic stockings, or, if in the vulva and vagina, by a pad and a T-bandage. The clothing should be loosely worn : an abdominal binder by supporting the heavy uterus will prevent a certain amount of obstruction of the pelvic circulation and thus prevent the development of varicosities. Prolonged rest in the dorsal position, the moderate use of mild laxatives and heart-stim- ulants, careful attention to the diet, and the avoidance of violent exercise or over-exertion constitute the main pro- phylactic measures to be adopted. In case rupture occur, direct digital compression will arrest the bleeding; this may be supplemented by the use of compresses of lint saturated with Monsel's solution. For the phlebitis and phlegmasia that occasionally develop, absolute rest, eleva- tion of the limb, and soothing applications, as lead-water and laudanum or chloroform-liniment, are indicated; should 344 -^ MANUAL OF OBSTETRICS. suppuration occur, free incision and evacuation of the pus will be required. Cutaneous irritation may be relieved by solutions of cocain and ichthyol, oxid-of-zinc ointment, vinegar and water, or carbolic-acid solutions. (7) Aneurysm is rare in pregnancy, but has occasionally been noted. When encountered the usual care must be observed ; the administration of potassium iodid in small doses may be of service. At the time of labor, when the os has been dilated to about the size of a dollar, forceps should be applied and labor terminated, so as to avoid the violent straining of the second stage, with the associated danger of rupture of the aneurysmal sac. (8) The Hemorrhages of Pregnancy (Antepartum Hem- orrhage). — The hemorrhages that may occur during gesta- tion include: {a) Those dependent upon the existent hy- dremia ; (^) those dependent upon placental anomalies ; (r) those taking place from the genitalia and not the result of placental anomalies. id) Hydremic Hemorrhages. — In speaking of the hy- dremia of pregnancy mention was made of the tendency manifested by patients presenting this condition in a marked degree to hemorrhages from the various mucosae in conse- quence of local congestions of these surfaces. Prominent among these may be mentioned cpistaxis. This, while occa- sionally encountered during pregnancy, is most prone to occur during labor, and the hemorrhage may then be so profuse as to endanger life ; it is quite intractable to treat- ment, and all that can be done is to plug the nostrils ante- riorly and posteriorly and rapidly terminate labor by the forceps. Hemoptysis appears, at times, toward the close of pregnancy, as a result of pulmonary congestion, or, in neurotic individuals, as the result of violent disturbance of the heart's action — the so-called '^cardiac nerve -storms'' of H. C. Wood — resulting in a secondary congestion of the lungs. It rarely assumes an alarming character. Its treat- ment is that of the hydremia that produces it; in the neur- DISEASES OF THE CIRCULATORY SYSTEM. 345 otic cases the nerve-sedatives (the broniids and chloral) are indicated. Hcviatcviesis is rare, and when present is generally dependent upon gastric congestion ; it may result from round ulcer of the stomach. Ice to the epigastrium and tannic or gallic acid internally, with the constitutional treatment of hydremia, will generally control it. (/;) Hemorrhage dependent upon Placental Anom- ALiE.s. — There are two varieties of hemorrhage of placental origin that may take place at some time during the last six months of pregnancy ; the first and most common is pla- centa praevia, or unavoidable hemorrhage, and the second, the so-called accidental hemorrhage (Rigby), or premature detachment of the placenta. I. Placenta Pi'csvia, or Unavoidable Henwrrliage of Preg- nancy. — This is a term applied to the condition in which the placenta is attached to that part of the uterine wall that becomes stretched as labor advances (the lower uterine segment), so that it precedes the advance of the presenting part of the fetus. This is a rare condition, said to occur but once in 1200- 1300 cases of gestation. Neces- sarily, the gravity increases in proportion to the downward displacement of the placenta. There have been described but two main varieties — namely, the complete placenta prsevia and the incomplete. The complete form comprises the so-called central implantation of the placenta, in which that organ is situated directly over and entirely covers the internal os uteri ; this is very rare. The incomplete form is that in which the placenta is situated largely to one or the other side of the uterus, generally the right; it embraces the following subvarieties in the order of their gravity: (i) Lateral, that in which the placenta is attached to the lateral surface of the lower uterine segment, but does not quite extend to the margin of the internal os ; as the segment dilates, detachment of the placenta may occur, with the production of slight hemorrhage ; (2) marginal, in which the placenta extends to and involves the margin of the in- 346 A MANUAL OF OBSTETRICS. ternal os ; hemorrhage during dilatation is earlier and more profuse ; {i) partial, in which the placenta partially occludes the internal os. Etiology. — The true cause of this interest- ing condition is not known ; among those factors that are said to be instrumental in its production are the following : I. Uterine subinvolution from whatever cause : placenta praevia is thus most frequently encountered in multiparae, whose uteri are apt to be flabby and over-sized ; in women who have passed through a number of pregnancies in rapid succession ; in women of the poorer classes who have been compelled to have an early getting-up after labor and cannot afford time for proper involution to take place ; and in those who have been the subjects of chronic endometritis; 2. Low fixation of the ovum ; this may be due to atrophy of the decidua, causing a dropping of the ovum to the lower uterine segment ; to abnormalities in the shape or size of the uterus ; to a severe preexisting endometritis ; to a flabby and relaxed uterus ; to an arrested threatened abortion, the ovum being partially displaced by the uterine contractions, but forming new attachments in the lower portion of the uterine cavity ; to fertilization of the ovum low down in the uterine cavity (Tyler Smith) ; or to a downward growth of the decidua reflexa, so that it becomes attached over the internal os. Pathology. — A curious feature asso- ciated with this affection is the varying degree of placental malformation that is generally present; this results from the uneven development of the decidual portion of the organ, which is massive and hyperplastic above, and attenuated and but poorly developed in the region of the internal os ; the placenta consequently is irregular in its form ; the abnor- mal circumstances give rise to a firm attachment of the hyperplastic portions with insufficient attachment of the attenuated portions ; as a result of this abnormality the risks of hemorrhage are much increased. The organ may assume a horseshoe shape, may show thrombi of various sizes that have undergone different degrees of fatty degen- DISEASES OF THE CIRCULATORY SYSTEM. 347 eration, or may be almost entirely separated into two por- tions by atrophic processes taking place over the internal OS. The funic insertion is also disturbed as a consequence of the abnormal conditions, and, instead of presenting a central implantation, the cord is generally found attached to some portion nearer one or the other side ; prolapse of the funis in the incomplete varieties is therefore not infrequent. Clinical Manifestations. — There is but one symptom — namely, a sudden painless flow of bright-red arterial blood, without apparent cause other than its frequent correspond- ence to what would normally have been a menstrual period. This may occur at any time during the pregnancy from the beginning of the third month to term, but it is most common at or after the sixth month, and especially during the last month of gestation ; its occurrence is earlier the more nearly the placenta is centrally implanted, while in the marginal variety there will be no bleeding until labor begins ; then after the first pain or two there will occur an alarming hemorrhage, and in the intervals between the pains this will increase in amount, the quantity decreasing during the height of the pain, owing to the obliteration of the caliber of the blood-sinuses by the uterine contraction. After the appearance of the first gush of blood there will be repeated hemorrhages, with increasing frequency and in steadily increasing amounts as the pregnancy advances. Occurring prior to the onset of labor-pains, these hem- orrhages are unattended with pain and are very abrupt in their appearance, the patient suddenly finding her- self standing or lying in a pool of blood. In some cases there may not be a profuse discharge of blood, but a steady dribbling for days or weeks, resulting in the aggregate in an immense loss of blood, and often inducing a profound anemia. Should the bleeding be profuse or repeated at short intervals, there will ensue the constitutional symp- toms of hemorrhage — vertigo, air-hunger, rapid running pulse, jactitation, cold clammy perspiration, headache, 348 A MANUAL OF OBSTETRICS. wandering of the mind, coma, convulsive seizures, death. The cause of the bleeding is laceration of the vessels in the uterine portion of the placenta consequent upon par- tial separation of that organ ; very little, if any, of the bleeding comes from the placenta itself The cause of the placental separation is not positively known, but it is gen- erally ascribed to a loss of proportion between the uterus and placenta, brought about either by a more rapid devel- opment of the lower uterine segment [Cazcauxs theory) or by an excessive growth of the placenta far beyond that of the uterine segment {Barnes' theory). Physical Signs. — Examination of the abdomen does not yield much valuable information. The stethoscope will show a low position of the placental bruit, and palpation may reveal an inability to clearly outline the fetal portions below through the addi- tional thickness of placental tissue. Examination per vagi- )iani is of more service. The cervix is found to be very soft and boggy, above the average size of the cervix in pregnancy, and situated lower in the pelvis than is usual ; its blood-vessels may be felt distinctly pulsating ; the canal is quite patulous (a condition never noted in normal preg- nancy), and readily admits the examining finger, which may detect at the internal os the characteristic spongy and gran- ular mass of the placenta instead of the hard fetal skull or the peculiar feel of the pelvic extremity of the fetus. The placenta may be distinguished from a blood-clot by the greater friability of the latter, which is easily broken up by the finger ; ballottement is difficult to elicit. In exceptional cases the cervix will be tightly closed and present an unu- sual degree of rigidity (Mijller). The diagnosis of placenta praevia is difficult, and can be made only by reference to the histor}' of the case and by physical exploration, with the discovery of the signs just enumerated. The diagnosis of a complete from an incomplete variety may be made by sweeping the finger around within the internal os close to the uterine wall ; in the incomplete variety the edge of the DISEASES OF THE CIRCULATORY SYSTEM. 349 placenta may be felt to one or the other side, generally to the left. The prognosis of placenta pra^via is grave for both mother and child. The fetal mortality is high, probably from 75 to 80 per cent; the cause of death is, in early pregnancy, placental apoplexy with abortion, which is painless, and in which the ovum is generally expelled in its entirety. In cases that have reached or gone beyond the period of viability death may result from inanition, from hemorrhage, from asphyxia from interruption of the pla- cental respiratory function, or from immaturity. Another element of fetal danger lies in the fact that placenta praevia is very frequently complicated by malpositions and malpres- entations necessitating operative procedure : this is due to the unusual shape of the uterus consequent upon the abnor- mal position of the placenta, to the fact that the placenta acts as a mechanical interference to the assumption of a proper position by the fetus, and to the great frequency of premature labor, either induced or spontaneous. The maternal mortality varies from 30 to 40 per cent., death following (i) from hemorrhage ; (2) from shock ; (3) from sepsis (increased liability to which is present from the low situation of the placenta, which favors ready access of the atmospheric germs ; from the great constitutional depression of the patient consequent upon the repeated and profuse hemor- rhages ; from the frequent manipulations that are necessary in the management of the case ; and from the decomposition of the large thrombi that form in the patulous uterine si- nuses) ; and (4) from postpartum hemorrhage consequent upon the uterine inertia that to a certain extent always ac- companies this complication, and which is due to the non- resisting nature of the presenting portion and to the muscular atrophy of the lower uterine segment resulting from the great distention produced by the placental development. Treatment. — In placenta praevia the woman is in imminent danger of death at any moment from hemorrhage. For this reason the so-called expectant plan of treatment is only 350 A MA A' UAL OF OBSTETRICS. applicable to those cases in which the patient can be retained in a maternity hospital, so that instant medical attendance may be secured if required. In the case of women not so advantageously situated the physician might readily be exposed to the charge of criminal neglect should the expectant plan of treatment be adopted and the woman perish from a sudden profuse hemorrhage. While true that it is rare for a fatal hemorrhage to occur before the seventh month of gestation, in exceptional cases it becomes necessary to induce abortion even as early as the third or fourth month in order to preserve maternal life. Should the patient first present herself after the viability of the child, consideration of the expectant plan of treatment should not be entertained for a moment ; it is then the duty of the medical attendant to at once proceed to the induction of premature labor. In detail, the expectant and active treatments are as follows : Expectant Treatment (not recommended). — The patient being under constant supervision, should a hemorrhage occur, the treatment for threatened abortion must be insti- tuted — namely, absolute rest, elevation of the foot of the bed, and the use of opiates, fluid extract of viburnum pruni- folium, and acidulated drinks; ice may be applied to the pelvic and perineal regions. Should maternal life be threatened, active interference is indicated. Active Treatment. — This may be instituted either during the height of, or in the interval subsequent to, a hemor- rhage. In either case rapidity of action during the process of delivery is most essential. If the patient be bleeding freely when first seen, the indication is to arrest the hemorrhage. This should be done by means of a vaginal tampon of antiseptic wool, if this can be secured, but, as haste is essential, anything that the hand can be laid upon must be forced into service. The vagina should be tightly packed with the material ; the common fault is to insufficiently tamponade ; the gauze or wool must be intro- DISEASES OF THE CIRCULATORY SYSTEM. 35 I duced until there is absolutely no room to hold more; the cervical canal being filled first, then the vaginal vaults, and finally the vagina to its utmost capacity. Colpeiirysis is favored by Braun in those cases in which the hemorrhage is not associated with rupture of the membranes ; this con- sists in the accomplishment of dilatation through the agency of hydrostatic pressure exerted by colpeurynters (inflatable rubber bags) of various sizes introduced into the external OS ; these bags control the hemorrhage while securing at the same time effective dilatation. The hemorrhage being arrested, assistance must be procured and the uterine con- tents evacuated. In this condition we find probably what has been regarded as the most urgent indication for the per- formance of accoiicJicment force — that is, the rapid manual dilatation, often accompanied with tearing, of the os uteri. This process includes the three operations of dilatation of the cervix, version, and immediate extraction of the child. It is a dangerous procedure, accompanied by a high mater- nal mortality, and is deservedly falling into disrepute. It has been largely supplanted by other methods of rapid dilatation not so destructive to the uterine tissues, and hence less menacing to maternal life, although more peril- ous to fetal existence. Among these may be mentioned Wyder's inet]iod,^\\\Q}i\ comprises the following steps: (i) Complete anesthetization (etherization) of the patient, who rests in the lithotomy position at the side of the bed, her feet supported by two assistants and the operator sitting directly in front ; (2) removal of the tampon (hemorrhage now usually recommences very profusely) and rapid dilatation of the os with Hegar's dilators, Barnes' bags, or the fingers to an extent sufficient to admit one or two fingers ; (3) displacement of the placenta (if in- complete placenta praevia) or perforation (if complete — Rigby' s method^, and rupture of the membranes ; (4) intro- duction of the hand into the uterine cavity, and the per- formance of podalic or bipolar version (Braxton Hicks' 352 A MANUAL OF OBSTETRICS. method). Generally the right hand is introduced, since it usually corresponds to the most accessible margin of the placenta, the smallest segment of which lies, as a rule, to the left side of the uterus. The fetal leg should be dragged down until the knee appears at the vulva, by which time the breech will have well engaged in the superior strait, and by its bulk and the pressure it exerts as a wedge-shaped plug with the base above, bleeding will be completely controlled. There is now no longer any danger of fatal hemorrhage, and the patient may be allowed to deliver herself as in an ordinary breech presentation. The anesthetic may be re- moved, the patient replaced in bed, and labor allowed to proceed. In certain cases, as when maternal or fetal life is threatened from any additional cause, or when it seems de- sirable to quickly terminate the labor, the traction may be continued and the fetus delivered rapidly. A very effective method of performing rapid digital dilatation of the os uteri (Plates 2, 3) has recently been suggested by Dr. Philander A. Harris of Paterson, N. J.^ The patient being anesthetized, the index finger is inserted to its largest diameter through the OS ; the finger is then withdrawn so that its tip merely enters the os, and the tip of the thumb is introduced beside it. When the tips of both index finger and thumb are thus within the os, and the second finger sharply flexed, with the OS resting on its palmar and inner laterodorsal aspect, the index and second fingers must be kept close together to form a notch from which tiie cervical ring cannot readily escape. This is \hQ: first position of the dilatation. The straightened and extended thumb, resting on the outer lateral side of the index finger, is now carried as far from the tip of the index finger as the enlargement of the os will permit ; the index and second fingers are slightly extended, and the second finger is introduced beside the index finger and thumb. This is the second position of the dilatation. The power for stretching is derived from fixation of the thumb on the first ^ Am. Jour, of Obs., Jan., 1894. DISEASES OF THE CIRCULATORY SYSTEM. Plate 2. A^\ Method of performing rapid maiuuil dilatation of tlie os uteri : i, position of lingers in tlie begin- ning of manual or digital dilatation of the cervix uteri— first position ; 2, limit of dilatation in first position ; 3, second position ; 4, limit of dilatation in second position ; 5, third position. (From pho- tographs by Dr. Philander A. Harris of Paterson, N. J.) DISEASES «., Hand 41, laf. 8, r i). of the womb, retrover- sion or retroflexion. It is probable in the great majority of instances of this dangerous and rather frequent com- plication of pregnancy that the physiologic condition has been engrafted upon a preexisting pathologic position of 388 A MANUAL OF OBSTETRICS. the uterus ; still, it must be admitted that excessive dis- tention of the bladder or a severe jolt or fall may cause an acute backward displacement of an impregnated womb. A relaxed condition of the uterine ligaments may likewise permit the enlarged uterus to topple over under the influ- ence of its increased weight, and the pathologic condi- tion may thus result secondarily to the physiologic en- largement. Syjnptoms. — Ordinarily, beyond a slight amount of vesical irritation resulting from the pressure exerted by the upward-tilted cervix upon the neck of the blad- der, and a varying degree of lumbosacral pain, this con- dition is not productive of discomfort to the patient dur- ing the first few weeks of its existence ; as the uterus pro- gressively enlarges the version or flexion at the internal os is proportionately overcome, and the fundus slowly rises from the pelvic cavity and sweeps past the sacral promon- tory to assume its normal position in the abdominal cavity : this spontaneous reposition, which is more likely to occur in retroflexion than in simple retroversion uteri, is accom- plished without any discomfort to the patient, and even without her knowledge. The vesical irritation associated at times with dysuria, or even with some incontinence of urine, will lead the accoucheur to suspect the existence of the uterine displacement, and on physical exploration the condition will be discovered. Another termination of this complication of pregnancy is spo7itaneoiis abortion, from in- terference with the growth of the fetus : this would prob- ably be the most common termination of the trouble were it not for the fact that there is a mechanical compression of the cervix whereby the escape of the product of conception is prevented ; the organ is so rotated upon its transverse axis as to carry the cervix far up against the symphysis pubis, pressure upon which will obliterate the cervical canal. Immediately on the termination of the abortion, should this occur, the symptoms, other than those the direct outcome of the displacement itself, will subside. DISEASES OF THE GENITOURINARY TRACT. 389 Finally, mention must be made of a third and unfortunate termination of this form of displacement of the gravid uterus. In those cases in which the pathologic condition has not been discovered and corrected by the accoucheur or spon- taneously by nature, the continued growth of the uterus may render impossible its escape from beneath the promontory of the sacrum, and ificarceration will occur. This is a truly serious complication of pregnancy, which the size of the uterus does not admit of until after the close of the third month of gestation. At that time the symptoms, which may have been gradually appearing, rapidly assume threatening proportions ; the dysuria that has persisted in a slight degree since conception now be- comes exceedingly prominent ; or there may be complete occlusion of the neck of the bladder with retention of urine. Physical exploration by the sound will reveal what appears to be an immensely elongated urethra, but what in reality is a compression of the lower extremity of the bladder by the uterine cervix, the urethra itself not being directly im- pinged upon. The bladder in consequence of this occlusion at its mouth becomes immensely dilated, reaching even to or beyond the umbilicus. Associated with this trouble there occurs a concomitant occlusion of the bowel from pressure by the hypertrophied and congested fundus. At first this will manifest itself in a progressively increasing constipation, with rectal tenesmus ; the occlusion finally becoming abso- lute, there results a paralysis of the bowel with entire arrest of defecation. The suffering of the patient now becomes extreme : she complains of severe pelvic pain ; edema of the vulva, perineum, and thighs may develop ; persistent vomiting with discharge of fecal matter may occur ; symp- toms of uremic and kopremic poisoning manifest them- selves ; or an acute peritonitis indicates some serious acci- dent in the pelvis, as vesical or uterine rupture or sloughing of the imprisoned organ. A vaginal examination of a woman suffering from an incarcerated retroflexed uterus will reveal 390 A MANUAL OF OBSTETRICS. a smooth, tense tumor filling Douglas's pouch, with an ab- sence of the fundus above on palpation through the abdom- inal wall. A rectal examination will permit of a more thor- ough examination of the mass. The cervix may not be felt at all, or may be discovered, after deep insertion of the fin- ger into the vagina, situated at or above the top of the sym- physis pubis. Examination of the abdominal surface may, in advanced cases, reveal a soft fluctuating tumor, yielding a dull note upon percussion, extending up to the region of the umbilicus ; this tumor is the immensely-distended bladder, as may be demonstrated by catheterizing the pa- tient, when the tumor will disappear. Diagnosis. — A physi- cal exploration of a patient presenting the foregoing clinical picture, associated with the normal signs of gestation, will generally reveal the nature of her complaint. It is possible, however, for the accoucheur to experience some difficulty in arriving at a precise knowledge of the existing state of affairs. Thus, the distinction between a beginning incar- ceration of a retroflexed uterus and an ectopic gestation may be obscure, particularly if there be much abdominal tenderness. Reference to the following points of difference, however, will permit of the formation of a diagnosis, especially if an anesthetic be employed : Incarcerated Rclrojlexed Uterus. Extrauterine Pregnancy. Tlie uterus is tilted upon its transverse axis, The uterus may be crowded forward, but is with the cervix .situated far up anteriorly not rotated upon its transverse axis; the and the fundus posteriorly. cervix and fundus are normally situated. The serious symptoms develop, as a rule. Rupture of an ectopic gestation-sac usually during the fourth month of gestation. occurs about the eighth week of gestation. There is vesical distention, with retention Vesical distention is not likely to be present. of urine. There is vulvar and vaginal edema. There is no vulvar or vaginal edema. The perineum is distended by the fundus The perineum is normal in appearance. uteri in advanced cases. Hraxton Hicks' sign is present. Braxton Hicks' sign is absent. Prognosis. — In simple retrodisplacement occurring in the early weeks of gestation the prognosis is good as far as maternal life is concerned; in the vast majority of cases .spontaneous reposition or spontaneous abortion will end DISEASES OF THE GENITOURINARY TRACT. 39 1 the condition. When incarceration has occurred, if the case be taken in hand early, the prognosis is still good, for with proper manipulation the organ may be replaced and gestation be allowed to continue to term. In neglected cases of retroflexion, or in those that have come under the obstetrician's notice late in their course, the maternal prognosis becomes grave. If unattended, it is possible for nature to terminate the case in one of the following ways: (i) Spontaneous expulsion of the entire retrodisplaced uterus, the perineum and posterior vaginal wall yielding to the violent expulsive efforts, and the uterus being extruded from the vulvar orifice through the ruptured tissues. The patient generally dies promptly of shock. (2) In very rare instances, not more than a dozen cases of which are on record in medical literature, the anterior uterine wall may stretch and form an immensely dilated sac within which the fetal body may develop to term, the head occupying a posi- tion in the hollow of the sacrum ; the fetus in this condition virtually holds an -oblique posi- tion in the uterine cavity, so that the shoulder or back pre- sents at the internal os. This rare and fortunate termination is known as sacculation of the uterus (Fig. 102). (3) In many cases the uterus and surround- ing tissues become so com- pressed and engorged that there is produced considerable interference with the pelvic cir- culation ; as a consequence sloughing of the organ occurs either into the rectum or the vagina, and the contents are discharged 'through the fistulous tract so formed, or the patient speedily succumbs to an acute peritonitis. Causes Fig. 102. — Sacculation of the uterus (Oldham). 392 A MANUAL OF OBSTETRICS. of Death in Incarcerated Uterus. — In this unfortunate con- dition maternal death results from one of a number of the following causes: i. Uremia from pressure upon the urethra and arrest of the vesical function ; 2. Septic peri- tonitis ; 3. Septicemia; 4. Exhaustion; 5. Shock follow- ing rupture or sloughing of the uterus ; 6. Rupture of the bladder; 7. Pressure-necrosis of the bowel. Treat- ment. — If the case be seen early, efforts must at once be instituted to restore the displaced organ to its normal position. This involves the removal, as far as is practi- cable, of the cause of the displacement; the distended bladder must be emptied and the bowels rendered patu- lous. The patient resting in the lithotomy position, the uterus may be raised by the bimanual method, the pre- caution being observed of exerting pressure, with two fingers in the vagina or with a repositor introduced into the bowel, upon the fundus obliquely upward and outward in the direction of either sacroiliac synchondrosis ; by this maneuver the promontory of the sacrum may be avoided and the uterus forced into position. This failing, the patient may be made to assume the genupectoral position, and pressure as before exerted upon the fundus, the influence of gravity facilitating the manual efforts. Downward trac- tion upon the cervix grasped by a volsellum- forceps may, if combined with the foregoing method, result successfully when other efforts have failed. Usually the uterus will yield under these manipulations, and it may then be held in place by a properly fitting pessary. The patient must be confined to bed for a few days. In the cases in which in- carceration has occurred a more vigorous course of treat- ment must be instituted. In these cases it may be impossi- ble to introduce a catheter through the distorted urethra. When the catheter is passed, it must be borne in mind that it may have to traverse six or seven inches of the canal be- fore the vesical cavity is reached ; for this reason a prostatic catheter may succeed when the ordinary instrument has DISEASES OF THE GENITOURINARY TRACT. 393 failed. Should catheterization be impossible, it is entirely justifiable under these circumstances to perform suprapubic puncture in order to withdraw the water. The patient must then be anesthetized and efforts at replacement instituted. These proving ineffectual, the final treatment consists in the induction of abortion ; and here may arise another compli- cation. The cervix may have been displaced so far upward as to be inaccessible ; it then becomes necessary to aspirate the uterine cavity through the posterior vaginal fornix; the removal of the liquor amnii by this method may so reduce the uterine bulk as to permit of a descent of the cervix, which may then be dilated in the ordinary manner and the remaining uterine contents evacuated. Should this be im- practicable, vaginal hysterectomy becomes the dernier res- sort in the attempt to save maternal life. In case of rupture or sloughing of the viscera the patient must be treated ac- cording to the condition that may be present. Antcversion and AnteflexioJi. — These displacements rarely assume pathologic importance, and should be considered as complicating pregnancy only when productive of dis- comfort to the patient. When occurring in the early weeks of gestation they manifest themselves by an aggravation of the normal vesical irritation, which gradually disappears as the uterus rises into the abdominal cavity. A variety of anterior displacement occurs late in pregnancy in women who have already given birth to several children, or in those who are the subjects of various forms of pelvic deformity associated with increased obliquity of the pelvis and a corresponding decrease in the vertical height of that structure, as in kyphosis or rachitis. In these cases the uterus, not finding room for its growth within the pel- vic cavity, rises above the pelvic brim, and, falling forward, causes a marked protrusion of the abdominal wall, constituting one form of pendulous abdomen. This condition may become so pronounced that the heavy fundus will occupy a position far below that of the cervix, 394 ^ MANUAL OF OBSTETRICS. which is carried backward and upward into the hollow of the sacrum. A similar condition is produced when there occurs a separation of the recti muscles, with a median ventral hernia of the uterus through the fissure thus pro- duced. It may readily be seen that such a state of affairs will greatly complicate labor by misdirecting the expulsive forces ; under the impetus of the uterine contractions the fetal presentation will be impelled directly backward against the sacrum, and its progress thus effectually blocked. In- carceration of an anteflexed pregnant uterus, while exceed- ingly rare, may occur should the displaced organ be bound down in its abnormal position by old bands of inflammatory lymph, as after the operation of suspensio uteri. Under such circumstances the urinary symptoms steadily increase in severity until the overstretched adhesions rupture and admit of the upward movement of the uterus, or until the gestation be terminated either by the spontaneous occur- rence of labor-pains or by mechanical interference on the part of the accoucheur. For the simple variety of ante- flexion but little treatment is required. Efforts at reposi- tion generally succeed ; the bands of adhesion may grad- ually be overcome by gentle manipulation and by prolonged resting in the dorsal decubitus. In the cases associated with ventral hernia and pendulous abdomen the organ may be replaced and its normal position maintained by means of an abdominal binder firmly applied and worn throughout the later months of gestation and during labor. In the rare cases of incarceration, taxis under etherization may over- come the bands of adhesion : if this should prove impos- sible, the pregnancy must be terminated and the anteflexion treated during and after the puerperal period. Prolapse of the titerus is also a rare displacement in preg- nancy, and when present is almost invariably found in mul- tiparcL'. It may be produced in one of two ways : Very generally the conception has occurred in an organ already procident ; much less frequently will the displacement oc- DISEASES OF THE GENITOURINARY TRACT 395 cur subsequently to conception, either from a sudden trau- matism, as a jar or fall, or from a sagging downward of the heavy and retroflexed or- f~ '^ ~ '_ 77 ~[ ' gan in women who have suf- ' "•-••- -. .^^.^i fered more or less destruc- tion of the pelvic floor at a previous labor. The de- gree of prolapse varies : usually it is but partial, the cervix or a small por- tion of the lower uterine segment protruding through the vulvar orifice ; in rare cases the prolapse may be almost complete. Terminations. — The course pursued by gestation so complicated is patent. In by far the great majority of cases there occurs a spontaneous reposition, the uterus as it increases in size slowly retreating up the vagina until it occupies its normal position, when pregnancy may continue unin- terruptedly to term. In other and rarer cases the heavy uterus fails to retract, and becomes incarcerated in its unnatural position. There then follows a rapidly suc- ceeding series of phenomena — pain ; pressure upon the rectum and bladder with arrest of the functions of these organs ; intense congestion of the uterus ; the occurrence of uterine contractions ; and, finally, expulsion of the ovum. In those cases in which there has been reported con- tinuance of the pregnancies to term in prolapsed organs the probable condition is one of hypertrophic elongation of the infravaginal portion of the cervix, the body proper of the uterus occupying its normal position. Treatment. — Fig. 103. — Partial prolapse of the womb in labor (Wagner). 396 A MANUAL OF OBSTETRICS. As soon as this displacement is discovered the uterus should be returned to the pelvic cavity and retained there by a properly fitting ball-pessary held in place by a bandage. This should be worn until the organ attains a size sufificient to prevent its descent through the vagina. If incarceration have taken place, efforts at reposition must be made. The woman should be placed at rest in the dorsal position with her hips elevated, and ice applied to the congested organ ; by these measures the congestion may so far be overcome that reposition will be rendered possible ; if necessary to facilitate this, anesthetization may be resorted to. If the parts be so edematous and so tightl)- bound down by inflammatory adhesions that a replacement is impossible, the induction of abortion is indicated. After confinement the gynecologic condition should be treated. Lateral Displacements of the Uterus. — These are unim- portant changes in the uterine position, generally dependent upon some congenital vice of conformation and develop- ment. A certain amount of tilting of the organ to the right is physiologic, and is produced by the situation of the bowel posteriorly and to the left. In rare cases the entire organ is carried bodily to one or the other side of the pelvis in consequence of a congenital shortening of the broad liga- ment upon that side ; to this condition is assigned the name of lateropositio)i of the uterus ; it has no effect upon the course of gestation. A flexion of the uterus to one or the other side is a result of nondevelopment of that side toward which the fundus is inclined ; it may complicate labor by producing an oblique position of the fetus. A rotation or torsion of the uterus from left to right to a limited extent is physiologic : if, however, it become excessive, so that the lateral aspect of the womb is caused to present anteriorly, the condition is abnormal, as in certain cases of severe in- flammatory disease of the pelvis. The ligamentous struc- tures are twisted and distorted, and the ovary of the affected side may be carried well forward in the abdom- DISEASES OF THE GENITOURINARY TRACT. 397 inal cavity, where it will be exposed to pressure by the abdominal muscles or during the manipulations peculiar to labor. The malposition should be corrected by operative procedures after labor. {c) Hernia of tlic Gravid Uterus. — It is exceedingly rare for the uterus in pregnancy to participate in a hernial pro- trusion : when such a complication exists, however, it will be, in the order of frequency, either as a ventral, an in- guinal, or an umbilical hernia. Ventral hernia, generally consequent upon separation of the recti muscles, is the commonest form of uterine hernia; the other varieties are mainly congenital in origin, and are not infrequently associated with congenital malformations of the organ, as the bicornate uterus. The symptoms of the ventral variety are unimportant and readily alleviated : when the hernia takes place into an inguinal canal, however, symptoms of incarceration and strangulation promptly supervene. The diagnosis is rendered easy by noting the absence of the uterus from its normal position, the presence of the enlarge- ment and protrusion at the site of the hernia, and the history of the signs of pregnancy. The prognosis is good in the ventral variety, grave in the inguinal. Treatment. — Ventral hernia may be controlled by means of a tightly fitting ab- dominal binder and pad until the close of labor ; after the puerperium it would be advisable to resort to operative measures in order to prevent recurrence of the condition. As soon as hernia into an inguinal sac be discovered, the induction of abortion is indicated if efforts at reposition fail. If the child be viable, a Porro-Cesarean section is indicated. {d^ Metritis. — Inflammation of the uterus is a not infre- quent complication of pregnancy, and is generally of long standing, the physiologic having been engrafted upon the pathologic condition. The symptoms of the preexisting dis- ease are greatly aggravated under these circumstances, and the condition of the patient may become serious. There may be intense pain in the pelvis, with the characteristic bearing- 398 A MANUAL OF OBSTETRICS. down sensation. The irritation of the diseased uterine tissue consequent upon the rapid growth of the organ causes an intensification of the reflex manifestations ; there are thus produced some of the gravest forms of the pernicious vomiting of pregnancy. Very generally abortion results either from apoplexy of the ovum or from loosening of the membranes with hemorrhage. The treatment is unsatis- factory at the best. Any form of application usually em- ployed in the management of uncomplicated metritis, as the glycerin-tampon, may result in the induction of abortion, and if such a course be adopted, the patient must be fully warned of the probable result. In the cases of pernicious vomiting abortion must be induced to save maternal life. (r) Hysteralgia {Uterine Rheiimatisni). — Certain women will suffer from neuralgic attacks in the womb of varying intensity at irregular intervals throughout gestation ; these attacks will be accompanied by contraction of the uterine muscles without cervical dilatation, and will be unassociated with systemic disturbance. The etiology of these neur- algias is quite obscure, but they have been noticed to follow undue exertion, as violent coughing or the lifting of heavy weights, whereby the abdominal muscles are brought to bear heavily upon the gravid uterus ; in some hypersensitive women the fetal movements even have been productive of severe uterine myalgia. A certain proportion of these cases will present a very patent rheumatic history, and in them the condition may be classed as uterine rheumatism. This is especially common during the closing months of gestation, and the attack is precipitated in those so inclined by any of the common causes of rheumatism, as exposure to cold, damp, and draughts. The pain may be localized in one portion of the uterus, as the fundus, or may be general ; it is increased by pressure and by the occurrence of the inter- mittent uterine contractions; it is inconstant, and may be peculiarly paroxysmal in its nature. A not infrequent accompaniment is the occurrence of vesical tenesmus, DISEASES OF THE GENITOURINARY TRACT. 399 probably due to an involvement of the bladder in the mor- bid process ; there are also, as a rule, some systemic manifestations, as in rheumatism elsewhere. In certain cases the paroxysms may become so severe as to insti- tute true labor-pains and induce a premature expulsion of the ovum. Treatment. — For the simple neuralgias of the womb absolute rest and the application of emollient and narcotic substances over the uterine tumor will generally result in a cure. The rheumatic cases will respond very promptly to full doses of sodium salicylate or salicylic acid, from 10 to 15 grains, two or three times daily. (/) Tumors of the Uterus. — Neoplasms of the gravid uterus are generally fibrous or myxofibrous in nature. Their growth, owing to the increasing vascularity of the organ, is usually rapid, but, while often causing a certain amount of pain and pelvic distress, as a rule they do not exert a deleterious effect upon the gestation ; they may, however, very seriously complicate labor. Small polypoid tumors are not infrequent upon the cervix uteri, and these may be productive of excessive hemorrhages. If their removal be attempted before term, the possibility of a premature 'termination of gestation must be remembered. {.S) Spontaneous rupture of the uterus is an exceed- ingly rare accident of pregnancy, resulting generally from some previous condition that has left the uterine wall in an extremely weakened state. Such cases usually pre- sent the history of a prolonged endometritis or metritis, with consequent morbid changes in the tissues of the uterus, so that the latter becomes attenuated at points. The progressive distention of pregnancy eventually causes a rupture at one of these weakened spots, usually at or near the fundus, and not seldom immediately over the point of implantation of the placenta. Other causes of rupture may be direct traumatism ; a previous uterine rupture ; Cesarean section or hysterotomy (myomectomy) for uterine fibroids ; or an unrecognized interstitial or cornual pregnancy. The 400 A MANUAL OF OBSTETRICS. symptoms are those of concealed hemorrhage with profound shock and early death. The fetus may escape into the abdominal cavity, when palpation will reveal a material decrease in the size of the uterine tumor, which may or may not be firmly contracted, and the presence of a second tumor behind or to one or the other side of the uterus. The prognosis is grave. Treatment consists in an imme- diate abdominal section, with removal of the blood-clots and the product of conception, and a thorough antiseptic toilet of the peritoneum. The uterine wound must be sutured as in the Sanger method of Cesarean section. Occasionally a Porro operation may be indicated. iji) Ccrz'ical Disease. — Granular erosion of the cervix ac- companying an old laceration — a true endocervicitis, mani- festing itself by an annoying profuse purulent discharge — and, rarely, a carcinomatous degeneration of the cervical tissues, have occasionally been encountered in pregnancy. It is unusual for these conditions to cause any serious trouble during the gestation, but at the time of labor they may constitute a somewhat grave form of obstruc- tion to the descent of the fetus. In marked cases of cervical laceration an untimely termination of pregnancy is by no means uncommon. Treatment must consist in nothing more than the application of antiseptic and astrin- gent solutions through a Ferguson speculum in order to avoid the induction of abortion. (4) Diseases of the Vulva and Vagina. — («) Liflamma- tion. — Various forms of vaginitis may occur in pregnancy, mo.st important of which is that due to gonorrheal infection. Simple vaginitis is productive of an increase in the leukor- rhcal discharge that is peculiar to pregnancy, together with a sense of lieat and discomfort. The gonorrheal form is accompanied by a profuse purulent discharge containing the gonococcus, by an irritable condition of the bladder, by some urethritis, by considerable pain, and frequently by the development of an abscess in one or both glands of Bar- DISEASES OF THE GENITOURINARY TRACT. 4OI tholini. While a source of great discomfort to the patient during gestation, the most serious results occur to both mother and child at the time of parturition. The presence of the specific germs renders the development of septic changes probable, and a grave or even fatal form of septic salpingitis and peritonitis may promptly follow an extension of the infection from absorption of the poison through the lacerations and abrasions of parturition. The infant in its passage through the diseased parturient canal comes in contact with the pathogenic germs, and may develop in a few hours a virulent form of gonorrheal ophthalmia that may result in a total loss of sight. These grave sequelae of gonorrheal vaginitis must be borne in mind as soon as the condition be discerned prior to the onset of labor, and vigorous therapeutic measures must be instituted to avert such disastrous consequences. Treatment. — In the simple nonspecific vaginitis the vulva and vagina should be bathed daily with warm antiseptic fluids, avoiding, however, the use of the douche. In the gonorrheal form of the disease vaginal douches are entirely justifiable, and should consist of a solution of mercuric chlorid (i : 2000) ; these douches may be administered twice daily, and should be followed by the introduction of a tampon of wool or cotton containing pure tannic acid, the glycerol of tannin, or a mixture of iodoform and tannic acid. To counteract the alkalinity of the vaginal secretions Doderlein's suggestion of the appli- cation to the vaginal walls of a solution of lactic acid (i per cent.) may be adopted. WinckeVs disease, colpohyperplasia cystica, is a form of vaginitis characterized by the develop- ment upon the vaginal walls of numbers of small transparent cysts containing a gaseous substance; upon perforation of the cyst- wall, these collapse with an audible sound. There is associated with this formation an increase of the normal leukorrhea, but otherwise no disastrous results attend its occurrence. {p) Varicosities. — Dilated veins are not infrequently present 26 402 A MANUAL OF OBSTETRICS. in both the vagina and vulva, though rarely extending above the lower third of the former. All that can be done for them is the avoidance of excessive constipation, the removal of anything that will obstruct the pelvic circulation, and the use of protective dressings to avert the danger of rupture from traumatism. Mild laxatives, the abolishintr of tisfht dressing and lacing, and the wearing of an abdominal band- age to support the heavy uterus will conduce to this end. A T-bandage will aid in supporting the enlarged veins and will tend to prevent accidental injury, {c) Vegetations are often noticed in and around the vulva, and are very generally a sequel to gonorrheal infection. They are known as goiiorrJical zvarts or pointed condylomata, are cauliflower-like in appearance, of a pinkish tint, and may give rise to more or less itching, pain, and offensive dis- charge. As a rule, nothing will be indicated in the line of treatment other than the application of a protective dress- ing ; any attempts at removal may be followed by the onset of labor-pains. If the condition, however, become exces- sively annoying to the patient, more vigorous measures may be adopted. Operation by the knife is exceedingly hemorrhagic, and a better method of removal would be the use of a strong caustic agent, as chromic acid. In many cases applications of astringents and drying-agents will answer every purpose. Glycerol of tannin, Labarraque's solution, and powders of calomel and bismuth or of salicylic acid and starch have been used with benefit. The vegeta- tions usually disappear entirely or diminish ver}^ consid- erably in size after parturition. {d) Vaginal Prolapse. — A certain amount of falling of the anterior vaginal wall, associated with a slight degree of cystocele, is not uncommon in pregnancy. It results from the increased congestion and consequent increased weight of the vaginal tissues (the edema of the cellular structures that generally exists causing a loosening of the mucosa from the subjacent structures) and the pressure from above DISEASES OF THE GENITOURINARY TRACT. 403 exerted by the gravid uterus. The symptoms are vesical tenesmus and irritation, and rectal irritation should the posterior wall participate in the condition. The treatment consists in a reposition of the displaced vaginal walls, and their retention in situ by means of a properly fitting pessary or by vaginal tampons inserted daily and held in place by a T-bandage. The bowels must be maintained in a patulous condition and the wearing of tight clothes prohibited. During labor such a condition may prevent the ready escape of the fetus. [c] Pruritus vulvcs may complicate pregnancy. In nature it may be purely a neurosis, while in many cases it is secondary to irritating leukorrheal discharges. The itch- ing may become intense and prove very resistant to treat- ment. A multitude of remedies have been suggested for its relief, prominent among which are lotions of mercuric chlorid, i : 2000, and an ointment of menthol, from 10 to 15 grains to the ounce of lanolin; a solution of borax with a little morphin in rose-water is a very elegant and effective application. Carbolic acid or cocain may be employed with success in some cases. (/) Edema of the Vulva. — A dropsy or serous infiltration of the vulvar tissues is not uncommon in those cases of pregnancy associated with renal insufficiency. Such a con- dition may also occur from direct mechanical pressure by the gravid uterus upon the pelvic veins, and then may be either unilateral or bilateral. It may be a part of a general anasarca or it may result from abscess of a Bartholini's gland. The labia become at times enormously swollen, and from attrition they may become excoriated or even the seat of deep ulcers. Treatinettt. — If the edema be slight, a removal of the cause, if this be possible, together with the application of hot fomentations, will generally relieve the condition. In some cases great relief may follow slight puncturing of the skin in order to permit of the escape of the exuded fluid. 404 ^ MANUAL OF OBSTETRICS. (5) Pathologic states of the Mammae. — Disorders of the mammary glands are very unusual in pregnancy. The most common pathologic condition noted, aside from ill development of the nipples, is an intractable form of eczema of the nipples, which, despite the best of treatment, will, when once established, generally persist until the ter- mination of labor. Abscess of the breast has been noted. 6. Diseases of the Nervous System. (i) Gestational Insanity. — It is rare for insanity to develop during gestation. When it does appear at such a time, it is generally in those individuals in whom there exists a strong predisposition to mental disorder: it may, however, occur in any pregnant woman as a result of excessive fright or long-protracted anxiety. As a rule, the type assumed is that of melancholia, often with a tendency to self-destruction. The usual period for its appearance is about the third month, and most commonly in elderly primipar^e. When once de- veloped, the condition will generally persist until after par- turition. The best treatment is confinement in an asylum until after birth of the child. (2) Insomnia. — The occurrence of sleeplessness in preg- nancy, especially toward the close of gestation, may be over- come by the judicious use of nerve- sedatives, as chloral, potassium or sodium bromid, sulfonal (5- to lo-grain doses), and the antispasmodics, notably camphor, valerian, and asa- fetida. The danger of the formation of the opium-habit will debar the administration of opium and its alkaloids. (3) Vertigo and Syncope. — Dizziness, with or without fainting-spclls, is especially liable to occur in women who are essentially hysteric in nature; and may result in part from the extreme anemia that complicates pregnancy, or it may foreshadow an impending eclamptic seizure and be associated with varying grades of albuminuria. The treat- ment consists in the use of aromatic spirits of ammonia, cold water, and smelling-salts during the attack, and, in the DISEASES OF THE NERVOUS SYSTEM. 405 intervals, the administration of tonics, especially iron, and the nerve-sedatives and antispasmodics, together with diuretics and laxatives. (4) The Neuralgias of Pregnancy. — It is not uncommon for the pregnant woman to complain of neuralgic pains in various portions of the body. Those occurring in the uterus itself have already been mentioned; other common situations are the head, hands, teeth, face, and breast. Tic doiilonreiix [face-ache), or neuralgia of the fifth nerve, is often noted. Like all these neuralgic affections, it is quite intractable to treatment. Sedative applications, as those containing aco- nite or belladonna, and liniments of chloroform or camphor, maybe tried; in very severe cases hypodermic injections of morphin must be administered. Internally, nerve-sedatives, as the bromids, chloral, or croton-chloral (in from 2- to 10- grain doses) will be of service. Mild galvanism may relieve the patient. By far the most frequent of the neuralgias of pregnancy is odontalgia, or toothache, which may or may not be accompanied by caries of the teeth. Usually it is the lower maxilla that is affected, and the pain may be unilateral or bilateral ; it very generally subsides by the close of the sixth month of gestation. It requires the treatment already given for face-ache ; in addition, the bowels must be kept patulous, and sedative mouth-washes, together with the ap- plication to the gums of sedative plasters (as of capsicum), should be employed. Should caries be present, appropriate treatment is indicated: it must be remembered, however, that slight operations on the teeth may be sufficient to initiate labor-pains. Pains in the muscles of the abdomen, and lumbago have also been noted in pregnancy, especially toward its close. Occurring near the ensiform cartilage or low down in the inguinal regions, they result from excessive stretch- ing of the attachments of the abdominal muscles. These pains are aggravated by voluntary motion, by pressure, and even by the fetal movements. In some cases they may be entirely dependent upon a hypersensitiveness of the cuta- 4o6 A MANUAL OF OBSTETRICS. neous nerves of these regions. Gentle rubbing with nar- cotic applications or slight blistering of the affected regions will generally allay the pain ; subcutaneous injections of morphin may be required for severe cases. Cramps in the thighs and in the legs are frequently complained of late in pregnancy and during the progress of labor. They are probably produced by the pressure exerted by the gravid uterus and advancing fetal presentation upon the lumbar and sacral plexuses of nerves. Attention to the bowels and a change in the position of the patient will often promptly correct these painful seizures. Cephalalgia and migraine, if present, may be counteracted by the prompt administration of chloral, the bromids, and tonics, and attention to the rules of hygiene. (5) Gestational Paralysis. — Various forms of paralysis may complicate gestation, and these have inappropriately received the name of puerperal paralysis: a much more fitting term, we think, is that given at the heading of this paragraph. Gestational paralysis may assume the form of a paraplegia, a hemiplegia, facial paralysis, or paralysis of the nerves of special sense. Paraplegia may be traumatic in origin, or may result from pressure upon the pelvic nerves by the fetal head, or from exhaustion of the spinal irritability. It exerts no deleterious effect whatever upon the pregnancy nor upon the labor ; in fact, women so afflicted may have much less difficulty in parturition than those in full control of their voluntary muscles. Hemiplegia is rather common in pregnancy. It may result from cerebral apoplexy following congestion of the brain, or, more rarely, from cerebral anemia, the hemorrhage in the latter case being an outcome of the hydremia of pregnancy ; or it may occur without the coexistence of any grave structural lesion of the nerve- centers. It cannot be said to constitute a grave complica- tion of pregnancy and labor, other than the inconvenience afforded the patient by the condition. Treatment consists in the administration of tonics and strychnin and in faradization DISEASES OF THE NERVOUS SYSTEM. 407 of the affected limb. The paralysis generally disappears after parturition. Facial paralysis is a rare condition in pregnancy, and may possibly result from the hydremia and anemia that are present. Paralysis of the nerves of special sense will result in amaurosis or deafness according to the nerve involved. In cases of amaurosis, partial or complete, the presence of renal disease should always be suspected and a urinary examination made. Occasionally, however, the blindness is entirely due to an anemic state of the retina. As a rule, both eyes are affected. If there have not occurred an effusion of blood into the retinal tissues, the sight will prob- ably be restored when the uterine contents are evacuated. Deafness is generally a temporary condition, and, while at times associated with albuminuria, in many instances is absolutely inexplicable. It may be unilateral or bilateral, and generally disappears when pregnancy is terminated. (6) The Neuroses Complicating' Pregnancy. — Hysteria to some extent exists in all pregnant women. The normally excitable nature of the woman is profoundly impressed by the existence of gestation, and any trivial cause may pre- cipitate an hysteric paroxysm. Under such circumstances moral suasion alone will suffice to correct the condition ; drugs are of no avail. It is possible for the hysteria to develop eventually into true insanity. Epilepsy is rare as a complication of gestation, largely from the fact that epi- leptic women are sterile in the vast majority of cases, prob- ably because of the under-development of their genital organs ; when such women do conceive, however, the disease generally does not unfavorably influence the course of the pregnancy. There may apparently be an arrest of the nervous disease, the spasms often disappearing entirely during pregnancy, only to reappear after parturition. When an epileptic seizure occurs, the condition must be diag- nosed from puerperal eclampsia : this can be done by an examination of the urine, which is albuminous in the latter condition. The children of epileptic women almost invari- 408 A MANUAL OF OBSTETRICS. ably die soon after birth from a transmission of the maternal disease. Chorea in its milder forms is occasionally encoun- tered in pregnancy, and mainly in primigravidae (in over 60 per cent, of the cases). The etiology of the disease is either an hereditary neurotic tendency, a former occurrence of the disease in the individual, or the ordinary causes of chorea — anemia and rheumatism. Its usual time of occurrence is during the first few months of gestation, and, having once appeared, it generally persists throughout the pregnancy, and even exhibits a remarkable tendency to recur in succeeding pregnancies. It does not manifest itself during sleep. In its grave forms it not infrequently results in maternal death fol- lowing premature expulsion of the ovum. The mortality of such cases is about 30 per cent. The causes of death are mus- cular exhaustion, syncope, and the sequelae of abortion. In a certain proportion of the cases incurable insanity develops. The treatment is that of the uncomplicated disease — iron. Fowler's solution, tonics, nutritious diet, and good hygienic surroundings. In the graver forms it may become neces- sary to prematurely terminate pregnancy. Tetany, or a tonic contraction of the muscles, usually confined to the wrists, but at times appearing elsewhere, may develop during gesta- tion; as a rule, it is a matter of but little gravity, but should the muscles of respiration become involved in the tetanic process, death from strangulation may follow, due to inter- ference with the respiratory muscles. The treatment is that of uncomplicated tetany. 7. Diseases of the Osseous System. (i) Relaxation of the Pelvic Articulations. — While, to a limited extent, a loosening of the pelvic joints from serous infiltration is physiologic in pregnancy, this separation of the bony structures may become so excessive as to con- stitute a veritable pathologic condition. It then becomes a source of great discomfort to the patient, giving to her a sense of insecurity and lack of support, or even rendering DISEASES OE THE OSSEOUS SYSTEM. 409 locomotion impossible. Simple movement of these relaxed joints may be productive of intense suffering to the patient, the pain radiating into the loins and down the thighs. Most commonly it is the symphysis pubis that is affected, and usually the symptoms do not manifest themselves until after the sixth month of gestation ; once begun, however, the undue relaxation is very liable to progressively increase until the end of gestation, after which there is a slow return tp the normal condition of the parts. The diagnosis of the pathologic state may be made by causing the patient to assume the standing posture, and then to shift her weight from one limb to the other while the accoucheur, resting upon his knee before her, inserts a finger into the vagina and rests it upon the inner surface of the symphysis. Another method is to place the patient in the dorsal position and alternately flex and extend the femurs, a finger at the same time being inserted into the vagina and caused to rest upon the various pelvic articulations. Treat- ment consists in rest in bed, with the firm application of a binder of linen, leather, or thin metal around the hips ; this should be worn after labor until the joints have assumed their normal degree of mobility. A plaster-of-Paris cast may be employed in severe cases. (2) Inflammation of the Pelvic Joints. — Occasionally, though very rarely, an inflammatory action is set up in the softened and relaxed joints. It manifests itself by severe pain, of a heavy, boring nature, with sharp, lancinating exacerbations, and tenderness on motion and pressure over the affected joints ; occasionally there is a small amount of edema and a slight degree of pyrexia. The trcatnient consists in rest in bed, the wearing of a binder, sedative applications and, if necessary, the administration of small doses of narcotics. (3) Osteomalacia. — Osteomalacia, or decalcification of the bones, is an exceedingly rare condition in the United States, although of frequent occurrence in certain portions of 410 A MANUAL OF OBSTETRICS. Europe, notably in Italy. It is produced by a variety of osteitis and periosteitis, probably resulting from defective nutrition of the parts, in combination with imperfect hy- gienic surroundings. The parasitic origin of the disease has not been fully established. Its main symptom is the intense boring, or at times acute, pain in the affected bones, which may be confounded with rheumatism ; in course of time the bones undergo a process of softening and distor- tion, giving rise, when there is an involvement of the in- nominate bones, to the peculiar formation of the pelvis that is known as the beaked or heart-shaped pelvis. The treatment of the condition consists in the administration of full doses of phosphorus and a nutritious diet, with rest in bed. After pregnancy castration should be performed in the hope of arresting the progress of the disease. 8. Diseases of the Cutaneous System. (i) Increased Pigmentation. — The cutaneous pigmenta- tion that is normally present in pregnancy to a moderate degree may become immensely exaggerated in certain indi- viduals, and even so marked as to constitute a true physical deformity. The spaces of the face — the brow, the cheeks, and the chin — may be darkened uniformly, constituting the condition known as the mask of pregnancy ; in other cases the blotches are irregularly scattered over these regions, appearing in spots of varying size, but usually symmetric in form ; these are known popularly as liver-blotches, liver- spots, or freckles, and technically as chloasmata or ephelidce. The areas of pigmentation are strictly confined to the open spaces and do not extend into the hairy scalp. They may also appear, although much less frequently, upon the breasts, thighs, and abdomen. Very generally they will disappear after parturition. They do not give rise to any subjective sensations. No treatment is indicated. (2) Pruritus. — Itching of the skin, while commonly con- fined to the region of the genitalia, may become general, DISEASES OF THE CUTANEOUS SYSTEM. 4II and then is a source of intense suffering to the patient. In such cases it is often most marked over the abdominal sur- face, and instances have been noted in which the neurosis was so exaggerated as to result in a premature discharge of the ovum. The treatment of this general form consists in the administration of alkaline baths — the ordinary soda-bath or one of potassium carbonate (five ounces of the salt to the bath) — and frictions with sedative lotions, as camphor or chloroform liniment, a solution of cocain, and prepara- tions containing opium, carbolic acid, or aconite, (3) Herpes Gestationis. — This is a peculiar neurotic skin-affection occasionally encountered in early pregnancy and running a protracted course, lasting until after parturi- tion. The eruption is multiform, partaking of the nature of pemphigus and erythema, and showing on different por- tions of the body papules, vesicles, and bullae. Its treat- ment consists in the administration of nerve-sedatives, to- gether with regulation of the mode of life, (4) Impetigo herpetiformis is a very serious skin-dis- ease but rarely seen complicating pregnancy, and when encountered appearing especially toward the close of gesta- tion. Its usual location is in the folds of the body, around the groins, umbilicus, and axillae, and under the mammae, the lesions, which are pustular in nature, spreading thence until they involve the entire cutaneous surface. There are marked concomitant symptoms of systemic disturbance — high fever of the intermittent type, associated with chills, gastric dis- turbance with vomiting, extreme prostration and delirium, followed often by coma and death. The treatment is symp- tomatic, with soothing applications locally. (5) Purpura hsemorrhagica very rarely complicates preg- nancy, but when encountered runs a very rapid course to a fatal termination, death always being preceded by premature expulsion of the ovum. The cause of maternal death is profound exhaustion, postpartum hemorrhage, or sepsis. 412 A MANUAL OF OBSTETRICS. IV. DYSTOCIA. In very many instances labor does not pass through 'its successive stages in the simple and uncomplicated manner portrayed in a preceding portion of this volume : there are a multitude of accidental or pathologic conditions, of varying degrees of gravity, that may interrupt its normal mechanism and give rise to obstruction to fetal descent and expulsion. To these irregularities in the progress of labor has been given the name of pathologic or difficult labor, or dystocia, from two Greek words meaning painful or difficult labor. If the abnormality of the labor be dependent upon some form of fetal irregularity, the condition is known as fetal dystocia, while if it be dependent upon some defect of or accident to the mother, it constitutes a variety of maternal dystocia. Under these two main headings will be described the various abnormal states that may be encountered during the process of parturition. I. Fetal Dystocia. The conditions connected with the fetus that may in any way render its entrance into the world difficult or even impossible if unaided by the accoucheur, or that in any way threaten its existence, may be grouped as follows: (i) Mal- positions and malpresentations ; (2) Fetal diseases and mal- formations ; (3) Abnormalities of the fetal appendages; and (4) Fetal accidents. (i) Dystocia due to Malpositions and Malpresentations of the Fetus. — [a) Backzvard Rotation of the Occiput in Vertex Presentations. — In certain cases of posterior vertex presentations it not infrequently happens (in about 2 per cent, of the cases) that the great law of the mechanism of labor — anterior rotation of the fetal presenting part — fails of fulfilment. When this occurs the expulsion of the fetus from the parturient canal becomes exceedingly difficult and protracted, and considerable damage to the soft structures BACKWARD ROTATION OF THE OCCIPUT 413 of the pelvis will almost inevitably follow. Extensive laceration of the perineum, involving the sphincter ani muscle, and even extending up the rectovaginal septum for a varying distance, is the rule. It may very readily be seen why the characteristic delay and damage should occur. Instead of lodging under the symphysis pubis while the softer structures of the face sweep over the perineum to emerge at the posterior portion of the vulvar outlet, the large, firm occipital portion of the fetal skull is driven down the sacral curve by the uterine contractions, and forward over the immensely distended pelvic floor to emerge at the vulvar outlet : this process necessitates the traversing of at least 25^ cm. (10.03935 in.) of space, half of which is the sacral depth and half the anterior continu- ation of the pelvic floor; the soft structures cannot undergo the tremendous distention thus entailed, and generally yield before the advancing head. Etiology. — There are various causes assigned for this anomaly in the mechanism of vertex presentations. In a large percentage of the cases it results from a failure of the head to assume the condition of extreme flexion, whereby some other portion of the skull, as the chin or brow, will first meet the resistance of the pelvic floor, and will advance under the symphysis while the occiput retreats into the hollow of the sacrum. In other cases, in which there has occurred a partial exten- sion of the head, the relationship of the fetal head to the maternal pelvic inlet is sufficiently disturbed to cause an en- gagement of the occipitofrontal diameter (n^ cm. — 4.6259 in.). It will be impossible for this large diameter to rotate anteriorly through the small transverse and into the oppo- site oblique diameter of the pelvic inlet, and the only course left for it to pursue is a backward rotation into the hollow of the sacrum. In still another, and quite a numerous^ group of cases flexion of the head may be perfect, but the resistant forces of labor are deficient, as will be the case when there exist old lacerations of the perineum or over- 414 A MANUAL OF OBSTETRICS. size of the pelvic cavity ; here, again, the head, faihng to advance, swings backward into the posterior position. Again, if the fetal head be under-sized or a certain amount of uterine or abdominal inertia exist, the head will not be driven against the pelvic floor with sufficient force to ensure its advance toward the symphysis, and, instead, it will as before swing backward into the sacral cavity. Finally, there may exist some great obstruction to the for- ward rotation of the head, flexion and the forces of labor being normal. Thus, in complex presentations, as of the vertex and a foot or hand ; when there exists some variety of contracted pelvis, as the justominor and the kyphotic; or when there is an over-size of the fetal head, as in hydro- cephalus, — the occiput under any of these circumstances finds its best accommodation in the posterior position. Also, an extreme prominence of the sacral promontory will present an obstruction to the forward sweep of the shoulders, and the occiput as a result will enter the cavity of the sacrum. Diagnosis. — Vaginal examination in these cases reveals the occiput and smaller fontanel posterior in the median line, while ante- riorly the bregma is within easy reach (Fig. 104). The sagittal suture corresponds to the conjugate diameter of the pelvis. If the complication be the result of an imperfect perineal floor, the head will be low down in the pelvic cavity, while if it occur from some insuperable obstacle to entrance into the superior strait, it will be found resting high up upon the pelvic brim. Abdominal palpation will, in the latter class of Fig. 104. — Ijack ward rotation of the occiput. BACKWARD ROTATION OF THE OCCIPUT. 415 cases, show an anterior median situation of the fetal ex- tremities, with a transverse position of the shoulders; the head may be readily mapped out, while the fetal heart- sounds will be indistinct, and only heard far back in the flanks, or they may be altogether absent. Fetal Diameters Involved. — The diameters of the fetal head engaged in the mechanism will be the same as in ordinary vertex presen- tations in some instances ; in many cases, according to the degree of extension that has occurred, the bitemporal diameter — 8 cm. (3.1496 in.) — may be substituted for the •biparietal, and the occipitofrontal — 11^ cm. (4.6259 in.) — for the trachelobregmatic diameter. Steps of the Alechan- isui. — If the case be left to nature, it is quite possible in many instances for a spontaneous termination of the labor to occur. This is accomplished in the following manner : I. There occurs a tremendous increase of flexion as the occiput is driven down the parturient canal to the vulvar orifice, where the anterior fontanel presents ; 2. Engage- ment of the brow under the symphysis ; 3. Birth of the occiput in a state of extreme flexion, the perineum retract- ing over the advancing head ; 4. Delivery of the face by a process of partial extension, the nape of the neck resting on the retracted perineum ; the parts emerge from under the symphysis in the following order : Supraorbital ridge, nose, upper maxilla, mouth, and chin; 5. There follows a very violent external rotation as the shoulders sweep around within the pelvic cavity to assume an anteropos- terior position ; 6. Delivery of the shoulders and remain- ing portions of the body. Dangers. — The risks to both mother and child in such a condition as this are manifest. I. Fetal. — The mortality of the child increases considerably under these adverse circumstances; from 9 to 15 per cent, of such children perish from fatal cerebral compression, pressure upon the cord, injuries contracted during opera- tive manipulation, and interference with the placental func- tion from tetanic contraction of the uterus. In every case 4l6 A MANUAL OF OBSTETRICS. of difficult posterior occipital delivery the normal configura- tion of the fetal skull is much distorted as a result of the extreme pressure to which it has been subjected. There is an immense and quite distinctive increase in the occipito- mental diameter, with a corresponding decrease in the trans- verse diameters : this disfiguration will generally disappear within a few days after birth. 2. Maternal. — Grave perineal laceration is the rule in these cases, and, if unaided, the mother will become more or less exhausted or even perish. In some cases the occiput may become firmly lodged above the point of obstruction, such as a prominent sacral promontory or a , protruding ischiac spine, and, the pressure continuing from above, a process of extension occurs, with the resultant con- version of the presentation into one of the anterior fontanel, the brow, or the face, according to the degree of devia- tion produced. Treatment. — The treatment varies accord- ing as to whether engagement of the part has not yet occurred, or whether posterior rotation has followed after the head has advanced as far as the pelvic floor, (i) The Head Above the Pelvic Brim. — The indications under these circumstances are, first, to secure, if possible, complete flexion of the fetal head, and, secondly, to secure and maintain a normal equilibrium between the forces of labor. Perfect flexion may be favored before rupture of the mem- branes by placing the patient in the lateroprone or obstetric position on that side toward which the occiput is directed ; the fetal body is then carried in the same direction, and the occipital portion of the head again becomes the short arm of the lever, so that the main bulk of the resistant force falls upon the anterior portion of the head, which is thus driven up upon the chest : in this way the occiput becomes the most dependent portion of the fetal presentation and its anterior rotation may follow. The genupectoral position may in some instances accomplish the same purpose. West's method consists in making upward pressure upon the brow in the hope of causing a descent of the occiput. The ex- BACKWARD ROTATION OF THE OCCIPUT. 417 pulsive power of the woman may be increased by the admin- istration of sHght stimulus, as a glass of sherry or a large dose of quinin. If the membranes have already ruptured and the head still remain above the pelvic brim in the posterior po- sition, it would be quite proper to introduce one hand — that corresponding to the fetal back — through the internal os, and with the assistance of the abdominal hand accomplish an anterior rotation of both the occiput and the shoulders — the latter to prevent a return of the head to its original position. (2) The Head Lodged zvitliin the Pelvic Cavity.- — In many of these cases backward rotation has occurred on account of a deficiency in the amount of resistance afforded the ad- vancing head by the pelvic floor ; this follows in cases of relaxed or lacerated perinei. Under such circumstances an extension of the head again occurs : this may be remedied by reverting to the maneuver already described. Should the change in the maternal position not result favorably, the resistant force may be restored by placing the index and middle fingers of the hand corresponding to the fetal back upon the posterior surface of the occiput, against which forward pressure is exerted ; a single blade of the forceps used as a vectis will accomplish the same purpose. If, notwithstanding these prophylactic measures against further posterior rotation, this should occur, the Simpson or the axis-traction forceps may be applied, and used mainly to lift the head from the over-distended perineum, and not as a tractor. In the difficult cases in which instrumental de- livery is required from the beginning, the occiput becoming engaged in the posterior position, the head must be dragged down to the vulvar orifice and the outward traction con- tinued until the brow become firmly fixed under the sym- physis ; the forceps must then be grasped in the right hand and the head lifted steadily upward until the occiput be almost on the point of emerging from the vulvar orifice, when the handles must be carried downward over the peri- neum, the face appearing from beneath the symphysis. In 27 4l8 A MANUAL OF OBSTETRICS. rare cases excellent results may be obtained by converting the abnormal position into a face presentation with the chin anterior. {b) Transvei'se Engagement of the Occiput. — In certain cases of deformed pelvis in which the main constriction has taken place in the conjugate diameter, the head is caused to assume a transverse position as it enters the superior strait: in such a position the smallest diameter of the fetal skull — the bitemporal, which measures but 8 cm. (3.1496 in.) — is made to correspond to the contracted pelvic conjugate diameter by the partial extension of the head that occurs in these cases. Diagnosis. — Vaginal examination will show the sagittal suture occupying a transverse direction in the pelvis with the posterior fontanel to one side — that corre- sponding to the fetal back — and the greater fontanel at the opposite extremity of the transverse diameter of the pelvis. The increase in the pelvic obliquity always noted in contracted pelvis produces an extreme lateral flexion of the skull upon the fetal body ; as a consequence, there results a presentation of the anterior parietal bone, or even of the ear. The danger of this condition is that there has occurred a slight degree of extension of the head, and, in consequence, backward rotation of the occiput may follow a primary impingement of the brow upon the pelvic floor. The treatntcnt' consists in securing anterior rotation of the occiput if possible, or delivery by the forceps, version, or symphysiotomy, according to the degree of contraction that may be present. The application of forceps to the head lodged transversely at the superior strait is always a difficult procedure. It is impossible to secure a proper grip upon the head, the blades grasping it over the face and occiput. It may readily be seen that compression of the skull will result in a compensatory enlargement of its transverse diameters, whereby the mechanism will become an almost imjwssiblc one. Attempts at extreme rotation of the blades in order to apply them to the sides of the fetal TRANSVERSE POSITION OF THE VERTEX. 419 skull are unjustifiable on account of the imminent danger of perforation of the posterior uterine wall thereby engen- dered. Under such circumstances the right-hand blade should be rotated slightly forward : in this way the head is grasped on one side of the forehead and upon the opposite side of the occiput ; the blades now will not lock with ease, and there is increased danger of producing a fracture of the skull ; to prevent this, or too much compression of the head, a folded towel should be placed between the handles. Traction is then made, and as the head descends and rotates within the grasp of the forceps the latter may be removed and the vicious grip corrected. [c] Transverse Position of the Head at the Infei'ior Strait. — A serious anomaly of vertex presentations results when, owing to certain irregularities of the pelvic or fetal outlines, descent of the head occurs without anterior rotation of the presenting portion taking place. Under these circumstances the head occupies the transverse diameter of the pelvic outlet. Maurice Muret^ claims that this position may be primary or secondary. A primary transverse position at the outlet occurs in the simple flat pelvis (rachitic or non- rachitic) in double congenital dislocation of the hips, and in the generally equally contracted and flat pelvis. In the simple flat pelvis the bregma occupies the lower position, while in the flat and contracted pelvis the posterior fon- tanel is lower. The primary position may likewise occur in the funnel-shaped pelvis, and in a larger pelvis when an undersized head is rapidly driven through after a sudden rupture of the membranes. Most of these cases are primarily occipitoanterior presentations. A scco7idary transverse position at the outlet occurs in those cases in which there exist a large head and a broad occiput, the latter starting and remaining posteriorly until the pelvic floor is reached. Here sufficient force may be encountered to secure a partial rotation of the occiput into the transverse 1 Rev. mid. de la Suisse Rom., xiv. No. i, 1S94. 420 A MANUAL OF OBSTETRICS. diameter of the outlet. The bregma usually occupies a lower position than the occiput in these cases. Again, this position may be reached secondarily in certain cases of flat pelvis large enough to allow the head to pass through the inlet in an oblique diameter with the occiput posteriorly, but so contracted below that complete anterior rotation cannot be accomplished. Symptoms. — The clinical course of these cases varies. At times the obstruction afforded to labor may result in an absolute cessation of the pains, and the head may remain stationary and impacted in its unusual position ; if this be not speedily corrected, sloughing of the vaginal walls and fistulse may result, and the child may perish from asphyxiation. Exceptionally, the pains may become so excessive as to drive the head through the bony outlet at the imminent peril of the perineal tissues, which are usually badly lacerated. At other times anterior rota- tion may occur, and usually rapidly, in the bony outlet, or even on the perineum, or posterior rotation may follow. Very rarely, the delivery may be spontaneous in the trans- verse position, especially when the pelvis is large, the head small, and there exists an old perineal laceration ; still, it is possible for the head to be born transversely in flat and contracted pelves, provided it remain strongly flexed. The prog}iosis for both mother and child is unfavorable. A large percentage of the children are stillborn, either from compression of the brain-centers or from injury during de- livery, and the mother is subjected to the risks of grave lacerations of the soft structures, sepsis, and exhaustion. The. treatment \s as follows: (i) Postural and Expectant. — The woman occupies a lateral decubitus, resting upon that side to which the occiput is directed. Anterior rotation may thus be favored, and this may be further supplemented by Tarnicrs inamial method of rotation — namely, by two fingers passed up behind the car that is resting against the symphysis. This latter method is useless in cases of contracted pelvis. The expulsive forces may be increased OTHER ANOMALIES OF VERTEX PRESENTATIONS. 42 1 by the administration internally of stimulants or by the employment of Kristeller's method of uterine expression. (2) Instriiviental. — These measures failing, the Simpson forceps may be applied in one of the oblique diameters of the pelvis, but never in the anteroposterior diameter. No efforts at forced rotation should be made. Gentle traction is required until the head reaches the muscular floor, when the instrument must be removed. Rotation may then be effected by Miirefs mamial method, which consists in pressure by two fingers upon the smaller fontanel (usually situated immediately above one of the sciatic tuberosities) and the projection formed by the union of the lambdoid and sagittal sutures, while two fingers of the left hand, introduced into the rectum, press the brow posteriorly. (3) Operative treatment is but rarely indicated. In the case of a funnel-shaped or contracted flat pelvis, if the child be living, symphysiotomy may be performed ; in case of fetal death craniotomy is indicated, [d) Other Anomalies in the Mechanism of Vei'tex Prcseii- tations. — In certain cases of contracted pelvis, or when there is a relaxed condition of the abdominal walls, there results a forward displacement of the gravid uterus, at times amounting to a true hernia. The method of correcting this anomaly, which may as long as it exists constitute an insuperable obstacle to the progress of labor, has already been described under the pathology of pregnancy (see page 394). A similar condition is an exaggerated tilting of the uterus to the right by the rectum. During the contractions of labor the fetal presentation will, under such circumstances, be driven against the left pelvic brim and wall, and all progress be arrested. The treatment consists in placing the woman upon the side toward which the womb is tilted, the fundus being lifted by means of a pad placed under her side. Delivery of the head in an oblique diameter is occasionally noted in cases of badly lacerated or much-relaxed perinei. The danger of such an anomaly is that there will follow a 422 A MANUAL OF OBSTETRICS. still more extensive destruction of the maternal soft struc- tures. Excessive external rotation of the head may occur in certain cases, and especially in occipitoposterior positions, due to an abnormal rotation of the shoulders within the pelvic canal. This may be produced in the following manner : The anterior shoulder catches upon the pelvic brim ; the posterior shoulder is then driven down, and, striking the perineum, is rotated forward under the sym- physis, thereby describing a semicircular moveinent ; the liberated head is rapidly whirled in a corresponding direc- tion in response to the extreme torsion of the neck. {e) hnpacted Breech. — By this term is meant that trouble- some condition in which the pelvic extremity of the child will, in an ordinary breech presentation, become firmly lodged at the superior strait or in the pelvis, so that the expulsive efforts of the mother fail to impel the fetus through the parturient canal. There are two varieties of impacted breech: i. That in which the fetal attitude is normal — with complete flexion of the thighs upon the abdomen and of the legs upon the thighs — but in which there exists a relative disproportion between the size of the breech and that of the pelvic inlet; impaction here occurs at or just within the superior strait; 2. That in which the fetal ellipse is altered in such a way as to constitute a wedge-shaped body with the base of the wedge above. This alteration is brought about by an extension of the legs, the thighs remaining fully flexed ; the feet are thus brought in apposition with the fetal head, and the combined bulk cannot engage in the superior strait. The breech in this variety has generally well descended into the pelvic cavity. Symptoms of Impacted Breech. — The symptoms of this anomaly are extreme delay in the progress of labor; failure of the pre- senting part to advance ; an increase in the maternal pulse- rate, the heart-beats becoming rapid and feeble; and an increasing degree of exhaustion. There may finally ensue a slight elevation of temperature. Physical SigJis. — Vagi- IMPACTED BREECH PRESENTATION. 423 nal examination reveals in the first variety a high position of the presenting part, which is very firmly fixed at the superior strait ; the extremities cannot, as a rule, be pal- pated. In the second variety the breech will be found lower down in the pelvic canal, and the thighs may be felt extend- ing upward along the fetal abdomen. Abdominal palpation in the latter case may reveal the extended feet in the fundus uteri in close approximation to the fetal head. Fetal Diam- eters Involved. — These are the same as in unobstructed breech presentations. Treatment. — There are several methods of treatment in vogue for the management of these cases, but in every instance it is preferable to place the woman under the influence of an anesthetic, i. Podalic Version. — In the first variety, in which there has been failure of the part to engage in the superior strait, the hand of the operator corresponding to the fetal abdomen may be intro- duced into the uterine cavity, a foot grasped and drawn down, and the pelvic extremity thus caused to engage. 2. Decomposition of the Breech [GoodeWs Method) — This is a method especially applicable to the second variety of im- pacted breech. It consists in dragging down one or both of the extended limbs, and by traction causing an engage- ment of the breech ; the fetus may then be rapidly delivered by the ordinary methods. 3. The Application of the Forceps. — When Goodell's method cannot be put into operation, it then becomes imperative to deliver by instrumental means : the special breech-forceps or the axis-traction forceps are peculiarly serviceable in these cases. The grasp is taken over the great trochanters, and, in order to avoid fracture of the pelvic bones or perforation of the abdominal walls, the handles must not be strongly compressed. If accurately applied and proper watchfulness be observed, slipping of the instrument may be avoided. The expulsion of the fetus may be facilitated by pressure from above. 4. Traction on the Breech. — There are several methods of performing this, as follows : (a) Traction iLpon the Groin. — Frequently the 424 A MANUAL OF OBSTETRICS. simple maneuver of hooking the index finger over the groin and making traction during the pains will suffice ; engage- ment of the part may thus be effected and internal rotation secured ; as soon as sufficient descent has been secured, the breech may be " decomposed " and delivery accomplished according to Goodell's method. Traction upon the groin may also be made by the fillet or by the blunt hook. The fillet is a strip of ordinary bandage, the extremities of which are passed around the lumbar region of the fetus from behind forward, and are brought down between the thighs in front of the external genitals ; when drawn taut the bandage be- comes accurately fitted to the fetal back and a powerful grasp is taken upon the breech. The main objection to this method is the extreme difficulty experienced in ap- plying the bandage. The blioit Jiook is the familiar upper extremity of the Hodge and other forceps. It is slipped around the groin from without inward and traction made. It is a dangerous instrument, and not infrequently results in perforation of the groin or in fracture or dislocation of the thigh : it should only be employed as a dernier ressort or after fetal death. (/;} Traction npon the Pelvic Bones. — This is a very difficult and almost impracticable method of manual delivery of an impacted breech. The hand is introduced well up along the fetal back ; the index and little fingers are hooked over the iliac crests on either side ; the middle and ring fingers are made to press firmly upon the spine, while the thumb grasps the body anteriorly; traction is then exerted, but owing to the imperfect grip but little power can be exercised. 5. Pinarcfs Method. — This is a manual method in which the index finger is inserted over the posterior surface of the thigh, which is then pressed upward and outward, thereby causing a certain amount of flexion at the knee. By this maneuver the heel is brought down within reach, when it may be grasped and the breech delivered. 6. Embryotomy is very rarely indicated ; it is applicable only in case of fetal death. ABNORMAL BREECH PRESENTATIONS. 