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1 



A MANUAL 



OF 



OBSTETRICS. 



BY 
A. F. A. KING, A. M., M. D., LL. D., 

Professor of OMetrics in the Medical Department qf the George Washington 
VnirerfUy, Wcuhingtan, D. C, and in the Vnivertity of Vermont; 
Frfgident (2885-86^) of the Washington Obstetrical and Gynx- 
coiotjical Society ; PresiderU {1883) qf the Medical Society of 
D. C. and of the Medical Association of D. a, 1903; 
Fdlou) of tfie British Gynecological and of the American Gynsecological Societies ; 
OjHsuUing Physician to the Children's Hosjntal, Washington, D. C. ; 
Ohstctrician to the George Washington Imvcrsity Hospital; 
Member of the Washington Academy of Sciences ; Fellow of the American Asso- 
ciation for the Advancement of Science ; Associate Member of the Philosophical 
Society of Great Britain; and Member of the Medical, Philosophical, 
Anthropological, and Biological Societies of Washington, D. C, etc. 



TENTH EDITIOX, REVISED AXD ENLARGED. 

WITH THREE HUNDRED AND ONE ILLUSTRATIONS IN 
TEXT AND THREE PLATES. 




LEA BROTHERS & CO., 
PHILADELPHIA AND NEW YORK, 

1907. 



Entered according to Act of Congrew, in the year 1907, by 

LEA BROTHERS & CO.. 

In the Office of the Librarian of Congress at Washington. All rights reseryed 



ILtCTItOTVPtO SV 
WUTOOTT fc TMOIMON. PMILADA. 



PRtSS O* 

. J. OORNAN. PHILAOA. 



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DESIGNED IN PARTICULAR FOR 

MY OWN STUDENTS, 



MEDICAL CLASSES OF THE GEORGE WASHINGTON 
UNIVERSITY, WASHINGTON, D. C, 



UNIVERSITY OF VERMONT; 



IS AFFECTIONATELY DEDICATED, 

WITH THE 

EARNEST HOPE THAT IT MAY BE OF SERVICE TO THEM, 
AND WITH THE BEST WISHES OF 

THE AUTHOR. 



PREFACE TO THE TENTH EDITION. 



As stated in the Preface to the First Edition the chief pur- 
pose of this book is to present, in an easily intelligible form, 
such an outline of the rudiments and essentials of Obstetrics 
as may constitute a good groundwork for the student at the 
beginning of his studies, and one by which it is hoped he 
will be the better prepared to understand and assimilate the 
extensive knowledge and classical descriptions contained in 
larger and more elaborate text-books. 

Whatever value the book may offer to the practitioner for 
purposes of reference, I cannot but hoj)e it may prove of 
service to those whose onerous duties allow but little leisure 
for consulting larger works, and who simply desire to refresh 
their minds upon the more essential i)oints of obstetric 
practice. 

In the preparation of the Tenth Edition such additions and 
changes have been made as the progressive development of 
Obstetric Science seemed to require. 

Some errors have been corrected and obsolete methoils of 
practice omitted. 

The chapter on ** Fecundation and Nutrition of the 
Embryo" has been almost entirely re-written. Extensive 
changes have been made in the chapters on " Pelvic Deform- 
ities," "Cutting 0[)eration8 upon the Mother," "Mutilating 
Operations upon the Child," " Placenta Pra>via," and 
"Puerperal Septicaemia," together with numerous minor 
modifications on various subjects throughout the work. 

For reference I have consulted most frequently the trea- 
tises of Williams, Hirst, Jewett, E<lgar, I)orland, Davis, 
Reynolds, Wright, Webster, and Minot ; also the " Manual 
of Midunfery" by Jellett of Dublin, and the two volumes on 
" Antenaial Pathology and Hygiene " by Ballantyne of Lon- 
don. To all of these authors it gives me pleasure to acknowl- 
edge my grateful indebtedness. 



VI PREFACE TO THE TENTH EDITION. 

With regard to the illustrations, I have endeavored as far 
as practicable to acknowledge in each instance the source 
whence they were obtained. Altogether forty new engrav- 
ings have been added to the present edition. 

The new plates illustrating ** Development of the Embryo," 
and the one showing " Peters' Ovum," were prepared under 
my direction by Mr. Henry R. T. Haines, an artist in the 
Bureau of Animal Industry of the United States Department 
of Agriculture. 

The general scope of the work remains, as from the first, 
elementary, the main object being such brevity and simplic- 
ity of statement as might be easily intelligible to all students. 

I thank the publishers most cordially for the attractive 
changes they have made in the preparation of the book, and 
for their faithful rendering of the colored plates and new 
illustrations. Nor must I fail to mention the great assistance 
received from their careful proof-reader while carrying the 
work through the press. 

Gratified by the generous approval accorded past editions, 
I trust the present one may he found equally deserving and 
satisfactory. 

A. F. A. K. 

1315 MAssAcnrsETTS Avenue, N. W., 

Wnshimjton, D. C, 1907, 



CONTENTS. 



CHAPTER I. 

INTRODUCTION. THE PELVIS. 

The Pelvis — Sacrum, Coccyx, and Innominate Bone — Planes and In- 
clined Planes — Sacro-sciatic Ligaments— Articulations of Pelvis—The 
Piirturient Canal — Canis's Curve — Mobility of Pelvic Joints — Meas- 
urements of the Pelvis — Diameters of the Straits and Cuvity— Mus- 
cular Appendages of the Pelvis — The Pelvic Floor and Perineum. 

pp. 17 to 33 

CHAPTER II. 

THE F(ETAL HEAI>. 

Compressibility, Shape, Sutures, Fontanelles, Regions, Diameters, and 
Measurements. pp. 33 to 38 

CHAPTER III. 

EXTERNAL CJENERATIVE ORGANS. 

Mons Veneris, I^abia Majora, Labia Minora, Fossa Navicularis, Clitoris, 
Vestibule, Urethra, Hymen, and Carunculae Myrtiformes. pp. 39 to 42 

CHAPTER IV. 

INTERNAL GENERATIVE ORGANS. 

Vagina, Uterus (its Structure, Ligaments, Arteries, Veins, Lymphatics, 
Mobility, Nerves, and Functions), Fallopian Tubes, and Ovaries — 
The Graafian Follicle and its Contents — Corpus Luteum— The Paro- 
varium — Mammary Glands. pp. 43 to 65 

ciiaptp:r V. 

MENSTRUATION AND OVITLATTON. 

Cause, Symptoms, and Accompanying Changes in Uterine Mucous Mem- 
brane — Efestiny of the Ovule — Signs of Puberty — Quantitv and Source 
of Menstrual Flow— Vicarious Menstruation — Periodicity and Nor- 
mal Suspension of Menses. pp. 66 to 70 



viii CONTENTS. 

CHAPTER VI. 

MATURATION, FECUNDATION, AND NUTRITION OF THE OVUM. 

The Human Ovum — Maturation — Fecundation — The Spermatic Fluid 
— Changes in Ovum after Impregnation — Segmentation — Kauber's 
Layer — Ectoderm, Mesoderm, Entoderm — Embiyonic Shield— Lat- 
eral Folds — Umbilical Vesicle — Ai^ea Vasculosa — Chorion and Am- 
nion — AUantois — The Placenta — The Trophoblast — Early Human 
Ova — Peters' Ovum — Umbilical Coixl — Nutrition of Embryo— Fcetal 
Circulation^^ize of Embryo at Different Periods. pp. 71 to 116 

CHAPTER VII. 

THE SIGNS OF PREGNANCY. 

Classification — Early Diaj^osis of Pregnancy — Positive Signs: The 
Foetal Heart Sounds, Quickening, Ballottement, Uterine Murmur and 
Intermittent Uterine Contractions, Hegar's Signt—Doubtful Signs: 
Suppression of Menses, Breast Signs, Morning Sickness, Morbid 
Longings, Changes in Abdomen, Softening and Enlargement of Os 
and Cervix Uteri, Violet Color of Vagina, Pigmentary Deposit in 
Skin, Mental and Emotional Signs— Monthly Succession of Signs- 
Differential Diagnosis of Pregnancy — Order of Examination in 
Suspected Pregnancy. pp. 117 to 144 



CHAPTER Vin. 

HYGIENE AND PATHOLOGY OF PREGNANCY. 

Hygiene and Management of Normal Pregnancy: Air, Dress, Exercise 
and Travel, Food, the Skin, Sleep, Sexual Abstinence — Diseases of 
Pregnancy— Classification — Salivation — Toothache and Dental C'aries 
— Excessive Vomiting — Constipation — Diarrhoea — Albuminuria — 
Diabetes— Bright*s Disease — Ursemia— Convulsions— In-itable Blad- 
der — Incontinence of Urine — Uterine Displacements — I^ucorrhcea — 
Pruritus Vulvte — Painful Manimsp- Palpitation— Syncone — Varicose 
Veins — Aniemia and Plethora — Cough and Dyspnoea — Nervous Dis- 
eases : Chorea, Sciatica, General Pruritus, etc. pp. 145 to 181 



CHAPTER IX. 

INTERCURRENT DISEASES OF PREGNANCY. 

Accidental Coincidem^es Intermittent Fever, or Ague— Relapsing 
Fever or Famine Fever— Ty|>h<)id and Ty|)hus Fevers— Yellow 
Fever — S<»arlet Fevor — Measles (RuK^ola) — >^mallpox (Variola) and 
Varioloid — ( 'liolera— Pneumonia— Phthisis— Heart Disease — Jaun- 
dice ^nd Acute Yellow Atrophy of the Liver. pp. 182 to 189 



CONTENTS, ix 

' CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Definition, Frequency, Causes, Period, Symptoms, Prognosis, Diagnosis, 
and Treatment— -"Imperfect" Abortion— " Missed " Abortion. 

pp. 190 to 200 

CHAl^ER XI. 

EXTRA-UTERINE PREGNANCY. 

Varieties— Tubal Pregnancy: Its Causes, Symptoms, Diagnosis, and 
Treatment— Tubal Abortion — Ovarian and Interstitial Varieties- 
Abdominal Pregnancy : its Diagnosis and Ti-eatment— Ilvdatidifonn 
Pregnancy— Moles: True and False— Polyhydramnios— Oligohy- 
dramnios— Hydrorrhoea. pp. 201 U) 227 

CHAPTER XII. 

LABOR. 

Mode of Foretelling Date of — Causes and Forces of— Labor-pains — 
The "Bag of Waters" — Stages of I^bor— Symptoms — Phenomena 
of the Several Stages— Duration and Management of Labor — Prep- 
aration for Emergencies — Antiseptic Midwifery and Antiseptics — 
Examination of Female : Verbal, Abdominal, and Vaginal— Pui*poses 
of Latter — Arrangements of Bed and Night-dress — Rupture of Bag 
of Waters — Attendants — Pinching of Os Uteri against rubes — Atten- 
tion to Perineum — Birth of Head— Tying the Coixl — Delivery of 
Placenta — The Binder— "Occlusion Dressing" — Attentions to New- 
bom Child— Dressing Stump of Navel String. pp. 228 to 269 

CHAPTER XIII. 

MANAGEMENT OF MOTHER AND CHILD AFTER DELIVERY. 

General Condition of Lving-in Woman— The Lochial Discharge — 
Afler-pains — Suckling the C'hild — The Infant's Bowels and Urine — 
The Mother's Bowels and Urine — Her Diet— Milk Fever — Sore 
Nipples — Sunken Nipples — Excess of Milk — De6cient Milk — Arti- 
ficial Feeding— Infantile Jaundice — Sore Navel — L'mbilical Heniia 
— Secondary Hemorrhage from Navel — Inflamed Breasts of Infant — 
Time of Getting Up after Delivery — Ophthalmia Neonatorum. 

pp. 270 to 282 

CHAPTER XIV. 

MECHANISM OF LABOR IN HEAD PRR^FNTATIONS. 

Posture of Child in Uterus— Four ** Positions" of Head "Presenta- 
tion" — Mechanism in I^eft Occipitoanterior Position — Flexion — 
Descent — Rotation — Extension — Restitution — Mechanism of Otlier 
Positions — Diagnosis of Position — Prognosis and Tn'atnient in Ot!- 
cipito-anterior Positions, and in Occipito-fxjsterior ones. 

pp. 283 to 299 



X CONTENTS. 