425 (/") Extension of the Anns in Br c cell Prcsefitations. — During the manipulations necessary for the reduction of an impacted breech ; or in consequence of too violent trac- tion upon the fetal body in an uncomplicated breech pres- entation ; or, rirely, without such interference on the part of the accoucheur, there may occur an upward displacement of the arms, so that they lie extended at full length by the sides of the fetal head. Before the latter can be delivered the arms must be freed from their unnatural position. The method of accomplishing this is as follows : The posterior arm — that nearest the hollow of the sacrum when the occiput has rotated under the symphysis, usually the right — is the first to be released, because of the greater room afforded by the concavity of the sacrum. The fetal legs are grasped with the left hand just above the malleoli, the middle finger being placed immediately above the two internal, and the ring and index fingers above the external malleoli ; the fetal body is then carried forcibly upward and outward over the right maternal thigh ; this causes the right shoulder of the fetus to descend well into the pelvic canal ; the index and middle fingers of the right hand are then passed up to the right scapula and along the dorsal surface of the arm past the elbow ; the latter, still unflexed, is pried forward into the hollow of the sacrum, so that the arm holds a position directly in front of the fetal face ; flexion of the arm is then secured by passing the finger through the elbow-joint and making steady downward traction until the latter appear at the vulvar orifice ; then by the process of extension the forearm may be delivered. The body of the child is then grasped by the right hand in the same manner as before, and carried well upward and over the left maternal thigh, while the fingers of the left hand repeat the maneuver already described, and the anterior arm is delivered. The head must then be delivered by one of the usual methods. The following rule may be formulated for the delivery of the extended arms in breech presentations : The arms must 426 A MANUAL OF OBSTETRICS. always be carried toward the anterior or abdominal surface of the fetus, and that arm must be first delivered which occupies originally a position nearest the anterior fetal surface. ^g) Nuchal or Dorsal Position of the Ann. — Occasionally, during traction upon the fetal body after version or in the delivery of a breech presentation, the anterior arm is not only displaced upward, but is at the same time carried backward by a forward rotation of the body ; it thus comes to occupy a flexed position across the occipital region of the head or is lodged at the nape of the neck (Fig. 105). Treatment. — There are two possible methods of treating this condition : (i) It may be possible to correct the malposi- tion by gently rotating the body in the opposite direction from that pro- ductive of the displacement. (2) The better method is to carry the fetal body downward over the edge of the bed, at the same time passing the Fig. io5.-Dorsai displacement finger uudcr the Symphysis and up of arm. . j i j r the child's back until the elbow is reached ; into this the finger is hooked and the arm swept outward and in front of the fetal face, where it is to be delivered as under the ordinary circumstances. In rare cases, when the arm is firmly fixed in this unnatural posi- tion, fracture may be justifiable in order to disengage it. A similar displacement of the arm may occur, though with much less frequency, in cephalic presentations. The arm becomes extended by the side of the head with the forearm flexed and carried back of the occiput, the hand resting in the hollow between the scapulae. This consti- tutes an absolute obstacle to the progress of labor. It can be discovered only by digital exploration. Trcatmetit, — ABNORMAL BREECH PRESENTATIONS. 427 As in the preceding instance, two methods of treatment are suggested : (i) It may be possible to cause extension of the arm by sweeping the forearm over the occiput, thereby changing the presentation into the complex one of both hand and head. (2) By far the preferable method is the immediate performance of podalic version and deliver}^ of the fetus as in the case of a breech presentation. {li) Backivard Rotation of the Occiput in Breech Presenta- tions. — This is a very rare complication of a breech presen- tation in which the occiput fails to assume a position under the symphysis pubis, but, instead, rotates into the hollow of the sacrum with the face directed toward the pubis. This results from a failure of the after-coming head to undergo the normal slight degree of extension on entering the pelvic inlet ; remaining flexed, the brow first strikes the pelvic floor and advances under the symphysis pubis. In the delivery of the head under these circumstances two posi- tions maybe encountered: (i) The head may remain firmly flexed, the nape of the neck becoming fixed in front of the perineum ; in this case the treatment consists in resting the fetal back upon the left arm while the fingers of the right hand are passed over the shoulder, flexion being secured by pressure upon the chin ; the fetal body is then carried downward over the side of the bed, the chin, face, brow, and anterior fontanel appearing in rapid succession from under the symphysis pubis. Should it become necessary to apply forceps with the child in this position, the body must be raised and supported by an assistant while the forceps are applied to the head from beneath ; by elevating the handles the occiput will be made to sink into the hollow of the sacrum. (2) In rarer cases an extension of the head occurs, so that the face is directed upward, and as traction is made upon the fetal body the protruding chin is caught by the inner and upper surfaces of the symphysis and the delivery of the head is arrested. Treatment now consists in carrying the fetal body upward over the maternal ab- 428 A MANUAL OF OBSTETRICS. domen, while pressure is exerted with the disengaged hand upon the head through the abdominal wall immediately above the symphysis pubis ; as this is done the external occipital protuberance, the posterior fontanel, the vault of the cranium, and, finally, the face, will emerge- from under the perineum. Management of the Arms in Baekivard Rotation of the Occiput. — If the arms remain flexed upon the thorax, they can be readily reached under the symphysis and delivered by the process of extension ; should they be- come extended by the sides of the head, the lack of space under the symphysis pubis will not permit an anterior sweep of the arm unless the fetus be considerably under size. Again are two methods of treatment suggested : (i) Gener- ally, under these circumstances, the hand should be intro- duced into the vagina and the bisacromial diameter of the thorax caused to assume an anteroposterior position, so as to bring one arm to the rear, when it may be delivered in the ordinary method ; the remaining arm may then be swept over the face and delivered as before. (2) Michaelis" method consists in passing the hand back of the child until the elbow is reached ; this is then grasped and drawn down- ward and backward, after which the forearm is pushed down over the thorax and caused to appear at the vulva ; this maneuver may be repeated upon the opposite side. {i) Malpresentations due to Imperfect Flexion of the Head. — Any deviation of the fetal head from its normal position of extreme flexion upon the thorax alters the form of the fetal ellipse and results in various malpresentations. According to the degree of extension that occurs will de- pend the variety of the presentation that will be produced. If there be but a slight reduction of the normal flexion, the bregma presents ; if the head occupy a position midway between full flexion and full extension, there results a pres- entation of the brow, while if it become completely ex- tended, the face engages in the superior strait. Presentation of the Bregma. — This is a very rare cephalic PRESENTATION OF THE BREGMA. 429 presentation in which the head is set squarely upon the shoulders, sufficient extension having occurred to bring its longitudinal axis into a right angle with that of the body. Vaneties. — It is possible for this presentation to occupy any of the four cardinal positions, with the frontal portion of the head directed to the right or left and ante- riorly or posteriorly. The diagnosis is not difficult. Vaginal examination reveals the bregma at the center of the plane of the superior strait, with the sagittal and frontal sutures extending therefrom in one or the other oblique pelvic diameter; the supraorbital ridges may be felt far up and anteriorly or posteriorly in an oblique diameter according to the position of the brow. Fetal Diameters Involved. — In such a presentation the occipitofrontal (11%^ cm., or 4.6259 in.) and biparietal (qY^ cm., or 3.6417 in.) diameters are brought into relationship with the diameters of the superior strait. Steps of the Mechanism. — This presentation may present the following mechanism : i . Engagement of the head in the superior strait; 2. Slow and difficult descent of the head to the pelvic floor; 3. Anterior rotation of the brow, accomplished only with great difficulty and with much damage to the maternal soft parts. Owing to the extensive dilatation of the upper portion of the vagina by the large fetal diameters the perineum begins to rupture long before the head has descended sufficiently to touch it, and this laceration not only involves the perineal body itself, but extends through the sphincter ani and for an inch or two up the rectovaginal septum; 4. Birth of the head by propulsion and partial extension, the parts emerging as in face presentation; 5, Delivery of the shoulders and remain- ing portion of the body in the normal manner. Treatment. — Should the diagnosis of the abnormal presentation be made before the beginning of labor, or, at least, before en- gagement of the part, cephalic version must at once be per- formed according to Baiidelocqne's method. This consists in introducing one hand — that corresponding to the fetal 430 A MANUAL OF OBSTETRICS. back — into the vagina, the woman being anesthetized and the membranes ruptured ; the thumb is placed upon the frontal region of the head, while the remaining fingers are passed over the external occipital protuberance ; by a " ratchet movement " the occiput is caused to descend while the anterior portion of the head is displaced upward ; at the same time the head is pushed slightly upward into the uterine cavity, counterpressure being exerted upon the fundus uteri. If the head be well engaged, the forceps must be applied and anterior rotation accomplished, care being taken to protect the perineum as far as possible. Presentation of the Brow. — This is probably, next to that of the bregma, the rarest of cephalic presentations, occur- ring in about % of i per cent, of all cases. In it the head occupies a position upon the shoulders midway between complete flexion and complete extension. Etiology. — This presentation may be produced in two distinct ways : In the first place, anything that will prevent a perfect flex- ion of the head upon the thorax will so alter the relations of the arms of the lever (see the etiology of vertex presen- tations) that the bulk of the head will lie slightly behind the longitudinal axis of the body ; consequently, a slight excess of the resistant force will be directed against the posterior portion of the head, and the chin will leave the thorax ; in other words, there is almost a balancing be- tween the amount of force directed against the anterior and posterior arms of the lever, the latter being but slightly longer than the former. Among the causes that will pre- vent a complete flexion of the head may be mentioned en- largement of the fetal thorax, as by an intrathoracic tumor ; the presence of certain anterior cervical tumors, as an hypertrophied thymus-gland ; tonic contraction of the pos- terior cervical muscles ; according to some authorities, a rigid contraction of the cervix around the neck, thereby dis- placing upward the chin, and an excessive coiling of the funis around the neck, may result in the same anomaly of flexion. PRESENTATION OF THE BROW. 43 1 Secondly^ anything that will favor extension of the fetal head will conduce to this disturbance of perfect flexion. Among such causes may be mentioned under- size with con- sequent undue mobility of the fetus ; any tumor of the fetal back or posterior cervical region, as one of the forms of meningocele or spina bifida ; an obliquity of the child in ntcro or of the uterus itself (Duncan), so that the fetal el- lipse lies obliquely with the abdominal surface directed downward, as may result from various forms of pelvic deformity, the flat rachitic pelvis {e. g.), the center of grav- ity of the fetal body being so displaced as to shorten the anterior arm of the lever ; sudden evacuation of the liquor amnii ; an abnormally elongated occipital portion of the fetal head (dolichocephalic skull — Hecker) ; catching of the occiput above the pelvic brim ; and an over-distention of the maternal bladder, causing a retrodisplacement of the fetal body. Finally, a brow presentation may result from any condition that will interfere with a normal engagement of the head, as overgrowth of the child or some exostosis or other tumor occluding the pelvic inlet. Varieties. — There are four possible positions of the brow — namely, with the frontal bone situated to the left or the right and anteriorly or posteriorly. Diagnosis. — The diag- nostic points of these positions of a brow presentation are as follows : (i) The brow anterior and to the left, leftfronto- anterior ; symbol, L. F. A. (Fig. 106). Vaginal examination reveals the brow directed anteriorly toward the left acetabu- lum; above may be felt the large fontanel with the frontal suture running downward and backward in the plane of the right oblique pelvic diameter; posteriorly may be felt the supraorbital ridges and the depressions of the eyes. The chin lies far up to the rear, beyond reach, and directed toward the right sacroiliac synchondrosis. Abdominal palpation reveals the fetal back to the left side, with the extremities above and directed toward the right side. The head is inclined partially backward toward the fetal 432 A MANUAL OF OBSTETRICS. back, hence palpation will reveal a groove between the head and back, closely resembling but not so deep as that found in a face presentation. The shoulders lie in the left oblique Fig. 106. — Brow presentation, L. F. A. ?"iG. 107.— Brow presentation, R. F. A. diameter, the right anterior, and directed toward the right acetabulum, while the left shoulder lies toward the left sacroiliac synchondrosis. The fetal heart-sounds may be heard on the left side below the umbilicus. They may be detected with about equal distinctness upon either surface of the fetal body. (2) The brow anterior and to the right, riglit frontoantc- rior; symbol, R. ¥. A. (Fig. 107). Vaginal examination re- veals the brow directed anteriorly toward the right acetabu- lum, with the bregma far up above and the frontal suture extending in the line of the left oblique pelvic diameter ; posteriorly, toward the left sacroiliac synchondrosis, are the supraorbital ridges, with the chin far up beyond reach. Ab- PRESENTATION OF THE BROW. 433 dominal palpation reveals the fetal back to the right side, with the extremities above and to the left. The shoulders lie in the right oblique diameter, the left anterior, and di- rected toward the left acetabulum, while the right shoulder lies toward the right sacroiliac synchondrosis. The fetal heart-sounds may be heard umbilicus. on the right side below the Fig. io8. — Brow presentation, R. F. P Fig. 109. — Brow presentation, L. F. (3) The brow posterior and to the right, right frontopos- terior ; symbol, R. F. P. (Fig. 108). Vaginal examination re- veals the brow directed posteriorly toward the right sacro- iliac synchondrosis, with the bregma above and the frontal suture extending in the line of the right oblique pelvic diam- eter; anteriorly toward the left acetabulum are the supraor- bital ridges, with the chin above beyond reach. Abdominal palpation reveals the fetal back to the right side, with the extremities above and to the left. The shoulders lie in the left oblique diameter, the left anterior, and directed toward 28 434 ^ MANUAL OF OBSTETRICS. the right acetabulum, while the right shoulder lies toward the left sacroiliac synchondrosis. The fetal heart-sounds may be heard on the right side below the umbilicus. (4) The brow posterior and to the left, left frontopostcrior ; s}'nibol, L. F. P. (Fig. 109). Vaginal examination reveals the brow directed posteriorly toward the left sacroiliac syn- chondrosis, with the bregma above and the frontal suture extending in the line of the left oblique pelvic diameter; an- teriorly toward the right acetabulum are the supraorbital ridges, with the chin above and beyond reach. Abdominal palpation reveals the fetal back to the left side, with the extremities above and to the right. The shoulders lie in the right oblique diameter, the right anterior, and directed toward the left acetabulum, while the left shoulder lies to- ward the right sacroiliac synchondrosis. The fetal heart- sounds may be heard on the left side below the umbilicus. Diagnosis when the Head is Above or At the Pelvic Brim. — It is very common in brow presentations in which engagement of the head has not occurred, to find the frontal suture occupying the transverse diameter of the superior straft, with the brow to the right or left and the supraorbital ridges and eyes at the opposite extremity of this diameter. Fetal Diameters hivolved. — In the presentation of the brow the greatest diameter of the fetal head — the occipitomental (13^ cm., or 5.3150 in.) — offers at the plane of the supe- rior strait. It is obvious that under the most favor- able circumstances — namely, with the chin anterior, the head small, and the pelvis roomy — the labor must be pro- tracted, while, should the chin occupy a posterior position or the pelvis be contracted even to a minor degree, a natural delivery is impossible from inability of the presenting por- tion to reach the pelvic floor and thus rotate anteriorly. Steps of the Mechanism. — In the anterior positions of the chin (R. F. P. and L. F. P.) the following are the possible stages in the delivery of the head: i. Prelinunary flexion and monlding. On account of the unfavorable presentation PRESENTATION OF THE BROW. 435 of the head this stage of the mechanism is much protracted, and, indeed, often unaccomphshcd. It is not a rare occur- rence for the labor-pains to have persisted for twenty- four or thirty-six hours without engagement of the part. In some cases, however, under the influence of the uterine contractions, the fetal head will be so altered in shape by the excessive moulding that its engagement becomes pos- sible. 2. Slozu descent of tJie broiu to tJie pelvic floor, accom- plished through the agency of the forcible uterine contrac- tions and with much suffering to the mother. 3. Anterior rotation of the chin (which first strikes the pelvic floor ante- riorly) tinder the symphysis : the chin rotates from left to right in R. F. P., and from right to left in L. F. P. presentations ; the occiput now lies in the hollow of the sacrum, while the infe- rior maxilla rests upon the symphysis. 4. Propulsion and delivery of the head by a process of partial flexion followed by a counter-movement of extension. For this to take place the neck and body of the child must begin to descend in the pelvic canal before the head has emerged from the vulvar orifice ; hence ensues increased retardation of labor with added risk of perineal and vaginal lacerations. The order of delivery of the cephalic portions is as follows : id) The occiput emerges from under the perineum as the flexion of the head is increased, {b) the head extends as the perineum retracts, and the brow, the upper maxilla, the mouth, and the chin emerge in succession from under the symphysis pubis. 5. Restitution, as in the case of the vertex, the head rotating from right to left in R. F. P., and from left to right in L. F. P. presentations. 6. External rotation of the head due to anterior rotation of the shoulders (from right to left in R. F. P., and from left to right in L. F. P. presenta- tions). 7. Delivery of the arms and body as in normal vertex cases. Prognosis of Broiv Presentations. — The prognosis at the best is doubtful for the mother and grave for the fetus. One child in three will perish, while the maternal mortality is about 10 per cent The causes of maternal death are exhaus- 436 A MANUAL OF OBSTETRICS. tion ; sepsis from operative manipulations and laceration of the parturient canal; and shock. Fetal death is produced by fatal compression of the skull, with asphyxia; the accidents of labor, as prolapse of the cord (a common complication of brow presentation) ; and some grave obstetric opera- tion (difficult forceps-application, craniotomy). It must be remembered, however, that not infrequently a presentation primarily of the brow may spontaneously be converted into that of the face or of the vertex ; in fact, every case of face presentation was at one stage of its development one of the brow. Unfortunately, this spontaneous version cannot be depended upon. The configuration of the fetal head after a prolonged labor with a brow presentation is quite typical. There is an immense caput succedaneum occupying the entire frontal region of the head, and of such a size as to completely overshadow the face ; the eyes are swollen and the lids closed and highly edematous ; the mentofrontal and occipitofrontal diameters are vastly increased in length. This change in the shape of the head is produced by com- pression of the posterior portion of the skull between the fetal back and the maternal symphysis pubis. Treatment of Broiu Presentation. — So serious are the con- sequences of this mechanism of labor, even when the most favorable circumstances are offered, that every effort of the accoucheur must be directed toward its alteration into one more favorable for both mother and child : especially for- tunate is it if the case be diagnosed before labor or before actual engagement of the presenting part have occurred, for then can be instituted measures attended with but com- paratively little risk. The management of a brow presen- tation may be stated as follows: i. Postural treatment, the woman being placed upon that side toward which the face is directed in order to secure perfect flexion of the fetal head upon the body. This method is of service only before the onset of labor. 2. The performance of ceplialic version. Be- fore engagement of the head has occurred it is generally PRESENTATION OF THE BROW. 4^y a simple matter to transform a brow presentation into one of the vertex. There are two methods by which this may be accomphshed : (a) The woman being anesthetized, ver- sion may be performed by external manipulation alone, downward pressure being exerted upon the occiput to secure perfect flexion of the head, while the body of the child is inclined in the direction toward which the fetal face is directed, (d) This failing, Baudelocque's method, as de- scribed in the management of presentation of the bregma, will generally succeed. This variety of cephalic version being impracticable should the brow be posterior and the chin an- terior, an effort may be made to convert the presentation into one of the face. This is performed by reversing the " ratchet- movement " of Baudelocque's method, the occiput being displaced upward, while downward traction is made upon the chin and mouth, if need be a finger being inserted into the latter in order to secure a firm hold. The body of the child should at the same time be carried in the direction toward which the fetal back is directed to secure complete extension of the head. 3. T/ie peffonnance of podalic ver- sion. Efforts at cephalic version proving futile, the next aim should be to secure a presentation of the pelvic ex- tremity of the fetal ellipse. To accomplish this, the hand should be introduced into the uterine cavity that, held mid- way between pronation and supination, will correspond to the fetal abdomen ; one or both feet may be grasped and dragged downward, the disengaged hand at the same time pushing upward through the maternal abdominal surface the cephalic extremity of the fetus. This procedure is con- traindicated by engagement of the brow in the superior strait or pelvic canal and by complete escape of the liquor amnii some hours previously ; under either of these circumstances the performance of podalic version would jeopardize the in- tegrity of the uterine walls. 4. Application of the forceps. Forceps are to be employed as a tractor in those cases only in which the brow is posterior and the chin anterior; they 438 A MANUAL OF OBSTETRICS. must never be so employed in frontoanterior positions, but merely as a rotator. 5. Should it be impossible in these cases to secure anterior rotation of the chin, and the fetus still be living, symphysiotomy may be performed, and the child then delivered by forceps. 6. Craniotomy is indicated when all other methods have failed and the child is dead. Craniotomy and Cranioclasm. — Craniotomy is an ob- stetric operation — a variety of embryotomy — in which the size of the fetal head is diminished by cutting or crushing the bones after evacuation of the cranial contents, when de- livery of the fetus by other means is impossible. The ope- ration is an -easy one, requiring not more than fifteen or twenty minutes for its performance. It should never be done, however, without professional consultation. Indica- catioiis for the Operation. — Craniotomy is indicated when the following conditions exist: i. Position of the head above the superior strait when other operative procedures are inexpedient. 2. Fetal death, as evidenced by absence of the heart-beat or absence of pulsation in the funis for at least ten minutes. A living child can generally be delivered by some other obstetric operation not neces- sitating the destruction of its life ; fetal life should there- fore be regarded as a contraindication to the performance of craniotomy. 3. Occasionally an over-size of the fetal head from intracranial disease, as hydrocephalus. In a case of this nature, if the condition be positively diagnosed, the destruction of fetal life may not be objectionable. This involves a serious question, however, and it should be re- membered that aseptic puncture of the fontanel with evacu- ation of the watery accumulation within the skull will con- siderably diminish the size of the head without necessarily proving fatal to the child. Instruments Required. — The nec- essary instruments include a volsella forceps, a perforator, a cephalotribe or basiotribe, a craniotractor or cranioclast, a vaginal syringe (the Household), and a hard-rubber catheter. There should be prepared a quantity of mercuric chlorid CRANIOTOMY. 439 solution (l : 2000) and of carbolized water (i : 40). The perforator or transforator is a scissor-like instrument with a cutting edge upon the external margins of the blade, and a sharp point ; a shoulder at the upper extremity of the blade prevents too deep penetration of the instrument, and by approximation of the handles of the instrument the blades are separated. Those most commonly em- ployed are Blot's perforator (which is so constructed that it cannot injure the maternal tissues) and the Smellie or the Hodge scissors. The ccphalotribe {basiotribc) or licad- crusJier is a heavy two-bladed instrument employed to crush or compress the fetal skull after evacuation of the cranial contents ; a blade is applied to either side of the cranial vault, and the handles are then approximated by means of a powerful screw ; if properly applied, the rigid base of the fetal skull may by this instrument be crushed and all ob- struction to fetal delivery removed. The instrument serves equally as well for the purpose of traction after compression. Those most commonly used are Karl Braun's, Braxton Hicks' (Fig. no), Tarnier's, and Lusk's. The craniotractor Fig. iio. — Cephalotribe of Hicks. {cranioclast) or Jicad-seizcr is an instrument intended to grasp a portion of the crushed skull and maintain such a hold that traction may be made and the head delivered. It consists of two blades, one of which is introduced within the cranial cavity through the perforation made in evacu- ating the cranial contents ; the other blade grasps the head externally ; by pressure upon the handles not only is a firm 440 A MANUAL OF OBSTETRICS. grasp secured, but injury to the maternal tissues is pre- vented, the exposed blade sinking into the tissues of the skull : there is but little danger of slipping, and should a portion of the skull be torn away, another portion may be grasped and the traction completed. The most common craniotractors employed are those of Karl Braun and Hirst. It is essential for proper and easy manipulation that the instrument should possess not only the cephalic, but the pelvic curve as well. Steps of the Operatiou. — i. The patient must be etherized and placed in the litliotoiuy position, with the hips extending beyond the edge of the bed ; the bladder and rectum must be thoroughly emptied. 2. Vaginal asepsis must be secured by means of a douche of warm mercuric-chlorid solution (i : 2000). 3. Fixation of the Head and Scalp. — This may be accomplished by an assistant steadying the head from above through the abdominal wall, while with a volsella forceps the scalp is grasped close to the point of operation, and slight outward traction made. 4. Cranial Perforation {transforation'). — The index finger of the left hand must be passed up to the cervix and a fontanel or suture located ; in case of a face presentation, perforation must be made through the most accessible orbit : it occasionally happens that none of these soft structures of the skull are within reach, as in lateral deviation of the head, and then it becomes necessary to perforate a bony plate, as one of the parietal bones ; in such an emergency extreme watchfulness is necessary to avoid slipping of the perforator, with con- sequent injury to the uterus or other maternal structure. According to Lusk, the instrument is less prone to slip if it be kept close to the .symphysis pubis. 5. Eidargement of the perforation, accomplished by opening the blades (by approximation of the handles), the instrument at the same time being rotated from side to side. 6. Disorganisation of the Brain-mass. — The perforator is passed up into the cerebral tissues and moved freely about in all directions in CRANIOTOMY. 441 order to destroy the continuity of the brain-mass ; special care must be observed to destroy the tissue at the base of the skull and thus ensure fetal death. 7. Deccrcbration {excerebratioii), by intracranial injections of warm carbolized water. 8. Cnisliing of the Sknll ; CepJialotripsy {Basio- tripsy). — The blades of the cephalotribe are applied in the same manner as those of the obstetric forceps, the left first, the head at the same time being steadied by an assistant, who exerts downward pressure through the abdominal walls. Fig. III. — Tarnier's ba- Fig. 112. — The first blade of Fig. 113. — The second blade siotribe in action : the per- the basiotribe has crushed the of the basiotribe has crushed forator is in place, as is occiput, and the second blade the sinciput. also the first blade. is applied. One of the blades, depending upon the pelvic diameter in which the head is resting, must be rotated upward and the instrument locked. Compression to the desired amount 442 A MANUAL OF OBSTETRICS. may be slowly made and the head delivered (Figs. 1 1 i-i 13). Very often the operator will find that after evacuation of the cranial contents the head will collapse to such an extent that it may be delivered by the craniotractor, crushing being rendered unnecessary. The eighth step of the operation, then, is extraction of tJic head by the craniotractor. One blade of this instrument is introduced through the cranial perfora- tion and passed upward until it grasp the base of the skull ; the outer blade is then applied directly over the ear or the face, and steady traction exerted, the vagina being guarded from injury by the fingers of the left hand. In some cases of great difficulty comminution of the skull becomes necessary, portions of the cranial bones being broken off by the cra- FiG. 114. — Craniotomy on the after-coming head : one method of perforating (Dickinson). niotractor. When this is done the utmost care is required to avoid laceration of the maternal soft parts by the sharp spiculae of bone. 9. Extraction of the trunk, either manually or by the craniotractor. Perforation of the After-conwig Head. — Occasionally, in breech presentations complicated by hydrocephalus or in PRESENTATION OF THE FACE. 443 those cases of contracted pelvis in which an unwarranted ver- sion has been performed, with ultimate inability to deliver the after-coming head, it becomes necessary to resort to cra- niotomy (Fig. 1 14). The operation in such a case is generally unattended with difficulty, the steps being as follows : i. An assistant grasps the fetal body and carries it upward and over the maternal abdomen. 2. Perforation. — This may be accomplished in one of two ways according to the position of the occiput. When the latter is anterior under the sym- physis pubis, the perforator may be introduced through the anterior portion of the neck and the hard palate ; if the occiput occupy a posterior position, an incision may be made through the skin at the nape of the neck and the perforator entered to one or the other side of the foramen magnum, or in other instances back of the ear. Other Methods of Craniotomy. — i. Easily sis. — This is a rarely-employed form of craniotomy in which the base of the skull is broken up by means of a heavy screw-shaped instrument introduced in the vicinity of the sphenoid bone. The operation is attended with considerable difficulty and danger — hence its disuse. 2. CcpJialotoviy or Lamination. — This consists in the removal of the head in portions or slices ; it is likewise a rarely-employed method of craniot- omy. The size of the head may be diminished by excision of a wedge-shaped section of the skull, or the entire skull may be halved and removed piecemeal. The operation is in no way superior to the generally adopted method of per- foration and crushing. Presentation of the Face. — Face presentation is by no means a very rare complication of labor : its frequency is stated at one-half of i per cent., or about twice that of the brow. The head occupies the position of complete exten- sion, the occipital portion of the skull being in close contact with the shoulders. Etiology. — This condition is induced by a disturbance of the relationship existing between the long axes of the body and head, so that the larger portion 444 A MANUAL OF OBSTETRICS. of the latter lies behind, rather than anterior to, the spinal column ; as a consequence the head as it engages in labor is extended instead of undergoing the normal process of flexion. The factors productive of this abnormal relation- ship are precisely the same as give rise to a presentation of the brow, acting, however, to a more absolute degree. The very generally accepted view is that this change occurs after the actual initiation of labor, but before engagement of the head in the superior strait. Varieties. — As for the other pres- entations, there are four possible positions for the face to as- sume — namely, with the most dependent portion, the chin, directed anteriorly or posteriorly and to the right or the left. Diagnosis. — (i) The chin anterior and to the left, left- mentoanterior ; symbol, L. M. A. (Fig. 115). This position Fig. 115. — Face pi-i;;,cnt.aion, L. M. A. Fig. 116. — Face presentation, R. M. A. is the second in order of frequency, owing to the right ob- liquity of the pelvis which is common to this presentation. Vaginal examination reveals a flattening of the vaginal vault with a high situation of the facial features — the orbits. PRESENTATION OF THE FACE. 445 malar processes, nose (the nostrils indicate the side of the pelvis toward which the chin is directed), and the mouth with its alveolar processes — the chin being directed ante- riorly and to the left acetabulum, and the hard rounded brow and frontal suture occupying the opposite extremity of the right oblique pelvic diameter toward the right sacroiliac synchondrosis. No fontanels can be detected. The mem- branes project well down into the vagina. Abdominal pal- pation reveals the fetal back directed posteriorly and to the right side, with a firm, hard, round mass — the cranial vault — just below, the two being separated by a characteristic deep groove; upon the opposite side of the abdomen, just above the pelvic brim, may be detected a soft body corresponding to the fetal neck and thorax. The shoulders lie in the left oblique diameter, the left anterior and directed toward the right acetabulum, while the right shoulder lies toward the left sacroiliac synchondrosis. The breech generally occu- pies a position upon the same side of the abdomen as the cranial vault, while the extremities are directed toward the left side of the maternal abdomen. The fetal heart-sounds may be best heard below the umbilicus and over the ante- rior surface of the fetal body — that is, on the left side of the maternal abdomen ; they cannot be detected over the dor- sum of the fetus, in strong contradistinction to a vertex presentation, in which the heart-sounds cannot be heard at all, or only indistinctly, over the anterior surface, but are quite distinct over the posterior aspect of the fetus. (2) The chin anterior and to the right, riglit vienioante- rior ; symbol, R. M. A. (Fig. 116). — This is the third posi- tion in order of frequency. Vaginal examination reveals the chin directed anteriorly toward the right acetabulum, with the brow posterior toward the left sacroiliac syn- chondrosis and the frontal suture corresponding to the left oblique pelvic diameter. Abdominal palpation reveals the fetal back directed posteriorly and to the left side, with the groove between the occiput and fetal dorsum below, just 446 A MANUAL OF OBSTETRICS. above the pelvic brim ; the breech is above to the left side, with the extremities directed toward the maternal right side. The shoulders lie in the right oblique diameter, the right anterior and directed toward the left acetabulum, while the left shoulder lies toward the right sacroiliac synchon- drosis. The fetal heart-sounds may be heard best below the umbilicus upon the right side of the abdomen. (3) The chin posterior and to the right, right uieiito- posterior ; symbol, R. M. P. (Fig. 117). — This is the most Fig. 117. — Face presentation, R. M. P. Fig. 118. — Face presentation, L. M. P. common position of face presentation : the preponderance of R. M. P. and L. M. A. positions may be explained by the right obliquity of the uterus. Vaginal examination reveals the chin directed posteriorly toward the right sacro- iliac synchondrosis, with the brow anterior toward the left acetabulum and the frontal suture corresponding to the right oblique pelvic diameter. Abdominal palpation reveals the fetal back directed anteriorly to the left side, with the groove rRESENTATION OF THE FACE. 447 between the occiput and fetal dorsum below, just above the pelvic brim ; the breech is above and to the left side, with the extremities directed toward the maternal right side. The shoulders lie in the left oblique diameter, the right anterior and directed toward the right acetabulum, while the left shoulder lies toward the left sacroiliac syn- chondrosis. The fetal heart-sounds may be heard best below the umbilicus upon the right side of the abdomen. (4) The chin posterior and to the left, left mentoposterior ; symbol, L. M. P. (Fig. 118). Vaginal examination reveals the chin directed posteriorly toward the left sacroiliac syn- chondrosis, with the brow anterior toward the right ace- tabulum and the frontal suture corresponding to the left oblique pelvic diameter. Abdominal palpation reveals the fetal back directed anteriorly to the right side, with the groove between the occiput and fetal dorsum below and just above the pelvic brim. The breech is above to the right side, with the extremities directed toward the mater- nal left side ; the shoulders lie in the right oblique diameter, the left anterior and directed toward the left acetabulum, while the right shoulder lies toward the right sacroiliac synchondrosis. The fetal heart-sounds may be heard best below the umbilicus upon the left side of the abdomen. Differential Diagnosis of Face Presentations. — Not infre- quently, in protracted labors with the face presenting, the great edema of the presenting part may, with inexperienced observers, lead to an error in diagnosis, and the condition be mistaken for a presentation of the breech. By a careful digital and abdominal exploration, with special reference to the points noted under the diagnosis of presentations of the pelvic extremity of the fetus (see page 149), the accoucheur may avoid such an error. Fetal Diameters Involved. — In face presentations the frontomental (8 cm., or 3.1496 in.) and the bimastoid (7^ cm., or 3.0018 in.) diameters offer at the superior strait. While the frontomental diameter may correspond to one or the other oblique pelvic diameter, it is 448 A MANUAL OF OBSTETRICS. not uncommon for the face to present transversely in the superior strait ; during the progress of labor this becomes altered, so that the head descends obliquely. The MccJianisni. — Only when there occurs an anterior rotation of the chin does labor become possible, and not infrequently, even under this most favorable circumstance, a considerable degree of dystocia may be experienced. A persistent mentoposterior position is an absolutely impos- sible labor. A face presentation should, therefore, always be regarded as a dangerous complication of parturition, and its progress must be closely watched if it be found imprac- ticable to convert the presentation into one more favorable to both mother and child. The gravity of the presentation lies not in the impossibility of delivery — for in mentoante- rior positions spontaneous delivery is by no means uncom- mon, and the labor may even be one of remarkable ease — but in the vastly increased fetal and maternal risks. Steps of the Mecliaiiisni. — In a normal delivery of a face presenta- tion the following steps in the mechanism may be noted : I. Complete extetision of the head upo)i the shoulders. It must be remembered that in the process of development all cases of face presentation pass through the various stages of extension from presentation of the bregma through that of the brow, until the extension becomes absolute, with the occiput in close apposition with the dorsum of the fetus. The greater portion of the face then lies posteriorly to the axis of the vertebral column, and, as the fetal body is impelled forward by the uterine contractions, the brow encounters the main portion of the resistance to labor, and extension of the head is completed with the chin oc- cupying the most dependent position. 2. Moulding of the face. A certain amount of moulding occurs during the process of extension. Owing to the firm ossification of the facial bones and sutures the moulding is accomplished with difficulty, and the characteristically long delay in the en- gagement of the face may be thus explained. 3. Lateral PRESENTATION OF THE FACE. 449 inclination of the head, with the anterior cheek farther down the pelvic canal than the posterior ; there is a backward inclination of the chin in order that the presentation may- accommodate itself to the pelvic cavity. 4. Dilatation of the soft parts. 5. Descent of the face to the pelvic floor ^ accomplished by the uterine contractions, together with a stretching of the fetal neck. Normally, the fetal neck from the chin to the sternum measures 4 cm. (1.5748 in.) ; under the stimulus of the maternal expulsive efforts this may pos- sibly be stretched from 7^ to 9 cm. (2.95275 to 3.5433 in.), and the chin thus be brought into contact with the pelvic floor. 6. Anterior rotation of the chin under the symphysis pubis in accordance with the cardinal rule of internal rota- tion, the occiput sinking into the hollow of the sacrum. In L. M. A. presentations the chin rotates from left to right anteriorly, and the brow and occiput from right to left pos^ teriorly ; in R. M. A. presentations the chin moves from right to left anteriorly, and the brow and occiput from left to right posteriorly. It is upon the complete and successful performance of this step of the mechanism that the possi- bility of labor hinges. The impossibility of spontaneous delivery in the majority of persistent mentoposterior posi- tions lies in the inability of the chin to strike the pelvic floor. If, from under-size of the fetal head or excessive roominess of the pelvic canal, anterior rotation be accom- plished in these cases, the chin after a considerable delay rotates slowly from right to left anteriorly in R. M. P. pres- entations, while the brow and occiput rotate from left to right posteriorly; in L. M. P. presentations the chin moves from left to right anteriorly, and the brow and occiput from right to left posteriorly. 7. Delivery of the head by a pro- cess of flexion. The chin engages under the symphysis pubis, and the face begins to appear at the vulvar cleft, the malar bones occupying the position between the pubic rami, and the upper portion of the head resting upon the peri- neum. As the latter retracts the chin emerges from under 29 450 A MANUAL OF OBSTETRICS. § 3 O. 'o u o a n he external occipital pro- tuberance. h. rt c rt u J.: J= > u X rem under the retracting peri- neum. K >,^ H H " H H s CQ H N ro -^j- Ut 1 .S g o u X s J3 t3 O i o n 2 c >^ u T) o (rt XI > llJ pa 1 ^ ^ 4) X. j: X ^1 X ^-^ H H H H H H » N m 4- lA b 3 o o u .J. a " ^ I. (^ "B V « . X u o .g o o c o 0} 0) e X c1 rt ri 0) S •£ ^ rt H j: J= X X £ X s 5 g ° " a u. 1 H H H H H V ' § >< X •S 3 •s ^ rt •" d. i o Pi IS . 3 O u i o E p. a 3 • X 5 X 6 E (U X c X O Ch X. R a> 0) aj 1> 4J .— ^ rt Vf j= X X X X E - 2 £ " c ^ ^'^ H H H H H C3 H N ro Tj- lO b 3 a III O . rt lA i- to O. Mi U X rt e «> S ^ = •>.. O 5 ^ 3 -U O f^ E -g %^ XX E 5. «■ ■5^ -i; .5 .« c X .-= ^ H H H H > m Ht n ro 4 .A vd tt. 3 O. "o IS o . X rt E X X 'c V o .| " a s.s 3 ;u x. "n 4) C a 3 . X .-t: 3 o E V X X ^1 3 o -• rt E ess £ Ji 3 jj >. '^ H r-i H H H '' 03 "' « m **■ .A u. •110 If •Sui -iV lUS9.iJ ■poi/PW •3311V.IV, //''> ./■V;./^ -XV3ice versa; the opposite hand is introduced into the vagina, while the index and middle fingers enter the cervical canal and rest upon the presenting shoulder; (4) the external hand presses the head downward and inward, while the fingers within the cervi.x press upward and outward ; the head generally adjusts itself to the pelvic brim quickly and with an almost audible snap; (5) rupture of the membranes; (6) delivery by the forceps. Hold's method of cephalic ver- sion is essentially the same as the preceding, with the ex- ception that the internal hand is that corresponding to the VERSION, OR TURNING. 469 head, upon which the external hand makes pressure, an assistant at the same time pressing the breech in the direc- tion primarily occupied by the head. (2) Pelvic version, or version by the breech, is a turning of the fetus by which a presentation of the pelvic extremity of the fetal ellipse is induced. Complete podalic version has very largely supplanted this method. Indications. — Version by the breech may be indicated under certain circumstances, thus : {a) Minor degrees of pelvic contrac- tion in which speedy delivery is not required; {b) presen- tations of the trunk in which the breech is nearest the plane of the superior strait, and therefore more readily caused to present ; the membranes must be intact, the abdominal walls relaxed, and the child freely mobile. Methods. — Two methods of performing pelvic version are described : {a) External manipidations , the steps of the method being as follows: (i) The patient is placed in the dorsal decubitus with the limbs somewhat flexed ; (2) the physician stands to the left side of his patient with his face directed to the head of the bed ; (3) the breech is pressed downward and inward and the head upward and outward, all manipulations being made in the intervals between the pains, {b) The combined method of Braxton Hicks, as described under cephalic version, the breech, however, being brought down instead of the head. (3) Podalic version, or version by the feet, is that variety in which the fetus is caused to rotate through a quarter or half of a circle, and one or both feet are brought down into the parturient canal. Indications. — This very com- monly employed variety is indicated in a number of con- ditions, as follows : {a) Malpresentations of the head when attempts at cephalic version have failed ; {b) transverse presentations of the fetus ; {c) minor degrees of pelvic contraction, the conjugate diameter of the superior strait being reduced from 9^ to 8 cm. (3.7401 to 3.1496 in.); in these cases it must be remembered that symphysiotomy 470 A MANUAL OF OBSTETRICS. may give better results; (<^/) placenta pr^evia; (^) anything indicating speedy delivery, as threatened maternal or fetal death from grave pathologic states (heart-failure, aneurysm, advanced tuberculosis, eclampsia) or from the accidents of labor (uterine rupture, accidental hemorrhage, funic prolapse) ; (/) sudden death of the mother. Contraindica- tions. — The contraindications to the operation are three in number: {a) Engagement or impaction of the presenting part ; {b) tetanic contraction of the uterus with ascent of Bandl's ring ; {c) extreme contraction of the pelvis. Con- ditions Favoring the Operation. — The conditions making the performance of podalic version easy are — [a) Dilatability of the cervix ; {b) tenuity of the abdominal walls ; {c) the pres- ence or the recent escape of the liquor amnii ; {d) a large pelvic capacity. Conditions Unfavorable to the Operation. — Should any of the following conditions exist, the operation becomes one of extreme difficulty : {a) Rigidity of the cer- vix uteri ; (b) congenital or acquired atresia of the cervix, vagina, or vulva ; {c) tetanic contraction of the uterus, as after the administration of ergot or in neglected cases ; {d) any increase in the bulk of the uterine contents, as in multiple pregnancy or when a fetal monstrosity presents ; (e) fixation of the fetus in the uterine cavity, as after escape of the liquor amnii ; (/) spasmodic contraction of the ab- dominal muscles from any cause (hysteria or eclampsia) ; [g) obesity of the patient. Advantages. — The reasons why podalic version is preferable in the properly selected cases are — {a) It permits of a rapid delivery ; {b) it may be per- formed early in labor. Dangers. — There are, however, some dangers to both mother and child in its performance. These are — (i) Maternal. — {a) Sepsis may follow the introduction of the hand into the uterine cavity, especially if proper pre- cautions be not observed ; (/;) rupture of the uterus may occur from injudicious haste in the operation ; (r) laceration of the cervix is not uncommon, since the operation is fre- quently performed before complete dilatation has been ac- VERSION, OR TURNING. 471 complished ; (c/) subsequent metritis and endometritis have been noted from injuries received during the necessary ma- nipulations. (2) Fetal. — Injury or death of the fetus may occur during the necessary traction. Methods. — Podalic ver- sion may be performed by the combined and the internal methods. The combined., bipolar, or B r axto n Hicks' method. — In this meth- od not only are the fin- gers introduced into the uterine cavity, but the manipulations are as- sisted by pressure ex- erted upon the fetal ellipse through the ab- dominal walls. Advan- tages. — This method is to be recommended for the following reasons : {a) It may be performed early in labor ; (^) there is a minimum of danger of sepsis ; (r) the danger of uterine rupture is less than in internal version. Steps. — The operation includes — (i) Complete anesthetiza- tion (etherization) of the patient, with evacuation of the bladder and rectum. (2) Thorough asepsis of the vaginal and cervical canals. (3) The Position. — The patient should occupy the dorsal position at the side of the bed, while the operator sits facing her. (4) TJie Internal Hand. — The generally accepted rule is to introduce into the vagina and uterus "the hand that midway between pronation and supi- nation will correspond to the fetal abdomen ; " thus, if the latter be directed to the maternal left side, the right hand Fig. 131. — The first step of bipolar podalic version : two fingers within the cervix lift the head toward the iliac fossa, while the breech is crowded over toward the other ilium (Dickinson). 475 A MANUAL OF OBSTETRICS. should be employed internally, and conversely. (5) The In- troduction of the Hand. — The internal hand and arm to the elbow, after thorough lubrication, should be slowly intro- duced into the vagina until two or three fingers enter the cervical canal (Fig. 131). The membranes, if intact, should not be ruptured. (5) First Step of the Version. — Dis- placement of the Presenta- tion. — This varies with the position of the fetus. If the liead present, it must l)c made to extend — that is, it must be pushed in the direction toward which the occiput is pointing ; thus, in the L. O. A. and L. O. P. positions the head is pressed toward the left maternal side, while in the R. O. A. and R. O. P. posi- tions it is displaced to the right. Simultaneously the , , , , , external hand inclines the Fig. 132. — Bipolar version: the shoulder and arm are pushed along; the breech is pushed brCCCh in the OppOsitC di- downward (Dickinson). ,. jr , recti on. If a transverse position exist, the shoulder should be displaced in the direc- tion of the head. (6) Second Step of the Version. — Displace- ment, as before, of the shoulder (in cephalic) and of the thorax and abdomen (in transverse presentations), together with further downward displacement of the breech. (7) Third Step of the Version. — Rupture of the membranes if these be still unruptured, and traction upon an extremity, the knee or foot (usually the former) being seized, the ex- ternal hand now directing the head upward. (8) Version being completed, delivery of the fetus by traction upon the extremity, as in an impacted breech presentation. VERSION, OR TURNING. 4?:-, Internal podalic vcj'sion is that form of podalic version in which the entire hand is introduced into the uterine cavity. Indications. — This operation becomes necessary when there has occurred an escape of the hquor amnii some time before Fig. 133. — Bipolar version ; the knee is almost within reach, the head is pressed upward (Dickinson). version is attempted. Dangers. — The risks attendant upon its performance are — [a) Increased liabiHty to sepsis, from introduction of the hand into the uterine cavity; [b) uterine rupture from such a considerable addition to the bulk of the uterine contents. Steps. — The steps of the operation in- clude — (i) Complete anesthesia; the bladder and rectum must be emptied. (2) Thorough vaginal and cervical asep- sis. (3) The Position. — The patient lies in the lateral posi- tion at the side of the bed : she is placed upon that side toward which the fetal feet are directed, thus favoring a low position of the latter, so that they become more acces- sible. (4) T/ie Internal Hand. — The same rule is adopted 474 ^ MANUAL OF OBSTETRICS;. as in the preceding method. (5) Introduction of the Hand. — The hand and arm, well oiled, are introduced into the vagina and the fingers into the cervix, counterpressure being maintained by the external hand over the fundus uteri. Should a uterine contraction occur, manipulations must cease until it have passed, when the hand should be advanced over the fetal abdominal surface and the knee grasped and hooked down, so as to bring the foot into ready reach ; in transverse presentations the latter is more accessible than in head presentations. (6) The foot is grasped in such a manner that the heel corresponds to the palm of the hand, and downward traction is made until the knee passes the vul- var orifice, the head at the same time being pressed upward by the external hand ; the anterior foot is the one that is usually seized, for the simple reason that it is the most accessible. It will suffice, and in fact is preferable, to bring down one foot only ; by so doing, with the foot grasped as described, an anterior position of the breech is secured, while the untouched limb, holding its position upon the fetal abdomen, tends to more thorough dilatation of the OS. (7) The administration of the ether is stopped, the pa- tient is placed in the recumbent posture, and the further progress of the case is left to the natural forces unless there exist some indications for speedy delivery. If it be desira- ble to terminate labor at once, both feet must be seized and the child extracted speedily. Complications. — There are certain conditions that may render the operation very difficult. These are — (i) Cervical Rigidity. — A rigid condition of the cervix may result from the employment of ergot during the early stages of labor ; it may exist as an accompaniment of the prematurity of the labor ; or it may be a natural condition, as in elderly primipar.ne. Usually it will disappear under thorough anesthetization, with the gradual introduction of one or more fingers arranged in the shape of a cone ; the smaller sizes of Hegar's dilators may be required to begin the dilatation. (2) Acqinred or Con- EMBR VOTOMY. 475 gejiital Atresia Vagiiice. — This frequently constitutes almost an insuperable obstacle to the introduction of the hand. If an entrance cannot be effected by gradual dilatation, numer- ous deep incisions in the vaginal wall will be necessary, and any hemorrhage that may result must be controlled by the usual methods. (3) Prolapse of an Arm. — Ordinarily, this cannot be regarded as a complication in the performance of the version ; it does not prevent the introduction of the hand, and may even be of service in facilitating the opera- tion. As the pelvic extremity is brought down, the arm rises with the thorax into the pelvic cavity : in order to favor this movement Galabin formerly suggested that the foot of the opposite side to that of the presenting arm should be seized ; he claimed, though erroneously, that more room is thus afforded for the ascent of the arm ; in point of fact, as is now generally admitted, the leg of the corresponding side is more easy of access, and version by this limb is more readily performed. To prevent extension of this extremity by the side of the head the following ma- neuver may be adopted : A piece of tape is secured around the fetal wrist and allowed to project from the vulva ; during the delivery of the abdomen and thorax this tape should be held taut, so that the arm is carried in front of the face and descends with the shoulders. (4) Difficulty of Rotation. — In some cases in which there has occurred a complete escape of the liquor amnii, followed by more or less rigidity of the uterine and cervical tissues, the fetus will be firmly grasped by the uterine walls, and traction upon the foot does not accomplish a rotation of the child. As a rule, this difficulty rnay be overcome by slipping a loop of tape over the ankle ; upon this traction may be exerted through the vulvar orifice, while the internal hand pushes the head and shoulders in the direction of the fundus. Embryotomy. — Embryotomy is a term given to an ob- stetric operation employed for the purpose of reducing the size of the fetus in order to render possible its transmission 4/6 A MANUAL OF OBSTETRICS. through the parturient canal. It embraces the operations of craniotomy (see page 438), evisceration, decapitation, and amputation of the extremities. 1. Evisceration {Excnteratioji). — This term indicates the opening of a body-cavity, thoracic or abdominal, and the removal of the contained viscera. Indications. — Such a mutilating operation is required — {a) when there occurs an impacted presentation of the abdomen ; {b) in certain fetal monstrosities. Instninioits. — The instruments re- quired for its performance are a pair of strong, straight scissors about 8 inches in length and having the handle turned downward, and a blunt hook. Steps of tJic Opera- tion. — The steps of the operation are — (i) Pressure by an assistant from above or traction upon a limb in order to secure as dependent a position of the presenting part as is possible : (2) Introduction of the index and middle fingers of the left hand as far as the cervical canal to serve as a guide ; (3) Passage of the scissors along the palmar surface of these fingers and perforation of the abdominal or thoracic parietes ; (4) Introduction of a finger or the blunt hook through the perforation and removal of the viscera by mor- cellement : the trunk-walls will then collapse ; (5) Traction upon the pelvic extremity of the fetus in order to facilitate its delivery. If this cannot be accomplished, spondylotomy or rachiotomy (section of the spinal column) may be per- formed by means of the scissors, the fetus being delivered as in corpore reduplicatio. 2. Decapitation {Decollation^. — Division of the fetal neck in labor when neither spontaneous delivery nor delivery by version is possible. Indications. — There are but three conditions in which decapitation may become necessary. These are — (i) Impaction of a shoulder presentation with high position of Bandl's ring ; (2) a twin presentation with locking of the chins; (3) certain fetal monstrosities. Instru- vicnts. — A decollator is required — usually Ramsbotham's sharp hook or Braun's blunt-hook (Fig. 134); as substitutes EMBRYOTOMY. 477 may be used a pair of scissors or a piece of twine or of flexible wire, which, being passed around the neck, may sever the latter by a sawing movement {Pajofs method^ ; a Sims speculum is also necessary. Steps of tJie Operation. — Theoperationconsistsin — (i) Traction by an assist- ant upon the prolapsed arm or other protruding portion. (2) Insertion of the hook around the neck and severing of the latter by a combined sawing movement with downward traction : if scissors be em- ployed, the index finger of the left hand must be passed around the neck and the latter snipped through from below up- ward. (3) Traction upon the prolapsed member, the trunk and extremities slipping out of the partu- rient canal. (4) Delivery of the Head. — This may be accomplished by hooking the index finger into the orifice at the base of the head and drawing it down to the orifice of the cer- vical canal, when pressure head may cause its escape Fig. 134. — Decapitation with Braun's hook (Dickinson). from above and traction on the This failing, the cephalotribe may be introduced and the head seized and extracted. 3. Amputations of the Fetal Extremities. — The removal of one or more limbs of the fetus in order to permit of its escape from the parturient canal. Indication. — This ope- 478 A MANUAL OF OBSTETRICS. ration is indicated only in certain forms of fetal monstros- ities. Fetal death or nonviability must be assured before the operation is performed. Instnivicnts. — A strong pair of scissors is all that will be required. Steps of the Opera- tion. — (i) The offending member must be dragged down so as to be rendered as accessible as possible ; (2) by short snips the tissues must be divided and the part then extracted. Mortality of Embryotomy. — There is no reason why there should be any maternal mortality in this operation, pro- vided it be performed at a proper time. There can be no doubt that the exhaustion consequent upon unsuccessful attempts at forceps-delivery, version, or traction before the mutilation of the fetus is responsible for most of the deaths. After-treatment of Embryotomy. — After the removal of the fetus thorough asepsis of the parturient canal must be ob- served, and the patient treated as after a normal labor. (/) Complex, Compounel, or Complicated Presentations. — These terms indicate a simultaneous presentation of two or more fetal parts ; thus, there may occur a presentation of the head and a hand ; the head and a foot ; a foot and a hand ; or, in transverse cases, the head and thorax. In multiple pregnancy a part of each fetus may present, giving a variety of compound presentation that will be treated of under the subject of plural births. The usual treatment of such a condition as this is the delivery of the main part first. Thus, if the head or hand present, the latter should, if pos- sible, be pushed back, and the head delivered by means of the forceps. Should a foot and a hand present, podalic version is the proper course to pursue in order to avoid a prolapse of the arm with resulting shoulder presentation. {in) Superimpregnation ; Mjiltiple or Plural Pregnancy ; Plural Births. — That form of pregnancy in which the gravid uterus contains two or more fetuses. This subject includes the two analogous conditions that have been termed, re- spectively, superfetation and supcrfccundation. By super- fetation is meant a supposed fertilization of an ovum when PLURAL BIRTHS. 479 there is another from a previous ovulation in uterogestation. There has been, and still is, considerable doubt as to the possibility of such an occurrence, and it may be stated that a second conception, if such a thing be possible, usually occurs within the first few days after the primary concep- tion — that is, before the formation of the decidua : an ex- planation may thus be afforded for those cases occasionally encountered in which a woman gives birth to two children, one of which is white and the other black. Another theory in explanation of this phenomenon, and one that is prob- ably more rational than the preceding, is that the semen has been deposited at two coitions occurring within a short period, but that the impregnation of the two ova has oc- curred at the same time ; the well-recognized fact that sper- matozoa retain their vitality in the female genitalia for a number of days after their deposition there renders such an occurrence not only possible, but very probable. The oc- currence of superfetation at an advanced stage in the devel- opment of the primarily fertilized ovum seems, however, to have been proved by remarkable cases reported by Bonnar, Fordyce Barker, and Tyler Smith, and quoted by Playfair and Lusk. In these cases, within a few weeks or months after the birth of the first child, a second fully-developed fetus was discharged. The subject is an interesting one and worthy of further investigation. By supcrfeciindation is meant the fertilization of more than one ovum of the same ovulation resulting from one or separate acts of coitus. This develops into a variety of twin pregnancy. A hvin or gcincllary pregnancy is one in which two fetuses are developed simultaneously in ntcro ; this occurs once in about 130 cases of gestation. When three fetuses are developed together they are termed triplets, and this occurs once in about 5688 pregnant women. Mira- beau ^ states that the more fertile a community — that is, the larger the number of multiparous women — the more com- ^ Ueber Drillingsgebiirten, Miinchen, 1894. 480 A MANUAL OF OBSTETRICS. mon are triple births; thus, in Russia the ratio is i in 4054 pregnancies ; in Sweden, i in 4400 ; in England, i in 4600 ; in Germany, i in 7129; and in France, i in 8256. Triple births are more common in muciparous women between thirty and thirty-four years of age, and the pregnancy is usually preceded by a long interval of sterility. Four chil- dren at a birth are termed quadruplets, and this will take place, according to Veit, only once in 371,126 pregnan- cies ; a set of five children at a birth is termed quintuplets ; and six offspring from a single gestation — one instance of which has been reported in Italy — are termed scxtuplets. Causes of Tzvin Pregnancies. — A predisposing cause of mul- tiple (twin) pregnancy may, according to Duncan, be stated to be primiparity, the greatest number of reported cases having occurred in first pregnancies ; in women who have once given birth to twins, however, there seems to be an increasing tendency to repeat the performance in subse- quent gestations. Another predisposing cause is family heredity, remarkable instances of multiple pregnancy having occurred in successive generations of a given family. The actual cause of multiple pregnancy varies in different cases : thus, it may result when two Graafian follicles, situated in the same ovary or one in either ovary, arrive at full maturity and rupture simultaneously, and the ova thus discharged undergo fertilization at or about the same time. In other instances one Graafian follicle expels two mature ovules, both of which become impregnated simultaneously ; or, finally, but one ovule may be discharged from a Graafian follicle, it having, however, two nuclei, both undergoing simultaneous impregnation ; this is termed the unioval origin of twins. According to the origin of the ova will arise the peculiarities in the development of the membranes and fetal appendages. Thus, if two ova from separate Graafian folli- cles are fertilized, there will result an independent devel- opment of both ; each will have its own placenta, cord, chorion, and amnion, and each will carry on a distinct PLURAL BIRTLIS. 48 1 intrauterine existence. The placentae, though they may be in close apposition, do not present vascular anastomoses. This condition has been termed placenta obsolcta. Should the two ovules have a common origin in a single Graafian follicle, the amniotic sacs will be distinct, but there will exist a chorion and a placenta in common, the two umbili- cal cords arising from the same placental structure. Finally, in those cases in which the twin pregnancy results from a single binucleated ovule, one placenta is formed with two cords, the fetuses being invested by a common chorion, but a distinct amnion. It occasionally happens that through abrasion by the fetal limbs or from some other cause the partition between the two amniotic cavities is ruptured : fetuses of this variety of twin gestation then erroneously appear to possess a common amniotic sac. Triplets commonly arise from two ova, one of which was binucleated and hence gave origin to two fetuses instead of one ; in this case there will be two placentae and two sets of membranes, the one containing two embryos, each with a distinct amnion, but a common chorion, and the other containing one embryo with a normal arrangement of the membranes. It is possible, however, for each fetus to be provided with independent membranes. The distribution of the sexes varies : in general, twins arising from a common ovum (unioval twins) are of the same sex, while those generated by distinct ova are of opposite sexes. Clinically, it has been found that, as a rule, the fetuses are of opposite sexes (about 38 per cent.) ; this failing, they are both likely to be males (34 per cent.), and, least frequently, both females (28 per cent.). Diagnosis of Multiple Pregnancy. — The diagnosis of this interesting condition, if it be made at all, must be accom- plished by digital exploration and by abdominal palpation and auscultation : in very many cases, however, the very first intimation of the unusual condition is the appearance of the second fetus during labor. The signs that may be 31 482 A MANUAL OF OBSTETRICS. elicited by external examination are as follows: i. By aus- cultation, the presence of tivo fetal lieart-sonnds. There may be heard at different points over the abdominal surface, it may be upon opposite sides, heart-sounds either of the same or different rates and intensities, and separated by an interval of space over which they cannot be heard at all, or only very indistinctly. This is a very valuable sign of multiple pregnancy, but by no means absolutely diag- nostic. Thus, in the case of a large fetus, thin maternal abdominal walls, or a deficient quantity of liquor amnii, the heart-sounds may be heard with more or less distinct- ness over the entire surface of the abdomen. Again, there may be present m titero two fetuses, one of which may be dead or so situated that the heart-sounds of but one can be transmitted to the listener's ear. 2. Auscultation may also reveal tzvo distinct placental sonffles. This is a sign of but little value. 3. Palpation reveals a number of signs of more or less value in formulating an idea of the existing condition. These signs are as follows : {a) Excessive size of the abdonie/i, with increased tension of the uterine walls and but slight fetal mobility : this is a suggestive sign ; {b) irregularity in the o'utline of the nterus, with abnormal increase in its width ; at times there may be detected a sulcus, longitudinal or transverse, indicating the space be- tween the fetal bodies : this is not diagnostic ; {c) the presence of a number of fetal extremities or parts : this is a sign of considerable value. If it be possible to palpate three or more fetal limbs, or the cephalic or pelvic extremities of two fetuses, as a head above and one below, or if a smooth, rounded dorsal curve may be detected in two distinct situa- tions, very conclusive evidence is afforded that more than the usual number of fetuses are contained in the uterine cavity. Again, if a head can be clearly outlined near the pelvic brim, and the maximum point of intensity of the fetal heart-sounds be found at some point above the umbilicus, it is probable that the two belong to different fetuses ; {d) inspection of the PLURAL BIRTHS. 483 abdomen may show the presence of a certain amount of edema of the region immediately above the pubis. This is depend- ent upon venous stasis, the result of the pressure exerted by the immensely distended gravid uterus upon the pelvic veins. It is not pathognomonic, however, as it is seen as well in extreme hydramnios. 4. The vaginal signs of mul- tiple pregnancy. There are no characteristic changes in the vaginal symptoms in this condition. Occasionally, after cervical dilatation has well advanced there may occur a simultaneous presentation of two bags of water, which sign, of course, would be absolutely diagnostic. Prognosis of Multiple Pregnancy. — This may be consid- ered from a maternal and from a fetal standpoint. The maternal prognosis is somewhat graver than in uncompli- cated gestation. The dangers are — (i) Uterine inertia, with prolongation of labor and subsequent tendency to post- partum hemorrhage ; (2) abnormal presentations, as of the shoulder or trunk ; (3) during pregnancy serious pressure 2ipon the ureters, resulting in the retention of effete matters in the blood, with the production of the kidney of pregnancy or even of eclampsia. So frequently is albuminuria present in a twin gestation that by many it has been regarded as almost a diagnostic symptom of that condition ; (4) prema- ture exp2ilsion of the ovum. It has been found that in about 25 per cent, of twin pregnancies labor occurred prematurely. T\\& fetal prognosis is much more serious than is the mater- nal : the mortality rises to 8 or 10 per cent, or more, and this mortality is higher when the fetuses are of unioval origin. The dangers to the fetuses are as follows: (i) De- ficient development from insufficient nutrition and lack of proper room. Owing to the crowded condition of the uterine cavity, proper play is not afforded the fetal limbs ; the lack of intrauterine gymnastics results in poor muscular develop- ment of the limbs and of the entire body. The average weight of twin children has been found to be about five or six pounds. It is not unusual for one fetus to manifest a 484 A MANUAL OF OBSTETRICS. greater degree of development than its fellow, and if this superiority of size occur at an early period in pregnancy, the impetus thus gained may attract to the larger and stronger fetus more than its share of nutrition ; as a natural consequence, the smaller fetus is progressively crowded to one side of the uterine cavity, and finally perishes : the pressure increasing with the growth of the surviving fetus, the deceased twin mummifies, and finally becomes com- pressed between its fellow and the uterine wall, until at term it has a thickness little greater than that of stout parch- ment : hence its name — -foetus papyraceus. After the death of the fetus it may be discharged instead of undergoing the process of mummification, and its fellow continue to full term. Putrefaction of the deceased ovum has even been known to occur /// iitero without deleterious effects upon the surviving fetus. (2) TJic fonnation of monstrosities. Owing to the intimate relationship existing between the developing ova, especially in the case of the unioval variety, it is not uncommon to find one or both of the fetuses presenting some variety of malformation. This is generally brought about by a complex anastomosis between the vascular elements of the fetuses and of the placentae. Thus, by a damming back of the circulation in the weaker fetus the entire direction of the blood-current may be reversed, an atrophy of the heart occur, and an acardiac monster result. Again, in the unioval variety of twins, should the division of the formative material be incomplete, there will be devel- oped various forms of double monstrosities according to the degree of interference with the process. (3) An increased tC7idcucy to diseases of the niendn'anes. Hydramnios is a not infrequent complication of multiple pregnancy resulting from some interference with the circulation of the parts. (4) Ufa/positions and nia/presentations. Transverse presen- tation of the fetus is quite a common complication of twin gestations: it occurs once in about 22 cases; presentation of the breech is also frequent. PLURAL BIRTHS. 485 TJic Clinical ATanifcstatioiis of Labor in Multiple Preg- nancy. — The labor is precisely like that occurring when but one fetus is contained in ntcro. K's, a rule, it is easy, owing to the inefficient character of the pains — a direct consequence of the extreme distention of the uterine walls and the small size of the fetuses : the first stage of labor, however, is protracted. After the birth of the first child the cord should be ligated and no attempt made to ex- tract the placenta. Within a short space of time — on an Fig. 1J5. — iuiiii, bwLh heads presenting (Dickinson). average not more than from twenty to forty-five minutes — the labor-pains return ; the os, which has partially recon- tracted, dilates and the second bag of water presents ; this second labor, the presentation being normal, is much easier than the first. Upon the delivery of the second child the two placentae appear and labor is terminated. It is unusual for separation of the first placenta to occur before delivery of 486 A MANUAL OF OBSTETRICS. the second child ; hence there is, as a rule, no hemorrhage during the progress of the labor. In those cases, however, in which the two fetuses and their membranes and append- ages are quite distinct, the fetus first presenting may be delivered with its appurtenances in its entirety ; this hap- pening, the interval elapsing before the birth of the second child may be quite protracted, even, though rarely, amount- ing to days or weeks (as in certain reported cases of super- fetation). The third stage of labor is likewise protracted on account of the atonic condition of the uterine walls ; hence the danger of hemorrhage during this stage of the labor and subsequently. Mechanism of Plural Births. — A question of considerable interest concerns the positions occupied by the two fetuses and the order of their de- livery. The possible pres- entations in their order of frequency are as follows (the percentages are those given by Hirst): Both fetuses pre- sent by the head (Fig. 135) in 49 per cent, of the cases ; one presents by the head and one by the breech (Fig. 136) in 31.7 per cent.; both present by the breech in 8.6 per cent. ; one by the head and the other transversely in 6.18 per cent. ; one by the breech and one transversely (Fig. 137) in 4.14 per cent. ; and both transversely (Fig. 138) in 0.35 per cent. The cause of the frequency of abnormal positions (almost 50 per cent, of the cases) is the distortion of the uterine cavity resulting in an increase in its transverse diameter, and lack of room for the Fio. 136. — Twins, he.Td and breech presenta tion (Dickinson). PLURAL BIRTHS. 487 Fig. 137. — Twins, breech and transverse presen- tation (Dickinson). two fetuses in normal positions, the second fetus having to accommodate its position to the space allotted it. When both heads present, they usually lie in the oblique diam- eters of the pelvis, with the occiput anterior (L. O. A. and R, O. A.), more room thus being afforded. The 07'der of delivery also varies. Thus, when both heads present, it is usually the larger that is delivered first; if one presents by the breech and the other by the head, the latter is gen- erally the first expelled ; and if one presents trans- versely and the other lon- gitudinally, again the latter almost invariably appears first. Management of the Labor. — The first child presenting normally, active interference on the part of the accoucheur is not indicated until the delivery of the fetus. After ligation of the cord, if it be found that the uterus con- tains another fetus, a vagi- nal exploration should be made with the object of ascertaining the presenta- tion of the second child. If a transverse position of this fetus be discovered, version, either cephalic or Fig. 138.— Twins, both transverse (Dickinson). podallC, mUSt bc performed, and I or 2 drains of the fluid extract of ergot administered to the mother in order 488 A MANUAL OF OBSTETRICS. to stimulate the exhausted uterus to contract, and nature permitted to terminate the labor. Only when hemorrhage occurs, or when there appear other signs of maternal or fetal danger, should the labor be terminated rapidly by forceps or completed version. If the second labor be unduly protracted, the attendant may rupture the mem- branes and employ frictions over the fundus uteri. After the delivery of the secundines a second large dose of ergot should be administered and a firm compress and abdominal binder applied. The subsequent treatment is that of a simple labor. Conip/ications of Plural Births. — Twin pregnancies are especially liable to the development of perplexing compli- cations during the progress of labor. Among the most important of these may be mentioned: (i) Compound Pres- entations. — Not rarely there may be manifested a tendency for both fetuses to engage simultaneously in the superior strait of the pelvis ; if this should occur, the indication is to favor the descent of the more important part, at the same time retarding the engagement of the other. Thus, there might be found — {a) A double head presentatio7i. In this case the hand may be introduced into the vagina and the head highest in the pelvis pushed back ; forceps must then be applied to the lower head and traction exerted until it become fully engaged, when a return of the complication will be impossible. (J}) Double footling presentation. In a case in which all four feet are found in the parturient canal, those belonging to one fetus should be dragged down, so as to secure a breech presentation of that child, while the extrem- ities of the other fetus may be pushed up to afford room for the descent of the breech, (r) Presentatioti of a head and an extremity. In such a case efforts must be made to displace the limb, while the head should be forced down by pressure from above or by traction with forceps. (2) Malpresenta- tions. — A transverse presentation (occurring in 10 per cent. or more of the cases) mu.st be treated, as in simple labor, PLURAL BIRTHS. 489 by podalic version. (3) Coiling or Tzuisting of the Cords. — Should the cord be coiled around one of the fetuses, pre- venting its descent, efforts must be made to relax it so that the encircled portion may be released : this failing, the cord must be ligated in two places and severed between the two ligatures, and the fetus delivered rapidly in order to avoid asphyxiation. (4) Locking of the Twijis. — A serious complication of multiple pregnancy is that in which the two fetuses become so wedged together that the further advance of either is rendered impossible. This may result in a num- ber of ways : {a) There may be an engagement and inter- locking of both heads. The head of the first child in these rare cases has entered the pelvis ; the head of the second child then engages at the pelvic brim together with the neck of the first child ; further descent causes simultaneous engagement of the thorax of the first and the head of the second child, and these become tightly jammed into the pelvic cavity, so that further progress is arrested. Treatment. — Under these circumstances un- locking is generally out of the question, and craniotomy is indicated upon the head of the second child, with an effort to save the other fetus by means of the forceps ; after its delivery the body of the second child must be extracted. {li) There may be a locking of the head or breech u'ith a transverse presentation. The child presenting in the longi- tudinal axis may have been partially delivered, when further descent is blocked by a partial engagement of the transverse fetus; if this should occur, it will be the head of the first child in a breech presentation, or the shoulders in a cephalic presentation, that will be detained above the pelvic canal, the fetus lying transversely being driven firmly against the neck of the longitudinal fetus in either case. An examination through the vagina, aided by man- ipulations from above, will reveal the condition of affairs. Treatment. — (i) An effort must be made to dislodge the transverse fetus ; if this prove successful, traction upon 490 A MANUAL OF OBSTETRICS. the longitudinal fetus, either by the head or by the feet, will cause its descent; version must then be performed on the second fetus. (2) This failing, if the fetus first present- ing be dead — as shown by absence of pulsation in the cord — decapitation may be performed ; the second child may then be delivered by version, after which the retained portion of the first child must be extracted. (>) prolapse of the cord, or a carrying downward of the cord with the gush of the liquor amnii at the time of the rupture of the mem- branes; (r) expression of the cord, a condition occurring late in labor, and signifying a forcing downward of a loop by the side of the presenting fetal head that has already become engaged. The ultimate result of all these condi- tions is the same; hence they may well be considered together. Frequency. — Funic prolapse occurs about once Fig. 142. — Prolapse of the cord. FUNIC PRESENTATION. 5OI in from 200 to 300 cases of labor ; it is therefore a not very infrequent complication. Etiology. — The causes of the prolapse may be fetal or maternal. The fetal causes are — id) certain malpositions and malpresentations, as posterior position of the occiput; presentation of the trunk, the face, the brow, and the breech ; multiple pregnancy, and complex presentations ; {B) iinder-size of the fetal head, as in prema- ture labor ; («:) anomalies of the fetal appendages, as hy- dramnios ; sudden escape of the hquor amnii, especially when the patient is standing ; excessive length of the cord ; marginal attachments of the cord ; placenta prsevia. The maternal causes are various degrees of contraction of the pelvis, preventing exact coaptation of the presenting part to the pelvic brim ; multiparity (the relaxed abdominal walls permitting a retraction of the presenting part from the pel- vic inlet) ; pendulous abdomen ; uterine fibromata and my- omata, causing malpositions and malpresentations of the fetus ; and lateral obliquity of the uterus. Diagnosis. — As a rule, funic prolapse may easily be recognized after rupture of the, membranes has occurred; prior to the escape of the liquor amnii it is difficult to detect, since the cord, on account of its nonresisting nature, recedes before the examining finger, and is therefore practically out of reach : the main point of diagnosis then lies in the discovery of the pulsations. Even after rupture of the membranes has occurred the cord has been mistaken for a prolapsed loop of intestine by in- experienced observers. The characteristic substantial feel of the cord, together with its appearance, the normal twists, the funic pulse, and the fact that the bowel has a mesenteric attachment while the cord has none, should make such an error in diagnosis almost impossible. The usual position for the cord to occupy is in one or the other side of the pelvic cavity ; very rarely it will lie either in front of the sacral promontory or directly back of the symphysis pubis : in these positions there is increased danger of compression by the fetal parts. Prognosis. — The maternal prognosis is 502 A MANUAL OF OBSTETRICS. not affected by funic prolapse, save that there is an in- creased danger of sepsis consequent upon the manipula- tions necessary in the proper management of the case. The fetal prognosis, however, is very grave, the mortality rising to between 50 and 55 per cent., and being higher in primiparae, in those cases in which the fetus offers by the vertex, in over-size of the fetus, and when rupture of the membranes has occurred early. The cause of fetal death is occlusion of the fetoplacental circulation from compres- sion of the cord, resulting in asphyxiation of the child. Should the funis show an absence of pulsation for a period often or fifteen minutes, and the fetal heart-beats cannot be detected by abdominal auscultation, death of the fetus may be assured. Tj'catincnt. — This is an important matter, vary- ing with the time at which the prolapse has occurred, (i) Prior to Rupture of the Mevibraues. — This is the most favor- able period in which to treat the case, for as long as the membranes are intact there is but a minimum amount of pressure exerted upon the cord and fetal life is not jeop- ardized. The indications for treatment, therefore, are : [a) preservation of the incvibrancs as long as possible ; {6) re- placement cf the prolapsed cord by the postural method. The woman should be made to occupy the genupectoral posture for from twenty to thirty minutes : while in tliis position the cervix uteri is most elevated, while the fundus uteri is placed almost vertically beneath it ; generally under the influence of gravity the movable cord will slowly settle to the fundus, and the abnormal condition will correct itself During the intervals between the pains the cord may be gently pushed back with the hand, care being taken to preserve the integrity of the membranes. Digital exploration showing an absence of the cord, the woman should slowly turn over into the Sims posture, and rest upon the side opposite to that occupied by the funis ; this will favor entrance and engagement of the presentation in the superior strait, when the funic prolapse cannot be FUNIC PRESENTAT/ON. 503 reproduced ; the membranes should then be ruptured and nature allowed to terminate the labor. The advantages of this method of treatment are — {a) Preservation of the mem- branes ; [b) the avoidance of protracted manipulations ; [c) retardation of labor, thus affording the cord an opportunity to recede from its unfavorable position. (2) After Riiptiwe of theMeuibranes. — The indications for treatment, under these circumstances, are likewise two in number — namely, if the fetus be living, replacement of the cord, or, this failing, speedy delivery of the child. If the child be dead, noninter- ference is. the course to pursue, {a) Replacement of the Cord. — Various methods of replacing a prolapsed cord have been suggested: (i) If the patient be seen shortly after escape of the liquor amnii, the postural method may again be of service. In order to succeed with this it will often become necessary to push up the presenting part, that room may be afforded to return the prolapsed cord. (2) The Manual Method. — The patient must be placed either in the Sims or the genupectoral posture, preferably the latter; an anesthetic is unnecessary. The cord is grasped by the fingers, and in the intervals between the pains is replaced within the anterior portion of the uterus by a process of taxis : it should be manipulated as little as possible, to avoid disastrous effects upon the fetal circulation. It should be carried well above the presenting part, that a return of the condition may be impossible. If the maneuver prove suc- cessful, the presenting portion of the fetus must be pressed into the superior strait and retained there by means of a compress and a tightly-applied abdominal binder. (3) The Instrumental Method. — The only instrument required for this operation is a hard-rubber catheter. A counteropen- ing may be made in this, and through the two fenestra a loop of tape passed : if desired, a steel stylet maybe inserted into the catheter, and around it a loop of tape secured ; or, finally, the tape, folded upon itself, may be passed through the instrument, the ends being introduced above at the eye 504 A MANUAL OF OBSTETRICS. and caused to emerge at the upper end of the catheter : whichever method may be chosen, the loop must be long enough to permit of its being hooked over the upper ex- tremity of the catheter after encircling the prolapsed loop of cord. The patient then being placed in the genupectoral position, or, if anesthetized, in the Sims posture, the pro- lapsed cord is secured to the catheter in the manner men- tioneTd, and the whole carried up into the uterine cavity ; the instrument may then be withdrawn, the loop slipping off the upper extremity ; or it may be left in the uterine cavity without fear of danger. As before, the presenting part should be made to engage to prevent a return of the condi- tion. (4) Podalic Version. — The foregoing methods failing, rapid delivery of the fetus is indicated, and this can best be accomplished by podalic version : the condition then re- solves itself into an ordinary breech presentation, and should be so managed. (5) Delivery by the Forceps. — This method is not so favorable for the fetus, but is necessary when the prolapse occurs after engagement of the head. The cord must be placed at that sacroiliac synchondrosis not occu- pied by the fetal head — where it will be least subjected to pressure — and delivery rapidly accomplished by the Simp- son or the axis-traction forceps. {b) Rupture of the funis is a rare complication of labor in which, during the process of parturition, the continuity of the cord is destroyed. The causes of this accident are ab- normal insertion of the cord into the placenta (the velamen- tous insertion or the mesocord) ; unusual shortness of the cord, either a congenital condition or one produced by repeated coiling of the funis about the fetus ; and precip- itate labor, the fetus being expelled while the mother is standing or stooping. It is a serious condition for the fetus, almost invariably resulting in its death from shock or asphyxiation, and but very rarely from hemorrhage. Bleeding does not occur, because of the retraction of the severed vessels and closure of their mouths by an over- PRECIPITATE LABOR. 505 lapping of the jelly of Wharton. Should rupture of the funis occur before the birth of the child, the latter should be delivered speedily either by version or by the forceps. (c) Decapitation of the fetus is a rare accident resulting from too vigorous efforts at delivery of the after-coming head either in a normal breech presentation or after the perform- ance of version. The retained head must be extracted by the forceps or the craniotractor, pressure being exerted from above to hold it secure during the application of the instru- ment. The maternal tissues may be lacerated by spiculae of bone if proper precautions be not observed. [d) Avulsion of tJie Fetal Extremities. — Only in the case of a premature or a partially macerated fetus can an extremity be forcibly torn from the trunk. Should such an accident occur, the remainder of the body must be promptly extracted and an intrauterine douche of a i per cent, solution of creolin given. 