CHAPTER XV. 

PACE PRESENTATIONS. 

Causes, Frequency, and Positions of— Mechanism in Mento-anterior 
Positions : Extension, Descent, Rotation, Flexion, and Restitution — 
Mechanism in Mento-pwterior Positions — Cause of Arrest after Pos- 
terior Rotation of Chin— Diagnosis, Prognosis, and Treatment of 
Face Caries — Conversion of Face into Head Presentation by External 
Manipulation — Brow Presentations. pp. 300 to 314 

CHAPTER XVL 

BREECH, KNEE, AND FOOT PRESENTATIONS. 

Positions of — Mechanism in Sacro-anterior Positions— Mechanism in 
Sacro-posterior Positions — Knee and Footling Presentations— Diag- 
nosis of Breech, Knee, and Foot— Prognosis and Treatment of Breech 
Cases -Delivery of After-coming Head— Difl&culty in Breech Cases — 
Forceps applied to Breech. pp. 315 to 339 

CHAITER XVU. 

TRANSVERSE PRESENTATIONa 

Position and Mechanism of — Spontaneous Version — Spontaneous Evo- 
lution — Causes and Diagnosis of Tninsverse Cases — Diagnosis of 
Shoulder and Elbow, and of One Shoulder from the Other — Pn>g- 
nosis and Treatment. pp. 340 to 349 

CHAITER XVIII. 

OPERATIVE MIDWIFERY. INSTRUMENTS. 

The Fillet, Blunt-hook, Vectis, and Forcei)s — Ix>ng and Short Forceps 
—Action of Foixxiiw — Ca.ses in which They are Used — The *' High " 
and "Low" Operations — Conditions Essential to Safety — Appliaition 
of Force|is at Inferior Strait after Anterior Rotation of Occiput — 
Oscillatory Movement — Application at Inferior Strait after Posterior 
Rotation— Application before Rotation -Application in Pelvic Cavity 
-The "High" Operation — Tamier^s, Lusk's, and Simi>s<)n's Axis- 
traction Forceps — Dangers of Forceps Operations — Forcejw in Face 
Presentations — Forceps to the After<?oming Head in Breech Cases. 

pp. 350 to 376 

CHAPTER XIX. 

VERSION OR TURNING. 

Cephalic and Podalic — Methods of 0|)erating: by External, BijKdar, 
and Internal Manipulation — Versi(m in Head Presentation — Version 
in Transverse Preston tat ions — Where to Find the Feet Prolape of 
the Arm — Difficulties of Version. pp. 377 to 397 



CONTENTS. XI 

CHAPTER XX. 

CUTTINO OPERATIONS ON THE MOTHER. 

Symphyseotomy: Closed Method, Open Method — Ayer's Operation — 
Caesarean Section: Conservative Operation: Indications and Con- 
tra-indications — Prognosis and Dangers — Preparation — Assistants— 
Operation — The Porro Operation— Radical Cwesarean Section — In- 
dications — Operation — Coelio-hysterectomy — Total Hysterectomy — 
Fritsch's Transverse Fundal Incision— Vaginal Caesarean Section — 
Coelio-elytrotomy. pp. 398 to 421 

CHAPTER XXI. 

MUni^TINO OPERATIONS UPON THE CHILD. 

Craniotomy — Indications for — Cranial Embryotomy — Perforators — 
Smellie's Scissors — Perforation — Trephines — Excercbration — Cranio- 
clast — Cephalotripy — Piece-meal Operation — Basiotripsy — Decapi- 
tation — Evisceration — Spondylotomy — Cleidotomy. pp. 422 to 441 

CHAPTER X>CII. 

PELVIC DEFORMITIES. 

The Flattened Pelvis — Generally Contracted Pelvis— Rachitic Pelvis 
— Lozenge of Micliaelis — Justo-minor and Justo-major Pelves — 
Juvenile Pelvis — Masculine Pelvis — Naegele and Roberts* Pelves — 
Spondylolisthetic, Kyphotic, and Scoliotic Pelves — Ix)rdosis — De- 
formity from Hip Diseaise — Tumors— Symptoms and Diagnosis — 
Pelvimetry — Pelvimeters — Mechanism of Labor in Deformed Pelves 
— Treatment, General Rules for. pp. 442 to 478 

CHAPTER XXIIl. 

INDUCTION OF PREMATURE LABOR. 

Cases I*roper for — Objects of Its Employment in Pelvic Deformitv — 
Methods of Inducing I^bor before Child is Viable — Best Metliixi 
when Child is Viable— Other Methods: the Vaginal Douche, Cohen's 
Method, Vaginal Tampon, Sponge-tent, Injections of Sterilized (ilyc- 
erine, Ei'got, etc. — Treatment of Premature Infants, pp. 479 to 489 

CHAPTER XXIV. 

PLACENTA PREVIA. 

Hemorrhage before Delivery — Causes, Consequences, Symptoms, Diag- 
nosis, and Prognosis of Placenta Pnevia — Treatment : before and after 
Viability of Child — Delivery — Bipolar Version — Forceiw — Ergot — 
de Ribes* Bag — Ca?sarean Section — Barnes— Cohen ancl Simpson's 
Methods. Accidental Hemorrhage— Symptoms, Prognosis and Tivat- 
ment pp. 490 to 499 



xu CONTENTS. 



(CHAPTER XXV. 

P08T-PARTITM HEMORRHAGE. 

" Flooding " — Its Causes, Pi-evention, Symptoms, and Treatment— Pi-e- 
ventive Measures — Remedies to Arrest Flow — Removal of Placenta 
and Blood Clots — Manipulation of Uterus — Lemon-juice, Vinegar, 
Ice, Hot Water — Compression of Aorta — No Tampon — Iodoform 
Gauze — Remedies for Syncope — Retained Placenta — Hour-glass Con- 
traction of Uterus— Spasm of the Os— Treatment of I^rge Placenta 
— Secondary or Remote Hemorrhage. pp. 600 to 612 



CHAPTER XX\^. 

INVERSION OF THE T'TERUS. 

Varieties (or Degrees), Causes, Symptoms, Prognosis, Danger, Diagnosis 
from Polypus, and Treatment ' pp. 513 to 516 



CHAPTER XXVII. 

RUPTITRE OF UTERUS. 

Causes, Symptoms, Prognosis, and Treatment— Laceration of Cervix 
Uteri — laceration of Vagina and Vulva —Thrombus of Vulva — 
Rupture of Perineum — Loosening of Pqlvic Articulations. 

pp. 517 to 529 

CHAPTER XXVIII. 

MTLTIPLE PREGNANCY, ETC. 

Twin, Triplet, Quadruplet and Quintuplet Births — Arrangement of 
Placentae m Twins — Diagnosis and Prognosis of Plural Pregnancv — 
Treatment of Twin Labors— Treatment of " L<x;ked Twins "-Hydro- 
cephalus: Its Diagnosis, Prognosis, and Treatment — Encephalocele — 
Ascites, Tymj>anites — I>istention of Bladder — Large Size of ('hild — 
Premature Ossification of Cranium. pp. 530 to 542 



CHAPTER XXIX. 

TEDlorS LAIJOR. 

Causes, Prognosis, Svmptoms, Diagnosis, and Treatment — Swelling of 
Anterior Lip of l' terns — Rigid (>s Uteri — Rigidity of Perineum — 
Mixle of Dfliveiy in Twlious I^})or — Powerless I^bor — Precipitate 
Labor: Its Causes, Symptoms, and Treatment. pp. 543 to 561 



CONTENTS, XlU 

CHAPTER XXX. 

DU'FICULT LABOR. 

Obstruction by Maternal Soft Parts— Imperforate Hymen— Atresia and 
(Edema of Vulva— Atresia of Vagina— Cystocele—Kectocele— Im- 
pacted Feces— Vesical Calculus— Vaginismus— Growtlis in Vaginal 
Walls— Hernia— Occlusion of Os Uteri— Atresia of Cervix Uteri- 
Cancer of Cervix— A nte-partum Hour-glass Contraction of Uterine 
Body— Polypus— Fibroid and Ovarian Tumors— Hernia of Gravid 
Uterus. PP- 5^2 to 565 

CHAPTER XXXI. 

PROLAPSE OF FUNIS. 

Qiuses, Prognosis, Diagnosis, and Treatment— Postural Treatment— 
Repositors— Sliort and Coiled Funis : Symptoms and Treatment- 
Knots in the Cord. PP- ^^ ^ 575 

CHAPTER XXXII. 

ANJSSTHI'mCS IN MIDWIFERY. 

General Use of— Chloroform— Sulphuric Ether— Hydrate of Chloral, 
Use of, in I^bor, Eclampsia, Mania, etc.— Ergot: Dangers and Con- 
tra-indications to Use of— Quinia as an Oxytocic. pp. 576 to 580 

CHAPTER XXXIII. 

PUERPERAL ECLAMPSIA DURING LABOR. 

Symptoms and Clinical History — Varieties — Prognasis and Treatment 
— Accouchement Forc^ — Methods of Rapid Dilatation — Incision- 
Csesarean Section, etc pp. 581 to 590 

CHAPTER XXXIV. 

PUERPERAL SEPTICEMIA. 

Definition and Synonyms— General Infections : Sapraemia, Septicaemia, 
Pyaemia — Local Inflammations— Etiology and Prophylaxis— Symp- 
toms and Diagnosis — Progncxsis — Treatment : Antiseptic Cleansing 
and General Support — Curctte — Treatment of Local Inflammations- 
New Remedies: Nuclein, Normal Salt Solution, Antistrepto(*oocic 
Serum — Credo's Ointment— Fochier's Method — Kezniarski and Risj*- 
mann's Methods. pp. 592 to 620 

CHAPTER XXXV. 

CENTRAL VENOUS THROMBOSIS (iIEARTH^LOT). 

Causes — Post-mortem Appearances — Symptoms, Prognosis, Diatnioeis, 
and Treatment— Peripheral Venous Thrombosis ("Milk liCp"), 
" Phlegmasia Alba Dolens": Causes and Pathology, Symptoms. Prog- 
nosis, Local and General Treatment — Arterial ThromlK)sis and Em- 
bolism : Symptoms and Treatment. pp. ()21 to 626 



xiv CONTENTS. 

CHAPTER XXXVL 

INSANITY DURING GESTATION, LACTATION, AND THE PUEBPEBAL 

BTATE. 

Inaanity of Gestation, Lactation, and the Puer{>eral State — Causes — 
Symptoms of each Variety— Prognosis as to Life and Mental Resto- 
ration—Treatment — Puerperal Tetanus — Tetanoid Contractions. 

pp. 627 to 632 

CHAI^ER XXXVIL 

INFLAMMATION OK BREASTS. 

Varieties — Causes — Symptoms — Treatment — Lactation and Weaning — 
Wet-nurses. pp. 633 to 640 

CHAPTER XXXVIIL 

RESUSCITATION OF ASPHYXIATED CHILDREN. 

Asphyxia Xeonatoruin — Causes — Symptoms— Varieties : Livid and 
Pallid - Pi-ognosis — Treatment — llemoval of Foreign Matters from 
Air-passages— Use of Catheter in Trachea— Getting Air into Lungs— 
Si'hultze's Method — Sylvester's Method — Laboixie's Method— Byrd- 
Dew Method— Buist's Method— Marshall Hall's Method. 

pp. 641 to 648 

CILVPTER XXXI X'. 

OBSTETRIC JURISPRUDENCE. 