2. Maternal Dystocia. The causes of difficult labor, maternal in origin, may be grouped under the four headings — Precipitate labor, Pro- tracted labor, Obstructed labor, and Maternal accidents. (i) Precipitate Labor. — By a precipitate labor is meant one in which the expulsion of the fetus and its appendages from the parturient canal is accomplished with unusual celerity, either with or without much suffering on the part of the woman. Etiology. — This condition can result in one of two ways. In the first place, there may be an exxcss in the expulsive poivers of labor, and, in the second place, these being normal, there may be a deficiency in the resistant poivers ; in either case the fetus is speedily propelled through the parturient canal with more or less detriment to the mother or the child. The increase in the expulsive power may be altogether involuntary — that is, uterine in origin, this being quite rare and onl}' encountered in prim- ipara; — or it maybe more or less voluntary, and is then due 5o6 4 MANUAL OF OBSTETRICS. to excessive use of the abdominal muscles and diaphragm during the second stage of labor. Excessive uterine con- traction may be encountered in young and delicately-con- structed girls, as well as in those of a more advanced age and robust muscular build : it should therefore be consid- ered as a manifestation of superabundant nerve-action of sympathetic origin, rather than an outcome of over-mus- cular development. The deficiency in the resistant forces may be the result of a number of conditions. In the first place, the fetus itself may be at fault : either it is an under- sized and puny child, or else the labor is occurring prema- turely and the fetus has not attained its normal bulk and dimensions. On the part of the mother it may be an out- come of some abnormal condition in the parturient canal. The pelvis itself may be over-sized and roomy; its axis may be unusually straight, as when the normal amount of sacral curve is absent; it may be the seat of certain deformities increasing its caliber above the normal ; or there may have occurred at some previous parturition an extensive lacera- tion of the cervix or of the pelvic floor, so that the advancing child is not directed forward throughout the full length of the parturient canal below the hard structures, but emerges suddenly through an orifice where normally the perineum should exist. The varieties of pelvic deformity conducive to speedy delivery of the child are the justomajor, the split pelvis, the advanced stages of the osteomalacic pelvis (the bones having become so soft that, although considerably distorted, the simple pressure of the child's head is sufficient to straighten the canal, and the fetus is driven forcibly through), and those pelves in which the synchondroses are not possessed of a normal degree of tenacity, so that the pressure exerted by the fetus produces separation of the bones: this is most likely to occur at the symphysis pubis, but the sacroiliac synchondroses may also yield. The justomajor, generally equally enlarged {pelvis icqua- bilitcr justomajor^, or giant pek'is is one characterized by PRECIPITATE LABOR. 507 an over-size of all its diameters, with, however, preser- vation of the normal proportions. Such a pelvis, unless very much above the normal in size, may readily be over- looked. During the progress of gestation in these cases there is very likely to be a marked exaggeration in the pressure-symptoms ; this follows the extreme descent of the uterus into the pelvic cavity, more room being afforded there for its development than is ordinarily the case; an irritable bladder, obstinate constipation, edema of the vulva, and pronounced varicosities may attend the pregnancy. In a split or inverted (Ahlfeld) pelvis (Fig. 143) the de- formity is usually situated at the symphysis pubis, although Fig. 143. — Split pelvis (Schauta). more rarely there may exist a congenital fissure of the sacrum and of the lower portion of the vertebral column. When the defect is situated anteriorly, the innominate bones, from the upward pressure of the femora, are rotated outward and backward, so that there occurs an approximation of the posterior superior iliac spines behind the sacrum, which bone is also displaced inward to a certain extent ; in this way a groove is formed posterior to the sacrum ; hence the name inverted pelvis. Generally the osseous defect is sup- plied by a certain amount of fibrous tissue ; there are often associated other congenital defects, as exstrophy of the blad- 508 A MANUAL OF OBSTETRICS. der. It is rare for conception to occur in this condition, and Klein states that but six such instances are recorded in medical literature. When the sacrum is cleft a meningocele often projects into the pelvic cavity, and this may seriously obstruct labor. Diagnosis of Precipitate Labor. — Occasionally the fetus is expelled with such rapidity — there occurring but one or two pains of any severity — that the condition becomes self- evident. These women are probably apathetic in nature, and, not experiencing much pain, are not aware of the extent to which labor has advanced. In other cases, in which the delivery is not accomplished so speedily, the patient suffers severely from exaggerated intensity of the pains, which are frequent in occurrence and prolonged beyond the normal duration. Vaginal cxauiinatio)i in such cases reveals a steady and rapid advance of the presenting portion, while palpation of the abdomen shows an almost tetanic action of the uterine muscle or a forcible contraction of the abdominal walls. Prognosis. — The consequences of pre- cipitate labor, while often insignificant prove quite serious. The dangers to the fetus are asphyxiation from rupture of the cord or premature detachment of the placenta, and injury from a fall upon the floor or into a commode; the maternal dangers are hemorrhage from premature detachment of the placenta, fatal syncope from sudden evacuation of the uterine contents, inversion of the uterus, laceration of the cervix or perineum, and postpartum hemorrhage. Treatment. — The management of precipitate labor includes the establishment of thorough mental and moral control over the patient, as well as the employment of remedies and measures to reduce the violence of the pains and to resist the too rapid expulsion of the fetus. When the voluntary muscles are brought stronglj' into play, their action may be inhibited by commanding the patient to open her mouth and to avoid efforts at straining. If the pains become exaggerated, especially in the early PROTRACTED OR RETARDED LABOR. 509 stages of labor, they may be reduced in intensity by the judicious administration of small doses of the bromids or of opium, or Playfaifs treatment may be instituted for the purpose of lessening the rigidity of the cervical tissues. This consists in the exhibition of a large amount of chloral hydrate within a short space of time; thus, three doses of 15 grains each may be given at intervals of fifteen minutes. The drug when thus administered deadens the patient's sensibility to a considerable degree, induces rapid softening of the cervical tissues, and renders the woman's condition so much the more tolerable. After the head has reached the pelvic floor, should rupture of the perineum appear immi- nent, the rapid advance of the presenting part may be pre- vented by direct pressure by the thumb of the accoucheur, or Sawyer's short straight forceps may be applied and the progress of the head thus controlled. Occasionally the ra- pidity of the labor may be considerably lessened by placing the patient in the genupectoral position, and while she is thus reclining allowing the child to be born : gravity is called into play here, as the advancing fetus must be driven up an inclined plane (the anterior uterine wall) in order to reach the lower portion of the parturient canal. Only rarely are inhalations of chloroform or ether demanded, and then in exceedingly hypersensitive individuals. (2) Protracted or Retarded Labor. — By a protracted, re- tarded, or tardy labor is meant one that is considerably pro- longed beyond the ordinary limit of normal parturition — namely, from ten to twenty hours in primiparas and from two to six hours in multiparae. Upon the degree of pro- longation and upon the stage of parturition in which it occurs will depend the gravity of the condition, but under all circumstances it is a more or less serious matter, in- volving risks to both mother and fetus. Should the delay occur before the second stage of labor, as in all instances of breech presentation, beyond the increased suffering of the mother usually no untoward effects will follow. Undoubt- 5IO A MANUAL OF OBSTETRICS. edly, an unusual prolongation at this time will render the patient less fit to endure the agong of the more active stages of parturition, and may induce extreme exhaus- tion, and thus, indirectly, some of the graver accidents of labor and the puerperium. Of much more serious im- port is a delay occurring after cervical dilatation has been accomplished : a protracted second stage of labor very gen- erally indicates an insuperable obstruction to the progress of the fetus, and this constitutes not a protracted or hard labor, but a true obstructed labor. The syniptoins of a pro- tracted labor are increasing maternal exhaustion, elevation of temperature, a rapid pulse (i 10-120), nausea and vomiting, restlessness and irritability of the patient, thirst, anorexia, a harsh, dry, and heated feel of the skin, and a decrease or absolute suppression of the quantity of vaginal secretions, the vagina becoming dry, hot, and hypersensitive. The fetus also manifests signs of exhaustion, as indicated by a primary increase in the pulse-rate, followed by a slowing, weakening, and irregularity of the heart's action, and finally by death, if the labor be not terminated. The dan- gers of protracted or obstructed labor are fetal and mater- nal. The fetal dangers are — (i) Asphyxiation from pro- longed compression of the vital centers, from arrest of the placental function by partial separation of that organ, or by a stoppage in its circulation from the tetanic uterine action, or from compression of the funis ; (2) the subsequent de- velopment of an inspiration-pneumonia from spasmodic attempts at respiration while still within the parturient canal : the efforts at inspiration carry into the bronchial tubes irritating material from the uterus or vagina, and pneumonia results. The maternal dangers are — (i) Ex- hau.stion and death ; (2) pre.ssure-necrosis, with the ulti- mate formation of vaginal fistulae communicating with the rectum or bladder ; (3) the development of septic changes from the subsequent atonic condition of the tissues and the operative manipulations that are necessary in order to ter- UTERINE INERTIA. 5 II minate the labor; (4) postpartum hemorrhage, a direct result of the atonic condition of the uterine muscle following a prolonged labor. The cause of protracted labor is some deficiency in the expulsive forces ; in other words, it is the result of what is known as uterine or abdominal inertia. Uterine and Abdominal Inertia. — By ntcrinc inertia is meant that condition in which the uterine contractions are irregular, weak, and ineffectual, not sufficing to induce dila- tation of the OS or expulsion of the fetus. By abdominal inertia is meant a similar condition of the voluntary mus- cles of the abdominal wall, by which the woman is unable to aid the uterine contractions of the second stage of labor by effective bearing-down efforts. Abdominal inertia may be the result of some exhausting disease, as pulmonary tuberculosis or a recent attack of typhoid fever; it may come from a weakened state of the muscles induced by improper hygiene ; or it may follow the inhibitory action of profound emotion, as shame or fear in the presence of the physician, or the intensity of the pangs of labor. Uterine inertia may appear in two forms, the primary and the secondary. The term primary or true uterine inertia designates that condition popularly known as " weak pains," in which from the very outstart of labor the uterine con- tractions have been few and far between, of but slight intensity, and utterly incapable of effecting any material progress in the expulsion of the uterine contents. This is essentially an unimportant condition so far as danger to the mother and child is concerned ; there are no signs of ma- ternal exhaustion, nor does the fetus appear to suffer any inconvenience from its slow progress into the world. In the course of some hours dilatation will be accomplished, the child will commence to descend the parturient canal, and will finally be expelled after two or three pains of some- what greater severity. Secondary uterine inertia, or " uterine exhaustion'' is quite another condition. Here labor has begun in a perfectly normal manner, and has progressed 512 A MANUAL OF OBSTETRICS. through the stage of dilatation, and, it may be, until the fetal presentation is well distending the perineum and causing marked bulging of the vulvar orifice : suddenly the pains, that have been of normal or even of exaggerated intensity, die out, and labor apparently seems to be at an end without the accomplishment of its ultimate purpose — the expulsion of the uterine contents. The woman may even fall into a deep sleep for some hours ; at the expira- tion of this time the pains will return with renewed or even increased severity, and speedy delivery will be accomplished. This is a condition of true uterine exhaustion, quite distinct from that which has just been described, in which at no time has the uterine action been sufficient to induce exhaustion or even a sense of fatigue. Causes of Uterine Liertia. — The etiology of this condition is obscure : {a) Very often no appreciable causation can be discovered, and in such cases the inertia is said to be due to a peculiar idiosyncrasy of the patient, characterized by an apathetic condition of the uterine muscle, which, it may be, shares in a similar condition of the entire system. Such patients will in successive pregnancies manifest the same condition of inertia, and labor in them is unattended with intense suffering; {U) advanced age of the woman; (r) multi- parity : inertia is much more frequent in multiparae than in primiparae ; (^) emotion^ especially in hysteric and neurotic females ; thus the mere presence of the physician is suffi- cient to " frighten away the pains ;" (r) certain local pelvic conditions, as over-distention of the bowel or of the blad- der, which by pressure increase the sufferings of the pa- tient and thereby inhibit the uterine contractions ; (/) temporary paralysis of the uterine muscles from over-disten- tion, as in the case of hydramnios or multiple pregnancy ; {g) any cause preventing tlie hydraulic action of the liquor aninii; thus, should the membranes be more closely adhe- rent than usual, they will fail to bulge to the normal extent into the cervical canal, and this, the most important UTERINE INERTIA. "513 stimulus to uterine contraction, will be absent; [li) it may be that weakness of the uterine muscle from some chronic or severe acute disease, or from poor nutrition the result of improper hygienic surroundings, may contribute to the pro- duction of uterine inertia : such a cause, if it exist at all, is rare. Uterine inertia, like excessive uterine action, seems very frequently to be quite independent of the muscular development of the individual. Clinical Manifestations of Uterine Inertia. — Clinically, a patient the subject of a true uterine inertia presents no symptoms other than a mere weakness of the uterine con- tractions. She is but little incommoded by the advent of her labor, and may even continue upon her feet after thorough dilatation of the os has been accomplished : a so- called precipitate labor may thus be engendered, due not to an actual increase in the expulsive power, but to ignorance on the part of the patient as to the extent to which the labor has progressed. Much more commonly, however, is the labor protracted, and the patient continues to experience her ineffectual pains until an artificial termination be made to her labor. There is no alteration in the pulse-rate, nor does the patient's facies present any trace of suffering. Physical Signs. — Abdominal palpation reveals feeble uterine contraction, lasting but for a few moments, and followed by more or less complete relaxation of the uterine walls. Owing to a similar relaxation of the abdominal walls, the fetal outlines may be very distinct. The straining efforts during the second stage of labor may be entirely absent. Vaginal examination reveals a very slight advance of the presenting part during the height of the feeble contrac- tion, and this will be followed by more or less retraction. Treatment. — The treatment of this condition resolves itself into prophylaxis, and the treatment of the first and of the second stage of labor, i. As regards prophylaxis, it has been clearly demonstrated by such men as Bell, Duff, and Edgar that strychnin administered judiciously during the 33 514' '4 MANUAL OF OBSTETRICS. closing weeks of gestation will so give tone to the uterine muscles and ncr\es, as well as to the entire organism, as to result in powerful uterine contractions during the pro- cess of parturition. Under the use of this drug the appe- tite improves, digestion is facilitated, the bowels become more regular, insomnia is controlled, the circulation is improved, and labor is rendered more normal and less painful. Duff claims that after its use after-pains are not so frequent, and the danger of postpartum hemorrhage is greatly reduced. The strychnin may be administered in doses of from -^ to 2V of a grain three or four times daily. 2. As long as the os is undilated and the membranes unruptured there is no danger to the mother or to the child, and the accoucheur should content himself with inaction, merely making use of such measures as will conduce to the greater comfort of his patient. The old method of stimula- tion of the uterus to more forcible contractions by large doses of quinin not only contributes materially to the nausea, and thus increases the discomfort of the woman, but has failed repeatedly in producing the desired effect. Of much more service is the administration of nerve-seda- tives, as chloral or the bromids, with the observance of rest and quiet and the favoring of sleep. It may be that by pursuing such a course as this the patient's system will be so stimulated that the intensity of the uterine pains may ultimately become materially increased. Food in small quantities at repeated intervals, together with a moderate amount of stimulation, as sherry wine, will also conduce to the same end. In the apathetic variety of inertia, in which the first stage of labor is inordinately prolonged, forcible injections of tepid water against the anterior cervical lip may be resorted to, the proper precautions being observed. Should the inertia be a direct outcome of hydramnios, simple rupture of the membranes will end the trouble, the pains assuming their normal intensity upon the escape of the liquor amnii. The application of a firm abdominal UTERINE INERTIA. 515 binder will often, by straightening the uterine axis, mate- rially shorten the duration of labor, as will also permitting the patient to walk about the room ; the administration of a rectal enema or of a hot sitz-bath, the insertion of Barnes' bags, or the employment of a mild faradic current (one pole being placed upon the posterior cervical lip and the other over the fundus uteri, or, according to Kihicrs nictliod^ one on each side of the uterus at a point midway between the umbilicus and the anterior superior iliac spine) will answer admirably in certain cases. After partial dilatation of the OS has occurred, manual friction of the fundus may be of benefit. The performance of uterine compression [cxprcssio foetus) is highly recommended by Kristeller and Playfair. The patient resting in the lithotomy or ordinary obstetric position at the side of the bed, the uterus is grasped between the palms, and during the continuance of a pain pressure is made downward and backward : in this way the intensity of the pain is considerably increased and the labor thereby materially shortened. The objection to this method is the amount of suffering imposed upon the patient by the process. F"inally, in some cases, other methods failing, it may become necessary to induce active labor-pains in the usual manner — namely, by the introduction of the hard-rubber bougie. A question of considerable interest that arises at this point is as to the advisability of the employment of ergot in these cases of true uterine inertia. Obstetricians of equal merit contend for and against the use of the drug, and it becomes obligatory upon the accoucheur in any given case to decide for himself as to whether or not any permanent advantage may follow its use. It is true that it may be, and has been, administered repeatedly without any subsequent ill effects, but when the possible accidents of considerable gravity to both mother and child that may attend the administration of the drug be taken into consideration, as well as the other less dangerous methods of terminating the labor, the medical attendant may well hesitate before resorting to a measure so 5l6 A MANUAL OF OBSTETRICS. fraught with imminent peril to both of his patients. Briefly stated, these dangers are, to the mother, the possibiHty of the production of irregular uterine contractions, whereby the discharge of the fetus or its appendages may be prevented and uterine rupture become imminent; and, to the fetus, asphyxiation from interference with the placental circulation. Much safer would it be in these cases to give the patient small hypodermic injections of strychnin sulphate, as -^ grain every fifteen minutes until three doses have been taken. Ustilago maidis may be used in dram doses with compara- tive safety : this drug very promptly stimulates the uterine muscle to contract in a normal rhythmic manner quite dis- tinct from the tetanic action induced by ergot. 3. After the sec- ond stage of labor has begun primary uterine inertia always demands prompt termination of the labor by version if the presenting part have not entered the pelvic canal, or by the application of the forceps if engagement have taken place. The artificial efforts at delivery must be made with the uterine pains if the patient be unconscious, or, if she be anesthetized, at corresponding intervals. Such a procedure largely prevents extreme maternal exhaustion and postpar- tum hemorrhage. Secondary uterine inertia, or uterine ex- haustion, on the other hand, is best managed by favoring sleep and by administering nerve-sedatives — chloral, the bromids, or small doses of opium. As soon as the physical strength shall have been recuperated labor will again begin and advance to a normal termination. Artificial delivery under these circumstances is always contraindicated. The Obstetric Forceps. — The obstetric forceps is an instrument devised for grasping the fetal head in difficult labor and by traction aiding its exit. Of all instruments that have been invented throughout the domain of surgery, this is preeminently the most valuable and. the most danger- ous : it is capable of accomplishing infinite good or infinite harm, according as to whether it be properly or improperly employed. Varieties. — Since the original primitive form of THE OBSTETRIC FORCEPS. 517 the instrument, as used by the famous Chamberlen broth- ers, a vast number of modifications have been offered to the profession. These may be grouped under two vari- eties — namely, the simple, including the sliort and the lo7ig, and the axis-traction forceps. A sliort forceps is one in which the blades of the instru- ment are attached directly to the handles without the inter- vention of a shank : it possesses the cranial or ceplialic curve only — that is, the outward bulging of the blades by which its accurate adaptation to the fetal head may be accom- plished ; this curve should be the arc of a circle the radius of which is about 1 1 /^ cm. (4.4291 in.). Probably the best variety of the short forceps is Sawyer's instrument (Fig. 144), which is exceedingly light and very small ; it is not Fig. 144. — Forceps of Sawyer. quite 10 inches in length, and weighs but 5 ounces : with it the head may be lifted from the perineum. Indications for the Use of the SJiort Forceps. — This instrument can be employed only when the head has descended to the pelvic floor; its use is therefore very limited, and the procedure is termed the low forceps operation. Its indications are — (i) To save the perineum when rupture seems imminent ; (2) to accomplish anterior rotation when the occiput remains posterior or rotates into the hollow of the sacrum. The long forceps may be used for the same purposes. The long forceps is one in which a shank is placed be- tween the handles and the blades for the purpose of adding length to the instrument. It has, in addition to the cepha- lic, the pelvic ciirve, or upward turning of the blade, corre- sponding to the curve of the parturient canal. By means 5i8 A MANUAL OF OBSTETRICS. of this curve, the concavity of which is directed upward, the instrument when applied at the superior strait rests in such a position that undue pressure is not exerted upon the perineum and soft pelvic structures. Like the cephalic, this curve should be the arc of a circle having a radius of about 11% cm. (4.4291 in.). Varieties. — The most important varieties of long forceps are the Simpson, the Hodge, the Wallace, and the Tarnier. The Simpson (Fig. 145), which Fig. 145. — Forceps of Simpson. is an English forceps, is steadily gaining in favor, and may be said to have become the most popular obstetric forceps in use. It is about 14 inches in length ; the blades are narrow, but are separated by an interval of 3 inches at their widest point, thus preventing extreme compression of the fetal skull ; the handles are serrated at their outer edges to afford a firm grasp, and are provided, just below the lock, with two shoulders, over which the fingers may be hooked during traction ; the blades are united by the so-called Etig- lisli lock, which consists of a groove at the shoulder of either blade into which the shank of the opposite blade Fit;. 146. — Forceps of Hodge. sinks. The lock is easily adjusted, and the blades are readily .separated as required. The Hodge (Fig. 146) and Wallace forceps are long, slender instruments, with narrow THE OBSTETRIC EORCEPS. 519 blades closely approximated, so that the compressing power of the instrument is much greater than that of the preceding. By an axis-traction forceps is meant a variety of long obstetric forceps in which, by an appliance or supple- mentary handle attached to the under surface of the blades, the traction-force is exerted in the line of the axis of the parturient canal, and therefore rendered more effect- ive, while at the same time it is reduced to a minimum. Traction is effected entirely by the supplementary, and not by the primary handles. The Tarnier axis-traction forceps (Fig. 147) is probably the best of the kind, although any Fig. 147. — Axis-traction forceps of Tarnier (to show the details the hand is represented in an improper position for traction; below is one of the traction-rods). long forceps — as, for instance, the Simpson variety — may be converted into an axis-traction forceps by means of a loop of tape passed through the fenestra made for the pur- pose in the blades of the instrument. This appliance is named, after its inventor, the Poullet tapc-attaclunent, and may be employed when the true axis-traction forceps can- not be had. The special advantages of this instrument are twofold — namely, the traction is exerted in the axis of the parturient canal, and therefore is reduced to the minimum, and the normal movements — flexion and rotation — are not interfered with, since the forceps move with the head. The 520 A MANUAL OF OBSTETRICS. disadi'antagcs are the increased danger of sepsis from the complexity of the instrument and the continued pressure exerted upon the head : the forceps held by the fixation- screw cannot readily be relaxed, as can the ordinary long instrument. Indications for tJic Use of the Long Forceps. — The general indication for the use of this instrument is impaction of the head during the second stage of labor for a period of two hours, the delay resulting from any of the following causes, which are stated in about the order of their frequency : (i) Insufficient expulsive pozvcr, as in uterine inertia (very common), abdominal inertia, or general muscular debility, such as accompanies certain acute or chronic diseases, as typhoid fever or pulmonary tuberculosis. (2) Increased resistance in the parturient canal, as minor degrees of pelvic contraction when the expulsive power is unable to over- come the additional resistance offered (as a rule, the forceps should not be used when the conjugate diameter of the superior strait measures less than 9 cm., or 3.5433 in.); abnormal rigidity of the cervix and other soft tissues ; prolapse of the vaginal walls ; edema of the structures. (3) Oi^er-size of the fetal head, as in prolongation of preg- nancy. (4) Threatened maternal life when more hasty de- livery is not indicated: among these indications may be mentioned — [a) Certain grave maternal diseases, as croupous pneumonia, valvular (mitral) disease of the heart, puerperal eclampsia ; (/;) certai)i maternal accidents, as hemorrhage from marginal placenta praevia or premature detachment of the placenta, sudden .syncope, rupture of the uterus after engagement of the fetal head. (5) Threatened fetal life, the rate and intensity of the fetal heart-beats being taken as the index by which the fetal danger may be recognized : if the heart-beats sink from the normal to 100 or less per minute, and this low rate persist, or if there be an undue rapidity, the pulse-rate rising above 160, the forceps must be applied at once. Among the indications under THE OBSTETRIC FORCEPS. 52 1 this heading may be mentioned funic prolapse, premature placental detachment, and sudden maternal death during the second stage of a labor with a cephalic presentation. (6) Certain abnormal positions and presentations of the fetus, as persistent occipitoposterior and mentoposterior positions ; in the latter case the forceps are used as rotators merely. Contraindications to the Use of the Forceps. — The contra- indications may be maternal and fetal : the maternal contra- indications are — (i) Any mechanical obstruction to the passage of tlie child thro2igh the parturient canal, including fibroma, sarcoma, myoma, or osteoma of the uterus, ovaries, or pelvis ; carcinoma of the cervix ; extreme degrees of pelvic contrac- tion. (2) Noji-dilatation or incomplete dilatation of the os — that is, under three-quarters dilatation — or an iindilatable condition of the cervix. When the os has dilated to at least three-fourths of its full extent it is perfectly justifiable under certain circumstances to introduce the blades of the forceps ; under the traction, aided by the relaxation con- sequent upon anesthetization, dilatation will probably be completed. The dangers of such a procedure are cervical laceration to varying degrees, and premature detachment of the placenta from traction upon the non-retracted mem- branes that may accidentally be included within the grasp of the forceps. (3) A distended condition of the bladder and rectum. The fetal contraindications are — (i) Non-rnpture and non-retraction of tJie membranes : these must always be ruptured before the blades can be introduced. (2) Non- engagemeiit of the presenting part. There is one well-rec- ognized exception to this contraindication — namely, in mar- ginal placenta praevia, the object being the employment of the head as a tampon to arrest the hemorrhage ; it is prefer- able, however, in such cases to at once perform a complete or an incomplete podalic version, thereby controlling the hemorrhage with pressure by the breech ; also in certain minor degrees of pelvic contraction the head may be made to engage by applying the forceps and exerting 522 A MANUAL OF OBSTETRICS. moderate traction. (3) Over-size or tinder-sise of the fetal head. In hydrocephalus the extreme distention of the fetal skull would render the grasp of the forceps insecure, and slipping an almost inevitable accident; an under-sized head would rotate within the blades of the forceps, and the mother be subjected to imminent risk. This would also be true of a head that had been reduced by perforation of the skull with evacuation of the brain-substance. (4) Maceration or decomposition of the fetus. A fetus under- going this process would be readily mutilated or decapi- tated by the traction that is necessary in a forceps opera- tion, and the woman would probably be seriously injured by the sudden escape of the instrument. (5) Assured death of the fetus or the impossibility of delivering a living fetus with the aid of the forceps. (6) Finally, the instriiment must not be employed for the purpose of traction xvlioi the fetus occupies such a position or presents in such a manner that delivery is impossible ; thus, persistent mentoposterior positions and brow presentations contraindicate the use of the forceps. High Forceps Operation. — When the long forceps is ap- plied to the head, situated at or above the pelvic inlet, the procedure is termed the Jiigh forceps operation ; when applied to the head while in the pelvic canal — that is, between the superior and inferior straits — it is termed a median forceps operation. A high operation is always a serious and difficult undertaking, and unless actual engage- ment have occurred or some other contraindication exist, version is the preferable procedure. The disadvantages of such an operation are manifest. In the first place, owing to the transverse position of the head and its mobility, there is secured a vicious grij) upon it; the blades will lie over the occipital and frontal bones, and the dangers of fatal compression of the skull or of slipping of the instru- ment become imminent. The cervix also has failed very generally to become well dilated, and difficulty may be encountered in the introduction, and serious laceration THE OBSTETRIC FORCEPS. 523 produced in this manner. Again, the compression of the head in its anteroposterior diameter causes a correspond- ing increase in its transverse diameter, whereby the proper moulding of the head is prevented. Finally, traction, to be exerted in the axis of the parturient canal, must be made at first backivard and dozvmvard — a difficult procedure save with the assistance of the axis-traction forceps. It is patent, therefore, that both the fetal and maternal dangers are ma- terially increased when it becomes necessary to resort to the use of the forceps before or immediately after engagement of the head has taken place. TJie Uses of the Forceps. — The primary use of the forceps is traction, which is exerted in the axis of the parturient canal. This must always be made with the pains, or, in their absence, as in complete anesthetization, at corresponding in- tervals. In order to avoid slipping of the instrument during this performance a safe rule to adopt is to keep the index finger of the right hand — which is grasping the left hand in the manner hereafter to be described — well extended and just in contact with the fetal scalp; should slipping occur, the finger, leaving the scalp, will indicate the danger and the instrument can be reapplied. In making traction the extent of the force applied should be limited to that which is pro- duced by exercise of all the muscles of the upper extrem- ities from the shoulders down : the muscles of the body or of the lower extremities should never be brought to bear upon the instrument. The forceps may be used to secure anterior rotation of the presenting part when this does not occur spontaneously ; it may be employed as a lever, the handles being swayed from side to side in order to loosen and favor the descent of an impacted head ; this is known as the " pendnhmi movement" of the forceps, the latter being securely locked and a firm grasp on the fetal head maintained in order to avoid slipping. A certain amount of leverage is employed in almost every forceps delivery, but the utmost care is required to prevent perforation of the maternal struc- 524 A MANUAL OF OBSTETRICS. tures. Finally, the forceps may, in certain selected cases and to a limited extent, be used for the purpose o{ compression in order to diminish slightly the size of the fetal head. During the process of traction more or less compression of the fetal skull is necessitated ; hence arises the need of alter- nately relaxing and relocking the instrument in order to simulate as closely as possible the action of the uterine contractions and thereby prevent fatal compression of the fetal brain-centers. It must be remembered that compres- sion of the handles of the instrument is not necessary to maintain the blades in close apposition to the fetal head : this is accomplished by the pressure exerted upon the blades by the structures, hard and soft, of the parturient canal, and any undue efforts at compression only result in compensatory elongation of another diameter of the fetal skull, with increased resistance in this diameter. If proper time be allowed and traction be made slowly, the head will gradually be moulded by the pressure of the walls of the parturient canal, and its delivery will be effected without damage to mother or child. In order to avoid excessive compression of the head a towel may be folded and placed between the handles. Dangers of the Forceps Operation. — There is always more or less danger attached to an instrumental delivery, not only to the mother, but also to the child. The fetal dangers are — (i) Fatal compression of the vital centers, with death from asphyxiation; (2) cerebral injury from compression, resulting in temporary or permanent mental defect; (3) cerebral hemorrhage, with corresponding paralysis : this is much rarer than the following: (4) meningeal hemorrhage, resulting in temporary paralysis of certain parts : these hemorrhages are more common at the base than on the periphery of the brain ; they are produced by the driving inward of edges or corners of the ununited bones, as the the parietals ; (5) fractures and distortions of the cranial bones ; (6) laceration of the scalp and features : an ear may THE OBSTETRIC FORCEPS. 525 be partially or completely torn away or an eye gouged out; (7) temporary paralysis of the facial nerve from pressure upon it at its point of exit from the skull. The maternal dangers are — (i) Laceration of the vagina and perineum; (2) laceration of the cervix uteri ; (3) severe contusions of the soft structures of the lower parturient canal ; {\) loosen- ing and separation, or even fracture, of the pelvic joints; (5) sepsis ; (6) shock ; (7) vaginal and vulvar thrombosis from subcutaneous rupture of a varicose vein, with secondary septic cellulitis and peritonitis. Tlic Application of the Forceps. — This most common of obstetric operations is probably the most often abused by the general physician. A thorough comprehension of the various steps of the operation and the reasons therefor is essential to a proper application of the blades. This in- cludes a consideration of certain preliminary measures and the steps in the application itself. (l) Preliminary Meas- jires. — [a] Assistance. — When the use of the forceps has been decided upon, certain preparations become necessary in order to ensure a successful termination of the case. In the first place, assistance is desirable, if not absolutely essen- tial, and trained assistants, either a physician or a nurse, or both, will add considerably to the ease and ultimate success of the operation. The patient herself and her family should be advised of what is contemplated, and their full sanction secured before anything further be attempted, {b) Anesthesia. — If it be a low operation, anesthesia is not necessary ; the application of the forceps in such cases is a simple matter, and does not in any way add to the suffering of the patient. In high forceps operations, requiring traction for at least an hour or two, anesthesia becomes necessary: not only does it alleviate the sufferings of the patient, but it induces relaxa- tion of the soft structures of the parturient canal and thereby renders the operation less difficult ; there is also much less danger of the patient injuring herself against the edges of the blades by some sudden movement. The disadvantages 526 A MANUAL OF OBSTETRICS. of anesthesia include relaxation of the uterine tissues as well as of the other soft structures, whereby the tendency to postpartum hemorrhage is materially increased. The vom- iting induced by the anesthetic, if ether be used, may become troublesome during the first few hours of the puer- perium, and the disturbance of the general system of the patient may result in the retardation of the appearance of the milk, it may be for a period of twenty-four hours or more, {c) Preparation of the Patient. — The bladder must be catheterized and the bowels emptied by a simple enema. The vagina and external genitals should be rendered thoroughly aseptic by green soap and water, and then by a douche of creolin (i or 2 per cent.) or mercuric-chlorid solution (i : 2000). The exact position and presentation of the fetus must be determined, and the rate and intensity of the fetal heart-sounds ascertained. The position occupied by the patient varies : usually she is placed upon her back in the lithotomy position, but some accoucheurs prefer the English, left lateral, or obstetric position. However placed, the hips must extend well over the edge of the bed, and should the dorsal decubitus be chosen, the assistants, one on either side, must support the knees, the feet resting upon two chairs, {d^ Preparation of the Instruments. — The blades, rendered absolutely clean by scrubbing with soap and hot water, are allowed to lie in a pitcher or basin of hot water or in a warm 5 per cent, solution of carbolic acid until they are required. As each is introduced into the pelvis it should be thoroughly anointed with carbolized vaselin. Application of the Blades. — Everything being in readi- ness, the instrument may be applied. This may be done in one of two ways. In the first place, the blades may be introduced to either side of the pelvis and locked, irrespec- tive of the grip taken upon the head ; this is termed the pelvic application of the forceps. Preferably they should be so applied that they will grasp the fetal head in its trans- verse diameters, and, in order to accomplish this, rotation THE OBSTETRIC FORCEPS. 527 of one or the other blade, according to the position occu- pied by the head, must be performed. This, the method now to be described, is known as the cephalic application of tlic forceps. When the forceps is appHed in this manner it occupies the opposite obh'que pelvic diameter to that in which the head is engaged, the fetal ears being opposed to the fenestra of the blades. Owing to the peculiar arrange- ment of the lock in the instruments generally employed, the left blade — that applied to the left side of the pelvis, and which is grasped by the left hand of the operator — is first introduced. The index and middle fingers of the right hand are passed into the vagina and up to and within the dilated cervix ; these serve as a guide whereby the blade may be passed through the cervical canal and not introduced ex- ternally to that structure. The blade, grasped lightly at the handle by the thumb and one or two fingers, is applied to the vulvar orifice in such a manner that its tip corresponds to the vulvar cleft, while the handle is inclined toward the patient's head. The blade glides over the palmar surface of the vaginal hand in the direction of the sacrum : as it reaches the orifice of the cervix the handle is gently depressed and at the same time carried away from the median line, the blade making a corresponding movement toward the left side of the maternal pelvis within the uterine cavity. This maneuver must be performed with the utmost care to avoid injury to either mother or child, and in no case should force be exerted to accomplish the introduction of the in- strument : if properly applied, it will glide into position almost without effort, and may then be held in situ by an assistant while the opposite blade is introduced. This, the right, is manipulated in the same manner, being seized, how- ever, by the right hand and made to assume a position to the right side of the maternal pelvis. The blades as now applied do not lie in the same plane : in order to permit of locking, one or other must be rotated anteriorly, so that the biparietal diameter of the fetal head may come within ,28 A MANUAL OF OBSTETRICS. the grasp of the instrument. There has been suggested, as follows, a ready rule of practice by which it may be known which blade must be rotated in order to secure a proper grasp upon the head : Should the fetal head occupy the right oblique pelvic diameter, as in the first (L. O. A.) and third (R. O. P.) positions of the vertex, the right blade — that corresponding in name to the pelvic diameter involved — must be rotated forward ; on the other hand, should the fetal head lie in the left oblique diameter of the pelvis, as in the second (R.O. A.) and fourth (L. O. P.) positions of the ver- tex, the left blade must be rotated for- ward. This rotation is accomplished not through the agency of the handles, but by the fingers of the vaginal hand — the left in rotation of the right blade, and the right when the position of the left blade must be altered. The biparietal diameter now being grasped, the instrument is readily locked and traction may be made (Fig. 148). Method of Delivery by the Forceps in the First Position {L. O. A.) of the Vertex. — The instrument having been applied as just described, the handles are locked and grasped by the fingers of the left hand, the middle finger of which is passed between the blades, while the index finger hooks over one shoulder of the instrument and the remaining fingers over the other shoulder; the right hand is then placed directly over the left, with the index finger cxtcndiner in the interval between the blades and resting Fig. 148. — Forceps applied to the head. THE OBSTETRIC FORCEPS. 529 lightly upon the fetal scalp. By the left hand steady traction is exerted outward while strong downward pres- sure is made with the right : the head moves in the direc- tion of the resultant of these two forces — that is, in the axis of the parturient canal. In order to secure the slight backward movement necessary at the beginning of the high forceps operation, upward pressure may be exerted upon the handles by the fingers of the left hand at the same time that the outward traction is being made. When the occiput has descended to a sufficient extent to have become fixed under the symphysis pubis while the perineum is well distended by the advancing head, the grip upon the forceps must be altered. The operator now moves to the left side of the patient, grasps the instrument with the right hand in such a manner that the thumb rests upon the top of the handles (dagger-fashion), and with the left hand spans the posterior commissure of the vulva in order to protect the perineum. Traction is now made directly up- ward until the fetal head emerge beneath the retracting perineum. If this maneuver be carried out as described, Goodell's suggestion that the blades be removed as soon as the vulvar orifice dilates, in order to avoid rupture of the perineum, need not be adopted. Grave laceration of the perineum should not attend a forceps delivery with the blades in situ upon the head if the foregoing precepts be followed. Should it seem desirable, however, to remove the forceps before delivery of the head have been accom- plished, the right blade — the last one introduced — should be the first withdrawn : this may be done by a reversal of the maneuver adopted in its introduction. Two fingers of the left hand are introduced into the vagina as far as the cer- vix, and so placed as to protect the soft maternal structures from the anterior margin of the blade as the latter is with- drawn. The left blade is then removed in a similar manner. Method of Delivery by the Forceps in the Third (R. 0. P.) Position of the Vertex. — In the right occipitoposterior posi- 34 53© A MANUAL OF OBSTETRICS. tion the application of the forceps is precisely the same as in the first position ; traction, likewise, is made as before until the head reach the pelvic floor, at which time ante- rior rotation of the occiput occurs while the head is still within the grasp of the forceps. The instrument is thus made to hold a vicious grip upon the head : instead of occupying, as normally, the extremities of the biparietal diameter, it grasps the head over the occipital and frontal bones. It becomes necessary, therefore, to remove the blades and to reapply them, rotating forward, however, the left blade, as the head has changed its position from the right to the left oblique pelvic diameter and now occu- pies the second (R. O. A.) position of the vertex. Traction is then continued as before and delivery accomplished as in a normal (L. O. A.) position. (3) Obstructed Labor. — An obstructed labor is one in which the spontaneous delivery of the fetus is prevented by the presence of some insuperable obstacle in the parturient canal. The subject is a large one, embracing many very im- portant subdivisions. The obstruction will be encountered either before or after canalization of the cervix, according as to whether the pathologic condition exist within the upper or the lower portion of the parturient canal. The general symptoms of obstructed labor in the early stages are those of protracted labor, aggravated, however, by the greater intensity of the local pelvic manifestations. Instead of the weak and inefficient action of the uterine muscles, there exists over-action of that organ, which, in its vain efforts to drive the fetus past the point of obstruction, soon falls into a condition of tonic or tetanic contraction. This is the path- ognomonic sign of insuperable obstruction to labor. The woman's sufferings in consequence of this excessive uterine action are intense. Her cry is exaggerated, and she soon develops symptoms of extreme exhaustion. There is an anxious cast of the countenance ; steadily increasing rapid- ity of the pulse, which at the same time becomes weaker OBSTRUCTED LABOR. 53' and thready ; the reflex symptoms become more pronounced, especially the nausea and vomiting; increasing nervous ex- haustion is indicated by extreme restlessness and jactitation. All these symptoms progressively increase in severity until the late clinical manifestations of a neglected case of obstructed labor assume a typhoid character, with profound depression and exhaustion, low, muttering delirium, coma, and death. Diagnosis of Obstructed Labor. — Strange as it may seem, in general practice the recognition of obstructed labor has never been a matter of ease : especially is it common to find this truly serious condition confounded with that other comparatively harmless state, secondary uterine inertia or uterine exhaustion, to which it does bear a passing likeness, only, however, upon careless examination. When prolon- gation of the second stage of labor with failure of the presenting part to advance is mentioned, the similarity between the two diametrically opposite conditions ceases. In the following table may be found some points of differ- entiation between the two pathologic states : Obstructed Labor. The uterine pains, at first normal in nature, soon become tonic. Abdominal palpation reveals a rigidity of the upper uterine segment, with a high position of Bandl's ring and more or less flaccidity of the lower uterine segment ; there is tenderness on manipulation. The fetal outline and extremities cannot be palpated. There is fetal immobility. Vaginal examination will usually reveal the cause of the obstruction. The vaginal finger is unable to move the pre- senting portion. If engagement of the part have occurred, there may be some vulvar and vaginal edema. The presenting portion in neglected cases is more or less disguised by an immense edema ; in the case of the head the caput succedaneum may even resemble a bag of waters. The general condition of the patient is grave. Uterine Exhaustion. The uterine pains are either very weak and far between, or entirely absent. Abdominal palpation reveals a relaxed ute- rine wall with a normal position of Bandl's ring, and no tenderness on manipulation. The fetus and its parts may be readily mapped out and moved about in the uterine cavity. Vaginal examination reveals absence of ob- struction ; the fetal presentation may even have reached the vulvar orifice. The presenting portion may be displaced to a certain degree by the vaginal finger. The edema of the soft parts is not greater than in a normal labor. There is no more than the usual disfigure- ment of the fetal presentation. The patient's general condition is good. 532 A MANUAL OF OBSTETRICS. The Dangers of Obstructed Labor. — The dangers of this con- dition are both fetal and maternal. The fetal dangers are asphyxiation from prolonged compression of the vital centers and from interference with the placental function ; injury from prolonged pressure upon the limbs ; the development of an inspiration-pneumonia ; injury from contact with the obstruc- tion, especially if the latter be more or less acuminate, as a spiny exostosis, a vesical calculus, or a prominent sacral promontory; and, finally, injuries from the manipulation necessary for the extraction of the fetus from the parturient canal. The maternal dangers are exhaustion and death ; pressure-necrosis of portions of the parturient canal; uterine rupture from tetanic contraction of the upper, and excessive dilatation of the lower uterine segment ; and, finally, sepsis from the necessary manipulations. Etiology. — The causes of obstructed labor may be fetal or maternal. The fetal cajiscs — namely, malposition, malpresentation, deformities, and over-size of the fetus — have already been considered under the subject of fetal dystocia. The maternal cause is some excess in the resistant forces of labor : this will include a multitude of conditions, as follows : {a) Contractions and deformities of the pelvis ; {b) Malformations of the uterus ; {c) Uterine displacements ; {d) Tumors, uterine, cervical, pelvic, and vaginal ; (r) Rigidity or atresia of the soft struc- tures of the parturient canal. {a) Pelvic Contraction. — Obstruction to labor the result of pelvic malformation is, probably, next to uterine inertia, the most common variety of dystocia. The relationship existing between the respective sizes of the fetal head and the maternal pelvis, necessitating even under the most favorable circumstances a varying amount of moulding of the fetal structures in order to permit of their transmission, is so close that it requires but a very moderate degree of deviation from the normal to cause a considerable amount of difficulty in the accomplishment of parturition. This dystocia varies in its intensity from a mere retardation of the CONTRACTED PELVIS. 533 fetus in its passage through the bony portion of the partu- rient canal, the result of increased friction between the fetus and the canal, to an absolute and insuperable obstruction to the progress of labor. So irregular is the shape of the human pelvis, and so complex are the forces by which this normal irregularity of shape is evolved, that the wonder is not that there should be a certain fair proportion of abnor- mally-shaped pelves encountered in an ordinary obstetric practice, but that this proportion of deformed pelves is not larger than it actually is. It is estimated that from 5 to 15 per cent, of all women confined present vary- ing degrees of pelvic contraction. Development of Pel- vic Deformities. — Pelvic deformity may be produced by three distinct processes : In the first place, it may be the result of distortion of the bony structures by various path- ologic conditions, as rachitis, osteomalacia, kyphosis, scoli- osis, spondylolisthesis, spondylolizema, coxalgia, and the development of neoplasmata ; secondly, it may result from traumatism, as fractures and dislocations, the deformity in the latter case being the remote effect of the accident; finally, the malformation may be a direct outcome of some disturbance of the equilibrium that normally exists between the forces that contribute to the production of the peculiar complicated shape of the adult pelvis. These forces are the normal growth of the individual pelvic bones, the trac- tion exerted on the developing bones by their ligamentous and muscular attachments, the pressure from the superim- posed trunk, and the counterpressure exerted through the femora below. Let any one of these forces be deficient or in excess, and the pelvic bones fail to that extent to assume their normal shape, direction, and development. Thus, let it be supposed that the pelvic bones, which during a por- tion of intrauterine life are united not by firm bony struc- tures, but by cartilaginous bands, should for any reason fail to undergo the normal process of development: there would necessarily result an abnormality in the shape of the pelvis 534 A MANUAL OF OBSTETRICS. that would constitute a form of the so-called congenitally- contracted pelvis ; such is the Naegele or Roberts pelvis. The action of the superimposed body-weight only comes into play after the child begins to assume the erect position; its tendency is to depress the sacrum and to press out- ward the pelvic brim (the iliac crests). The counterpressure from below through the femora is exerted in a direction upward and outward. These two forces, becoming active, are opposed by the action of the ligamentous and car- tilaginous unions and the traction exerted upon the bones by the muscular attachments. As a consequence of this third, or modifying, force, the soft and developing bones of the pelvis undergo a curious process of curving and twisting that ultimately results in the characteristic formation of the pelvis of the adult. The sacrum is pushed downward, but since this force is opposed by its union with the innomi- nate bones and by the counterforce from below trans- mitted from the femora, the sacrum is altered in shape from the straight fetal to the curved bone of the adult pelvis with the concavity directed inward. Let the down- ward pressure be excessive, and the increased bowing of the sacrum throws the promontory too far forward, with a consequent diminution in the conjugate diameter of the pelvis. The sacrum being fixed posteriorly and the sym- physis anteriorly, the outward pressure upon the iliac crests results in the production of the normal curve of these por- tions. Let the symphysis be relaxed or congenitally .split, and the iliac bones will be rotated outward and backward.. In case the bones are softened by disease, the body-weight with the counterforce below displaces inward the soft struc- tures, and greatly distorts the pelvic outline. Varieties of Pelvic Deformity. — Clinically, pelvic deformi- ties may be grouped into four distinct classes, as follows : I. Anteroposteriorly-contracted pelves, or those contracted in the conjugate diameter only. Here may be included the simple flat and the spondylolisthetic pelves. 2. CONTRACTED PELVIS. 535 Obliquely-contracted pelves, or those in which the pelvic outline is irregularly distorted, with greater narrowing in one half of the structure than in the opposite half, and with an increased inclination of the pelvis. Here may be included the rachitic, the coxalgic, the scoliotic (rachitic and non-rachitic), the osteomalacic, and Naegele's (or the obliquely ovate) pelves, and the distortion of the pelvis due to traumatism, such as fractures and luxations. 3. Trans- versely-contracted pelves, or those in which the main con- traction lies in the transverse diameter of the pelvis. This group includes Roberts', the kyphotic, and the kyphosco- liotic pelves. 4. Generally-contracted pelves, or those in which there is more or less diminution in all the pelvic diameters. Here may be mentioned the justominor or small round and the generally-contracted and flat pelves. Description of the Varieties. — i. Anteroposteriorly-con- tracted pelves. — (i) The Simple Flat Pelvis. — An exceed- ingly common form of pelvic deformity. It consists in a simple diminution in the anteroposterior or conjugate diameter of the superior strait of the pelvis, without any disturbance in the size of the other pelvic diameters. The flattening in this variety is never excessive, and nothing is known as to its etiology. It is as common among the higher classes as among the lower, and among the gener- ally well-developed as among those who are under-devel- oped. The true conjugate diameter of the inlet may measure but gyC, cm. (3.7401 in.), the internal conjugate diagonal 11 cm. (4.3307 in.), and the external conjugate 18 or 19 cm. (7.0866 or 7.4803 in.). There is a slight forward displacement of the sacrum, but the pelvic outline is quite symmetric, and there will be neither accompany- ing spinal curvature nor signs of rachitis. There is a mod- erate disturbance in the relationship between the inter- spinous and intercristal diameters, due to a slight turning forward of the iliac fossae. The characteristic clinical features are — (i) Flattening of the pelvis in the conjugate 536 A MANUAL OF OBSTETRICS. diameter; (2) slight anterior displacement of the sacrum; (3) but slight, if any, disturbance in the relationship be- tween the iliac crests and spines ; (4) perfect symmetry of the pelvis ; (5) some difficulty in reaching the lateral pelvic walls on vaginal examination. This variety of pelvic de- formity does not result in serious interference with labor, although an instrumental delivery may be required should there exist a tendency to uterine inertia or a slight over-size of the fetal head. The first stage of labor is generally pro- tracted : after engagement has once occurred the difficulty is overcome. As a rule, the head enters the pelvis trans- versely and extended to a slight degree, so that the bregma may be palpated. There is exaggerated lateral {Naegeles) obliquity, the sagittal suture approaching the sacral prom- ontory. This is termed i\\e. anterior parietal position, and is a favorable conservative process of nature. Should the re- verse occur, as it rarely does, the sagittal suture approaches the symphysis pubis, and the so-called posterior parietal position is produced : this is usually noted in primipara;, and, if pronounced, results in an insuperable obstacle to the progress of labor, necessitating version or symphysiotomy. (2) The Spondylolisthetic Pelvis {Kilian's Pelvis; Roki- tatiskfs Pelvis; the Prague Pelvis). — By spondylolisthesis, in obstetrics, is understood a forward dislocation of the last lumbar vertebra, the body of which slides inward and downward and rests upon the upper and anterior por- tion of the sacral promontory (Fig. 149) : there results a marked diminution in the anteroposterior diameter of the pelvic inlet, rendering labor in such a pelvis an absolute impossibility. There is, in fact, a backward dislocation of the sacrum, so that the true conjugate actually measures above the normal, but the bulk of the displaced vertebra so encroaches upon the pelvic inlet as to prevent engage- ment of the fetal presentation. Spondylolisthesis is more commonly encountered in obese subjects (Harris). The causes of the deformity are — (i) Incomplete ossification of" CONTRACTED PELVIS. 537 the last lumbar vertebra, resulting in separation of the an- terior from the posterior portion under the pressure exerted by the superimposed structures {spondylysis ariicularis) ; (2) sudden or violent exertion or strain acting- upon the pre- ceding deformity. The displaced bone is compressed be- hind by the weight from above, so that it assumes a cha- racteristic wedge- shape ; further dis- location is prevented by an ossification of the intervertebral substance between it Fig. 149. — Spondylolisthetic pelvis. and the sacrum. Such patients generally present the his- tory of a long siege of sickness during the development of the deformity. The characteristic clinical features are — (i) Diminution in the stature of the patient, with approxima- tion of the ribs to the pelvic brim : in marked cases the ribs and iliac crests are in actual contact ; (2) an extreme degree of lordosis ; (3) separation of the posterior superior iliac spines; (4) diminution in the pelvic inclination, as a result of which the iliofemoral ligaments are thrown upon the stretch. These, by exerting undue traction upon their respective innominate bones, draw the latter inwardly below, so that there is an approximation of the ischial tuberosities, while the iliac crests are flared out ; consequently, there is in this pelvis a diminution in the transverse diameter of the pelvic outlet with an increase in the transverse diameter of the pelvic inlet; (5) vaginal examination reveals extreme shortening in the conjugate diameter of the inlet, due to a bony prominence posteriorly, in front of which may be de- 538 A MANUAL OF OBSTETRICS. tected the abdominal aorta v/iih its bifurcation into the two common iliac arteries ; also frequently the lower edges of the kidneys may be palpated. A condition analogous to the foregoing is that known as spond)'lolizema. Here, however, the deformity is not con- genital in origin, but is a direct outcome of a caries of the body of the last lumbar vertebra, which, yielding to the superimposed weight, permits a forward falling of the ver- tebrae above. The pelvic inlet may be so encroached upon that the displaced vertebrae are in almost actual contact with the top of the symphysis pubis, and to this condition, as well as to extreme degrees of rachitic deformity of the pelvis, has been given the name of pelvis obtecta. (2) Obliquely-contracted Pelves. — (i) The Rachitic Pelvis (PI. 4, Fig. i). — Owing to the frequent occurrence of rickets in infants and children, the pelvic deformity resulting from this disease is very commonly encountered. Next to the simple flat, it is probably the most frequent variety of deformed pelvis met with by the obstetrician. It occurs in two well-recognized forms — namely, the flat, and the flat and generally-contracted. In the former the pelvis is closely allied in contour to the simple flat pelvis : the deformity, how^ever, is more marked and the pelvic obliquity greater in the rachitic condition, and there are also present the cha- racteristic epiphyseal changes. There is generally associated more or less pelvic asymmetry, one side being more roomy than its fellow : this results from the irregular action of the disease upon the osseous tissue. The mode of production of this deformity is as follows : During the process of growth the lack of lime-salts peculiar to the disease results in an abnormal softening of the bones, which, in conse- quence, yield more readily to the forces acting upon them. Extreme distortion of the pelvic bones may thus be pro- duced. The pressure of the superimposed body upon the softened sacrum results in excessive bowing of the latter, with exaggerated prominence of the promontory and a CONTRACTED PELVIS. 539 marked decrease in the vertical height. There is a back- ward bowing of the vertebral column, as a result of which the body-weight is directed from above downward and from behind forward ; the pelvic crests are flared outward, and there results an upward and anterior inclination of the iliac fossae, together with a marked separation of the anterior superior iliac spines, whereby the relationship existing be- tween the intercristal and interspinous diameters is materi- ally altered, the dimensions of the two being approximated. The obliquity or inclination of the pelvis is also increased, as in all forms of obliquely-contracted pelves : this induces greater traction upon the ligaments attached to the ischial tuberosities, and as a result these tuberosities are drawn outward and the pelvic outlet thereby increased in size. The pressure from below transmitted through the femora drives out the softened innominate bones, thereby increasing the width of the pelvis : this increase, however, is more than compensated for by the underdevelopment of the entire pelvis that characterizes the disease. The sacrum shows imperfect development of its alae and thus contributes to the narrowing of the pelvis ; as a consequence, the pos- terior surfaces of the iliac bones approach each other, as shown by an approximation of the posterior superior spines. In addition, all the articulations participate to a varying degree in the epiphyseal thickening. Tlic cJiarac- teristic clinical features of the rachitic pelvis are — (i) The presence of the peculiar epiphyseal changes; (2) extreme shallowness of the pelvic cavity, the direct result of excessive bowing of the sacrum; (3) a widening of the pubic arch from outward traction of the obturator muscles upon the readily yielding bones : this is accompanied by widening of the entire pelvis, and if it coexist with marked flattening, the so-c^W.^^ figurc-of 8 pelvis results ; (4) distortion of the outline of the pelvic brim, which is kidney-shaped or, as has been said, occasionally resembles the figure 8 ; (5) dis- turbance of the relationship existing between the intercristal 540 A MANUAL OF OBSTETRICS. and interspinous diameters, the two being almost or alto- gether equal from outward displacement of the spines ; (6) under-size of the entire pelvis: the external conjugate di- ameter will measure 19 cm. (7.4803 in.) or under, while the internal conjugate diagonal will be reduced to 1 1 cm. (4.3307 in.) or less (in estimating the true conjugate, 2 cm., or 0.7874 in., must be deducted from this diameter) ; (7) undue promi- nence of the sacral promontory as determined by vaginal examination ; (8) great pelvic obliquity with increase of the conjugato-sympJiyscal angle (that formed between the sym- physis pubis and the true conjugate diameter of the pelvic inlet) ; (9) the presence of rachitic changes in other bony structures, as bowing of the legs, prominence of the shins, bossellated skull, pigeon-breast, shortness of the long bones, enlargements of the joints, and spinal curvature; (10) down- ward displacement of the indentation beneath the spine of the last lumbar vertebra, whereby the lozenge-.shaped figure present in the normal individual (formed below by the pos- terior angle of the natal folds, to either side by the dimple corresponding to the posterior superior iliac spines, and above by the depression beneath the spine of the last lumbar vertebra) becomes almost, if not altogether, triangular in shape. (2) TJic coxalgic pelvis (PI. 4, Fig. 2) is that variety of pelvic deformity resulting from hip-joint disease. The pelvis becomes contracted obliquely from overuse of the well side and imperfect use of the affected Hmb. The entire body-weight is thrown upon the sound limb; con- sequently, the pressure from below drives backward and outward the innominate bone, while rotation of the sacrum upon its long axis occurs, the ala corresponding to the sound side being carried posteriorly: in this way there is produced a contraction of the sound side, while the forces that should normally develop the adult shape upon the op- posite side are not brought into play, that portion of the pelvis retaining its rounded fetal or infantile conformation. CONTRACTED PELVIS. 54 1 or, at least, the degree of alteration it had undergone at the time of the development of the coxalgia. The amount of deformity depends upon the period at which the disease has developed, the extent to which it has progressed, and the occurrence or nonoccurrence of luxation. The charac- teristic clinical features are — (i) Marked asymmetry of the pelvis ; (2) more or less rotation of the pelvis upon the spinal column; (3) the presence of an ankylosed hip and other signs of the primary disease ; (4) marked shortening of the conjugate diameter of the pelvis. (3) The scoliotic pelvis (Pi. 4, Fig. 3) is that form of pelvic deformity resulting from scoliosis, or lateral curvature of the spinal column. It may be either rachitic or non-rachitic in origin, and varies in pathologic importance according as to whether it has developed before or after complete ossification of the pelvic bones : the rachitic variety is that most frequently encountered. In this deformity the body-weight is thrown upon that side of the pelvis toward which the convexity of the lumbar portion of the spinal column is directed. The counterforce from below must necessarily be greater and more effective upon the same side, which is, therefore, compressed from above and from below ; the sacrum is carried obliquely forward and outward toward the acetabulum, and the latter is dis- placed upward, backward, and inward ; the iliac crest of the affected side is acutely bent upon itself, and the sacro- cotyloid diameter (that extending from the promontory of the sacrum to either acetabulum) of the same side is con- siderably shortened. The pressure from the femur on the opposite side is directed upward and outward, thereby dis- placing outwardly the innominate bone and dragging the symphysis pubis to that side. The cJiaracteristic clinical features are — (i) Marked asymmetry of the pelvis, coexist- ant with an appreciable degree of scoliosis ; (2) marked shortening of the internal conjugate diameter, associated with an inequality between the two sacrocotyloid diameters. 542 A MANUAL OF OBSTETRICS. (4) Tlic osteomalacic, malacostcan, or ^-shaped pelvis (PL 4, Fig. 4) is a variety of pelvic deformity rarely seen in the United States, but of rather common occurrence in various portions of Southern Europe : it is due to the affection known as osteomalacia, in which the pelvic bones undergo a remarkable degree of softening from absorption and removal of their lime-salts. This patho- logic process is carried to such an extreme degree that the upward pressure transmitted through the femora drives inward the innominate bones, often asymmetri- cally, while the attachment of the muscles to the pubis holds it in place ; as a result there occurs a characteristic protrusion of the symphysis pubis resembling the beak or rostrum of a ship; hence its name, the " bcak-shapcd" or rostrate pelvis. The body of the sacrum, also softened by the disease, is carried downward and forward by the super- imposed body-weight, while the muscles and ligaments attached to its alae drag the latter backward and upward ; the convexity of the sacrum is, therefore, anteriorly from above downward and from side to side. There is an out- ward displacement of the tubera ischii, resulting in an increase in the transverse diameter of the pelvic outlet. The attachments of the sacrosciatic ligaments to the lower extremity of the pelvis draw it inward, so that there is a pronounced anterior curvature of this portion of the bone, and the coccyx almost entirely obliterates the pelvic outlet in its conjugate diameter. The characteristic clinical features are — (i) Marked softening and asymmetry of the pelvis; (2) a characteristic beak-like projection of the symphysis pubis, into which, on vaginal examination, the finger may be inserted ; (3) a sharp anterior curvature of the tip of the sacrum and the coccyx, almost totally occluding the pelvic outlet ; (4) an increase in the transverse diameter of the pelvic outlet, as shown by a separation of the ischial tuber- osities ; (5) extreme prominence of the sacral promontory ; (6) extreme tenderness of the pelvic bony structures, with CONTRACTED PELVIS. 543 softening to such a degree (in advanced cases only) that their shapes may be altered by manual efforts ; (7) the history and symptoms of the disease — inability of the patient to stand or walk, pain on motion, paroxysms of dyspnea, cough, cramp-like pains in the muscle, from collapse of the pelvis. Women lose from six inches to a foot or more in height in this disease, which always origi- nates during a previous pregnancy. (5) Naegele's or the obliquely ovate pelvis (PI. 4, Fig. 5) is an exceedingly rare variety of pelvic deformity consequent upon absence or imperfect development of one ala of the sacrum. As a result, the pressure from the femur upon the corresponding side is directed upward, so that the innomi- nate bone is carried upward and inward : on the opposite side of the pelvis the pressure is directed upward and out- ward : hence there is an actual enlargement of that side, the acetabulum and the symphysis pubis being carried outward ; the iliac fossa of the sound side is directed more anteriorly and externally. The characteristic clinical fea- tures are — (i) Marked asymmetry of the pelvic crests; (2) lateral displacement of the symphysis pubis (toward the sound side) ; (3) approximation to the sacral spines of the posterior superior iliac spine of the affected side ; (4) an in- crease of the oblique diameter running from the posterior superior iliac spine of the affected side to the anterior su- perior iliac spine of the sound side; (5) on vaginal exam- ination a marked diminution in the oblique diameter run- ning from the point just over the central portion of the obturator foramen on the affected side to the opposite sacro- iliac synchondrosis, as determined by direct pelvimetry. (6) TJie Oblique Pelvis due to Traumatism (PI. 4, Fig. 6). — Fractures and luxations, whether congenital (intrauterine) or resulting in after-life, give rise to grave forms of con- tracted pelvis. Such pelves are asymmetric, at times unde- veloped (when fracture has occurred early in life), and are always associated with much deformity. The contraction 544 A MANUAL OF OBSTETRICS. lies in the fractured side of the pelvis. In congenital luxa- tion of the hips the rotator muscles of the thighs are put on the stretch, and the pelvic inclination thereby increased, the sacrum occupying an almost horizonal position. The heads of the femora rest in these cases upon the iliac dorsa; the pressure from below results in an inward displacement of the iliac bone, with outward traction upon the tuberosity of the ischium, which is displaced from the median line ; the pelvic inlet is lessened, while the outlet is increased in size : this is especially marked in cases of double dislocation. In unilateral dislocations the pelvis be- comes obliquely contracted, the symphysis pubis being slightly drawn to the affected side. A similar contraction occurs in the sitz pelvis — that resulting from the removal of one limb in early life. 3. Traiisversely-contracted Pelves. — (i) Robert's pelvis {V\. 5, Fig. i) is a very rare variety of deformed pelvis, not more than eight or nine specimens having been recorded in all medical literature. It consists in a duplication of the con- genital defect in Naegele's pelvis ; that is, there is absence or imperfect development of both sacral alae. As a direct consequence of this extreme narrowness of the sacrum the pelvis is much diminished in its transverse diameter. There is a slight forward displacement of the sacrum, with a corre- sponding diminution in the conjugate diameter of the inlet; the anterior convexity of the sacrum is marked, the curve of the iliac crests is less than normal, and the posterior superior iliac spines are not carried as far back as usual. The characteristic clinical features are — (i) Marked diminu- tion in all the transverse diameters of the pelvis ; (2) the space between the posterior superior iliac spines is slightly increased; (3) by vaginal examination the promontory is found to be much higher than normal ; (4) there is an approximation of the ischial tuberosities; (5) there is a diminution in the pubic angle. (2) The kyphotic pelvis (PI. 5, Figs. 2, 3) is that pelvic de- CONTRACTED PELVIS. Plate 4. 5 ti Abnormalities of the female pelvis {American Text-Book of Obstetrics) : i, typical flat rachitic pel- vis ; 2, coxalgic pelvis; 3, scoliotic rachitic pelvis; 4, osteomalacic pelvis; 5, obliquely-contracted pelvis (Naegele) ; 6, fracture of the pelvis (Otto). CONTRACTED PELVIS. Plate 5. '5 « Abnormalities of the female pelvis [Atnerican Text- Book of Obstetrics) : i, transversely-contracted pelvis (Robert); 2, contracted outlet of a kyphotic pelvis (Barbour) ; 3, kyphotic pelvis from above (Bar- bour) ; 4, asymmetrical contraction of the outlet from kyphoscoliosis ; 5, justominor pelvis ; 6, fetal ill-devel- oped pelvis, probably an arrested development from rachitis. CONTRACTED PELVIS. 545 formity resulting from kyphosis or Pott's disease of the spine when the site of the spinal lesion is so low that the compensatory lordosis cannot correct the maldirection of the force exerted by the superimposed body-weight. In consequence of the break in the axis of the spinal column the body is inclined forward ; the downward pressure is thrown from before backward, and as a result of this altera- tion in the pressure there occurs a backward displacement of the sacrum, with a diminution in the pelvic inclination. The sacral promontory rises and the conjugate diameter of the brim is increased. The backward pressure upon the sacral promontory is resisted by the sacroiliac synchondroses, and there is produced in this way an increased anterior con- cavity of the bone from side to side, with a corresponding diminution in its width : the ischii are thereby approxi- mated, and the pelvis is narrowed throughout its entire depth, the most appreciable diminution in width being manifested at the pelvic outlet from inward displacement of the ischial spines. The inferior strait is, moreover, further impinged upon by a compensatory forward displacement of the coc- cyx and the tip of the sacrum. From the increased outward pressure upon the iliac crests, supplemented by the extra strain thrown upon the tense iliofemoral ligaments (which drag the anterior inferior iliac spines outward and down- ward) there is afforded more room above at the pelvic inlet in proportion as the pelvic outlet is straitened. In pelves of this description the first stage of labor may be perfectly normal or even more precipitate than usual, but when the fetus descends through the pelvic cavity it encounters in- creased resistance at the outlet, and the obstruction may even prove insuperable. It has been found that occipito- posterior positions are by no means infrequent in this con- dition : this may be accounted for by the backward dis- placement of the promontory affording greater room for the dorsum of the fetus. The characteristic clinical features are — (i) The associated kyphosis with its characteristic fea- 30 546 A MANUAL OF OBSTETRICS. tures ; (2) slight increase in the dimensions of the pelvic inlet; (3) approximation of the ischial spines; (4) dimi- nution of the conjugate diameter of the outlet; (5) by vaginal examination difficulty in palpating the sacral promontory. (3) The kypJioscoliotic pelvis (PI. 5, Fig. 4) is that deform- ity arising from a coexistence of kyphosis and scoliosis, the combination resulting in a minor degree of obliquely- contracted pelvis, but with the main contraction lying in the transverse measurements of the pelvis. The tendency of the kyphosis is to dilate the superior strait of the pel- vis : the scoliosis tends in the diametrically opposite direc- tion, but, as it is the secondary condition, the pelvis has largely acquired its deformity before the scoliosis begins to act upon it. It presents, therefore, some of the character- istics of both, and also retains some of its original funnel shape. The joints all present the usual alterations of rachitis: there is an increase in the conjugate diameter of the inlet, and a general transverse flattening of the pelvis, as in kyphosis ; there is a slightly oblique contraction of the pelvis, the symphysis pubis being drawn to the side oppo- site to that toward which the lumbar convexity is directed ; the sacrocotyloid diameter of the side corresponding to the lumbar convexity is shorter than that of the opposite side. The characteristic clinical features are — (i) Marked asymmetry; (2) lateral contraction to a degree less than that noted in the kyphotic pelvis ; (3) the combined presence of rachitic and kyphotic deformities in the bones of the spinal column ; (4) the vaginal signs are the same as in the kyphotic pelvis. 4. Generally-contracted Pelves. — (i) The Justominor , syni- inetrically or generally equally contracted {pelvis (zqualibiier justoniinor), dxvarf, or small roiaid pelvis (PI. 5, Fig. 5) is that variety of pelvic malformation in which the entire pel- vis is undersized, although preserving the normal relation- ship between its various diameters. This variety of pelvic CONTRACTED PELVIS. 547 deformity is quite frequent, especially in hospital and dis- pensary work, and is commonly encountered among shop- and mill-girls and in those women who have been reared in poverty and under bad hygienic surroundings. It may, however, be found in women who are otherwise normally developed. There is an increased concavity of the sacrum from side to side ; the promontory is displaced upward ; there is an approximation of the iliac crests and spines, with a separation of the posterior superior iliac spines. More or less difficulty is encountered at the beginning of labor, and this rapidly increases as the labor progresses ; the narrowing of the pelvic canal results in overflexion of the head and undue prominence of the posterior fontanel, the sagittal suture occupying an oblique diameter. Ante- rior rotation occurs early and is complete, but the descent fails to occur, and there is almost invariably an absence of the lateral obliquity noted in flat pelves. Tlie characteristic clinical features are — (i) Slight diminution in the trans- verse measurements; (2) marked shortening of the conju- gate diameter of the superior strait ; (3) the lateral pelvic walls are in easy access, and frequently the iliopectineal line may be traced around the entire pelvis ; (4) the sacral promontory is situated high up. (2) The masculine , fetal, lying-dozvn, undeveloped, juve- nile, infantile, or fuiinel-shapcd pelvis (PI. 5, Fig. 6) is that pelvic deformity produced by a failure of action of the forces upon which the development of the peculiar shape of the pelvis depends. This is an exceedingly rare variety of misshapen pelvis : it is generally encountered in those girls or women who have been afflicted with infantile par- alysis, or who, for other reasons, have never walked ; slight degrees are also encountered in very young pregnant girls. There persists the characteristic shape of the fetal pelvis — namely, abnormal length and narrowness of the sacrum, marked transverse contraction of the pelvis, unusual height of the promontory, and increase in the length of the diago- 548 A MANUAL OF OBSTETRICS. nal conjugate diameter. The cliaractcristic clinical fcaUires are — (i) Extreme narrowness of the entire pelvis, with lack of the normal hip-expanse ; (2) unusual straightness of the sacrum ; (3) high position of the sacral promontory. (3) The generally-contracted and fiat pelvis is a rather common form of pelvis in which the deformity is not the result of rachitis, but is a congenital defect. There is a diminution in all the pelvic diameters, but especially in the conjugate diameter of the inlet. Labor is more seriously impeded under these circumstances than in the case of a simple flat pelvis, for the reason that compensatory room is not afforded for the fetal head in the oblique diameters. The sacral promontory is situated high above the pelvic brim, and the alae are underdeveloped, as are also the innominate bones. TJic characteristic clinical features are — (i) An increase in the diagonal conjugate diameter, owing to the increased height of the sacral promontory ; (2) a diminution in the true conjugate; (3) under-size of the entire pelvis. Diagnosis of Contracted Pelvis. — The diagnosis of pelvic contraction is an important matter, and is generally made by reference to and discovery of the characteristic clinical features of the various forms of deformity as enumerated in the foregoing pages. The previous history of the indi- vidual case will likewise be of assistance in arriving at the probable variety of deformity present. The appearance of rachitic malformations elsewhere will lead to the strong supposition of the coexistence of pelvic deformity. The history of the previous labors is valuable, as indicative of the probable course of the existing pregnancy. In addi- tion to these methods of diagnosis, resort to the use of the pelvimeter is essential when a pelvic contraction is suspected. The normal measurements of the pelvis have already been given (see page 31), and the main alterations in the various deformed pelves are enumerated in their proper places under the description of these deformities. Spiegclberg CONTRACTED PELVIS. 549 suggests the following general aids to diagnosis in the case of pelvic contraction: i. If the interspinous and intercris- tal diameters be less than normal but their relation un- changed, the pelvis is probably uniformly contracted. 2. If the intercristal diameter be normal but the interspinous diameter increased, there is probably a contraction of the conjugate diameter of the inlet. 3. If both the interspi- nous and intercristal diameters are diminished but their relation is abnormal, the interspinous equalling or ex- ceeding the intercristal diameter, the pelvis is probably uniformly contracted, and presents also a shortening of its conjugate. As suggested by Grandin and Jarman, in pelvic contraction there is also a disturbance in the nor- mal relationship existing between the height of the fun- dus uteri and the top of the symphysis pubis ; there is generally an increase in the distance between the two. Thus, at the sixth month, instead of the fundus correspond- ing to the umbilicus, it will probably occupy the position of the fundus at the seventh month, unless there be asso- ciated a degree of pendulous abdomen, as is not uncom- mon, in which case it may even rest in front of the sym- physis. The height at the other months of gestation will show a corresponding alteration. Prognosis of Contracted Pelvis. — When pregnancy and labor are complicated by pelvic contraction a serious obstetric condition is to be dealt with. Not only is a grave form of dystocia to be anticipated, but even during pregnancy itself may serious complications arise. Should the uterus be retroverted, the danger of incarceration is greatly enhanced by a flattening of the pelvis ; later in the course of pregnancy anterior and lateral displacements of the gravid uterus are produced by the undue prominence of the sacrum with consequent shortening of the conjugate diameter ; pendulous abdomen is thus a frequent accom- paniment of flattened pelvis. From inability of the fetal presentation to engage in the superior strait the usual 550 A MANUAL OF OBSTETRICS. symptom of lightening does not occur, and the patient is frequently a victim of distressing paroxysms of dyspnea. Still more serious than the foregoing are the maternal and fetal dangers during parturition. These may be enumer- ated as follows: i. The maternal dajigers include — (i) Non- engagement of the part, with prolongation of the labor, and death from exhaustion if relief be not afforded by operative interference ; (2) rupture of the uterus from tetanic contraction of the upper uterine segment, with rise of Bandl's contraction-ring and overdistention of the lower uterine segment ; rupture of the vagina may also occur from overdistention of its tissues ; (3) premature rupture of the bag of waters, with resultant dry labor and all its attendant evils ; (4) sloughing of the cervix uteri or upper vaginal tract from prolonged pressure by the presenting part ; vesicovaginal and rectovaginal fistula; may be produced in this manner ; (5) increased tendency to postpartum hemor- rhage from exhaustion consequent upon excessive uterine action ; (6) increased liability to sepsis from the frequent manipulations or the operative procedures necessitated by the abnormal condition of the pelvis. The fetal dangers are — (i) Asphyxiation, from compression of or interference with the placental circulation ; (2) malpresentation and mal- position, from undue mobility of the uterus ; (3) funic pro- lapse, from imperfect approximation of the fetal presenta- tion to the pelvic inlet ; (4) deformity of the presenting part, from excessive edematous infiltration due to the extreme prolongation of the labor; (5) fatal compression of the vital centers, with death from asphyxiation ; (6) the production of ecchymotic spots, or even of extensive sloughing of the soft structures of the head, from pressure exerted by the contracted pelvis ; (7) excessive moulding and deformity of the head, from distortion of the birth- canal. The varieties of deformity thus produced are mani- fold. There may be a simple overlapping of the bones, with consequent diminution of the transverse measurements CONTRACTED PELVIS. 55 I of the fetal head and compensatory elongation of its long diameters. The dangers arising from this deformity are fatal compression of the cerebral centers and intracra- nial hemorrhage from laceration of the brain-sinuses. In other -cases grooves or indentations of the parietal and other bones result from the excessive pressure exerted by the sacral promontory or by the forceps-blades during the process of extraction : these are not actual fractures, and generally disappear during the first few months or years of the child's existence. Still more rarely actual fractures of the cranial bones are produced, and the child may perish from fatal compression of the brain-centers or from intra- cranial hemorrhage ; (8) fractures and dislocations of the extremities, dislocation of the neck, or even decapitation from overtraction. The Treatment of Co7itracted Pelvis. — Necessarily, the treatment of labor occurring in a woman with pelvic con- traction will depend upon the degree of deformity, and especially upon the amount of diminution in the conjugate diameter of the inlet. In the minor degrees of contraction the labor may be spontaneously terminated after considerable prolongation of its stages ; or it may become necessary to artificially bring it to an end by the performance of some of the minor obstetric operations, as the application of the for- ceps or the performance of version. In the more advanced degrees of contraction embryotomy or one of the mutilating maternal operations will be indicated. Bearing in mind that there is no fixed rule for the management of these labors, and that each case must be treated according to the con- ditions therein found, a safe general rule to follow is that which has been adopted by most of the leading obste- tricians, as follows: (i) Should the abnormal condition be discovered some time during the early months of gestation, and the contraction in the conjugate diameter amount to but i^ cm. (0.5906 in.) or less — the true conjugate meas- uring between 11 cm. (4.3307 in.) and 9}^ cm. (3.7401 in.) — 552 A MA A'' UAL OF OBSTETRICS. such a patient may, without undue hazard, be allowed to proceed to term : it is probable that both maternal and fetal life will be saved and the fetus will not be exposed to the risks of prematurity. The dangers of such a labor are — {a) Exhaustion from increased violence of the expulsive efforts and prolongation of the labor; (/;) in multiparae and exhausted primiparae the woman must probably be subjected to the risks of an instrumental delivery, or, should engage- ment fail to occur, to the dangers of version ; {c) in a large proportion of the cases some fetal abnormality, as mal- position, malpresentation, or funic prolapse, will further complicate the labor. When such a course as the fore- going is adopted the progressive increase in the size of the fetal head in successive pregnancies must always be borne in mind. It not infrequently happens that a woman with such a pelvic contraction will spontaneously deliver herself in the first two or three pregnancies, each labor being at- tended with increasing difficulty, which at the succeeding parturitions becomes insuperable without manual interfer- ence. Another factor to be considered is the relative pro- portion of the parents' heads and shoulders as influencing the size and development of the fetus. If the uterine con- tractions alone are unable to effect delivery, the forceps must be applied if the fetus present in a favorable head position ; in other cases, as face or brow presentation, posterior parie- tal position, or nonengagement of the head, or when there coexists some complication, as a compound presentation or a funic prolapse, the indication is to perform podalic version. (2) Should a greater degree of pelvic contraction exist, the true conjugate diameter of the inlet ranging between 9^ and 8 cm. (3.7401 to 3.1496 in.), it would be injudicious to allow the woman to proceed to term : such a course would neces- sarily result in the performance of a mutilating operation upon mother or child. When it is remembered that at the end of the ninth lunar month (two hundred and fifty-second day or thirty-sixth week) each diameter of the fetal head CONTRACTED PELVIS. 553 is I or I j^ cm. (0.3937 or 0.5903 in.) less than at term, and that a child delivered at this period has an almost equal chance of survival with one born at term, it becomes patent that the induction of premature labor is eminently proper. This should be performed early in the thirty-second week if the true conjugate measure but 8 cm. (3.1496 in.), and per- haps not until the thirty-sixth week if it measure 9 or 9}^ cm. (3.5433 to 3 7401 in.). It must be remembered that the size of the fetal head varies in different individuals, and that what might prove an easy labor in one woman at the thirty- sixth week with a conjugate measuring 9^ cm. (3.7401 in.) would in another woman with the same conjugate, but a larger fetal head, be almost an impossible labor. In any given case in which it is deemed advisable to induce labor prematurely at a certain period, it would be well to make a careful examination at least two weeks prior to that date, in order to ascertain the relative proportion of the fetal head to the pelvic inlet; and should any disproportion be found to exist, labor must be induced immediately. After labor has begun, should engagement fail to occur and the patient begin to suffer from exhaustion, podalic version must be performed and the child extracted : after engagement of the head, if the unaided uterine contractions fail to accomplish the delivery of the fetus, the forceps may be applied and labor terminated artificially. (3) In still greater degrees of contraction in the conjugate diameter of the inlet (from 8 to 7 cm. — 3.1496 to 2.7559 ''^•)' according to the present teaching of the most advanced obstetricians, there is found the indication for symphysiotomy : this may be performed from two to four weeks before term in the graver degrees of contraction, and even then labor will require instrumental assistance in order to be successfully terminated. Should such a case be encountered at term (that is, with the con- jugate measuring from 7 to 6j^ cm. — 2. 7559 to 2.5590 in.), it is probable that the more judicious proceeding would be the performance of a Cesarean section if the consent of the 554 ^ MANUAL OF OBSTETRICS. patient and her family can be obtained. In case of fetal death craniotomy alone must be considered. The applica- tion of the forceps is absolutely contraindicated in all major pelvic contractions. (4) Finally, in all degrees of contrac- tion under 7 cm. (2.7559 i"-) there are but three methods of treatment presented : In the first place, in case a patient with such a grave pelvic contraction be seen during the early months of gestation, the extreme importance of an early termination of the pregnancy should be impressed upon her, and, with her consent, steps to that effect should be instituted. If this course be refused, or if the patient be seen only at or near term, there remain but two procedures either a Cesarean section followed by a Porro operation, or, if fetal death be assured, craniotomy. The Treatment Indicated in the Special Forms of Pelvic Deformity. — The foregoing course of treatment for all pelvic contractions may be specialized as follows: (i) TJie Simple Flat Pelvis: {a) The induction of premature labor if the contraction be extreme : this should be done as early as from the thirty-second to the thirty-sixth week of gesta- tion, if) At term the application of the forceps, the per- formance of version or symphysiotomy, or, in case of fetal death, craniotomy. (2) The Spondylolisthetic Pelvis: The treatment varies according to the degree of deformity and the time at which the patient is seen. It may consist in the induction of premature labor, the application of the for- ceps, or the performance of version, Cesarean section, or craniotomy, the latter only in the case of fetal death. (3) The Rachitic Pelvis : The treatment is the same as that of the simple flat pelvis, with the addition of Cesarean section and the Porro operation in extreme contraction. (4) The Coxalgic Pelvis : The treatment is the same as that of the spondylolisthetic pelvis. (5) The Scoliotic Pelvis: (a) In minor degrees of contraction the treatment is that of the simple flat pelvis. (^) In pronounced contraction .symphy- siotomy, Cesarean section, or craniotomy (in case of death CONTRACTED PELVIS. 555 of the fetus). (6) TJie Osteomalacic Pelvis: {a) Usually labor is not interfered with in the very slight or even in some well-marked cases of the deformity : indeed, in the latter cases it may be so precipitate that energetic efforts at retardation of the advancing head will be indicated, [b) In many cases forceps, symphysiotomy, or version may be required, (c) In rare cases the obstruction may be so abso- lute as to indicate Cesarean section with the performance of a Porro operation. (7) Naegcle's Pelvis : {a) If diagnosed early in pregnancy, labor should be induced as early as the twenty-eighth or thirtieth week of gestation, {b) At term Cesarean section must be performed, or, if the child be dead, craniotomy. Iscliiopubiotomy, or Farabeuf's ope- ration, has been highly recommended (Morisani) in the treatment of labor at term in this pelvis, but its value is doubtful. (8) The Oblique Pelvis of Traumatism : {a) If it be seen early in pregnancy, the induction of premature labor is indicated, [b) At term the treatment is that of the rachitic pelvis. (9) Robert's Pelvis: (a) If seen early in pregnancy, the induction of abortion is required, {b) At term Cesarean section or craniotomy must be performed. (10) The Kyphotic Pelvis : (a) If the pelvic deformity be marked, labor should be induced at from the thirtieth to the thirty-fourth week, (b) At term, after engagement of the head, the forceps should be applied unless the con- traction at the outlet be extreme, when either symphysi- otomy, Cesarean section, or craniotomy (in case of death of the fetus) is indicated. (li) The KypJioscoliotic Pelvis: The treatment is that of the kyphotic or of the rachitic pelvis, according to the type of deformity that is most pro- nounced in the individual case. (12) The Justomi)ior Pelvis : The treatment varies. If seen before term, premature labor must be induced at from the thirty-fourth to the thirty- sixth week ; if seen at term and engagement take place, the child may be delivered by forceps or by symphysiotomy ; if the fetus be dead, craniotomy must be performed ; if en- 556 A MANUAL OF OBSTETRICS. gagement fail to occur, Cesarean section is indicated if the fetus be living, and embryotomy if it be dead. Version is never indicated in this variety of deformity. ( 1 3) TJie Mas- culine Pelvis : {a) If seen early in pregnancy, abortion should be induced. (/;) At term the only course is Cesa- rean section, unless the child be dead, when craniotomy must be performed. (14) The Generally-contracted and Flat Pelvis : (a) The induction of premature labor from four to six weeks before term, (d) If seen at term and en- gagement take place, the fetus may be delivered by for- ceps or by symphysiotomy ; if the fetus be dead, crani- otomy must be performed, (c) If engagement fail to occur and the contraction be not excessive, version may be per- formed; otherwise Cesarean section is indicated if the fetus be living. Pubic Symphysiotomy, or Sigault's Operation. — Pubic .symphysiotomy is the operation of cutting through the pubic symphysis for the purpose of increasing all the diameters of the pelvic canal. Indications. — The main indication for this operation is a marked contraction of the pelvis, from 8 to 7 cm. (3.1496 to 2.7559 i"-)> when the fetus is living and delivery by version or the forceps is impossible. By this operation it is possible to mate- rially increase all the diameters of the pelvic inlet, and thereby render possible a labor that must otherwise be terminated by Cesarean section or craniotomy. According to Hirst, the amount of increase in the pelvic dimensions is as follows: When the pubic bones have been separated by an interval of 7 cm. (2.7559 '^^•) there is an increase in the conjugate diameter of 13^ cm. (0.5906 in.), in the oblique diameter of 3^ cm. (1.3879 in.), and in the transverse diame- ter of a little over 3 cm. (1.1911 in.): with such an increase as this the fetal head can be delivered through a canal that would otherwise be impassable. In the graver degrees of pelvic contraction — that is, in ])elves having a conjugate diameter under 6y^ cm. (2.5590 in.) — there would not be a rUBIC SYMPHYSIOTOMY. 55: sufficient increase in the pelvic diameters after the perform- ance of symphysiotomy to permit of the dehvery of a hv- ing child : such degrees of contraction, therefore, contrain- dicate the operation, as do also assured fetal death and ankylosis of the sacroiliac synchondroses. It is important that the cervix be dilated or thoroughly dilatable. The operation is obviously intended to supplant the radical ope- ration of craniotomy and thereby save the fetal life. Other indications are persistent mentoposterior positions when the child is living, occasionally in occipitoposterior positions and in the presence of small pelvic tumors. Methods of Operating. — There are two well-recognized methods of per- forming symphysiotomy, known respectively as the Italian, or subcutaneous, and the German, or open, methods. The latter consists in making an incision directly over the sym- physis pubis and continuing it down through the line of cartilaginous union. There are two well-founded objections to this plan of procedure : in the first place, the great vessels that are situated at this point are more exposed to injury during the operation; in the second place, the divided joint is exposed directly to contact with the atmosphere and is liable to be soiled with the lochia, thereby favoring the development of sepsis. By far the better method is that adopted by the Italians, the steps of which will now be de- FiG. 150. — Galbiali knife. scribed. Instruments Required. — The Galbiati or Morisani knife (Fig. 150) (a falcate or sickel-shaped knife especially devised for the operation) or a blunt-pointed bistoury; a simple scalpel; two or more hemostatic forceps; a chain-saw (in case osseous union be found) ; a needle-holder and nee- 558 A MANUAL OF OBSTETRICS. dies ; an obstetric forceps ; a metallic catheter; strips of iodo- form-gauze ; strips of adhesive plaster ; Chinese silk for ligatures; antiseptic cotton ; and a strong abdominal binder. The Sti'ps of the Operation. — i. The woman is placed in the lithotomy position at the edge of the bed or table. 2. Thorough asepsis of the abdominal surface, the pubes, the genitalia, and the perineum ; the mons veneris must be shaved. The parts should first be scrubbed with soap and water, and then bathed in boiling water, then in benzine to remove the fat, and, finally, in a i : looo mercuric-chlorid solution. The bladder and bowels must be emptied. 3. Exposure of the Retropubic Space [Space of Retziiis). — A short incision is made in the median line just above the symphysis, about i ^ to 2 inches long and extending to about ^ of an inch above the upper edge of the symphysis pubis ; this incision is carried down to the fascia that lies directly above the recti muscles. 4. The attachment of the recti muscles to the rami of the pubes is then severed to an extent sufficient to permit the introduction of the left index finger, which is passed down over the inner surface of the symphysis to its lower margin, where the line of junction is located. 5. The metallic catheter is passed into the urethra to locate that structure, which is then carried downward and to the right, where it will be least likely to be injured by the operation. 6. Division of the SynipJiy- sis. — The Galbiati knife is passed along the left index finger and made to hook under the symphysis, and at the same time inclined slightly toward the left to avoid the urethra; by a rocking or sawing movement the joint is severed from below upward and from within outward, the bones separating with an audible sound. Care must be taken to divide the subpubic ligament. Occasionally this process requires the exertion of a considerable amount of force : the hemorrhage that invariably follows division of the symphysis must be checked by the introduction of a wedge of iodoform- gauze. The catheter is then removed. PUBIC SYMPHYSIOTOMY. 559 y. Delivery of the Child. — The os is now dilated, the mem- branes ruptured, and, if engagement have taken place, the forceps applied and the head rapidly extracted : as traction is made and the head descends there is produced a consid- erable gaping of the symphysis, and to prevent this from becoming too excessive an assistant should support the sides of the pelvis and the two trochanters ; otherwise rup- ture of one or both sacroiliac synchondroses might follow. If engagement have not occurred, version may be per- formed. During the process of delivery the abdominal incision must be protected by a pledget of iodoform- gauze. 8. After-treatment. — Uterine contraction must be secured in the usual manner. The abdominal wound is then closed — after reintroduction of the catheter — with from four to five sutures, the lower of which passes, if de- sired, through the upper cartilaginous surface of the sym- physis : wiring of the bones, as recommended by many German operators, is an unnecessary and dangerous pro- cedure, not infrequently resulting in necrosis and fistulae ; an antiseptic dressing is applied and secured by adhesive strips. The vagina must be packed with a strip of iodo- form-gauze or filled with a mixture of iodoform and boric acid, I part to 8. A firm abdominal binder, preferably furnished with eyelets, is adjusted and tightly laced. During convalescence a pad must be placed between the knees, and the limbs bound together to secure accurate adaptation of the severed symphyseal cartilages. Catheter- ization of the bladder may be required. The woman must be confined to bed for from three to five weeks. This ope- ration is entirely extraperitoneal, and in the hands of a skilled obstetrician may be performed in five or ten min- utes. Llortality of the Operation. — Taking into considera- tion all the cases reported under the present method of operating, from 5 to 10 per cent, of the patients lose their lives. A certain proportion of this number perish because the operation is not attempted until the vitality is ex- 560 -4 MANUAL OF OBSTETRICS. hausted : an early interference would probably mate- rially lessen the death-rate. Others die from septic infection, exhaustion, pneumonia, and hemorrhage (open method). The infantile mortality is about 20 per cent., mainly arising from injuries during the process of extrac- tion. Dangers of the Operation. — (i) Sepsis. — The close proximity of the genitalia to the abdominal wound and the marked tendency in bone- and joint-wounds to the development of septic processes render the utmost care necessary to avoid contagion after the operation. The strict confinement of the limbs adds materially to the difficulty of thoroughly disinfecting the genitalia and re- moving the lochia. (2) The Development of Vesicovaginal and Urethrovaginal Fistulce. — These may result from care- lessness in the approximation of the pelvic bones. When the symphysis is separated there occurs a forward bulging of the peritoneum above and of the bladder below to such an extent as to almost fill the gap produced. Should these not be carefully replaced prior to the adjustment of the bones, they may readily be caught between, with the sub- sequent production of a fistula. Another possible mode of production is the direct nicking of the bladder by the Galbiati knife at the time of operation. However pro- duced, should .spontaneous cure under antiseptic precau- tions and constant catheterism of the bladder not occur, a secondary operation will be indicated after the close of the puerperal period. (3) Snbseqtieiit Interference with Loco- motion. — For a varying period following symphysiotomy the patients will generally complain of some degree of motility of the joint, inducing a curious waddling gait, which will persist until the fibrous tissue thrown out between the bones becomes organized. In a few cases more or less permanent disability has been noted, but whether or not this is to be an item of serious import in the consideration of symphysiotomy it is too early as yet to determine. (4) Hemorrhage, as has already been CESAREAN SECTION. 56 1 stated, occurs only in the open method of symphysiotomy, due to the cutting or tearing of the venous plexus sur- rounding the neck of the bladder, or of the erectile tissue of the urethra and clitoris. It is exceedingly difficult to control. This is best done by inserting a piece of gauze into the wound and approximating the thighs. This fail- ing, M. L. Harris suggests acupressure made by passing long needles around the bleeding surfaces, with counter- pressure in the vagina. (5) Injuries of the Soft Struc- tures. — In a number bf reported cases lacerations of the urethra, bladder, and vagina have been noted as occurring during the extraction of the child. Such accidents are largely unnecessary, and may be avoided by a careful ex- traction of the child in the axis of the parturient canal, whereby the deep perineal fascia is not subjected to exces- sive strain : lacerations of the soft tissues can occur only when this fascia has been ruptured. Incontinence of urine may follow extensive laceration of the urethra. Cesarean Section. — This is an extraction of the fetus through an incision in the median abdominal line and the uterine wall when delivery through the normal passages is impossible. There are certain so-called absolute indi- cations for the performance of Cesarean section that exist when the delivery of the fetus by any other method is absolutely impossible and the operator has no choice in the selection of the method of delivery. The absolute indica- tions are — extreme degrees of pelvic contraction, as when the conjugate diameter measures 6)^ cm. (2.5590 in.) or under; the presence of large bony growths or exostoses in the pelvis, or of large fibrous or myomatous tumors of the uterus; extreme atresia of the lower genital tract, either congenital or acquired ; the presence of certain irreducible vaginal tumors ; or the occurrence of a grave accident in labor, as rupture of the uterus or sudden maternal death. The advance in obstetric surgery, resulting in a lessened death-rate, has largely diminished the so-called relative indi- .36 562 A MANUAL OF OBSTETRICS. cations in which Cesarean section is the operation of election to the exclusion of other more objectionable operations. One would be justified now in considering any condition that would prevent the delivery of a living child by natural means or by the minor operative procedures as an absolute indication for the performance of Cesarean section, with the view of preserving fetal without undue risk of maternal life. With the adoption of such a view craniotomy on a living child and Cesarean section change places, and the former becomes the more objectionable of the two. With the bril- liant showing of the statistics of the improved Cesarean section, craniotomy should be relegated to those cases in which fetal death is assured. The final decision of such a question must never be assumed by the accoucheur, hov/- ever : after a full explanation of the situation he should submit the matter to the friends of the patient and throw upon them the responsibility of the course pursued. Time of Operation, — The operation may be performed either before or during labor or after the mother's death. The preferable time under any of the absolute indications is from two to four weeks before term, when it is called the elective Cesarean operation. In order to secure a dilated or dilatable cervix at this time a hard-rubber bougie should be introduced into the uterine cavity a few hours before the time set for operation, and labor-pains be thus instituted. In cases in which the patient be not seen until actually engaged in labor, the operation should be performed as early as possible in order to avoid the profound exhaustion that invariably attends neglected cases and adds so materi- ally to the mortality of the postponed operation. Postjnortem Cesarean section is readily performed, and should be done, in late pregnancy, immediately after the death of the woman. The fetal viability is destroyed, as a rule, shortly after, or at the most within thirty minutes after maternal death. Varieties of the Operation. — The simple or original Ce- sarean section consisted in a median abdominal incision CESAREAN SECTION. 563 followed by incision of the uterine wall and extraction of the fetus and its appendages, after which the uterus was allowed to contract and the abdominal wound closed. The improved Cesarean section includes the modifications of this primitive operation as suggested by Sanger, Mijller, and Porro. With the aim in view of preventing leakage of the uterine secre- tions and hemorrhage into the peritoneal cavity, Sanger suggested closure of the uterine wound in the manner here- after described. This, which is known as the conservative Cesarean section, should be done in every case in which it is deemed best to preserve the uterus after extraction of the fetus. In order to prevent the escape of any of the liquor amnii or uterine secretions into the peritoneal cavity, Miiller suggested that after the incision in the abdominal walls the uterus should be lifted in its entirety from the abdominal cavity and secured by hot towels packed around it. The fetus and its appendages may then be removed, and the sec- tion concluded as a Sanger or a Porro operation. Porro sucrcrested that in all cases in which the absolute indications for Cesarean section exist, the proper procedure would be the extraction of the fetus in the usual manner, followed by extirpation of the uterus and its appendages, in order to prevent a subsequent impregnation. The indications for the Porro operation may be stated as follows : (i) Extreme de- grees of pelvic contraction; (2) marked atresia of the cervix^ vagina, or vulva ; (3) the presence of large bony growths in the pelvic canal; (4) large fibrous or myomatous tumors of the uterus; (5) extensive rupture of the uterus, with involve- ment of adjacent structures and profuse hemorrhage ; (6) a relaxed and flabby condition of the uterus after the section, predisposing to postpartum hemorrhage; (7) a septic con- dition of the uterus, with threatened general septic infection. The ijistniments required are those that are needed in any celiotomy. They include a large scalpel ; a pair of scissors; a pair of dissecting-forceps ; a grooved director ; half a dozen hemo-static forceps ; some curved needles ; a needle-holder ; 564 A MANUAL OF OBSTETRICS. some ligatures (fine catgut, silk, and silkworm gut); a num- ber of sterilized towels ; iodoform-gauze in strips 2 inches in width ; a piece of india-rubber tubing 2 feet in length ; two stump transfixion-needles. Four assistants are required — one to administer the anesthetic, one to assist in the opera- tion, one to attend to the instruments and sponges, and one to take care of the child. The temperature of the room should be from 75° to 80° F. Preparatory Treatment (when possible). — (i) Evacuation of the bowels by mild laxatives for two or three days prior to the operation ; (2) thorough asepsis of the vagina and abdomen, including shaving of the pubes, disinfection of the umbilicus, and a vaginal douche of mercuric-chlorid solution, I : 2000 ; the abdominal surface is prepared as for symphysiotomy ; (3) catheterization of the bladder imme- diately before the operation; (4) the primary injection of I dram of ergotin into the thigh. Steps of the Operation. — (i) The patient is placed in the dorsal position, and the entire abdomen, except the field of operation and the upper portion of the thighs, is covered with sterilized towels. (2) The operator, standing to the right side of the patient, with the large scalpel makes an incision through the linea alba down to the uterus : this incision may be enlarged until about 6 inches in length, extending almost to the symphysis pubis and an inch or two above the umbilicus. (3) Miiller's procedure of lifting out the uterus is next performed, and warm sterilized towels are packed into the abdominal wound around the lower portion of the uterus, to prevent the escape of blood or amniotic fluid into the peritoneal cavity. (4) Incision into the Uterus. — The uterus being steadied by the assistant, who also grasps the vessels of the broad-ligament on both sides in order to temporarily control hemorrhage as far as possible, an incision from 4 to 5 inches in length is rapidly made in the anterior median line of the organ. This will be sufficiently large to permit of the ready extraction of the child. The hemorrhage fol- Cesarean section. 565 lowing this incision will be quite profuse, notwithstanding the compression exerted upon the vessels ; especially will this be the case should the placenta be situated under the line of the incision, as not infrequently happens. Rapidity of action is therefore very essential, and the child is grasped by the most accessible portion of its body — usually by the extremities — and immediately extracted. A ligature is thrown around the cord — or two clamps are applied — and it is severed, the child being handed to the assistant specially intended for its care. Attention is now directed to the pla- centa, which, together with the membranes, usually peels off very readily as a result of the rapid contraction of the uterine walls. (5) Treatment of the Uterus. — The termination of the operation depends entirely upon concomitant conditions. If it be desirable to retain the uterus, the procedure suggested by Sanger will be adopted ; if there exist some reason why a subsequent impregnation is undesirable, a Porro opera- tion must be performed. Tlie Sanger operation consists in closure of the uterine wound — after thorough cleansing of the cavum uteri with a 2 per cent, creolin solution — by two tiers of sutures, the primary or deep, that pass through the muscular walls down to the mucosa, and the secondary, snperficial, or seroserons, that are intended merely to effect accurate coaptation of the peritoneal edges, thereby effectually preventing leakage of blood or fluid into the peritoneal cavity. The uterus is first temporarily packed with gauze. The deep sutures (of strong silk, No. 4 or 5) are placed about ^ or ^ of an inch apart, and to expedite their insertion it is suggested that they be introduced as a continuous suture, the loops being left about 4 inches in length : when the loops are cut a row of interrupted sutures is left for tying. The seroserous sutures (of fine silk or catgut, No. i) are introduced, according to the Lem- bert method, at intervals of a quarter of an inch, to secure absolute union of the peritoneal surface : they may also be inserted as a continuous suture, and many operators prefer to 566 A MANUAL OF OBSTETRICS. employ the butt07ihole stitch, which is made by placing the thread beneath the point of the needle before it is drawn through. The adhesions that form close the wound perma- nently within eighteen to twenty-four hours. The iodoform- gauze in the uterine cavity is retained there for twenty-four hours : it prevents further hemorrhage and acts as a means of drainage. TJie Porro operation consists in amputation of the uterus at the cervical junction immediately after the ex- traction of the fetus. The methods of performing this ope- ration are two, based upon the manner in which the pedicle is treated. These methods are known respectively as the intraperitoneal and extraperitoneal methods. The former is the more perfect operation, but is dangerous if the ope- rator be not well versed in the intricacies of abdominal sur- gery : in the hands of an experienced surgeon, however, it is the preferable method. The extraperitoneal method is readily performed, and, the stump being absolutely under control, any hemorrhage that may supervene can be thor- oughly controlled. It is open to the serious objection that it imposes upon the patient a prolonged and tedious convalescence, with increased danger of septic infection and more or less distortion of the pelvic contents and dis- figurement of the abdominal wall. The steps of these two operations are as follows: i. The intraperitoneal method of treating the stump. The fetus having been extracted, the operator secures perfect hemostasis by ligating first the ova- rian and then the uterine artery on each side, the sutures being passed through broad-ligament tissue only, whereby their subsequent loosening from the contraction of enclosed cervical or uterine tissue will be avoided. The uterus is then excised from the broad ligament on both sides, its peritoneal covering incised before and behind, and the cervix ampu- tated by a transverse V-shapcd incision, forming a posterior and an anterior flap: these are united by two or three sutures. There are thus formed three stumps — one of the broad ligament on each side, and that of the cervix below. CESAREAN SECTION. 567 Hemostasis being assured, the pedicles are dropped into the peritoneal cavity, which is then flushed with sterihzed water, and the abdominal wound is closed. 2. Tlic extra- peritoneal method of treating the stump. Should the fore- going method not be adopted, the operator may proceed as follows : The uterus having been lifted from the abdominal cavity, according to Miiller's suggestion, the india-rubber tubing is passed over the fundus and secured firmly around the cervix as low as possible, any adjacent intestinal loop being avoided. The ends of the tubing are drawn tightly, whereby all circulation within the uterine walls is con- trolled. The objection to the use of this tube when a sim- ple Sanger operation is intended is the subsequent tempo- rary paralysis of the uterine tissue that almost invariably follows, with consequent predisposition to hemorrhage. The ligature being applied, the uterine incision is then made, the fetus and placenta are extracted, and, the uterus having shrunk considerably, the rubber ligature is again drawn taut and the knot made secure by one or two addi- tional ties. The transfixion-needles are now passed through the cervix at right angles just above the ligature, and the uterus is excised from one-half to three-quarters of an inch above the needle. The stump thus prepared is next secured at the lower extremity of the abdominal wound. (6) The Toilet of the Peritoneum. — The uterine operation having been completed by one of the three foregoing methods, the peritoneal cavity must be thoroughly fliushed with warm sterilized water, which may be drained off through a ster- ilized glass tube, moderate pressure being exerted at the same time upon both flanks to force out whatever fluid may remain. It is not absolutely essential that all the water be removed, for the peritoneum is fully able to dis- pose by absorption of the small amount that may be left. (7) Closure of the Abdominal Wound. — In the simple San- ger and the intraperitoneal Porro operations this is the same procedure as after an ordinary abdominal section. 568 A MANUAL OF OBSTETRICS. Interrupted sutures of silkworm-gut are placed at intervals of half an inch, each suture passing through all the coats of the abdominal wall, including the peritoneum. Care must be observed to include a goodly portion of the mus- cular tissue in order to avoid subsequent development of a ventral hernia. From eight to twelve of these deep sutures will be required. When they are applied, superficial ap- proximation-sutures, including merely the cutaneous and upper muscular layers, must be passed midway between the deep sutures to secure accurate adaptation of the skin- flaps. When the extraperitoneal Porro operation has been adopted, the lowest deep suture of the abdominal incision must be caused to traverse the stump a short distance {^/^ to yi inch) below the rubber ligature : this secures the stump in place and closely approximates the abdominal wall thereto. (8) Tlie Antiseptic Dressing. — When there is no external stump the dressing is that employed after every abdominal section. The site of the incision and the surrounding abdominal surface are bathed in sterilized water and well dried. A thick dusting of acetanilid, iodo- form, or aristol is made over the incision, the umbilicus, and the pubes ; several layers of moist antiseptic gauze are placed above this, and over all a thick layer of dry gauze. This dressing is securely held in place by strips of adhesive plaster of sufficient length to reach from flank to flank. A many-tailed bandage may then be applied and the patient placed in a prepared bed. The dressing for the stump, when this is secured in the abdominal wound, includes accurate trimming of its edges ; suturing together of the peritoneal edges, to reduce as far as possible the size of the raw surfaces ; the placing around it of a square of rubber dam ; and the application of some drying and antiseptic powder, as acetanilid, equal parts of acetanilid and iodoform, aristol, or equal parts of iodoform and tannic acid. Over this are placed some layers of gauze, and over all the dressing as already described. The stump will require daily dressing CESAREAN SECTION. 569 until it sloughs off in from ten to fifteen days ; the wound remaining must then be dressed with rigid antiseptic pre- cautions. Mortality of Cesarean Section. — Improved technic and better knowledge of the surgery of the abdominal cavity have wrought a marvellous change in the mortality of this grave operation. In the hands of the most skilled operators the maternal mortality of the Sanger-Cesarean section to-day is about 8 per cent., while Porro's operation is attended by a maternal mortality of 37.78 per cent, and an infantile mortality of 22.4 per cent. The causes of in- fantile death are asphyxia from occlusion of the placental circulation or from pressure upon the cervical vessels by the contracting uterus, and traumatism during the process of extraction. Maternal death results from shock, exhaustion, peritonitis, septicemia, and hemorrhage. After-treatment of Cesarean Section. — The after-treatment of this operation is essentially that of an ordinary abdomi- nal section. The patient is kept in the dorsal, position for forty-eight hours, and without a pillow for at least twenty- four hours. At the end of eighteen or twenty hours a pillow may be placed under the knees to alleviate the pain induced by the prolonged dorsal decubitus. An injection of "I" or -^ grain of morphin sulphate should be administered immediately after the operation to diminish the shock and to overcome some of the pain that always follows an ab- dominal section. No food should be allowed for at least twenty-four hours. The intense thirst may be partially relieved by sips of warm water and by frequent moistening of the lips by a cloth wrung out of cold water or contain- ing small pieces of ice. At the expiration of twenty-four hours dram doses of barley-water, alternating with dram doses of milk and lime-water, may be administered at fre- quent intervals (one or two hours), and the quantity grad- ually increased as the patient's stomach can tolerate it. Should nausea and vomiting ensue, all alimentation by the 570 A MANUAL OF OBSTETRICS. mouth must be stopped and rectal enemata given. At the end of forty-eight hours small quantities of beef-juice or peptonized milk may be administered. If the bladder be not evacuated at the expiration of eight hours, a sterilized catheter must be introduced, and this is repeated at eight- hour intervals as required. The child should be given the breast as in normal cases. Unless unfavorable symptoms (tympanites, pain, rapid pulse, vomiting) supervene, the bowels should not be opened until the evening of the second or the morning of the third day. At that time calomel in minute doses (|- or \ grain) may be given every half hour or hour until there result an inclination to a bowel-move- ment, which may then be facilitated by the administration of a rectal enema of soapsuds containing, if desired, a small amount of glycerin and turpentine : the bowels once patu- lous, they should be so maintained. If a Sanger operation have been performed, the intrauterine tampon must be re- moved at the expiration of twenty-four hours, and a second introduced with great care, should there exist any tendency to hemorrhage ; otherwise the simple occlusive dressing may be placed over the vulva and the woman treated as an ordinary puerperal patient. Removal of the Sutures. — The abdominal sutures should be removed on the usual day, the tenth, unless extreme tympanites indicate an earlier removal of one or two to relieve tension. The usual antiseptic dressing is then applied and the abdominal binder firmly secured. The latter must be constantly worn for at least twelve months in order to secure firm union, thereby pre- venting the formation of a ventral hernia, and also tending to preserve the normal degree of rotundity and tonicity of the abdominal walls. The patient may be propped up in bed on the twelfth or fourteenth day, and at the expiration of an additional week or ten days may be permitted to leave her bed, but not the room. The convalescence may be protracted, and during this time the patient must be guarded and treated in the usual postoperative manner. DYSTOCIA DUE TO UTERINE MALFORMATIONS. 57 1 (/;) Malformations of tJie Uterus. — Any variety of uterine deformity may be productive of degrees of difficulty in parturition varying according to the amount of uterine distortion present. Fortunately, most of the cases of impregnation in a double uterus induce long before term symptoms of such gravity that the artificial termina- tion of gestation becomes imperative. Very exceptionally, such a uterus may permit of sufficient dilatation to allow the pregnancy to continue uninterruptedly to term. When the woman falls into labor in such a case, while it is true that parturition may be uncomplicated, she is exposed to the double risk of hemorrhage and obstruction to fetal expulsion. The latter will occur when the unimpregnated uterus is so rotated and displaced downward as to fill the pelvic cavity. The obstruction may become insuperable, in which case uterine rupture will be imminent unless artificial assistance be afforded. Hemorrhage may occur from rup- ture of the attenuated uterine wall, or it may follow partial separation of the placenta, especially when the latter is attached to the inner wall of the uterus — that adjacent to the unimpregnated side : the latter, not undergoing the vigorous contractions of the opposite side, will fail to suf- ficiently compress the lacerated sinuses, and active hem- orrhage ma/ ensue. In such a case rapid evacuation of the uterine contents is imperative, followed by thorough tam- ponade of the bleeding cavity and the administration of ergotin hypodermically and by the mouth. Should lacera- tion of the uterus have occurred, it must be treated accord- ing to the condition that may be present. Under the heading of uterine malformations may be mentioned the so-called antepartum hour-glass contraction (Hosmer), or tetanoid falciform constriction of the litems (Harris), an extremely rare condition in which there exists an absolutely nondilatable internal os : as a result of this obstruction the uterus promptly falls into a condition of tetanic contraction and rupture becomes imminent. The 572 A MANUAL OF OBSTETRICS. treatment consists in the administration of large (15-grain) doses of chloral to induce softening of the cervical tissues. This failing, complete narcosis from ether or chloroform should be induced, and the fetus extracted by forceps or by podalic version, irrespective of the danger of cervical laceration. It may be that Cesarean section will be required before delivery can be accomplished. if) Uterine Displacements. — As has already been remarked, a considerable degree of obstruction to labor may be induced by the various displace- ments of the gravid uterus. The cause of the difficulty is purely mechanical, and the remedy is patent. As far as possible the displace- ment must be corrected, after which the labor will progress satisfactorily. The axis of an antedisplaced uterus may be made to approximate more closely to that of the parturient canal by a firmly-applied abdominal bandage ; that of a laterally deviated uterus may be straightened by a large compress placed under the uterus while the patient lies upon that side to which the fundus is directed. Should a prolapsed uterus fail to assume its normal position during the progress of labor (Fig. 151), the use of the forceps may become necessary to accomplish the delivery of the fetus. The only treatment applicable to that rare condition, sac- culation of an incarcerated retrodisplaced pregnant uterus, is podalic version, extreme care being taken not to rupture the immensely attenuated anterior wall. The feet in such a condition arc generally just within the os, within ready access, and version may be accomplished with unusual ease. Fig. 151. — Partial prolapse of the womb and hypertrophy of the cervix (Faivre). DYSTOCIA DUE TO TUMORS. 573 (^) Tumors — Uterine, Cervical, Pelvic, and Vaginal. — A very serious obstruction to labor results when the partu- rient canal is blocked by neoplasmata, benign or malig- nant. These growths may be situated at any point in the birth-canal, and when present generally constitute an insu- perable obstruction to the descent of the child. The body of the uterus itself may be the seat of fibromata or myo- mata of varying size. The degree of obstruction arising from such tumors will depend largely upon their situation. A fibroid tumor of considerable size may be situated near the fundus, and, aside from the increased bulk thereby produced, give rise to absolutely no trouble. Again, al- though situated in the lower uterine segment, if in the anterior wall of the uterus the tumor may be carried up- ward out of the pelvic cavity by the vigorous uterine contractions, and labor proceed in a perfectly normal man- ner. When such a growth, however, is situated low down in the posterior uterine wall, it becomes impacted under the sacral promontory and constitutes an absolute obstruction to labor. Even should the tumor be displaced during the delivery of the child, it is a constant menace to the safety of the patient. Thus, in the progress of labor the growth may be subjected to such pressure that its vitality, at the best low, will be so impaired that it will undergo sloughing, and cost the woman her life from suppurative peritonitis. Again, it may so interfere with the process of uterine con- traction and involution that convalescence will be pro- tracted, and the woman subjected to the risks of hemorrhage and sepsis and the suffering dependent upon irregular ute- rine contractions. The treatment of these uterine tumors will vary according to the time at which they are first encountered. If the patient be seen early in pregnancy^ the induction of abortion is justifiable in order to avoid the greater dangers attendant upon labor at term ; or a myomectomy may be performed and the pregnancy al- lowed to proceed, if it will do so. If the patient be seen 574 ^ MANUAL OF OBSTETRICS. at term, and the tumor be pedunculated and situated in the most favorable position — on the anterior wall — pos- tural treatment (the woman in the knee-chest position) may, with the aid of suitable manipulations, carry the tumor up out of the pelvic cavity and into such a position that it will be subjected to a minimum amount of pressure. If this cannot be accomplished, the progress of labor must be carefully watched and Cesarean section performed if the tumor fail to retract into the abdomen under the influence of the uterine contractions. Generally, Cesarean section is the only procedure available, and this must be performed as soon as the woman falls into labor. It is interesting to note that, owing to the distortion of the uterine cavity by the abnormal growth, unusual positions of the fetus — as presentation of the breech or a transverse position — are by no means uncommon, and contribute still more to the difficulties of the case. Fibrosarconiata of tJie uterus are occasionally noted. They assume an unwonted rapidity of growth under the stimulus of pregnancy, and may attain enormous dimensions. The only treatment is the Porro operation, performed when the nature of the new growth is ascertained. The cervix uteri may be the seat of mucous polypi, fibroid tumors, or car- cinoma. The mucous polypi must be snared off immediately after the woman falls into labor, as must also the fibroid growths if they be pedunculated ; if sessile and partially intraligamentous, a Porro-Cesarean section is the only proper course of treatment. Advaticcd carciiuvna may induce such a degree of cervical rigidity from cellular infiltration that labor will be absolutely impeded ; therefore it becomes perfectly justifiable to induce abortion or premature labor immediately upon the confirmation of the diagnosis. In case the condition be first noted at the onset of labor, the progress of cervical dilatation must be closely watched, and should the os not dilate, radiating incisions may be made in the hardened tissue to the extent of about one-fourth of an DYSTOCIA DUE TO TUMORS. 575 inch. If dilatation will not then follow, a Cesarean section becomes imperative, after which total extirpation of the uterus should be performed, provided there have not oc- curred an extension of the disease to the vaginal tissues. Among the tumors encountered within the pelvis, and occasionally constituting an obstruction to parturition, are ovarian cystomata, sarcomata of the pelvic bones, bony exostoses, and splanchnic displacements. Cysts of tJie ovary that are most likely to cause serious obstruction to labor are those of small and medium size that have not yet ascended into the abdominal cavity, and that generally, not causing symptoms, are unsuspected before the ad- vent of labor. They occupy a position low down in the pelvis behind the uterus. In cysts of the smaller size the obstruction may not be absolute, but the patient is subjected to the same danger as in uterine fibroids — namely, devitalization and suppuration of the cyst from pressure. The treatment of this condition may be stated as follows: I. If the condition be discovered during gestation, an abdominal section should be performed : in a large per- centage of cases pregnancy will not be interrupted by the operative procedure, especially if care be observed to ma- nipulate the uterus as little as possible. 2. If the tumor be not discovered until the advent of labor-pains, and a more or less distinct pedicle exist, a postural method of treat- ment may succeed, the woman assuming the knee-chest position, and the presenting portion being made to engage after the dislodgement of the growth. This method will answer in a limited number of cases only. '3. Generally it will become necessary to puncture the cyst under thorough antiseptic precautions, draw off the fluid, and allow labor to proceed. The vagina must be cleansed with soap and water and douches of mercuric-chlorid solution (i : 2000). An aseptic trocar is then intro- duced through the posterior vaginal fornix and the fluid allowed to escape : the cyst-walls collapse, the obstruc- 576 A MANUAL OF OBSTETRICS. tion is removed, and the labor proceeds. An abdominal section may then be performed, and the sac removed in the usual manner. 4. Occasionally, owing to the gelatinous nature of the cyst-contents, aspiration of the sac will not suffice. It will then be necessary to perform a Sanger- Cesarean section, and follow this by enucleation of the ovarian cyst. Sarcomata and cncJio)idroniata of the pelvic bones are fortunately of very rare occurrence. When present they so absolutely block up the pelvic canal that labor can only be terminated by a Porro-Cesarean section. Bony exostosis of the pelvis (^pelvis spinosa, Haiidcrs pelvis, acanthopelvis, acanthopelys, spiny or thorny pelvis^ is likewise exceedingly rare. The spinous pelvis is characterized by the presence at various portions of its structure of bony knobs, spines, spicules, ridges, and other outgrowths. The more blunt and rounded projections show a predilection for the sacroiliac synchondroses and the sacral promontory, while the sharper spines are generally attached to the pubic and iliac crests and to the iliopectineal eminences : this is not invariably true, however. The dangers attendant upon such a condition, aside from obstruction to labor when the growths have attained any considerable size, are perforation of the uterine walls during the descent of the head and in- juries of the fetal skull. Should such a condition be dis- covered during early pregnancy, the induction of abortion would be justifiable ; or, if the exostosis be of but small size, labor should be induced from four to six weeks before term, whereby serious injury to mother and child maybe averted. In rarer cases Cesarean section may be required. Renal dislocation has proved in a few recorded instances an almost insurmountable obstacle to the delivery of the child : the displaced organ, sinking to the pelvic inlet, has become lodged near the sacral promontory, where it has become incarcerated by the advancing fetal presentation. If such a condition be encountered, podalic version should DYSTOCIA DUE TO TUMORS. 577 be attempted. This will probably succeed, the kidney being displaced upward as the fetus is dragged down. This fail- ing, a Cesarean section must be performed and the displaced viscus returned to its normal situation. There is quite a variety of vaginal Uunors and analogous conditions that may cause more or less obstruction to labor. Prominent among these may be mentioned the various grades of colpocele, especially of the anterior wall when complicated with cystocele. The advancing presentation under these circumstances pushes the prolapsed and boggy tissues before it until quite a considerable protrusion, often assuming the appearance of a fluctuating tumor, is noted. The treatment of such a condition consists primarily in catheterization of the bladder, followed by an upward dis- placement of the prolapsed tissues. The presenting part may then be dragged down by forceps and further prolapse thereby prevented. In case the catheter cannot be passed, owing to the excessive distortion of the urethra, aseptic a.spiration through the vaginal wall should be performed. Posterior colpocele is exceedingly rare. When encountered it is usually dependent upon constipation with an accumu- lation of scybala in the rectum. When these are removed by enema or by the spoon the obstruction disappears. Vagi- nal cnterocele is also of very rare occurrence, but when en- countered constitutes a serious obstruction to labor. The mass of bowel extends down the posterior vaginal wall, con- stituting in fact a prolapse of Douglas's cul-de-sac, and may even protrude through the vulvar orifice. The danger of such a complication is serious pressure of the bowel with ultimate gangrene. By appropriate taxis, the patient rest- ing in the lithotomy or in Trendelenburg's posture, the hernia may be reduced, after which extraction of the fetus by forceps is indicated to prevent a return of the condition. Vaginal cysts, if noted, must be punctured as soon as labor be initiated, and vesical calculi must be removed by incision through the vaginal wall in order to prevent sub- 37 5/8 A MANUAL OF OBSTETRICS. sequent vesicovaginal fistiiLne and injury to the fetal skull during its transit through the birth-canal. Edema of the vulva, if excessive, may be relieved by puncturing the tis- sues with a fine aseptic needle and allowing the exuded serum to be drawn away. {e) Rigidity or Atresia of the Soft S true tii res of the Partu- rient Canal. — A not inconsiderable amount of difficulty may result from an undue tonicity or over-rigidity of the soft tissues of the lower birth-canal. Such a condition is especially noted in the case of elderly primiparae or in hyperesthetic individuals, a true condition of vaginismus and perineal spasm existing in the latter. Probably the more serious results follow a nondilatable condition of the external os of the cervix uteri. Rigidity of the cervix to a certain degree is by no means an infrequent occurrence. When present it is productive of a vast amount of suffering to the patient and of consider- able anxiety and trouble to the accoucheur. It may arise from a number of causes. As has already been stated, it may be purely a neurotic condition, and is thus especially marked in elderly primiparae and in highly neurotic women. This condition may assume a considerable degree of import- ance on account of the excessive suffering of the patient, which materially interferes with effective uterine contrac- tions. In another comparatively infrequent group of cases the rigidity is a direct outcome of an early escape of the liquor amnii, the cervix not having been subjected to the gradual dilating influence of the bag of waters (" dry labor ") : the attendant pain results mainly from the direct pressure exerted by the fetal presentation upon the cervical lips. Nondilatation very often results in these cases from failure of the presenting part to engage after the early rupture of the membranes, the orifice being insufficient to admit the blunt presenting portion. If the condition be not speedily relieved, it is not uncommon for the uterus to fall into a state of tetanic contraction, when all the RIGIDITY OF THE TISSUES. 579 symptoms and dangers of grave obstruction to labor will supervene. Again, the rigidity may be due to ineffectual uterine contractions — the so-called primary uterine iner- tia — or to an abnormal induration or infiltration of the parts, eitlier from the presence of cicatrices or from in- flammatory products : it may be the result of constipation or distention of the bladder; it may be due to a pre- mature onset of labor, the parts not yet being prepared for the escape of the fetus ; or there may be a natural in- elasticity of the tissues. Whatever the cause, the symptoms of cervical rigidity are the same. There is an exaggerated suffering on the part of the patient ; the uterine contractions are irregular and deficient in power ; the os fails to dilate ; and the symptoms of obstruction supervene. A physical exploration will reveal the existing condition. The treat- ment will depend largely upon the cause of the rigidity. If it be neurotic, Playfair's treatment, as already de- scribed, is an excellent plan to pursue. Under the influence of the chloral the tissues rapidly soften, the nervousness is controlled, and the pains lose much of their irregularity and become stronger while more infrequent. The drug may be given by the mouth or in the form of a rectal suppository or enema. Hot vaginal douches directed against the ante- rior cervical lip are likewise very efficient in inducing more powerful uterine contractions, while at the same time caus- ing rapid softening of the cervical tissues. In some highly sensitive women it may become necessary to administer small doses of a narcotic, or to deliver by instruments under an anesthetic after forcible digital dilatation, repairing immediately any cervical laceration that may result. Rigidity of the perineum, or perineal spasm, is occasion- ally noted in primiparae. It may likewise be purely a neur- osis, but is generally due to a contracted pubic arch, which prevents close apposition thereto of the occiput : the latter is in consequence forced down upon the perineum, and a rupture of the floor results. In multiparae it may excep- 580 A MANUAL OF OBSTETRICS. tionally follow from the presence of cicatricial tissue due to an old laceration or some previojjs operation. When perineal rigidity exists to a moderate degree, it may be partially overcome by the frequent anointing of the parts with cocain-and-belladonna ointment. Gentle manipulation, together with the application of the methods of preserving the perineum already described, may prevent extensive lace- rations. Should the latter occur, however, immediate repair is indicated. Atresia, either congenital or acquired, may be found at any point from the internal os to the vulvar orifice. Atre- sia of the cervix is very rarely complete, and then is cica- tricial in origin, resulting either from extensive laceration at a previous labor or operative procedure, or, more rarely, from severe cervical endometritis with erosion and adhe- sion of the lips, the latter taking place after impregnation has occurred. The degree of contraction may be so ex- treme that but a mere indentation will indicate the site of the external os. The treatment consists in hot vaginal douches and the administration of large doses of chloral. If the tissues do not yield before the pressure exerted by the presenting part, a uterine sound may be forced through the indentation, or two or three small radiating incisions made by a guarded bistoury (preferably under ether) : the opening thus secured may be increased in size by the fin- gers. A certain amount of dilatation having been accom- plished, the further progress of labor will be normal. That variety of atresia, if such it may be termed, depend- ent upon a condition of hypertrophic elongation of the cer- vix is exceedingly rare. The dangers incurred under these circumstances are prolongation of the labor from slow dila- tation of the OS, and incarceration of the cervical lips between the symphysis pubis and the fetal head, with edema and, it may be, ultimate sloughing of the devitalized tissue. It is possible for an almost complete obstruction to follow such a condition, and cases are on record of the RIGIDITY OF THE TISSUES. 58 1 performance of Cesarean section to overcome the diffi- culty. Such a termination, however, will scarcely ever be justifiable. The usual measures should be adopted to in- duce softening and complete dilatation of the parts, and when this has been accomplished, efforts must be made to displace the elongated lips above the presenting part, where they will escape any excessive pressure. To accomplish this it may become necessary to make numerous radiating incisions, or even to amputate a portion of the redundant tissue. The pressure of the fetal head, which must then be delivered by forceps, will arrest any undue hemorrhage, and after the delivery of the child the bleeding vessels may be immediately ligated. Atresia of the vagina., or colpostcnosis — a congenital con- dition or the result of lacerations during previous labors, obstetric or gynecologic operations, or phagedenic ulcer- ation — may exist in any degree, from that constituting a trivial obstruction to labor, to an almost complete oblitera- tion of the canal. The minor degrees of contraction usu- ally yield readily before the advancing part. It may, how- ever, become imperative to dilate the constricting bands by the Barnes or the Champetier bag, by numerous incisions (care being taken to arrest any hemorrhage), or by instru- mental delivery. In the graver cases a Cesarean section may be required. Vulvar obstruction may be due to cicatricial contraction, to agglutination of the lips from some severe inflammatory process occurring during gestation, to an extensive hemor- rhoidal condition, to marked edema of the parts, or to a persistence of the hymen. Cicatricial contraction must be overcome by free incision with dilatation by Barnes' bag or by the fingers, followed by instrumental delivery of the fetus. The agglutinated lips must be freed by incision, and after the delivery of the child the parts separated by pledgets of antiseptic gauze. The hemorrhoidal or throm- botic obstruction may be largely averted by a proper atten- 582 A MANUAL OF OBSTETRICS. tion to the bowels during the later weeks of gestation. Should a large effusion of blood occur, the mass must be evacuated by an incision, the fetus delivered at once by forceps, and the bleeding points ligated. Subsequently great care must be exercised to avoid septic infection. Edema of the vulva is rare, and is generally a concomitant of renal disease. Not only will the labia be immensely swollen, but the edema may even extend to the abdomen or down the thighs and into the perineum. The obstruc- tion may be relieved by numerous aseptic punctures of the edematous tissue whereby the exuded serum may drain away. Very generally a persistent hymen will yield before the advancing part : nothing, therefore, need be done in this condition unless the hymeneal structures be of unusual density, when one or two radiating incisions will remove all obstruction. (4) Maternal Accidents. — {a) Rupture of the Birth-canal. — The most common accident to the parturient woman is rupture or laceration of some portion of the birth-canal. Fortunately, such a complication is most likely to occur in the lower parturient canal, involving the cervix, vaginal walls, or perineum, where it is attended with the minimum amount of danger and is most accessible to treatment. Rarely, however, the upper portion of the canal yields, and that alarming condition, rupture of the uterus, must be dealt with. These various forms of rupture, together with the marginal variety of placenta praevia and adher- ence of the placenta, give rise to that complication known as intrapartum hemorrhage. Rupture of the uterus \'~, TiL laceration of some portion of the uterine wall occurring during the process of parturi- tion, and giving rise to hemorrhage, pain, and collapse. This is an exceedingly rare accident of labor, occurring not more than once in 4000 cases. Rupture of the ute- rus may occur during pregnancy and during the pucrpe- rium, as well as in labor itself Tims the mere stretch- RUPTURE OF THE UTERUS. 583 ing of the uterine wall by the developing fetus may in- duce the so-called spontaneous rupture of the uterus as already described; or a rapidly developing cystic degenera- tion of the chorion may involve so much of the uterine muscle as to result in perforation of the wall. When the accident occurs during the puerperium it can result only from one of two conditions : either the woman is septic and suffering from a dissecting metritis with purulent foci in the uterine walls, one of which has yielded, or there has been a nipping of a portion of the wall between the pubic bones or a projecting exostosis and the fetal head, resulting in so much devitalization of the tissues that an extensive slough- ing has occurred. Etiology. — The exciting causes of ute- rine rupture during labor are some insuperable obstruction to the delivery of the child, misdirected or injudicious efforts at version or other obstetric manipulation, and tetanic action of the muscle of the upper uterine segment produced by the administration of ergot during the early stages of labor. This includes all that has been considered under the subject of obstructed labor. This accident is especially liable to occur when certain predisposing causes, maternal and fetal, exist. The maternal predisposing causes are — frequent childbearing, resulting in a diminished tonicity of the uterine walls; undue prolongation of labor, resulting in exhaustion or paralysis of the uterus ; some variety of uterine deformity, as bicornate uterus. The/l'/rt/ predispos- ing causes are — male sex of the child, from the concomitant over-size and more rigid cranial ossification ; hydramnios; and malpresentations. The site of the rupture varies, but it is always low down in the lower uterine segment, generally upon the posterior wall, and very frequently to the left of the median line. It is generally situated transversely to the uterine axis or sometimes obliquely, and may extend from its point of origin into the upper segment, and even involve the fundus uteri. The latter situation is exceedingly rare, and usually occurs when uterine deformity is present or 5S4 A MANUAL OF OBSTETRICS. when there has preexisted at this point some variety of uterine traumatism : this, therefore, is the usual seat of rupture during gestation. That occurring during labor is usually situated low down, near or slightly above the cervix. The extent of the tear varies from a slight yielding of the muscular coat only {incomplete rupture) to a rent involving the entire length of the uterus and penetrating into the peritoneal cavity {complete rupture; Fig. 152). Occasionally all the tissues yield with the exception of the peritoneal coat: in this case the hemorrhage that results collects un- der the delicate serous tissue as an extrauterine and, at the same time, extraperitoneal he- matocele, no com- munication having been formed with the free abdominal cavity. Again, though very rarely, the rupture may be confined entirely to the peritoneal coat, the patient rapidly bleeding to death. Some observers remark that the longi- tudinal tears arc more frequent and are caused by shoulder presentations, while circular tears result generally from con- tracted pelvis. The accuracy of this statement has not been positively demonstrated. Symptoms of Uterine Rifpture. — Rupture of the uterus does not occur abruptly in ob- structed labor. Parturition begins in a natural manner, the woman experiencing normal uterine pains of average severity. The membranes finally rupture and the liquor aninii escapes, but the solid contents of the uterine cavity Fig. 152. — Complete rupture of the uterus (Auvard). RUPTURE OF THE UTERUS. 585 — either because of some malposition of the fetus, as a transverse presentation, or other form of obstruction, as a pelvic contraction, fibroid tumor, or over-size of the fetal head — cannot engage in the superior strait. The uterine contractions become more frequent and more severe, the upper uterine wall becoming dense as the pains increase in severity. Owing to the somewhat fixed position of the cervix below, the intervening portion of the body of the uterus — the lower uterine segment — stretches as the upper segment retracts, and the thinning of this segment manifests itself clinically by an ascent of the contraction-ring of Bandl, which is to be recognized as the premonitory sign of ute- rine rupture, and which, when once discovered, constitutes a positive contraindication to any obstetric maneuver that will throw additional strain upon the already overtaxed lower segment. Podalic version cannot be attempted when such a combination of circumstances exists. Should the condition still be overlooked, notwithstanding the discovery of the furrow across the anterior uterme wall, the pains will become almost, if not entirely, one continu- ous tonic contraction, the woman's sufferings will be intense, and the abrupt onset of a characteristic group of symptoms will indicate a yielding of the over-distended uterine wall. During the height of an intense uterine contraction the woman will experience an acute agonizing pain, causing her to emit an ear-splitting shriek. This, it is said, may be accompanied by a sound of tearing tissues audible not only to the patient herself, but to those in attendance in the room. Instantly there will occur an absolute cessation of all uterine contractions, and the patient will almost immediately fall into a state of collapse with symptoms of internal hemor- rhage. Her expression is anxious ; the pulse becomes exceedingly rapid, small, and irregular ; the face is pallid, the skin moist and cold ; respiration is shallow and rapid, and usually air-hunger is noted ; there is a tendency to nausea and vomiting; muscae volitantes and tinnitus aurium 586 A MANUAL OF OBSTETRICS. are complained of; and in neurotic individuals one or more convulsions may be noted, the woman rapidly falling into a state of coma. There may occur a free hemorrhage from the vaginal canal, or this may be entirely absent, the blood escaping into the abdominal cavity. Not infrequently the presenting fetal part will be found to have disappeared from the internal os, while in its place may be felt a ragged rent through which may protrude one or more loops of intestine. Palpation may also discover in rare instances a certain amount of subperitoneal emphysema on the anterior or lat- eral aspects of the uterus. This results from putrefactive changes or from the entrance of a small amount of air beneath the peritoneal investment. The diagnosis of this serious accident is to be made mainly by a physical exploration after the appearance of the foregoing group of symptoms. The state of collapse, the recession of the presenting part, the presence of two distinct abdominal tumors, the hemorrhage, and the detec- tion of the rent by digital exploration will at once reveal the condition. Occasionally, when the fetal part is not dis- placed and there exist only the symptoms of hemorrhage and collapse, the accoucheur may be called upon to dif- ferentiate between complete and incomplete uterine rup- ture and premature detachment of the placenta. Each of these accidents is attended by profuse hemorrhage, and each induces collapse. There are some points in the his- tory, however, that will aid in the diagnosis. The points of differentiation from accidental hemorrhage have already been noted. From incomplete rupture : Coviplete Uterine Rupture. Iticomplete Rupture. There will be an escape of a portion of the There will be a protrusion to one side of the fetus into the abdominal cavity, where it uterus, consisting of the fetus surrounded may be palpated and its parts recognized. by the unruptured portion of the uterine wall. The fetal parts cannot be clearly outlined. The additional tumor is movable. The uterine projection is immovable. The fetal presentation will recede. The fetal presentation will persist. kUPTURE OF THE UTERUS. 587 Prognosis. — No more serious condition than this can be encountered in the practice of obstetrics. If unrcHeved, as is generally the case in the usual country practice, fully 90 per cent, will perish, death following almost imme- diately from shock or primary hemorrhage, or within two or three days from repeated secondary hemorrhage or the development of septic peritonitis. Under the improved methods of treatment the mortality in the best hands is still as high as 55 to 60 per cent. Several complications may exist and add materially to the gravity of the case. Thus the rent may involve the rectum, in which case there may occur an escape of feces into the peritoneal cavity ; or the bladder may be lacerated simultaneously, with an escape of urine into the pelvic cavity or a gradual infiltration into the surrounding tissues, and resultant gangrene of the parts ; a loop of intestine may slip through the rent into the uterine cavity, and there be incarcerated by the uterine contraction, the woman perishing from intestinal obstruction with gan- grene ; marked pelvic and abdominal emphysema may ag- gravate the case, or an immense hematocele may rupture secondarily, causing sudden death from hemorrhage, or it may suppurate, with the production of a late septic peri- tonitis. The /cY^^/ mortality is at least 95 per cent., death resulting from asphyxiation from interference with the feto- placental circulation or from obstetric manipulations. The treatment consists in the adoption of stringent pro- phylactic measures: this will necessitate an absolute diag- nosis of the existent condition before labor commences and during the progress of its initial stages. The judicious em- ployment of anesthetics in neurotic individuals in whom there is manifested a tendency to tetanoid uterine contrac- tions may avert much trouble. In minor degrees of pelvic contraction a close watch must be kept over the uterine contraction, and a rise of Bandl's ring will constitute an urgent indication for the artificial termination of labor either by forceps or by perforation in case of fetal death. In 5^8 A MANUAL OF OBSTETRICS. neglected transverse presentations version is absolutely con- traindicated, and the only resource left will be decapitation. The fundamental principle in all cases of threatened uterine rupture is early termination of labor irrespective of fetal risk, and by the method most conducive to maternal safety. Rupture having occurred, the active course of treatment only should be adopted. As already stated, the expectant method is almost certain to result in maternal death, while absolutely fatal to the offspring. The exact course to pur- sue will depend entirely upon the extent of the rupture and the amount of fetal displacement. It must be borne in mind that rupture of the uterus does not necessarily im- ply rupture of the fetal sac at the same point, and while the sac remains intact above there can be no escape of the anmiotic fluid or other uterine contents into the free peri- toneal cavity, although there may exist a protrusion of the membranes through the rent. If this favorable condition exist, the accoucheur is perfectly justifiable in adopting the least radical procedure that the exigencies of the case will permit. Merz of Basel, who has made an exhaustive study of uterine rupture, has suggested a plan of treatment under various conditions that may be offered as the general con- sensus of opinion of the leading obstetricians and abdom- inal surgeons. Briefly stated, this (somewhat modified) is as follows: i. If the fetus be lying within the uterus, po- dalic version should be performed at once and the child rapidly extracted. A careful examination must then be made as to the site and extent of the rent : if it be low down, small, and absolutely closed by the uterine contrac- tions, and especially if it be situated posteriorly, an expect- ant course of treatment may be adopted. This will include an immediate evacuation of clots and shreds of membrane, the administration of a douche of warm sterilized water or of a weak solution of creolin (j^ per cent.), the administra- tion of one or more hypodermic injections of ergotin, the introduction of a strip of iodoform-gauze to the fundus RUPTURE OF THE UTERUS. 589 uteri, and the application of a firm abdominal binder. The gauze may be removed at the expiration of twenty- four or thirty-six hours. Upon the first indication of peritonitis an abdominal section must be performed and the peri- toneal cavity flushed with hot sterilized water. A high situation of the rent will contraindicate the adoption of this plan of treatment, as will also a tear in the anterior ute- rine wall (Lusk remarks that all such tears invariably terminate fatally). 2. When the rent is large and a portion of the fetal body has escaped into the abdominal cavity, the head, however, remaining fixed or resting just above the pelvic brim, forceps should be applied and the child rapidly extracted. This failing, abdominal section must be performed, the child removed, and, if possible, the rent closed according to the Sanger method. The abdominal cavity must then be irrigated and the patient treated as a case of simple Cesarean section. 3. If the entire fetus have escaped into the abdominal cavity, or the lower portion alone remain in the uterine cavity, abdominal section must be performed at once, the child removed, and the uterine rent sutured. 4. If the rent be extensive and ragged, involving adjacent structures, or if there exist a septic condition of the parts, a Porro-Cesarean section, or, better still, a total extirpation of the uterus with complete closure of the peritoneal cavity, is the only plan to pursue. Laceration of the bowel or bladder must be repaired in the usual manner by the Lembert suture. The after-treatment is essentially that of an ordinary ab- dominal section. The patient should immediately receive a hypodermic injection of \ or \ grain of morphin, with j^q- grain of atropin. A close watch must be kept over the gauze drainage if the uterus be left in situ, or over the glass tube if this be employed. Stimulants in suitable amounts are indicated, and the usual dietetic precautions must be adopted. Should the patient recover and subsequently become impregnated, the induction of premature labor at 590 A MANUAL OF OBSTETRICS. the eighth month is strongly recommended by some ob- stetricians to avoid the possibiHty of a spontaneous rupture of the uterus. Rupture of the uterus during pregnancy or the puerpe- rium must always be treated by abdominal section. In the puerperal variety extirpation of the uterus is generally re- quired; the mortality of such cases is almost absolute. Laceration of the Cervix. — Some degree of laceration of the cervix uteri occurs in almost every labor, and in- variably in the case of primiparae. By this statement is meant that the external os uteri no longer retains its original form : it is lacerated bilaterally to a certain extent, and this laceration constitutes one of the signs of a previous labor. In many cases this normal laceration becomes exag- gerated, and the condition is then recognized as laceration of the cervix. Most commonly such a tear occurs in the anterior median line, as may be demonstrated by a routine examination of the cervix immediately after parturition. The lips of the rent in these cases are not exposed to outward tension, and, in consequence, by the close of the puerperium union has occurred and the condition com- monly escapes observation. The most common clinical variety of cervical laceration is that extending to one or the other side of the cervix {tinilateral laceration) or that in- volving both sides {bilateral laceration). Not infrequently there occurs a partial yielding of the tissues on each side without entire division through the vaginal mucosa : the OS in these cases is quite patulous, but there is no ever- sion of the lips, as in the case of complete bilateral lacera- tion. This condition is known as an incomplete cervical laceration, or more commonly as "« patnlons cennx." On the contrary, the tear may be very extensive to one side, and include not only the external os, but extend from the internal os through the cervical tissues, including the vaginal junction. This condition has been termed by Pryor extraperitoneal rupture of the nterus. Again, LACERATION OF THE VAGINA. - 59 1 there may occur three or more radiating tears dividing the cervix into sections, and this is termed a stellate laceration of the cervix. Finally, the entire portio vaginalis may be torn away and extruded in front of the fetal presentation. Cervical lacerations seldom fall into the hands of the obstetrician for repair. It is only Vi^hen the laceration is extensive enough to involve the circular artery or one of its branches, thereby inducing active hemorrhage, that immediate treatment becomes necessary. One or two sutures of silkworm-gut may then be passed and the hemorrhage controlled, after which a vaginal douche should be given and a strip of iodoform- gauze inserted into the vagina and retained there for twenty- four hours. Generally the tear is allowed to remain until some date subsequent to the puerperium, at which time a secondary trachelorrhaphy is performed. The primary operation upon the cervix has not been followed by the best results, and has fallen into disrepute. Laceration of the Vagina. — The vagina may be ruptured in either its upper or its lower extent. The more serious con- sequences follow rupture of the upper vaginal region, and this in its etiology and symptomatology closely simulates rupture of the uterus. In certain cases of obstructed labor, notably those associated with neglected trunk presenta- tions, the firm contraction in the upper uterine segment, together with the upward traction exerted by the longi- tudinal bands of muscular tissue, not only carry upward the lower segment of the uterus, but also cause the dilated cervix to retract above the impacted shoulder. The main strain consequently falls upon the vagina, which is thinned to an alarming degree and may eventually rupture. Again, in certain cases of pendulous abdomen associated with vary- ing degrees of pelvic contraction, rupture of the distended posterior vaginal wall is not uncommon. Extensive lacera- tion of the cervix may be continued through the vaginal walls and even open into the cavity above. In difficult 592 A MANUAL OF OBSTETRICS. high forceps operations enormous tears of the vaginal walls may be produced, extending from the cervix to the vulvar orifice and involving not only the mucosa but the deeper tissues. Large vessels have thus been ruptured, and even such important organs as the ureters injured. During the puerperium, if there have been a protracted labor with a long-continued pressure of the child's head upon the vaginal walls, extensive sloughing of the devitalized tissues may ensue, with the formation of vesicovaginal or rectovaginal fistulae. Vaginal lacerations, it will be noticed, therefore, may occur spontaneously from overstretching of the parts : they may, and most commonly do, result from instrumental interference, or after labor from sloughing of the devitalized tissue. The most common seat of vaginal tears due to stretching is the upper posterior wall, while sloughs are more common upon the anterior wall, and in- strumental lacerations occur either posteriorly or anteriorly. The only symptom of vaginal laceration is hemorrhage, which may be profuse, but is rarely excessive. The remote consequences of such an accident are of more serious im- port. More or less vaginal subinvolution will follow, the puerperium will be protracted, the lochia increased in amount and altered in quality and appearance, and the woman exposed to greater risks of sepsis. The proper course of treatment is immediate suture of the laceration under antiseptic precautions, followed by the introduction of a vaginal suppository of iodoform (25-30 gr.), and a daily douche of a 2 per cent, solution of creolin. If slough- ing occur to a limited degree, the resulting fistula may be healed by daily applications of silver nitrate or nitric acid to favor granulation. Larger fistulne must be closed by some appropriate plastic operation. Laceration of tlic vulva is occasionally noted. It is ex- ceptional for the fourchet to escape intact in a first labor, and not infrequently the tear becomes a true perineal lace- ration. In difficult instrumental labor more or less serious LACERATION OF THE PERINEUM. 593 lesions of the nymphse, and even tears and erosions involv- ing the labia majora, are by no means rare. These lacera- tions must be repaired at once, if of any extent, one or more silkworm-gut sutures being inserted. Contusions and minor lacerations of the vulva require antiseptic washes and the introduction daily of a vaginal suppository of iodoform. Laceration of the Perineum. — The most common lacera- tion of the birth-canal is that involving the pelvic floor. Perineal lacerations occur in from 25 to 35 per cent, of all primiparae and in from 3 to 6 per cent, of multiparae. The causes of this accident are excessive rigidity of the tissues, as frequently noted in elderly primiparae; a small sub- pubic angle ; malpositions and malpresentations of the fetal head; over-size and precipitate delivery of the fetal shoulders and abdomen ; the improper use of the obstetric forceps ; and extreme friability of the parts, as in grave specific infec- tion, marked obesity, or pathologic cutaneous conditions. Even when these predisposing factors are present, however, careful supervision of the forces of labor will save many a perineum that would otherwise inevitably be lacerated. After every labor it should be the routine duty of the ac- coucheur to examine closely for perineal lacerations — not only the simple median tears, but those that are more readily overlooked because not involving the cutaneous surface. To discover these the labia must be well sep- arated in a strong light, and a visual, as well as a digital, examination made. The varieties of perineal laceration are — i. Incomplete lacerations, or simple tears in the me- dian line extending down from the fourchet and dividing the perineal body. These appear as ragged rents vary- ing in depth from a mere scratch to an inch or more, but not involving the sphincter muscle of the bowel. There may be an associated tear of the vaginal mucosa of varying extent. 2. Lacerations of the vaginal sulci, one or both. These are tears that, often beginning in a central laceration, but very frequently occurring independently of any external 38 594 ^ MANUAL OF OBSTETRICS. rupture, extend obliquely upward and outward along the line of junction of the anterior and posterior vaginal walls. They may consist merely in a superficial separation of the mucous and submucous tissues, or there may be an actual division of the fibers of the levator ani muscle, resulting in permanent disability with relaxation of the pelvic floor, whereby the support of the pelvic viscera is impaired and their ultimate prolapse favored. 3. Complete rupture of the perineum, a laceration in the median line extending entirely through the perineal body and destroying the continuity of the sphincter ani muscle. Such a tear may begin at the fourchet and extend into the bowel, or in rarer instances the rectovaginal septum may be ruptured high up by a mis- placed fetal extremity, and the tissues intervening between this perforation and the anus may be torn through during the delivery of the child. These tears involving the rectum are the most troublesome to the physician and the patient : inducing an absolute incontinence of flatus and feces, they reduce the woman to a most deplorable condition, and if not corrected, absolutely exclude her from social duties and render her an object of aversion not only to her family and friends but also to herself It seems almost in- credible that such a condition should be permitted to exist for weeks, and even for ten to twenty years or more, as has been recorded in some instances. Unlike simple median tears, there is shown but little tendency for such extreme lacerations to heal spontaneously during the puerperium : this results mainly from the contraction of the torn fibers of the sphincter ani muscle, which separates the lips of the wound. Ver)' rarely, however, even under these unpropitious circumstances, a spontaneous cure has followed an expectant course of treatment with appropriate antiseptic washes and close approximation of the knees. 4. Central perforatio7i of the perineum. In a certain number of cases, especially in those in which there has not been maintained a perfect flexion of the fetal head, an undue amount of pressure is LACERATION OF THE PERINEUM. 595 brought to bear upon the vaginal wall some distance above the pelvic floor. A rupture occurs at this point, and the fetal head, instead of pursuing the usual curve of the lower parturient canal, is driven forcibly through the perineal body and produces a rupture of the skin-perineum midway be- tween the anal orifice and the fourchet. It is even possible, though extremely rare, for the entire fetus to escape through such an opening without the tear communicating with the vulva above or the rectum below. Tears of the perineum very seldom produce immediate symptoms. It is only when a vessel is torn that the hem- orrhage will call attention to the condition of the parts. Not infrequently the tissues may be seen to yield before the advancing presentation, or they may be felt to tear as the trunk and extremities are driven through the vulvar orifice. Treatment. — The most important element in the treatment of perineal lacerations is prophylaxis. A very large pro- portion of tears may be avoided by skilful management of the forces of labor, as already described (page i66j. If, notwithstanding these measures, a laceration result, the proper course is the immediate repair of the injury. Pri- mary perineorrhaphy, if carefully performed, is almost in- variably followed by satisfactory results. There exist weighty reasons why the operation should be performed immediately after the injury. In the first place, the edges of the wound are fresh, and no loss of tissue is incurred by denudation ; secondly, the patient is saved the incon- venience of a secondary operation and the danger of septic infection during the period of granulation ; finally, if the wound be immediately closed and the edges of the muscular fibers coaptated, the perineal floor will not be irretrievably weakened as a consequence of muscular atrophy arising from disuse, as will almost inevitably follow a neglected laceration. Operation. — Perineorrhaphy is most satisfactorily performed under anesthesra : a thor- ough exploration of the parts can then be effected 596 A MANUAL OF OBSTETRICS. and the amount of injury accurately ascertained. An antiseptic vaginal douche should be given, and the wound, if not a complete laceration, closed by silkworm-gut or catgut sutures. For the simple median tear all that is required is the passage of one or more deep sutures, including the entire depth of the wound down to the vagi- nal mucosa, and entering and emerging on the cutaneous surface at equal distances from the perineal raphe on each side ; these sutures are tied in the median line. If there be a vaginal laceration extending up the sulcus upon one or both sides and dividing the fibers of the levator ani muscle, vaginal sutures must first be inserted after the manner prescribed in Emmet's operation, and the perineal wound closed as before. The closure of a complete lacera- tion through the sphincter ani muscle is a more difficult procedure. The operation resolves itself into three stages : In the first place, a strong suture of silkworm-gut must be inserted from the skin-perineum to the depth of the wound, and in the plane of the rectovaginal .septum, in such a manner as to include within its grasp the torn fibers of the sphincter ani muscle. This suture emerges at a corre- sponding point upon the opposite side of the perineum. It need not be made taut until after the other sutures are passed. The next step includes the suturing of the rectal and vaginal mucosae, which are closed by a sufficient num- ber of fine catgut sutures, beginning above at the apex of the rent on the vaginal surface and extending down so as to include the rectal mucosa. Some prefer to close the two mucosiK separately — first the rectal, the sutures being tied within the rectum, and then the vaginal, with the knots lying within the vagina: this method will answer very well in many cases. The rectovaginal septum having been re- paired, the sphincter-suture may be drawn taut and the rectal orifice thus firmly closed. There now remains the third stage of the operation — namely, closure of the peri- neal laceration — which is accomplished by a series of silk- VAGINAL AND VULVAR THROMBOSIS. 597 worm-gut sutures passed in the manner already described. The injury being thus repaired, a thick coating of acetanilid or iodoform is dusted over the wound and a vaginal sup- pository of iodoform inserted. In the graver tears it will be well to bind the knees together, a towel being placed between, for a few days. The after-treatment consists in attention to cleanliness, the opening of the bowels on the third or fourth day, and the administration of daily vaginal douches. The sutures, if of silkworm-gut, must be re- moved on the seventh or eighth day. ip) Vaginal and Vulvar TJirombosis ( Vulvar or Labial Hematoma ; Pudendal Hematocele). — The varicose condi- tion so common in the pelvis, vulva, and vagina during the later weeks of pregnancy may become a condition of con- siderable menace to the patient. Rupture of one of the dilated vessels may follow at any moment, and especially during the progress of labor. Should this occur externally, a profuse hemorrhage, that may even result fatally, will follow. If rupture take place subcutaneously, there will result an effusion of blood into the cellular tissue. There will thus be formed a labial, vaginal, or subperitoneal {broad- ligament) hematocele, according to its situation. Curiously enough at first sight, it has been demonstrated that puden- dal thrombosis is more common in primiparae, in whom the varicose condition is rarely so excessive as in multiparas. This frequency in first labors may be explained as fol- lows : In the first place, the varicosities, not having attained the enormous size that is common in multiparae, are not so productive of discomfort, and, if entirely vaginal, are not discovered by the patient ; consequently, she does not exercise the same care in avoiding injury; secondly, the chronic phlebitis that invariably follows a protracted vari- cose condition renders an additional support to the dilated veins in subsequent pregnancies by causing an immense hypertrophy of the adventitia of the vessels ; hence rup- ture in these veins cannot so readily occur. Hematocele 598 A MANUAL OF OBSTETRICS. of the broad ligament may speedily prove fatal by second- ary rupture into the free abdominal cavity. Vulvar hema- tocele occurs most commonly during labor, and is then generally produced by direct traumatism, either from the pressure exerted by the fetal head or from the use of the forceps. According to Winckel, this complication is en- countered but once in 1600 labors. Syniptoins. — During the height of a paroxysm the woman will suddenly ex- perience an acute lancinating pain in the region of the vulva, quickly followed by intense bearing-down pains at irregular intervals, and associated with symptoms of con- cealed hemorrhage — collapse, rapid small pulse, coldness of the surface, and vertigo. The pain radiates to the lum- bosacral region and down the thigh. Very shortly there follows a swelling of the vulvar tissues that may be slight, or so extensive as to actually constitute an obstruction to the further progress of labor, attaining at times the dimen- sions of a fetal head at term. This swelling is more or less rounded and circumscribed, is of an intensely dark-blue or purplish appearance, of a firm consistence, not yielding to pressure, and intensely sensitive. Not infrequently a marked vaginal tenesmus is noted. The diagnosis is easy. The sudden appearance of the tumor, the intense pain, the signs of collapse, and the irreducible nature and physical signs of the swelling are conclusive. Prognosis. — Labial hematoma is a serious accident at the best. While true that immediate death is exceptional, or even unknown if secondary rupture do not occur, the patient is exposed to all the risks of subsequent hemorrhage or septic infection. The prognosis must therefore be guarded. Treatment. — i. If the effusion be limited in amount, the child should be delivered as quickly as possible, and with care to avoid ex- ternal rupture. Extreme care must then be observed to prevent infection of the exuded blood by thorough anti- septic treatment of the parts and the application of suitable substances, as ice-compresses, to favor speedy removal of INVERSION OF THE UTERUS. 599 the clots. Should suppuration occur, a free incision must be made and the condition treated as an ordinary abscess. 2. In larger effusions in which labor is obstructed it becomes necessary to evacuate the clots and then deliver speedily by forceps. The incision is best made on the external (cutane- ous) surface, parallel to the vulvar cleft. After the delivery of the child the wound must be thoroughly cleansed, any bleeding point ligated, and a tampon of iodoform-gauze inserted : this may be held in place by a T-bandage, and must be changed once or twice a day to prevent septic in- fection. If sepsis occur, the patient must be treated on general principles. {c) Inversion of the Uterus. — By this term is meant a turning of the uterus inside out, either completely or in part (Figs. 153, 154). This may appear in two varieties — namely, the complete and the incomplete or partial inversion of the organ. This is an exceedingly rare — undoubtedly the rarest — complication of labor, the statistics of lying-in hos- pitals giving a frequency of i case in 200,000 labors ; it occurs most commonly in primiparae. Etiology. — Beckman has collected from literature 100 reported cases of this acci- dent, with a purpose of ascertaining, if possible, its actual cause. In 54 of these cases the condition occurred spon- taneously ; that is, the fundus of the uterus or that portion occupied as the placental site, while apparently in a condi- tion of paralysis, spontaneously sank in, forming a cup-like depression in the uterine substance ; the uterus at once contracted and endeavored to expel this mass, thereby aggravating the condition. In other cases the accident was the result of direct operative interference, as when there had been injudicious traction exerted upon the cord, either when the placenta was partially attached to the fundus or when it was so lodged in the lower uterine segment as to exclude the possibility of the entrance of air. Traction in the latter instance may produce such suction within the uterine cavity that the fundus is drawn down, when the 6oo A MANUAL OF OBSTETRICS. uterine contractions quickly complete the process. The same effect may be produced in precipitate expulsion of the fetus or delivery of the child while the woman is in the erect position. Again, injudiciously applied efforts at Fig. 153. — Inversion of the uterus. The lumen of the rectum is seen, and also the inversion funnel, in which are the tubes and an ovary (after J. Veit). F'iG. 154. — Inversion oi the uterus, drawn from an old specimen in alcohol. The atonic chief site of placental attachment (c) is shrunken by the alcohol, and thus its lessening is explained: ^, contraction-ring ; a, external os uteri (after J. Veit). Crede's or Hoening's methods of expression may force in the fundus uteri. Inversion has even been known to fol- low violent bearing-down efforts on the part of the woman. The symptoms of an acute inversion of the uterus are three — namely, acute pain, hemorrhage, and varying degrees INVERSION OF THE UTERUS. 