Unusual Prolongation of Pregnancy — .\ge of Maternity — Short Preg- 
nancies with Living Children — Appearance of Fwtus at Different 
Peri(xls of (testation — Suspecte<l Conjugal Infidelity — Moles — Diag- 
nosis of Pregnancy — Signs of Recent Abortion — Signs of Recent 
Delivery at Term — Unconscious Delivery — Feigned Delivery— Crim- 
inal Abortion — Medicinal Oxyto<'ics — Mode of Examination after 
Instrumental Methods — Infanticide — Inspection of Child's Body — 
Duration of Survival after Biith — Evidence of Live Birth— Static 
Test — Hydnwtatic Test— Value of Respiration as Evidence of Live 
Birth — Evidence fn>ni Circulatory Organs and Stomach — Natural 
Causes of Dt«th in Newborn Chihlren — Violent Causes, Accidental 
and Criminal — Strangulation — Me<lical Evidenw of Rape — Marks of 
Violence on Genitals and Body — Examination of Clothing— Venereal 
Diseases — Signs of Virginity — Pregnancy Resulting from Rape — 
Impotence. ' pp. 649 to 669 



Appendix. Obstetrical Nomenclature. pp. 670 to 673 



LIST OF ILLUSTRATIONS. 



no. PAGE 

1. Pelvis: superior strait and its diameters 18 

2. Pelvis : inferior strait and its dianietera iJ3 

3. Axis of parturient canal 26 

4. Conjugate diameter of superior strait 29 

5. Fontanelles 36 

6. Foetal head and its diameters 38 

7. Generative orsans — internal and external 45 

8. Relative position of organs, bladder and rectum empty .... 46 

9. Section oi uterus before preprnancy 47 

10. Section of uterus after childbirth 47 

11. Internal genenitive organs 49 

12. Internal generative organs seen from above 60 

13. Blood-supply of uterus 61 

14. Longitudinal section of Fallopian tube . 64 

15. Relations of ovary with uterus and Fallopian tube 55 

16. Graafian follicle and its contents (diagrammatic) 56 

17. Section of ovary of human foetus with developing ovules ... 58 

18. Section of mammalian ovary showing germinal epithelium . . 59 

19. Corpus luteum of menstruation, third week 60 

20. CJorpus lyteum of pregnancy, fourth montli 61 

21. Corpus luteum of pregnancy at term 61 

22. Parovarium, ovarv, and Fallopian tube 62 

23. Globules of healtliy milk 63 

24. Galactophorous ducts 64 

25. Colostrum and ordinary milk globules 65 

26. Full-grown human ovum 72 

27. Human spermatozoa 74 

28. Structure of a spermatozoon 74 

29. Segmentation of the ovum 77 

30. Further stages of segmentation 78 

31. Formation of blastodermic vesicle 79 

32. Mammalian bla.stoderniic vesicle 80 

33. Erabrvonic shield and Hensen's knot 82 

34. Medullary folds and groove 83 

35. Medullary canal, etc 83 

36. Neural canal further doveloiKxl 84 

37. Folding off of embryonic l)ody 87 

38. Human ovum and embryf) at end of third week 92 

39. Commencement of allan'tois 93 

XV 



XVI LIST OF ILLUSTRATIONS. 

FIO. PAOB 

40. Further development of allantois 93 

41. Completion of allantoic. Chorion and its villi 94 

42. Decidua vera 97 

43. Decidua reflexa and serotina 97 

44. The same further developed 98 

45. Diagrammatic section of placental structure 101 

46. Portion of Peters' ovum highly magnified 103 

47. Spec's human ovum 104 

48. Section of same 104 

49. Front view of Reichert's ovum , 105 

50. Side view of Reichert's ovum 105 

51. The same in diagrammatic section 105 

52. His's ovum, seen from right side 106 

53. Human ovum during thiiti week 106 

54. Uterine surface of the placenta 107 

55. Foetal surface of the placenta 108 

56. Measurements of fcetus at different periods 114 

57. Minot and His's measure lines 115 

58. Examination for quickening 121 

59. Examination for ballottemcnt 122 

60. llegar'ssign: Change of sha|)e 125 

61. Shape of non-pregnant uterus 125 

62. Shape of uterus in early pregnancy 125 

63. Demonstration of HegaVs sign 126 

64. The same with fundus uteri forward 127 

65. Hegai-'s sign by recto-vaginal examination 128 

66. Size of uterus at various periods of pregnancy 134 

67. Demonstrating enlarged uterus by abdominal palpation . . . .135 

68. Retroversion of gravid utenis at twelfth week 170 

69. KeiTO-flexion of gravid uterus, sixteenth week 171 

70. Hisacculated gravid uterus 172 

71. Pregnancy in external third of left tube 202 

72. Tubal pregnancy : Corpus Ititeum in opposite ovarv 202 

73. Tubal abortion .......' 204 

74. Pregnancy in right tube, partially intra-ligamentous 207 

75. Interstitial or tubo-uterine pregnancy 212 

76. Ovarian pregnancy, left si<le 213 

77. Uterus and f<etus in abdominal pi*egnancy 214 

7S. Lithopanlion ' 216 

79. Kydatidiform degeneration of chorial villi 219 

80. Double sac explaining hydrorrlupa 226 

81. Diagram for <letemiining date of labor 229 

82. Digital diaiu'nosis of commencing dilatation of the os uteri . . 232 

83. ()s uteri further dilate<l 233 

84. Complete dilatation of the OS uteri 234 

8>. I K'ad at vulvar opening distending perineum 235 

8(». I Ioa<l al>out to pass the vulvar o|H»ning 236 

S7. Flt'xioii causinjf occiput to descend and forehead to rise .... 244 

88. Palpating head in lower part of uterus, above pelvic brim . . 245 

89. Paljiating the breech 246 



LIST OF ILLUSTRATIONS. xvii 

FIG. PAGE 

90. Palpating plane of back and movable small parts 247 

91. Palpating hard globular head with one hand 248 

92. Palpation : head in pelvic cavity 249 

93. Mode of effecting relaxation of the perineum 257 

94. Regulating birth of head (Jewett) 258 

95. Indiiiect method of pixjserving the i)erineum (Jellett) .... 259 

96. Kellogg's elastic funis ring applicator 262 

97. Credo's expression of the placenta 264 

98. Faulty method of extracting placenta 265 

99. Normal doubling of placenta 266 

100. The abdominal binder 268 

101-106. Six " positions " of head " presentation " 284 

107. Influence of flexion in permitting descent 287 

108. Occiput at inferior strait after i-otation 289 

109. Upward extension of occiput 290 

110. Restitution 291 

111. Successive stages of mechanism in occipito-anterior position of 

head presentation 293 

112. Delivery by backward extension in occipito-posterior case . . 294 

113. Successive stages of mechanism in occipi to-posterior position . 295 
114-119. Six "positions" of face "presentation*' 301 

120. Transverse position of face at superior strait 302 

121. Influence of extension in permitting descent 304 

122. Anterior rotation of chin . . 304 

123. Deliveiy by flexion of chin over pubes 304 

124. Successive stages in mento-posterior position of face, with an- 

terior rotation of chin 306 

125. Arrest of mechanism after posterior rotiition of chin .... 307 

126. Showing flexion if neck were long enough 307 

127^ Changing face to vertex by external manipulation 311 

128. Baudelocque's method of changing face to head presentation 312 
129-134. Six "positions" of breech "presentation" 316 

135. Breech presentation, legs extended 317 

136. Rotation and delivery of hips 318 

137. Rotation of shouldere 319 

138. Delivery of lower shoulder first at perineum 320 

139. Anterior rotation of occiput of after-coming head 321 

140. Posterior rotation of occiput and delivery by flexion .... 322 

141. Posterior rotation of occiput and deli ver>' by extension . . .323 

142. Diagnosis of pelvic presentation by palpation 325 

143. Extraction of head in breech cases 328 

144. Manual extraction of after^'oming head 329 

145. Delivery of head arrested at su|>erior strait 330 

146. Traction with handkerchief, head arrested high up 331 

147. Tamier's forceps applied to thighs 332 

148. The fillet to breech when legs are extended • 333 

149. Method of bringing down f(H>t when legs are extended .... 334 

150. Traction by Angel's hooked in groin 335 

151. Blunt-hoolc applied in breech presentation 336 

152, 153. Two " positions " of right shoulder " presentation " . . .341 



XVI II 



LIST OF ILLUSTJiATlONS, 



FI6. PAGE 

154, 155. Two '* positions " of kit shoulder " DresenUtion " , , . 341 
156. CJbiara's fixjaeri section showing arregled Bpontaneoiis evolu- 
tion ,...,,,,. . . .342 

157* S]>ontfiiiernis fvolutiim— hi^t triune . il43 

158, SpouLtiiiiHHis rvnliUiMTi — st'tMmil MiiiL^e . , 344 

151K Spnntuneous t'volutinii-^thini stax»i ' » 345 

WO. Evohjtiii enmldplic-jito rorjtore - 346 

161. lJ>i:i|tfnii«i.s<»f ^hoiiltk'r |^n'st•Illllti^^^ hv pal|i$ition * 347 

WL Hlmit-liook . liTA 

l<i3. X'ociiH . 352 

li»4, Dfnman'M short fotrefkH . 352 

lti5. Utidjfe'H loii]^ forctfjMi , . 353 

IHfi, Siuijwon'M long ft>r(vjjrt . . . 353 

167- F*>rtL'[»f< ul iHiileL Ifiirrxhui ion of first bla^le . .356 

lt>H, Inli-<MiiuMioii nf Htxonil bljuio , . 357 

180. Lifting lmntlli*< to t\>llow ext^uisjun ......»..-» 258 

17(h ImiiHlni'iiun o( hiwer bliuh' cif faivi?|«; patient on left side . 359 

171. lnirf»ftu('lion of iip^HT blade; i^aticiit in stinii^ iMwilion , . -359 

172. Ftjivt'|>!4 in position. Axjsr-iniotion. I*uti*'iit on Itft side 360 

173. ijAnt Htfige. Extr:u'licm of ht^'ul. Patiunt «»ii left j^ide . . . Ml 

174. Fonx'tiM ill inferior strait, ihTt{mt t** i* ft wflithttlum <. . . .363 

175. iji*k's huMlilication of TamitM-'s axifi-tnu^tioii furivfis . , , . 36d 

176. Sinii>s<jn^s axis-triiolion forcvps 367 

177. WalchLVs iKJsiliun . , 3(58 

178. Diiijfram showing lenji^thening of nor^ngate by Watcher's posi- 

tion .....,.,...., , 36g 

179. Mid'Vrran'H fi>rfL*]iH . , 3ti9 

IW. Ste\^ht'n^m\ invtbod of ttxis-tmetion . 370 

18L Breu^V axis-tnu'tion r«K\i'|H . . . .H70 

1S2, Tnii-iiori wilh SiinpH<Ki'« fon'fr'pN , 371 

183. Traction wilh a7ci«-tnhMinn fofvofw , 372 

184. Axi'i-tnu'tion with ordiniiry fi»fti'jis . . 373 

185. Fnrcejjw in Tnee pri-senUition mI niiih'l , 374 
18(1 Foivt*jw iipplieij to ttflor-iniming head .375 

187. Bi|»ol:ir vorsinn -lirst step ... 380 

188. Biptjliir vensinn — second Mtop . 381 
189* Btpdur version — ihinl ntep . 382 
lUtK I'< win lie version; ^rajij^ting ihi' ftH't . .384 

191. I *«K hi lie version; tiirnini; the rhihl .385 

192. Riirhl Imml yrjinpin^f iViM^in rij^dil shnniu* r preMniuij.n , , 386 

193. I^>|> fiiitul trni'ipinj* ffot« in loll jihiMilder [irt-s^ntntion ... 387 

194. Hi^ht liantl proiiatin^ itmnd hreerh to ^^rohp fe<ft in dorno 

pin/f-riW " jMkhitiiin " of rivdiMinn prt'^ntntion .... ;i88 

195. FHreci ntethcKl of rc^chinj? ft^et in donMi-no*Jti'iJMj tiiN.*H , . . 390 

196. Ikdiverv of posterior arm when esrtendtJ . . IWH 

197. r>ehverv of anfeHor firm wlien extenf1e<l .'195 

198. 199. lK»'r<il <t: n( nf the ami . 39»> 
2tH». (oilhiati'Hwv -nv knife . . .402 
201,202. Knturint^ mi4 iinr nuiiiiim in Cifsain-no ^.M-tion . 411 
20iV*20a, Various fttrrua of {lerfonttors 424 




LIST OF ILLUSTRATIONS, xix 

no. PAGE 

206. Perforation of the skull 425 

207. Martin's trephine 427 

208. Perforation with trephine 427 

209. Tamier's perforator 428 

210. Cranioclast 429 

211. Braun's cranioclast 429 

212. Cephalotribe 430 

213. 214. Craniotomy forceps 432 

215,216. Straight and curved craniotomy forceps 433 

217, 218. Crotchets 433 

219, 220. Simpson's basilyst . . •. 434 

221, 222. Simpson's improved basilvst 435 

223. Tamier's basiotribe .....' , . 436 

224, 225. Application of Tamier's instrument : Iiasiotrii)8y .... 437 
226, 227. Decapitation with Braun's hook 438 

228. Disarticulation of cervical vertebra* with Braun's hook . . . 439 

229. Rachitic pelvis, with backwanl depression of pubes 444 

230. Woman with flat i)elvis 445 

231. Woman with normal pelvis. Lozenge of Michaclis 445 

232. Flat TMm-rachitic pelvis 446 

233. Justo-maior and justo-minor pelves, con^jared with the normal 

pelvis 448 

234. Juvenile (infantile) pelvis 449 

236. Masculine or funnel-shaped pelvis 450 

236. Osteomalacic pelvis, with beak-shaped pub&s 451 

237. Osteomalacic pelvis 451 

238. Oblioue deformity of Naegele 452 

239. The Roberts pelvis 453 

240. The spondylolisthetic pelvis 453 

241. The kyphotic pelvis 454 

242. Kyphotic pelvis showing contracted outlet 455 

243. The kyphoscolio-rachitic ]>elvis 456 

244. Side view of woman with kyphoscolio-rachitic pelvis .... 457 

245. Back view of same case . .' 457 

246. Obliquely contracted pelvis from coxitis 458 

247. The split pelvis 459 

248. Bony tumor of sacrum 400 

249. Baucielocque's calipers. Also Coutouly's ]>elvimeter applied .461 

250. Coll^rePs iKjlvimetcr 462 

251. Pelvimetry with the finger 4(>.S 

252. Measuring the diagonal conjugate with two fingt^rs 464 

253. Measuring conjugate diameter with the whole hand .... 465 

254. Greenhalgh's pelvimeter 406 

255. Lumley Earle's pelvimeter 466 

256. Front and back view of woman with sixmdylolisthetic jK'lvis . 468 

257. Head passinf^ inlet of flat pelvis ......... . . 470 

258. Marked flexion of head in passing a generally contracttni 

pelvis * 471 

259. Narrow base of fretal head 474 

260. Further narrowing after podalic vereion 474 



XX LIST OF ILLUSTRATIONS. 

FIO. PAOB 

261. Relative scale of inches and centimeters 477 

262. Karnes' water-bag 484 

263. Dilator and force|i8 of Champetier de Kibes 484 

264. A simple incubator (Auvard*s) 487 

265. Tube and funnel for gavage 488 

266. Bimanual compression producing anteflexion 503 

267. Hour-glass contraction, with encystment of placenta .... 510 

268. Three degi'ces of inversion beginning at the fundus 514 

269. Invention beginning at the cervix 514 

270. Impending uterine rupture in arm presentation 518 

271. Impending rupture in hydrocephalus 519 

272. A caseof sexlets (sextupleta) 530 

273. Twins : one head, one breech . 532 

274. Ixxjked twins, both heads presenting 535 

275. Locked twins, one breech, one head 536 

276. liabor impelled by hydrocephalus 537 

277. Encephal(K'ele 540 

278. Distention of urinary bladder obstructing labor 541 

279. Elongated cervix wilh nrocidentia during labor 553 

280. C'ystocele obstructing la nor 558 

281. Polypus obstructing labor . . 561 

282. Ovarian tumor obstructing lal)or 563 

283. Prolapse of umbilical cord by side of head 567 

284. Postural treatment of prolapse of the cord 568 

285. Eei)Osition of cord 570 

286. Hraun's reposition of conl 570 

287-289. Other methods of rci)lacing conl 571 

290. Hand pmlaixsed by side of head 573 

291. Harris' metncxl of dilating OS and cervix uteri 584 

292. I'xlgar's bimanual method of dilatation 585 

293. The same, more advanced 58() 

294. Photograph showing Edgai-'s method 587 

295. 296. KoHsrs dilator, open and dosinl 588 

21^7-299. iXklcrlein's syringe and tube* 603 

300, 301. Schultze's method of artificial respiration 644 



LIST OF PLATES. 



PLATE PAGE 

I. Embryonic Development 90 

11. PtrrERs' Ovi'M 102 

III. QriNTrpi.i-rrs 530 



OBSTETRICS. 



CHAPTER I. 

INTRODUCTION —THE PELVia 

Obstetrics is the science and art of midwifery. Its object 
is " the management of woman and her offspring during preg- 
nancy, labor, and the puerperal state/' In its wider 6co\ye it 
embraces a knowledge of the structure and functions of the 
reproductive organs and of their relations to the general 
system. 

THE PELVIS. 

The word " pelvis " means basin. It is a strong frame- 
work of lx)nes, in which the reproductive organs are contained 
and to which they are attached, and its cavity contributes to 
form a canal through which the child must pass during par- 
turition. 

It is composed of the right and left innominate bones, 
sacrum, and coccyx. 

The Sacrom and Coccyx. — The following anatomical fea- 
turas of the sacrum are of obstetrical importance : 

Firsty its promontory — the central, pn)jecting, anterior bor- 
der of the superior surface (or base) of the bone. From 
this promontory the antero-posterior diameter of the Mm of 
the pelvic basin is measured, and a material re<luction in its 
distance from the symphysis pubis, directly opposite, con- 
stitutes the most common variety of |)elvic deformity. The 
smooth convexity of the anterior border of the promontory is 
imfxirtant, for it causes the globular head of the child to 
glide off, during labor, to one or other side of the median 
line, where there is more room for it to pass, as will be ex- 
plained hereafter. 

2 17 



18 



L\TR(Ui I 'f TIfKW— THE Pi^l^ VIS\ 



Sreovd. The antvtivr nutcave surfaee or '^hoffotc^* of tlie 
surriuu. It tMinributei to give anii>lituile aud curvature to 
the jMilvie etiiKil. It is in eoiifonnity \\illi this curvMture of 
llie sacrum thiit tlie hniy:; obstelrieal tbreeps Im niiuU* with wimt 
ia called its **!*ncnt] curve/* ^laterial iiirreaseor decrea^^ in 
the ile^ree of sacnil curvature constitutes dofonnily, aud may 
reuder hdior meclianic^dly difficult or iiiUKja^ihle. llarcly 
houy tumors (exoHlixse!^) spring from the anterior surtace of 
the sfUTuni and ol>struct delivery. This suriiice of the houe 
IH pierced by the anterior .niKvral foramirm, which give exit to 
the anterior sacral nervct*. 

Third. Each later a I Hiirfare of the sacrum presents a 
rough, ear-4shapetl area — the auricular^ articular stirjuce — 




). Antero-poit^rlor (ooi^ngtttci. 2. lii»-iU«c (tmnffv^nc). S. Otiltqu^^, 

wvered with cartilage, which joins a t<imihir !r»lia|)ed .«urfa<'e 
on the iliac lx>ne, c^mstitutin^ the mcrtJ-iiine i^ifttrhoudroHh, 
The )Ki6terior ends of the obliqttt^ diam^*(erH of ihi* |>elvic brim 
terminate at the sacro-iliac p\^ichondro«ies. That portion of 
the Iwine extending fnmi the ^acro-iHac synchondroj^it* to the 
«ide of the body of the lirst sacral vertebni i.^ cnllctl the vfhttj 
(ala) of the sacrum ; one mi each »i<le, of cour^*. ( See Fi^. 1 . ) 
Fourth, The apex, or inferior extremity i>f the sacrum, 
presents a transven^ely oval fwet, coveretl with cartilage^ for 
articulation with a corresponding oval surface u{jod the coccyx. 




THE INNOMINATE BONK 



19 



The saiTo-coceygcal jirtkujIntiLHi l^an amphiarthnjsis «jr mixed 
joint* t'liriiishecl with n symnial fueniliniae, iiud is iiiovalile; 
that is, the chihF^ heaJ duritit^^ its paswige out of the fielvis 
forces the coccyx baekwurdi i<o as to leave more room })etween 
itii tip aiiti the ^yiopliVHii* [Hilii!^. In women past the prime of 
life Uiis joiut heeoriie^'? aoehylose*!, ihe coccyx refuses to yield 
before the advauciiig Ui'mh tin*! hence ilifficult labor. 

Fifth, It is of the utmost iinix*rUinee to rememl)er that the 
vertical mcasureoient of the .siicrum and cotTyXtiu the median 
liiie — t. e., from the centre of the pacral prfimoutory above to 
the tip of the coccyx below — the lioe of measurement being a 
chord of the sacro-eoccygeal curve — iB four inches ftnd a half 
(4J) in length or 1L4 ciik; exactly^ fhrre timf^ a^ hng a.fthe. 
vertimi ikpth of the tftfinpitymH pubis^ which ig one inch aud a 
half (11 ) or :IS em/ 

The Coccyx, ^ — Tlic cm-cyx is triangular in i?haj>e. It is 
comjMjyetl of four rudimentary (caudal ) vertelira% which 
iliminiiih in i*ize frr»m above downward. Its l>ai*e i^ attached 
til tite lower extn'ioity of the jsarrum, as already explained* 

The InEomiBate Bone.- The internal aspect of the bone 
only re/^uires study. There we find a prominent line or ridge 
begiimitig at the saeri>iliac synchoiidrusLs a little below the 
level of the sacral promontory, and extending obliquely f«»r- 
ward, slijLrhtly downward, ami at the jj^anu* time deHcrilnnfr a 
somewhat &emicirc*ular curve inward toward the median line, 
where it eventually joins its fellow of the i»pp)site i*ide at the 
syniphysis jtuliis ; this line m the finra iiifhjit'cthiea of anato- 
mistH. It forms, with the 5tacral pnmionltiry, antl two jibort 
ridges crosj^in^ the winjjfs of the f^acrnm between the promon' 
toryand sacnHliac gyncluaidrotie^ a sii>rt of cordiform outline, 
which is, in fact, the brim of the pelvic basin, or, technteally, 
liie jniperitrr strait of the pelvis^ To rc<'apitulate, the entire 
enntonr of the Hnj)erior strait may fie thus dehcribeil : Begin- 
ning in the median line at the centre of the i^acral promontory, 
it passes outward aenj«s one lateral half of the promontory 
until reaching the wiuiLi; of the sacrum, then acros^^ the wing 
outward, forward, and slightly rlownward, until reaching the 
sacro-iliac synchondrosis, then it traverties the ilium and pubis, 
aa just <Ie»cril>ed, along the liuea ilicv|)eelinea^ until arriving 
at the gpiue of the pubis, and from tbeuce to the symphysis 
pubiii, and k> on back, over the op|K>site side, until again 



20 INTRODUCTION. — THE PELVIS, 

reaching the centre of the sacral promontory from whence it 
started. (See Fig. 1, page 18.) 

The "false'* pelvis, so-called, is all that portion of the 
pelvis situated a6ot'e the 8ui>erior strait, and is made up chiefly 
by the wings, crests, and spinous processes of the iliac bones. 
Its bony wail is deficient in front ; hence it is, of course, an 
imperfect or ** false *' basin. 

The ** true " pelvis is all that portion of the basin situated 
below the brim. Its cavity is a little wider in every direction 
than the brim itself, while the false pelvis is a great deal 
wider ; the brim is, therefore, a somewhat narrowed bony ring 
or aperture between these two; hence the term "strait" is 
given it 

In the cavity of the pelvis we find, on each side, the promi- 
nent spine (spinous process) of the ischium and the inclined 
planes of the ischium. The ischial spinous process projects 
from the posterior border of the body of the bone, about mid- 
way between the highest border of the great sciatic notch 
above and the lowest margin of the tuberosity of the ischium 
below. Its tip points at once downward, backward, and in- 
ward toward the median line, and extending from it forward 
and upward toward the uppc^r margin of the acetabulum is an 
indistinct ridge of bone. Now the sni(K)th, slanting internal 
surface of the ischium in front of and below this indistinct 
ridge is called the anterior inclined plane of the ischium, or 
the anterior inclined plane of the pelvis — no matter which. 
Note, however, its direction : it slants downward, /o/vmrr/, and 
inward toward the median line ; so that a rounded Inxly like 
the foetal head, coming down from alK)ve and impinging upon 
it, would glide at once lower domiy more fonrnrd, and also 
inward toward th(^ pubic symphysis!. IIcMice it is instrumental 
in producing what is called ** anterior rotation'* of the oc^ciput 
in the mechanism of labor. 