6oi of shock. The pain may be so severe as to cause the woman to cry out in her agony, and it is probably the most active element in the production of the shock. The hem- orrhage maybe profuse if the mouths of the uterine sinuses be not closed, or it may be insignificant, adding nothing to the gravity of the case. The pulse is rapid and thready, and the other symptoms of collapse — coldness of the ex- tremities ; moist, clammy skin ; anxious expression ; extreme pallor ; nausea and vomiting ; syncopal attacks and occa- sional convulsive seizures — are present. Occasionally, even with symptoms of such gravity as the preceding, the con- dition has been overlooked, and after a period of serious illness of varying duration there has occurred a slow ame- lioration of the symptoms and a protracted convalescence. The uterine condition has now passed from the acute to the chronic state : adhesions form between the inverted fundus and the vagina, and a restoration of the parts to their original position becomes impossible. A physical exploration made at the time of the onset of the acute symptoms would prevent any such misapprehension of the condition. There will then be discovered by the abdom- inal hand a characteristic cup-shaped depression of the fundus in which may be detected the uterine appendages — tubes and ovaries. The vaginal hand will in a complete in- version of the uterus discover a pendulous pear-shaped elastic tumor, lined with the hypertrophied uterine mucosa, emerging from the cervical canal : this tumor will not be present in an incomplete inversion. Diagnosis. — An acute inversion should not be confounded with any other con- dition. It is possible, however, for the inverted organ to be mistaken for a uterine polyp, especially if it remain undis- covered for a day or two. The points of diagnosis between the two are quite distinct. The surface of the polyp will be covered with the normal uterine mucosa, while that of the inverted uterus will consist of decidual tissue and will show the site of placental attachment. The uterine tissue is more 602 A MANUAL OF OBSTETRICS. elastic and less fibrous to the feel than is the polyp. It may be that the orifices of the Fallopian tubes can be detected by close inspection of the inverted organ : these would not be present on a polyp. The polyp will be more pedunculated than an inverted uterus ; and, finally, the pas- sage of the uterine sound will be conclusive evidence : in the case of a polyp it will penetrate to the normal depth, or more probably for three or more inches, while in the inverted uterus it can be passed but a short distance to the rim of the cervix. Prognosis. — Fully 65 per cent, of these women perish within a few hours after the occurrence of the accident. Not only is there the possibility of imme- diate death from hemorrhage and shock, but, if the con- dition be overlooked or if the accoucheur be unable to restore the uterus to its normal position, death may follow from sloughing of the organ due to interference with the circulation from cervical constriction, or the woman may perish from septic infection. The prognosis must therefore be guarded. Treatment. — As in the case of uterine rupture, prophylactic measures are important. These will consist in guarding against a precipitate expulsion of the fetus, and in avoiding traction upon the cord and the exertion of un- necessary force in the performance of Crede's manipulations. If the inversion occur spontaneously, the active treatment will consist in the immediate reduction of the tumor, fol- lowed by efforts to secure firm uterine contractions, whereby a return of the condition will be prevented. Any delay in replacing the fundus will add materially to the difficulty encountered. The steps of the procedure arc as follows : I. Complete anesthetization of the patient. 2. Catheteriza- tion of the bladder and evacuation of the rectum. 3. Res- toration of the fundus by properly applied taxis. If the inversion be partial, the index and middle fingers passed through the dilated cervix will probably suffice to press the fundus into position, the uterus being steadied by counter- pressure made through the abdominal wall. It may be DIASTASIS OF PEL VIC JOINTS. 603 that a uterine repositor may answer in such a case if the fingers should fail. In complete inversion more skill is required. The inverted fundus must be grasped in the palm of the right hand while the finger-tips are introduced within the cervix, and efforts at dilatation made while pressure is exerted upon the mass in the direction of the upper parturient canal — upward, forward, and to one or the other side — the organ, as before, being fixed by the left hand applied externally. To accomplish this, the fundus must first be carried bodily backward into the cavity of the sacrum, the promontory of that bone thereby being avoided. If this method should fail, Nocggeratli s maneuver, progressive reduction of the mass, may succeed. The in- verted fundus is grasped between the thumb and index finger of the right hand, and pressure exerted upon it, first upon one side and then upon the other. A partial reduction of the tumor is thus accomplished and its bulk somewhat diminished. Direct pressure is then exerted by the finger- tips upon the center of the tumor in a direction upward and forward, when the fundus will probably slip into posi- tion. 4. Reduction having been accomplished, an intra- uterine douche of creolin must be given, and a strip of iodoform-gauze inserted to secure uterine contractions and to prevent a return of the abnormal condition : it is well to administer at this time a hypodermic injection of ergotin. 5. In neglected cases, in which the acute stage has passed and adhesions have formed, it may be that under complete anesthetization, with carefully applied taxis according to one or other of the foregoing methods, the fundus may be replaced. These measures failing, the advisability of com- plete extirpation of the organ to avoid sepsis or sloughing must be taken into serious consideration. [d) Diastasis of the Pelvic yoints. — Among the rarer com- plications of labor mention must be made of the occasional abnormal separation of the various pelvic s\'nchondroses. In the consideration of the physiology of pregnancy it was 6o4 A MANUAL OF OBSTETRICS. noted that to a certain extent a relaxation of the pelvic joints is normal, this being one of the conservative pro- cesses on the part of nature whereby parturition is facili- tated. The edema of these structures may, however, be- come so serious as to constitute a truly pathologic condi- tion, and even a menace to the subsequent comfort and health of the patient. Under these abnormal conditions it may readily be perceived that the excessive distention of the parts necessary to the transit of the fetal -head may result in an abnormal separation of one or more of the joints from a yielding or laceration of the ligamentous structures surrounding them. A true dislocation of the pelvic joints may thus be induced. The pubic symphysis, where the greatest amount of relaxation occurs during ges- tation, is the joint most commonly involved. The sacro- iliac synchondroses may, however, be similarly affected. The causes of this accident are excessive relaxation of the ligamentous structures, over-size and extreme rigidity of the fetal skull, undue force exerted in the instrumental delivery of a fetus, or a pathologic fragility of the car- tilaginous union of the joints. The symptoms are severe pain upon motion; an undue mobility of the parts, whereby efforts at locomotion are impeded or even rendered impos- sible ; and the presence of a sulcus between the edges of the bones. It may be in cases of extreme separation that dangerous laceration of the adjacent soft structures may occur, as rupture of the bladder, vagina, pelvic fascia, or blood-vessels. The only treatment is thorough immobili- zation of the affected joint either by a firmly applied canvas bandage or by a plaster-of- Paris support. The patient must be kept absolutely at rest until the parts be restored to their normal condition. If union do not occur, it may become necessary subsequently to perform some surgical operation, as the suturing or wiring together of the synchondroses, (r) Fracture of tJie Pelvic Bones. — Very rarely, during the violent efforts at traction necessitated by an instrumental SUBCUTANEOUS EMPHYSEMA. 605 delivery in badly-contracted pelves, some portion of one of the innominate bones may be fractured. This is never pardonable, for in such grave pelvic deformity instru- mental deliveries are contraindicated, symphysiotomy, craniotomy, or other major obstetric operation being the proper procedure to adopt. It is possible for a pelvic bone, rendered brittle by rachitis or other abnormal pro- cess, without having undergone marked alteration in shape, to yield during a properly conducted instrumental delivery, but such an occurrence is exceedingly rare. In case of frac- ture the fragments must be properly coaptated and the pelvis immobilized by a closely-fitting plaster-of- Paris jacket. A variety of fracture that is not of such rare occurrence is that noted in elderly primiparae at the site of the firmly- ossified sacrococcygeal joint. The head as it descends in the pelvic cavity impinges upon the sharply anteverted coc- cyx, and, not encountering the normal resiliency, violently drives backward the protruding bone. This accident is followed by that painful condition known as coccygodynia, which can be relieved only by total extirpation of the detached bony process. (/) Subcutaneous EmpJiyscnia of the Head and Neck. — Occasionally, during the violent bearing-down efforts of a labor in which a certain amount of obstruction exists, an alarming condition may develop. There may suddenly ensue an emphysematous condition of the neck, face, and upper thoracic regions, the parts being distended to a remarkable degree and yielding a peculiar and character- istic crackling upon manipulation. This alarming but not dangerous condition results from the rupture of one or more pulmonary alveoli, or of some other portion of the respiratory tract, with an escape of air into the surrounding cellular tissues. Each renewed straining effort drives more air into the tissues, with the remarkable result described. There is but little gravity connected with this accident unless there be associated emphysema of the deeper struc- 6o6 ^ MANUAL OF OBSTETRICS. tures of the chest and lungs, as the interlobar connective tissue or the subpleural fascia, in which case respiration may be so impeded as to cause extreme dyspnea. The patient and her friends, however, will be terribly alarmed by her condition. Under the circumstances the labor should be terminated at once by instruments, and all bearing-down efforts avoided as far as possible. If the cutaneous disten- tion be extreme, it may be relieved by minute punctures with an aseptic needle and gentle massage of the parts. The patient should be kept quiet and instructed to refrain from any violent respiratory efforts. i^g) Rupture of a Blood-vessel ; Hemoptysis. — An alarm- ing accident, and one that may or may not be attended with serious consequences, is the spitting of blood during partu- rition. This accident may occur in a woman who is the subject of some organic pulmonary or cardiac disease, as tuberculosis or grave mitral lesion, or it may take place in a plethoric woman in perfect health as a result of almost su- perhuman efforts at expulsion of the fetus, one of the pul- monary vessels yielding. The amount of blood lost may be excessive or only a trace, depending entirely upon the size of the ruptured vessel. When such a symptom appears, labor must be terminated at once by instrumental measures and cardiac and pulmonary sedatives administered. A hy- podermic injection of morphin and one of ergotin should be given at once if the hemorrhage be profuse, and the ergot continued in 20- or 30-drop doses while bloody expectoration persists. {ji) Sudden Maternal Death djiring Parturition. — No more demoralizing event can be imagined than the sudden decease of a parturient or puerperal woman : it becomes, however, the sad fate of all accoucheurs who have attained a large experience in their chosen avocation to be called upon to witness such a calamity at least once if not more frequently. It may be that in the midst of an extreme uterine paroxysm the woman suddenly falls into a state of SUDDEN MATERNAL DEATH. 607 collapse quickly followed by death ; or the fetus may have been expelled, and the physician is congratulating himself on the happy conclusion of the labor, when the woman suddenly perishes without any appreciable cause. Such an event may result from a number of conditions, as has been demonstrated by postmortem examinations of these women. Probably the most common causes are the fol- lowing : I. Sudden cardiac syncope, especially when there preexists a fatty degeneration of the heart, either primary or the result of renal disease, or a myocarditis that may soften the tissues or give rise to numerous pus-foci in the walls of the ventricle, causing spontaneous rupture of the heart. 2. Acute pulmonary congestion and edema, the result of cardiac or renal disease. The sudden effusion of blood and serum will so overpower the heart and lungs that the vital powers yield. 3. Puerperal thrombosis and embolism, a large clot obstructing the pulmonary artery or a main venous trunk or forming within the right cardiac ventricle. 4. Air-embolism of the iiterine sinuses or other vessels. This accident most usually follows placenta praevia in which there has been a sudden removal of the placenta ; it may occur after a profuse postpartum hemorrhage or during the administration of an intrauterine douche. The associated symptoms are sudden collapse ; air-hunger; extreme dysp- nea; pallor and clamminess of the surface; nausea and vomiting ; rapidity, smallness, and irregularity of the pulse; and early death. 5. Postpartum hemorrhage, the uterus relaxing and an immense volume of blood escaping within a minute or two, the patient perishing before relief can be afforded her. 6. Rupture of the aorta or other large vascular trunk the seat of an aneurysmal dilatation that has escaped detection. 7. Rupture of a hematoma, such as frequently follows a varicose condition of the pampiniform plexus of the broad ligament. 8. Profound mental emo- tion. In a few cases recorded in medical literature, imme- diately after the birth of the child the woman has suddenly 6o8 A MANUAL OF OBSTETRICS. expired without the existence of any adequate cause as re- vealed by the postmortem examination. The only possible explanation of such an occurrence is that, owing to the intensity of some mental emotion, as extreme joy, shame, or fear, combined with great physical depression, the maternal vital powers have yielded. In every instance in which maternal death occurs during the progress of labor instant delivery of the fetus must be accomplished, otherwise it will perish from interference with the fetoplacental circulation. If engagement of the head have taken place, the forceps may be applied and the fetus quickly extracted. If engagement have not occurred, the maternal tissues will be so relaxed that podalic version may be performed with surprising ease and the child deliv- ered. Postmortem Cesarean section may be performed if the accoucheur be so inclined, but the other methods sug- gested would appear to be the preferable procedures. V. PATHOLOGY OF THE PUERPERIUM. When a woman has passed safely through labor with all of its numerous possibilities for evil, as just enumerated, her condition is by no means devoid of danger. The puerperium is as beset with evils stii generis as is labor itself Thus, there may ensue a profuse hemorrhage that may terminate her life with scarcely a moment's warning ; septic germs of intense virulence may gain entrance into her system and play havoc with the normal process of in- volution, or destroy the patient with lightning-like rapidity ; there may ensue a profound alteration in the tissue-metab- olism, especially in the hematopoietic system, whereby a progressive grave anemia may be developed; the profound depression and shock to the general system that are un- avoidable consequences of such a tremendous exertion as that necessitated during the expulsion of a fetus predis- THE HEMORRHAGES OF THE PUERPERIUM. 609 pose her to the malign influence of extraneous causes by lessening her resisting powers : she is therefore more prone to develop a pneumonia or other concurrent disease during the early days of the puerperium, or to reveal some latent dyscrasia probably heretofore unsuspected ; the profound mental strain in association with the extreme physical de- pression may temporarily, or, indeed, permanently, destroy the equilibrium of the mind, and that deplorable sequence of parturition, puerperal insanity, develop ; and, finally, lac- tation and the mammary development are beset with numer- ous accidents that may seriously alter the normal process of the puerperium. These and other pathologic conditions may appear during the six weeks of uterine involution, and so modify its course as to either greatly prolong the period of convalescence or abruptly terminate it. In about the natural order of their development these pathologic con- ditions may be stated as follows : I. The Hemorrhages of the Puerperium. Foremost among the grave accidents of this critical period stand uterine and vaginal hemorrhages, which may appear immediately after the termination of labor or not until some days or weeks of the puerperium have elapsed. To that variety occurring at any time during the twenty-four hours after parturition has been given the name of postpartum hemorrhage, while any bleeding occurring subsequent to this period and during the six weeks of involution is desig- nated as puerperal hemorrhage proper. I. Postpartum Hemorrhage ("Flooding"). — The prob- ability of the occurrence of this alarming accident should be ever before the mind of the accoucheur : however small his experience, he will invariably sooner or later be called upon to cope with it. It is important, therefore, that the etiology of any given case be promptly recognized in order that the proper course of treatment may be instituted. Post- partum hemorrhage can follow one of two causes : either 39 6lO A MANUAL OF OBSTETRICS. there has occurred a relaxation of the uterus, whereby the large lacerated uterine sinuses are allowed to gape and throw out an immense volume of blood, or some portion of the tower birth-canal has been lacerated to such an extent as to involve a vessel of considerable size, the uterus itself remaining firmly contracted. The most frequent of these conditions is that due to uterine relaxation. If the peculiar nature of the uterine walls at term be taken into considera- tion, as well as the remarkable changes that have occurred in the vessels and other tissues of the pelvis during gesta- tion, the wonder is that this frightful accident does not occur with even greater frequency than is actually noted. The wonderful conservative processes of nature are alone responsible for the marvellous immunit}' that the great ma- jority of puerperal women display. These processes are three in number — namely, changes in the vessel-walls, changes in the blood itself, and changes in the uterine muscle-fibers. Probably the most important changes are those involving the walls of the uterine sinuses. The rap- idly growing organ demands a corresponding increase in its blood-supply, and in order to accommodate the vastly in- creased current of blood thrown into the uterus by the uterine and ovarian arteries, and to facilitate its ready return to the circulation, there occurs an immense dilatation of the vessels traversing the substance of the uterine walls and of the return veins in the broad ligaments and pelvic fascia. This dilatation is accomplished at the expense of the vessel- walls themselves, which lose in thickness as the pregnancy advances. Little by little the muscular and external or ad- ventitious coats are absorbed, until at the expiration of the full period of gestation there remains but the delicate intima, closely invested by the network of hypertrophied uterine muscular fibers. The veins are therefore transformed into vast channels or sinuses, having largely lost the normal characteristics of blood-vessels. This loss of substance per- mits an absolute obliteration of the channels under the in- THE HEMORRHAGES OF THE PUERRERIUM. 6ll fluence of the firm uterine contractions, and this is probably the most important element in the prevention of postpartum hemorrhage. Supplementing this compressibility is the marked elasticity of the intima, as a result of which the edges of the torn sinuses retract into the substance of the uterine muscle, which overlaps and thus mechanically closes the gaping vessel-mouths. The second conservative pro- cess is the increased coagulability of the blood during ges- tation, due to a peculiar hyperinosis. Mention has already been made of this alteration in the constitution of the blood, which, while mainly conservative and beneficial and an essen- tial element in the prophylaxis of postpartum hemorrhage, may constitute an active source of danger under other cir- cumstances shortly to be described. As a direct conse- quence of the slowing of the blood-current in the dilated sinuses and of the extreme attenuation of the vessel-walls, diapedesis of the white blood-corpuscles readily occurs, and these escaped cells, rapidly proliferating in the connective tissue around the vessels, still further obstruct the lumen, and mechanically prevent an escape of blood from the si- nuses at the time of the separation of the decidua. Finally, the third conservative process in the prevention of postpar- tum hemorrhage consists in the immense physiologic hyper- trophy of the individual muscle-fibers of the uterus, which by their conjoined exaggerated action exert such a pressure upon the attenuated vessels as to effectively obliterate their lumina. Having, thus, a lucid understanding of the normal con- ditions that should hold, it will more readily be perceived how a postpartum hemorrhage may occur from the so-called relaxation of the uterus. There must necessarily be, in the first place, anything giving rise to a condition of uterine in- ertia; secondly, anything preventing a proper retraction of the ends of the vessels; and, thirdly, any mechanical cause preventing an absolute contraction of the muscle. Among the causes of uterine inertia may be mentioned — i. Extreme 6l2 A MANUAL OF OBSTETRICS. exhaustion, as that induced by oft-repeated childbearing ; excessive uterine action in primiparae ; poor hygienic sur- roundings; malnutrition; overdistention, as from hydramnios or twin pregnancy; grave general disease, as pulmonary tuberculosis, chronic nephritis, or valvular lesion. 2. Ab- nonnalitics in the nterine ivall, as from imperfect develop- ment of the uterus or of the individual muscle-fibers ; an imperfect or deficient nerve-supply ; a nonresponsiveness of the nervous organism, as in so-called uterine apathy. 3. Temporary paralysis of the uterine muscle, as from complete anesthetization ; a precipitate labor or rapid de- livery of the fetus by version or forceps, the uterine cavity being evacuated so rapidly that the walls have not the proper stimulus to contract ; profound mental emotion, resulting in an inhibition of the uterine contractions. Retraction of the ends of the severed vessels will be pre- . vented when there exists an adherence of a portion, how- ever small, of the placental tissue. The partially separated vessels persist as wide, open-mouthed channels that pour out an immense volume of blood as long as the placental adhesions last. Finally, mechanical obstacles to absolute uterine contraction may exist, as when there are retained within the uterine cavity large clots of blood or fragments of the secundines, or when there exists without the uterus or in the substance of its wall some abnormal condition preventing its proper contraction, as the presence of firm bands of adhesion in Douglas's cul-de-sac, or anteriorly between the uterus and the bladder; a largely distended bladder or rectum ; the presence of an immense pyosalpinx, hydrosalpinx, pelvic exudate, or ovarian cyst ; an anky- losed condition of the muscle-fibers as a result of an extinct metritis ; or a large fibroid tumor in the fundus or walls. A second variety of postpartum hemorrhage is that due to actual traumatism at some point in the lower birth-canal. Most commonly the bleeding comes from an extensive THE HEMORRHAGES OF THE PUERPERIVM. 613 laceration of the cervix and vaginal vault involving the cir- cular artery, or from the lower anterior vaginal wall near the orifice of the urethra ; more rarely, an over-sized perineal artery may be divided and hemorrhage result. Such trau- matisms are of rare occurrence at the best, and are gener- ally the result of an injudicious use of the obstetric forceps. They may, however, follow the yielding of cicatrices before the advancing presentation. The symptoms of postpartum hemorrhage, if it be pro- fuse, are those of collapse, together with the presence of the blood, which may be ejected in immense quantities, saturating the bed-clothes and mattress and overflowing upon the floor. In these tremendous bleedings death may follow within a minute or two, preceded by all the manifes- tations of hemorrhage — extreme pallor ; coldness of the extremities ; great rapidity, feebleness, and irregularity of the pulse ; an anxious expression of the countenance ; air- hunger; dimness of vision, with muscse volitantes ; tinnitus aurium ; mental confusion ; and, finally, a convulsion rap- idly terminating in death. In the moderate cases the blood will be seen escaping in gushes or in a constant stream. The diagnosis of the condition is plain. The es- cape of blood from the vulva will be conclusive evidence as to the state of affairs. The only question that will arise is as to whether the bleeding is the outcome of uterine re- laxation or whether it comes from some laceration below the cavum uteri. This point is at once determined by placing the hand upon the abdominal surface directly over the uterine fundus. In relaxation of the organ there will be detected a large flabby structure, nonresilient and imper- fectly defined through the abdominal tissues. The appli- cation of energetic friction over this mass (Crede's method) will excite uterine contractions, and as the organ hardens under this stimulation there will occur a sudden .spurt of blood from the vulvar orifice as the fluid contained in the uterine cavity is expelled. This hemorrhage is quite dis- 6l4 -4 MANUAL OF OBSTETRICS. tinctive as compared with that arising from lacerations of the cervix or vagina. In the latter case the uterus may be found quite firmly contracted, while, notwithstanding this tonic condition, there is a constant flowing or spurting of blood from the vagina. Examination of the vulvar and vaginal regions will then reveal the bleeding point. The prognosis of postpartum hemorrhage is doubtful. If the condition be detected at once, it is a simple matter to apply appropriate measures to control the bleeding and prevent further hemorrhage. If assistance be not at hand, or if the medical attendant be a man slow of wit or igno- rant of the proper measures to be taken, a fatal termination will quickly ensue. Especially dangerous is that variety of postpartum hemorrhage in which, owing to the forma- tion of a vaginal or cervical clot or the introduction of a vaginal tampon, the hemorrhage is converted from an open into a concealed bleeding. Here it becomes imperative that the accoucheur recognize the diagnostic points between the hard rounded mass of a firmly-contracted uterus and the large flabby body of uterine relaxation. The ireatnicnt of postpartum hemorrhage includes, pri- marily, prophylaxis, and, secondarily, the means to control the active bleeding. I. The prophylactic treatment has already been touched upon. In any given case in which one of the predisposing causes of hemorrhage is known to exist, or when there is reason to fear varying degrees of uterine inertia, the most energetic measures should be instituted to avert such a disastrous sequence. Too rapid evacuation of the uterine contents must be prevented, and as the fetus and secun- dines descend the lower birth-canal gentle pressure above on the fundus uteri through the abdominal walls, either by the disengaged hand or, preferably, by the nurse or other assistant, should maintain the uterine walls in close appo- sition to the fetal body and other solid contents. A firm degree of uterine contraction may thus be maintained and THE HEMORRHAGES OF THE PUERPERIUM. 615 the possibility of relaxation prevented. It is well, in doubt- ful cases, when the head is born, to administer a dram or two of the fluid extract of ergot by the mouth, or, if the patient be under the influence of an anesthetic, to inject into the thigh a syringeful or more of ergotin. Immediately after the removal, by Crede's manipulations, of the secundines and whatever clots may be contained in the parturient canal, a vaginal douche of creolin may be given and a firm abdom- inal binder with a uterine pad applied : these maintain a constant pressure upon the sensitive uterus and thereby excite it to continuous tonic contraction. Excessive mov- ing of the patient from one side of the bed to the other, or any mental disturbance, must be avoided. In instrumental labors the greatest care must be observed to avoid undue damage to the soft structures. 2. Curative Treatment. — As soon as the hemorrhage is discovered the fundus of the uterus must be grasped and the kneading movements of Crede instituted, while with the disengaged hand the uterine cavity is explored for fragments of placental tissue or membranes or for clots : these must be evacuated, the hand not being removed until expelled by strong uterine contractions. The uterus firmly contracted, repeated hypodermic injections of ergotin must be given and the pad and binder firmly applied as before. In the vast majority of cases such a course of treatment will con- trol the hemorrhage. Occasionally one of the trying cases of uterine inertia or apathy will be encountered, and it then becomes imperative to resort to other methods of treatment. The experience of most obstetricians is that in any case in which Crede's manipulations fail, the immediate resort to Duhrsseiis method — thorough tamponade of the uterine cavity with iodoform-gauze — will most quickly and at the same time effectively control the bleeding. The gauze should be in readiness, cut in long strips an inch or two in width : it must be carried to the fundus, which is supported by pressure exerted by the abdominal hand, and packed 6l6 A MANUAL OF OBSTETRICS. firmly in until the uterine cavity will not contain more. Great care must be observed during this procedure not to cause such distention of the vagina and cervix as to give entrance to a large amount of air : fatal air-embolism may thus be induced. The uterus being plugged, a vaginal tam- pon may be inserted and the woman allowed to rest. The gauze may be removed at the expiration of from six to eight hours, and, if the bleeding be under absolute control, a creolin douche administered and the woman treated as an ordinary puerperal patient. If iodoform-gauze be objected to, other measures to con- trol the hemorrhage must be employed, as follows: (i) Va- rious applications to the titerine cavity, foremost among which may be mentioned injections of hot zvatcr, which is always available and at the same time antiseptic. The temperature of the water should be high, at least iio° to 120^ F., and the quantity injected not less than one or two pints. Simple hot water may be used for the purpose, or a weak solution of mercuric chlorid (i : 5000). If firm uterine contractions do not follow within from fifteen to thirty seconds, the other extreme may be adopted, and injections of ice-water be given or a lump of ice be carried bodily into the uterine cavity. This method is objectionable, because of the chilling of the patient and the difficulty of securing the ice. Probably a more useful method, although one attended with more suffer- ing to the patient, is the employment of vinegar as a styptic. A piece of gauze may be saturated with the fluid, carried to the fundus, and there squeezed dry: when the vinegar comes into contact with the sensitive uterine tissue, there occurs an immediate contraction that will expel the hand and all other uterine contents. (2) If these measures fail and a faradic battery be at hand, very effective uterine contractions may be obtained by introducing one of the electrodes to the fundus of the uterus, the other, in the form of a large flat electrode, being applied to the external abdominal wall over the site of the fundus. If desired, the two electrodes may THE HEMORRHAGES OF THE PUERPERIUM. 617 Fig. 155. — Herman's method of controlling postpartum hemorrhage. be used externally, one being placed upon each side of the fundus uteri. (3) ^ If this fails or a battery cannot be obtained, Her- inaiis method of continual manual compression (Fig. 155) may be attempted. This is accomplished by inserting the entire left hand into the vagina, for- cing the cervix backward, so that the anterior uterine wall restsuponthe upturned palmar surface of the fist. The right hand then grasps the strongly anteverted fundus through the abdominal wall and presses it firmly down upon the vaginal hand, so that the uterine circulation is completely controlled and any clots that may be contained within the cavity of the uterus are forced out through the cervical canal. An excessive amount of force is not re- quired, and the pressure may be maintained until thrombi have formed in the uterine sinuses, as shown by absence of bleeding when the abdominal hand is relaxed. Other methods of direct manual compression of the uterus have been suggested. That employed by Zweifel consists in strongly anteflexing the uterus, the cervix being pressed upward by the vaginal hand against the fundus uteri, which is depressed by the abdominal hand. This method has the disadvantage of preventing the escape of any clots that may be retained in the uterine cavity, thereby preventing the recurrence of firm uterine contraction. Another unsat- isfactory method consists in a retroversion of the uterus by the external hand, which compresses the organ against the rounded prominence of the vertebral column. Still an- other, equally unsatisfactory, consists in carrying the vagi- nal hand far up into the posterior fornix, whence firm ante- 6l8 A MANUAL OF OBSTETRICS. rior pressure is made, the fundus thus being compressed against the symphysis pubis. By far the best method is that of Herman, as just described. (4) Compression of the aorta may be accompHshed by sinking the fingers into the ab- dominal surface just above the level of the fundus uteri. The direct compression of the uterus is much to be pre- ferred. (5) The intrauterine injection of styptic drugs is a method that is mentioned but to be condemned. The drug most commonly used for the purpose is Monsel's solu- tion, although the solution of the perchlorid of iron and tincture of iodin have been employed. Monsel's solution is used in about 25 per cent, strength, the perchlorid of iron in 16 or 17 per cent., and the tincture of iodin in 50 per cent, strength. The main objection to the use of these drugs is the formation of dense coagula, which by their presence prevent firm uterine contraction, which may become the seat of septic processes, or from which emboli may become detached and cause the death of the patient. Again, there exists the possibility of the escape of a small portion of the styptic fluid into the free peritoneal cavity through a dilated Fallopian tube, with resultant fatal peri- tonitis ; or the mere injection of such an irritant fluid may give rise to considerable shock and thus precipitate death. 3. The treatment of that variety of postpartum hem- orrhage consequent upon lacerations of the lower birth- canal is generally a very simple matter. Immediately upon ascertaining that the body of the uterus is in a state of tonic contraction, a firm vaginal tampon of iodoform- gauze should be inserted until the patient can be prepared for a thorough examination of the vaginal tract and the necessary assistance can be secured. The patient should then be placed in the lithotomy position — if need be, under the influence of an anesthetic — and the gauze slowly re- moved, a close watch being kept upon the vaginal walls in order to detect the site of the hemorrhage. If a laceration be found to exist upon the anterior wall, a running suture THE HEMORRHAGES OF THE PUERPERIUM. 619 of catgut should be inserted from below upward, each stitch being taken as a portion of the gauze is removed, until the spurting point is reached, when a final stitch will control the bleeding vessel. If the hemorrhage come from a laceration of the circular artery of the cervix, it may like- wise be controlled by one or two properly inserted sutures. It may become necessary to employ a Sims speculum to facilitate this operation. 4. The aftcr-treatnicnt of postpartum heinorrJiage is essen- tially the same as that already described for acute anemia. The patient's head must be kept low and her feet elevated. Hypodermic injections of cardiac and respiratory stimulants, as strychnin, ether, digitalis, or strophanthin, are essential. Hot applications to the feet and limbs and autotransfusion may be of service. In very grave cases hypodermoklysis of normal saline solution or the intravenous injection — into the median cephalic vein — of this fluid may be employed. In performing the latter operation extreme care must be ob- served not to allow the entrance of air into the veins. It is very essential that the patient be kept absolutely at rest to avoid sudden cardiac syncope, the displacement of the thrombi, or the production of thrombosis and embolism elsewhere, to which accident women are especially prone subsequently to a postpartum hemorrhage. Alimentation should consist of teaspoonful doses of brandy or whisky and hot water or coffee, repeated at quarter-hour intervals until the patient have rallied sufficiently to assimilate stronger food, as small amounts of the freshly expressed juice of beef, beef-tea, or mutton-broth. If the stomach prove re- bellious, rectal alimentation should be resorted to, the nutri- tious enemata consisting of whisky, small amounts of pan- creatized milk, or the yolk of an o.^^ and hot water. 2. Puerperal Hemorrhage Proper, or Secondary Post- partum Hemorrhage. — By these terms is indicated a hem- orrhage from the parturient canal occurring at any time during the puerperal period subsequent to the first twenty- 620 A MANUAL OF OBSTETRICS. four hours. This accident is not of nearly so frequent occurrence as is true postpartum hemorrhage. When it does occur, it generally indicates the retention within the uterine cavity of some portion of the placenta or mem- branes, that has just become detached, thereby opening one or more of the uterine sinuses. Under these cir- cumstances the uterus will be found much heavier than normal, and the hemorrhage will probably have been pre- ceded for some time by a more or less fetid lochia or by an increased quantity of a too sanguineous discharge. The hemorrhage will occur suddenly, and often in profuse amount, almost exsanguinating the patient. A second rather frequent cause of puerperal hemorrhage is a dis- placement of the thrombi that block up the uterine sinuses, occurring as a result of a sudden exertion on the part of the patient, as on sitting up or turning in bed or straining at stool, or more rarely due to a septic decomposition of the clot in that peculiar and serious form of puerperal sepsis, uterine phlebitis. The hemorrhage in this case is very pro- fuse, appears without any previous warning, and may be ex- tremely difficult to control. Relaxation of the uterus either as a result of retained matter in the cavum uteri or from lack of nervous inhibition, as when the patient is the subject of profound mental emotion (extreme fright or grief), may induce alarming or even fatal hemorrhage. Again, displace- ments of the heavy puerperal uterus by a distended bladder or rectum or from pathologic conditions may, by main- taining an undue engorgement of the organ and thereby preventing the proper involution, be productive of profuse irregular hemorrhages. The same result may follow an early getting up or any other cause tending to subinvolu- tion, as the presence of uterine tumors (fibromata, mucous polypi, and cervical carcinomata) ; intense pelvic congestion, as when there exists a varicose condition of the pampini- form plexus of veins, or ovarian or tubal disease ; or some disease, as a mitral valvular lesion, productive of a general PUERPERAL THROMBOSIS AND EMBOLISM. 62 1 venous engorgement. There is nothing distinctive in the hemorrhages attendant upon these conditions. The trcat- 1/u'iit will vary with the cause. If there be a retention of placental debris or an hypertrophied and congested decidua, the uterine curet must be employed and all extraneous mat- ter removed. A displaced uterus must be replaced and the bladder and rectum kept empty. In simple uterine relaxa- tion or that due to emotion the uterine cavity should be packed with a strip of iodoform-gauze : this is also neces- sary in the case of a septic hemorrhage and in one due to displaced thrombi from any cause. In this latter variety the use of the curet must be rigorously prohibited. Pro- fuse hemorrhage arising from the presence of uterine fibro- mata may likewise necessitate a thorough uterine tam- ponade, while internally may be administered remedies conducive to the absorption of the neoplasms, as ergot, ammonium chlorid, strychnin, and quinin. A judiciously applied course of faradism may be of some service in these cases. Mucous polypi may be snared off or removed by the curet. The aftcr-trcatmcnt is that required subsequently to a postpartum hemorrhage. 2. Puerperal Thrombosis and Embolism. By this term is meant the sudden clotting of the blood in one of the venous trunks, whereby the circulation is impeded and serious consequences result, or more com- monly instant death. Puerperal women are especially prone to this accident from the extreme hyperinosis that characterizes the gravid state. There also exists with this increased coagulability of the blood a sluggish circulation, and all that is required to produce an actual thrombosis at any point is some form of mechanical obstruction. This may be furnished by a small clot displaced in one of the immense uterine sinuses, which, being carried into the gen- eral circulation, lodges at some convenient site. From the resultine thrombus small emboli are broken off, and these. 622 A MANUAL OF OBSTETRICS. lodging in the brain, heart, or lungs, rapidly induce death. The most common period for a puerperal thrombosis to de- velop is shortly after a profuse postpartum hemorrhage, at which time there exists a still greater tendency to coagula- tion of the blood because of the decreased tension of the blood-current. Emboli are most common in the pulmo- nary artery and in the cavities of the right side of the heart, and may consist of solid particles of coagulated blood, particles of fat, or bubbles of air, the latter being noted in certain cases of placenta prasvia in which there has occurred a rush of air into the uterine cavity. The symptoms of puerperal thrombosis are abrupt and startling. Without warning there suddenly occurs a most intense dyspnea, with violent efforts at respiration and marked air-hunger. The patient manifests all the symptoms of one in the ex- tremity of suffocation. She tears at her throat and chest ; her eyes strongly protrude ; she endeavors to rise from her bed; her face and general surface become deeply cyanosed or, more rarely, extremely pale ; the skin is cold and clammy; there is a violent action of the normal and aux- iliary muscles of respiration ; the heart's action is rapid, tumultuous, and irregular; the pulse rapidly becomes small and feeble, or is altogether imperceptible ; there is a consciousness of impending death ; and an epileptiform seizure may promptly end the scene. In a few reported cases there has occurred a gradual amelioration of this frightful group of symptoms, with ultimate recovery of the patient as the clot is removed by a slow process of absorp- tion. The diagnosis of puerperal thrombosis is patent. There is no possible condition with which such a grave train of symptoms can be confounded. The prognosis is extremely grave. Most of the women die before any at- tempt at medical relief can be made. The cause of death is probably asphyxia, although this is disputed, some author- ities claiming that death results from cerebral anemia, and others from cardiac syncope. Treatment. — The attack is so PUERPERAL ANEMIA. 623 fulgurant and the fatal termination so abrupt that but httle treatment can be attempted. In the few cases in which death does not rapidly supervene, cardiac and respiratory stimulants must be administered in full doses. These will include whisky, camphor, ether, and strychnin subcuta- neously, and brandy and aromatic spirits of ammonia inter- nally. Pulmonary congestion may be relieved by local bleeding by cups or leeches, and by the use of revulsives, as hot foot-baths and cataplasms to the calves. Absolute rest and quiet are essential to prevent further dislodgement of emboli and increased dyspnea from exertion. The diet must be absolutely liquid, and mainly milk, although broths and meat-juices may be administered. Inhalations of oxygen may be of service. 3. Puerperal Anemia. The condition of the blood throughout pregnancy is that of marked hydremia : there is an excess of the watery constituents with an overdistention of the vascular system. After the delivery of the child this unusual condition of the blood is gradually corrected, so that before the termi- nation of uterine involution the blood will have attained its normal state. It occasionally happens, however, that there occurs a failure of this process of hemic involution, the blood retaining its watery quality and the woman pre- senting a condition of marked anemia. Just what are the causes of such a development cannot be definitely stated. There may be a preexistent dyscrasia or a latent grave sys- temic disorder, as pulmonary tuberculosis or carcinoma. It may be that the woman's recuperative powers are poor, and the strain consequent upon lactation and the normal puerperal discharges are too great for her to sustain. In some cases the condition originates in an acute anemia en- gendered by a profuse intrapartum or postpartum hemor- rhage, or from some concomitant disease. Whatever the ori- gin, the woman's appearance will plainly indicate the trouble. 624 A MANUAL OF OBSTETRICS. There will be an unusual intensity of pallor ; the usual de- gree of strength will be but slowly regained, or it may be there will be a progressive failure of strength manifested by an inclination to abstain from any exertion. She will be compelled to seek her couch more frequently than usual ; intense backache and neuralgia will be present ; the appetite will be capricious and often poor; she will complain of gid- diness and incapacity for cerebration ; and later there may be manifested a tendency to hemorrhages, usually small, from the various mucosae. The diagnosis of the condition is plain. The prognosis is doubtful, for it will be impossible to say to what extent the anemia may progress. A true pernicious anemia may result fatally if the disease be not speedily cor- rected. Fortunately, the condition is generally amenable to appropriate treatment, which will consist in rigid enforce- ment of the rules of hygiene; in the taking of a rich and nutritious but carefully selected diet; if need be, in the early weaning of the child and the drying of the breasts to remove the strain of lactation ; in a suitable change of scene and locality ; and in appropriate mental diversion. Courses of ergot and tincture of nux vomica, in doses of from 5 to 20 minims each, three times daily, may favor uterine involu- tion and thereby diminish the excessive lochial discharge. The hemic condition may be alleviated by the administra- tion of iron in some easily assimilated form, as a solution of the albuminate in 5- or lo-grain doses, the peptomanganate solution in dram doses, or a Blaud's pill three or four times daily. This drug may be supplemented by arsenic in suit- able doses. As the condition improves the remedies may be decreased in amount, and the diet altered and increased as the stomach can bear it. Plenty of fresh air is essential. 4. Puerperal Sepsis (Sepsis Puerperalis). l^y puerperal sepsis, puerperal septicemia, septicopyemia, mctria, or childbed fever is meant that serious complexus of symptoms arising from the introduction into the system of PUERPERAL SEPSIS. 625 the puerperal woman of septic germs and their ptomains, and consisting in great alterations in the temperature and pulse-rate, in profound physical depression, and in marked local (vulvar, vaginal, and pelvic) manifestations. Know- ledge of this grave disease has been marvellously developed within the past few years, largely owing to the wonderful progress made in bacteriology and pathology, and we are in a position to-day to offer a more thorough classification of its various clinical phases than would have been possible less than a decade ago. As has been concisely pointed out by Ernst of Boston, in order for the development of the disease there is required, in the first place, a spe- cific virus ; secondly, a means of entrance for this virus into the system ; and, thirdly, a certain constitutional con- dition that will favor the development of the disease, the other two factors being present. The specific virus may be any one of a large number of pathogenic microbes that have from time to time been discovered in the various puerperal patients examined : very probably, however, it is the strep- tococcus pyogenes (Fehleisen's diplococcus of erysipelas) that is the most frequent causal organism. The investiga- tions of Kronig, Williams, Chase, and others would seem to demonstrate the truth of this statement. Other micrococci and bacilli may likewise prove effective in the production of puerperal sepsis of minor degree, and chief among these may be mentioned the staphylococcus pyogenes aureus — a variety present in ordinary fevers — the staphylococcus pyogenes albus, the staphylococcus pyogenes citreus, the bacillus pyocyaneus,the bacillus pyogenes foetidus, together with a vast number of others. Whatever the variety of microorganism concerned in the origination of the disease, in order to become pathogenically active it must either have lain dormant in the genital canal for some time prior to parturition or it must be introduced therein during or shortly after labor. An entrance into this region once effected, further encroachment upon the organism is facili- 40 626 A MANUAL OF OBSTETRICS. tated by the numerous abrasions and lacerations present after every labor, however normal. It must be borne in mind that a mere mucosal abrasion is fully as dangerous as is a more extensive destruction of tissue. The individual susceptibility of the patient to the action of the specific virus is a variable factor dependent upon the original vitality of the woman. Throughout the entire gestation there is a progressively increasing drain upon her powers : with re- duced vitality she enters upon the stages of, it may be, a tedious and often exceedingly difficult parturition ; and to the additional strain thus placed upon her may be super- imposed an intrapartum or postpartum hemorrhage, whereby her defensive powers are still further broken down. Under these unfavorable circumstances the introduction into the vaginal tract of a germ that might otherwise be successfully combated will probably be followed by the most disastrous results. Then, again, the virulence of the germs seems to be increased in proportion to the suitable condition of their environment, or, as has been pointed out by Waterhouse, Klein, Lachowicz, and others, the effects produced by bacteria are influenced by the media in which they rest. The factors that would seem to favor the development of puerperal sepsis in any case may be stated as follows : a greatly reduced vitality ; the presence of numerous abrasions and lacerations in the parturient canal, whereby a ready entrance is afforded the pathogenic microbes ; and the extreme difficulty that will be experienced in preserving a proper degree of cleanliness owing to the anatomic peculi- arities of the parts. It may be clearly seen, therefore, that even after the most rigid observance of the laws of asepsis and antisepsis, patients in whom this unfortunate combina- tion of circumstances exists may unexpectedly develop the disease and perish. As to the mode of action of the streptococcus pyogenes, which may be regarded as the t\'pe of septic germ most con- cerned in the pro^luctionof the disease, much has been conjee- PUERPERAL SEPSIS. 627 tured, though but little is known. Doleris has recently sug- gested ' that its pathogenic action maybe — i. Hypertoxis, by its toxins, and limited to the first stage of the inflamma- tion ; 2. Destruction of vitality and a cause of necrobiosis en masse of the tissues ; 3. Pyogenesis or sepsis at the same time. It is probable that the great malignancy manifested by the streptococci is largely dependent upon their enor- mous power of propagation, rather than upon any special inherited virulence on the part of the germs. Be this as it may, it is certain that by their presence the following changes in the woman's organism are effected : In the first place, there occurs an enormous propagation of the germs implanted within the parturient tract : these give rise to the formation of very deadly substances known as ptomains, that are readily absorbed by the vessels and lymphatics of the region and quickly enter the general circulation. There then ensue grave alterations in the constitution of the blood and the vital fluids of the body. Varying degrees of hydremia and of leukocytosis may be noted, and, finally, vast numbers of the germs themselves and large quantities of their poisonous products may be detected in the blood and body-serum. An offensive odor emanates from the blood of patients who have died from this disease : the fluid is of a dark color and is deficient in red corpuscles. Ecchymoses in various organs are also found. Locally, there are frequently produced very marked alterations in the tissues of the genitalia. An inflammatory process of greater or lesser intensity may be noted : this may consist merely in an engorgement of the parts, with catarrhal manifestations ; there may occur a marked diapedesis, with exudates of varying degrees of consistence ; or there may be produced such a devitalization of the tissues as to result in necrobiosis or even absolute gangrenous changes with the formation of extensive sloughs. Varieties. — According to the amount of ptomain-intoxication, the method of intro- ^ Nouvelles Archives d' Obstetrique et de Gynecologic, No. 3, 1S94. 628 A MANUAL OF OBSTETRICS. duction of the virus into the system, and the pathologic changes and chnical manifestations produced thereby, will depend the variety of the septic infection. It has only been of recent years that any classification of the various forms of puerperal sepsis has been attempted. The grouping of Spiegelberg and, more recently, that of Kehrer are probably the best that have as yet been offered, but both of these are largely defective, in that they fail to include the rarer mani- festations of the disease and give no clue to their pathologic basis. In the preparation of the following table, which is founded on a combined clinical and pathologic basis, an effort has been made to give a rational presentation of the various aspects of the disease, including not only the more familiar but the rarer forms as well. Clinically, the disease is encountered in two main varieties — namely, that due to infection from without — the heterogenetic form — and that arising from self-infection — the autogenetic variety — which' is exceedingly rare. Heterogenetic puerperal sepsis is divided into two classes — namely, that in which there has occurred a general systemic infection, and that in which the general infection is subordinate to the local manifestations. Under these main divisions the various forms of the disease are grouped according to their pathologic features. A. Heterogenetic Puerperal Sepsis. Class I. Those cases in which general sepsis predominates : I. Hemic or vascular infection. (i) Puerperal septicemia. (2) Puerperal phlebitis (infectious pltlebiti!; : septicemia venosa'), with thrombosis {tliromhophlebitis) and embolism ( puerperal embolism). a. Uterine and parauterine phlebitis (phlebitis uteritia ; puerperal metrophlebitis'). b. Puerperal pyemia (septicopyemia ; pyemia metastatica : pye.itia multiplex). c. Puerperal (septic) pneumonia. d. Puerperal (septic) ulcerative endocarditis. e. Puerperal rheumatism ; puerperal (septic) arthritis. f. Femoral (crural) phlebitis (phlegmasia alba dolens). (3) Puerperal (infectious) erythema (scarlatiniform erythema). (4) Puerperal (septic) infectious pemphigus. {5) Puerperal tetanus (tetanus puerperaruni). (6) Puerperal neuritis. Class II. Those cases in which the sepsis is mainly localized in or around the uterus and its adnexa : I. Lymphatic infection (septicamia lyniphatica; puerperal lymphangitis). PUERPERAL SEPSIS. 629 (i) Puerperal metritis. a. Phlegmonous {metritis purule7ita). b. Gangrenous (iiietritis gangrcEuosa) . (2) Puerperal pelvic cellulitis {puerperal parametritis ; puerperal perimetritis ; puerperal ovaritis). (3) Puerperal peritonitis, pelvic or general {peritonitis puerperalis). 2. Involvement of the genital mucosae, (i) Vulvitis. a. Catarrhal or suppurative {vulvitis catarrhalis). b. Phlegmonous or ulcerative {vulvitis puruletita). c. Gangrenous {znilvitis gangrcenosa). d. Diphtheric {vulvitis diphtheritica). (2) Endokolpitis. a. Catarrhal or suppurative {endocolpitis catarrhalis). b. Phlegmonous or ulcerative {endocolpitis purulenta). c. Gangrenous {endocolpitis gangmnosa) . d. Diphtheric {endocolpitis diphtheritica). (3) Endometritis. a. Catarrhal or suppurative {endometritis catarrhalis). b. Phlegmonous or ulcerative {efidotnetritis purulenta), c. Gangrenous {endometritis gangrcsnosa). d. Diphtheric {endometritis diphtheritica). (4) Endosalpingitis. Phlegmonous or ulcerative {e}idosalpingitis purulenta ; puerperal or septic pyo- salpingitis). 3. Puerperal (septic) urethritis, cystitis, ureteritis, and pyelitis. 4. Puerperal (septic) proctitis. B. AuTOGENETic PuERPERAL Sepsis. — Autoinfection. DESCRIPTION OF THE VARIETIES. A. Class I. General heterogenetic puerperal sepsis, in which there i.s mainly an involvement of the vascular sys- tem of the body. I. Hemic or Vascular Infection. — Here are grouped those forms of the disease in which the poison enters the general system through the medium of the blood and the blood-vessels, including the most common clinical variety — puerperal septicemia — the grave form of puerperal phlebitis with associated thrombosis and embolism, and the rarer manifestations of puerperal rheumatism and arthritis, puer- peral or infective erythema, puerperal tetanus, and puer- peral neuritis. (i) Puerperal Septicemia. — Synonyms : Sapremia (Dun- can) ; Resorptive fever; Ptomainemia; Ptomain-poisoning; Ptomain-intoxication ; Septic intoxication; Septic fever; Putrid infection ; Putrid intoxication. Puerperal septicemia is that very common, and generally 630 A MANUAL OF OBSTETRICS. rather favorable, manifestation of puerperal fever due to the absorption into the uterine sinuses and other veins of the genital organs, and from thence into the general circu- lation, of the products of decomposition, the ptomains. These ptomains are produced by the action of the germs of putrefaction upon retained fragments of placenta or membranes, clots, and the lochial discharge. The method of introduction of the germs varies. They may be car- ried into the cavum uteri by the hands of the physician himself, by uncleanly instruments, by a septic catheter, by carelessness on the part of the nurse, or through the agency of unhygienic surroundings in which the rigid observ- ance of the laws of antisepsis is impossible. Whatever the mode of entrance, a more favorable nidus for the growth and multiplication of these germs cannot be imagined. Within the genital tract they find a suitable condition of heat and moisture and a most nutritious pabulum in the coagulated blood-serum and decomposing fleshy particles. In very short order a vast amount of ptomains is engen- dered by the process of decomposition and disintegration of the albuminous materials, and it is from the absorption of these materials that the symptoms characteristic of sapremia arise. Once admitted into the general circulation, they in- duce such a disorganization of the blood — proving especially destructive to the leukocytes — that the resisting-powers of the woman are still further lessened, and the germs them- selves then gain admittance to the circulation, where they more rapidly perform their destructive function. According to the amount of hemic intoxication will be the gravity of the symptoms, and, while this form of puerperal sepsis gives the most favorable prognosis and responds most promptly to an appropriate course of treatment, there are nevertheless ca.ses in which the amount of septic absorption is so great and the destructive action so overwhelming that death rapidly ensues. To these fulgurant cases Garrigues has very aptly ascribed the name of scptic(zmia acutissiina. PUERPERAL SEPSIS. 63 I Symptoms. — (i) General. — Sapremia is characterized by a peculiar fever, preceded, as a rule, by one or more initial chills, and quickly becoming intermittent in type or at times markedly remittent. This symptom is not an invari- able feature of the disease. In the rapidly fatal cases the depression accompanying the introduction of the virus may be so profound as to throw the woman into a condition of collapse: in these cases it is not exceptional to find an en- tire absence of fever, or even a subnormal temperature. To a certain extent, however, the degree of hemic intoxication bears a relationship to the temperature-variations, and so constantly is the elevation of temperature noted in the ordi- nary cases of puerperal sepsis that any rise over 99° F. during the puerperium must lead at once to suspicions of beginning septic changes. The pyrexia most commonly first appears from the third to the fifth day, although in some cases the woman is septic from the time of labor; in other cases there occurs no elevation of temperature until the tenth day or even later. When there is sudden and high elevation, as up to 101° or I02° F., without any warn- ing other than a chill mainly referred to the back and lower extremities, a severe form of the disease may be anticipated, probably of the fulgurant type : generally there occurs a gradual but steady elevation of temperature, each day's record being slightly above that of the preceding day. These progressive elevations indicate successive absorp- tions of septic matter. Associated with the elevation of temperature there is an extreme rapidity of the pulse, which is much out of proportion to the temperature-rate. Thus with only a moderate degree of fever the patient may have a pulse- rate of 120 to 140 or more beats per minute. This rapidity of the pulse is a much more ominous feature of the disease than is the fever. It is always to be noted, except in the beginning of the rarer cases in which the sepsis originates during or immediately after labor: in these cases, however, the pulse quickly assumes its unusual rate. The 632 A MANUAL OF OBSTETRICS. pulse is full and in the minor degrees of sepsis is of but moderate tension ; in the more virulent forms it becomes small and exceedingly rapid. There is a rapid respiration- rate, even amounting to 60 per minute. Profound physical depression characterizes every case of sepsis, no matter how mild the degree of intoxication. The depression, like the pulse-rate, is quite out of proportion to the physical manifestations. Headache is invariably present, and is often bitterly complained of The gastrointestinal symp- toms are marked. There is a bad taste in the mouth ; the tongue soon becomes thickly furred ; the breath is quite offensive ; there is more or less epigastric tenderness ; the appetite is variable and capricious, or there may be total anorexia; the ingested food may be retained, or occasion- ally there will be nausea and vomiting ; jaundice of but slight intensity may be noted ; the bowels usually become loose, and profuse diarrhea is the rule; the stools are fre- quently light in color, exceedingly offensive, and in the graver cases will be passed involuntarily. The skin is very apt to become leaky, and some patients will be almost con- stantly bathed in a profuse perspiration. The secretion of the mammary glands may be much diminished, or an abso- lute agalactia may ensue : this, however, is never noted in the milder cases, and only appears late in the more serious forms of the disease. The lips become parched and chapped, and herpes labialis is sometimes observed. The face pre- sents an anxious cast of countenance, and in some of the graver cases a peculiar duskiness, or even a brownish cast, of the entire surface of the body may be noted. The urine is scanty and febrile in reaction. There is tenderness over the region of the spleen, and careful palpation may detect the enlarged organ. (2) The /^^«/ manifestations of simple puerperal septicemia are not many, and have special reference to alterations in the lochia and the condition of the uterus. Upon the de- velopment of the septic condition the discharge is diminished PUERPERAL SEPSIS. 633 in quantity, and may even be entirely suppressed : at the same time its normal appearance and quality undergo a marked change. It loses its peculiar mawkish odor and becomes horribly putrescent and darker in color, at times sanguinolent or purosanguinolent. The odor is not indica- tive of the presence of dangerous pathogenic germs, although these may be present, but is almost, if not entirely, dependent on the presence in the fluid of immense numbers of the bac- teria of decomposition. There may be an entire absence of the lochia or of the putrescent odor, and yet the secretions of the parturient canal maybe loaded with streptococci, sta- phylococci, or diphtheric or other virulent microorganisms, thus proving the utter dissociation of odor with virulency ; again, there may be noted, in connection with the lochial discharge, an extremely foul odor which investigation will demonstrate to be entirely dependent upon an uncleanly condition of the external genitals without any coexistent general sepsis. Of much more value than the foregoing in the early diagnosis of puerperal septicemia are the uterine manifestations. These will consist, in the first place, in the development of an undue tenderness on manipulation, espe- cially over the region of the fundus, associated with a certain am.ount of abdominal distention. By a careful bimanual examination the uterus will be found to be con- siderably larger than normal, and of a soft and flabby con- sistence ; difficulty may be experienced in clearly defining the outlines of the organ ; it is noncontractile, and shows at times complete loss of the muscular tonus ; the cervix will be much softer than usual, and the external os quite patulous, so that the index finger can be readily introduced up to or even within the internal os. There may or may not be noted in these simple cases of septicemia a certain amount of tenderness in the region of the broad ligaments. Diagnosis. — The diagnosis of puerperal septicemia should not be attended with much difficulty. Unfortunately, how- ever, the general physician is so averse to admitting, even 634 ^ MANUAL OF OBSTETRICS. to himself, that he has a case of- sepsis upon his hands that he is very prone to argue himself into believing that his patient is suffering from an attack of some other intercur- rent disease, as an intermittent or remittent fever or an in- fluenza. It is true that such a noninfectious condition may engender symptoms that closely simulate those of true puerperal sepsis, but it may be excluded by careful atten- tion to the clinical manifestations in any given case. Espe- cially is it of the utmost importance that malarial infection be recognized. The following points may aid in formulating a correct diagnosis between the two diseases : Puerperal Sepsis. Malarial Infection. The chills are irregular in their appearance The chills occur at regular intervals, and are and are associated with marked altera- followed by the usual elevation of tempera- tions in the temperature-rate. ture and then a sweat. The constitutional disturbance is profound. The constitutional depression is moderate, and quite out of proportion to the sever- ity of the paroxysm. The pulse-rate is exceedingly rapid and The pulse-rate is in proportion to the ominous. amount of febrile reaction. There will be associated uterine subinvolu- There will not be noted any peculiar local tion and tenderness, and probably altera- pelvic manifestations, tion in the lochia. The patient's condition steadily grows worse Within a few hours there will occur a without appropriate treatment. marked amelioration of the symptoms. Influenza will occasionally be found as a complication of the puerperal state. It may be recognized, however, by the following characteristic features : There will be pres- ent the usual pains and soreness over the body, especially in the back and limbs ; the local manifestations of puer- peral sepsis will not be noted — in fact, involution will prob- ably progress normally — nor will there be such a marked disproportion between the febrile reaction and the pulse- rate as in septic infection ; there will be more pronounced gastric and pulmonary disturbances than in septic infection ; and, finally, in from four to seven days the disease will have exhausLcd itself and the patient will return to her normal puerperal condition. It is quite possible, however, for a true puerperal sepsis to develop during an attack of influ- enza in the lying-in woman. PUERPERAL SEPSIS. 635 Other causes of elevation of temperature during the puer- peral period are constipation, croupous pneumonia, mastitis, the development of a mammary abscess, tonsillitis, profound mental emotion or shock, reflex gastric and intestinal dis- turbances, and the rapid development of pulmonary or gen- eral tuberculosis. These morbid conditions may be readily recognized by a careful examination of the affected portions and by a history of the case. Prognosis. — Owing to the utter inability on the part of the medical attendant to definitely state what will be the progress of any given case of puerperal septicemia, the prognosis must remain doubtful. It is true that this is the most favorable form of puerperal sepsis and the most amenable to treatment. A certain proportion of the women, however, will invariably perish either within twenty-four or forty-eight hours or after a few days. The causes of death are profound toxemia and great de- pression ; the development of grave organic lesions through- out the body ; asphyxia from great destruction of the red blood-corpuscles ; and paralysis of the nerve-centers. The mortality of simple puerperal septicemia may be stated as varying from ^ to i per cent. ; in the hands of the gen- eral profession it will probably reach as high as from 2 to 5 per cent. Treatment. — i. Prophylaxis. — The treatment of puerperal septicemia, as of all forms of puerperal sepsis, should be mainly prophylactic. A very essential element in the prophylaxis of the disease, as pointed out by More Mad- den, will be the observance of proper sanitation and the maintenance of a good constitutional condition of the pa- tient by a judicious course of hygienic and dietetic treat- ment, tog-ether with the administration of ferruginous tonics throughout the later months of pregnancy. Since the in- troduction by Semmelweis (in 1846) of antisepsis in obstet- ric practice the old mortality of 10 to 15 per cent, has been reduced to its present figure. The greatly reduced vitality 636 A MANUAL OF OBSTETRICS. of the parturient woman, rendering her more susceptible to microbic invasion, is ample reason for the observance of special precautions to prevent the access of germs to her genital tract. Thorough asepsis of the patient and her sur- roundings, of the attendants, physicians, and nurse, and of the catheter, instruments, and syringe, must be insisted upon. The employment of sterilized water and suitable germicidal agents, within proper limits, is justifiable, but it must be remembered that overzeal in the prosecution of antisepsis may defeat its own purpose : septic infection has resulted from the use of the vaginal douche itself, and it is now very generally conceded that in normal labor, in women who are perfectly healthy, vaginal douches are unnecessary, and are more harmful than beneficial. In such cases there is more commonly manifested a rapid pulse and an elevation of temperature after, than before, the douching. Only in those cases in which a certain amount of dystocia has occurred or an obstetric operation has been performed are the douches indicated and efficacious. Some men, notably Leopold and Sporlin of Germany, have advocated the conduct of labor without vaginal examination, believing that by such an ob- servance the frequency of puerperal sepsis will be mate- rially lessened. They have suggested a purely external method of examination, with particular manipulations in proper succession (see Figs. 46—49, p. 10 1), whereby a normal labor may be managed without the introduction of the fingers into the vagina. While this method can- not be generally recommended, it is without doubt proper to limit the number of vaginal examinations as far as is conducive to the safety of the fetus and the maternal structures. Frequent douching also should be limited to those cases in which there already preexists a septic con- dition of the vaginal tract : in normal cases the general practice is to administer but one douche of creolin or mer- curic chlorid, and that immediately after the expulsion of the placenta, in order to remove any clots or fragments of tissue PUERPERAL SEPSIS. 637 which, if allowed to remain in the vagina, might undergo decomposition and serve as a nidus for microbic develop- ment. It has been demonstrated that a hot vaginal injection of mercuric chlorid, carbolic acid, or other dis- infectant, administered during the early stages of labor, has a tendency to contract the vaginal mucosa by constrict- ing the capillaries : it also removes the mucus that nor- mally lubricates the parts, and thereby materially retards the labor by augmenting the friction between the fetal presentation and the vaginal walls. Again, Kronig and Schroeder consider vaginal injections as dangerous, since they may lessen the chemical resistance of the tissues to bacterial action, and may even wash the germs into the uterine cavity. A very convenient cleansing douche for routine practice after labor is one consisting of warm ster- ilized water containing a small amount of boracic acid or sodium borate, the solution having about the specific gravity of blood (i part in 25). A 2 per cent, solution of creolin, a solution of carbolic acid (i : 40), a solution of hydrogen dioxid, or a solution of mercuric chlorid (i : 2000 or 4000), may be employed in the same manner. The objection to the creolin is its color, which will so disguise the nature of the vaginal discharge as to render it absolutely useless as a means of diagnosis. The mercuric solution has resulted repeatedly in systemic poisoning, and when it is em- ployed the vagina should immediately afterward be flushed with boracic acid or sodium-borate solution. Two sub- stances that have recently been employed as vaginal douches with considerable satisfaction are lysol in a i or i ^ per cent, solution, and eucalin (a coal-tar product combined with eucalyptol) in the proportion of i to lOO of distilled water. The vaginal douches are best given through the or- dinary fountain syringe, to which is attached a glass nozzle with an olive-shaped tipper fo rated laterally only, thereby still further diminishing the necessary amount of manipula- tion of the part, and preventing the forcing of the fluid or 6t,8 a manual of obstetrics. of bubbles of air into the uterine sinuses or the Fallopian tubes, with resultant air-embolism or the production of a metroperitonitis. Murray suggests the cleansing of the parts after each micturition by one of the foregoing antisep- tic solutions. Firm uterine contraction may be secured, and thereby the formation of intrauterine clots prevented, by the administration, immediately after the delivery of the fetus, of one or two drams of the fluid extract of ergot. 2. Ti'catvient of the Disease. — When the disease has actu- ally developed and the woman is manifesting the symptoms of putrid absorption, active interference alone will limit the amount of systemic infection. The indications for treat- ment are to remove the source of infection, to eliminate the poison already in the system, and to sustain the patient during the period of profound physical depression conse- quent upon the hemic intoxication. These indications will be met by general and local medication. {a) Local Treatment. — By far the more important are the means employed to prevent further absorption of the bac- teria and their ptomains. This can be accomplished only by thorough disinfection of the parturient canal. It will not suffice to douche the vagina alone, for Ahlfeld, Jewett, and others have clearly demonstrated that the seat of most active absorption of the toxic material is the placental site, the vagina ranking next in importance. Hence arises the necessity of thorough intrauterine irrigation and curetnient in all cases of puerperal septicemia. Local asepsis embraces the following steps: i. Thoro7tgli asepsis of the hajids and the instninients to be employed. This will be secured according to the methods already described in the section on the treatment of labor. The patient must then be placed in the lithotomy position at the side of the bed, with a Kelly pad under her hips and a vessel below to receive the fluid. It is preferable that an anesthetic be given to secure absolute relaxation of the parts and to prevent suffering. 2. Asepsis of the vulvar orifice. It is patent that PUERPERAL SEPSIS. 639 in any case in which it becomes necessary to resort to ute- rine cleansing and medication the passageway from the ex- terior to the internal os must be rendered as aseptic as possible. The vulvar and pubic region, if they be not pri- marily rendered aseptic, may very readily infect the interior of the vaginal canal by direct transference of the germs during the necessary manipulations. This may be accom- plished as nearly as possible by thorough washing of the parts with soap and water and, if need be, the brush, and then with alcohol, after which they may be cleansed with pieces of lint saturated with a mercuric-chlorid solution (i : 2000). 3. Asepsis of the vagina. The vagina must be cleansed by a solution of green soap and water, especial attention being paid to the folds of the mucosa around the ostium, the lat- eral sulci, and the vaginal fornices ; a douch of mercuric chlorid (i : 2000 or 4000), or of creolin (2 per cent.), may be administered. 4. Asepsis of the utei'ine cavity. No diffi- culty will be experienced in gaining admission to the ute- rine cavity, since as long as any foreign material remains within the uterus closure of the cervical canal will not take place : the os will be found to be quite patulous. Asepsis of the cavum uteri will be accomplished in three stages : id) Qirctinent. For this purpose a moderately sharp curet should be employed : the dull wire curet of Thomas will not answer. Tarnier suggests that before the curet be employed it might be well to scrub out the uterine cavity with a brush closely resembling that employed for cleaning the ordinary test-tube, and this operation he terms ecoiivillonage. We cannot see that this procedure is espe- cially desirable, and would much prefer to proceed at once to the use of the curet. The instrument, well asepticized, should be carefully introduced to the fundus and the entire cavity energetically scraped, care being taken not to perforate the softened uterine wall. The perforated curet that allows a constant stream of sterilized water to flow over the site of operation is particularly to be recom- 640 A MANUAL OF OBSTETRICS. mended. By it the field of operation is kept clean, and the detached fragments of tissue and placental debris are constantly washed into the receptacle placed to receive them. It is very important that all the recesses of the cavity be well scraped, especially around the tubal orifices and over the site of the placental attachment. Large frag- ments of placental tissue may be torn away with placental forceps, or the finger may be introduced and the pieces grasped and removed. Every portion of retained tissue must be removed before the curet is laid aside, thereby preventing further decomposition and ptomain-absorption. {b) Inigation of the uterine cavity. All debris must be washed out by copious douches of warm sterilized water, which should be allowed to flow until it return clear in color and free from organic matter, (r) Medicinal applica- tions to the cavity. Further disinfection may be secured by the introduction of some antiseptic agent.. Most com- monly employed is iodoform in the form of a bacillus or uterine suppository, in suspension in an oily fluid, or as iodoform-gauze. The iodoform increases diapedesis, and is claimed to be an excellent antiseptic to living tissue, although this has recently been vigorously con- tested. Ten to 30 grains of the drug may be used in the form of a suppository, which may be introduced into the cavity by a long pair of dressing-forceps. A mixture very highly recommended is one composed of 2 drams of iodoform in 3 or 4 ounces of warm sweet oil. If not anti- septic, the drug can at least do no harm. Other substances that may be employed in the uterine cavity for disinfecting purposes are a 10 per cent, solution of carbolized glycerin, tincture of iodin, a 5 to 10 per cent, solution of zinc chlorid, a I to 3 per cent, solution of creosote in glycerin, and a i per cent, solution of phcnosalyl. Bonnaire suggests swab- bing out the cavity with the following solution: Potassium iodid, i^ drams ; metallic iodin, 40 minims ; water, 3 fluid- ounces; the entire solution to be mixed in a quart of steril- PUERPERAL SEPSIS. 64 1 ized water. Whatever substance be used, special care must be taken to secure an escape of the fluid in order that poisoning from absorption or too extensive cauterization shall not ensue. The most remarkable and gratifying re- sults will follow such a course of treatment. Within a few hours there will be noted a marked fall in temperature: the patient will feel more comfortable, and her pain will have largely left her. It may be that the one treatment will answer, and the more thorough the first treatment the greater the probability of its sufficing. Upon the return of a rise of temperature, without delay a second curetment and intrauterine treatment must be performed, and the vagina packed with iodoform-gauze or a vaginal supposi- tory of iodoform introduced. ib) General Treatment. — The further introduction of septic material into the general system of the patient having been largely prevented by the preceding local course of treatment, the poison already absorbed must be eliminated and the woman sustained through the period of depression. The drugs most efficacious for these purposes are quinin in full doses, alcoholic stimulants to the ut- most capacity of the patient, the cardiac stimulants, and a rich and nutritious diet in suitable quantities at frequent intervals. To these may be added germicidal agents as required, of which Madden prefers sulphurous acid in 30-minim doses every three hours, especially in cases in which the gastrointestinal disturbance is marked. Turpen- tine in capsules in doses of from 10 to 20 minims is also well borne in many cases. The quinin may be given in pill form, 8 to 10 grains daily, or by suppository. The whisky should be administered in the form of a milk-punch, half an ounce of the stimulant being given every three or four hours, and the quantity increased as the patient can tolerate it. Strychnin sulphate in doses of -^^ of a grain three or four times daily, the tincture of digitalis, 10 drops, three times in the day, or the tincture of strophanthus in 41 642 A MANUAL OF OBSTETRICS. 2- to 5-iTiinim doses, may be of service. Under their ad- ministration the extreme rapidity of the pulse is regulated and the circulation brought under control. Bonnaire would further tone up the patient in the more pronounced cases of the disease by the hypodermic injection of from 8 to 10 drams of Hayem's serum (sodium chlorid siss ; sodium sulphate siiss ; water Oij). The diet should consist largely of milk with a small amount of lime-water every two to four hours. This may be supplemented by beef-extract, meat-broths, and other light liquid preparations. The diarrhea that is usually present may be regarded as one of nature's efforts to eliminate the poison from the sys- tem ; for this reason, if the discharges be not too profuse and weakening, energetic treatment will not be indicated. Eulenberg and others have claimed that the copious dis- charges from the intestinal canal will not weaken the patient, and that they may be readily controlled at the proper time. Based upon this beneficial view of the diarrheal discharges of puerperal sepsis has arisen the treatment of the disease by saline laxatives in those cases in which the bowels are sluggish. Especially has this course of treatment been earnestly recommended by Schroeder, Seyfert, and Breslau. Under its influence the temperature falls and the local pel- vic manifestations are improved. The remedies to be em- ployed for this purpose are a saturated solution of Epsom salts, full doses of calomel or castor-oil, compound jalap- powder, and the Hunyadi and other laxative waters. The offensive odor of the stools may be corrected in part by the administration of the intestinal antiseptic agents, as salol, zinc sulphocarbolate, benzonaphthol, naphthol, or bismuth salicylate, in suitable doses. In addition to the action of the quinin and laxatives, the temperature may be reduced by cold sponge-baths with friction of the extremities, by the cold-water abdominal coil, or by the Kibbee cot (cold-water mattress). Cold baths, as in typhoid fever, have been successfully employed by Mace in those PUERPERAL SEPSIS. 643 cases in which the patient is not profoundly depressed or in which there do not exist peritoneal and broad-ligament involvement or other grave sequelae, as phlegmasia alba dolens. The simple cases of puerperal septicemia may be much benefited by these baths judiciously employed. The aftcr-ircatniciit will consist in the free administration of tonics and in the cultivation of the appetite. A change of air and scene should be recommended when the patient has gained sufficient strength. Every precaution must be observed to prevent the development of intercurrent dis- eases, to which the woman is extremely subject from greatly reduced vitality. (2) Puerperal Phlebitis. — Synonyms : Infectious phle- bitis ; Septicaemia venosa. — This is a very grave form of puerperal sepsis in which there occurs an acute inflamma- tion of the venous channels of the uterine walls, with septic infection of the thrombi that normally block up their mouths : these thrombi, undergoing a rapid disintegration, induce general or localized embolisms. Beginning in a septic infection and inflammation of the uterine sinuses, the disease quickly spreads to the adjacent vessels in the pelvic connective tissue. Small emboli escape into the general circulation, inducing either a general pyemia with multiple abscess-formation, or causing localized thromboses in various portions of the body. Occasionally there occurs a rapid extension of the disease to the iliac and femoral veins, resulting in the familiar complication, phlegmasia alba dolens. {a) Uterine and parauterine phlebitis {phlebitis iitcrina ; puerperal metrophlebitis) is a peculiar septic process occur- ring late in the puerperal period, and originating in a pri- mary infection of the thrombi formed in the mouths of the uterine sinuses immediately after the separation of the pla- centa. Labor may have been, to all appearances, abso- lutely normal : the first few days, or even three or more weeks, of the puerperium may have elapsed, and the patient 644 ^ MANUAL OF OBSTETRICS. to all intents is out of danger and doing well. It is true that there may be an insidious onset, and a close investiga- tion of the temperature-chart may reveal a trivial evening exacerbation to 99° or 99J^°F., with a corresponding rapidity of the radial pulse and a slight flushing of the face — a group of symptoms not striking enough to cause any anxiety on the part of the patient and her friends. These prodromal manifestations may be absent, and the disease develop with an alarming abruptness. There may suddenly occur a rise of temperature to 103° or 105° F., associated with an anxious cast of countenance, great prostration, and marked rapidity of the pulse. This may or may not be pre- ceded by a true rigor : generally the chill is not noted. After persisting for a few hours there very frequently occurs a break — either a decided remission or an intermission — in the fever, and with this it is not uncommon for a profuse perspiration to bathe the surface of the body. The patient may remain apyretic for a day or two or for more than a week, and then experience a relapse characterized by all the symptoms of the original attack. In other cases there is no remission, and the patient is extremely ill, with con- tinued fever characterized by irregular exacerbations, pro- found depression, and a rapid running pulse. There are present certain evidences of gastrointestinal disturbance ; the tongue is extremely coated ; there is an unpleasant taste in the mouth ; the appetite is poor or there is complete anorexia ; and the bowels may be constipated. Pressure upon the abdomen does not, as a rule, elicit any tenderness, nor is meteorism to be noted. Local examination fails to elicit any special manifestations. The womb is undergoing the normal process of involution, and is not oversensitive upon manipulation : it is freely movable, in strong contradistinction to the cases of local pelvic peritonitis with pelvic exudate firmly fixing the heavy uterus in the pelvic cavity ; pathologic masses of any description are conspicuous by their absence ; the PUERPERAL SEPSIS. 645 lochia may be scanty, but are not characterized by foulness of odor. The only local clinical manifestation of uterine phlebitis is the occasional occurrence of an abrupt and very profuse hemorrhage, resulting from a dislodgement of one or more of the disorganized thrombi. This consti- tutes one of the most serious forms of puerperal or sec- ondary postpartum hemorrhage : the flooding may be so profuse as to jeopardize the patient's life, and, indeed, the repeated hemorrhages may terminate fatally. The pathology of this condition is not thoroughly known. Winckel, who has given considerable attention to the sub- ject, claims that the thrombi are normally converted into tough cords of connective tissue through the agency of the leukocytes that wander in from the neighboring vasa vasorum ; later these cords undergo canaliculation and the blood-current is restored. During this process of organi- zation the thrombi form admirable foci for the accumula- tion of any pathogenic germs that may find entrance to the uterine cavity, and, once infected, a speedy involvement of the circulation follows. Bumm remarks that the thrombi that jut out from the placental site undergo disorganiza- tion primarily in the line of their axes : from these central points the process rapidly spreads peripherally until the endothelium and the vessel-walls become affected, and these break down into a mass of necrotic tissue into which have wandered numbers of leukocytes, and which contains immense numbers of the bacteria. The diagnosis of this condition is not an easy matter. The distinction between puerperal phlebitis and simple puerperal septicemia is ex- ceedingly ill defined. In many cases only when there is noted an aggravation of the symptoms after an attempt at intrauterine irrigation will the phlebitic condition be sus- pected. The prognosis must necessarily be grave. The patient may perish suddenly from profuse hemorrhage, or emboli may be carried to distant regions of the body, either causing death from occlusion of some important arterial 646 A MANUAL OF OBSTETRICS. trunk or giving rise to general pyemia. The course of the disease is protracted, often lasting from three to twelve weeks. The treatment can be general only. It has been found that when the uterine cavity is curetted and douched there almost invariably follows an exaggeration of the symptoms, or profuse hemorrhage may result. This is due to a further dislodgement of septic particles from the dis- organizing thrombi, some of which are forced into the gen- eral circulation with disastrous consequences. The uterine cavity must therefore be rigidly avoided, except when there is a hemorrhage : this must be controlled by thorough tam- ponade of the cavity with a strip of iodoform-gauze, which may be left in situ for from eighteen to twenty-four hours, at the expiration of which time it may be removed and another introduced should the bleeding recur. The constitutional treatment will embrace the exhibition of stimulants in large amounts and the administration of nutritious food. Alcohol is best given in the form of whisky, in doses of from half an ounce every hour to a pint or more in a day. If whisky cannot be tolerated, brandy or wine (preferably champagne) may be substituted. The diet must consist mainly of milk, either fresh or partially digested, of which the patient may take as much as desired (three or four quarts). Beef-extract and other preparations of beef may be taken in the intervals in suitable doses. Digitalis, strych- nin, quinin, and strophanthus may be employed as needed. Absolute rest must be enforced, and persisted in for at least two weeks after the subsidence of all symptoms. {b) Pnej'peral pyemia {septicopyemia ; pycsmia metastatica ; pycemia multiplex^ is a grave manifestation of puerperal sepsis, a direct sequence of puerperal phlebitis, in which there occurs a profound involvement of the general system with the formation of purulent foci throughout the tissues and organs of the body. These abscesses are the result of multiple emboli carried into the circulation from the dis- integrating uterine thrombi. Having once entered the PUERPERAL SEPSIS. 