Of course, there is an " inclined phine " of this sort on both 
sides of the pelvis, called resj>e<!tively the right and left ante- 
rior inclined plane.^. 

The posterior inclined planes of the pelvis are rather difficult 
to <leHne, but wo may map them out as follows: Draw a line 
on the inner surface of the pelvic cavity from the spinous proc- 
ess of the ischium to the i lio-pect in eal eminence (in most jxelves 
an indistinct ridge may be observed along this line). This 



THE SACRO-SCIATIC UGAMENTS. 21 

line divides the anterior from the posterior inclined plane. 
But as there is only a small remaining surface of the ischium 
behind the dividing line to form the jtoderior plane, it is evi- 
dent that, in the living woman, this plane is completed by the 
sacro-sciatic ligaments and the muscular structures, etc., that 
fill up and cover the sacro-sciatic foramina. In a dried pelvis, 
therefore, especially when divested of its sjicro-sciatic liga- 
ments, it is possible to see only a very small part of the pos- 
terior inclined plane, viz., that part where it begins on the 
back of the dividing line just mentioned. Its continuance or 
extension downward and backward to the median line of the 
hollow of the sacrum can only be seen when the musclas and 
ligaments are intact ; and of which, in fact, the larger portion 
of the posterior inclineil plane is made up. 

The |X)sterior inclined phmc causes the presenting |)art of 
the child impinging u|)on it to rotate downward, backward^ 
and inward toward the median line of the sacrum. Of 
course, there is a posterior inclined plane on each side — right 
and lefl. 

Complete ossification of the |)clvic l)ones does not take place 
till alK)Ut twenty years of age, which affords a probable expla- 
nation why a first lalwr is generally more easy during the early 
part of adult life than later. The bones yield a little, and, 
afler labor is over, the pelvis probably retains to some extent 
the size and sha))e acquired by the first early delivery, so as to 
render subsequent labors more easy. 

After thirty years of age the mcro-coccygeal joint may 
become firmly anchylosed and ossifie<l so as to prevent yielding 
of the coccyx before the pressure of the child's head, thus 
adding another ol>stacle to delivery. 

The Sacro-sdatic Ligaments. — The greater sacro-sciatic 
ligament (sometimes called the "posterior" one) arises from 
the posterior inferior spinous process of the ilium, the lower 
part of the lateral margin of the sacrum, and from the c<x*cyx: 
it is inserted into the tnheroHity of the ist^hium. The frniffr (or 
"anterior ") sacro-sciatic ligament a ris<\s from the lateral mar- 
gin of the sacrum and (*occyx, and is inserted into the Hpinoiis 
proceMi of the ischium. 

These ligaments convert the great sciatic notch into the 
great sciatic foramen, and the lesser sciatic notch into the 
lesser sciatic foramen. 



22 



lyTROD UCTIO.W— THE PEL VIS. 



The Great Sacro-sciatic Foramen. -^T lit* ^rrml sarro-Mnatic 
fonuiiHi truiismiLs the jjyntbrjiiis iii use-It*, tlu' jirlutenl vet*j*t*l8 
and nerve, thi^ L^'biutif ve^setB nnd nerve^ the internal iridic 
ves^ls and iiervts and the nerve lu the obturator ioternus 
uiusw'le. 

Tlie Lesser Sacro-sciatic roramen. — The lesser sacro-iveiatic 
foramen triinsiuits the tenfiou of the obturator internum musele, 
its nerve, and the internal pndie vea^ds and nerve. 

The Obturator or Thyroid Foramen. — The ol>turator or 
thyroid foramen i.s j^ituated in the autero-hiterni ]>art of the 
IK'lvie wail, l>etwecm the pubis and isehiuni, sonieiinies called 
the ** foramen ovale, ■' It is brid^^ed over by a strong mem- 
branous wel) of li|j^aTtientoui4 tissue, called the obturaior 
membrane^ from the inner and outer surfaces of which arise, 
res|iectively, the iuternal and external ohtymtor nuiwles. 
The obturator ve*«els and nerve ymnB through an aperture in 
the U])[ML«r nuirgin «if the obturaior memlirune. 

The Fubic Aick — The pubic arch is formed by the two 
deiU'ending rami of the pni»e?, and « in the lennde) its inner 
snuxith 8urfa(*e, lined at its* central upper part by thei^ohpnbic 
ligament, ii^of^iich a *tize ami nhajw im^ to be absolutely in 
iiiiimMi with and adapleil to admit the jmssage of the side^ and 
hase of the occipital pole of the fcetal heail, ae we shall see in 
describing the mechanism of labor in vertex ]>rei^entntifU]s. 

The Inferior Strait or ** Outlet " of the Pelvis.- The 
drieii bony pelvis, dive*?te<l of it.M numeular ap|>endage.s, is a 
basin without a l>ottom. The opening where the bottom ought 
to he is the inferior f^trait or outlet. Its con too r nuiy Ik? 
descril>eil, in particular, an tolloww: Beginning at the summit 
of the pubie a re h, in the median line of the IkmIv. it passes 
downward and backward along the inner margin of the de- 
scending ramns of the pnhes and the ramus of the isehium 
until reaehing the tuberosity of the ischium, then along the 
great sacro-sciatic ligaiueut to the side of the sacrum and 
ccK'oyx, and tip of the latter bone; then back along the oj>f>o- 
site side f>f the pelvis to the jx)iut of starting at the pubie arelu 
(Bee Fig, 2, page 23. ) 

ArticuUtioiiB of the Pelvis : 

Ftrd. Tlie hinge-joint of the base of the voceyx with the 
a{)ex of the sacrum (the mcro^orcyfifftf artipnlalion ). 

Second. The junction of the auricular-^hapd articular sur- 




AliTfCULATIONS OF THE PELVIS. 



23 



face of the f!i<lt« of thr Hiicrinn, \\\\h a sidiilar ^^IiuiichI siirfueo 
upon the tMijucetit ilium, the urhi-ular snirfjice on Iwitb lumtt* 
aiveretl by a plate of cartilage. This is the sacro-iliac ^t- 

Tftint The symphysis puhin, formed by the apposition of 
the two iKMliea of the \y\%\m hm\m \n the medijiii line. The 
articular surfiices are n^ughened Ijy a i^eriej^ of uipple-ehttjx'd 
projeetititii^ which dip into thf layers of cartilage that cover 
them, Tbe?ie plates t»f nirtibige are thicker iii front than be- 
hind : tht^y aljsKj fli\ erixt' from eacb other [posteriorly, espeeinNy 
at the upper part of tlie artieulation, letiving" a little %\n\t^ 
which 18 occupied by a ayiiovial meiDbraue, while lower down 

Fid. 2. 




Inibrlor strait, or outlet of p«1iris. 



thr interartienlar space h tilled with fibrous elastic tissue. The 
joint i?i further ;*tri'n^'thene<1 by several layers of the anterior 
pubic litrmneiit iti front; the jKisterior pubic lijL'ament kdrind ; 
the ^upcM'ior pubie ligament above; and below by a thick, 
triangular arch of liirrtmentous tisane fthe sid>pubir lijrnment \ 
whi<'h forms the upiHT bonndstry of the ptdiii-undu Tht^ joint 
is rendered Ktill more stvure liy the dense membntne of the 
deep f)enDejil fn*K'ia ( triautruhir b^rament), the a)>ex of whieh 
18 attachetl above to the symphysis pid>is unci sybpubi<' bj^n- 
m^iit, iind extends biternlly to the rnnn of the iscbia and 
pubes, thus braciijtr the sides of the arch tOL'ether as the hides 
of the gable-en»l of a house are braced together by cross 
limheni. 



24 



lyTROD UCTIfKW— THE PEL VIS, 



J*hnrffK The* /tnnhff-Httcntl artiruhtion^ wIk'TL" llie iiiferii^r 
aspect of the inHJy o( llie hi^t luitil>ar vertt'hra ( fuvtTiMl wilh 
cartiliijLre) n\sti!i upon the MijuTior ,siirfa<*e of tht* hat^e of the 
saeruiij, which is nUu eovcrei! hy ucsirtiliigiiiouh plutc, Tliese 
two hiyen* of intervertchral cjirtihige sire much tliicker ixi 
front than hehind^ wliich, of eour^^e^ tilts tlie saenuu huck- 
ward. and eontrihuto** lo form tlio promontory. 

Fifth, The hip- joint hut with rej^ard to this we need only 
remember the po^ilivn of the 4icetuhnlum in relation to the 
pelvic lirim ; it is situated near the a titero- lateral part of the 
linni's (iroumference — in fact, nearly ohli(|nely o|iposite tlie 
sacroiliac HyochondroHig of t lit; other side, which is, of conrH^^ 
placed m the imdtiro-lati'nd jnirt of tlie ^ndvic circnmference. 

Planes of t£e Pelvis, — The inr/ined planes of the ifichium, 
Boraetimea called ine/inal planes of the pelvu, already studied, 
have nothing whatever to do with the plaues of the britn, 
outlet, and pelvic cavity, now to lie coni*idere<L I^et it he dis- 
tinctly uuder>5totnl that the **tdatjes" an*! '' ineiint'fV^ plaiiee 
are ilifferent thinjtp?. 

If we till an ordinary basin witli water, and float ujxm the 
surface a disk of |>a|»er whose circumference shall aci-urately 
fit the rim of tlie l»asiu, the Hurlnce of the paper disk won Id 
represent the plane of the brim of that particular lisu^in ; in 
like manner, a disk of |m|>er placed in the sn|>erior strait of 
the pelvis so that its circnmferent*6 accurately tits the contour 
of the |»elvic hrini, would represt*nt on its surface the *^jti(i7ie 
of the ifnpeeior jttrmt^'' or hrini, of the jielvic hanin. A tli?*k of 
|m|)er, similarly phu^e<l, in ttie outlet or inferior j^tniit, w<mld 
n^prei^erit on its snrfatv^ the ** /thvw of the inferior dntit,*' or 
outlet, of the (pelvis. The surfaces of other disk?? placed at 
intermiKtiate (let>ths l>etween the ><ut)erinr and inferior straits 
(Buch as mipht he imitau^! in (he earthen i»at*in liy its different 
dejrreesof fulness) would constitute phittfAof the pelvie. vavihj^ 
which latter might, of course, b© multiplied in nnn\ber indefi- 
nitely. 

The ajiM of the plane of the 9U|ierior strait is an imaginary 
!ine jmssin^ throvfjh J he eenirr of the |datie, at riijht autjlcH to 
itn Hnrfaee^ ju.-^t as ari axle-tree pa^*H>» at nj^-ht anjt?les through 
the centre of a (*art-wheeh 

Owing to the anterior inclination of the f>elvis when the 
woman stands erects the hrim is, as it were, lilted up liehiml. 



PLANES OF THE PELVIS. 25 

80 that the plane rests at an angle of about 60° with the hori- 
zon. Hence, therefore, its axis, instead of being vertical, is 
so disposed as nearly to agree with a line drawn from the 
umbilicus to the coccyx. 

The plane of the outlet is more nearly horizontal than that 
of the superior strait, but it is still elevated posteriorly, so 
that a line drawn from the tip of the coccyx to the highest 
point of the pubic arch will meet the horizon at an angle of 
about 11°, which, however, is subject to variation, inasmuch 
as the pressing back of the coccyx during labor also presses its 
tip downward to some extent, which, of course, renders the 
angle more acute. The axis of the plane of the inferior strait 
nearly agrees with a line drawn from the sacral promontory 
to the anterior verge of the anus. 

The axes of the planes of the pelvic cavity are lines drawn 
through the centres of the planes at right angles to their sur- 
face. The axes of a great numl)er of such planes, placed end 
to end, would form an imj)erfectly circular curve, or at least 
a polyhedral arc of a curve, which would represent the real 
axis of the pelvic canal. Cams attempted to desc^ribe this 
curve (hence known as " Carus's curve") by placing one leg 
of a pair of compasses on the middle of the posterior edge of 
the symphysis pubis (in a bisected i)elvis), the other leg of the 
compass having its point placed midway l)etween the pubis 
and sacrum, and being moved so as to describe a curve from 
the superior to the inferior strait. But the true axis of the 
pelvic canal is not so geometrically perfect an arc of a circle 
as to admit of being drawn in this manner ; it is more nearly 
the curve of an irregular paralwla. (See Fig. 3, page 26.) 

The pelvic canal in the living female does not really termi- 
nate at the inferior strait. In so far as its osseous walls are 
concerned it does, but the muscles and soil parts below form a 
continuation of the canal, and when these are stretched during 
parturition the pasterior wall of the lower muscular part of 
the canal, viz., from the coccyx to the mouth of the vagina, 
measures quite as much as does the uj)per bony part, viz., 
from the coccyx to the sacral promontory. The anterior wall 
of the muscular part of the passage, corresponding with the 
pubis of the bony part, is, of course, deficient, and necessarily 
so, or the child could never l)e extruded in delivery. (See 
Fig. 3, page 26.) 



26 



INTRODUCTION.— THE PELVIS, 



The female pelvis differs from that of the male exactly in 
tha«« particulars which render it better adapted to facilitate 
parturition, notably (first) in being altogether vdder in every 
direction, which gives more room for the child to pass ; and 
(second) in being altogether shallower, which lessens the dis- 



Fia, 3w 




Axis of the pelvic canal. 



tanee through which the child has to be propelled ; and (third) 
the bones are thinner and smcH)ther. 

In the femal** »v»lvis the pubic arch is broader and rounder, 
the hollow of the sacrum is lc»8s curved (esi)ecially a.-* regards 
its three upj)er segments, which are almofst straight), the 



AiSASUREMENTS OF THE PELVIS, 



27 



ohturator ibranieu is larger, aiul a little further^ hit e rally, 
from ihe gympbysLs |»ul)k; the saerul |>rorii(jntory, i;:ii*hial 
epiDous processes*, aod tip of tbti cocryx are leas |>rotiurieni (w) 
that they eiicniach t<» a lei« dej^ree upou tlie cavity of the 
pelvic aiual), and the t<acru -sciatic uotcbes are more spaduua 
tliun in tlie male, 

Cliaiiges Taking Place in the Female Pelvis toward the End 
of Pregnancy* — The iMtenirlieular eartilages hec<»me thicker; 
the hgikuwuis mftf r aiul :*nittttrlntl vAaxed; syimvial iiuid Is 
formed more pleutifully iti the articuiatioiifl ; and the juinlii 
l)eoome, to an exvtetfimjitj Ihnitt'd fxtent, morable^ i^o as to he 
ca|>able of yielding a very little, if uecesisary, to perudt the 
passage of the child. The swollen cartilages also act as 
cushions between the hones, thus lessening the meehanicnl 
shock of fiilH etc*, somewhat like the *^ buffers" of railway 
cars. 

Proof That the Joints Actually Yield during Labor. — Proof 
that the joints iietyuUy yield during labnr i.-i iid'erred not oidy 
from the fact of its ixt'urrence in the lower aidraab (in tbe 
guinea-pig the syoiphysis pubis !r*eparates an inrh» so that the 
8ftcr(Miliac 8ynchoiidrosi>* jifay.'? the part of a hinge-joint ; aiul 
in the eow tbe sacrum sinks down between the innominate 
l>OQe8^ 4*0 m to push tbcuj wider a part \ Imt id so from lite cir- 
cumstances (hat in women d^nng during labor separation of 
the bones has Jieen fontid on dift^ection ; and in certain caaeft 
where tbe physiological loosening of the urticnlatitnis hiis been 
[pathological ly exaggerated, locomoti<m has been interfered 
with, and the pubic symphysis fbunrl separated an inch or more. 
Again, if the pul|» of tbe index finger Ih^ placed upm the 
lower end of the symphysis, at the snnjniit of the pubic iirch, 
and kept tbere while tbe woman walks, or stands first on one 
foot, then in\ the other, the iMiues on each side of the synAfdiysig 
win l>e felt to glide n\\ and down with eaf*b ste}), the side cor- 
responding to the advancing limb being lower than the other. 
This IB more marked in multipane ; may be unappreciable in 
primipara\ It can be observed toward the end of pregnancy. 

Measurements of the Pelvis, — The oliject of measuring the 
pcdvis is to compare the length of its diameters with the tliam- 
eters of the child tbat passes thr<mgb it; without thjs it would 
be impossible to nnderstand the mechanism of lalwir i»r to 
rentier suitable assi stance i 1 1 cases of d i the u 1 1 del i v cry . 



2A 



LXTKOn VVTION.— THE PEL VIS, 



Tlir Hi/,0 iit' thr |u Ivis is iioi the same in all wumeiL It 
tlilli^rM ill diMbrt'ul rut'cs of inaiikiiid aiul in different iadi- 
viiiuab ot* iUv mimv rnve. There \s no re4ia*ju why tiie pelves 
nf \my twu watueii nhouhl In.* HMjre exactly alike than the 
liii^lli tij'lhe.ir feel ur tlie ieuturei* uf their hieee, 

Hiere are nu iJiran?; hy u hieh we can ni ensure with preei^ion 
(fiiy witiiin um^tit'th ur even une-ioiirth iif an ineh i ihe diaiii' 
eterii uj" the pelvis hi a living feniah* ; our meats are mentis 
under f*mli rireuniHtanee^^ vnu oidy (tjtprouimfttt' the truth, 
Nfiiher are there iiny mvuim hy \\iueh we can niea^nre aay 
njure aeeunitely the diameter of a ehiid'*? head before it is 
lx>i*n ; wc erin miurcely do better than giiei^ even iti« ajiproTt- 
mtdf int^nHurementi*. 

Hence there is lui prBctical use in trying to iletine and teach 
the nu'aHnrenient« of ihi' average I'enude [lelvifi with that 
extreme ]tre<'i«inn (down to tfie smaller trnetions of an inch) 
«ttcnr])iiM| in many ohjiietrie lext-lM>okf?, It e«J!n|ilira1ei< the 
matter withont ar»y j^peeiai advantage ; an ajiproxiniate pre- 
cision is all that in reiptisite- — all llmt in |K.»ssihle. 

Diameters of Uie Superior Strait O^e Fig. 1^ page 18) : 

Firtii. The oittcro-poatenor f sacro-pubic, *'eonjugate," 
^UHnijuijata irnj/' «ir trueconjngale), extending from the niid- 
illci>f thettacral pronioiitoiy to the ^o;^ of the irtynjphy,si.H pubis, 

StrortiL The tranttverjie (Ins-iliac), extending aerosM the 
widci^t part of the utrait, from one lateral margin of the brim 
to the other. 

ThinL The ricfhl oblique (dlagonaHi* dextra ), extendir»g 
IVom the right ^^ac^nMltae synchondntfiH to the left acetaiiulniu 
(or left ilio-pectineal eminence, which is nearly the same thing). 

Fourth. The if*fl ohfifpif (tliagonalis heva)» extending from 
the left wicr*>iliac synchondrosis to the right acetabulum. 

Fiffh, The tiimjiwnl roHfttgate /"e^mjugala dingonalis i, ex- 
lending from the auddle of the sacral pnmmntory to the iawrr 
eud of the pidnc HVmphyKiK. Since the puhh* end f»f this 
dianjeter is really at the infmor strait, it is nftt> strietly, one 
of the diameters of the i»i/;jrWffr strait, hut a diagonal between 
tin' i\\*> plraiti*, a?^ itj" name express*^ (See Fig. 4, rl— c» p. 29,} 

Diameters of the Inferior Strait i Fig. 2» jmge 2;f ) : 

Fi rut T h e a 71 terthpmterio r ( co< ♦( 'v- 1 >u 1 »i e, en 1 1 eil a 1 so * ' con- 
jugate''), extending fmm the tip of the eixTyx to the lower 
end of the uytnphysis juihis. 



DIAMETERS OF THE PELVIC CAVITY, 



29 



Second, The transverse (bis-iachiatic), extending across the 
outlet from one tul)erosity of the ischium to the other. 

Third. The oblique (of which, of course, there are two, 
right and left, as at the brim), extending from about the 
middle of the lower border of the great sacro-sciatic ligament 
of one side to the thickened portion of bone where the de- 
scending ramus of the pubis joins the ascending ramus of the 
ischium, or thereabouts, on the other. 

Fig. 4. 




c-v. Conjugate diameter of superior strait. d-< Diagonal conjugate, as. 
Axis of plane of superior strait, p-o. Plane of the outlet, or inferior strait. 
k-h. Line of the horizon. In this ligure the woman is supposed to be standing 
erect. 



Diameters of the Pelvic Oavity : 

First The aniero-jyoMerior (conjugate), extending from the 
centre of the symphysis pubis to the centre of the hollow of 
the sacrum. 

Second. The tranm^ersey extending across from a point 
nearly opposite the lower edge of the acetabulum on one side 
to a corresponding point ujxm the other. 

Third. The oblique (of which there are two, right and 
left), extending from the centre of the great sacro-sciatic fora- 
men on one side to the obturator foramen on the other. 



30 



LSTROD UCTfOX— lUE PEL VfS, 



(The (liiuut'lf r?i of the cavihj are not m im\MTtant in^ those 
oi' the brim mid outlet.) 

The Average Approximate Length, — The avrrarje appnixi- 
mute lenf^^th of tiie dianieten* of ihe jx^lvie canal in the livitig 
wummi 18 us tblJows : 

Antenj-pKsterior of the brim, or 

superior strait . . . , . 4 iuehej*, llM em. 
Transverse of ihe hr'\in iii the 

iiving femaJe , , 4 inches, lOJ cm. 



(The tr«n8ver»c i?s *> inrln-s^ 12.T cm., in th*« ib-ied 
owing to tht* removal of the [mnxn ina^nus muscle, 
takes up hull" an inch of ^pace on eat'h side in Ihe 
\mA vis. ) 

1 Hilique^of the brim (rij^ht and 

lefl alike) 4} ff> 5 inches, 1 K4 to ll 



I K' I vis 
which 
recent 



Diagonal conjugate 



. 41 inches, 1 1.4 em. 



Antert>-j»o8teriorof the outlet €>r 

inferior strait 41 to rnnche.s 1 L4 lo 12,7 em, 

Tnmsverse offhe ruitlet ... 4 inches, JtKl em. 
t>!>lir|Ues of the outlet (right 

and left alike J 4 irichei*» KM vm. 

Anterf>'|K>**teriorof the cavity . ^ iriehe^, 12.7 em. 
Transverse of the cavity . . . 5 inches^ 12.7 em. 
01 cliques of the cavity (right 

ami left alike) ... * . 5 inches 12.7 eni. 

The most imiKirtant fact tlevehiiwd by these mea^itirementB 
ig that the brim is longest in it.H otilique «liariieter«> while the 
outlet is longest in its aatero-jiostenor mea^ureuienl, which 
explaimH the ueeessity of what is railed "rotation*' in the 
iiieehanism of labor. 

In addition to these measyrement* of the jielvis it is net^es- 
Rftry io remendier the depth of it8 walls ; lhns> the depth of the 
untrrinr ivitff—^i f., from llie top to liie Imttoni of ihe sym- 
physiH pubis — \h 1* indjes, :{.H em. ; while tlie depth of the 
poaicrior wttil, from the sacral promontory to tlie tip of the 
coccjTt (the line being a chord of the aacro-coccygeal curve), 



DIAMETERS OF THE PELVIC CAVITY, 31 

is just three times as long, viz., 4i inches, 11.4 cm. The 
depth of the lateral wall is not of much importance ; it is 
about 3i inches, 8.8 cm. In measuring the i>elvis of the living 
woman externally, for the detection of deformity, it is especially 
necessary to remember the following : 

1. Between the widest part of 

the iliac crests (inter-cristal 

diameter) lOi inches, 26,6 cm. 

2. Between the anterior supe- 

rior spinous processes of the 
ilia ( inter-spinous diam- 
eter) 9 J inches, 24.1 cm; 

3. Between the front of the 

symphysis pubis at its upper 
end, and the depression just 
below the spinous process 
of the last lumbar vertebra 
(conjugate diameter) . . 7J inches, 19 cm. 