647 general circulation, the noxious particles are carried over the body, lodging here and there, and, wherever arrested, producing localized thromboses and infarcts which them- selves may become the sources of other emboli. No portion of the body appears to be exempt from their invasion : the entire circulatory system is septic, and miliary abscesses and abscesses of larger size may form in the liver, spleen, kid- neys, lungs, brain, and elsewhere. The areolar and subcu- taneous connective tissue may become the seat of extensive suppurative cellulitis, being literally riddled with multiple abscesses. Moser has noted in two instances suppurative parotitis. The function of the liver may be so interfered with, as a result of the septic abscesses in its substance, as to result in a marked jaundice. Litten records the develop- ment of retinal hemorrhages ; emboli may lodge in the eye, and a grave panophthalmitis with suppuration and destruction of the eyeball result; purulent foci may even form within the muscular substance of the body [iiiyositis pwndenta piierperarmii); the pleura may be involved ; and Hirst and Fussell record a case in which there occurred a thrombosis of the longitudinal sinus of the brain. Symp- toms. — As may readily be imagined, the symptoms of this grave condition are very pronounced. There is profound physical depression, and in the later stages a rapid run- ning pulse (which at first is only moderately accelerated) ; the temperature partakes more of the hectic type ; there are abrupt elevations, with corresponding periods of apyrexia or even of subnormal temperature, though this is rare ; after the formation of abscesses the temperature remains con- stantly elevated. The pulse loses its bounding character and becomes rapid and thready ; a low, muttering delirium may supervene, with lucid intervals ; the skin is dry and pun- gent ; the tongue is darkly coated and fissured. Repeated chills are noted, occurring not only at the onset of the dis- ease, as occasionally in simple sapremia, but also at irregular intervals throughout the entire course of the malady. These 648 A MANUAL OF OBSTETRICS. chills occur more commonly in the morning and afternoon than in the evening and night. As in the preceding variety of sepsis, the local manifestations are slight : there may be at first some odor attached to the lochia, but this soon dis- appears ; pelvic peritonitis may be present, but is rare, and generally the abdomen is flat or concave, tenderness not being elicited on manipulation. The diagnosis is plain. The prognosis is grave ; death often ensues rapidly, or life may be prolonged for two or three weeks. The treatment is the same as that for uterine phlebitis. {c) Puerperal {septic) pneumonia is but a special manifes- tation of puerperal pyemia, in which there occurs a throm- bosis of the pulmonary artery or some of its branches, as a result of the lodgement therein of one or more of the septic emboli from the infected uterine sinuses. The symptoms are those of an acute pneumonia with marked dyspnea, pro- nounced depression, and feeble pulse. There will probably be associated septic abscesses elsewhere in the body. The onset of the disease is abrupt at a late date in the puerpe- rium ; the physical signs are not those of a typical croupous pneumonia : the course of the disease is irregular, and a fatal termination is frequent. Crepitation is not marked, and the sputum may or may not be rusty. The treatment must be sustaining, consisting mainly in the exhibition of stimulants and nutritious food, with local counterirritation over the affected region of the lungs. {(i) Puerperal {septic) 7ilcerative endocarditis is an exceed- ingly grave — perhaps the gravest — variety of puerperal pyemia. Not only does there occur a metastasis of septic material from the primary seat of infection to the left heart, but the pathogenic microbes themselves are carried thence, and continue in this organ their work of destruction. It is a late manifestation of the septic infection, usually not de- veloping earlier than the second or third week of the puer- perium. This special complication of the pyemia is ushered in by a pronounced rigor, associated with great elevation PUERPERAL SEPSIS. 649 of temperature and profound shock. The pulse becomes exceedingly rapid, at times dicrotic and very feeble, and is readily compressed; its rate may reach from 140 to 160 beats per minute. There may be experienced some pain in the region of the heart ; purpuric spots will be detected over various regions of the body, and auscultation will reveal a loud systolic murmur in the mitral area, and at times a double aortic and mitral systolic murmur. Small emboli may be lodged in the retinal vessels, and retinal hemor- rhage, with corresponding obstruction to vision, is gener- ally noted. Low muttering delirium or a flighty condition is often present, and intense headache, jactitation, and in- somnia may contribute to the gravity of the clinical picture. Diagnosis. — The recognition of this complication is not a difficult matter if the pronounced cardiac manifestations, the feeble and dicrotic pulse, the purpuric spots, and the grave general condition be taken into consideration. The prognosis is fatal. These cases invariably die in from five to ten days. The treatment C'dxi be symptomatic only, and will em- brace the administration of strychnin, digitalis, or strophan- thin, large amounts of alcoholic liquors, and a nutritious diet, (r) Puerperal Rheumatism ; Puerperal {Septic) Arthritis. — Not infrequently there has been noted in the puerperium a condition characterized by the occurrence of pains of a rheumatic nature, generally localized in or around the larger joints, and developing at any time from the second to the fifteenth or twentieth day after labor. It is now known that these pains are the result of a mild degree of septic intoxication, and as long as no organic changes occur in the affected joints the condition is designated piierperal rheumatism. Unfortunately, however, the morbid process shows a marked tendency to pass beyond a simple inflam- mation characterized by pain, redness, and swelling of the joints. The knee is especially prone to involvement in this specific process, and not rarely the articulating surfaces become seriously impaired, and abscess-formation with 650 A MANUAL OF OBSTETRICS. subsequent ankylosis is the result. The symptoms of puer- peral rheumatism are intense pain in the affected joint, with great swelling and redness of the surface. Charpentier describes the color as a " claret-red, a blue, or a pale-rose." Associated with these local manifestations are a consider- able elevation of temperature (i03°-i05° F.), which is often preceded by a chill, and a corresponding increase in the rapidity of the pulse, which ranges from no to 140 beats per minute. As a rule, there are no changes in the vaginal and pelvic conditions. The lochia does not become offen- sive, nor will manipulation of the uterus elicit abnormal tenderness. It is not exceptional for vague pains to be experienced in other remote regions of the body, and the patient may even develop a well-marked pleurodynia or severe myalgic pains in the back and shoulders. The in- flammatory process may, though rarely, exhibit the ordinary fugacious character of simple rheumatism, and shift from one large joint to another with astonishing rapidity, the course of the disease being thus protracted to a consider- able length. Very generally the trouble is stationary in the joints primarily affected. Frequently profuse perspiration will also be noted. When the inflammation advances to suppuration a different clinical picture presents itself The general symptoms now assume more of a hectic type. The chills are of repeated occurrence, and soon the edema and puffincss of the joints indicate a formation of pus. Diag- nosis. — The diagnosis between puerperal arthritis and simple acute rheumatism is not always an easy matter. The main points of differentiation consist in the following : Puerperal Arthritis. Simple Acute Rheumatism. I'wo or more joints are liable to be simul- The disease very commonly shifts from one taneously affected, and there is usually no joint to another, that first affected improv- metastasis from joint to joint. ing as the next becomes inflamed. There is a great tendency to suppuration. The tendency to suppuration is not marked. There is pronounced physical depression. Prostration is not so pronounced. The patient may die suddenly from em- Death is very rare. holism. The salicylates and ordinary antirheumatic Responds readily to the usual antirheumatic remedies fail to give relief. remedies. PUERPERAL SEPSIS. 65 I Prognosis. — Necessarily, the prognosis is doubtful : the condition may develop into one of general pyemia, or sudden death may ensue from pulmonary, cardiac, or cerebral embolism. At the best, the course of the af- fection is protracted and tedious. Treatment. — The salic- ylates and other antirheumatic remedies are absolutely inefficacious in relieving the symptoms. This may be regarded as a therapeutic test of the septic nature of the disease. Relief can be secured only by insisting upon ab- solute rest of the affected joints as well as of the entire body, together with the administration of full doses of alcoholic and other stimulants, the ingestion of plenty of nutritious food, and an appropriate course of local treat- ment, consisting in counterirritation by tincture of iodin, and the application of ointments of ichthyol, belladonna, or mercury. After there has occurred a subsidence of the active inflammation, gentle massage and passive move- ments of the joint should be instituted in order to avoid the production of ankylosis, to which, as has been noted, there is a strong predisposition. (/") Femoral or crural phlebitis ( phlegmasia alba dolens ; milk-leg; anasarca serosa; white-leg; oedema lacteiim ; peripheral venous thrombosis) is a peculiar late manifesta- tion of puerperal sepsis in which there occurs a thrombosis of the iliac or femoral veins on one side, usually the left, with an immense edema of the affected limb, which presents a characteristic white or milky appearance from which has originated the appellation of " milk-leg." The disease was formerly attributed to a metastasis of milk from the mam- mary glands, and by some the popular name is believed to have thus originated. It is possible for phlegmasia alba dolens to occur as a sequel of uterine phlebitis, coagula being carried from the placental site into the hypogastric veins : lodging here, they obstruct the flow of blood through the crural veins. Again, the disease may occur as a result of a direct extension of an inflammatory pro- 652 A MANUAL OF OBSTETRICS. cess originating in a phlebitis of the uterine sinuses, the veins of the pampiniform plexus of the broad ligament next becoming involved, and finally the iliac and femoral veins ; or the affection may be purely localized in its origin, beginning as a crural phlebitis. In the former in- stance {tlirombotic pldcguiasid) the prominent clinical mani- festation, edema, is first noted at the ankle, from which it rapidly rises until the entire limb is involved. In the pri- mary pelvic variety the edema progresses steadily down- ward from the groin to the foot : it then results not so much from the primary formation of thrombi in the veins as from direct pressure exerted by the inflammatory exu- date thrown out around the pelvic veins of the correspond- ing side ; this condition has been termed by some writers pressure-thrombosis, and by others celhilitic phlegmasia. Pressure-thrombosis may occur during the later weeks of pregnancy, inducing all the manifestations of phlegmasia before childbirth. Etiology. — The direct causation of the disease has already been indicated. There are, however, some predisposing factors that favor its development. Among these may be mentioned the hyperinosis peculiar to pregnancy ; weakness of the system from multiparity or some systemic dyscrasia ; the increased tendency of the blood to clot during an acute anemia dependent upon a profuse hemorrhage, as from retained placenta, relaxation of the uterus, or placenta prsevia ; grave obstetric operations or extreme prolongation of labor ; and, finally, an acute ex- acerbation of some preexisting pelvic inflammatory disease, as an old pelvic exudate. Symptoms. — As has already been stated, phlegmasia alba dolens is a late manifestation of sep- sis, occurring usually in the third or fourth week of the pucrperium, and more rarely as early as the second week. Until the onset of the disease the patient may have been progressing .satisfactorily. Then there occurs, more or less abruptly, an elevation of temperature to 101° or 103° F. ; a marked rigor may or may not precede the fever. The PUERPERAL SEPSIS. 653 patient is depressed and uncomfortable ; she is fretful and generally indisposed to exertion; she cannot sleep and tosses from side to side ; there is an unpleasant taste in her mouth, and other evidences of gastrointestinal dis- turbance — furred tongue and torpidity of the bowels — exist. The pulse is rapid and full. If she be nursing her child, the latter will by its constant crying indicate an alteration in the quality of the milk, or lactation may be completely arrested. The lochia are diminished in amount and are extremely fetid. There now appears the premonitory sign of Meigs, upon which considerable stress has been laid — namely, severe cramp-like pains in the calf of the affected leg: this pain is very constant, although not always begin- ning in the calf. It may start above in the pelvic region and extend down toward the knee, following the course of the femoral vein, or it may begin below in the foot and ascend. Whatever its origin, it is very marked and very characteristic of the affection. The patient cannot move her limb without causing an exacerbation of her sufferings. Edema promptly supervenes, and the limb assumes the peculiar dead-white, glistening appearance that has originated the popular name "milk-leg." The swelling is extreme; pittings half an inch or more in depth result from digital pressure. The leg is sensitive to the touch at first, but this rapidly disappears with the increasing edema, until the impression given to the sufferer is that of a dead limb. A painful line of induration may extend along the course of the femoral vessels, and local thermometry reveals an increased temperature of the part ; there is also more or less duskiness of the skin of this region. The inguinal glands are hard, enlarged, and sensitive, and the edema may extend over the iliac region of the abdomen and into the external genitals. The coiirse of the disease is not constant. The fever is subject to marked variations : it may be persistently high, or may gradually fall from the initial rise and entirely disappear in the more favorable cases long before the limb has returned to its normal pro- 654 --^ MANUAL OF OBSTETRICS. portions. If suppuration occur, the temperature-chart shows the characteristic hectic type broken by irregular chills. The disease may be limited to one limb, or both may be involved either simultaneously or, more often, consecutively. The duration of the disease varies greatly. The acute symp- toms generally subside in from one to two weeks, but the local manifestations may persist long beyond this period, or the limb may never regain its original healthy condition. The tcnninatious of phlegmasia alba dolens are — complete resolution, occurring in at least one-half of the cases; suppu- ration with local abscess-formation, especially common in the cellulitic variety; general pyemia with metastatic ab- scess-formation ; or gangrene and death. Diagnosis. — There can be no difficulty in diagnosticating phlegmasia alba dolens. There is no other condition that in any respect resembles it in its clinical manifestations. The prognosis must be guarded. Not only is there the possibility of a fatal outcome, but there is always more or less danger of permanent disability of the limb. Death, when it occurs, results from exhaustion following general pyemia or gan- grene, or from embolism of some important venous trunk. It has been estimated that a mortality of 33 per cent, attends the disease. Should the thrombosis of the femoral vein fail to be absorbed, there will result varying degrees of dis- ability of the limb until venous anastomosis occur of suf- ficient size to compensate for the occluded vessel. This may require months or years, and during this period the patient is invalided. Treatment. — As in the other forms of puerperal sepsis, the constitutional treatment of phleg- masia alba dolens is mainly supi)orting. The diet must be liquid, but very nutritious, consisting largely of milk (pep- tonized, if necessary), beef-extracts, broths of various kinds, oyster-soup, and clam-juice. Whisky should be exhibited in suitable amounts according to the condition of the pa- tient's pulse. Tonics, including iron, strychnin, and quinin, are always indicated in full doses ; the bowels must be kept PUERPERAL SEPSIS. 655 patulous by gentle laxatives only, free purgation, except at the onset of the disease, being contraindicated. For the pain, opiates, preferably Dover's powder or hypodermic in- jections of morphin, are essential, and for the insomnia later in the disease mild hypnotics are of service. Abso- lute rest must be enjoined, not only of the affected limb, but of the entire body, to overcome the tendency to addi- tional thrombosis or the detachment of emboli. Recently a solution of potassium nitrate in 5-grain doses adminis- tered hourly was employed by Hovnanian in the acute stage of the disease, with the most satisfactory results : the symptoms ameliorated rapidly, and in two or three days the patient was practically convalescent. Locally, there is not much that can be done. The affected limb must be elevated slightly and allowed to rest upon a pillow: it should be kept absolutely quiet and handled as little as possible. During the initial inflammatory stage anodyne poultices containing laudanum, belladonna, and other seda- tives may be applied along the course of the femoral vein, and the whole covered with oiled silk to maintain a certain degree of moisture in the parts. When the edema is marked and the limb becomes cool from sluggishness of the circulation, its temperature maybe maintained by envel- oping it in layers of surgical cotton. After the subsidence of the acute inflammatory symptoms, ointments of lanolin containing ichthyol, belladonna, or iodin may be gently rubbed in the skin over the femoral vessels, and potassium iodid or ammonium chlorid exhibited internally, to favor absorption of the clots and exudate. As the swelling dis- appears cautious massage of the part may be attempted, but the possibility of producing embolism must be con- stantly borne in mind. Should abscess result, free incision under absolute antiseptic precautions becomes necessary, and drainage must be secured. If embolism occur, the treatment is that already indicated. In case gangrene de- velop, amputation above the line of demarcation must be 656 A MANUAL OF OBSTETRICS. performed and the case treated surgically. Convalescence is necessarily protracted. During this period the patient must be restrained from undue haste in rising from her bed. Even after she is permitted to rise she should employ crutches for some time in order to avoid using the weak- ened limb until the clots have fully disappeared or danger of embolism has passed. An elastic bandage will be a source of much comfort to her in supporting the relaxed tissues and preventing the development of edema. It must be remembered that relapses are not uncommon, and may be precipitated by injudicious haste or exertion during the convalescence. Tonics and rich diet are essential, and as soon as possible the patient should be removed to the sea- shore or the mountains, where she may the more rapidly recuperate her strength. (3) Puerperal (infectious) erythema {scarlatiniforni ery- tlicma) is a rare manifestation of puerperal sepsis character- ized by the development upon the skin — usually in the folds of the body, although at times upon the entire surface — of a bright-red punctate eruption, associated with a moderate febrile reaction and general malaise. With this there is more or less suppression and odor of the lochia, and there may or may not be uterine tenderness. The fever is very moderate, seldom rising over 100° F., and is unaccom- panied by chills. The general depression is not profound : there are anorexia, constipation, and fetor of the breath ; the tongue is coated ; the pulse is somewhat increased in rapid- ity; but there is no gravity connected with the condition. The eruption closely resembles that of scarlatina, and, while most marked on the trunk and neck, may rarely occur on the face and extremities : there is occasionally associated with it an intense pruritus, and vesicles have been noted at various points of the body. There is no accompanj-ing angina, nor is there any albuminuria. The rash quickly fades, and may be followed by a slight desquamation. The diagnosis is plain. The prognosis is good. Treatment con- PUERPERAL SEPSIS. 657 sists in cleanliness of the genital tract and the exhibition of tonics and stimulants. A vaginal and intrauterine douche of hot water or of creolln will generally result in a cure. (4) Puerperal (septic) infectious pemphigus is an ex- ceedingly rare manifestation of puerperal sepsis, in which the disease appears in the form of a pemphigoid skin-erup- tion covering at times the entire cutaneous surface. The blebs first appear on the fourth or fifth day of the puerpe- rium, are of various sizes, and are attended by a moderate degree of systemic involvement. There is a slight accelera- tion of the pulse-rate and a moderate elevation of tempera- ture, as a rule not exceeding 101° Y. ; the face is moderately flushed, and there is more or less physical depression. The lochia are somewhat suppressed, and may or may not become fetid. The local pelvic manifestations are slight. A curious feature of this mild variety of septic infection is its tendency to spread throughout the ward in which it first appears, and for this reason the patient should be isolated and the room well fumigated after her recovery. The diagnosis of the condition is patent ; the prognosis is good. The treatment is the same as that of the other forms of sepsis. The blebs may be protected by soothing ointments and covered by pieces of antiseptic lint. (5) Puerperal Tetanus (Tetanus Puerperaritni). — Very rarely during the puerperium there may develop a true condition of tetanus due to the invasion of the system by Nicolater's bacillus of tetanus. Like the preceding, it is an exceedingly contagious affection, and a patient suffering with the disease should be isolated. Etiology. — The ex- citing cause is the introduction into the system of the specific germ of the disease. Among the predisposing causes that will render the system more susceptible to the action of the germs are warmth and moisture of climate ; lack of cleanliness of the parts ; primiparity, mainly be- cause in primiparje abrasions and lacerations of the soft structures are most common; unhygienic surroundings; 42 658 A MANUAL OF OBSTETRICS. exhaustion from mental anxiety or emotion or after pro- tracted and tedious labors. The disease is just as likely to follow abortion or miscarriage as it is to occur after labor at term. Symptoms. — Puerperal tetanus usually ap- pears at any time during the first and second weeks, but may develop as late as the fourth or fifth week after labor. The symptoms are practically the same as tetanus in the nonpuerperal state. The disease begins with feelings of general malaise and a sense of aching and drawing about the fauces. The pain is increased when the patient at- tempts to swallow, and finally develops into marked dys- phagia. The countenance is anxious ; the temperature is not much elevated, seldom rising over 100° or 101° F. ; the pulse is rapid and weak. The spasmodic muscular action soon involves the muscles of the trunk, and the patient may develop marked opisthotonos or emprosthoto- nos. The dysphagia becomes absolute, and unless relief be promptly afforded the woman soon perishes from ex- haustion. The diagnosis should not be difficult. The prognosis is very grave. According to Vinay, the mor- tality is as high as 88.8 per cent. The treatment consists mainly in absolute cleanliness and the observance of prophylaxis. Upon the slightest sign of beginning tetanus the patient should be subjected to a thorough curetment of the uterine cavity, followed by copious intrauterine and vag- inal douches of creolin (2 per cent, solution) or of mercuric chlorid (i : 4000). After the disease is well developed such procedures may be followed by beneficial results, but more probably they will only aggravate the condition. To allay the spasms, chloral hydrate, morphin, or curare hypodermi- cally, and inhalations h{ chloroform, may be tried. Recently good results have been claimed from the use of the antitoxin of Tizzoni and Cattani (a solid substance obtained by treating blood-scrum with alcohol and allowing it to dry in a vacu- um). This is administered in doses of from 15 to 20 cm. daily in solution in sterilized water, and it should be given PUERPERAL SEPSIS. 659 as soon as the disease manifests itself. It is as yet too early to give any statistics bearing upon the value of this remedy. (6) Puerperal neuritis may be septic or non-septic in origin. The latter variety may be designated as a pressure- neuritis, a traumatic neuritis, or a pressure-degeneration of the nerves, dependent upon irritation of the pelvic nerve- plexuses by the gravid uterus, or arising from actual injury of these structures during the process of parturition, espe- cially if instrumental measures have been resorted to. The protected situation of the pelvic nerve-trunks, lying as they do mainly within a bony recess near the sacrum, is the only reason why more serious pressure-symptoms than are gen- erally noted do not arise. In the elliptic variety of the pel- vis, fortunately very rare, they are not thus protected. This pressure-neuritis is characterized by severe lightning-like pains extending down the course of one or both sciatic nerves and associated with more or less cutaneous hyper- esthesia. This may persist for one or two weeks, and then gradually pass away, or there may follow paralysis of one or both limbs. Treatment consists in courses of g-entle massage, together with the application of mild electric currents. Another variety of nonseptic puerperal neuritis, according to Lamy, is that arising from an extension of pelvic inflammation to the nerve-trunks, with secondary disease of these structures. Aside from these nonseptic forms of the disease, there undoubtedly is a true septic variety of puerperal multiple neuritis dependent upon the absorption of pathogenic sub- .stances from the birth-canal. This variety of sepsis has been recognized only since 1888, when Mobius first de- scribed it, and all observers agree that it is of extremely rare occurrence. Etiology. — The predisposing cause of the disease appears to be a depressed or cachectic con- dition of the system, as that induced by mental or physical strain or by an insufficient action of the kidneys, the blood being in consequence overloaded with effete material. The 66o A MANUAL OF OBSTETRICS. exciting cause is the introduction into the system of septic material. Symptoms. — The cHnical manifestations vary greatly. The disease may appear in the later weeks of pregnancy, or may not manifest itself until the puerperium be well established. The patient may gradually develop paroxysms of pain in the affected region, or the onset may be abrupt and the disease reach its acme at once. Most commonly the nerves of the upper extremities — the median and ulnar — are involved, and in these cases the affection is generally bilateral : when the pelvic plexuses of nerves are involved, there is usually developed a unilateral form of the disease, manifesting itself in the lumbosacral or crural re- gions. The symptoms are pain, of a severe lancinating nature, limited to the lines of the nerves ; the pulse is accelerated ; the action of the heart is at times irregular; the countenance is anxious ; respiration is often impeded, or even severe spells of dyspnea may supervene. There may be some edema of the face and extremities. There quickly follows upon these acute symptoms a progressive numbness and weakness of the affected extremities, ultimately resulting, in some cases, in absolute paralysis. The muscles of the pharynx may be involved, and there then occurs more or less dysphagia; if the eye-muscles be involved, diplopia occurs. The reflexes are diminished or abolished, and the muscles do not respond promptly and completely to electric stimulus. There may be a certain degree of vertigo, and slight facial paralysis may be noted. Some patients become absolutely paraplegic. The diagnosis of the condition should be easy. The prog- nosis must be guarded, and will depend largely upon the severity of the attack. It is good for the milder forms of the disease, but doubtful for the generalized forms, and grave when there occurs pharyngeal involvement. If the paralysis be well marked, there may never be a complete recovery. Treatment. — For the pain injections of morphin may be reciuired, and Eulenberg suggests injections of a 2 per cent, solution of phenol along the seat of the nerve. Strychnin PUERPERAL SEPSIS. 66 1 and curare in moderate doses may be of service in restoring muscular tonicity. Thorough cleanHness of the parturient tract is essential, and the patient must be placed upon a rich nutritious diet and on full doses of tonics, including quinin, arsenic, and iron. Class II. Local p2ierpcral sepsis — that variety in which the sepsis is mainly localized in or around the uterus and its adnexa, including the forms dependent upon lymphatic ab- sorption, and those cases in which there is a localized inflam- matory process beginning in the genital tract and extending to the subjacent tissues. I. Lymphatic Infection (Septicemia Lymphatica ; Pu- erperal Lymphangitis). — The poisonous material is rapidly absorbed by the lymphatics of the uterus and the vagina, whence it is carried to the intricate network of lymphatics in the broad ligaments and the pelvic fascia. According to the region that is most actively concerned in the morbid process is the condition to be recognized as a puerperal metritis, a puerperal pelvic cellulitis, or a puerperal peri- tonitis. There is always associated with these processes more or less systemic involvement ; the local symptoms are, however, more prominent. (i) Puerperal Metritis, — In this grave form of late puer- peral sepsis the immensely hypertrophied lymph-channels running through the uterine walls become the site of a most active septic process. This condition may be, and often is, secondary to a septic endometritis of virulent form, or it may result from a primary lymphatic involvement, the in- flammation spreading from the lymph-channels to the sur- rounding connective tissue and thence to the muscular sub- stance. According as to which of these origins the disease may have had, infection has occurred at the placental site or through lacerations or abrasions of the upper vaginal tract. The symptoms are at first those of a simple putrid infection. There is a chill followed by fever of a slight intensity. The lochia become partially suppressed, of increased consist- 662 A MANUAL OF OBSTETRICS. ence, and later of a very fetid odor. There is a moderate amount of pain localized in the uterus and its immediate proximity, and there may occur a slight amount of ab- dominal tympanites. The patient suffers more or less from severe after-pains. The pulse is not very rapid. There frequently occurs in the affected portions of the endome- trium and metrium a rapid disintegration of tissue, so that the lochia are soon found to contain fragments of necrotic tissue and detached portions of muscular fibers that have sloughed from the uterine wall : at times an entire cast of the uterus may be shed, and to this stage of the disease has been given the name of dissecting or gangrenous metritis {inetritis gangi'CBnosd). The areas of ulceration are limited in size, rarely exceeding an inch or two in diameter. Pal- pation shows a marked increase in the size of the uterus, which is soft and boggy to the touch and very sensitive. Manipulations must be practised with the utmost care, as the necrotic areas may be very thin and yield on pressure, thus affording direct communication between the uterine and pelvic cavities. Such an accident may occur spon- taneously from active sloughing of the parts, and this con- dition is described as perforating metritis. General peri- toneal infection may be prevented by the bands of inflam- matory lymph that are usually thrown out around the attenuated portions of the uterine wall ; otherwise, a rap- idly fatal termination may be looked for. In some instances minute abscesses form throughout the uterine wall in im- mense numbers, the organ being riddled with them, and resembling on removal an immense sponge from which streams of pus emerge when pressure is made upon it (^phlegmonous metritis or metritis puruie?ita). These pus- foci are localized mainly along the line of the connective- tissue fibers. In the later stages of this disease, if there have occurred an extension of the process to the uterine sinuses, emboli may be cast into the circulation, and the patient develop a general pyemia with profound systemic PUERPERAL SEPSIS. 663 depression. It is quite possible, however, for the disease to remain localized in the uterine walls for days or even weeks without grave systemic involvement, and even without an involvement of the tubes and ovaries. The diagnosis of this condition may be made by the increased size and ten- derness of the uterus and by the gravity of the local mani- festations. The prognosis is grave, once the true uterine substance is involved : very commonly these patients die of profound blood-poisoning or of a rapid extension of the disease to the peritoneum with general peritonitis. Treat- ment. — In the early stage the uterine cavity should be well douched with creolin or mercuric-chlorid solution. If, notwithstanding this measure, the fever continue and the condition of the patient be not materially improved, a thorough curetment of the uterine cavity is in order. When the disease has invaded the muscular tissue and pus-foci have formed, the removal of the endometrium is useless : the seat of the disease is beyond the reach of the curet. Experience has likewise clearly demonstrated that the performance of salpingo-oophorectomy is of no avail in these cases, since the uterine walls are themselves involved, and the disease is not eradicated by this procedure. There remains, therefore, hysterectomy as the only operative pro- cedure that will give the patient the best chances of recov- ery. As to when this operation should be performed opinions vary. It would appear that the most favorable period lies somewhere between the first few days after the infection and its generalization. The vast majority of the operations performed after the seventh or eighth day of the disease have thus far resulted fatally, while those performed earlier have almost as uniformly resulted in a perfect cure. If any doubt exist as to the true state of the uterine walls, an exploratory incision would be justifiable, and if they be found to be soft and spongy, the organ should be extirpated. (2) Puerperal Pelvic Cellulitis (Puerperal Parametri- tis ; Puerperal Perimetritis) . — By this term is indicated 664 --^ MANUAL OF OBSTETRICS. that condition of local lymphatic infection in which there is a special involvement of the cellular tissue of the pelvis extending up to, but not involving, the pelvic peritoneum. This condition is not so common as is true pelvic peri- tonitis. It may result from absorption of septic material through abrasions in the lower birth-canal ; it may be the result of direct traumatism with septic infection, as in severe cervical lacerations involving the vaginal vault and sub- mucous tissues ; or it may occur secondarily after pres- sure-necrosis of the vaginal tissues. Having once involved the vascular and loose connective tissue, an acute in- flammation is started, and this spreads rapidly between the layers of the broad ligament and through the pelvic fascia in all directions. The process is generally limited by the peritoneal investment, although the ovary may be involved (^puerperal ovaritis), as well as the other structures surrounded by the diseased cellular tissue. A marked exu- dation, partly serous and partly cellular, is quickly thrown out, so that digital exploration detects a firm hard mass closely simulating in feel a fibroid tumor of the uterus. The vaginal fornices are tense. The uterus is immovably fixed and pressure elicits tenderness. Should the peritoneal covering of the uterus share in the process, the condition is known as pelvic perimetritis, constituting a variety of pel- vic peritonitis. The symptoms of pelvic cellulitis are largely local, although there is more or less constitutional involve- ment. The patient has a decided elevation of tempera- ture — to 101° or 103° F. This is associated with chills or chilly sensations, malaise, headache, anorexia, and systemic depression. The lochia become scanty and offensive, and the patient complains of pain localized in and around the uterus. There may be developed more or less edema of the limb upon the affected side, a direct result of the mechanical pressure exerted by the pelvic exudate upon the large venous trunks. The course of the disease is toward resolution or suppuration. In the former instance PUERPERAL SEPSIS. 665 there occurs primarily an absorption of the serous effusion, and, more slowly, of the cellular exudate, the woman finally recovering, possibly without even bands of inflammatory adhesion to mark the morbid process. In other instances the solid exudate may persist in the form of adhesions, inducing uterine displacement and distortion of the other pelvic viscera, and necessitating at some subsequent date an operative procedure to relieve the patient. Again, the inflammatory process may become so diffuse and so virulent that a rapid necrosis of tissue takes place and a large pelvic abscess results. This very commonly occurs, and suppuration is indicated by a hectic type of symptoms and by the presence of a soft fluctuating tumor where pri- marily had been detected a mass of firm exudate. The abscess shows a tendency to point in the inguinal region just above Poupart's ligament, but it may open into the vagina, rectum, or bladder : it may burrow downward and point upon the thigh as a psoas abscess or near the great trochanter, or posteriorly and simulate a perinephritic ab- scess, or point to the side of the sacrum. As a rule, reso- lution or suppuration will have been accomplished within ten days or two weeks. The diagnosis of pelvic cellulitis is not always plain. It is difficult at times to differentiate between this condition and pelvic peritonitis ; in fact, not infrequently the two coexist. In the following table are to be found some of the most essential points of difference : Pelvic Cellulitis. Pelvic Peritonitis. Very rare. Of very frequent occurrence. No abdominal distention, as a rule. Marked distention, with tympanites. Bimanual examination reveals a mass situ- Bimanual examination reveals a solid mass ated in the affected side ; the uterus is of exudate surrounding the uterus on all displaced to the opposite side of the pelvis. sides. The uterus maybe normal in size or only There is marked subinvolution of the uterus. moderately subinvoluted. There is moderate constipation. There is marked constipation. Moderately severe constitutional symptoms. Very marked constitutional manifestations. The tendency is to abscess-formation, with There is no formation of abscesses. rupture externally or internally. With the appearance of pus the symptoms There are no hectic symptoms. assume the hectic type. dd^ A MANUAL OF OBSTETRICS. Prognosis. — Generally the prognosis of pelvic cellulitis is good as concerns life. Within a week or two resolution or suppuration will have occurred. If rupture of the pelvic abscess take place internally, the patient may die from gen- eral peritonitis or from exhaustion following the formation of a fistulous tract. After pus-formation the progress of the disease is tedious, although the patient may eventually recover without any serious sequelae. Treatment. — The management of a case of puerperal cellulitis is essentially local. In the first place, it includes efforts at allaying the pelvic inflammation. Thorough asepsis of the uterus and vagina is secured by frequent vaginal douches of mcrcuric- chlorid solution (i : 2000) or of carbolic acid (i ;40). Prob- ably nothing has afforded more relief to these patients than the application of cold compresses or the ice-bag to the lower abdomen and the perineum. In the acute stage Kisch's method of intravaginal irrigation with cold water may be tried. The pelvic congestion may, in pleth- oric cases, be materially relieved by the application of a few leeches to the groin of the affected side. Ointments of ichthyol, belladonna, or mercury, or of potassium iodid, may also be applied in the inguinal region, as well as counterirritation by tincture of iodin or weak solutions of croton oil. The vaginal vault and the cervix may also be painted with iodin, and disinfection secured by a vaginal suppository of iodoform, 20-40 grains. The fever must be combated by suitable antipyretics, mainly quinin in full doses, while the depression is overcome by tonics and stimulants as required. Potassium iodid in 5 -grain doses three times daily may prove efficacious in absorbing the exudate. If suppuration occur not- withstanding these measures vigorously employed, early evacuation of the abscess is imperative. This is best ac- complished through an incision made just above (i or 2 cm., 0.3937 or 0.7874 in.) and parallel to Poupart's ligament, and about 2 or 3 cm. (0.7874 to 1.181 1 in.) from the anterior PUERPERAL SEPSIS. 66y superior iliac spine, peritoneal involvement thereby being avoided. Evacuation through the vagina may become necessary in neglected cases, but this procedure is not to be recommended as a primary measure, because of the in- creased risk of septic infection. When spontaneous rup- ture has occurred into the vagina or rectum, as thorough drainage and disinfection as is possible must be secured, and the patient sustained during the period of suppuration. Not uncommonly such patients pass into the hands of the abdominal surgeon for permanent relief by operation. (3) Puerperal Peritonitis, Pelvic or General (Perito- nitis Puerperalis). — Septic puerperal inflammation of the peritoneum is of rather rare occurrence. It may be in- duced in one of two ways : either it is entirely lymphatic in origin, the primary seat of the disease being remote, in the vagina or vulva, and infection occurring through the lymph-channels ; or it arises secondarily to uterine and tubal infection by direct contiguity of tissue, the inflamma- tory process extending through the fimbriated extremities of the tubes, or directly through the uterine walls {inetro- pcritonitis), following the network of intramuscular inter- spaces. Whatever its origin, the disease begins as a local- ized affection involving only the pelvic peritoneum, or, it may be, but a limited portion of this {^pelvic peritonitis). A high grade of inflammation is rapidly produced, and this through its extreme intensity is very prone to limit itself through the agency of the exudate that is promptly thrown out around the focus of disease. At the site of the disease, however, there often ensues a rapid de- struction of tissue, and deep localized abscesses of various sizes are produced within the pelvic cavity. These bur- row in the direction of least resistance, and discharge themselves into the rectum, vagina, or bladder, or are evac- uated by surgical measures. The symptoms attendant upon this condition are mainly pelvic. There is intense pain in the region of the uterus and ovaries, as manifested by the 608 A MANUAL OF OBSTETRICS. dorsal decubitus and drawn-up thighs. Vaginal explora- tion made with the utinost care reveals an immobilization of the uterus, together with the presence of an extremely sensitive mass to one or the other side or completely filling the cavity of the pelvis. More or less abdominal tympany is noted. The countenance of the patient is anxious and drawn ; her pulse is rapid and wiry ; there is a moderate rise of temperature and some degree of prostration. If, now, the limiting bands of inflammatory lymph become invaded and the inflammatory action extend beyond their confines, a rapid involvement of the entire peritoneal surface follows, and the patient quickly succumbs. This general puerperal peritonitis is, fortunately, very rare. An exam- ination of the abdominal cavities of patients dying of this condition reveals the intestinal coils bathed in a thin, creamy pus, and here and there bound together by delicate bands of plastic exudate. The pus, examined bacteriolog- ically, is found at times to contain vibriones, micrococci, and the bacilli of putrefaction. Occasionally {peritonitis piier- peralis lynipJiatica, or fnlgiirant puerperal peritonitis) no pus or exudate of any kind, save a greenish or brownish fluid, will be discovered, the patient being overwhelmed by the septic intoxication and perishing before inflammatory action is begun. The symptoms of general puerperal peritonitis are not nearly commensurate with the serious character of the disease. Save for the extreme rapidity of the pulse — which rapidly reaches 130 to 180 beats per minute — and the profound general depression, the clinical manifestations are not marked. Owing to the general paralysis of the intestinal walls, abdominal tympany is constant, and may become quite marked, especially toward the close. Ten- derness on percussion will be noticed in the early stages, but as the disease progresses this may be entirely lost, the woman not complaining of the most vigorous abdominal manipulation. There may be moderate vomiting, although this also may be absent throughout. The temperature PUERPERAL SEPSIS. 669 varies : generally it is not very high, but it may reach a very high mark just before death supervenes; in other, notably the fulgurant, cases there may be a subnormal temperature from the beginning, and the patient be comatose throughout. Generally the woman retains consciousness until the end. The bowels are markedly constipated, the urine is scanty and febrile, the breath is foul, and the tongue is coated. There is always intense thirst. The diag)iosis of puerperal peri- tonitis is evident. The prognosis of the local variety is good if it can be properly managed. The general form almost inevitably proves fatal. Treatment. — When a puerperal pa- tient has once developed a peritoneal inflammation she should be rigidly watched. As long as the disease remain localized in the pelvic cavity medical treatment may avail much. Internally, quinin, iron, and stimulants must be pushed to their utmost limit, while, locally, pain may be relieved by opium suppositories or by an occasional hypo- dermic injection of morphin sulphate. The inflammation may be relieved by frequently repeated poultices or stupes ; salines, if used at all, should be administered in small amounts, and preferably at the onset of the disease. A 2 per cent, solution of cocain in lo-drop doses may correct the vomiting; and tympany, if extreme, maybe relieved by the cautious introduction of the rectal tube or by small enemata of milk of asafetida. For the thirst rectal injec- tions of hot water may be given or the patient may be per- mitted to suck fragments of cracked ice. Once the limit of the pelvis is exceeded, the case becomes a surgical one. An abdominal incision must then be made, and the peri- toneal cavity well flushed with hot water in order to remove all purulent or plastic exudate. Treatment, at the best, is of but little value when the disease has progressed thus far. The surgical treatment of this form of puerperal sepsis is much more effective if attempted at an early period, before involvement of the general peritoneal cavity has taken place. Abdominal section performed early and the ap- 6/0 A MANUAL OF OBSTETRICS. pendages removed (if they be the menacing seat of the disease), or supravaginal hysterectomy performed (if the primary disease exist in a suppurative metritis), will give a much more promising outlook to the patient than when attempted later in the course of the disease. This is a serious question, however, and no fixed rule can be formu- lated to which every given case can be made to conform. Inauspicious as these late and neglected cases are, they should in every instance be given the one chance left them in abdominal section. A fatal termination is almost inevi- table with the operation, and absolutely so without it. 2. Involvement of the Genital Mucosa. — (i) Vul- vitis. — Puerperal inflammation of the vulva is seldom found alone, but generally in association with a similar inflamma- tion of the vaginal mucosae. It is not surprising that these parts should become at times the seat of a septic infection, if it be remembered to what severe contusions and lacera- tions they are subjected during the process of parturition. The process may assume the form of a simple catarrhal or suppurative inflammation [inilvitis catarrlialis) ; a higher grade of inflammation may be produced, and ulcers and abscesses result — plilcgmonoiis or ulcerative vulvitis {vul- vitis purulcnta) ; or there may occur such a devitalization of all the tissues that they die en masse, when the condition is known as gangrenous vulvitis {vulvitis gangrcsiiosa). A rare and very unfavorable variety of vulvitis is that charac- terized by the formation of diphtheric patches, diphtheric vulvitis {vulvitis diphtheritica). Symptoms. — There is more or less edema of the vulvar tissues, both lips usually being involved, although one is generally more tumescent than the other ; the mucous surfaces are reddened, and at first dry, glazed, and hot; later the lips are bathed in a creamy fluid if the case be one of simple catarrhal inflammation. In the phlegmonous form small ulcerations quickly develop throughout the substance of the labia, and especially are the glands of Bartholini liable to share in the process and sup- PUERPERAL SEPSIS. 6/1 purate ; if the inflammation be more intense, a necrosis of the mucosa and submucosa will ensue, sloughs of considerable extent at times separating and leaving deep excavations or ulcers, bathed in a grayish-yellow exudate, which, if the woman survive, must heal by a tedious process of granulation. The pus from these ulcers contains large numbers of strepto- cocci and other bacilli. In the diphtheric variety charac- teristic grayish patches of membrane form over the vulvar erosions and ulcerations. The symptoms associated with this condition are — more or less pain ; enlargement and ten- derness of the inguinal glands, which may even advance to suppuration ; malaise and pyrexia of varying degrees. Not infrequently there is an associated septic disease of the urethra and bladder. The diagnosis is made by direct in- spection of the parts. The prognosis varies according to the nature of the inflammatory process, but is always doubt- ful. The treatment is the same as that for similar conditions of the vaginal mucosa. (2) Endokolpitis (Elytritis). — Septic inflammation of the vaginal mucosa may be catarrhal {endocolpitis catarrhalis), phlegmonous or idccrative [endocolpitis gangrcsnosci), or diph- theric {endocolpitis diphtheritica). In the first form the vagi- nal mucosa is red and angry-looking ; dry and glazed at first, within twenty-four or thirty-six hours it becomes bathed in an irritating creamy leukorrhea. In the phleg- monous variety abscesses of varying size form in the vaginal walls, usually low down near the vulvar orifice, although occasionally they may be found in the upper third of the vagina, in which case the gravity of the con- dition is materially increased. These abscesses run a rapid course, and either open spontaneously or must be evacu- ated. They may become gangrenous, and, as in the vulva, cause extensive sloughing of the parts, together with more or less profound general toxemia. In the diphtheric variety gray patches of closely adherent pseudomembrane form upon the ulcers and abrasions : the patches, at first isolated, 672 A MANUAL OF OBSTETRICS. soon coalesce, and in these cases, which are almost invariably fatal, the general symptoms are very grave. The patient may fall into a state of collapse from the very beginning, with subnormal temperature and extremely rapid, feeble pulse. The lochia are very offensive or altogether suppressed. The diagnosis is made by inspection through a speculum. The. prognosis is doubtful at the best, and very grave in the diphtheric variety. The treatment consists primarily in the observance of thorough asepsis of the genitalia by frequent vaginal douches of warm mercuric-chlorid solution (i : 2000), followed by the introduction of a vaginal suppository of iodoform, 20-30 grains ; or the entire vagina may be sprayed with an ethereal solution of iodoform. The vagina may first be painted with a weak solution of silver nitrate, 10 grains to the ounce, after which the iodoform, or a mixture of equal parts of iodoform and boracic acid, may be intro- duced and repeated daily. Cold compresses over the vulva may considerably ameliorate the symptoms. In the phlegmonous form the abscesses must be promptly evacu- ated and the resulting ulcers treated with mild caustics, as weak carbolic-acid solutions, and then dusted with powdered zinc oxid or zinc oleate. Garrigues recommends for this purpose equal parts of zinc chlorid and water, but such an application is exceedingly painful and therefore objection- able. In the graver cases it may be well to curet the ulcera- tions before applying the caustics and alteratives. Dipli- tJieric patches must be thoroughly cleansed, the pseudo- membrane removed, and the bases cauterized with a strong solution of mercuric chlorid (i : 500 or looo), zinc chlorid, or silver nitrate {40-60 grains to the ounce). The general treatment is the same as for all forms of puerperal sepsis. (3) Endometritis. — As before, we find the following varieties of septic inflammation of the endometrium in the puerpera : catarrhal or suppurative {c7idometritis catarrhalis) , phlegmonous or ulcerative {endometritis pnrulenta), ^TiWgvQ- WQxxs {endometritis gaiigresnosa), and diphtheric [endometritis PUERPERAL SEPSIS. 673 diphtheritica). Endometritis may exist as a distinct condi- tion, originating primarily at the placental site in the de- composition of retained portions of secundines ; it may arise secondarily to a vaginitis as a direct extension of the morbid process from continuity of tissues, or to a metritis of lymphatic or phlebitic origin, the endometrial disease again occurring from extension of the disease from con- tiguity of tissue. In every case of puerperal metritis there is of necessity a coexistent puerperal endometritis. The symptoms of the disease seldom manifest themselves prior to the third day of the puerperium, and often not for many days after this period. The patient may have passed safely through an apparently normal convalescence before any pathologic symptoms supervene. Especially is this true in those cases in which the disease arises as a consequence of direct infection of the endometrium from without, as after the introduction of an unclean instrument or hand. When, as usual, it follows in the course of an ordinary sapremia, the symptoms appear shortly after labor and run a course of varying severity. There may at first be noted a distinct chill or chilly sensation, or this may be entirely absent. The temperature is only moderately elevated — 99^-100° F. — but with each successive day there occurs a more marked elevation, until it is not at all uncommon to find the thermometer registering 103°, 104°, or 105° F. Co- incident with this elevation of temperature there is a cor- responding decrease in the quantity of the lochia, which are also radically altered in quality. They become now more or less grumous in character and decidedly fetid. The pulse is rapid, the expression anxious, the skin more or less muddy, and the patient complains of a feeling of malaise. Physical exploration reveals an enlarged and boggy uterus, slighty sensitive to pressure, indicating a certain amount of metritis. Later in the disease, when there has occurred an extension to the parametrium, there will be noted, in addition, more or less abdominal disten- 43 6/4 ^ MANUAL OF OBSTETRICS. tion. The bowels are constipated, the tongue is coated, the appetite lost, and the breath fetid. In those cases in which a rapid necrosis of the endometrium occurs, the lochia, at first partially suppressed, become very profuse and con- tain shreds of the decomposing tissue. The patJiology of septic endometritis varies according to the intensity of the inflammatory process. In the simple catarrhal cases the greatest changes are to be noted at the placental site. Sur- rounding this portion of the endometrium there is thrown out a zone of cellular infiltration whereby the pathogenic microbes are largely limited in their action. Within this zone there occurs more or less necrosis of the placental debris, while around it the endometrium is congested, red- dened, and softened. When this limiting zone of cellular infiltration fails to form, the graver varieties of septic en- dometritis are developed : the entire endometrium becomes infected, and a rapid disintegration of the decidual tissue ensues. Small ulcers may be formed here and there, and these may or may not coalesce {ciidovictritis piwiilcntd). The whole endometrium may quickly be transformed into a grayish-yellow pultaceous mass dotted with patches of necrosed tissue {cndoDictritis gangrcB)iosd) : in some of these grave cases a thick membranous formation occurs, deeply penetrating into the muscular tissue of the uterine walls and filled with pathogenic microbes : this is the so-called diplitJicric endometritis. The uterine cavity when split open reveals an angry multicolored surface covered with a puru- lent exudate and revealing at points masses of necrosed tissue. These cases prove very rapidly fatal as a rule, the patient often being comatose from the beginning and having a subnormal temperature. The membranous tissue is of a whiter color than the membrane of diphtheria, and very generally does not contain the Klebs-Loffler bacillus. The diagnosis of puerperal endometritis is easy. The prognosis is doubtful, and in the gangrenous and diphtheric forms very grave. Treatment. — When the endometrium has once PUERPERAL SEPSIS. 675 become infected the only course to pursue is thorough cleansing and disinfection of the uterine cavity, which may be accomplished according to the method already suggested in the treatment of puerperal sapremia. In addition to this, ulcerations, when present, must be cauterized with a 50 per cent, solution of zinc chlorid, silver nitrate (oj to the ounce), or a I : 500 solution of mercuric chlorid ; diphtheric mem- branes must be removed, the resulting ulcerations cauterized, and the uterine cavity packed with iodoform-gauze. The patient's strength must be maintained by full doses of stim- ulants, quinin, and tonics, and by a rich and nutritious diet. (4) Endosalpingitis. — Inflammation of the mucosa of the Fallopian tubes during the puerperium is always secondary to a puerperal endometritis. It is quite a common condition, especially after the minor grades of catarrhal septic endome- tritis. Beginning as a catarrhal inflammation, it is not long before a purulent secretion is established [cndosalpingitis piiridcntd), and this, leaking outward through the fimbriated extremity of the tube, induces repeated attacks of localized pelvic peritonitis. Bands of adhesion result, the distal ex- tremity of the tube becomes occluded, and an acute pyo- salpinx is formed {^puerperal or septic pyosalpingitis). The patient is an intense sufferer. Her pain is localized in and around the affected appendage, and is acute, lancinating, and paroxysmal. She is compelled to assume the dorsal decu- bitus, with her knees drawn up. The abdomen is tense, and a certain amount of tympany exists. The bowels may be constipated throughout, or alternate spells of constipation and diarrhea may characterize the attack. The pulse is rapid and wiry, the temperature hectic in type, and chilly sensa- tions or actual rigors may be noted. A pelvic examination will reveal a fulness in the vaginal fornix of the affected side, while the uterus will be found displaced to the opposite side and partially immobilized. Pressure in the region of the broad ligament will elicit tenderness. The diagnosis of this variety of puerperal sepsis is plain. The prognosis is 676 A MANUAL OF OBSTETRICS. good if prompt and appropriate treatment be instituted. Treatment. — In these cases abdominal section with enucle- ation of the affected tube will alone effect a cure. The ap- pendage of the opposite side may or may not be removed, according to the exigencies of the case. (3) Puerperal (Septic) Urethritis, Cystitis, Ureter- itis, AND Pyelitis. — A grave and, fortunately, rare variety of puerperal sepsis is that involving the genitourinary system. The disease begins as a urethritis that quickly extends to the bladder. The cystitis thus produced may be checked, or there may occur a further extension of the disease to one or both ureters, with ultimate involvement of the renal pelves, as was first demonstrated by Kaltenbach. The usual cause of this grave variety of sepsis is the careless intro- duction of an unclean catheter into the urethra, either by the physician himself or more usually by the nurse. Mann of Buffalo and Skene of New York have called attention to a form of puerperal ureteritis resulting from injuries during labor, especially from pressure exerted by the fetal head or by the forceps during the pendulum movement of that in- strument. This traumatic variety of ureteritis is quite dis- tinct from the septic condition now under consideration. The local symptoms of the septic variety are those of an aggravated cystitis — frequent micturition with burning and tenesmus, and the passage of bloody and scanty urine, alkaline in reaction and containing pus-corpuscles and shreds of mucus. Unless prompt treatment be instituted, an extension will occur to the ureters. The temperature then becomes high — I03°-I05° F. There is extreme pros- tration; the pulse is rapid, feeble, and at times irregular; the skin is cold and clammy. The mind may be clear, or there may be periods of mild delirium. There is an incessant desire to micturate, which is a most distressing symptom in all the cases. The anemia is profound ; the condition of the bowels varies, there being present in many cases a troublesome diarrhea associated with more or less abdom- PUERPERAL SEPSIS. 677 inal distention. An examination of the urine that is voided, which is always scanty in amount (as low as 6 ounces in twenty-four hours — Mann), shows it to be acid in reaction, usually of low specific gravity, and to contain a sediment composed of uric acid, urates, pus in large quantities, blood- corpuscles, and vesical, and it may be renal, epithelium. In the case of ureteral involvement there will not be much mucus in the urine, while if the disease be mainly localized in the bladder much mucus and an ammoniacal urine is the rule. Albumin is generally absent, or present only in minute quantities. In these cases of ureteral involvement physical exploration will reveal, in addition to the ordinary signs of cystitis, extreme tenderness along the course of the ureters, associated with considerable pain in the loins. In order to elicit this symptom palpation of the ureters must be practised according to the pelvic method recommended by Kelly and Mann, or by Tourneur's abdominal method. The pelvic method is thus described by Mann : ^ " The finger is carried along the anterior vaginal wall upward and outward near the brim of the pelvis to one side of the uterus. It is then pressed forward, stroking the pelvic wall and carefully feeling for a cord-like body under it. Sometimes a bimanual examination will greatly aid in discovering the ureters." When the inflamed structure is touched there is at once elicited marked tenderness and an almost uncontrollable desire to micturate. In very marked cases and in inexperienced hands the sufferings of the pa- tient may contraindicate prolonged efforts at ureteral palpa- tion. Tourneur's method of abdominal palpation of the ure- ters is more difficult. Tourneur claims that the ureter can be found at the level of the superior strait, at one-third the dis- tance that separates the anterior superior spines of the ilium. In order to detect it, however, the abdominal walls must be relaxed, the bowels empt}', and the patient resting in the re- cumbent posture on a hard table with the knees drawn up. ' Gynecological Transactions, vol. xix. 6yS A MANUAL OF OBSTETRICS. The pathology of this form of puerperal sepsis consists essentially in a catarrhal inflammation of the mucous lining of the urethra, bladder, and ureters. There is con- siderable swelling of the tissues, with some desquamation of the epithelial lining, at times terminating in suppu- ration and ulceration ; there may result more or less per- manent thickening of the inflamed tissues. It is a curious fact that the left ureter is more frequently affected. The diagnosis of septic involvement of the urinary system is made by attention to the symptoms, by physical explora- tion, and by a chemical and microscopic examination of the urine. The prognosis is always grave. Treatment consists in both local and constitutional medication. In the first place, the bladder must be kept in as aseptic a condition as possible. This is best accomplished by repeated (two or three times daily) irrigation with a saturated boric-acid solu- tion or a weak solution of creolin (i/^ of i per cent.) or of mercuric chlorid (i : 8000), the boric acid being preferable because of the lesser degree of pain produced. The quality of the urine may be altered by the administration of boric or benzoic acid or of salol in full doses (as shown by an odor of carbolic acid in the urine). Free stimulation is essential, as in the other forms of sepsis, and, in addition, full doses of tonics (quinin, iron, and strychnin) must be exhibited. Convalescence is protracted and must be treated on general principles. Good hygiene and diet, mental and physical rest, and change of climate are essential. 4. Puerperal (Septic) Proctitis. — Septic inflammation of the rectum is invariably the result of direct infection through the agency of an unclean nozzle of a syringe. It is an exceedingly rare complication of the puerperium, and when encountered almost invariably terminates fatally within a very short time. It is usually diphtheric in nature, al- though it may be purely catarrhal, and in these cases re- covery may follow. The symptoms are those of profound septicemia, without any of the local manifestations of that PUERPERAL SEPSIS. 679 condition. In the virulent cases the patient may succumb very promptly, and the true condition may be discovered only at the autopsy. The treatment consists in disinfection of the bowel as far as possible by injections of hot sterilized water or water containing boric acid. Diphtheric membranes must be removed, and the ulcerated surfaces cauterized with silver nitrate or chromic acid. The usual constitutional treatment is indicated. B. AUTOGENETIC PUERPERAL SePSIS (AuTOINFECTIOn). — The possibility of self-infection by the puerperal woman has been disputed ever since the era of antisepsis was inaugurated. It is now generally admitted that in very rare instances a variety of true puerperal sepsis may arise irrespective of any immediate infection from without. F. Ahlfeld concludes that usually in these cases there exists a true resorption-fever from retention of the infectious child- bed secretions, the poisonous materials being taken into the system mainly through the lymphatics of the uterine mu- cosa — especially those at or near the placental site — and of the vagina. Such a morbid process may arise in a case in which no previous examination has been made, the labor having been conducted according to the method advocated by Leopold and Sporlin. For the most part these cases run an uneventful course, characterized by a moderate elevation of temperature and symptoms of comparative unimportance, but a fatal termination is not at all improbable ; hence they should excite as much apprehension and receive as careful attention as the true cases of heterogenetic infection. There is another class of so-called autoinfection, arising from the rupture of an old pus-tube during labor or the ab- sorption of germs from a latent gonorrhea, both having escaped notice. This is a true heterogenetic infection, and these cases cannot properly be included under the present heading. With much more justice, however, may here be grouped those very rare cases of puerperal peritonitis aris- ing from a pressure-necrosis of a fibromatous or myoma- 68o A MANUAL OF OBSTETRICS. tons growth, or of the muscular walls of a moderately- contracted pelvis. In these cases there is manifestly no infection from without, and yet the patient exhibits all the symptoms of a true septic process, and must be subjected to the same course of treatment. 5. Puerperal Insanity. Insanity occurring during the puerperium may manifest itself at any time from childbirth to the end of the process of involution. The frequency of this accident is greater than one would at first thought imagine. It has been proved from careful statistics made on the subject that i parturient woman in every 400 will become insane, or in a population the size of that of Philadelphia, where from 30,000 to 35,000 children are born annual!}', from 75 to 80 of the women will suffer. The most common period for the dis- ease to manifest itself is from the third to the tenth day, and, in contradistinction to gestational insanity, which is usually melancholic in type, puerperal insanity is most generally maniacal. When appearing later in the puerperium, at the sixth or seventh week, it has been designated lactational in- sanity, and at this period the type again reverts to that of the gestational form, the melancholic, with strong suicidal and homicidal tendencies. Etiology. — Much has been writ- ten as to the causation of puerperal insanity. In brief, it may be stated that there are five chief etiologic factors — heredity, primiparity, anxiety, dystocia, and septic infection. In a large percentage of the reported cases an hereditary taint can be detected, insanity having existed either in some member of the immediate family of the patient or in some of the near ancestors. If true insanity cannot be discovered in the family, it is not uncommon to find a strong neurotic tendency, as manifested by the history of chorea, epilepsy, or marked hysteric manifestations. The frequency of in- sanity in primipara; may be explained largely by the over- wrought nervous systems of these women, who are passing PUERPERAL INSANITY. 68 1 through an entirely unique experience, and who are exposed to a much more intense nervous and physical strain than are multiparse. Anxiety especially plays a powerful etiologic role in the production of insanity in those women who are illegitimately pregnant and who dread the results of their indiscretion. A prolonged and difficult labor, especially if instrumental, adds materially to the nervous strain to which the patient is subjected, and, when acting on those in whom the nervous element predominates, may be sufificient to de- stroy the mental equilibrium. Finally, the influence of septic infection, either autogenetic, as that arising from renal insuf- ficiency, or heterogenetic — true puerperal sepsis — in the de- velopment of puerperal insanity can no longer be overlooked. The literature of this subject is daily increasing, and there have been reported a large number of cases attributable to sepsis alone. Extreme fright, intense anemia, and profound general depression are also noted as predisposing to the condition. Symptoms. — The disease commonly appears with alarming abruptness. Without warning the patient becomes maniacal or wildly delirious, and suffers from the most peculiar hallucinations, A homicidal tendency is often manifested, the objects of her hatred not infrequently being those in whom her dearest affections are centered. Infanticide is a very common crime among these unfor- tunate women. With this mental aberration there are cer- tain physical abnormalities. It is not uncommon to note a marked elevation of temperature, and there is often a strong aversion to food of all kinds, so much so that forced feed- ing through a stomach-tube introduced through the nose, or injections of nutritive enemata, may be necessitated. The mania may become so violent as to greatly exhaust the vital powers of the patient and result in an early fatal ter- mination. The melancholic cases are more treacherous. A surprising amount of cunning will be manifested by these patients in order to deceive or elude the vigilance of their attendants, and the most disastrous results to the 682 A MANUAL OF OBSTETRICS. patient herself and to others may attend the slightest relaxation on their part. A suicidal tendency is especially to be suspected in these cases. The diagnosis of puerperal insanity should not be difficult. Fortunately, the prognosis is not grave. From 65 to 75 per cent, of the cases even- tually make a complete recovery. The remaining 25 to 35 per cent, either die from exhaustion induced by the violence of the attack or from septicemia, or remain permanently insane. Treatment. — The most satisfactory management of these women is to be found in a pri- vate hospital or asylum, where more thorough isolation can be secured, a closer supervision of the patient main- tained, and injury to herself and others prevented. The indications are to control mental disturbance, to combat septic processes, and to nourish the patient. The nerve- sedatives in the form of the bromids in full doses, chloral hy- drate, hyoscyamin, hyoscin, and sulphonal, are of the great- est value in these cases. Vaginal and uterine disinfection and the administration of salines in full doses are required in cases of suspected septic infection. If any degree of hyper- pyrexia exist, it may be controlled by cold sponge-bathing, the abdominal coil, and the ice-cap. Antipyretics, except quinin, may be of service in moderate doses. Stimulants of all kinds are contraindicated, but tonics, as iron, arsenic, and the hypophosphites, supplemented by a nutritious diet, are essential. Proper hygiene must be insisted upon, and change of scene and travel with an attendant (in the melan- cholic cases) may aid materially in effecting a cure. In no case should the woman be permitted to nurse her child ; it must be fed by a wet-nurse or placed upon a course of arti- ficial feeding. 6. Subinvolution of thp: Uterus. By this term is indicated a contlition of imperfect or incomplete contraction of the womb after delivery, where- by that organ fails to regain its normal size, and remains SUBINVOLUTION OF THE UTERUS. 683 heavy and over-voluminous. The process of involution has been fully described in a previous section, and the normal size of the uterus at the successive periods of the puerperium has been noted. It will be remembered that the reduction in the size of the organ is accomplished by a process of fatty degeneration to which the hyper- trophied muscular fibers of the uterus are subjected because of their diminished blood-supply. Now, it may readily be conceived that any condition that will arrest the process of degeneration will prevent the return of the uterus to its primary condition. This arrest of involution is brought about entirely by changes in the circulation of the uterus and its immediate vicinity : in other words, it is congestive in origin, and this congestion may be active or passive, the increased blood-supply in either case sufficing to nourish the excess of uterine tissue and thereby prevent its removal by fatty degeneration and absorption. The causes of active congestion of the puerperal uterus are various : it may result from an acute inflammation, as that following extensive laceration of the cervical tissues and vaginal vault ; it may follow an acute anteflexion or retro- flexion of the heavy organ, with arrest of the circulation at the angle of flexion ; there may be retained in the uterine cavity large fragments of placental or decidual tissue ; or the marital relation may have been resumed at a period too early after parturition. Passive congestion of the uterus and of all the pelvic viscera may be induced by chronic cardiac, pulmonary, or hepatic disease ; by the presence of pelvic tumors, as uterine fibroids or mucous polypi, ovarian cystomata, bony exostoses or osteosarcomata ; by over- loading of the rectum; by extreme distention of the bladder; by pelvic inflammatory conditions, either old or of recent septic origin ; by too early resumption of the active duties of life. Syiiiptoms and Diagnosis. — In every case in which there fails to occur a proper involution of the organ there ensues a train of symptoms which are highly suggestive if 684 A MANUAL OF OBSTETRICS. not diagnostic. The patient complains of weight in the pelvis ; the lochial discharges remain profuse and bloody, or, havdng become mainly serous, there is a return of the bloody flow ; there is more or less pain and tenderness on manipulation of the abdomen, with backache and reflex manifestations ; and if a displacement of the ute- rus exists, there will supervene the accompanying pres- sure-symptoms — irritability of the bladder and increasing constipation. An absolute diagnosis of the condition will be afforded by a bimanual examination. The uterus will be found to be considerably above the normal size for the period of involution. It is large, soft, and boggy, and more or less tender on pressure. The cause of the con- dition, if neoplasm, displacement, or laceration, will also be revealed by this examination. The prognosis is good as regards life. The condition may require a prolonged course of treatment before an absolute cure is obtained. The treatment will vary according to the etiology of the case. If it be the result of cervical or vaginal laceration, an appropriate trachelorrhaphy or kolporrhaphy will result in a cure. Retained fragments of placental and decidual tissue, associated with a grumous and offensive discharge, require thorough curettage and disinfection of the uterine cavity, after which involution will proceed normally. A chronic systemic condition must be combated according to general methods. A pelvic tumor may be removed after abdominal section, or, if it be a small uterine fibroid, an attempt to reduce its size and limit its further growth may be made by the internal administration of ammonium chlorid in lo-grain doses three or four times daily, or of ergot in doses of from 15 to 30 minims every four hours. Constipation must be corrected, the action of the kidneys maintained, and the bladder evacuated at regular intervals. Gentle daily massage of the uterus may hasten involution. The excess of lochia necessitates hot vaginal douching (110° to 115° F.) night and morning. INTESTINAL ABNORMALITIES. 685 7, SUPERINVOLUTION (HyPERINVOLUTIOn) OF THE UtERUS. Very rarely the reverse of the foregoing process has been noted, and the involution, instead of being arrested when the uterus has attained its normal dimensions, is continued beyond that period ; in other words, there occurs a fatty degeneration not only of the excess, but of the true uterme tissue also. The uterus in these cases of over-involution practically undergoes a process of atrophy, and may become quite small or even almost entirely disappear. Just what is the true etiology of this remarkable occurrence it is difficult to say. It is probably not the result of a special trophoneurotic action, the effect of suckling on the pelvic organs, as has been claimed by some observers. It is far more reasonable to consider it a direct result of the profound general anemia noted in some women, and that may or may not be associated with protracted lactation. The deficient blood-supply of the body consequent upon the drain through the functionating mammae is quite suf- ficient to account for the process. The symptoms of the condition are generally obscure. There may be some vague pelvic manifestations ; menstruation may fail to return at the usual period after childbirth, and this may excite apprehension ; or the condition may accidentally be discovered during a bimanual examination, which will reveal an unusual smallness of the uterus with or without concomitant pelvic abnormalities. The treatment must consist in the weaning of the child, the administration of full doses of tonics, notably strychnin, iron, arsenic, and a full and nutritious diet. Good hygiene and change of air and occupation are of service. 8. Intestinal Abnormalities. (i) Constipation. — In the majority of cases, after the bowels have been opened on the evening of the second or the morning of the third day of the puerperium, the daily routine action is reestablished and the woman 686 A MANUAL OF OBSTETRICS. resumes her normal habit. It not infrequently happens, however, that an annoying constipation persists, and in these cases much skill must be exhibited in securing a moderate daily evacuation of the bowels without resorting to hypercatharsis. If possible, this should be secured by a suitable diet : this means failing, a Seidlitz powder, half a bottle of magnesium citrate at bedtime, or a pill of aloin, strychnin, and belladonna may be administered. With the cultivation of the habit of daily evacuation of the bowels most of the unpleasant sequences of this condition may be averted. (2) Acute Tympanites. — An annoying and at times an alarming condition may follow a sudden paralysis of the intestinal walls in the puerperal woman. This is encoun- tered only in neurotic individuals, and in some instances to an unprecedented extent. The abdominal walls become immensely distended, and true orthopnea may be induced by the extreme upward displacement of the diaphragm. The peristaltic movement is abolished, and absolute con- stipation, with consequent vomiting, hiccoughing, and other symptoms of obstruction of the bowels, supervenes. Treat- ment comprises the administration of nerve-sedatives, the application of a firm abdominal binder, and frequently re- peated injections of strychnin sulphate. A bowel-move- ment may be hastened by enemata of turpentine and milk of asafetida, and by mild cathartics given by the mouth. In extreme cases only will the use of the rectal tube or resort to intestinal puncture be necessitated. (3) Hemorrhoids. — Not infrequently a most annoying hemorrhoidal condition will persi.st after parturition, or perhaps it may manifest itself only at this time. The pain induced by these varices is most intense, and if the tenes- mus be great the tumors may attain considerable bulk. Clotting often occurs, and ulceration or gangrene of the occluded vessels may follow. In the early stages of this painful condition rectal injections of cold water or the in- INCONTINENCE OF URINE. 687 troduction of a suppository containing opium, belladonna, and tannic acid may give much relief. Lotions of hot lead- water and laudanum are beneficial, and Barker and Lusk emphasize the curative value of a pill of aloin, j^ grain, night and morning. Should strangulation occur, ligation and excision of the hemorrhoids become imperative. 9. Incontinence of Urine. The involuntary escape of urine, either immediately after the birth of the child or within a few days, should excite the apprehension of the accoucheur, and an immediate exami- nation should be instituted as to its cause. If the symptom be accompanied by intense cramp-like pains in the lower abdominal region, and the urine escape a few drops at a time or with an occasional slight spurt, the so-called incon- tinence of retention should be suspected. In this case ex- ploration will reveal a tumor in the median line of the abdomen extending up as a dome from the symphysis pubis. Percussion over the distention elicits absolute dul- ness, and the introduction of an aseptic catheter will be fol- lowed by the escape of a large amount (a quart or more) of urine. If the escape of urine be unattended with pain and occur subsequently to a tedious or instrumental labor, a vesicovaginal fistula from pressure-necrosis or direct trau- matism should be looked for. If this be discovered and it be of but minute size, the natural reparative powers of nature may effect a cure : if not, the application of a caus- tic, as chromic or nitric acid, the acid nitrate of mer- cury, or a strong solution of silver nitrate, may produce sufficient granulation to close the orifice. In more exten- sive destruction of tissue some plastic operation will be necessitated. Rarely (about once in 2000 cases) thorough physical exploration fails to detect any adequate cause for the escape of the urine, and in these cases the only plausible explanation is a pressure-paralysis of the urethra and the vesical sphincter. The sphincteric action may gradually 688 .4 MANUAL OF OBSTETRICS. reassert itself, or the condition may remain permanent. Strychnin in full doses, mild faradism of the urethra, and gentle massage may aid in effecting a cure. lo. Retention of Urine. Much more common than the foregoing is the tendency to urinary retention after labor. To a certain extent this is to be expected for a few hours, owing to the increased ca- pacity of the bladder after reduction of the uterine bulk and the removal of the action of the abdominal muscles. It is possible, however, for a true obstruction to the flow of urine to result from traumatism of the parts during the passage of the child's head. This may consist merely in a temporary swelling of the urethral walls, with a serous exudate, or there may have occurred an unwonted disten- tion and twisting of the caliber of the urethra. In either case a delay of not more than eighteen hours is justifiable. If at the expiration of this period of time the urine have not been voided, an aseptic catheter must be introduced and the bladder evacuated. In women of a strongly neurotic temperament this procedure may necessitate vesical cathe- terism for days or even weeks, the bladder-walls apparently becoming apathetic and utterly incapacitated for perform- ing their customary function. The use of strychnin and nerve-sedatives in full doses will largely overcome this hysteric manifestation. It is also advisable in these cases to permit the patient to assume the sitting posture, a simple change of position effecting a cure. Not infrequently the sound of running water will be followed by a relaxation of the sphincter and evacuation of the bladder. 1 1 . Pathology of the Mamm.e. (i) Inversion of the Nipple. — In many young girls a congenital defect of the nipple will be noted. This usually consists in a depression or flattening of the nipple, or an actual inversion whereby there exists a cavity {cratcr-nipplc) PATHOLOGY OF THE MAMMM. 689 instead of a protuberance. Such a defect as this consti- tutes an absolute impediment to lactation, and, when discov- ered, efforts should be made to remedy the condition. The close reflex relationship existing between the mammary- glands and the pelvic viscera must be constantly borne in mind, and this will contraindicate any active manipulation of the gland prior to the last three or four weeks of gesta- tion. During this final stage, however, gentle traction upon the nipple by the fingers of the physician, the nurse, or the patient herself may be advantageously practised daily. If not successful, more powerful suction maybe substituted through the agency of a breast-pump. Even this fails in some cases, and the infant must then be made to nurse through an arti- ficial nipple held over the breast, or it must be given to the care of a wet-nurse or raised upon the bottle. (2) Fissured Nipples. — The constant alternation of moist- ure and dryness exposes the nipples to the danger of chafing, and in many cases deep and most exquisitely tender fissures develop. There are very few, if any, parturient women who have not suffered to varying degrees from this condition. Aside from the suffering inflicted, the especial menace to the patient lies in the entrance of pathogenic germs that may at any time institute an active inflammation of the glandular substance. The treatment is mainly prophylactic. During the later weeks of gestation a certain amount of hardening of the nipples may be secured by exposing them daily for from twenty to thirty minutes to the action of the atmosphere. It has been found that after the birth of the child the frequent bathing of the nipples with some anti- septic solution will very effectively diminish the frequency of chafing. Most commonly employed for this purpose is a saturated solution of boric acid. To use this with the greatest satisfaction, not only should the nipple be cleansed with it after each nursing, but the baby's mouth also both before and after feeding. The nipple should be well dried, a drop or two of olive oil rubbed in, and a small 44 690 A MANUAL OF OBSTETRICS. compress of lint saturated with the boric-acid solution placed over it. Before the next nursing the oil must be removed and the nipple bathed in the boric-acid solu- tion. This procedure should be adopted at each nursing. The use of astringent remedies is to be deprecated. The child should not be permitted to sleep with the nipple in its mouth, as this prolonged maceration increases greatly the tendency to Assuring. If, notwithstanding these measures or because of their neglect, Assuring result, the pain attend- ant upon the condition and the imminent danger of septic infection necessitate an energetic course of treatment. In all cases in which the Assuring is deep and active ulceration is present it is well to keep the child from the nipple until the soreness disappears. In the mean time applications of ichthyol in lanolin or glycerin, or of aristol in liquid vaselin (aristol 3j to 3v of the vaselin), or of an ointment of bismuth subnitratc and castor oil, i dram of each (Hirst), should be made at frequent intervals. Among the other local reme- dies that have been employed with considerable satisfaction may be mentioned the compound tincture of benzoin and a 4 to 8 per cent, solution of silver nitrate, of which a few drops are applied after each nursing (if the child be allowed the breast), or three or four times daily if the breast be not used. The milk should be drawn at regular intervals when the child is not given the nipple. In these ulcerated cases Lepage recommends bathing the sore with the following solution: Red iodid of mercury, 10-20 cgm. (2-4 gr.); spirit of wine, 50 gm. (i^ oz.) ; glycerin and distilled water, each 700 gm. (i pint). He claims that the pain is greatly dimin- ished by this course of treatment. Finally, if the child nurse from the breast, it should always do so through a large white-rubber nipple-shield, which can be more readily cleansed than the ordinary small rubber shield. This must be kept absolutely clean by immersing it between-times in a saturated solution of boric acid. (3) Mastitis (Mammary Lymphangitis ; Galactophor- PATHOLOGY OF THE MAMMM. 69 1 itis; Mammitis). — Inflammation of the mammary glands is, as a rule, an absolutely avoidable complication of the puerperium. When the flow of milk is established there naturally ensues an intense engorgement of the glandular substance, and any lack of attention on the part of the accoucheur at this critical period might readily result in the so-called caking of the breasts. In this condition there occurs an accumulation of the milk in the galactophorous ducts, and the attendant congestion in a small proportion of cases acts as a predisposing factor in the production of a parenchymatous inflammation of the mammae. This, how- ever, is not the common mode of development of a mas- titis. In the vast majority of cases the condition may be traced directly to a septic infection of the gland following Assuring of the nipple, as already mentioned. Inflammation of the mammae should, therefore, be regarded as one variety of heterogenetic puerperal sepsis, the germs entering the system independently of the genitourinary tract. In a certain proportion of cases direct traumatism is the cause. The pathology of mastitis consists essentially in an acute in- flammation of the cellular tissue of the gland which may or may not terminate in suppuration, the latter condition being described under the terms mammary abscess and gathered breast. The inflammatory process may be located imme- diately under and around the nipple, producing a superficial form of mastitis — the subcutaneous variety; more commonly it involves the deeper structures, and generally to one or the other side of the gland below its transverse diameter, while in rather rare instances the cellular tissue beneath the true gland-structure becomes inflamed through lymphatic infec- tion — a postmammary or submammary inflammation with or without resultant abscess. The symptoms of mastitis are acute pain, inflammation, and slight reddening of the surface ; induration of the affected lobule or lobules of the gland ; malaise ; eleva- tion of temperature, with one or repeated rigors ; loss of 692 A MANUAL OF OBSTETRICS. appetite ; rapid pulse ; cephalalgia ; and flushing of the face. Manipulation of the gland elicits marked tender- ness, and nursing is interfered with in consequence in many cases. These symptoms develop gradually in a breast the seat of a fissured nipple or of a parenchy- matous engorgement with occlusion of the milk-ducts, and are, accordingly, most frequent during the early days of the puerperium. The tendency is to resolution or suppuration. In the favorable cases an appropriate course of treatment is followed by a steady amelioration of the symptoms until the breast has resumed its origi- nal healthy condition and a normal lactation is inaug- urated. The symptoms attendant upon suppuration — which is most common in the third or fourth week of the puerperium — are as follows : The inflammatory manifesta- tions rapidly increase in severity ; the pain loses its acute, lancinating character, and becomes duller and more throb- bing, as in an abscess elsewhere ; a distinct rigor or repeated chills usher in the pus-formation, and the fever assumes the hectic type. Palpation of the inflamed nodule then shows distinct softening of the indurated portions, and in many instances fluctuation. The surface is soft and edematous, and a characteristic glazing and lividity of the skin are noted. The abscess shows a tendency to point upon the cutaneous surface, and spontaneous rup- ture will generally follow if the surgeon's knife do not terminate the process. In these neglected cases the pus shows a marked tendency to burrow and invade the healthier portion of the gland. The adjacent lobules may become affected, and very extensive glandular destruction follow. Sinuous tracts leading to areas around the periph- ery of the gland, and not infrequently to remote regions, are unpleasant complications of this condition. When the ab- scess is situated deeply in the alveolar tissue beneath the gland and just above the pectoral muscles, the condition known as postinaniniary {subnianunary) adscess results. This PATHOLOGY OF THE MAMMM. 693 is accompanied by a very characteristic train of symptoms. The pain is not locahzed in any one spot, but is general throughout the gland, and is increased by the slightest movement of the arm of the affected side ; there is no marked change in the macroscopic appearance of the gland other than a tendency to general edema and a pro- trusion of the whole breast from the subjacent structures, so that it assumes a prominence that is both striking and suggestive. The accumulation of pus in this case may be- come excessive, and the burrowing a much more marked feature than in suppuration of the gland itself Diagnosis. — Mammary inflammation and abscess should not be difficult to recognize. In the earliest stages of pus- formation the change in the color of the skin and that in the consistence of the induration are the most distinctive features, and upon their appearance immediate free incision becomes imperative in order to prevent further destruction of tissue and extensive burrowing of pus. The prognosis as regards life is good. In neglected cases the utility of the gland may be permanently destroyed. Treatment. — Much good will result in a threatened mastitis by prompt prophy- lactic treatment. In caking of the breast this will consist in gentle massage of the gland, with oiled fingers, from the periphery to the nipple : the pressure need not be sufficient to forcibly express the milk, but rather to impel it onward in the milk-ducts, so that it will slowly flow from the nipple : this may be further facilitated by the application of the child to the breast, the judicious use of the breast-pump, and the administration of full doses of salines in order to secure free purgation. Nursing may be contraindicated because of the pain thereby produced or on account of the delete- rious effect upon the child. The induration may be relieved by hot compresses of lead-water and laudanum, together with an elevation of the entire gland by a closely fitting mammary bandage (Figs. 156, 157), which may consist of a strip of unbleached muslin, three or four inches in breadth 694 A MANUAL OF OBSTETRICS. and long enough to encircle the chest, to which are attached two broad upright strips that pass over the breasts and are secured to the transverse band posteriorly. The bandage should be as firmly secured as is consistent with comfort. Fig. 156. — Mammary bandage (Auvard). Fig. 157. — Mammary bandage applied (Auvard). If the nipple be fissured, a very important prophylactic measure in the treatment of mastitis is proper attention to this condition in the manner already suggested. If active inflammation of the gland-substance ensue notwithstanding the foregoing measures, much relief may be afforded, and suppuration may be prevented, by the prompt application of cold, either in the form of lint compresses or by an ice- bag or an ice-coil. These measures may be supplemented by the application of absorbents and counterirritants, as bel- ladonna and ichthyol ointments or pigments of tincture of iodin. The mammary binder firmly applied, so as to exert an equable pressure, is also very essential at this time. When the symptoms indicate inevitable suppuration the process may be hastened by hot poultices, care being ob- served not to continue these measures too long. Upon the first appearance of pus, free incision of the abscess must be insisted upon, the line of incision corresponding to the radiating course of the milk-ducts in order to avoid the subsequent development of a milk-fistula. The escape of pus should be facilitated by douching the abscess-cavity PATHOLOGY OF THE MAMMyE. 