4. Between the anterior superior 

spinous process of one ilium, 
and the poderior suj)erior 
spinous process of the other 
(the oblique diameter) . . 9 inches, 22.8 cm. 

In measuring the conjugate externally, a deduction of 3i 
inches (8.8 cm.) must be allowed for the soft parts and thick- 
ness of the bones, which, when subtracted from the 7i inches 
(19 cm.) of the external measurement, leaves 4 inches (10.1 
cm.) — the normal conjugate of the brim, as we have already 
Been. 

The above measurements, of course, refer to norma! pelves. 
Numerous other measurements, employed for the detection of 
special forms of pelvic deformity, will be considered with the 
diagnosis of those abnormalities. (See Chapter XXII., on 
" Pelvic Deformities." ) 

Muscular Stmctures of the Pelvis. — Above the brim the 
muscles of the abdominal walls complete the wall of the "false" 
pelvis, where its bony wall is deficient in front, and they form 
the abdominal cavity, roofed above by the diaphragm, which 



32 ly TROD UCriON. — THE PELVIS. 

agrees §(jmewhat iti shA|>e wUh the fiill-tfnn gnivid uterus, 
80 that by the uoii traction of tht* alulonniitil Tnuist'U%s ant I liia- 
phrngra during; the pams of lal)or the womb b lightly tviu- 
hraeed by tliem, aiu) as^suHtetl in its expuli»ion of the chihl. 
At tlie hrirn we tiinl the psoai* mitiriui:?^ which, arisitig fnnii 
the f*j<ie of the last «hjrsiil and from tht' 8ide« (»f all tlit* lutidmr 
vertehne, passes down :irid crosses the hriiii, where it tuke?; ujj 
half an ineh of spare at each end ut' thr iraiisverMr iliameter 
of the j^iijierior strait, to he inserte<L with the ecinjuitied tendon 
of the iliaeus internum TiiiiRde, into the k*Aser troehnnter of the 
iemuT. The action of tliestr two ninscles is to tlex the thigh 
n|K>ii the j>elv!« and rotute the femnr outward, and as thi» is 
the posture ussnally a><«uined hy the parturient femaks the 
niu^ele,* are firevented fr<uii l>ein;: stretelied taut, and thereby 
encroach h:^-j on the brim an*l thus offer \v^ <dtstrycti(in to 
the paHsa^e of the ehdd. 

Structures Formiag the Floor of tlie Pelvis and Makmg a 
Bottom to the Basiit — The jx'l vie i\myr < ** pelvic diapii ragni '* ) 
is (xunph^ed, eiiietly^ of ftL^^eia, muscle^ and connective lifl*iue. 
its i^ujjerior surfa«*e h lined l>y |K^riltjrteijin, Next Ijehnv. and 
in ch>6e contiict with the f>eritoneuin, conies the tongh, elastic, 
** int<?rnal pelvic fai^'ia/' which is altiiche<l to the (jt-lvic brim. 
Here it meeti^ from above the fasw^ia transvei'stilis of the 
abdcuninal wall and the fascia lining the iliac foasie. Below 
the brirn it h firmly attached to the [)erio**teumt and forjim a 
tendinous arch (arrttj* trniiinfm) reaching from the inner 
border of the pul>e?i Uy the Hfiine of the l^i^^hium ; fmm this 
arch it extendi to the median line of the body. Immediately 
below the internal jxdvic fa^^^ia are two thin mnsch^, viz, : 
l8t. The /4*vntor ani, each half of which ariJ^es frorn tlie ImmIv ami 
horizoutiil ramus i)t' the pubes and from the nrcns tcndineus, 
and passes downward and inward to meet \ls fellow of the 
opjKisite sitle in the uiedian line» where it h inserted into a 
tendinous raphe extending from the cix*cyx to the rectum, 
while simie fibres pass between and to the ndes of the bhidder 
and rei*tum, atitl to the vagirnil and rectal j^pliincters, 2d. 
The Mc/*io-Cf>ccyf/crM f called alst^simjdy "ctM^cygcus '')♦ wfiich 
i« a narn»w, trianguhir slip, Mitnate*! parallel with and |»o^ 
terior to the levator aui. eloping in a little sj»aee which the 
latter mustde, as it were, failed to cover. It arises by it** apex 
from the isehial spinous procc^, and \& inserte«l into the side 




STRUCTURES FORMING FLOOR OF THE PELVIS. 33 

of the coccyx. Below these muscles the pelvic floor is further 
strengthened by another layer of fascia — the perineal fascia. 
Its posterior portion — consisting of a single layer — is attached 
to the suies of the pelvis and arcus tendineus, from whence it 
is reflected over the inferior surface of the levator ani muscle, 
while its anterior part is divisible into a deep layer (covering 
the lower surface of the levator ani), a median and a superficial 
layer. Within these latter layers are lodged the pudic vessels 
and nerves, and the superficial muscles of the perineum. 
These muscles are (1) the constrictor vaginiB, each lateral half 
of which arises, posteriorly, from the i)erineal fascia midway 
between the anus and iscihium (a small slip only passing to 
join the sphincter ani muscle ), and passes forward to unite, by 
aponeurosis, with its fellow of the o[)[>osite side, near the clit- 
oris ; (2) the sphincter aniy which arises from the tip of the 
coccyx and « is inserted into the tendinous centre of the peri- 
neum ; (3) the transversus perineiy a narrow, transverse slip 
arising from the ascending ramus of the ischium, and inserted 
into the sides of the vagina and rectum. 

To the several structures of the |)elvic floor above given 
must now be added the inte<]:ument and the very numerous 
interstitial layers of elastic connective tissue, which latter weld 
the parts together and a<ld strength and elasticity to the whole 
fabric. 

Besides their motor function, the muscles covering the inner 
surface of the pelvis (including the pyriformis — not yet men- 
tioned — which arises chiefly from and wvers the hollow of the 
sacrum) provide a sort of muscular upholstery to the interior 
of the pelvis by which its bony lines and prominences are 
cushioned over, so as to prevent injury to the soft parts during 
the passage of the child, while the infant itself receives the 
.same protection. 



CHAPTER II. 

THE F(ETAL HEAD. 

The head of the foetus requires 8i)ecial study, because, from 
its size and incompressibility, it is the most difticult [)art of the 
child to deliver ; when the head is born, the rest of the labor 
is usually complete in a few minutes. The child's head, how- 
ever, is not absolutely incompressible. Its lx)ny wall is elas- 
tic to a certain extent in all parts except the base. By this 
arrangement, yielding of the bones permits pressure only upon 
the upper part of the foetal brain, where, when moderate in 
degree, it is harmless ; the same pressure upon the biise of the 
brain and medulla would be fatal. While it is not true that 
the short transverse diameter of the child's head, viz., from 
one parietal protul)erance to the other, is less than the tnms- 
verse diameter of the trunk, viz., from one acromion process 
of the scapula to the other, still the l)ones and muscles of the 
arms, shoulders, and trunk are so mobile and flexible that, 
when they are jammed into the pelvis, the bisacromial diameter 
is capable of being easily reduced to a less width than the 
transverse diameter of the skull ; hence the head, though 
apparently noty practically is wider than across the shoulders. 

Shape of the Foetal Head. — This does not correspond per- 
fectly to any geometrical figure, but it will best suit our pur- 
|)ose to (consider it ovoid or egg-sha|)ed — the chin C()rres|M)nd- 
ing to the small end of the ^^, the occiput to the large end, 
an<l the widest transverse circumference i)assing over the 
jmrietal protuberances. One aspe<*t of the ovoid, viz., its base, 
is considerably flattened, and so are the sides of the head, but 
to a less extent. 

The fd'taj cranial hemes are imperfectly ossified (and are 

therefore elastic) ; their sutural borders are surmounted by a 

rim of cartilage, an<l the cartilaginous rims of two cimtiguous 

bones are only united by bandsof fibrous tissue which become 

34 



FONTANELLES. 35 

ossified later. The bones are further held in apposition by the 
dura mater, pericranium, and skin ; their borders, however, 
can be pressed closer together, or even made to lap one over 
the other, during parturition. The posterior borders of the 
parietal bones especially overlap the anterior borders of the 
occipital. The union of the upi)er, squamous part of the 
occipital bone with its basilar portion being only fibro-cartilag- 
inous in character, this junction is somewhat movable, like a 
joint ; hence pressure upon the prominence of the occiput easily 
depresses its anterior borders beneath the posterior borders of 
the parietal bones. The distance between the two malar bones 
can be reduced, by compression, only in a very slight degree. 

The base of the skull is sufficiently ossified as to be incom- 
pressible ; it is, however, narrower than the top of the skull, 
and needs no reduction in size to facilitate its passage through 
the pelvis in ordinary cases. 

Sutnres of the Cranium. — They are : 

First. The coronal suture (or fronto-parietal), passing be- 
tween the posterior border of the frontal bone and the anterior 
borders of the two parietals. It goes over the arch of the 
craniuin from one temporal bone to the other. 

Second, The sagittal suture (or biparietal ), running along 
and between the suj^rior borders of the two parietal bones 
and extending from the superior point of the occiput to the os 
froutis. It must l>e noted, however, that, in the fietus, the 
two halves of the frontiil bone have not yet united ; they are 
divided by what is called the frontal suture almost to the root 
of the nose, and by some writers this frontal suture is regarded 
aa a continuation of the sagittal. 

Third. The lambdoidal suture (or occipito-parietal), running 
between the superior, or rather antero-lateral, borders of the 
occiput and the posterior borders of the parietals, and extend- 
ing from near the mastoi<l i)rocess of one temjwral bone to 
that of the other. 

Fontanelles. — The fontanellcs are spaces left in the skull 
at points where the angles of two or more l)ones finally meet. 
They are due to deficient ossification, and are explained by 
the general principle that ossification, beginning near the cen- 
tre of a l)one and extending toward its cinuimference, reaches 
the angles last l>ecause they are generally furthest from the 
centre. There are six fontanelles, but only two of them are 



36 



THE FiETAL HEAD. 



Flo, 5. 




of f>l»ste4ric imi>orlauce. These are the {interior (or fronto- 
purkH-ti! ) tbiitaiielle and the posterior (or DCcipito-|iarietiil) 
one. 

The simpe ol'tbe antrnor one may Ite uppjroximHtelj de- 
scriljed In* dm wing lines between the fourpoiuU of a erudtix ; 
it is a foyr-i^ided tigure, two uf whose sides areetjuiil — lozeage- 
shaped — the loug, acute angle I m:;! tig formed hy defidetitossiti- 
eatioii iu the |Kisteriorsiij:ierior angles 
of the two halves </f the frontal bone, 
and the short obtuse angle tiy deti- 
eient ossi heat ion in the anterior sjUjx^- 
rior anglers of the parietul liooe.^. Its 
situation is where the corona) suture 
crosses the sagittal. In size it is a 
wjijsiderable nieniliranouss]>acet easily 
reeognized by the hnger, and often by 
the eye, and through it the motion 
of |>uLsatioii iQ the cerebral arteries 
njay be both seen and ielt. It b 
not completely closed till one or two 
yenrs afler birth. Iletnember partic- 
ularly that the hivj angle of this 
fontanelle |n^int^ toward the forehead 
and nose; the short one toward the iM^eiimt. {See Fig, 50 

The /^^k'rfor fontanelle is miieh smaller in size, l)eing simply 
a triangular depression situated at the point where the sMi^nttal 
suture meets the lambdoidal ; radlatiuL' fnon it are ^/irt-^stitural 
arms, via., the sagittal sutiire and tlie two anus of the lamb- 
doidjiL It elosc*s a few months after birth. 

The other four fontanel les, two on each side, are placed at the 
iuferior antrles of the parietal Iwmes. They are ynimjKirtant. 
Regions of the FcBtal Skull. — One of the most inijior- 
tatit ts the vertex. Literally this means the highest )>art 
or ** crown" of the head ; but when in midwifery wes|)eak of 
II *• vertex presentation,'* we refer to a more jxisterior region 
of the (ikulh which I have already comfmre*! to the larger, 
nHuided extremity of an egg, antl which has (I think verj' 
pr(»|HTly) Ihh^h tcnnc*d l»y gome writei's the ** (distetrical ver- 
tex " ; it nuiy be delined as a circular sjmce whose ct^nJre is the 
tt|>ex of the j^jsterior fontanelle, and the circumfereuce of 
which passes over the occipital protuberance. 



ehrtwing lb<? sbarvL' of fon- 
tiinct lo>. the lung acute 
Auglv of thti anterior one 
point itif; toward ihe now?* 
A-B. Bi- parietul diameter. 