695 with a mild disinfectant solution of carbolic or boracic acid or mercuric chlorid (i : 4000). A strip of iodoform-gauze may then be introduced for the purpose of drainage, and the wound covered with a layer of moist aseptic lint, and over this a thick layer of cotton, and the breast supported by a tight bandage. In old cases in which extensive bur- rowing has occurred the fistulous tracts must be opened, carefully cleansed and disinfected, and thoroughly drained. If excessive granulations occur, they may be destroyed by daily applications of the silver-nitrate stick. The constitu- tional treatment will embrace care in the dietetic regimen, proper hygiene, the avoidance of exposure to damp and cold, absolute rest to the breast, and the administration of tonics (iron, quinin, strychnin) and good food. In the early stages mild opiates may be needed to overcome the pain and the insomnia induced thereby. (4) Oligogalactia ; Agalactia. — A deficiency in the quantity of milk in the breasts of a puerperal woman is a not infrequent occurrence. Complete suppression of the mammary function is, however, exceedingly rare. When it is ascertained that the supply of milk is absolutely inade- quate to nourish the offspring, every effort must be made to increase both its quantity and its quality. This is best accomplished by the administration of an abundance of rich food, with the addition between meals, at regular intervals, of a glass of malt or milk, and a careful course of massage of the gland, either with or without galvanism. Tonics, especially the iron-preparations, are of much value in these cases. The condition is one most difficult to manage, how- ever, and it is to be regretted that in very many of these cases the progress is from bad to worse until resort must be had to the service of a wet-nurse, to mixed feeding, or to purely artificial feeding. By mixed feeding is meant the supplemental employment of a prepared food at intervals between the regular nursings from the breast. If a ivet- mirse be secured, the physician should always assume the 696 A MANUAL OF OBSTETRICS. responsibility of her selection. He must ascertain that she be absolutely healthy, especial investigation being made as to her freedom from syphilitic and tuberculous infection. Her milk should be subjected to a close chemical and physical examination. It has been found that the most suitable milk for this purpose is furnished by a woman who is between twenty and thirty years of age, and who has given birth to a child at about the same time as the woman whose place she is to assume. The breasts must be well developed and the nipples prominent and of proper shape. It is important, as a final consideration, that the woman be of a mild disposition, willing and able to accom- modate herself to her surroundings and to subject herself absolutely to the dictates of the accoucheur. Artificial Feeding. — This is a subject of such mag- nitude that for its proper consideration not merely pages but an entire volume would be required. All that can be expected here is an indication of the essential features in the process — namely, the choice of a suitable pabulum, the method of administration, and the quantity to be given at any one feeding. Through the investigations of many eminent obstetricians and physicians, it has been definitely ascertained that cows' milk, when modified in the way hereafter to be mentioned, most closely resembles mothers' milk, and is, accordingly, best suited as a substi- tute for it when for any reason a premature weaning of the child becomes necessary. The most essential points of difference are an excess of casein and acidity and a slight deficiency in the sugar of the cows' milk, together with the presence of germs in the latter within a few hours after it is drawn from the udders. While, according to Gautrelet's figures, there is practically the same amount (6 per cent.) of sugar and fat (4 per cent.) in the two, mothers' milk contains about 2 per cent, of casein, while cows' milk contains about 3^ per cent., or almost twice as much, so that the latter is much more indigestible PATHOLOGY OF THE MAMM^. 697 than the food suppHed by the mother. As a necessary consequence, an infant placed upon an unmodified cows' milk would very quickly manifest evidences of malnutrition, or speedily perish from gastrointestinal complications en- gendered thereby. Bearing these truths in mind, it becomes evident that in order to convert a given sample of cows' milk into one more closely similating the milk from the human breast it will be necessary to dilute it in order to diminish the relative amount of casein, and to add a cer- tain amount of fat and sugar to bring these substances to the proportion normally existing before the dilution was made. At the same time, the germs contained in the cows' milk must be destroyed by some process of sterilization, preferably by Pasteurization, which has been proved effi- cient for the purpose without exerting any deleterious effect upon the nutritive value of the milk. From such a work- ing-basis various formulae have been suggested, notable among which may be mentioned those of Meigs, Hirst, Rotch, and Biedert, which are suitable for the various periods of an infant's existence up to the normal time of weaning. The substances employed in the production of these pabula have been cows' milk — either condensed or fresh — lime-water, cream, and maltin. These are to be combined in quantities proportionate to the age and diges- tive powers of the infant in question, and any formula giv- ing absolute satisfaction at first must be increased in nutri- tive power every two to four weeks. The famous Meigs mixture consisted of cream (14-16 per cent, fat), 2 ounces; milk, I ounce ; lime-water, 2 ounces ; and sugar-water (milk-sugar, 17^ drams; water, i pint), 3 ounces. This is strongly alkaline in reaction, containing no starch, 3^ per cent, of fat, and 6}^ per cent, of sugar. BiedcrfS' crcavi- mixt'ure, which is most suitable for an infant of three months, consists of cream, i ounce ; milk, i ounce ; water, 3 ounces; and milk-sugar, i dram. This is acid in reaction, contains no starch, not quite 3 per cent, of fat, and almost 4 698 A MANUAL OF OBSTETRICS. per cent, of sugar. Its nutritive value is scarcely sufficient. Rotch has suggested numerous formulae, of which the fol- lowing may be considered as a type : Cream, ^ ounce ; milk and lime-water, each i ounce; water, 17^ ounces; milk-sugar, 2 measures. This is the quantity for twenty- four hours, the amount at each feeding varying with the age of the infant. Hirst has had satisfactory results from the following : For the first two weeks of infantile exist- ence he employs a mixture consisting of condensed milk, I part; boiled water, 12 parts; cream, i part; and lime- water, I part. This contains a little less than i per cent, casein. It should be given to the infant in suitable quan- tities every two hours. For the next two weeks he uses a mixture of cows' milk, 4 parts ; boiled water, 5 parts ; and cream and lime-water, each i part. This is relatively poor in sugar; hence he adds to the mixture from 8 to 10 grains of sugar of malt (maltin) after the first month. The child is fed every two and a half hours during the second month. When the child is three months old the formula is altered so as to contain 5 parts of milk and 4 parts of boiled water, and the strength of the mixture is gradually increased in proportion to the growth of the child. Whatever the substance employed, it must be well steril- ized and the bottle and nipple must be chemically clean. It has been found that Pasteurization, while not destructive to spores, will destroy all pathogenic germs without also affecting deletcriously the quality of the milk. The pro- cess is as follows : The bottles for a day's (twelve hours') feeding, six in number, are filled with a sufficient quan- tity of the selected mixture proportionate to the age of the infant. These are stoppered with plugs of cotton-wool, and are then placed in an Arnold sterilizer or other closed receptacle (an ordinary clothes-boiler will answer admi- rably). Around the bottles boiling water is poured until the fluid in the receptacle has reached the level of the mix- ture in the bottles. The lid is then firmly secured and the PATHOLOGY OF THE MAMM^. 699 water allowed to cool. By this method the temperature of the milk is raised to 175° or 180° F. — a temperature suffi- ciently high to destroy whatever germs may be present. The stoppers are allowed to remain in the bottles until the time of feeding, when the stopper from the bottle to be used is removed and a sterilized nipple applied. The bottles should be provided with necks of sufficient width to per- mit the introduction of the index finger, and should be rounded at the angles, so that all uncleanness may be re- moved. They are best washed by a mixture of soap, water, and liquor ammoniae, and to avoid breaking should be moderately heated before pouring in the boiling water. Before and after using, the rubber nipple should be inverted and well cleansed, and in the intervals between nursings it may be kept in a tumbler containing a solution of boracic acid. The quantity of food to be given at any one feeding will depend entirely upon the age of the infant. It must be remembered that the capacity of an infant's stomach at birth is very limited — not exceeding one ounce — and that this capacity increases at the rate of one ounce per month until the sixth month of life, and afterward at the rate of half an ounce per-month. An appropriate amount of the selected mixture having been placed in the bottle and sterilized in the manner mentioned, the child should be held in the nurse's arm in a recumbent position, and not allowed to consume the food in less than twenty minutes. This will approximate the time required for normal nursing, and such a procedure will prevent the hasty ingestion of large quan- tities of milk, with the necessary consequence of curdling and gastric disturbance. The child should not be allowed to rest in the crib with the bottle in its hands or on the pillow. By the observance of some such code of rules as the foregoing much unnecessary infant morbidity and mor- tality may be prevented. (5) Polygalactia ; Galactorrhea. — During the first two 700 A MANUAL OF OBSTETRICS. or three days of lactation an excessive flow of milk from the engorged breasts is a physiologic phenomenon. In a large number of instances, however, the flow becomes so excessive as to constantly keep the clothing of the patient saturated, and on account of the discomfort thereby pro- duced and the consequent strain upon the constitution it becomes necessary to remove the excess of milk. This is best accomplished by feeding the infant at regular periods, and in the intervals removing the excessive secretion through the agency of the breast-pump or by careful mas- sage. If this condition occur after death of the infant or after the child has been weaned, efforts must be made to dry up the breasts as speedily as possible. For this pur- pose ergot may be administered internally in small doses (lO minims four times daily), either alone or in combina- tion with potassium iodid, lOto 20 grains three times daily. Locally, belladonna-ointment should be applied, or, if this prove inefficient, the nipple may be bathed five or six times daily in a 5 per cent, solution of cocain hydrochlorate in equal parts of glycerin and water (Joise). It is claimed that by this procedure suppression of milk will be observed in from two to six days. The danger of idios}'ncrasy must be borne in mind during the employment of cocain. (6) Galactocele. — Occasionally there will be noted in the breast of a nursing woman a soft cystic tumor con- taining a collection of milk, and resulting from occlusion of one or more of the galactophorous ducts. There is gen- erally no pain attendant upon this condition, and no dis- comfort is induced thereby unless the tumor attain unusual dimensions. It may then become necessary to puncture the cyst, evacuate its contents, and provide suitable drain- age until closure of the wound has occurred. (7) Tabes Lactealis. — In the lower classes of society it is not infrequent to find lactation continued until the child is eighteen months or even two or two and a half years old. While such an unusual prolongation of the period of lac- PATHOLOGY OF THE NEW-BORN. 70 1 tation — known as hyper lactation — may not be deleterious to mother or child, the reverse is more likely to be true. Very generally under these circumstances the child will wean itself, refusing to take the breast, or weaning will become imperative on account of the manifest disagree- ment of the milk with the child. Should this not occur, the mother herself may develop marked constitutional symp- toms, including a condition of more or less profound anemia, associated with severe neuralgic attacks in the arms and chest, especially marked while the child is at the breast. The treatment of this condition is self-evident. Immediate weaning must be insisted upon, and the mother placed upon full doses of tonics, including strychnin, iron, arsenic, and the fats. Her diet must consist of the most nutritious and readily assimilated articles, and, if possible, a change of air and scene must be urged. VI. PATHOLOGY OF THE NEW-BORN. I. Prematurity. In the foregoing pages frequent mention has been made of the untimely termination of a gestation. This may occur at any period from conception up to the full expiration of the normal term of pregnancy, and the time at which the accident occurs will determine the possibility of infantile existence. It is self-evident that a termination of pregnancy prior to the period of fetal viability can have no bearing upon the question in hand : the term premature can be ap- plied only to an infant born before its time, but capable of an independent existence for any period, no matter how brief It has been very conclusively demonstrated that a fetus expelled during the first six months after conception will inevitably perish at the time of delivery. From the sixth month the probability of living steadily increases to term. A fetus, therefore, is said to be viable when it has attained 702 A MANUAL OF OBSTETRICS. six months of intrauterine existence, although if born pre- cisely at this time the chances are strongly against its sur- vival. The number of infants expelled during the last trimester of pregnancy is enormous, and it is necessary to consider carefully the means of preservation of these feeble lives until the normal degree of vitality have been attained. These means resolve themselves into two — namely, the maintenance of a normal temperature and the administra- tion of a suitable food. Immediately after birth there occurs a rapid fall of fetal temperature of from 0.86° C. to 1.7° C, largely arising from a dissipation of heat through the agency of the skin. If this be true of a healthy fetus at term, and it become necessary even under the most favorable circumstances to maintain a normal temperature by suitable wraps and Fig. 158. — Auvard incubator or couveuse. an environment of proper warmth, it is much more imper- ative that these immature creatures be afforded the same favorable circumstances, and even to a greater degree. The fetal temperature may best be maintained at the normal PATHOLOGY OF THE NEW-BORN. 703 point through the agency of an apparatus technically known as a couveiise or incubator, various forms of which have been devised. Those most commonly employed in hospitals and maternity-institutions are Tarnier's, Crede's, Auvard's (Figs. 158, 159), and Rotch's. Tarnier's couveuse consists of a box with two compartments, in the upper of which the child is placed, while the lower is filled with warm water, by Fig. 159. — Interior view of the Auvard incubator (Fig. 158). which a uniform temperature of sufficient degree is main- tained. Crede's apparatus is in the form of a copper bath- tub with hollow walls and base through which heated water is allowed to flow : the temperature within the tub may thus be maintained at or slightly above blood-heat. The other varieties of incubators are based upon modifications of the foregoing. In the absence of such apparatus a very effi- cient incubator may be improvised from an ordinary baby- tub or a wooden box. The child may be placed in this, well surrounded with cotton-wool, and a proper temperature maintained by hot bricks or hot-water bottles frequently changed. By such procedure, promptly instituted, many a fetal life will be saved that otherwise would almost in- evitably be lost. Especially is this method of treatment 704 A MANUAL OF OBSTETRICS. of service in the rearing of children born from four to six weeks before term. Fully 95 per cent, of these infants may- be saved. Probably not more than one-fourth of the six and six-and-a-half months' babies survive under the best of care. The large majority of such infants succumb to the curious condition known as sclerema Jiconatorum {hide-bound dis- ease ; skin-bound disease) — a disease peculiar to new-born infants, and characterized by an induration of the subcuta- neous cellular tissue, especially of the lower extremities, with or without an associated edema of the parts, and by a subnormal temperature. The skin of the front of the chest seems to be exempt from the disease, which is very rarely present at birth, but develops within a few hours. The loss of temperature is usually the first symptom noted, the atten- tion of the nurse or those in attendance being called to the icy coldness of the surface of the child. As low a temper- ature as 33° C. (92° F.) has been recorded. The skin is hard and dry to the touch, and cannot be pinched up in folds as in a healthy infant ; it has a smooth, tense appearance ; occa- sionally pitting on pressure may be noted, as may also more or less rigidity of the joints. A certain amount of icterus is very generally present, the color of the skin varying from yellowish-white to livid or bluish-red. There is also an appreciable loss of cutaneous sensibility, and, in conse- quence of the changes in the texture of the cutaneous tissue some delay in the falling of the cord is common. Other more or less constant symptoms are dysphagia, digestive disturbances, constipation or diarrhea, slow and feeble pulse (70 to 90 beats per minute), diminished frequency with ir- regularity of respiration (the rate ranging from 15 to 35 per minute), feeble cry, tonic and clonic convulsions, and a tend- ency to hemorrhages from the mucous .surfaces. As to the etiology of this curious disease but little is known, al- though various theories have been advanced. From a care- ful study of the conditions present in these cases it would PATHOLOGY OF THE NEW-BORN. 705 seem that the fundamental process in its development is a lack of vitality. This would explain the great prevalence of the disease in immature infants, and this theory is further supported by the fact that when the affection develops in children born at term, it selects those that are constitu- tionally debilitated and undersized and exposed to unfavor- able hygienic surroundings. The disease is also most com- mon in the cold and moist months of the year, when there would naturally be a greater demand upon the heat-pro- ducing centers of the body. The actual cause of the cuta- neous induration has been very plausibly explained by Hirst as a congelation of the fatty acids of the body, especially the palmitic, a direct consequence of the abnormally low body-temperature. This is especially suggestive when it is remembered that these acids become solid at a compara- tively high temperature. The prognosis will depend largely upon the ability of the physician and parents to place the child under the most favorable hygienic and dietetic con- ditions. Sclerema neonatorum is a very grave disease, fully 50 per cent, of the children perishing. The best re- sults are obtained by the employment of the incubator, daily applications of warm oily inunctions (olive oil, cam- phorated oil, mercurial ointment), the internal administra- tion of alcoholic stimulants or ether in appropriate form and quantity (from one to two drops of either being exhib- ited in the food), and the feeding of the infant, if it cannot nurse, by the process of gavage. This is a term employed to indicate the nourishing of a child by small quantities of the maternal milk introduced into its stomach at regular intervals through a soft-rubber tube. It is a very valuable method of feeding in premature infants who either cannot take the nipple or for whom the mother is unable to furnish food. The infant can very readily be taught to swallow the tube, when the introduction of the milk through a small graduated glass funnel is but a simple matter. The tube must be quickly withdrawn to avoid reflex vomiting. 45 706 A MANUAL OF OBSTETRICS. The best position for the child to occupy is upon its back in the arms of its nurse, with its head shghtly elevated. In very young and feeble infants the milk should be admin- istered every hour in quantities not exceeding i dram ; the brandy may be added to this. Under such a course of treat- ment from 20 to 50 per cent, of the infants may be saved. The use of the incubator and gavage must be persisted in for varying periods of time dependent upon the age of the infant and its progressive gain in strength and vitality. Usually not less than one or two months of such treat- ment will be necessary. 2. Asphyxia (Apncea) Neonatorum (Asphyxia Nascen- tium). It is a very common occurrence for a child to be born with the respiratory functions in abeyance : such a child is said to be asphyxiated. If efforts at resuscitation prove ineffectual, it is said to have been stillborn. It is probable, as has been very effectually demonstrated by Morrison and others, that the primary cause of this condition is some in- terference with the fetoplacental circulation, resulting in an intense venous congestion of all the organs of the fetus, with, it may be, here and there ecchymoses or even more extensive effusions of blood. The postmortem examination of infants perishing from this cause would seem to indicate some such origin as this. Evidences of vascular engorge- ment are to be noted in the right heart, in the cortex of the brain, in the spinal c^nal, in the lungs and pleurae, in the liver and spleen, and in the intestinal walls. In those cases in which there have occurred ineffectual efforts at respira- tion the pulmonary tissue is more intensely congested, and may even be the seat of numerous apoplexies, while the visceral pleura reveals frequent patches of hemorrhagic ex- travasation. Sections of the lungs are heavj', and when placed in water immediately sink to the bottom of the vessel. A secondary cause of the asphyxia is to be found PATHOLOGY OF THE NEW-BORN. JOJ in some interference with the respiratory organs themselves or with the respiratory center at the base of the brain. The possible causes of the circulatory obstruction are many. Among those of fetal origin may be quoted syph- ilitic stenosis of the vessels of the placenta and cord ; some abnormality of the heart or great vessels ; an early separa- tion of the placenta, or an accidental hemorrhage, as in placenta praevia ; also undue pressure upon the vessels of the cord, as in prolapse of that structure or when either extensive coiling, knotting, or torsion exists. Maternal causes are sudden death of the mother during parturition ; grave organic disease resulting in weakness of the circula- tion, and thereby an imperfect exchange of fetal and mater- nal blood; and copious hemorrhage from any cause. Respiration itself may be impeded by some anomaly of the respiratory tract whereby the entrance of air to the lungs is prevented. The asphyxia may follow a paralysis of the cerebral respiratory center from extreme compression of the fetal skull during an instrumental delivery or a tedious passage through a contracted parturient canal ; or, finally, it may result from some mechanical obstruction to respiration, as when, a caul is present, or when, during pre- mature attempts at respiration, some of the discharges of the parturient canal are sucked into the bronchial tubes. The latter cause is not infrequent during certain cases of dystocia, and these spasmodic respiratory efforts are often accompanied by a fetal cry, which, according as to whether it is heard while the fetus is still within the uterus or when it has descended to the vagina, has been termed the vagitiis iiterimis vol vaginalis. The signs of impending death from asphyxiation during labor are a progressive weakening and slowing of the fetal heart-beats, as detected by auscultation ; efforts at respira- tion while the fetus is still traversing the birth-canal ; and the discharge of meconium, as evidenced by a staining of the amniotic fluid. The latter sign is considered by many 708 ^ MANUAL OF OBSTETRICS. as indicative of an advanced stage of asphyxia. The ap- pearance of the child varies. In the vast majority of cases its face is deeply congested, bluish or livid. This is de- scribed as the simple "blue," "cyanotic," or "apoplectic" variety, or asphyxia ncoiiatoriun livida. It is the more favor- able variety, and denotes the minor degrees of asphyxiation. The discoloration is most marked in the face and upper portion of the body, gradually shading off into the natural flesh tints. The lips are swollen and protruding and the pupils dilated. Examination shows that the muscular tonus and the reflexes are preserved, while the heart-beats are moderately strong and regular, and the»vessels of the um- bilical cord are distended. Gasping respirations occur at irregular intervals. In the graver variety of the condition the surface of the child is pale and anemic, and the condi- tion is then termed the " pale," " anemic," or " paralytic " variety, or asphyxia ncoiiatoruvi pallida. Respiration now is altogether abolished ; there is absolute loss of muscular tonus and the body-reflexes ; the circulation is very feeble, and the heart-sounds irregular and indistinct; the vessels of the umbilical cord are generally collapsed ; the features are placid, and the pupils widely dilated. The diagnosis of asphyxia of the new-born child is plain. The prognosis is grave in the livid and very grave in the pale variety : it will depend entirely upon the degree of pulselessness as indicated by cardiac auscultation. As to the ultimate results of asphyxia neonatorum not much is known. This much can be said, however, that many of the children resuscitated at first develop eventually pulmo- nary, cardiac, and nervous manifestations, of which they die. Atelectasis, omphalorrhagia, paralysis, convulsions, and idiocy have all been noted as sequelae of the condi- tion, and it is not improbable that these symptoms may be directly traceable to some hemorrhagic effusion into the brain and spinal cord or pulmonary tissue. The treatment includes prophylaxis as well as the restor- PATHOLOGY OF THE NEW-BORN. yog ative measures. The prophylactic measures embrace the building- up of both mother and fetus throughout preg- nancy whenever there is reason to believe that a tendency to syphilis or other disease liable to result in fetal asphyxia exists ; this may be accomplished mainly by the adminis- tration of arsenic, potassium chlorate, and the salts of iron and mercury. During labor every precaution must be taken to preserve the cord and vital centers from undue pressure. In the cyanotic variety of asphyxia, in which the pulsa- tion in the funis is strong, increased congestion of the vital organs will be prevented by prompt ligation of the cord, after which measures of resuscitation may be insti- tuted. In the pale variety it may be that some good will result from a delay in severing the funis, although as soon as placental separation is assured the cord must be ligated in order to prevent fetal loss of blood. After division of the cord oxygenation of the fetal blood must be promptly secured by the establishment of respiration. The less en- ergetic measures may be first tried. These embrace sus- pension of the child by the feet in order to cleanse the bronchial tubes of all extraneous matter, when one or two blows with the hand or with a wet towel upon the buttocks or the back will generally suffice to start respiration. This failing, a little ether or whisky may be dropped upon the epigastrium of the child, or a quantity of cold water poured from a height upon the same spot, the rest of the body being immersed in warm water to avoid undue chilling. Cooke's method of the rapid introduction of the lubricated finger into the rectum may prove successful, but the possible danger of permanent rectal incontinence must be borne in mind. In the advanced stages of the cyanotic variety Bed- ford Brown claims excellent results from the hypodermic injection into both arms of 5 or 6 drops of brandy or whisky : this is useless in asphyxia pallida; the main objection to the method is the liability to the formation of an abscess at the site of injection. 710 A MANUAL OF OBSTETRICS. Of the methods of artificial respiration that have been suggested those of Schultze, Dew, Laborde, and Prochow- nick are probably the best. ScJmltzcs victliod (Figs. i6o, i6i) claims the largest number of adherents, and is unde- niably very efficacious. It is performed as follows : The Fig. i6o. — Schultze's method of respiration : inspiration. infant is grasped in such a manner that the thumb of each hand rests upon the anterior aspect of the thorax ; the index finger enters the axilla from behind, and the remain- ing fingers extend along the dorsal aspect of the thorax. The child is thus suspended with its back to the operator. This is the position of inspiration, the thorax being fully distended, and the entire weight of the body resting upon PATHOLOGY OF THE NEW-BORN. 711 the index fingers in the axilla. The operator, slightly sepa- rating his legs, gently swings the infant upward until the body bends over at the loins, its weight thus being ex- erted upon the diaphragm, and thereby producing a forcible expiratory movement. This is the position of expiration, Fig. 161. — Schultze's method of respiration : expiration. the body now mainly resting upon the thumbs placed on the anterior aspect of the thorax. This maneuver may be repeated every few seconds until respiration is estab- lished. The main objection to the method is the danger of traumatism, as the rupture of some of the viscera of the abdomen or of the thorax, fracture of the ribs, disloca- tion of a vertebra, or undue strain upon the spinal cord. 712 A MANUAL OF OBSTETRICS. In Deiv's method the infant is grasped in the left hand in such a manner that the neck rests between the thumb and forefinger and the head hangs over in the position of full extension, thereby securing a wide opening of the epiglot- tis ; the upper portion of the back and scapulae rest in the palm of the hand, while the remaining fingers are inserted into the left axilla. The knees are then grasped by the right hand, the right knee resting between the thumb and forefinger, the left knee between the index and middle fingers, and the thighs in the palm of the hand. The right hand depresses the body to favor inspiration, while to secure expiration the movement is reversed and the child doubled upon itself, the thighs resting upon the abdomen and the knees and head being approximated. This move- ment may be repeated as often as required. Rosenthal vaodx- fies the foregoing methods in the following manner : The child resting upon a table with its neck supported by a roll, the feet are seized with the thumbs in contact with the soles, the index fingers with the back of the feet, and the ring finger resting upon the Achilles tendons : in regular order the knees, hip, and spine are bent so that the knees come in contact with the chest, thereby securing compression of the abdomen and full expiration ; on extending the body inspi- ration follows. Compression of the larynx is thus avoided. Recently Labonics method of rhythmic tongue-traction has attracted considerable attention on account of its sim- plicity. It consists in seizing the tongue with catch-forceps or by the finger and thumb wrapped in a piece of cloth, and strongly drawing it out of the mouth, after which it is allowed to fall back into its normal position. This maneuver may be repeated about fifteen times in the minute. It is supposed to act by creating a reflex irritation of the respi- ratory center through the motions of the base of the tongue, transferred through the motor nerves (the superior laryn- geal, the glossopharyngeal, the laryngeal, and the phrenic). Its efficacy is not yet confirmed. PATHOLOGY OF THE NEW-BORN. 713 Prochownick' s method consists in suspension of the child by the feet with the left hand, the middle finger being passed between the ankles from behind forward, and the remaining fingers resting on the lateral aspects of the legs. The head barely rests upon some support, allowing full extension of the neck. The thorax is moderately com- pressed with the right hand until all mucus is expressed : the pressure is then relaxed and an inspiratory effort fol- lows. This movement may be repeated six or eight times, after which the child should be immersed in a hot bath. Methods based upon the action of the pectoral muscles (Sylvester's, Pacini's, Forest's) are generally useless on ac- count of the deficient development of these muscles. Should efforts at artificial respiration by the foregoing methods fail, resort may be had to raouth-to-mouth insuf- flation or to the use of the tubes of Ribemont, Chaussier, or DePaul. In the moutli-to-moiitJi iiisufflation the child is laid on its back in a position of full extension, the chest resting upon a roll ; a towel is placed over the infant's mouth, and the operator, taking a quick, full inspiration, applies his mouth to the towel and gently expires into the latter ; compression of the chest is then secured by bending the head upon the thorax. In catheterization of the larynx care must be taken to introduce the tube into the larynx and not into the esophagus. This may be ac- complished by passing the left index finger into the pharynx and locating the arytenoid cartilages ; the tube is passed along the palmar surface of the finger, when it will readily glide into the glottis : if it be in proper position, the chest will expand ; if it be in the esophagus, a gurgle will be heard and the abdomen will become inflated. The air will be expelled by the elasticity of the pulmonary tissues. 3. Traumatisms of the Infant. (i) Caput succedaneum is an edema or serous infiltra- tion of the soft tissues situated upon the presenting part of 7H A MANUAL OF OBSTETRICS. the fetus. The degree of edema depends entirely upon the duration of the labor, and its situation varies with the pres- entation. Thus in the most common presentation — that of the vertex with the occiput anterior and to the left — the caput succedaneum is always found at or near the site of the ante- rior fontanel ; in posterior occipital presentations it is often of considerable size and is situated over the posterior por- tion of the scalp ; in brow presentations there is an im- mense edema and distention of the frontal region ; and in difficult posterior chin presentations of the face the features may become almost unrecognizable from the amount of serous infiltration. In precipitatate labors there may be absolutely no exudation of serum. The explanation of the formation of the caput succedaneum lies in the complete ab- sence of pressure upon that portion of the fetus correspond- ing to the orifice of the parturient canal, the rest of the body being subjected to tremendous muscular force. The con- dition need not excite apprehension : it will spontaneously disappear within three or four days after birth. (2) Cephalohematoma. — Of very serious import is the condition known as ccpJialoJiciiiatoiim, or an exudation of blood at some point beneath the pericranium (Fig. 162). This is encountered about once in 200 to 300 cases of childbirth. It generally develops on the second or third day after a dif- ficult labor, and is due to the pressure exerted upon the part by forceps or by the pelvic wall during the passage of the head. As would be expected, there- fore, it is most commonly seen upon the lateral aspect of the head, and, being subpericranial, is confined to the bone or bones that have been injured, being limited by the dipping in of the pericranium at the Fig. i6z. — Cephalohematoma. PATHOLOGY OF THE NEW-BORN. 715 sutures. It is generally unilateral — over the parietal bone — but there may be an effusion upon both sides. Appearing at the time stated, the tumor rapidly increases in size : at first it is soft and elastic to the touch, but later, owing to the osteogenetic action of the elevated pericranium, small foci of ossification occur, and the tumor acquires a parch- ment-like feel, distinctly crepitating under pressure. Once developed, cephalohematoma may persist for one or two weeks. The tendency is to resolution or suppuration. Diagnosis. — There is but one condition — caput succeda- neum — with which this tumor may be confounded, and that only on superficial investigation. The points of differentia- tion are — Cephalohematona. Caput Succedaneu7n. This is a bloody effusion beneath the peri- This is a serous effusion in the epipericra- craniunn. nial tissues. Develops two or three days after birth. Present at birth. Usually localized at the sides of the head. Always over the presenting part. Generally due to pressure. Due to lack of pressure. At first soft and cystic to the touch ; later Soft, non-fluctuating. crepitant. Persists for a week or two, and may suppu- Disappears in two or three days. rate. The prognosis is good. Treatment, if the tumor be small, consists in protecting the part or in the application of cold compresses to limit the amount of effusion. If suppuration occur, free incision must be practised, the pus evacuated, and the wound treated antiseptically. (3) Caput Obstipum. — Wry-neck is occasionally noted after the extraction of the head in breech presentation, and in some cases of protracted posterior occipital presentation. In the former case it results from undue traction upon the cervical muscles, and in the latter from excessive rotation of the head upon the shoulders, which remain fixed in their original position. The condition generally disappears within a few days : in a limited number of cases, however, it remains permanently. But little can be done for it other than the application of emollient ointments. 7l6 A MANUAL OF OBSTETRICS. (4) Fractures. — In every case of labor, with the excep- tion of breech presentations, the cranial bones are more or less displaced by the pressure to which they are subjected during the passage of the head. As a result of this mould- ing of the head characteristic distortions have been recognized for the various presentations. In over-size of the head or under-size of the pelvis it may readily be conceived how the increased pressure may result in frac- ture of one or more of the bones. The occiput and the parietal bones are those most commonly involved, and the result is generally, though not necessarily, fatal. Should the fetus survive the injury, it must be treated on general principles, and cerebral compression avoided as far as practicable. Fractures of the long bones of the body are not extremely rare. Most commonly it is the humerus that suffers ; next in frequency is the femur ; then the tibia and fibula ; and very rarely the clavicle. The fracture may partake of the nature of a separation of the epiphysis and diaphysis : it may be partial of the shaft {greenstick frac- ture), or there may be a complete fracture of the shaft. The arm is not infrequently broken during its extraction in a breech presentation : crossing of the limbs may be the cause, or there may exist an abnormal fragility, as in con- genital rachitis. The trcatmctit must be based upon gen- eral principles. (5) Perforations of the body are most commonly the result of traction by the blunt hook, and are then found in the groin. In the careless application of the forceps to a breech one blade may be forced between the nates, and a severe or even complete laceration of the perineum result. Eyes have been gouged out by the careless introduction of the finger into the orbit during the delivery of the after- coming head, or by slipping of the forceps when a vicious grip upon the head had been obtained. If the fetus be not dead, the treatment must be based upon the principles of general surgery. PATHOLOGY OF THE NEW-BORN. 717 (6) Paralyses. — Paralysis of some one of the peripheral nerves may be noted after birth. Probably the most com- mon form of paralysis in the infant is that of the facial nerve, resulting from pressure by an improperly applied forceps. Fortunately, this form gives a favorable prognosis, as the con- dition is very amenable to treatment in the form of faradism or the application of small blisters along the course of the nerve. Paralysis of the nerves of the brachial plexus may follow extraction of the shoulder or arms in head and breech presentations. The injury in this case may be slight, or permanent disability may result. The usual treatment is required. 4. Affections of the Respiratory System. (i) Atelectasis (congenital apneumatosis) is a condi- tion of non-inflation of the air-vesicles of one or both lungs, or only of a lobe or a portion of a lobe of one lung. The cause may be some mechanical obstruction to the entrance of the air into the affected portions, or the condition may result from some unknown cause. Complete atelectasis is necessarily fatal. In the partial variety there is more or less disturbance of respiration, which is shallow and rapid and associated with a certain degree of cyanosis ; the cry is feeble, and the child does not appear to be well ; there is no eleva- tion of temperature. Physical examination will reveal dul- ness on percussion over the affected area. The treatment is that required for the moderate degree of asphyxia. If an entire lung be involved, it may be necessary to catheter- ize the larynx and gently inflate the collapsed tissue. (2) Catarrhal Pneumonia. — It is within a compara- tively recent period that pneumonia of the new-born child has been recognized as a distinct pathologic entity. It is now very generally admitted that many of the deaths formerly attributed to inanition, injuries during birth, and septic infection may be directly traced to an irritative pneu- monia resulting from an imbibition of some of the maternal yi8 A MANUAL OF OBSTETRICS. or fetal discharges. Such an accident can occur only when premature attempts at respiration have been made, and inquiry will generally elicit a history of dystocia, the fetus having been retained for a considerable period in the lower birth-canal. Very rarely, if ever, does the disease develop from exposure at the time of birth. The symptoms appear in from twenty-four to forty-eight hours after birth. At this time the child, which has hitherto seemed absolutely well, becomes restless and irritable : it refuses to take the breast, constantly cries as if in pain, and gasps for breath, the respirations becoming very rapid, numbering as high as 100 to 1 20 per minute. The skin becomes dusky or even livid as a result of the nonoxygenation of the blood, and palpation reveals a heated, pungent condition. The thermometer introduced into the rectum shows a high tem- perature — I03°-I05° F. In many cases a cough develops, and this may become almost incessant. The strength rapidly fails, and death frequently follows in from three to four days. Should recovery take place, the entire illness will not cover over eight or nine days. The diagnosis is difficult, and can be determined only by the exclusion of sepsis of the cord and by attention to the history of the case. The prognosis is always grave. The trcatincnt can be symptomatic only, and will be largely directed toward the sustenance of the patient's strength and the stimulation of respiration. Owing to the inability of the child to nurse, resort must be had to hourly feeding with freshly drawn maternal milk by a spoon or a medicine-dropper. To this may be added from one to five drops of brandy every hour, and for cardiac stimulation one drop of the tincture of digitalis every three or four hours, or oftener as re- quired. A cotton jacket should be applied and respiratory stimulants administered in suitable quantities. Small doses of syrup of ipecac, containing from J/^ to ^ grain of am- monium carbonate, may be administered three times daily, and, to relieve the pain, paregoric in 5- or 6-minim doses PATHOLOGY OF THE NEW-BORN. 719 may be exhibited at suitable intervals. The room must be kept warm, the atmosphere slightly moist, and draughts avoided. If there be much tendency to asphyxiation, the child may be placed for three or four minutes in a weak mustard-bath containing half an ounce of mustard to three or four gallons of hot water, 100° F. It should then be wrapped, without drying, in a warm blanket for thirty minutes, and further stimulation resorted to. As con- valescence advances the usual course of systematic nursing must be resumed. (3) Coryza. — Aside from the characteristic snuffles of congenital syphilis, the new-born babe very frequently ex- hibits all the manifestations of an acute coryza. This re- sults from exposure at the daily bathing, from a draughty and improperly heated room, or from a lack of sufficient clothing. It may be corrected by attention to the foregoing details, and by insisting upon the wearing, day and night, of a linen cap to supplement the lack of hair. 5. Affections of the Digestive System. (i) Stomatitis. — The mouth of the new-born baby is es- pecially prone to the development of inflammatory condi- tions. Most common among these is the apJithous or fol- licular stomatitis {apIithcE), which is characterized by the formation on the lips, gums, tongue, and inner surface of the cheeks of small white vesicles or ulcers, associated with more or less elevation of temperature and symptoms of in- digestion. The vesicular precedes the pustular stage. After ulceration the spots assume a grayish-yellow color and are surrounded by a distinct bright-red areola. The treatment consists in the use of ordinary weak honey of borax (5-10 grains to the ounce). Bcdnar's aplitlice is a very care and very grave form of stomatitis encountered in cachectic infants, and characterized by the presence of two symmetrically placed oval ulcers on the hard palate near the velum, one on each side of the median line. 720 A MANUAL OF OBSTETRICS. These ulcers resist all efforts at treatment and sooner or later involve the bony structure. The children almost in- variably die of marasmus. Parasitic stomatitis {thrush, sprue, zvhite mouth), resulting from the presence of a specific fungus, the saccliaromyccs albicans, appears as pearly-white elevated patches, vary- ing in size, situated on the tongue, lips, cheeks, or hard palate, and as a rule not inducing ulceration. Marked di- gestive symptoms may be present. The treatment com- prises thorough cleansing of the mouth with hot water and a clean cloth and the application of a strong honey of borax (15 to 20 grains to the ounce). Very rarely a gonorrheal stomatitis may be encountered, associated with the presence on the lips and gums of pustules containing the gonococcus of Neisser. This form may be cured by cleansing with a weak mercuric-chlorid solution (1:7000 or 8000). (2) Vomiting" in infants is generally nothing more than the regurgitation consequent upon over-feeding, and, as such, its correction lies in a regulation of the time of nursing and the amount of milk ingested. It may indicate an abnormal amount of gastric irritability, due either to a pernicious quality of the mother's milk or to a lack of digestive power in the gastric juice. In all such cases a thorough chemical and physical examination of the milk must be made and a suitable pabulum administered. It may be that the admin- istration of a small amount of lime-water before or after the nursing may correct the condition. If the digestive powers of the infant be deficient, ]4- or i -grain powders of saccharated pepsin may be administered three times daily, or small quantities of bismuth subnitrate dropped upon the tongue. In the case of bottle-fed children both the bottle and the milk must be well sterilized, or the milk entirely stopped and the child placed temporarily upon the well-known albu- min-water (the white of an egg broken into a tumblerful of water), of which a ^cvj teaspoonfuls may be given every hour as required. Calomel y^ grain and sugar-of-milk in small PATHOLOGY OF THE NEWBORN. 72 1 powders, given every hour, may correct the trouble, or ben- zonaphthol (in i- or 2-grain doses in powder form) may prove efficacious. Daily washing out of the stomach with boiled water may result beneficially in aggravated cases. (3) Colic is always the result of indigestion, and atten- tion to the laws laid down in the foregoing paragraph will often promptly result in a cure. It may be necessary to resort to the use of one or two drops of gin or brandy, a weak peppermint-water, or five or six drops of paregoric. The latter should never be used unless absolutely indicated. (4) Icterus Neonatorum (Pedicterus). — On the first or second day after birth almost every infant will show a cer- tain amount of jaundice, most marked on the face and the anterior aspect of the thorax. As a rule, this discoloration is very slight and will disappear in a day or two without an}' treatment. Occasionally the jaundice will become so intense as to excite apprehension. Usually it is hematogenic in origin, due to a rapid disintegration of the red blood-cor- puscles after birth, with deposit of the coloring-matter in the tissues. In the graver forms the urine is heavily loaded with the bile-pigments. These cases are generally septic in origin and almost invariably prove fatal. For the milder cases all the treatment necessary will be the hourly adminis- tration of yV grain of calomel in i or 2 grains of sugar of milk. Nothing can be done for the septic cases. (5) Marasmus is a term formerly much more employed than at present to indicate a progressive wasting of infants without any appreciable cause, and most commonly encoun- tered in bottle-fed and immature children. Marasmic chil- dren are small, undersized, and wizened in appearance, with wrinkled, flabby, and yellowish skin : the emaciation becomes extreme and is associated with profound loss of strength. The condition is symptomatic rather than a dis- ease in and of itself It is associated with some grave sys- temic dyscrasia, as congenital syphilis, rachitis, or tuber- culosis, or it results from poor hygienic surroundings or 46 J 22 ■ A MANUAL OF OBSTETRICS. ill feeding with corresponding digestive disturbances. Sey- dcts sign of marasmus is an atrophy of the thymus and inner thoracic glands. In order to correct the condition the pri- mary cause must be ascertained, and the infant placed upon an appropriate course of treatment. If it be bottle-fed, a suitable pabulum must be provided, and blood-making and alterative remedies, as the syrup of the iodid of iron, mer- cury, arsenic, and cod-liver oil, administered in full doses. Daily inunctions of cod-liver oil are often beneficial. Change of air and careful regulation of the diet will frequently work a marvellous change in these infants, and if taken in time a large percentage of them may be saved. (6) Constipation. — The intestinal torpidity of young in- fants often assumes serious proportions. If the usual dose of a dram or two of sweet oil or castor oil fails to have the desired effect, it is very seldom that small doses of the cor- dial of cascara sagrada or the small-sized glycerin supposi- tories will not induce a bowel-movement within twenty to thirty minutes : if these measures fail, a second suppository may be introduced, or an enema of 15 to 20 minims of gly- cerin in I dram of water given. The ordinary soap supposi- tory may be tried in the milder cases. Should all these means fail, an enema of soap-suds, i or 2 ounces, will in- variably have the desired effect. This should be admin- istered gently through an absolutely clean soft-rubber cathe- ter attached to a small glass funnel. If need be, this treat- ment may be repeated daily. Anal imperforation must always be looked for in these cases of constipation. (7) Diarrhea. — The bowels of young infants respond very promptly, as a rule, to any indiscretion in diet, and if the weather be warm a troublesome form of diarrhea may develop. Prompt regulation of the diet and thorough sterilization of the food will generally effect a cure. If these measures fail, the bowels may be washed out with boiled water and the movements controlled by injections of starch- water and paregoric, 6-10 minims to the ounce, or by the PATHOLOGY OF THE NEW-BORN. 723 internal administration of paregoric and aromatic sulphuric acid in doses of 4 to 5 minims each, in a little water. 6. Affections of the Circulatory System. (i) The Hemorrhages of Infancy. — {a) In a certain, though small, proportion of new-born children there will be encountered a puzzling and very annoying condition known commonly as heuiophilia or bleeder's disease, or the hemorrhagic diathesis — an inherited tendency to bleed. This condition may not be suspected until some slight trau- matism, as a scratch or a pin-prick, may occasion such an unwonted amount of bleeding as to attract attention or even excite alarm. As a rule, hemophilia rarely manifests itself before the end of the first year, although this is by no means a constant rule. The condition persists through life, such individuals being known as " bleeders." On inquiry there may often be found a strong family history of the same malady running through several generations. Hither- to the generally accepted belief has been that the hemor- rhagic diathesis was transmitted through the females only, who never exhibited any of its clinical manifestations, to the males, who alone were subject to the hemorrhages, but who never transmitted the disease. To a certain extent this statement must now be modified. While the rule generally holds true, there have been reported a number of cases that prove conclusively that females may occasionally mani- fest the clinical peculiarities of the diathesis, and even perish in one of the profuse hemorrhages. As to the etiology of the affection absolutely nothing is known. In a number of the cases reported a strong specific taint ex- isted, and in such cases a possible clue as to the proper course of treatment to be instituted is suggested. Gener- ally all therapeutic efforts are useless. {b) Melcena neonatoriun is a hemorrhagic discharge from the stomach and bowels of the new-born infant, occurring usually during the first or second day of its life. It may 724 A MANUAL OF OBSTETRICS. partake of the nature of a simple vomiting- of blood, or there may occur the passage of tarry or bloody stools, or the two may be combined. If the amount of blood vomited be small and the discharge occur shortly after the child has nursed, it maybe due entirely to an ingestion of blood from a chafed nipple, and this possible source of the hemorrhage must be investigated. The disease is commonest in male children. The etiology of these gastrointestinal hemor- rhages of the new-born is not yet fully understood. With- out a doubt, in a certain proportion of cases they may be ascribed to the curious hemorrhagic diathesis, and in other cases to some local ulceration in the stomach or bowels. Other cases cannot be explained on these grounds, and the theory recently advanced by Preuschen seems to afford a very rational exposition of the etiology of the obscure dis- ease. Recognizing the truth of the statement made by Schiff, that there exists a certain distinct relationship be- tween cerebral lesions and gastric hemorrhages, Preuschen was led to investigate the possible etiologic relation existing between melsna neonatorum and injuries of the brain sus- tained during parturition, many of the cases of melena occurring after difficult labors. The results of his investi- gations seem to conclusively establish an intimate relation- ship between the two, but further observation will be nec- essary before a positive statement can be made. Town- send and Gartner are inclined to attribute to the disease a specific infectious quality. Melena, according to Townsend, is self-limiting and of brief duration : the fatal cases ter- minate within a week ; the others recover in from five to nine days. The diagnosis of the disease is plain ; the prognosis is grave, fully 50 per cent, of the infants perishing. The treatment consists in the internal administration of astrin- gents, as I or 2 grains of gallic acid hourly, the applica- tion of cold to the abdomen, and the hypodermic injection of ergotin. Persistent pressure over the abdomen answers most effectually in controlling the bleeding. The infant PATHOLOGY OF THE NEW-BORN. 725 must be kept warm, and, should collapse develop, alcoholic stimulation will be beneficial. {c) OuipJialorrJiagia. — Hemorrhage from the umbilicus or the umbilical cord may be either primary or secondary. Pri- mary hemorrhage results from loose ligature or laceration of the cord, and occurs immediately after birth. It is of trivial import, all that is required being a re-ligation of the stump in a proper manner. Secondary hemorrhage is much more serious, but, fortunately, is quite rare. It occurs either at the time of separation of the cord, on the third or fourth day, or shortly afterward, between the fifth and fifteenth days. An explanation of its occurrence at this time maybe found in the manner in which coagulation takes place in the arteries of the cord. As soon as the ligature is applied a coagulum is formed in these vessels, and this clot pro- gresses inwardly along the course of the hypogastric ar- teries. Should a portion of the coagulum be dragged out with the separating funis, or should the coagulability of the blood be deficient, the vessels may be left patulous, when of necessity a more or less profuse hemorrhage will result. Of all the cases of secondary umbilical hemorrhage thus far reported, two-thirds have occurred in male children. The hemorrhage is generally abrupt, without premonition, and may be quite profuse. In some cases a marked jaun- dice may precede the attack. The prognosis is always grave, from 75 to 90 per cent, of the infants perishing from exhaustion. Treatment consists in re-ligation of the stump if this be possible. In the slighter hemorrhages the appli- cation of a firm compress saturated with an astringent solution, as vinegar, tannic acid, or Monsel's solution, may sufifice. In other cases it may become necessary to apply a permanent dressing of plaster of Paris, or even to transfix the abdominal wall with hare-lip pins above and below the umbilicus, and around these secure a figure-of-eight ligature. These pins may be removed in four or five daj's, and a simple iodoform or acetanilid dressing applied. 726 A MANUAL OF OBSTETRICS. {d) Vulvar or Vagmal Hemoj'rhagc. — A curious phenom- enon occasionally noted (once in lOOO cases) is a slight dis- charge of blood from the vulvar orifice of an infant two to seven days after birth. In some cases the discharge assumes a marked periodicity, as in menstruation ; in others the bleeding is of irregular occurrence ; while in still a third class it occurs but once, and may be regarded as a mere incidence. It is generally believed that the source of the bleeding is the uterine mucosa. The etiology of the condi- tion is unknown, although various theories have been sug- gested, notably a too early ligation of the cord — that is, before cessation of pulsation — and a too firm application of the binder, resulting in pelvic congestion. The prognosis is good. No trcati>ic)it is required. (2) CEdema neonatorum is a condition occasionally en- countered in the new-born infant, and characterized by the presence in the cutaneous tissue, either locally or generally, of a serous exudate. The edema usually develops at or shortly after birth — on the third or fourth day — in the legs first, gradually spreading upward. The skin of the affected portion is of a livid or purplish color, of normal elasticit\', and pits on pressure. If a crack or a fissure occur, a certain amount of serous oozing will follow. The body-tempera- ture is slightly above normal. The condition is a symptom of cardiac, renal, or pulmonary disease, which may be de- tected on physical exploration. The diagnosis is not diffi- cult ; the prognosis is fatal. No satisfactory treatment can be indicated. (3) Cyanosis Neonatorum. — Cyanosis in the new-born infant, as in other individuals, indicates some obstruction to the circulation or aeration of the blood. It is purely symptomatic, indicative of some organic disease. Most commonly this is to be found in the respiratory tract in the form of an atelectasis or pneumonia, or it may be due to some cardiac or vascular anomaly. The pressure of an enlarged thymus gland upon the trachea may be the dis- PATHOLOGY OF THE NEW-BORN. 727 turbing factor. The treatment consists in an eradication of the cause, if this be possible. 7. Affections of the Cutaneous System. (i) Strophulus (red gum) is a form of miliaria occurring in infants, and resulting from overheating of the skin from too much clothing, or from irritation and rubbing during the cleansing of the child. It occurs as a dense eruption of small pin-head or pin-point papules, giving a charac- teristic blush to the affected parts. While causing much anxiety to the mother, it is a harmless condition and shortly fades away. Treatment consists in the avoidance of irritation in cleansing, the wearing of soft clothing, and the application of a bland ointment, as cold cream or vaselin. (2) Ritter's disease (dermatitis exfoliativa infantum vel neonatorum ; keratolysis neonatorum) is a rare acute disease of the skin of the new-born child, characterized by hyperemia with excessive exfoliation of the epidermis, ac- companied at times by a vesicular or bullous formation, and by a high mortality. It is more common in male than in female children. The disease generally appears in the sec- ond week, and is very rare after the fourth or fifth week. At first apparently healthy, the infant suddenly develops an erythematous blush upon the face or buttocks, which soon becomes general ; there is no fever, nor is there gastric dis- turbance. Exfoliation of the epidermis quickly follows, the cuticle falling off in large flakes. In a very short time a new epidermis is formed, and the entire process, occupy- ing a week or two, may be unaccompanied by systemic manifestations. In many cases, however, there will develop complications, as diarrhea, pneumonia, or marasmus, and the child ultimately perishes of exhaustion or from loss of body-heat due to the removal of so much of the epidermis. Eczema and subcutaneous boils are occasionally noted as sequelae. The diagnosis is not difficult ; the prognosis is grave. Treatment consists in the application of emollient 728 A MANUAL OF OBSTETRICS. ointments containing ichthyol, boric acid, or resorcin ; pro- tection of the surface with cotton ; and the administration of good milk and tonics, with proper attention to hygiene. (3) Pemphigus neonatorum is a rare acute specific skin- disease occurring at any time within the first six weeks of infant Hfe, and characterized by the formation over the en- tire body, with the exception of the palms and soles, of vesicles and bullae of varying size. There are no constitu- tional manifestations, and no treatment will be required. The disease is to be distinguished from syphilitic pemphigus by the noninvolvement of the hands and feet. 8. Ophthalmia (Blennorrhcea) Neonatorum (Purulent Ophthalmia). By this term is meant a purulent inflammation of the conjunctiva of the infant, due to infection at birth by gonor- rheal virus contained in the uterine and vaginal discharges. This is an exceedingly virulent form of ophthalmia, in many instances resulting in total loss of sight from perforation of the cornea and destruction of the superficial tissues. It has been claimed that over 40 per cent, of all cases of total blindness have originated in this disease. While direct infection with Neisser's gonococcus is the exciting cause of the disease, there would seem to exist in many cases some predisposing factors, as the strumous diathesis, poor hygienic surroundings, insufficient nourishment, and ex- posure to cold. One eye or both may be affected. The average period of incubation of the disease is from two to five days. The symptoms are at first a characteristic reddening and edema of the palpebnx', with agglutination of the Hds. There quickly follows a profuse seropurulent, and finally a thick and purulent, yellowish or greenish-yel- low, discharge. The disease at first is limited to the palpe- bral conjunctiva, but soon spreads to the conjunctiva of the eye and the cornea. An examination shows a bright-red and angry appearance of the eye, and in the later stages of PATHOLOGY OF THE NEW-BORN. 729 neglected cases a hazy condition, and finally ulceration and perforation of the cornea, with escape of a portion or the whole of the aqueous, and at times of the vitreous, humor, with collapse of the eyeball. In cases in which this does not occur, iritic adhesions, corneal opacities, and staphyloma are very common sequelae. The child may or may not suffer pain: in many cases it seems to be absolutely free from suffering. As a rule, there are no systemic manifesta- tions. The rt'/<^^«^.f/i" of purulent ophthalmia is plain; the prog)iosis is grave. Treatment should be mainly prophy- lactic, and includes careful disinfection of the vagina, in sus- pected gonorrheal cases, before and during labor by frequent vaginal douches of mercuric chlorid (i : 2000). As soon as the child is born Crcdes inet/iod of prophylaxis should be practised. This consists in cleansing the eyes with warm sterilized water, followed by the instillation of a few drops of a 2 per cent, solution of silver nitrate. The eyes should be cleansed twice or thrice daily in this manner as long as any danger of the development of the disease exists. After the disease has appeared the cleansing must be done hourly with warm water, followed in alternate hours by mercuric chlorid (l : 5000 or 8000) and a saturated solution of boric acid or potassium permanganate (i : 1000). Twice daily an application of a 4 per cent, solution of silver nitrate should be made. If corneal ulceration result, some good may fol- low the use of a solution of quinin sulphate, 4 grains to the ounce, twice or thrice daily. The cloths used for cleansing the eyes should be of gauze or thin muslin well sterilized, and should be destroyed when once used. A small glass syringe may be used for douching the eyes. If but one eye be affected, the healthy eye should be protected from infection by a properly applied collodion dressing. 9. Mastitis. Inflammation of the breasts of the infant occasionally follows efforts at evacuation of the fluid that exists in vary- 730 A MANUAL OF OBSTETRICS. ing amounts in the mammse of both sexes for two or three weeks after birth. Handling of the distended breasts dur- ing this time should be strictly forbidden, for fear of mam- mary abscess, which, because of the poor development of the pectoral muscles, might readily result in a septic pleuritis. As a rule, nothing should be done in the line of treatment, the colostrum disappearing spontaneously in a short time. Should the glands become inflamed, emollient applications, as lead-water and laudanum, a weak ichthyol ointment, or a lead-plaster, may be made, and on the first indication of the presence of pus it must be evacuated and the wound treated aseptically. lo. Convulsions. Convulsive seizures in infants are of frequent occurrence, and, as a rule, are indicative of nothing more severe than gastrointestinal disturbance. When the spasm develops, the feet should be immersed in hot water (avoiding scald- ing), and the head kept cool by the application of moist cloths. An emetic of syrup of ipecac should be given, and the bowels emptied by an enema of warm salt-water con- taining a spoonful or two of sweet oil or 15 to 20 minims of glycerin. In severe cases it may become necessary to administer an enema of chloral hydrate in 23^2 drams of water, or to control the spasm by inhalations of chloroform. II. Septic Infection. {a) General septic infection of the new-born infant has its origin, as a rule, in an improper management of the cord. For several reasons this, which should be regarded as a physiologic wound, is especially prone to septic infec- tion : these reasons are the close proximity of the delicate peritoneum, with direct avenues of access to it ; the pres- ence of three large vessels, and of a large amount of de- composing or mummifying tissue in the remnant of the funis. Any error in the aseptic management of this wound PATHOLOGY OF THE NEW-BORN. 73 1 may very readily result in a localized sepsis followed by prompt systemic involvement. The symptoms of infection are an abrupt and high elevation of temperature, fretful- ness and irritability of the child, and a refusal on its part to nurse. An examination of the umbilicus will reveal an angry appearance of that structure, which may be covered with a dirty greenish-white mass of diphtheric exudate. Should the deeper tissues of the umbilicus be involved in the process, a true omphalitis exists, and this will be charac- terized by an edema and induration of a large portion of the surrounding tissue of the abdominal wall, the entire in- flamed area protruding in a conical manner, the apex of the cone being the angry umbilical ulcer. (b) Occasionally the septic process will manifest itself as the rare condition known as tetanus {trismus^ neonatorum {trismus nascentiuni), which is characterized by all the symptoms of tetanus in the adult. The child manifests an extreme degree of restlessness, refuses the nipple, cries con- stantly, and develops a progressively increasing rigidity of the jaws, and finally of all the voluntary muscles. There is but slight elevation of temperature. The nervous system of the infant is so strained that the slightest noise, as in speaking or walking, or the softest touch, will suffice to de- velop a spasm. As to the origin of thia disease nothing very definite is known. It is most common among the off- spring of the indigent and untidy, and especially in the colored race. It occurs irrespective of climatic influence. [c) In very rare cases the sepsis manifests itself in the interesting forms known as Buhl's and Winckel's dis- eases. Buhl's disease is a grave variety of infantile sepsis characterized by profound jaundice, cyanosis, vomiting, diarrhea, and an acute fatty degeneration of all the viscera. It always terminates fatally. Winckel's disease is practically the .same as the foregoing, with the addition of hemoglo- binuria. A fatal termination is usual, but not invariable. The diagnosis of infantile sepsis is not difficult. The prog- 732 A MANUAL OF OBSTETRICS. nosis is very grave, from 75 to 90 per cent, of the children perishing. The treatment varies according to the form of the disease. When there is present a diphtheric exudate upon the umbilical ulcer, thorough cauterization and disin- fection are imperative. This is best accomplished by a strong solution of niercuric chlorid (i : 500), the silver- nitrate stick, and the application of the usual salicylic- acid dressing. Should suppuration occur, free incision is required with disinfection of the wound. Tetanus is best treated by the antitoxin of Tizzoni and Cattani, with hourly feeding by gavage, the milk containing one or two drops of brandy. One-grain acetanilid powders, three or four times daily, small doses of chloral and the bromids, and laxative and sedative enemata, may be of service. 12. Congenital Syphilis. Syphilitic infection of the fetus may manifest itself before birth, and result in fetal death and a premature termination of the gestation. In other cases, though rarely, the child may manifest the disease at birth. The usual course is for the child to be born apparently free from the disease, strong and healthy-looking ; or it may be scrawny and but poorly developed. At the expiration of four or five weeks the characteristic mrnifestations of the disease appear. These are primarily the " snuffles " or coryza, characterized by the constant flowing of an intensely acrid and irritating discharge, quickly followed by excoriation of the lips and nasal alae. Shortly the cutaneous eruptions may be noted, assuming the form of roseola or the maculopapular syphilid over the entire body : with it may be a pemphigoid erup- tion, involving also the hands and the feet. On account of the mucous patches common around the mouth of the child, nursing from a noninfected wet-nurse should be forbidden. An examination of these syphilitic children shows them to be more or less marasmic, with temperature- fluctuations (without, as a rule, any high elevations), and PATHOLOGY OF THE NEW-BORN. 733 with enlargement of the hver, spleen, and other organs. Hemorrhages from the mucous surfaces are not rare, and the tendency in neglected cases is sooner or later to the development of bone-disease. The diagnosis of congenital syphilis is easy. The prognosis in nursing infants is excel- lent, but is very grave in bottle-fed infants and in those not placed under the best hygienic surroundings. The treat- ment must be energetic. It consists in the administration of mercurials, preferably in the form of the mild chlorid in doses of 3I2 of^a- grain twice or thrice daily. If the stomach prove rebellious to this, the mercury may be given exter- nally in the form of the blue ointment rubbed in on the binder. As required, cod-liver oil internally or by inunc- tion should be exhibited, together with iron in the form of the syrup of the iodid. Under this course of treatment the improvement is generally prompt and permanent, 13. Congenital Defects. (i) Tongue-tie (ankyloglossia) is a congenital shorten- ing of the frenum of the tongue, causing more or less inter- ference with nursing. Treatment consists in snipping the edge of the frenum with sharp-pointed scissors, avoiding too deep an incision for fear of wounding the artery of the frenum. (2) Hare-lip is a congenital fissure of the lip due to arrested facial development. It may be single or double, slight or pronounced. If decided, it causes inability to nurse, and must be corrected a few days after birth by one of the recognized plastic operations. (3) Cleft palate is a congenital splitting of the palate, hard or soft, usually associated with a similar defect of the upper lip. Because of the inability to nurse, some relief must be afforded to the child until it reaches an age suit- able for operative interference. This is best secured by means of an artificial rubber palate attached to the nipple of the bottle from which the child is fed : this, fitting into 734 ^ MA A^ UAL OF OBSTETRICS. the roof of the mouth, completes that structure sufficiently to permit of suction. When the child is two or three years of age some form of plastic operation must be performed. (4) Supernumerary Digits. — An extra number of digits, fingers or toes, is a not unusual occurrence. They are sel- dom fully developed, and are usually cartilaginous in struc- ture. They should be removed at once after ligation. (5) Phimosis is a congenital elongation and constriction of the prepuce with adherence of the mucosae, whereby exposure of the glans penis is rendered impossible. If uncorrected, it is very liable to be followed by enuresis and a tendency to spasms and masturbation. When the child is about two weeks old, the condition should be treated by stretching and retracting the foreskin, at the same time with a blunt instrument separating the adhe- sions between the glans and the mucous surface. A few drops of sweet oil may then be applied. The stretching should be repeated every few days until the glans can be readily exposed. In some cases circumcision may be necessary. (6) Imperforate Rectum. — In a limited number of cases the anal orifice will be absent. Usually a mere mucous diaphragm closes the opening, and this can be corrected by a crucial incision. In other instances there, is an entire obliteration of the rectum for the space of an inch or more, and in these more serious cases it is necessary to resort to the formation of an artificial anus in the inguinal or lumbar region to give vent to the fecal accumulation. If at a sub- sequent operation a new rectum can be formed, the artificial anus maybe closed and the fecal contents diverted into their proper channel. (7) Spina bifida (spinal meningocele, hydrorrachitis, or cleft spine) is a congenital hernia of the spinal mem- branes through a cleft or abnormality, usually of the lower (lumbosacral) portion, of the vertebral column, containing more or less cerebrospinal fluid, and due to a deficiency of PATHOLOGY OF THE NEW-BORN. 735 the arches of one or more of the vertebrae (Fig. 163). It is very frequently associated with other congenital defects and intrauterine disease, as hydro- cephalus. It appears as a fluc- tuating tumor of varying size, becoming more tense and ex- panded under voluntary mus- cular efforts such as accompany violent crying, and capable of being diminished by conipres- sion of the sac. Simple com- pression of the tumor, however, may induce spasms due to cere- bral irritation and compression. Certain other congenital tumors of a less serious nature (lipoma, fibroma, or myxoma) may oc- cupy a similar position, but '--^^:^::::S^:;'^ these are rare, and are readily recognized, as a rule, by their peculiar characteristics. A distinguishing feature of cleft spine is the attachment of the Cauda equina to the tumor, an area of indurated tis- sue marking its point of origin. The prognosis is grave : the child generally dies soon after birth from ulceration and rupture of the sac or from cerebral convulsions. A small proportion of cases are cured by proper operative procedure. Treatmeiit. — Only when the tumor is large or manifests a tendency to increase in size is operative inter- ference absolutely indicated ; in the minor degrees protec- tion by suitable shields will answer. It is better, however, to ensure safety from ulceration or injury, to puncture the sac (to one side of the median line to avoid injury of the cord), evacuate its contents, and apply compression by a soft pad ; this may be repeated, if need be, after a few days, and again as required until the fluid is removed. Excision of the sac and closure of the wound by buried catgut sutures 736 A MANUAL OF OBSTETRICS. have been suggested. Morton s treatment consists in the withdrawal of about a dram of the contained fluid, and the immediate slow injection of a dram of a solution containing iodin 10 grains and potassium iodid 30 grains in an ounce of glycerin. The pedicle of the sac is compressed during the injection to prevent entrance of the fluid into the spinal canal. The injection may have to be repeated from time to time before the sac is obliterated by the inflammatory action produced by the irritating fluid. (8) Umbilical Hernia (Exomphalos). — Owing to the weakened condition of the abdominal wall at the site of the navel, intestinal protrusion at this point in the infant is not rare. Very commonly it is a trivial condition, consist- ing in the mere pouting of a small loop of intestine, and can be corrected by the application of a firm compress held in place by a tightly secured abdominal binder. In the graver cases, in which there exists a true exomphalos with deficient development of the part, some form of plastic ope- ration is indicated to correct the condition. The prognosis in these cases is grave. INDEX. Abdomen, pigmentation of, 84 Abdominal imllottement, 85 binder, 188 enlargement in pregnancy, 83 hematocele, 291 inertia, 5 1 1 palpation in pregnancy, 100 percussion-note in pregnancy, 85 plates, 50 pregnancy, 275 signs of pregnancy, 83 souffle, 82 walls in pregnancy, 75 Ablactation, 211 Abortion, 109, 251 after-treatment, 265 causes, 251 complete, 256 contagious, 252 diagnosis, 258 duration, 257 embryonic, 255 habitual, 250 incomplete, 256 induction of, 265 inevitable, 255 instantaneous, 257 interstitial, 279 intramural, 279, 292 methods of inducing, 268 missed, 272 ovular, 254 prognosis, 259 symptoms, 254 threatened, 255 treatment, 260 tubal, 292 Abscess, mammary, 691 pelvic, 665 postmammary (submammary), 692 Absorption of the fetus, 318 Acanthopelvis, 576 47 Acanthopelys, 576 " Accessory head," 208 Accidental hemorrhage, 356 Accouchement force, 351 Acute anemia, 355 tympanites, 686 Adherent placenta, 235, 499 Adipoceration, 319 After-birth, 55 stage of, 125 After-coming head, methods of de- livery, 174 perforation of, 442 After-pains, 193 Agalactia, 695 Ahlfeld's method, 112 Air-embolism, 607 Air-hunger, 290 Albinism, 300 Albuminuria of pregnancy, 364 Albumin-water, 720 Allantoic nutrition, 60 stalk, 54 Allantois, 54 " Alligator boy," 314 Alterations in the genitalia in preg- nancy, 72 Amaurosis in pregnancy, 407 Amnion, 51 diseases of, 227 dropsy of, 230 rupture of, 228 Amniotic hydrorrhea, 229 sac or cavity, 52 Amniotitis (amniotis), 227 Amputation of fetal extremities, 477 intrauterine (spontaneous), 228 Anasarca of the fetus, 310 serosa, 651 Anemia, acute, 355 puerperal, 623 Anencephalus, 493 737 738 INDEX. Anesthetics in labor, 172 Aneurysm in pregnancy, 344 Ankyloglossia, 733 Annular placenta, 243 Anomalies of the placenta, 243 of vertex presentations, 421 Anorexia in pregnancy, 324 Antedisplacement of the gravid womb, 393 Antepartum hemorrhage, 344 hour-glass contraction, 571 Anterior interspinous diameter, 35 parietal position, 536 vaginal vault, 22 Anteuterine hematocele, 291 Antisepsis in labor, 160 Antitoxin of Tizzoni and Cattani, 658 Anvil-shaped uterus, 385 Aphthte, 719 Bednar's, 719 Apneumatosis, congenital, 717 Apncea neonatorum, 706 Apoplexy, decidual, 220 of the placenta, 238 Appendages, fetal, 50 Application of the forceps, 525 Arantius, duct of, 63. Arcuate uterus, 385 Area, germmal or embryonic, 49 pellucida, 49 Areolre of pregnancy, 95 Arm, nuchal (dorsal), position of, 426 Arms in backward rotation of the occi- put, 42S in breech presentation, 425 Artery, omphalo-mesenteric, 60 Arthritis, puerperal (septic), 649 Artificial feeding of infants, 696 respiration of infants, 709 Ascites, 103 in the fetus, 309 Asphyxia nascentium, 706 neonatorum, 706 Asthma gravidarum, 332 Atelectasis, 717 Atresia vagina?, 581 Atrophy of tlie decidua, 221 Autogenetic ]uierperal sepsis, 679 Autoinfcction, 679 Antotransfusion, 355 Aveling's apj)aralus, 355 Avulsion of fetal extremities, 505 Axis of pelvis, 26 Axis-traction forceps, 519 Baby's outing, 213 Bacilli of Doderlein, 194 Backward rotation of the occiput, 412 Bag of waters, 121 Ballottement, 90 abdominal, 85 cephalic, 85 vaginal, 90 Bandage, mammary, 693 Bandl's ring, 21 Barnes' bags, 270 Barnes' method in placenta prsevia, 353 theory of eclampsia, 370 theory of placenta prsevia, 348 Bartholini's glands, 23 Basilysis, 443 Basiotribe, 439 Basiotripsy, 441 Bathing in pregnancy, 108 Battledore placenta, 58, 243 Baudelocque's cephalic version, 429, 437> 455 diameter, 32 pelvimeter, 31 Bayer's method of inducing labor, 272 Beak-shaped pelvis, 542 Bearing-down pains, 122 Beccaria's sign, 93 Bed in labor, 163 Bed-pads, 190 Bednar's aphthae, 719 Belly-band, 207 Bicornate uterus, 386 Biedert's cream-mixture, 697 Bifid uterus, 386 Binder, abdominal, 188 mammary, 198 Bi parietal suture, 134 Bipolar cephalic version, 468 podalic version, 471 Birth with a caul, 497 Birth of the shoulders, 142 Birth-canal, rupture of, 582 Bisacromial diameter, 13.5 BisiHac diameter of pelvis, 26, 136 Bisischiac diameter of pelvis, 27 Bladder in ]iregnancy, 85, 381 Blanc's tlieory of eclampsia, 370 Blastoderm, 48 INDEX. 739 Blastodermic membrane, 48 vesicle, 49 Hlastosphere, 47 Bleeder's disease, 723 Blennorrhoea neonatorum, 728 Blighted ovum, 221 Blood in the puerperium, 184 Blood mole, 221 Blunt hook, 424 Bony pelvis, 24 Botal (Botallo), duct of, 64 Bowels, fetal, 66 in the puerperium, 186 Braun's blunt hook, 476 Breast, 196 caking of, 69 1 drying of, 212 gathered, 691 of the new-born, 204 Breech, decomposition of, 423 impacted, 422 presentation, 147 backward rotation of occiput in, 427 cause of, 147 diagnosis, 148 extension of the arms in, 425 management, 173 mechanism of, 150 Bregma, 134 presentation of, 428 Broad ligament, hematoma of, 29 1 Brow presentation, 430 mechanism, 434 treatment, 436 Brown's (Bedford) method, 709 Bruit de choc fetal, 97 Bruit, placental, 82 uterine, 82 Buhl's disease, 731 Bulging of perineum in labor, 124 Buttonhole stitch, 566 Cachexia, serous, 335 Caduca, 50 Caillant's sign, 126 Caking of the breast, 691 Calcareous mole, 221 Calcification of the fetus, 319 Canal, parturient, 22 Capacity of the infant's stomach, 210 Capuron, cardinal points of, 31 Caput obstipum, 158, 715 succedaneum, 208, 713 " Cardiac nerve-storms," 344 palpitation in pregnancy, 335 symptoms of pregnancy, 93 Cardinal points of Capuron, 3 1 Care of the umbilical cord, 206 Carneous mole, 221 Carus, curve (circle) of, 26 Catarrhal pneumonia in the new-born, .717 Catheterization of the larynx, 713 Caul, 122, 497 Cause of labor-pains, 119 Cavity, amniotic, 52 of the pelvis, 26 Cazeaux's theory of placenta prsevia, 348 Cells, decidual, 50 Cellulitic phlegmasia, 652 Cellulitis, pelvic, 663 Central perforation of the perineum, 594 Cephalalgia in pregnancy, 406 Cephalic application of the forceps, 527 ballottement, 85 curve of forceps, 517 version, 466 Baudelocque's, 429, 437, 455 bipolar method, 468 Hicks' (B.) method, 468 Hohl's method, 468 Schatz's method, 455 Wiegand's method, 467 Cephalohematoma, 714 Cephalotomy, 443 Cephalotribe, 439 Cephalotripsy, 441 Cerebral meningocele, 312 Cervical disease in pregnancy, 400 pregnancy, 221 Cervicobregmatic diameter, 135 Cervix uteri, 19 laceration of, 590 in pregnancy, 75 rigidity of, 578 softening of, 88 Cesarean section, 561 Cessation of menstruation, 79 Champetier's bags, 271 Change of life, 42 Chantreuil's method, 36 740 INDEX. Charpentier's method, 378 " Cheesy varnish," 66 Childbed fever, 624 Chill, postpartum, 126, 187 Chins, interlocking of, 490 Chloasmata, 91 Choc fetal, 97 Cholera in pregnancy, 321 Chorda dorsalis, 50 previa, 500 Chorea in pregnancy, 408 Chorion, 54 cystic disease of, 222 diseases of, 222 fibromyxomatous degeneration of, 227 frondosum, 55 la^ye, 55 . . Chorionic villi, 54 Chorionitis, 222 Chronic cystic elephantiasis, 315 Chyluria in pregnancy, 384 Circle of Carus, 26 Schultze's, 115 Circulation, fetal, 62 in the puerperium, 184 Cleft palate, 733 fpine, 734 Climacteric, 42 Clitoris, 24 Clothing in pregnancy, 107 jCoccyjuibic diameter of pelvis, 27 Coiling of the umbilical cord, 247 iCoition, 43 Colic, infantile, 721 " Collodion fetus," 314 Colostrum, 95 Colostrum-corpuscles, 95 Colpeurynters, 351 Colpeurysis, 351 Colpohyperplasia cystica, 401 Colpostenosis, 581 Combined podalic version, 471 Complete aliortion, 256 Complex presentation, 478 Complicated presentation, 478 Compound presentation, 478 Conception, 43 Confinement, date of, no Congenital apneumatosis, 717 defects, 733 desquamation, 315 encephalocele, 312 Congenital goiter, 308 hydrocephalus, 493 luxation of the hips, 544 rachitis, 304 syphilis, 304, 732 Conjugata vera, 31 Conjugate diameter of pelvis, 23 Conjugatosymphyseal angle, 540 Conservative Cesarean section, 563 Constipation of infants, 722 in pregnancy, 86, 108, 330 in the puerperium, 685 Contagious abortion, 252 Contracted pelvis, 532 treatment, 551 varieties, 534 Contraction-ring of Bandl, 21 Convulsions, infantile, 730 puerperal, 367 Cooke's method, 330 Copeman's method, 709 Copulation, 43 Cord, umbilical, 58 Cordate uterus, 385 Cords of Pfliiger, 38 Cornual pregnancy, 296 Coronal resonance, 85 suture, 134 Corpore conduplicato vel reduplicato, 463 Corpus luteum, 41 Coryza of the infant, 719 Cough, nervous (spasmodic), 333 Couveuse, 703 Coxalgic pelvis, 540 Cramps in pregnancy, 87, 406 Cranial curve of forceps, 517 Cranioclasm, 438 Cranioclast, 439 Craniotomy, 438 Craniotractor, 439 Crater-nipple, 688 Crede's method of expression, 180 method of prophylaxis, 729 Creolin, 160 Cross-birth, 457 Croupous pneumonia in pregnancy, 333 Crural phlebitis, 651 Cul-de-sac, Douglas's, 20 Cumulus proligerus, 39 Curve of Carus, 26 Cutaneous manifestations of pregnancy, 9» INDEX. 741 Cuvier, right duct of, 64 Cyanosis neonatorum, 726 Cystic degeneration of the placenta, 241 disease of the chorion, 222 mole, 222 Cystitis in pregnancy, 382 puerperal (septic), 676 Cystoma, ovarian, 104 Cysts of the umbilical cord, 245 Date of confinement, estimation of, lio of quickenmg. III " Dead limbs," 87 Deafness in pregnancy, 407 Death of the fetus, 316 Decapitation of the fetus, 476, 505 Decerebration, 441 Decidua, 50 atrophy of, 221 diseases of, 215 hemorrhage from, 220 reflexa, 51 serotina, 51 tumors of, 221 vera, 51 Decidual apoplexy, 220 cells, 50 moles, 274 Deciduitis, 215 Deciduoma, 221 malignant, 222 Deciduosarcoma, 222 Decollation, 476 Decomposition of the breech, 423 Degeneration of the placenta, 240 Delabout's rule, 71 Delivery of the after-coming head, 174 Denman's method of inducing labor, 272 Dental caries in pregnancy, 323 Dermatitis exfoliativa infantum vel neonatorum, 727 Desquamation, congenital, 315 Destructive placental polyp, 242 Development, fetal, 68 of pelvic deformities, 533 Deventer method, 177 Dew's method of artificial respiration, 711 Diagnosis between multipara; and primiparae, 106 Diagnosis of pregnancy, 100 Diameter, anterior interspinous, 35 Baudelocque's, 32 bisacromial, 135 bisiliac, 136 bisischiac, 27 cervicobregmatic, 135 coccypubic, 27 external conjugate, 32 of the fetal skull, 135 frontomental, 135 indirect conjugate, 33 intercristal, 35 intertrochanteric, 35, 136 Lohlein's, 35 mentobregmatic, 135 occipitofrontal, 135 occipitomental, 135 posterior interspinous, 35 sacrocotyloid, ■^^t,, 541 sacropubic, 25 trachelobregmatic, 135 Diaper, 207 Diarrhea of infants, 722 of pregnancy, 331 Diastasis of the pelvic joints, 603 Diet in pregnancy, 107 in the puerperium, 192 Differential diagnosis of pregnancy, 103 Digestive system in pregnancy, 78 Digital pelvimetry, 31 Digits, supernumerary, 734 Dilatation of the os in labor, I20 Discus proligerus, 39 Diseases of the amnion, 227 of the chorion, 222 of the decidua, 215 of the fetus, 298 of the membranes, 215 of the new-born, 701 of the ovum, 215 of the placenta, 235 of pregnancy, 320 of the puerperium, 608 of the umbilical cord, 244 Disinfection, FUrbringer's method, 162 Kelly's method, 162 of the patient, 162 Dissecting metritis, 662 Doderlein's bacilli, 194 Diilichocephalic skull, 431 Dolores presagientes, 120 742 INDEX. Dorsal plates, 50 position of the arm, 426 Double uterus, 385 Douching in pregnancy, 108 Douglas's method, 464 pouch or cul-de-sac, 20 Draw-sheet, 190 Dressing of the infant, 207 occlusive, 191 protective, 190 Dry labor, 1 22, 497 Drying of the breasts, 212 Dropsy of the amnion, 230 of the chorionic villi, 222 Dublin method of expression, 180 Duct of Arantius, 63 of Botal (Botallo), 64 (right) of Cuvier, 64 galactophorous, 197 lactiferous, 197 of Miiller, 385 omphalic, 53 pronej)hric, 385 segmental, 385 vitelline, 53 vitellointestinal, 53 Ductus arteriosus, 64 venosus, 63 Duer's method, 378 Duhrssen's method, 615 Duncan's (Matthews) rule, IIO theory of placental expulsion, 156 Duration of normal labor, 127 of pregnancy, 1 10 Duverney's glands, 23 Dwarf pelvis, 546 Dyspnea of pregnancy, 332 Dystocia, 412 fetal, 412 maternal, 505 Eclampsia gravidarum, 367 parturientium, 367 puerperal, 367 puerperarum, 367 Ecouvillonage, 639 Ectopic gestation, 274 Edema of the placenta, 240 of the vulva in pregnancy, 403, 582 Effects of labor-pains, 119 Egg- cords, 38 Elective Cesarean section, 562 Elephantiasis, chronic cystic, 315 Ellipse, fetal, 49, 128 Elytritis, puerperal, 671 Embolism, puerperal, 621 Embryonic area, 49 abortion, 255 line, 49 Embryotomy, 475 Emphysema in pregnancy, 333 Encephalocele, congenital, 312 Endocarditis in pregnancy, 339 puerperal, 648 Endochorion, 55 Endocolpitis catarrhalis, 671 diphtheritica, 671 gangrenosa, 671 puerperal, 671 Endometritis catarrhalis, 672 diphtheritica, 672 gangrenosa, 672 puerperal, 672 purulenta, 672 Endosalpingitis, puerperal, 675 purulenta, 675 Enemata, nutritive, 328 English lock of forceps, 518 position, 164 Enterocele, vaginal, 577 Ephelidte, 410 Epiblast, 49 Epilepsy in pregnancy, 407 Episiotomy, 168 Epistaxis in pregnancy, 344 Erythema, infectious, 656 puerperal, 656 scarlatiniform, 656 Estimation of date of confinement, no Eucalin, 637 Eustachian valve, 63 Eutocia, 109 Evisceration, 476 Evolution, spontaneous, 463 Examination in labor, 163 Excerebration, 441 Excessive rotation of the occiput, 422 Excoriatio foetus, 315 Excretions, fetal, 65 Exenteration, 476 Exercise in pregnancy, 107 Exochorion, 55 Exomphalos, 736 Exophthalmic goiter in pregnancy, 362 Expressio ftetus, 515 INDEX. 743 Expression of the cord, 500 Exjxilsive forces of labor, 132 Extension of the arms in breech pres- entation, 425 External conjugate diameter, 32 genitals, 18, 23 hydrocephalus, 312 migration, 41 ovarian pregnancy, 281 Extraperitoneal rupture of the uterus, 590 Extrauterine fetation, 274 pregnancy, 274 diagnosis, 285 etiology, 275 pathology, 277 prognosis, 288 rupture of, 289 spontaneous cure of, 293 symptoms, 282 treatment, 294 Face-ache, 405 presentation, 443 mechanism, 448 persistent mentoposterior posi- tions, 451 treatment, 453 Facial paralysis in pregnancy, 407 "Falling of the womb," 117 Fallopian tubes, 18 tube, hematoma of, 292 False moles, 273 pains, 120 pelvis, 24 placentas, 243 pregnancy, 221 " False waters," 218 Fasbender's method, 167 Fecundation, 45 Feeding, artificial, 696 mixed, 695 Female pronucleus, 48 Femoral phlebitis, 651 Fertilization, 43 Fetal anasarca, 310 appendages, 59 ascites, 309 bowels, 66 circulation, 62 death, 316 signs of, 317 development, 68 Fetal dystocia, 412 ellipse, 49, 128 excretions, 65 heart, 63 heart-sounds, 98 ichthyosis, 314 innervation, 66 jaundice, 309 keratolysis, 315 kidneys, 65 liver, 66 malformations, 299 membranes, 50 mensuration in pregnancy, 112 movements, 96 nutrition, 59 pelvis, 547 physiology, 59 respiration, 61 secretions, 65 skin, 66 skull, diameters of, 135 premature ossification of, 492 at term, 133 symptoms of pregnancy, 96 syphilis, 304 theory of eclampsia, 370 traumatism, 316 tumors, 308 urine, 66 viability, 701 Fetation, extrauterine, 274 Fetoamniotic bands, 228 Fetometry, 133 Fetus, absorption of, 318 decapitation of, 595 diseases of, 298 over-size of, 491 postmortem changes in, 317 at term, 71 white pneumonia of, 307 Fibroid, uterine, 104 Fibromyxomatous degeneration of the chorion, 227 Fibrous myxoma of the placenta, 241 Figure-of-8-pelvis, 539 Fillet, 424 Fissured nipples, 689 Fistula, vesicovaginal, 687 Flashes of heat, 43 Fleshy mole, 217, 221, 273 Flint's mixture, 329 Floating kidney, 3S0 744 INDEX. Flooding, 609 Flow, 42 Fluctuation, uterine, 91 Foetus papyraceus, 484 sanguinolentus, 318 Fokis, medullary, 49 Follicular stomatitis, 719 Fontanels, 134 Foot (footling) presentation, I47, 151 Foramen ovale, 63 Forceps, application of, 525 obstetric, 516 operation, high, 522 low, 517 median, 522 Forces of labor, 132 Fossa navicularis, 24 umbilical, 207 Fourchet, 23 Fracture of the pelvic bones, 604 Fractures in the new-born, 716 Freckles in pregnancy, 410 French's theory of eclampsia, 370 Frontal suture, 1 34 Frontomsntal diameter, 135 Frontoparietal suture, 134 Fulgurant puerperal peritonitis, 668 Fundus uteri, 20 in pregnancy, in Funic presentation, 500 pulse, 58 souffle, 99 Funicle, 58 Funis, 58 rupture of, 504 Funnel-shaped pelvis, 547 rUrbringer's method, 162 Galactocele, 700 Galactophoritis, 690 Galactophorous ducts, 197 Galactorrhea, 699 Galbiati knife, 557 Gangrenous metritis, 662 Gathered breast, 691 Gavage, 705 Gelatin, Wharton's, 58 Gemeliary ])regnancy, 479 Generative organs, 18 Genitalia in pregnancy, 72 in the puerperium, 181 German method of symphysiotomy, 557 Germinal area, 49 spot, 39 vesicle, 39 Gestation, ectopic, 274 Gestational insanity, 404 paralysis, 406 " Getting-up," 195 Giant pelvis, 506 Gingivitis of pregnancy, 323 Glands, mammary, 196 of Montgomery, 95 Glandular activity in pregnancy, 93 Glans clitoridis, 24 Glycosuria of pregnancy, 283 Goiter, congenital, 308 Gonorrheal stomatitis, 720 warts, 402 Goodell's method in breech presenta- tion, 423 of perineal relaxation, 168 sign, 88 Graafian follicles, 38 Gravidin test, 77 Great suture, 134 " Green waters," 194 Greenstick fracture, 716 Groove, medullary, 49 primitive, 49 Growth of the child, 210 of the uterus in pregnancy, 81 Gubler's theory, 364, 369 Gum, 204 Gum-rash, 204 Habitual abortion, 250 Halbertsma's theory of eclampsia, 369 treatment of eclampsia, 3S0 Hardie's measurement, 32 Hare-lip, 733 Harris's method, 352 Hauder's pelvis, 576 Hayem"s serum, 642 Head-crusher, 439 Head-fold of the fetus, 49 Head-seizer, 439 Head transverse at inferior strait, 419 Hearing in the new-born, 204 Heart, fetal, 63 Heart-shaped pelvis, 410 Heart-sounds, fetal, 98 Hegar's sign, 88 Hcmatemesis in pregnancy, 345 Hematocele, abdominal, 291 INDEX. 745 Hematocele, anteutefine, 291 pelvic, 291 retrouterine, 291 Hematoma of Ijie broad ligament, 291 of the sac. 392 of the tube, 292 of the vulva, 597 Hematuria of pregnancy, 383, 384 IIemi]5legia in pregnancy, 406 1 leniiterata, 299 Hemophilia, 723 Hemoptysis in labor, 606 in pregnancy, 344 Hemorrhage, accidental, 356 antepartum, 344 from the cord, 735 from the decidua, 220 from the genitalia in pregnancy, 361 intrapartum, 582 postpartum, 609 puerperal, 619 uteroplacental, 238 Hemorrhages, hydremic, 344 of infancy, 733 of pregnancy, 344 of the puerperium, 609 Hemorrhagic diathesis, 723 Hemorrhoids of the bladder, 383 in pregnancy, 331 in the puerperium, 686 Henle's theory, 40 Herman's method of manual com- pression, 617 Hernia of the gravid uterus, 397 umbilical, 736 of the umbilical cord, 245 Herpes gestationis, 411 Heterotaxis, 301 Hicks' (B.) method of cephalic ver- sion, 468 method of podalic version, 471 sign, 82 Hide-bound disease, 704 High forceps operation, 522 Hilum of the ovary, 18 Hirst's pelvimeter, 34 Hodge forceps, 518 Hoening's method of expression, 264 Hold's method of cephalic version, 468 method in labor, 167 Holl's signs, 256 Horseshoe placenta, 243 Hour-glass contraction of uterus, 498 relaxation of uterus, 498 Iluguier's glands, 23 Hyaloplasm, 39 Hydatidiform mole, 222 Hydatiform mole, 222 Hydatids, uterine, 222 Hydatoid mole, 222 Hydramnios, 230 Hydremia of pregnancy, 335 Hydremic hemorrhages, 344 Hydrocephalus, 312 congenital, 493 Hydroencephalocele, 493 Hydroperione, 51, 52 Hydrorrachitis, 734 Hydroirhea, amniotic, 229 decidualis, 218 gravidarum, 218 Hygiene of pregnancy, 106 Hymen, 23 Hyperemesis gravidarum, 325 Hyperinvolution of the uterus, 685 Hyperlactation, 701 Hyperosmia in pregnancy, 332 Hypoblast, 49 Hysteralgia, 398 Hysteria in pregnancy, 407 Ichthyosis congenita, 314 fetal, 314 intrauterine, 314 Icterus gravidamm, 331 neonatorum, 721 Impacted breech, 422 Impaction of the shoulder, 462 Imperforate rectum, 734 Impetigo herpetiformis, 411 Impregnation, 43 method of, 46 time of, 46 Impressions, maternal, 310 Incarceration of womb, 389, 394, 395 Incomplete abortion, 256 Incontinence of retention, 186, 382, 6S7 of urine, 687 Incubator, 703 Indigestion in pregnancy, 325 Indirect conjugate diameter, 2)'}) Induction of abortion, 265 of premature labor, 266 Inertia, abdominal, 511 746 INDEX. Inertia, uterine, 511 Inevitable abortion, 255 Infantile pelvis, 547 Infectious erythema, 656 ]5hlebitis, 643 Inferior strait of pelvis, 27 Inflammation of the pelvic joints, 409 Influenza in pregnancy, 322 Innervation, fetal, 66 Insanity, gestational, 404 lactational, 680 puerperal, 680 Insemination, 43 Insertio velamentosa, 249 Insomnia in pregnancy, 404 Instantaneous abortion, 257 Insufflation, mouth-to-mouth, 713 Intercristal diameter, 35 Interlocking of chins, 490 Intermittent fever in pregnancy, 322 Internal genitals, 18 hydrocephalus, 312 ovarian pregnancy, 280 podalic version, 473 Interstitial abortion, 279, 292 pregnancy, 275, 279 Intertrochanteric diameter, 35, 136 Intraligamentous pregnancy, 278 Intramural abortion, 279, 292 pregnancy, 279 Intrapartum hemorrhage, 582 Intrauterine amputations, 228 ichthyosis, 314 Introitus vagina;, 23 Inversion of the nipple, 688 of the uterus, 599 Inverted pelvis, 507 Involution, 181 of the vagina, 183 Irritable bladder in pregnancy, 85, 381 uterus, 85, 381 Ischuria in pregnancy, 384 Isthmus of the uterus, 20 Italian method of symphysiotomy, 557 Jacquemin's sign, 87 Jaundice of the fetus, 309 ui ]:)regnancy, 331 Jelly, Wharton's, 58 Jorisenne's sign, 93 Justomajor pelvis, 506 Justominor pelvis, 546 Juvenile pelvis, 547 Kelly's method of disinfection, 162 Kennedy's, sign, 99 Keratolysis, fetal, 315 neonatorum, 727 , Kibbee cot, 642 Kidney, fetal, 65 floating (wandering), 380 of pregnancy, 364 -shaped pelvis, 539 in pregnancy, 108 Kiestin test, 77 Kilian's pelvis, 536 Kilner's method, 515 Kisch's method, 666 Kiwisch's method, 272 Knee presentation, 147, 151 Knotting of the umbilical cord, 246 Krause's method of inducing labor, 269 Kristeller's method of expression, 180, 354 Kyestein test, 77 Kyphoscoliotic pelvis, 546 Kyphotic pelvis, 544 Labia majora, 23 minora, 23 Labial hematoma, 597 Labor, 115 after-treatment, 187 anesthetics in, 172 antisepsis in, 160 bed in, 163 birth of the shoulders, 142 bulging of perineum in, 124 causes of, 1 1 5 dilatation of os in, 120 dry, 497 duration of, 127 examinations in, 163 forces of, 132 hemoptysis in, 606 management of, 158 of the third stage, 178 maternal death in, 606 mechanism of, 137 missed, 297 (jbstiucted, 530 ovarian cysts in, 575 pains of, 117 perineum in, 166 ]")henomena of, 1 17 physiologic cry of, 124 INDEX. 7A7 Labor, placental stage, 125 posture in first stage, 122 precipitate, 505 premature, 109, 251 prognosis of, 157 protracted, 509 retarded, 509 rotation of occiput in, 139 stages of, 120 tardy, 509 at term, 109 time of commencement of, 1 17 tumors in, 573 uterine contractions of, 117 vesical calculi in, 577 Laborde's method of artificial respira- tion, 712 Laceration of the cervix, 590 of the perineum, 166, 593 of the vagina, 591 of the vulva, 592 Lactation, 196 Lactational insanity, 680 Lactiferous duels, 197 Lambdoid suture, 134 Lamination, 443 Larynx, catheterization of, 713 Lateral obliquity of the uterus, 74 Lateral plates, 50 Lateroflexion of the uterus, 396 Laterojwsition of tlie uterus, 396 Left-lateral recumbent position, 164 Leopold's and Sporlin's method, 1 61 Leube's pancreatic-meat emulsion, 329 Leukorrhea in pregnancy, 88 Lever's theoiy of eclampsia, 369 Ligation of the cord, 170 Lightening, 117, 138 Line, embryonic, 49 Linea fusca, 84 nigra, 84 Linere albicantes, 75, 94 Lipuria in pregnancy, 384 Liquor amnii, 52 putrefaction of, 234 folliculi, 39 seminis, 44 Lithopedion, 319 Little's solution, 355 Liver-blotches, 91 fetal, 66 patches, 91 Local puerperal sepsis, 661 Lochia, 194 Lochia! guards, 190 Locking of twins, 489 Lohlein's diameter, 35 Lowenhardt's method, in Long forceps, 517 Longings, 78, 93 Loops of Pfliiger, 38 Low-forceps operation, 517 Lower uterine segment, 22 Lumbago in pregnancy, 405 Lungs in the puerperium, 187 Luxation of the hips, congenital, 544 Lying-down pelvis, 547 Lying-in period, 181 room, 161 Lymphangitis, mammary, 690 puerperal, 661 McClintock's rule, 189 Maceration, 318 Macromazia, 300 Macula germinativa, 39 Malacia, 324 Malacosteon pelvis, 542 Male and female pelvis, 37 pronucleus, 47 Malformations of the fetus, 299 of the uterus, 384 Malignant deciduoma, 222 Mammse, 196 Mammary abscess, 691 bandage, 693 binder, 198 changes in pregnancy, 94 glands, 196 in pregnancy, 109 lymphangitis, 690 Mammitis, 691 Management of pregnancy, 106 third stage of labor, 178 Marasmus, 721 Maret's formula, 329 Marginal placenta, 249 Masculine pelvis, 547 Mask of pregnancy, 410 Mastitis, 690 in the infant, 729 Maternal death in labor, 606 dystocia, 505 impressions, 310 physiology, 72 Mauriceau method, 175 748 INDEX. Mayor's sign, 98 Measles in pregnancy, 321 Mechanism of normal labor, 127 the third stage of labor, 155 Meconium, 66 Median forceps operation, 522 Medullary folds, 49 groove, 49 Meigs' mixture, 697 sign, 653 Melsena neonatorum, 723 Melanism, 300 Membrana granulosa, 39 Membrane, blastodermic, 48 diseases of the, 215 vitelline, 39 Membranes, fetal, 50 removal of tlie, 180 Meningocele, cerebral, 312 spinal, 734 Menopause, 42 Menses, 42 retained, 104 Menstrual flux, 42 molimina, 42 suppression in pregnancy, 79 Menstruation, 41 and nursing, 200 and ovulation, 40 in pregnancy, 361 Mensuration of the utenis. III Mental occupation in pregnancy, 109 Mentobregmatic diameter, 135 Mentoposterior positions, 451 Merkerttschiantz's method, 168 Mesoblast, 49 Mesocord, 250 Metacyesis, 281 Methods of inducing abortion, 268 of inducing jiremaiure labor, 269 Metria, 624 Metritis, dissecting, 662 gangrenosa, 662 perforating, 662 jjhlegmonous, 662 in pregnancy, 397 jRierpcral, 661 purulenta, 662 Metroperitonitis, 667 Metrophlel)itis, pucr|)eral, 643 Michaelis' methi>d, 428 Micromazia, 300 Micropyle, 46 Midwifery, 17 Migration of the ovum, 40 Milk, 197 fever, 198 globules, I97 leg, 951 quality of, 1 98 quantity of, 198 uterine, 61 Miscarriage, 109, 251, 257 Missed abortion, 272 labor, 297 Mixed feeding of infants, 695 Mola carnosa, 221 hydatidosa incipiens, 224 partialis, 225 totalis, 225 sanguinea, 221 Molar pregnancy, 221 Mole, blood, 221 calcareous, 221 carneous, 221 cystic, 222 false, 273 fleshy, 217, 221 hydatidiform, 222 placental, 222 sanguineous, 221 stone, 221 true, 273 vesicular, 222 Mons veneris, 24 Monster, 302 Monstrosities, 299 Montgomery, glands of, 95 tubercles of, 95 " Morning sickness," 92 Morton's treatment, 736 Morula, 48 Moulding of the head, 208 Mouth-to-mouth insufflation, 713 Movements, fetal, 96 MuUer, canals or ducts of. 385 Cesarean section, 563, 564 Mulberry mass, 48 Multigravida, 44 Multipara, 44 Multijjarity, 44 Multiple pregnancy, 478 Mummification, 319 Mural pregnancy, 275 Muret's manual method, 42 1 Muriform body, 48 INDEX. 749 Murmur, placental, 83 Muscles of the pelvis, 29 Myositis purulenta puerperarum, 647 Myxoma fibrosum, 227 Myxomatous degeneration of the cho- rion, 222 Naegele's obliquity, 138 pelvis, 543 rule. 1 10 Napkin, 207 Nausea and vomiting in pregnancy, 92 Navel ring, 58 sac, 53 string, 58 Nephritis in pregnancy, 363 Nerve-symptoms in pregnancy, 86 Nervous cough, 333 symptoms in pregnancy, 93 system in pregnancy, 78 Nerves, pressure-degeneration of, 659 Neuralgias of pregnancy, 405 Neuritis, puerperal, 659 septic, 659 traumatic, 659 Neuroses of pregnancy, 407 New-born, bathing of, 205 bowels of, 203 breasts of, 204 circulatory system of, 20I cleansing of, 205 dressing of, 207 eyes of, 204 growth of, 210 hearing of, 204 management of, 200 micturition in, 203 moulding of the head of, 208 physiology of, 200 respiration of, 202 septic infection of, 730 skin of, 204 stomach of, 210 taste in, 204 temperature of, 204 torticollis of, 158 weight of, 211 Nipple, 197 tissuring of, 689 inversion of, 688 in pregnancy, 95 Noeggerath's maneuver, 603 Normal labor, 109 Notochord, 50 Nuchal position of the arm, 426 Nullipara, 43 Nulliparity, 43 Nursing, 208 and menstruation, 200 time of, 209 Nutrition, allantoic, 60 fetal, 59 placental, 60 tubal, 59 vitelline, 60 Nutritive enemata, 328 Nymphte, 23 Oblique diameters of pelvis, 26 pelvis of traumatism, 543 Obliquely ovate pelvis, 543 Obliquity, lateral, of the uterus, 74 Naegele's, 138 of the pelvis, 25 Roederer's, 138 Solayre's, 136 Obstetric call, 159 case, 159 forceps, 516 position, 164 Obstetrics, 17 pathologic, 214 Obstructed labor, 530 Occipitofrontal diameter, 135 Occipitomental diameter, 135 Occipitoparietal suture, 134 Occiput, excessive rotation of, 422 posterior in breech presentation, 427 transverse, at superior strait, 418 Occlusive dressing, 191 Odontalgia in pregnancy, 405 CEdema lacteum, 651 neonatorum, 726 Oligogalactia, 695 Oligohydramnios, 229 Oligospermism, 45 Olshausen's method, 169 Omphalic duct, 53 Omphalitis, 731 Omphalo-mesenteric artery, 60 OmphaloiThagia, 725 Onychogryphosis, 314 Oophoron, 18 Oosperm, 47 Ophthalmia neonatorum, 728 Orgasm, 45 750 INDEX. Osiander's sign, 88 Osseous system in pregnancy, 78 Osteomalacia in pregnancy, 409 Osteomalacic pelvis, 542 Osteophytes in pregnancy, 78 Ostitc/n abdominale of the tube, 19 Ova moles, 273 Ovarian cystoma, 104 cysts in labor, 575 pregnancy, 275, 280 Ovaries, 18 Ovaritis, puerperal, 664 Over-size of the fetus, 491 Oviducts, 18 Ovisacs, 38 Ovular abortion, 254 Ovulation, 38, 39 and menstruation, 40 Ovum, 39 blighted, 221 cystic disease of, 222 diseases of, 215 migration of, 40 premature discharge of, 250 Pad, uterine, 187 Pains, bearing-dovk'n, 122 false, 120 of labor, 117 Pajot's law of accommodation, 129 method of decapitation, 477 Palate, cleft, 733 Palpation of the ureters, 677 Paralysis, gestational, 406 of the new-born, 717 puerperal, 406 Parametritis, puerperal, 663 Para])legia in pregnancy, 406 Parasitic stomatitis, 720 Parity, 43 Paroophoron, 18 Parturient canal, 22 Pasteurization, 698 Pathologic obstetrics, 214 Patulous cervix, 590 Peaslee's Hjrmula, 329 Pedicterus, 721 Pelvic al)scess, 665 apjilication of the blades, 526 articulations in pregnancy, 76 relaxation of, 408 cellulitis, 663 contents in pregnancy, 76 Pelvic contraction, 532 curve of forceps, 517 deformities, development of, 533 hematocele, 291 inlet, 25 joints, inflammation of, 409 ligaments, 28 outlet, 27 perimetritis, 664 peritonitis, 667 presentation, 146 version, 469 Pelvimeter, 31 Pelvimetry, 30 Pelvis ajquabiliter justomajor, 506 justominor, 546 axis of, 26 beak-shaped, 542 bisiliac diameter, 26 bisischiac diameter, 27 bony, 24 cavity of, 26 coccypubic diameter, 27 conjugate diameter, 25 contracted, 532 coxalgic, 540 dwarf, 546 false, 24 fetal, 547 iigure-of-8, 539 funnel-shaped, 547 generally contracted and flat, 548 giant, 506 Ilauder's, 576 infantile, 547 inferior strait of, 27 inverted, 507 justomajor, 506 justominor, 546 juvenile, 547 kidney-shaped, 539 Kilian's, 536 kyphoscoliotic, 546 kyphotic, 544 in life, 28 lying-down, 547 malacosteon, 542 male and female, 37 masculine, 547 muscles of, 29 Naegele's, 543 oblique diameters of, 26 obliquely ovate, 543 INDEX. 751 Pelvis obliquity of, 25 obtecta, 53S osteomalacic, 542 position of, 25 Prague, 536 rachitic, 538 Robert's, 544 Rokitansky's, 536 rostrate, 542 scoliotic, 541 simple flat, 535 sitz, 544 small round, 546 spinosa, 576 spinous (spiny), 576 split, 507 spondylolisthetic, 536 superior strait of, 25 symmetrically contracted, 546 thorny, 576 traumatic, 543 true, 25 undeveloped, 547 Y-shaped, 542 Pelzer's method of inducing labor, 271 Pemphigus neonatorum, 728 puerperal, 657 septic, 657 Pendulum-movement of forceps, 523 Penrose's method, 456 Peptonuria in pregnancy, 384 Perforating metritis, 662 Perforation of the after-coming head, 442 Perforations of the infant, 716 Perforator 439 Perimetritis, puerperal (pelvic), 663 Perineal laceration 166 spasm, 579 Perineum, 189 bulging of, in labor, 124 central perforation, 594 laceration of, 593 rigidity of, 579 Periodoscopes, 112 Peripheral venous thrombosis, 651 Peritonitis, general, 668 pelvic, 667 puerperalis, 667 lymphatica, 668 Permanganate method, 162 Pernicious anemia of pregnancy, 338 vomiting of pregnancy, 325 Persistent mentoposterior positions, 451 Peters' theory of eclampsia, 370 Pfliiger, cords (loops) of, 38 Phimosis, 734 Phlebitis, crural (femoral), 651 infectious, 643 puerperal, 643 uterina, 643 Phlegmasia alba dolens, 651 Phlegmonous metritis, 662 Phthisical placenta, 237 Physiologic cry of labor, 124 obstetrics, 17 Physiology, fetal, 59 maternal, 72 of pregnancy, 59 Physometra, 319 Pica, 78, 93, 324 Pigeon-breast, 304 Pigmentation of the placenta, 242 in pregnancy, 84, 410 Pinard's method, 424 sign, 149 Pining, 78, 93 Placenta, 55 adherent, 235, 499 annular, 243 anomalies of, 243 battledore, 58 bipartita (duplex), 243 cystic degeneration of, 241 degeneration of, 240 diseases of, 235 duplex, 243 edema of, 240 fenestrata, 243 fibrous myxoma of, 241 horseshoe, 243 marginal, 249 marginata, 243 membranacea, 243 obsoleta, 481 phthisical, 237 pigmentation of, 242 pra;via, 244, 345 after-treatment, 354 treatment, 349 premature detachment of, 356 retention of, 498 stone, 241 syphilis of, 235 at term, 56 752 INDEX. Placenta tripartita, 243 tumors of, 242 Placentae spurite, 243 succenturiata;, 243 Placental apoplexy, 238 bruit, 82 mole, 222 murmur, 83 nutrition, 60 polyp, 242 souffle, 82 stage of labor, 125 Placentitis, 235 decidualis, 235 Placentoma, 242 Plates, abdominal, 50 dorsal, 50 lateral, 50 Playfair"s method of perineal relaxa- tion, 168 treatment, 165, 509 Plethora, serous, 335 Plural births, 478 births, complications, 488 mechanism of, 486 treatment of, 487 pregnancy, 478 Pneumonia, catarrhal, in the infant, 717 puerperal (septic), 648 white, of the fetus, 307 Podalic version, 469 bipolar, 471 Combined method, 471 Hicks' (B.) method, 471 internal, 473 Pohlman's theory of labor, 116 Pointed condylomata, 402 Polar globules, 48 Polygalactia, 699 Polyhydramnios, 230 Polyp, jilacental, 242 Polyspermism, 45 Polyuria of pregnancy, 384 I'orro-Cesarean section, 563, 566 Position, 128 English, 164 left-lateral recumbent, 164 obstetric, 164 of the pelvis, 25 of the uterus in pregnancy, 74 Positions of the vertex, 137, 143, 144, 145 Positive signs of pregnancy, 102 Postage-stamp layer of decidua, 51 Posterior commissure of vulva, 23 interspinous diameter, 35 parietal position, 536 vaginal vault, 22 Postmammary abscess, 692 Postmortem Cesarean section, 562 changes in the fetus, 317 Postpartum chill, 126, 187 hemorrhage, 609 secondary, 610 shock, 187 Posture in labor, 122, 125, 126 Poullet tape-attachment, 519 Prague method, 176 pelvis, 536 Precipitate labor, 505 Pregnancy, abdominal, 275 enlargement in, 83 palpation in, \oo percussion-note in, 85 signs in, 83 walls in, 75 albuminuria of, 364 alterations in the genitalia in, 72 amaurosis in, 407 aneurysm in, 344 anorexia in, 324 areolae of, 95 ballottement in, 90 bathing in, 108 Praxton Hicks' sign in, 82 cardiac symptoms of, 93, 335 cephalalgia in, 406 cervical, 221 disease in, 400 cervix uteri in, 75 cessation of menstruation in, 79 chloasmata in, 91 cholera in, 321 chorea in, 408 chyluria in, 384 clothing in, 107 constipation in, 86, 108, 330 cornual, 296 cramps in, 87, 406 croupous pneumonia in, 333 cutaneous manifestation of, 9 1 cystitis in, 382 deafness in, 407 dental caries in, 333 diagnosis (jf, 100 INDEX. 753 Pregnancy, diarrhea of, 331 diet in, 107 differentia! diagnosis of, 103 digestive system in, 78 douching in, 108 duration of, 1 10 dyspnea of, 332 emphysema in, 333 endocarditis in, 339 epilepsy in, 407 epistaxis in, 344 exercise in, 107 exophthalmic goiter in, 362 external ovarian, 281 extrauterine, 274 facial paralysis in, 407 false, 221 fetal mensuration in, 1 12 symptoms of, 96 freckles in, 410 fundus uteri in, in gemellary, 479 gingivitis of, 323 glandular activity in, 93 glycosuria in, 383 growth of uterus in, 81 hematemesis in, 345 hematuria of, 383, 384 hemiplegia in, 406 hemoptysis in, 344 hemorrhage from the genitalia in, 361 hemorrhages of, 344 hemorrhoids in, 331 hydremia of, 335 hygiene of, 106 hyperosmia in, 332 hysteria in, 407 indigestion in, 325 influenza in, 322 insomnia in, 404 intermittent fever in, 322 internal ovarian, 280 interstitial, 275, 279 intraligamentous, 278 intramural, 279 irritable bladder in, 85, 381 ischuria in, 384 jaundice in, 331 kidney of, 364 kidneys in, 108 leukorrhea in, 88 lipuria in, 384 48 Pregnancy, lumbago in, 405 mammary glands in, 94, 109 management of, 106 measles in, 321 menstruation in, 361 mensuration of uterus in, in mental occupation in, 109 metritis in, 397 molar, 221 multiple, 478 mural, 275 nausea and vomiting of, 92 nephritis in, 363 nerve-symptoms in, 86, 93 nervous system in, 78 neuralgias in, 405 neuroses of, 407 nipples in, 95 odontalgia in, 405 osseous system in, 78 osteomalacia in, 409 osteophytes in, 78 ovarian, 275, 280 paraplegia in, 406 pathology of, 320 pelvic articulations in, 76 contents in, 76 peptonuria in, 384 pernicious anemia of, },'i^'?> vomiting of, 325 physiology of, 59 pigmentation in, 84, 410 plural, 478 polyuria of, 384 position of uterus in, 74 positive signs of, 102 pressure-symptoms in, 85 pruritus of, 410 vulvae in, 403 ptyalism of, 323 and pulmonary tuberculosis, 334 recurrent vomiting of, 326 reflex manifestations of, 92 relapsing fever in, 322 respiratory system in, 77 salivation of, 323 scarlatina m, 321 sexual intercourse in, 108 signs of, 79 soft cervix in, 88 " soft," signs of, 102 soft uterus in, 89 striae in, 84 754 INDEX. Pregnancy, strj'chnin in, 513 subperitoneoabdominal, 279 subperitoneopelvic, 278 subsidence of the uterus in. 1 1 7 syncope in, 335 syphilis in, 322 tetany in, 408 thyroid gland in, 362 toothache in, 405 trimesters of, 102 tubal, 275 tuboovarian, 279 tubouterine, 275 tumor of, 81 twin, 479 typhoid fever in, 321 typhus fever in, 321 umbilicus in, 84 unavoidable hemorrhage of, 345 urinary system in, 77 uterine displacements in, 387 fluctuation in, 91 symptoms in, 79 tumors in, 399 uteroabdominal, 275 uterus in, 72 vagina in, 75 vaginal discoloration in, 87 heat in, 88 prolapse in, 402 pulse in, 88 signs of, 87 varicosities in, 401 vaginitis in, 400 varicosities in, 86, 341 variola in, 321 vascular system in, 76 vertigo in, 404 vulva in, 75 vulvar edema in, 403 vegetations in, 402 zymotic diseases in, 320 Premature detachment of the placenta, 356 discharge of the ovum, 250 labor, 109, 251 induction of, 266 methods of inducing, 269 ossification of fetal skull, 492 Prematurity, 701 Premonitory lalx)r-pains, 1 20 Prepuce clitoridis, 23 Presentation, 127 Presentation of the breech, 147 of the bregma, 428 of the brow, 430 complex, 478 complicated, 478 compound, 478 of the face, 443 of the feet, 147 funic, 500 of the knee, 147 pelvic, 146 preternatural, 457 of the shoulder, 458 transverse, 457 of the trunk, 457 of vertex, 136 Preservation of the perineum in labor, 166 Pressure-degeneration of nerves, 659 Pressure-neuritis, 659 Pressure-symptoms in pregnancy, 85 Pressure-thrombosis, 652 Preternatural presentation, 457 Primigravida, 44 Primipara, 44 Primiparity, 43 Primitive trace or groove, 49 Prochownick's method of artificial respiration, 713 Proctitis, puerperal (septic), 678 Prolapse of the cord, 500 of the gravid womb, 394 Prolapsus funis, 500 Pronephric duct, 385 Protective dressing, 190 Protracted labor, 509 Pruritus of pregnancy, 410 vulviTe in pregnancy, 403 Pseudocyesis, 103 Ptomainemia, 368, 629 Ptomain intoxication, 629 poisoning, 629 Ptyalism of pregnancy, 323 Puberty, 38 Pubic symphysiotomy, 556 I'udendal hematocele, 597 Puerperal albuminuria, 364 anemia, 623 arthritis, 649 constipation, 685 convulsions, 685 cystitis, 676 eclampsia, 367 INDEX. 755 Puerperal eclampsia, treatment, 376 elytritis, 671 embolism, 621 endokolpitis, 671 endometritis, 672 endosalpingitis, 675 erythema, 656 hemorrhage, 619 infectious pemphigus, 657 insanity, 680 lymphangitis, 661 metritis, 661 metrophlebitis, 643 nephritis, 364 neuritis, 659 ovaritis, 664 paralysis, 406 parametritis, 663 pelvic cellulitis, 663 perimetritis, 663 period, 181 peritonitis, 667 phlebitis, 643 pneumonia, 648 proctitis, 678 pyelitis, 676 pyemia, 646 pyosalpingitis, 675 rheumatism, 649 sepsis, 624 autogenetic, 679 varieties, 628 septicemia, 624, 629 tetanus, 657 thrombosis, 621 ulcerative endocarditis, 648 ureteritis, 676 urethritis, 676 vulvitis, 670 Puerperium, 181 blood in, 184 bowels in, 186 circulation in, 184 diagnosis of, 196 diet in, 192 genitalia in the, 181 hemoiThages of, 609 lungs in, 187 management, 187 pathology of, 608 physiology of, 181 regimen in, 192 retention of urine in, 185 Puerperium, secretions and excretions in, 185 skin in, 186 temperature in, 184 urine in, 185 visits in, 191 Pugh's method, 176 Pulmonary tuberculosis and pregnancy, 334 Pulse, funic, 58 vaginal, 88 Pulvermacher's method, 178 Purpura hsemorrhagica, 41 1 Purulent ophthalmia, 728 Putrefaction of the fetus, 319 of the liquor amnii, 234 Putrid infection, 629 mtoxication, 629 Pyaemia metastatica, 646 multiplex, 646 Pyelitis, puerperal (septic), 675 Pyemia, puerperal, 646 Pyosalpingitis, puerperal (septic), 675 Quadruplets, 480 Quickening, 96 date of. III Quintuplets, 480 Rachiotomy, 476 Rachitic pelvis, 538 rosary, 304 rose-garland, 304 Rachitis, congenital, 304 Ramsbotham's sharp hook, 476 Rasch's sign, 91 " Ratchet movement," 430 Rayer's disease, 364 Ready reckoner. Smith's, 112 Rectum, imperforate, 734 Recurrent vomiting of pregnancy, 326 Red gum, 727 Reflex manifestations of pregnancy, 92 Regurgitation of infants, 210 Relapsing fever in pregnancy, 322 Relaxation of the pelvic articulations, 408 Renal dislocation, 380 insufficiency in pregnancy, 364 Rennie's formula, 329 Resistant forces of labor, 132 Resonance, coronal, 85 756 INDEX. Resoiptive fever, 629 Respiration, artificial, 709 fetal, 61 of new-born, 202 Respiratory system in pregnancy, 77 Restitution, 141 Retained menses, 104 Retarded lal)or, 509 Retention, incontinence of, 687 of placenta, 498 of urine in the puerperium, 185, 688 Retrodisplacement of the gravid womb, 387 Retrouterine hematocele, 291 Retzius, space of, 558 Rheumatism, puerperal, 649 of the uterus, 398 Rigby's method, 351 Right duct of Cuvier, 64 Rigidity of the cervix uteri, 578 perineum, 579 Rima pudendi, 23 Ring, navel, 58 Ritgen's method, 169 Ritter's disease, 727 Robert's pelvis, 544 Roederer's obliquity, 138 Rokitansky's pelvis 536 Room, lying-in, 161 Rosary, rachitic, 304 Rose-garland, rachitic, 304 Rosenthal's method of artificial res- piration, 712 Rostrate pelvis, 542 Rotation of the bladder, 527 of the occiput in labor, 139 Rotch's formula, 698 Routh's method, 327 Rugse of vagina, 22 Rule, Delabout's, 71 Rupture of the amnion, 228 of the birth-canal, 582 of the funis, 504 of the Graafian follicle, 40 spontaneous, of the uterus, 399 of the uterus, 582 Sac, amniotic, 52 navel, 53 vitelline, 53 Saccharomyces albicans, 720 Sacculation of the uterus, 391 Sacrocotyloid diameter, 33, 541 Sacropubic diameter of pelvis, 25 Sanger Cesarean section, 563, 565 Sagittal suture, 134 Salivation of pregnancy, 323 Sanguineous mole, 221 Saponification, 319 Sapremia, 629 Sardonic grin, 372 Sawyer's forceps, 517 Scarlatina in pregnancy, 321 Scarlatiniform erythema, 656 Schatz's method of cephalic version, 455 Schultze's circle, 115 method of artificial respiration, 710 theory of placental expulsion, 156 Sclerema neonatorum, 704 Scoliotic pelvis, 542 Seborrhoea squamosa neonatorum, 314 Secondaiy postpartum hemorrhage, 619 Secretions, fetal, 65 Secundines, 125 Segmental duct, 385 Semen, 43, 44 Sepsis puerperalis, 624 Septic arthritis, 649 cystitis, 676 fever, 629 infection of the new-born, 730 intoxication, 629 neuritis, 659 pemphigus, 657 peneumonia, 648 proctitis, 678 pyelitis, 676 pyosalpingitis, 675 ulcerative endocarditis, 648 ureteritis, 676 Septicaemia acutissima, 630 lymphatica, 66 1 pueiperal, 624, 629 venosa, 643 Septicopyemia, 624, 646 Serous cachexia, 335 plethora, 335 Sextuplets, 480 Sexual intercourse in pregnancy, 108 Seydel's sign, 722 Shadow-corpuscles, 202 Shock, postpartum, 187 Short forceps, 517 Shoulder, mipaction of, 462 INDEX. 757 Shoulder presentation, mechanism, 461 treatment, 465 " Show," 120 Sigault's operation, 556 Signs of fetal death, 317 of pregnancy, 79 Simple flat pelvis, 535 Simpson forceps, 518 Simpson's method, 354 method of inducing labor, 269 theory of labor, 116 Sinciput, 134 Sitz pelvis, 544 Skin, fetal, 66 of the new-born, 204 in the puerperium, 186 Skin-bound disease, 704 Skull, fetal, at term, 133 Small round pelvis, 546 Smith's (R.) ready reckoner, 112 (Tyler), theory of eclampsia, 369 theory of labor, 115 " Snuffles," 732 Soft cervix of pregnancy, 88 "Soft" signs of pregnancy, I02 Solayre's obliquity, 136 Souffle, abdominal, 82 funic, 99 placental, 82 umbilical, 99 uterine, 82 Space of Retzius, 558 Spasm of the perineum, 579 Spasmodic cough, t^t,t, Spermatin, 44 Spermatozoa, 44 Spiegelberg's laws of contracted pel- vis, 548 method, 1 11 theory of eclampsia, 370 Spina bifida, 734 Spinal meningocele, 734 Spine, cleft, 734 Spiny (spinous) pelvis, 576 Split pelvis, 507 Spondylolisthesis, 546 Spondylolizema, 538 Spondylotomy, 476 Spondylysis articularis, 537 SpongioplasTO, 39 Spongy layer of decidua, 51 Spontaneous amputations, 228 Spontaneous evolution, 463 fracture of fetal jjones, 304 rupture of the uterus, 399 version, 461 Sprue, 720 Squamous sutures, 134 Square, 207 Stage of the after-birth, 125 of dilatation and effacement, 120 of expulsion, 122 Stages of normal labor, 120 Stalk, allantoic, 54 Stephen's method, 172 Stillbirth, 706 Stoltz's sign of fetal death, 317 Stomach of the new-born, 2IO Stomatitis, follicular, 719 gonorrheal, 720 parasitic, 720 " Stone child," 319 Stone mole, 221 placenta, 241 Striae, 75, 84, 94 String, navel, 58 Stripping of the cord, 171 Strophulus, 204, 727 Strychnin in pregnancy, 513 Subcutaneous emphysema of the head and neck, 605 Subinvolution of the uterus, 105, 682 Submammary abscess, 692 Subperitoneoabdominal pregnancy, 279 Subperitoneopelvic pregnancy, 278 Subsidence of the uterus in pregnancy, 117 Subsidiary placentas, 243 Sugar-water, 697 Suicidium fcetus in utero, 247 Superalbuminosis, 364, 369 Superfecundation, 479 Superfetation, 478 Superimpregnation, 478 Superinvolution of the uterus, 685 Superior strait of pelvis, 25 Supernumerary digits, 734 Sutures of the fetal skull, 134 Symmetrically contracted pelvis, 546 Symphysiotomy, 556 Syncope in pregnancy, 335 Syphilis, congenital, 304, 732 fetal, 304 of the placenta, 235 in pregnancy, 322 758 INDEX. Tabes lactealis, 700 Table of fetal positions and presenta- tions, 130, 131 Tailfold of the fetus, 49 Tangling of the umbilical cord, 248 Tardy labor, 509 Tarnier's forceps, 519 manual method of rotation, 420 sign, 256 Taste in the new-born, 204 Teat, 197 Temperature of the new-born, 204 in the puerperium, 184 Temporal sutures, 134 Teratism, 302 Teratology, 299 Term, fetal skull at, 1 33 fetus at, 71 placenta at, 56 Tetanoid falciform constriction of the uterus, 571 Tetanus neonatorum, 731 puerperarum, 657 Tetany in pregnancy, 408 Thorny pelvis, 576 Threatened abortion, 255 Thrombosis, puerperal, 621 Thrombotic phlegmasia, 652 Thrush, 720 Thyroid gland in pregnancy, 362 Tic douloureux, 405 Tizzoni and Cattani, antitoxin of, 658 Tongue-tie, 733 Toothache in pregnancy, 405 Torsion of the umbilical cord, 246 Torticollis of the new-born, 158 Tourneur's abdominal method, 677 Trace, primitive, 49 Trachelobregmatic diameter, 135 Transforation, 440 Transforator, 439 Transverse engagement of the occiput, 418 presentation, 457 Traube and Rosenstein's theory of eclampsia, 371 Traumatic neuritis, 659 pelvis, 543 Traumatism of the fetus, 316 of the infant, 713 Trimesters of pregnancy, 102 Triplets, 479 Trismus nascentium, 731 neonatorum, 731 Trousseau's method, 377 True genitals, 18 moles, 273 pelvis, 25 Trunk presentation, 457 Tubal abortion, 292 nutrition, 59 pregnancy, 275 Tubercles of Montgomery, 95 Tuboabdominal pregnancy, 275 Tuboovarian pregnancy, 279 Tubouterine pregnancy, 275 Tumor of pregnancy, 81 Tumors of the decidua, 221 of fetal trunk in labor, 496 of the fetus, 308 in labor, 573 of the placenta, 242 of the uterus in pregnancy, 399 Tunica albuginea, 18 tibrosa, 39 propria, 39 vasculosa, 39 Turning, 466 Twin pregnancy, 479 Twins, locking of, 489 Tympanites, acute, 686 uteri, 319 Typhoid fever in pregnancy, 321 Typhus fever in pregnancy, 321 Ulcerative endocarditis, puerperal, 648 Umbilical cord, 58 care of, 206 coiling of, 247 cysts of, 245 diseases of, 244 expression of, 500 function of, 58 hernia of, 245 knotting of, 246 ligation of, 170 prolapse of, 500 stripping of, 171 tangling of, 248 torsion, 246 fossa, 207 hernia, 736 souffle, 99 vesicle, 53 INDEX. 759 Umbilicus in pregnancy, 84 Unavoidable hemorrhage of pregnancy, 345 Undeveloped pelvis, 547 Unioval origin of twins, 480 Upper uterine segment, 21 Urachus, 54 Ureteritis, puerperal (septic), 676 Ureters, palpation of, 677 Urethritis, puerperal (septic), 676 Urinary incontinence, 687 retention, 688 system in pregnancy, 77 Urine in eclampsia, 374 fetal, 66 in the puerperium, 185 Uterine bruit, 82 contractions of labor, 1 17 displacements in pregnancy, 387 " exhaustion," 511 fibroid, 104 fluctuation, 91 hydatids, 222 inertia, 5 1 1 involution, 18 1 milk, 61 pad, 187 rheumatism, 398 souffle, 82 symptoms in pregnancy, 79 Uteroabdominal pregnancy, 275 Uteroplacental hemorrhage, 238 Uterus, 19 after parturition, 105 bicornis, 386 cordiformis, 385 didelphys,-385 double, 385 growth of, in pregnancy, 81 hernia of, 397 hour-glass contraction of, 498 relaxation of, 498 hyperinvolution of, 685 incudiformis, 385 inversion of, 599 irritable, 74, 254 lateral obliquity of, 74 lateroflexion of, 396 lateroposition of, 396 malformations of, 384 mensuration of, in pregnancy, 1 1 1 in pregnancy, 72 position of, in pregnancy, 74 Uterus, rupture of, 582 sacculation of, 391 septus, 386 softness in pregnancy, 89 spontaneous rupture of, 399 subinvolution of, 105, 682 subsidence of, in pregnancy, 1 17 superinvolution of, 685 unicornis, 386 virginal, 105 Vagina, 22 laceration of, 591 in pregnancy, 75 Vaginal atresia, 581 ballottement, 90 discoloration in pregnancy, 87 enterocele, 577 heat in pregnancy, 88 involution, 183 prolapse in pregnancy, 402 pulse, 88 rugae, 22 signs of pregnancy, 87 thrombosis, 597 varicosities in pregnancy, 40I vaults, 22 Vaginitis in pregnancy, 400 Vagitus uterinus vel vaginalis, 707 Valve, Eustachian, 63 Varicosities in pregnancy, 86, 341 Variola in pregnancy, 321 Vascular system in pregnancy, 76 Veit-Smellie method, 175 Veratrum viride in eclampsia, 378 Vernix caseosa, 66 Version, 466 by the breech, 469 cephalic, 466 by the feet, 469 by the head, 466 pelvic, 469 podalic, 469 spontaneous, 461 Vertex, 136 presentations, 129, 136 anomalies, 421 cause, 129 head transverse at inferior strait, 419 management, 164 mechanism, 136 occiput posterior, 412 760 INDEX. Vertex presentations, transverse en- gagement of the occiput, 418 Vertigo in pregnancy, 404 Vesical calculi in labor, 577 hemorrhoids, 383 Vesicle, blastodermic, 49 umbilical, 53 Vesicovaginal fistula, 687 Vesicula germinativa, 39 Vesicular mole, 222 Vestibule of vagina, 24 Viability, fetal, 701 Villi, chorionic, 54 Virginal uterus, 105 Vitelline duct, 53 membrane, 39 nucleus, 48 nutrition, 60 sac, 53 Vitellointestinal duct, 53 Vitellus, 39 Volland's method, 457 Vomiting in infants, 720 (pernicious) of pregnancy, 325 Vulva, 23 edema of, 582 laceration of, 592 in pregnancy, 75 Vulvar atresia, 580 hematoma, 597 hemorrhage in infants, 726 pads, 190 thrombosis, 597 vegetations in pregnancy, 402 Vulvitis catarrhalis, 670 diphtheritica, 670 gangraenosa, 670 puerperal, 670 purulenta, 670 Walcher's position, 454 Wandering kidney, 380 " Waters," 52 bag of, 121 Weaning, 21 1 Weight of infants, 211 West's method, 416 Wet-nurse, 695 Wharton's jelly or gelatin, 58 White-leg, 651 White mouth, 720 pneumonia of the fetus, 307 Wiegand's method, 354 of cephalic version, 467 Wiegand-Martin method, 174 Winckel's disease, 40I, 731 Womb, 19 Wry neck, 715 Wryder's method, 351 Y-SHAPET) pelvis, 542 Yelk, 39 Zona pellucida, 39 Zweifel's method of manual compres- sion, 617 Zymoses in pregnancy, 320 STANDARD Medical and Surgical Works PUBLISHED BY W. 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Thornton's Dose-Book and Manual of Pre- scription-Writing 26 Van Valzah and Nisbet's Diseases of the Stomach 31 Vierordt and Stuart"s Medical Diagnosis . 12 Warren's Surgical Pathology 11 WolfFs Chemistry 28 Wolff's Examination nf Urine 28 The works indicated thus (*) are sold by subscription {not hy booksellers), usually through travelling solicitors, but they can be obtained direct from the office of publication (charges of shipment prepaid) by remitting the quoted prices. Full descriptive circulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States ; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. ^ 8 GENERAL INFORMATION. One Price. Orders. How to Send Money by JWail. Shipments. Subscription Books. Latest Editions. Bindings. Descriptive Circulars. One price absolutely without deviation. 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Books in our catalogue marked " For sale by subscription only" may be secured by ordering them through any of our authorized travelling salesmen, or direct from the Philadelphia office ; they are not for sale by booksellers. All other books in our catalogue can be procured of any bookseller at the advertised prices, or directly from us. We handle only our own publications, and cannot supply second-hand books nor the publications of other houses. In every instance the latest revised edition is sent. In ordering, be careful to state the style of binding desired — Cloth, Sheep, or Half-Morocco. A complete descriptive circular, giving table of contents, etc. of any book sold by subscription only, will be sent free on application. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph.D., M. D., Professor of Physiologj' in the Johns Hoplvins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices: Cloth, ^6.00 net; Sheep or Half- Morocco, ^7.00 net. This work is the most notable attempt yet made in America to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, particularly from the standpoint of the student of medicine and of the medical practitioner. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him; another, and perhaps the most important, advantage is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different standpoints assumed, and the differences in emphasis laid upon the various lines of procedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. The main divisions of the subject-matter are as follows : General Physiology of Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition — Movements of the Alimentary Canal, Bladder, and Ureter — Blood and Lymph — Circulation — Respiration — Animal Heat — Central Nervous System — Special Senses — Special Muscular Mechanisms — Reproduction — Chemistry of the Animal Body. CONTRIBUTORS : HENRY P. BOWDITCH, M. D., 1 WARREN P. LOMBARD, M. D., Professor of Physiology, Harvard Medi- cal School. JOHN G. CURTIS, M. D., Professor of Physiology, University of Michigan. GRAHAM LUSK, Ph. D., Professor of Physiology, Columbia Uni- ] n <• r r>i • '1 '' -i-- 1 in j- i versitv. N. V. rO^^We of Phvsirians Professor of Physiology, \ ale Medic»J versity, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph.D., Head-Professor of Neurology, Univer- sity of Chicago. W. H. HOWELL, Ph.D., M. D., Professor of Physiology, Johns Hopkins University. FREDERIC S. LEE, Ph. D., Adjunct Professor of Physiology, Colum- bia University, N. Y. (College of Physicians and Surgeons). School. W. T. PORTER, M.D., Assistant Professor of Physiology, Har- vard Medical School. EDWARD T. REICHERT, M. D., Professor of Physiology, University of Pennsylvania. HENRY SEWALL, Ph.D., M. D., Professor of Physiology, Medical Deparfr ment. University of Denver. PV. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices: Cloth, ^7.00 net; Sheep or Half- Morocco, $8.00 net. The arrangement of this volume has been based, so far as possible, upon modern pathologic doctrines, beginning with the intoxications, and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems — digestive, re- spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS : Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, 111. John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Philada., Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain, Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Col. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. VV. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Paris, France. Dr. James Hendrie Lloyd, Philadelphia, Pa. John Noland Mackenzie, Baltimore, Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell. Philadelphia, Pa. W. P. Northrup, New York City. William Osier, Baltimore, Md. Frederick A. Packard, Philadelphia. Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Rake, London, England. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia, Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Philadelphia, Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the allevia- tion of disease. The endeavor throughout has been to conform to the title of the book — Applied Therapeutics — to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. While the scientific superiority and the practical desirability of the metric system of weights and measures is admitted, it has not been deemed best to discard entirely the older system of figures, so that both sets bave been given where occasion demanded. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D. One handsome octavo volume of over looo pages, with nearly 900 colored and half-tone illustrations. Prices : Cloth, ^7.00; Sheep or Half-Morocco, $8.00. The advent of each successive volume of the series of the American Text- Books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics" the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for dis- cussion, the correlation of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judgment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is super- seded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CONTRIBrXORS ; Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Henry J. Garri^ues. Barton Cooke Hirst. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. "At first glance we are overwhelmed by the magnitude of this work in several respects, viz. : First, by the size of the volume, then by the array of eminent teachers in this depart- ment who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the te.xt is ren- dered. This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students." — Neio York Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that 1 have ever seen. I congratulate you and thank yon for this superb work, which alone is sufficient to place j'ou first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skene. IV. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about looo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume : Cloth, ^5.00 net; Sheep or Half-Morocco, ^6.00 net. VOLiUME I. CONTAINS: Hygiene. — Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing). — Scarla- tina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actino- mycosis, Glanders, and Tetanus. — Tubercu- losis, Scrofula, Syphilis, Diphtheria, Erysipe- las, Malaria, Cholera, and Yellow Fever. — Nervous, Muscular, and Mental Diseases etc. VOLiUME II. CONTAINS: Urine (Chemistry and Microscopy), — Kid- ney and Lungs. — Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins. — Peritoneum, Liver,and Pancreas. — Diathet- ic Diseases (Rheumatism, Rheumatoid Ar- thritis, Gout, Lithaemia, and Diabetes.) — Blood and Spleen. — Inflammation, Embolism, Thrombosis, Fever, and Bacteriology. The nrticles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causa- tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the knowledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without consulting works specially devoted to the subject. CONTRIBUTORS : Dr. J. S. Billings. Philadelphia. Francis Delafield, New York. Reginald II. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Gilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best text-books on the practice of medicine which we possess.' A consideration of the second '•nd last volume leads us to modify that verdict and to say that the completed work ¥>, in our opinion, the dest of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be." — Ne^v York Medical yournal. " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge." — American Lancet. " A trusty counsellor for the practitioner or senior student, on which he may implicitly rely." — Edinburgh Medical yournal. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam \V. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), with 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. SECOND EDITION, REVISED AND ENLARGED, With a Section devoted to "The Use of the Rbntgen Rays in Surgery." The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, espe- cially by teachers of surgery; hence, when it was suggested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. While there is no distinctive Amer- ican Surgery, yet America has contributed very largely to the progress of modern surgery, and among the foremost of those who have aided in developing this art and science will be found the authors of the present volume. All of them are teachers of surgery in leading medical schools and hospitals in the United States and Canada. Especial prominence has been given to Surgical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asep- sis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cerebral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been submitted to all the authors for their mutual criticism and revision — an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the important sur- gical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens. CONTKIBFTORS : Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, N. Y. Lewis S. Pilcher, New York. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia. J. Collins Warren, Boston. J. William White, Philadelphia. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."— London Lancet. fV. B. SAUNDERS' For Sale by Subscription. AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, with 341 illustrations in text and 38 colored and half-tone plates. Prices : Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. SECOND EDITION, THOROUGHLY REVISED, In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely de- pended upon to elucidate the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to dis- cuss mooted points, still the most important of these have been noted and ex- plained. The operations recommended are fully illustrated, so that the reader, having a picture of the procedure described in the text under his eye, cannot fail to grasp the idea. All extraneous matter and discussions have been carefully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. CONTRIBUTORS : Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. J. H. Etheridge. William Goodell. Dr. Howard k. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887, .... and the most complete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon, and the general practitioner who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book surpasses anything we have seen." — Boston Medical and Surgical yournal. " A valuable addition to the literature of Gynecology. The writers are progressive, aggressive, and earnest in their convictions." — Medical Ne^us, Philadelphia. " A thoroughly modern text-book, and gives reliable and well-tempered advice and in- struction." — Edinburgh Medical Journal. " The harmony of its conclusions and the homogeneity of its style give it an individuality which suggests a single rather than a multiple authorship." — Annals 0/ Surgery. " It must command attention and respect as a worthy representation of our advanced clinical teaching." — American journal 0/ Medical Sciences. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by THOMPSON S. Westcott, M. D. In one handsome royal-8vo volume of 1 250 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Net Prices: Cloth, $7.00; Sheep or Half- Morocco, ^8.00. SECOND EDITION, REVISED AND ENLARGED. The plan of this work embraces a series of original articles written by some sixty well-known podiatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a PRACTICAL book, suitable for constant and handy reference by the practi- tioner and the advanced student. Especial attention has been given to the latest accepted teachings upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil- dren, with the introduction of many special formulae and therapeutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro- cedures coming within the province of the medical practitioner are carefully considered. CONTRIBUTORS : Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. D.ivid Bovaird, New York. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. \V. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago. Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Curtin, Philadelphia J. M. DaCos'a, Philadelphia. I. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schwcinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. J. P. Crozer Griffith, Philadelphia. W. A. Hardaway. St. Louis. M. P Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit. Henry Koplik. New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K Mills, Philadelphia. James E Moore, Minneapolis. F. Gordon MorriU, Boston. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia- F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Micii Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William White, Philadelphia. J. C. Wilson, Philadelphia. lO IV. B. SAUNDERS' A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia; Vice-President of the American Pjediatric Society; Ex-President of the Association of Life Insurance Medical Directors ; Editor " Cyclo- psedia of the Diseases of Children," etc.; and Henry Hamilton, author of " A New Translation of Virgil's ^neid into English Rhyme ;" co- author of " Saunders' Medical Lexicon," etc. ; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix containing important Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur- gery, Poisons and their Antidotes, Weights and Measures, Thermometric Scales, New Official and Unofficial Drugs, etc. One very attractive volume of over 800 pages. Second Revised Edition. Prices: Cloth, ^5.00 net; Sheep or Half-Morocco, ^6.00 net ; with Denison's Patent Ready-Refer- ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half- Morocco, $5.00 net. PROFESSIONAL. OPIXIOIVS. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Hbnry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. LiNDSLEY, M. D., Professor of Theory and Practice 0/ Medicine, Medical Dept. Yale University : Secretary Connecticut State Board of Health, Neiu Haven, Conn, AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro- fessor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontispiece engraved on steel. Price per Volume, ^^2.50 net. This autobiography, which was continued by the late eminent surgeon until within three months of his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men — surgeons, physicians, divines, lawyers, states- men, scientists, etc. — with whom he was brought in contact in America and in Europe ; the whole forming a retrospect of more than three-quarters of a century. CATALOGUE OF MEDICAL WORKS. II SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL.D., Professor of Surgery, Medical Depart- ment Harvard University; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, with 136 relief and litho- graphic illustrations, -^,2, of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices : Cloth, $6.00 net; Half-Morocco, $7.00 net. " The volume is for the bedside, the amphitheatre, and the ward. It deals with things not as we see them through the microscope alone, but as the prac- titioner sees their effect in his patients ; not only as they appear in and affect culture-media, but also as they influence the human body ; and, following up the demonstrations of the nature of diseases, the author points out their logical treatment." (^Ne%v York Medical Jotimal). " It is the handsomest specimen of book-making * * * that has ever been issued from the American medical press" [American Journal of the Medical Sciences, Philadelphia). Without Exception, the Illustrations are the Best ever Seen in a Work of this Kind. " A most striking and very excellent feature of this book is its illustrations. Without ex- ception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section. " — Annals of Surgery , Philadelphia. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515 engravings, including full-page colored plates. Prices: Cloth, $6.00 net; Half-Morocco, ^7.00 net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a de- gree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the busy practitioner, and a reliable, safe guide for the surgeon. The more difficult operations are fully described and illustrated. More than one hundred of the illustrations are original, while the remainder were selected from books and medical journals not readily accessible. " The most exhaustive of any recent book in English on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed and the author has given a notable and lasting contribution to surgery." — Journal 0/ ATnerican Medical Asso- ciation, Chicap;o. 12 IV. B. SAUNDERS MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medicine at the University of Heidelberg. Translated, with additions, from the Fifth Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume of 600 pages. 194 fine wood-cuts in the text, many of them in colors. Prices: Cloth, $4.00 net; Sheep or Half- Morocco, $5.00 net. FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND ENLARGED GERMAN EDITION. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clin- ical work by a master teacher, characterized by thoroughness, fulness, and accu- racy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI- LITIC AFFECTIONS. (American Edition.) Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy- sician to, and Physician to the department for Diseases of the Skin at, the Middlesex Hospital, London. Photo-lithochromes from the famous models of dermatological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts, at ^3.00 per Part. Parts i to 8 now ready. "The plates are beautifully executed." — Jonathan Hutchinson, M. D. (London Hospital). " The plates in this Atlas are remarkably accurate and artistic reproductions of typical examples of skin disease. The work will be of great value to the practitioner and student." — William Anderson, M. D. (St. Thomas Hospital). " If the succeeding parts of this Atlas are to be similar to Part i, now before us, we have no hesitation in cordially recommending it to the favorable notice of our readers as one of the finest dermatological atlases with which we are acquainted." — Glasgo7v Medical yournal, Aug., 1895. " Of all the atlases of skin diseases which have been published in recent years, the present one promises to be of greatest interest and value, especially from the standpoint of the general practitioner." — Atiierican Medico-Surgical Bulletin, Feb. 22, 1896. "The introduction of explanatory wood-cuts in the text is a novel and most important feature which greatly furthers the easier understanding of the excellent plates, than which nothing, we venture to say, has been seen better in point of correctness, beauty, and general merit." — Ncm i^ork Medical Journal , Feb. 15, 1896. " An interesting feature of the Atlas is the descriptive text, which is written for each picture by the physician who treated the case or at whose instigation the models have been made. We predict for this truly beautiful work a large circulation in all parts of the medical world where the names 5"/. Louis and Baretta have preceded it." — Medical Record, N. Y., Feb. 1, 1896. CATALOGUE OF MEDICAL WORKS. 1 3 PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, $1.75 net. SECOND EDITION, THOROUGHLY REVISED. In this volume the author explains, in popular language and in the shortest possible form, the entire range oi private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work will be found in the directions to the nurse how to improvise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections : I. The Nurse : her responsibilities, qualifications, equipment, etc. II. The Sick- Room : its selection, preparation, and management. III. The Patient : duties of the nurse in medical, sifrgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy. The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick ; Recipes for Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Computing the Date of Labor; List of Abbreviations ; Dose-List; and a full and complete Glossary of Medical Terms and Nursing Treatment. "This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her patient." — American Journal of Obstetrics and Diseases of VVoinen and Children, Aug., 1896. A TEXT-BOOK OF BACTERIOLOGY, including the Etiology and Prevention of Infective Diseases and an account of Yeasts and Moulds, Hsematozoa, and Psorosperms. By Edgar M. Crookshank, M. B., Pro- fessor of Comparative Pathology and Bacteriology, King's College, London. A handsome octavo volume of 700 pages, with 273 engravings in the text, and 22 original and colored plates. Price, ^6.50 net. This book, though nominally a Fourth Edition of Professor Crookshank's " Manual of Bacteriology," is practically a new work, the old one having been reconstructed, greatly enlarged, revised throughout, and largely rewritten, forming a text-book for the Bacteriological Laboratory, for Medical Ofiicers of Health, and for Veterinary Inspectors. 14 W. B. SAUNDERS" A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, $6.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology ; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. "We would most cordially recommend it to all students of histology." — Dublin Medical Journal. " It is pleasant to give unqualified praise to the colored illustrations ; . . . the standard is high, and many of them are not only extremely beautiful, but very clear and demonstra- tive. . . . The plan of the book is excellent." — Liverpool Medical yournal. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb. A series of collotype illustrations, with descriptive text, illustrating the applications of the New Photography to Medicine and Sur- gery. Price, per Part, ^i.oo. Parts I. to V. now ready. The object of this publication is to put on record in permanent form some of the most striking applications of the new photography to the needs of Medicine and Surgery. The progress of this new art hns been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, M. B., D. P. H., Lecturer on Public Health, King's College, London; Editor of the "Journal of State Medicine," etc. i2mo, 43S pages, illus- trated. Handsomely bound in Cloth, with gold side and back stamps. Price, $2.25 net. This work will furnish any one interested in public health the information requisite for forming an opinion as to whether any supply or proposed supply is sufficiently wholesome and abundant, and whether the co.st can be considered reasonable. The work does not pretend to be a treatise on Engineering, yet it contains sufficient detail to enable any one who has studied it to consider intelligently any scheme which may be submitted for supplying a community with water. CATALOGUE OF MEDICAL WORKS. 1 5 DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac- tice. By G. E. DE SCHWEINITZ, M. D., Professor of Ophthalmology in the Jefferson Medical College, Philadelphia, etc. A handsome royal- octavo volume of 679 pages, with 256 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, ^5.00 net. The object of this work is to present to the student, and to the practitioner who is beginning work in the fields of ophthalmology, a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question ; and the method of examination, the symptomatology leading to a diagnosis, and the treatment of the various ocular defects have been brought into prominence. THIRD EDITION, THOROUGHLY REVISED. The entire book has been thoroughly revised. In addition to this general revision, special paragraphs on the following new matter have been introduced : Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltration-Anaesthesia, and Steriliza- tion of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. An Appendix has been added, containing a full description of the method of determining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotations of the eyes with the tropometer of Stevens. The chapter on Operations has been enlarged and rewritten. " A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical scxencs."— British Medical Journal. " The work is characterized by a lucidity of expression which leaves the reader in no doubt as to the meaning of the language employed. . . . We know of no work in which these diseases are dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with the practice of the most advanced ophthalmologists." — Mari- time Medical News. " It is hardly too much to say that for the student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published." — Medical News. " The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, and is certainly a work which not only commends itself to the student, but is a ready reference for the busy practitioner." — International Medical Revie-w. PROFESSIONAL. OPINIOSfS. "A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." William Pepper, M. D. Provost and Professor of Theory and Practice of Medicine and Clinical Medicine in the University of Pennsylvania. " Contains in concise and reliable form the accepted views of Ophthalmic Science." William Thomson, M. D., Professor of Ophthalmology, Jefferson Medical College, Philadelphia, Pa. 1 6 W. B. SAUNDERS' TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 497 pages, finely illustrated. Price, Cloth, $2.50 net. SECOND EDITION, REVISED AND GREATLY ENLARGED. The wotk is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training in this department of medi- cal science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc. are ample for the student's needs, and will afford to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. In this second edition the work has been brought up to date in all depart- ments of the subject, and numerous additions have been made to the technique in the endeavor to make the book fulfil the double purpose of a systematic work upon bacteria and a laboratory guide. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written. — London Lancet, Aug. 29, 1896. " The author has succeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bacteria. . . . The work, we think, should have a wide circulation among English-speaking students of medicine." — N. V. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science." — Edinburgh Medical "jfournal, July, 1896. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veteri- nary Science, Sheffield Scientific School, Yale University. Illustrated. Price, Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work " It is a convenient and useful little work, and will more than repay the outlay necessary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages." — American Med.- Surg. Bulletin. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk — Importance of the Subject of Feeding in Early Infancy — Proportion of Casein and Sugar in Human Milk — Time to Begin Arti- ficial Feeding of Infants — Amount of Food to be Administered at Each P'eed- ing — Intervals between Feedings — Increase in Amount of Food at Different Periods of Infant Development — Unsuitableness of Condensed Milk as a .Sub- stitute for Mother's Milk — Objections to Sterilization or " Pasteurization " of Milk — Advances made in the Method of Artificial Feeding of Infants. y-jv CATALOGUE OF MEDICAL WORKS. 17 ESSENTIALS OF ANATOMY AND MANUAL OF PRACTI- CAL DISSECTION, containing " Hints on Dissection " By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the University of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy ; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition, irost 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price : Extra Cloth or Oilcloth for the dissection-room, $2.00 net. Neither pains nor expense has been spared to make this work the most ex- haustive yet concise Student's Manual of Anatomy and Dissection ever pub- lished, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy, " The plates are of more than ordinary excellence, and are of especial value to students in their work in the dissecting-room," — Journal of American Medical Association. " Should be in the hands of every medical student." — Cleveland Medical Gazette. " A concise and judicious work." — Buffalo Medical and Surgical Journal. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Penn- sylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations, and includes the. following sections: General Diseases, Diseases of the Digestive Organs, Diseases of the Respiratory System, Diseases of the Circulatory System, Diseases of the Nervous Sys- tem, Diseases of the Blood, Diseases of the Kidneys, and Diseases of the Skin. Each section is prefaced by a chapter on General Symptomatology. Post 8vo, 520 pages. Numerous illustrations and selected formulje. Price, ^2.50, bound in flexible leather. FIFTH EDITION, REVISED AND ENLARGED. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teaching, the author has been enabled, by classification, to group allied symp- toms, and by the judicious elimination of theories and redundant explanations to bring within a comparatively small compass a complete outline of the prac- tice of medicine. IV. B. SAUNDERS' MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 445 pages. Price, Cloth, ;f2.25. SECOND EDITION, REVISED. This wholly new volume, which is based on the last edition of the Pharma- copaia, comprehends the following sections : Physiological Action of Drugs ; Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incom- patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being elucidated by more than two hundred formulje. " The author is to be congratulated upon having presented the medical student with as accurate a manual of therapeutics as it is possible to prepare." — Ther-apeutic Gazette. " Far superior to most of its class ; in fact, it is very goo.d. Moreover, the book is reliable and accurate." — New York Medical Journal. "The author has faithfully presented modern therapeutics in a comprehensive work, . . . and it will be found a reliable g;a\Ae." — University Medical Magazine. NOTES ON THE NEWER REMEDIES: their Therapeutic Ap- plications and Modes of Administration. By David Cerna, M. D., Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in the University of Pennsylvania. Post-octavo, 253 pages. Price, ;^l.25. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chemical formula. It thus forms a very valuable addition to the various works on therapeutics now in existence. Chemists are so multiplying compounds, that,, if each compound is to be thor- oughly studied, investigations must be carried far enough to determine the prac- tical imponance of the new agents. " Especially valuable because of its completeness, its accuracy, its systematic considor- atlon of the properties and therapy of many remedies of which doctors generally know but little, expressed in a brief yet terse manner."— CA/Vrt^o Clinical Review. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x13^ inches. Price, per pad of 25 charts, 50 cents. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of lyphoid Fever. CATALOGUE OF MEDICAL WORKS. 1 9 SAUNDERS' POCKET MEDICAL LEXICON ; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., editor of " Cyclopaedia of Diseases of Children," etc. ; author of the " New Pronouncing Dictionary of Medicine ;" and Henry Hamilton, author of " A New Translation of Virgil's jEneid into Eng- lish Verse;" co-author of a " New Pronouncing Dictionary of Medicine." A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents j Leather Tucks, ^i.oo. This new and comprehensive work of reference is the outcome of a demand for a more modern handbook of its class than those at present on the market, which, dating as they do from 1855 to 1884, are of but trifling use to the student by their not containing the hundreds of new words now used in current litera- ture, especially those relating to Electricity and Bacteriology. " Remarkably accurate in terminology, accentuation, and definition." — Journal of Atner- ican Medical Association, "Brief, yet complete .... it contains the very latest nomenclature in even the newest departments of medicine." — New York Medical Record. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1800 Formulae, selected from several hundred of the best-known authorities. Forming a handsome and con- venient pocket companion of nearly 300 printed pages, with blank leaves for Additions; with an Appendix containing Posological Table, Formulae and Doses for Hypodermatic Medication, Poisons and their Antidotes, Diameters of the Pemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Fourth edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, $i.7S "^'^• A concise, clear, and correct record of the many hundreds of famous formulae which are found scattered through the works of the most eminent physicians and surgeons of the world. The work is helpful to the student and practitioner alike, as through it they become acquainted with numerous formulae which are not found in text-books, but have been collected from among tke rising genera- tion of tke profession, college professors, and hospital physicians and surgeons. "This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable." — New York Medical Record. " Designed to be of immense help to the general practitioner in the exercise of his daily calling." — Boston Medical and Surgical yourral. 20 JF. B. SAUNDERS' DISEASES OF WOMEN. By Henry J. Garrigues, A.M., M. D., Professor of Gynecology and Obstetrics in the New York School of Clinical Medicine; Gynecologist to St. Mark's Hospital and to the German Dis- pensary, New York City. In one handsome octavo volume of 728 pages, illustrated by 335 engravings and colored plates. Prices : Cloth, ^4.00 net ; Sheep or Half Morocco, ^5.00 net. A PRACTICAL work on gynecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough know- ledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chap- ters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is eluci- dated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of \!cv& female genitalia, besides exemplifying, whenever needed, morbid condi- tions, instruments, apparatus, and operations. Second Edition, Thoroughly Revised. The first edition of this work rnet with a most appreciative reception by the medical press and profession both in this country and abroad, and was adopted as a text-book or recommended as a book of reference by nearly one hundred colleges in the United States and Canada. The author has availed himself of the opportunity afforded by this revision to embody the latest approved advances in the treatment employed in this important branch of Medicine. He has also more extensively expressed his own opinion on the comparative value of the different methods of treatment employed. "One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. a. Rhamv, M. D., LL.D., Professor 0/ Clinical Gynecology , Medical College 0/ Ohio ; Gynecologist to the Good Samaritan and Cincinnati Hospitals. A SYLLABUS OF GYNECOLOGY, arranged in conformity with "An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Vir- ginia, etc. Price, Cloth (interleaved), $1.00 net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the text-book it will also have an independent value as an aid to the practitioner in gynecological work, and to the student as a guide in the lecture- room, as the subject is [.resented in a manner at once systematic, clear, succinct, pnd practical. CATALOGUE OF MEDICAL WORKS. 21 A MANUAL OF PHYSIOLOGY, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M. A., M. D., D. Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Handsome octavo volume of 800 pages, with 278 illustrations in the text, and 5 colored plates. Price, Cloth, $3.50 net. " It will make its way by sheer force of merit, and amply deserves to do so. It is one oj the very best English text-books on the subject." — London Latzcet. " Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Professor Stewart's volume." — British Medical Journal. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagno- sis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers. Price, $1.25 net. SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, ^2.00 net. " This work is so far superior to others on the same subject that we take pleasure in call- ing attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the direc- tions given. No details are regarded as unimportant; no minor niatters omitted. We ven- ture to say that even the old practitioner will find useful hints in this direction which he can- not afford to despise." — Ne'M York Medical Record. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with " An American Text-Book of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This, the latest work of its eminent author, himself one of the contributors to " An American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of or supplement to the larger work. " The author has evidently spared no pains in making his Syllabus thoroughly comprehen- sive, and has added new matter and alluded to the most recent authors and operations. Full references are also given to all requisite details of surgical anatomy and pathology." — British Medical Journal, London. fV. B. SAUNDERS' AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical Col- lege, Philadelphia. Price per Pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank, suitable for all operations, giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. On the back of each blank is a list of instruments used — viz. general instru ments, etc., required for all operations ; and special instruments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat pad, arranged for hanging on the wall of a sur- geon's office or m the hospital operating-room. "Will serve a useful purpose for the surgeon in reminding him of the details of prepa- ration for the patient and the room as well as for the instruments, dressings, and antiseptics needed " — Neiu York Medical Record " Covers about all that can be needed in any operation." — American Lancet. " The plan is a capital one." — Boston Medical and Surgical Journal. LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin, M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price, Cloth, ^2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. Illustra- tions have freely been used to elucidate the text, and a complete index to facil- itate reference has been added. " There is no work like it in the pharmaceutical or botanical literature of this country, and we predict for it a wide circulation." — American Journal of Pharmacy. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages ; illustrated. Price, Cloth, $1.50. Useful to those who have to nurse, feed, and prescribe for the sick. In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. CATALOGUE OF MEDICAL WORKS. 23 HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow of the College of Physicians and Surgeons of Philadelphia; Vice-President of the American Psediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous cuts to elucidate the text. Second edition. Price, Cloth, ;g2.oo net. " This is by far the most useful book which has yet appeared on insurance examination, a subject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone, the book should be at the right hand of every physician interested in this special branch of medical science." — The Medical News, Philadelphia. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome lamo volume of 484 pages, profusely illustrated. Price, Cloth, ^^2.00 net. This original work on the important subject of nursing is at once comprehensive and systematic. It is written in a clear, accurate, and readable style, suitable alike to the student and the lay reader. Such a work has long been a desidera- tum with those entrusted with the management of hospitals and the instruction of nurses in training-schools. It is also of especial value to the graduated nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus- trated. Price, ;^2.oo net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children in the University of Penn- sylvania. 25 charts in each pad. Price per pad, 50 cents net. A convenient blank for keeping a record of the child's weight during the first two years of life. Printed on each chart is a cur\'e representing the average weight of a healthy infant, so that any deviation from the normal can readily be detected. 24 JV. B. SAUNDERS' THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clinical Professor of Diseases of Children, University of Pennsylvania; Physician to tlie Children's Hospital, Philadelphia, etc. 404 pages, with 67 illustrations in the text, and 5 plates. 121110. Price, ^1.50. SECOND EDITION, REVISED. A reliable guide not only for mothers, but also for medical students and practitioners whose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a mas- ter hand. It can be read with benefit not only by mothers, but by medical students and by any practitioners who have not had large opportunities for observing children." — Atiierkan yoiirnal of Obstetrics. THE NURSE'S DICTIONARY of Medical Terms and Nursing Treatment, containing Definitions of the Principal Medical and Nursing Terms, Abbreviations, and Physiological Names, and Descriptions 01 the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods, Appliances, etc. encountered in the ward or the sick-room. By Honnor Morten, author of "How to Become a Nurse," "Sketches of Hospital Life," etc. l6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended for use merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physicia-n to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, Cloth, ^1.50 (Send for specimen List.) One hundred and sixty detachable (perforated) diet lists for Albuminuria, Anemia and Debility, Constipation, Diabetes, Diarrhoea, Dyspepsia, Fevers, Gout or Uric-Acid Diathesis, Obesity, and Tuberculosis. Also forty detachable sheets of Sick-Ruom Dietary, containing full instructions for preparation of easily-digested foods necessary for invalids. Each list is numbered only, the disease for which it is to be used in no case being mentioned, an index key being reserved for the physician's private use. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Stark, M. D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. Price, ^1.25 net. The first series of blanks are prepared for the first seven months of infant life; each blank indicates the ingredients, but not the quantities, of the food, the 'latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formui '. fo iftc preparation of diluents and foods are appended. "''!»»««sawBWK. saunders' New Series OF Manuals for Students and Practitioners, THAT there exists a need for thoroughly reliable hand-books on the leading branches of Medicine and Surgery is a fact amply demonstrated by the favor with which the SAUNDERS NEW SERIES OF MANUALS have been received by medical students and practitioners and by the Medical Press. These manuals are not merely condensations from present literature, but are ably written by well-known authors and practitioners, most of them being teachers in representative American colleges. Each volume is concisely and authoritatively written and exhaustive in detail, without being encumbered with the introduction of "cases," which so largely expand the ordinary text- book. These manuals will therefore form an admirable collection of advanced lectures, useful alike to the medical student and the practitioner : to the latter, too busy to search through page after page of elaborate treatises for what he wants to know, they will prove of inestimable value ; to the former they will afford safe guides to the essential points of study. The SAUNDERS NEW SERIES OF MANUALS are conceded to be superior to any similar books now on the market. No other manuals afford so much information in such a concise and available form. A liberal expenditure has enabled the publisher to render the mechanical portion of the work worthy of the high literary standard attained by these books. Any of these Manuals will be mailed on receipt of price (see next page for List). W* B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia. SAUNDERS' NEW SERIES OF MANUALS. VOLUMES PUBLISHED. PHYSIOLOGY. By Joseph Howard Raymond, A.M., M. D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital, etc. Price, $1.25 net. SURGERY, General and Operative. By John Chalmers DaCosta, M. D,, Demonstrator of Surgery, Jefferson Medical College, Philadelphia, etc. Octavo, 911 pages, 386 illustrations. Cloth, ^4.00 net; Half- Morocco, ^5.00 net. DOSE-BOOK AND MANUAL OF PRESCRIPTION- WRITING. By E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. Price, ^1.25 net. MEDICAL JURISPRUDENCE. By Henry C. Chapman, M. D., Pro- fessor of Institutes of Medicine and Medical Jurisprudence in the Jeffer- son Medical College of Philadelphia, etc Price, ^1.50 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the German Poliklinik ; Instructor in Surgery, New York Post-Graduate Medical School, etc. Price, ;?i.25 net. MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. (Double number.) Price, ;jS2.5onet. SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito- urinary Diseases, in Rush Medical College, Chicago. (Double number.) Price, ^2.50 net. PRACTICE OF MEDICINE. By George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. (Double number.) Price, ^2.50 net. OBSTETRICS. By W. A. Newman Dorland, M. D., Asst. Demonstrator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital. (Double number.) Price, ^2.50 net. DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to the Middlesex Hospital, and Surgeon to the Chelsea Hospital for Women, Loudon; and Arthur E. Giles, M. D., B. Sc. Lond., F. R. C. S. Edin., Assistant Surgeon to the Chelsea Hospital for Women, London. 436 pages, handsomely illustrated. (Double number.) Price, ;g2.50 net. VOLUMES IN PREPARATION. NERVOUS DISEASES. By Charles W. Burr, M. D., Clinical Pro- fessor of Nervous Diseases, Medico-Chirurgical College, Philadelphia, etc. NOSE AND THROAT. By D. Braden Kyle, M. D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia. *** There will be published in the same series, at short intervals, carefully prepared works on various subjects, by prominent specialists. SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, MOST COMPLETE, and BEST ILLUSTRATED SERIES OF COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature students and Practitioners in every City of the United States and Canada. THE REASON \VHY. They are the advance guard of " Student's Helps " — that DO help; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large colleges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have be- come Professors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-four subjects, has been kept thoroughly revised and enlarged when necessary, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the mar- ket, none of them, approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence : 1. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. V^' Any of these Compends will be mailed on receipt of price (see over for List). SAUNDERS' QUESTION-COMPEND SERIES. Price, Cloth, $1.00 per copy, except when otherwise noted. 1. ESSENTIALS OF PHYSIOLOGY. 3d edition. Illustrated. Re- vised and enlarged by H. A. Hare, M. D (Price, ^l-oo net.) 2. ESSENTIALS OF SURGERY. 6th edition, with an Appendix on Antiseptic Surgery. 90 illustrations. By Edward Martin, M. D. 3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. i8o illustrations. By Ch.\rlp;s B. Nancrede, M. D. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 4th edition, revised, with an Appendix. By Law- rence Wolff, M. D. 5. ESSENTIALS OF OBSTETRICS. 4th edition, revised and en- larged. 75 illuNirations. By W. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 7th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION-WRITING. 4th edition. By Henry Morris, M. D. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. An Appendix on Urine Examination. Illustrated. By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Es- sential Forniulse, selected from eminent authorities, by Wm. M. Powell, M. D. (Double number, price ^2.00.) 10. ESSENTIALS OF GYNAECOLOGY. 4th edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. 11. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, re- vised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M. D. (Price, $1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illu-strations. By Edward Mariik, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E. Armand Semple, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. Second edi- tion. By William 11. Powell, M. D. 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and A. A. EsHNKR, M. D. 55 illustrations, some in colors. (Price, |5l. 50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. Savrk. 2d edition, revised. 20. ESSENTIALS OF BACTERIOLOGY. 3d edition. 82 illustra- tions. By M. V. Ball, M. I). 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 3d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised. By Frkd J. Brockwav, M. I). (Price, gl-OO net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By IJAVID D. Stewart, M. D., and Edward S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Glea- son, M. D. 114 illustrations. Second edition, revised and enlarged. RECENT PUBLICATIONS PENROSE'S DISEASES OF WOMEN A Text=Book of Diseases of Women. By Charles B. Penrose, M.D., Ph.D., Professor of Gynecology in the University of Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Octavo volume of 529 pages, handsomely illustrated. Cloth, $3.50 net. "I shall value very highly the copy of Penrose's "Diseases of Women " received. I have already recommended it to my class as the best book." — Howard A. Kelly, Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore , Md. SENN'S GENITO=URINARY TUBERCULOSIS Tuberculosis of the Qenito=Urinary Organs, Male and Female. By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, $3.00 net. SUTTON AND GILES' DISEASES OF WOMEN Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middle- sex Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, handsomely illustrated. Cloth, $2.50 net. BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR= MACOLOQY. Second Edition, Revised A Text=Book of Materia Medica, Therapeutics, and Pharmacology. By George F. Butler, Ph.G., M.D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, Northwestern University, Woman's Medical School, etc. Octavo, 858 pages, illustrated. Cloth, $4.00 net ; Sheep, fc.oo net. SAUNDBY'S RENAL AND URINARY DISEASES Lectures on Renal and Urinary Diseases. By Robert Saundbv, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirur- gical Society ; Physician to the General Hospital; Consulting Physician to the Eye Hospital and to the Hospital for Diseases of Women ; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illustrations and 4 colored plates. Cloth, $2.50 net. PYE'S BANDAGING Elementary Bandaging and Surgical Dressing, with Directions Concerning the Immediate Treatment of Cases of Emergency. For the Use of Dressers and Nurses. By Walter Pye, F.R.C.S., Late Surgeon to St. Mary's Hospital, London. Small i2mo, with over 80 illustrations. Cloth, flexible covers. Price, 75 cents net. MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE Pathological Technique. By Frank B. Mallorv, A.M., M.D., Assistant Professor of Pathology, Harvard University Medical School ; and James H. Wright, A.M., M.D., Instructor in Pathology, Harvard University Medical School. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2. 50 net. "I have been looking forward to the publication of this book, and I am glad to say that I find it to be a most useful laboratory and post-mortem guide, full of practical infor- mation, and well up to date." — William H. \Wbi.ch, Professor of Pathology, Johns Hopkins University, Baltimore, Md. ANDERS' PRACTICE OF MEDICINE. Second Edition A Text=Book of the Practice of Medicine. By James !VL .Anders, M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of Clinical Medicine, Sledico- Chirurgical College, Philadelphia. In one handsome octavo volume of 1287 pages, fully illustrated. Cloth, I5.50 net ; Sheep or Half Morocco, S6.50 net. ANOMALIES AND CURIOSITIES OF MEDICINE. BY GEORGE M. GOULD, M. D., and WALTER L. PYLE, M. D. Several years of exhaustive research have been spent by the authors in the great medical libraries of the United States and Europe in collecting the material for this work, iledical literature of all ages and all languages has been carefully searched, as a glance at the Bibliographic Index will show. Th« facts, which will be of extreme value to the author and lecturer, have been arranged and annotated, and full reference footnotes given, indicating whence they have been obtained. In view of the persistent and dominant interest in the anomalous and curious, a thorough and systematic collection of this kind (the first of which the authors have knowledge) must have its own peculiar sphere of usefulness. As a complete and authoritative Book of Reference it will be of value not only to members of the medical profession, but to all persons interested in general scientific, sociologic, and medico-legal topics ; in fact, the general inter- est of the subject and the dearth of any complete work upon it make this volume one of the most Important literary innovations of the day. An especially valuable feature of th« book consists of the Indexing. Besides a complete and comprehensive General Index, containing numerous cross-references to the subjects discussed, and the names of the authors of the more important reports, there is a convenient Bibliographic Index and a Table of Contents. The plan has been adopted of printing the topical headings in bold* face type, the reader being thereby enabled to tell at a glance the subject- matter of any particular paragraph or page. Illustrations have been freely employed throughout the work, there being 165 relief cuts and 130 half-tones in the text, and 12 colored and half-tone full- page plates — a total of over 320 separate figures. The careful rendering of the text and references, the wealth of illustrations, the mechanical skill represented in the typography, the printing, and the bind- ing, combine to make this book one of the most attractive medical publications ever issued. Handsome Imperial Octavo Volume of 968 Pages. PRICES: Cloth, $6.00 net; Half Morocco, $7.00 net. 30 JUST ISSUED AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND SKIN DISEASES Edited by L. Bolton Bancs, M.D., Late Professor of Genito-Urinary and Venereal Diseases, New Vork Post-Graduate Medical School and Hospital ; and William A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. Octavo volume of over 1200 pages, with 300 illustrations in the text, and 20 full-page colored plates. Prices : Cloth, I7.00 net ; Sheep or Half Morocco, |8.oo net. MOORE'S ORTHOPEDIC SURGERY A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Ortho- pedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. 8vo, 356 pages, handsomely illustrated. Cloth, $2.50 net. MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT Surgical Diagnosis and Treatment. By J. W. Macdonald, M.D. Edin., L.R.C.S. Edin., Professor of the Practice of Surgerv and of Clinical Surgery in Hamline Uni- versity ; Visiting Surgeon to St. Barnabas' Hospital, Minneapolis, etc. Octavo volume of 800 pages, handsomely illustrated. Cloth, $5.00 net ; Half Morocco, $6.00 net. CHAPIN ON INSANITY A Compendium of Insanity. By John B. Chapin, M.D., LL.D., Physician-in-Chief, Pennsylvania Hospital for the Insane; late Physician-Superintendent of the Willard State Hospital, New York, etc. i2mo., 234 pages, illustrated. Cloth, $1.25 net. KEEN ON THE SURGERY OF TYPHOID FEVER The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Surgery and of Clinical Surgery, Jeffer- son Medical College, Philada. Octavo volume of 400 pages. Cloth, $3.00 net. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH Diseases of the Stomach. By William W. van Valzah, M.D., Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic ; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, 53-5° net. IN PREPARATION AN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR, NOSE, AND THROAT Edited by G. E. de Schvveinitz, M.D., Professor of Ophthalmology in the Jefferson Medical College; and B. Ale.xander Randall, M.D., Professor of Diseases of the Ear in the University of Pennsylvania and in the Philadelphia Polyclinic. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES Nervous and Mental Diseases. By Archibald Church, M.D., Professor of Mental Diseases and Medical Jurisprudence, Northwestern University Medical School, Chicago; and Frederick Peterson, M.D. , Clinical Professor of Mental Diseases, Woman's Medical College, New York, etc. KYLE ON THE NOSE AND THROAT Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jetferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital, etc. STENGEL'S PATHOLOGY A Manual of Pathology. By Alfred Stengel, M.D., Physician to the Philadel- phia Hospital; Professor of Clinical Medicine in the Woman's Medical College; Physician to the Children's Hospital, etc. HIRST'S OBSTETRICS A Text=Book of Obstetrics. By Barton Cooke Hirst, M.D., Professor of Ob stetrics. University of Pennsylvania. HEISLER'S EMBRYOLOGY A Text-Book of Embryology. By John C. Heisler, M.D., Professor of Anatomy. Medico-Chirurgical College, Philadelphia. NOW READY, VOLUMES FOR 1896,1897,1898. AMERICAN YEAR-BOOK OF MEDICINE and SURGERY, Edited by GEORGE M. GOULD, A.M., M. D. Assisted by Eminent American Speoialibts and Teachers. 5 Notwithstanding the rapid multiplication of medical and surgical works, © still these publications fail to meet fully the requirements of the general physician, «S ^ inasmuch as he feels the need of something more than mere text-books of well- "^ "^ known principles of medical science. Mr. Saunders has long been impressed ^ ,^ with this fact, which is confirmed by the unanimity of expression from the pro- ^ S fession at large, as indicated by advices from his large corps of canvassers. ^_ fe This deficiency would best be met by current journalistic literature, but most ^ "aj practitioners have scant access to this almost unlimited source of information, ««i S and the busy practiser has but little time to search out in periodicals the many «, ^ interesting cases whose study would doubtless be of inestimable value in his J; O practice. Therefore, a work which places before the physician in convenient tw ^ form an epitomization of this literature by persons competent to pronounce upon ? g The Value of a Discovery or of a Method of Treatment « cannot but command his highest appreciation. It is this critical and judicial and dogmatic, and will include only what is new. Moreover, through expert condensation by experienced writers these discussions will be Comprised in a Single Volume of about 1200 Pages. The work will be replete with original and selected illustrations skilfully reproduced, for the most part in Mr. Saunders' own studios established for the purpose, thus ensuring accuracy in delineation, affording efficient aids to a right comprehension of the text, and adding to the attractiveness of the volume. Prices: Cloth, $6.50 net ; Half Morocco, $7.50 net. W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia. .52 function that will be assumed by the Editorial staff of the " American Year- •w Book of Medicine and Surgery." *^ g It is the special purpose of the Editor, whose experience peculiarly qualifies «. § him for the preparation of this work, not only to review the contributions to (jg American journals, but also the methods and discoveries reported in the leading § _fe medical journals of Europe, thus enlarging the survey and making the work ^ © characteristically international. These reviews will not simply be a series of " ** . ... . Ot S undigested abstracts indiscriminately run together, nor will they be retrospective g ^ of " news " one or two years old, but the treatment presented will be synthetic ?• V) \.i ! > 1 ;. .;'>;'. .■>, :\'.•■.'J;,'•,\.■y;,■^s>n, ■ ^m'