DIAMETERS AND LENGTH OF CHILD'S HEAD. 37 

Other regions of the foetal head have been described, but 
they are not of great importance, viz,, the " base" or flattened 
8ur&ce directed toward the neck, and the facial, frontal, and 
lateral regions, which explain themselves. 

The space occupied by the anterior fontanelle is sometimes 
called sinciptdf or bregma.^ 

Diameters of the Child's Head, and Their Ajyproxhnate Average 
Length, (Fig. 6, page 88.) 

The occipito-mental, extending from the 

point of the chin to the superior angle 

of the occiput 5 J inches, 14 cm. 

The ocdpito-frontal, extending from the 

centre of the forehead to a jx)int on 

the median line of the occiput a little 

above its protuberance 4 J inches, 11.4 cm. 

The bi'parietaly passing transversely from 

one parietal protuberance to the other 3} inches, 8.8 em. 
The cervico-hregmatic (called also "tra- 

chelo-bregmatic"), passing vertically 

from the posterior angle of the anterior 

fontanelle to the anterior margin of the 

foramen magnum 3i inches, 8.8 cm. 

The froni(hmentaly going from the top of 

the forehead to the end of the chin . 3 J inches, 8.8 cm. 
The bi'temporaly going across from one 

temporal bone to the other, l)etween 

the two lower extremities^ of the coro- 
nal suture 3} inches, 8.2 cm. 

The subocctpito-bregniatie, going from the 

union of the neck and occiput to the 

centre of the anterior fontanelle . . 3J inches, 9.5 cm. 

Several other cranial diameters are given in some of the 
text-books, and the number might be indefinitely multiplied, 
but the above are all that recjuire to be remembered."* 

' The terms " vertex " "fincip'it," and "hrtfjmn*' are defined so diflerently by 
diff^erent aathors that I shall avoid usinn th«jm as far as practicable. See 
Appendix on Uniformity in Nomenclature, etc.. at the end of this book. 

* It should he noted that the head may be pressed out of its natural shape 
(** moulded ") during delivery, and the direction of such distortion will vary 



38 



THE FiETAL HEAD. 



i)rii^ otlier miasurenioiit (of j^reat inipjrtaiice when consid* 
eriiJg the nieehanij^in « if face pre8eiUnii(*iis ) iimy Ik- added, viz., 
the sterno-iueirUil k'li^rtli i>i' i\w <:\\iUV^ neck when the ehin id 
removed as far us [xnssible from the .sleriuKti , it ih I i iuehe^ — 
exaeily tlte same lus the <le(»ih ut' the yym|tliyriis ptihis. 

Artaculation and Movements of the Head, — I'lie ntotiuiit* of 
flexion and extension are provided fur, in pan, by the artleu- 
hitioii of tlie <K"eipiial eondylivs with the utlui*, a!id, ni jjart, 
by the jirticulationi* of the eervieal verlebrie. Tlie motion of 
rotation (whieh euiniot be foreed beyond llie fourtli of aeirele 




Ctcri of Ai!i«1 heiMl. t-5. fV<*1f»Ho ftont«L S-« 0<«*ipUtvnieiual. 
M^, CiTvfv<^breirruiLiic«(>r vcrtlciit). T-a Prouto-racniJiK 

without danrrer) is pn>vide<l fr^r rhiefly by the articulation of 
the athb* with llie axis, and (larily by iJie jt»intH between the 
other eerviejil vertebne, Tlie artienhitii^n of the atbis with 
the eraniuui, l>einjir nearer the weipilal than tlie npjMmite |jole 
of the beadj i» of itnjH»rlanee in promoting **rtexirin'* dnrin^ 
laiwr, m will \m exiduined further on. (See IMiapter XIV.) 

Vint! f»r jiTfwmtrttion, and c/uwcqMcatly tUfemliliil tniimfclt*ri will 

rtl Dmi till' •»)Hi*ri nrmt'd^iiHnir nny pnrhcnlHr <1l<im' 
M ,n nf the' hrftfl Its tljnt r>nv fnri.'r,'1nTi. nrnT. Wtini- mi 



ft Tri»- unillati im.' ^.1 ttn- < 



'flpUl iuritifft I 



-ijromfiu i.^u^i.yj 



CHAPTER III. 

EXTERNAL ORGANS OF GENERATION. 

The structures generally included in the external genera- 
tive organs of the female are : the mons veneris, labia niajora, 
labia minora (nympha*), clitoris, vestibule, urethra and its 
meatus, the fossa navicularis, hymen, and carunculse myrti- 
formes. The term " vulva " is generally used to express all 
of the genital structures just mentioned except the mons 
veneris. The term *' pudenda** has a similar meaning. 

The Mons Veneris {Mont de Venus). — The mons veneris 
is a cushion of adipose, cellular, and fibrous tissue, situated 
upon the front of the symphysis and horizontal rami of the 
pubes. Its thickness varies with the ol)esity of the individual, 
and its prominence differs according to the degree of projection 
of the pubes. After puberty it is covered with hair, and is 
abundantly supplied with sweat and sebaceous glands. Its 
function is not positively known. It possibly serves the pur- 
pose of a brow, in preventing irritating secretions from the skin 
trickling into the vulvar fissure. 

The Labia Majora. — The labia majora, called also " labia 
externa " and " labia pudendi," are the lii)s of the genital 
fissure, placed side by side in an antero-posterior direction. 
They begin at the lower part of the mons veneris (as if by a 
bifurcation of that structure), w^hich is their thickest part, and 
pass at first downward, then horizontally backward, becoming 
thinner in their course, and join each other at a point about 
one inch in front of the anus. Their point of junction in 
front is called the anterior commissure, and their point of 
apposition * behind, the posterior commissure. 

They have two surfaces, an external surface covered with 
ordinary skin, abundantly supplied with hair follicles and 

J The labia do not unite posteriorly at nn aixjle, but running side by side, close 
to each other, the vulvar fissure terminates in n sort of horizontal ** gutter" 
continuous with the perineum : hence I have applied the term " apposition " 
instead of "junction * to the posterior union. 

39 



40 



EXTEKNAL ORGANS OF GENEPUTWy, 



BehtkCkHnin glaiuls, antl an htfrrnal HiirfaL-e, als<> of skiu, hut m 
gmooth as to be alinui^t iudis^tiiij^njisliaiilt' fruiii a luiinnKs uieni- 
bmue. The transition from tskiii to mucniiM riieiul»nuie really 
take*i place in the hihia rriiuoni, heiiee llie coveruiji; uf thejse 
latter organs is de^serihed by some wrilers as skiii^ by others as 
m ueoii^ mem l>rane. 

Untier the skin of the labia majora is a thin layer of uastri- 
ated nuiHcular trbreS' — the "woman's ilarJos" — ami liene^ilh 
this, emtietlded in a*li|K>iit^ and cjjntjeeiive tissue, a piear-shaped 
8111% the narrow neck of whieh is coiitinnou.s with tlie external 
ijiguinal riog. It Is known an " Jiroea'ts puurh'' ; fMiitiuiLs fat 
and eouneetive tisane, ami oofasionally, In yonng suhjeetii, a 
pnK^esa uf [jeritooeum, homologt^ya witbtlu* pnx'est^ya vagintdis 
of the mak% km>wii as the ** eanal of >inek/' 'Yh\i^ canal 
nsnally lvecomi*y obliterated, but nvay H)mct lines |»en?ist and 
beeome the seat cif hernia. It follows the course of the round 
ligament of the uterus, stune of the fibres of which termimite 
in the labia majora. 

The Fossa Kavic^ axis. — ^.Just !ief«ire the hdiia c<mie together 
potiteriorly they arc uin'ted hy a trans vei^e lldd tif pvuoiut* 
mendtrane (which j^^mewhat rcsenddcs the webof j*kin between 
the thumb and tinger) called the j\ntrrltr(tt (or fnenolum 
jiudeudi ), and tlie little, flepresst*d spa<*e i>etwee» thii^ and the 
jjotiterior commissure in the/fM.'*ri Hurintlnrh. It is generally 
obliterated ai^er hilvor by rupture ni' the fourehettcf. 

The Lahia Minora. — ^The labia minora, or ny alphas are 
thick, donldi' foldn of mucous mernhrane, alwrnt one inch and 
a half hmg, wliich begin hy grsidually ])roje<nJng from the 
inner surtace of the labia majora^ nndway between the two 
cc )it j m JFs u res, T 1 1 cy th e u [ wiss fo r ward u n t i I rei i c 1 lin j^' 1 1 1 e c 1 i t - 
oris, when they split horizontally int»i two f(dds. The u|iper 
folds |>as8 aiiove ilie elitorij*, and, joining in the mediiiu line, 
tHmtrlbute to form the prfpuee of that organ, while the hnver 
uDes join underneath, fornnng its fmnum. The nympha* are 
eovert^l with tesgellutetl efiithelium : they contain connective 
aod muscular tissue, vascular papillic, t^ed seliaceous ghinds. 
They are verj' %^ascular, als*j erectile, antl seerete an tMlon>U8 
sebaceous mucus which bduicjiti^ their suHaee ami prevents 
adhesive union. TIreir funcliou is not <»ertainly knowiL 

The Clitoris, — The <diti»ris is a small, erectile bcwly, about 
one ineh in length, plaeetl just inside the vulvar tis^ure, half 



THE UYMEK 



41 



acli l)t'liiii<l tlie iinterior t*om mi ensure. It is coinp()S4Ml of 
two corpora ciivernosu, whidi lire united in the intclijui line 
aiitl eufl anteriorly in ihe ;^rliins elilondis, hut se[iaratL' from 
eucKotlier iumteriorly to t'orni tlie two crura, which are jittacheii 
to the rami c»f the puhesuud I^^'hia. It i.s couslilered tti l>e the 
analogue of the peoies, but diffl*rs fn>iii thij* organ in haviug 
no corpus spon^aoHuni or uretbrnl taiiah The va:«cular hullis 
of the vestibule au*l the intermediate plexus of veins uniting 
Ibeui on each side with the ve^^i^els of the clitoris, would, if 
united in the median liu(% rejiresent the cor[)y9 spon^ioaum of 
the penis and l)ulbuf tiie male urethra. The iiitori8 has two 
ertH-tor niusele^; it is aimndantly supplied with venseLs and 
fierveji, and coni^titutes the prineipal w-at of sexual sensation. 
Il 18 s^HuircMl to the pubis by a suspensory ligament 

The Vestibule, — The vestibule ls a triangular surface of 
mucous merrdtrane whose base i» the anterior marii:in of the 
vaginal orifice ; ita apex ternjinates at the clitoris, and its two 
^Bides are bounded by the nymphfe. It is of little ini|Mjrtanee 
except x\A a guide for finding the meatus nrinariim, (daeed 
near it^ lower margin. 

On each side of the orifice of the vagina, enclosed in a thin 
layer of tibroun tis^tue, u ruler the lid^ia nnijora, I« a spongy, 
oblong niassof snialb convolnteil veins, which, when distended 
during sexual excitement, a^sumea, in its entirety, the form 
of a filled leech or of a diminutive banana. These are called 
the btdhi veMihuli, sometimes the mtjinai bulha. Their veins 
are continuous with thij4*e of the clitoris and vagina. 

The Female Urethra. — The female urethra is one inch and 
H half in length ; is larger than that of tlie male, and more 
teasily dilatable; it begins at the meatus, which is mtnated 
iinniel lately Inflow the rim of the pubic arch, and imsses back- 
ward, curving a little upward, to the neck of the bladder It 
m (*t»m|x*se«l of a mucous, mus<nilar, and vascular coat. About 
one-eighth of an inch within the meatus are the 0f>ening8 of 
two tubular glands, just large enough to admit a No. I probe 
of the French tactile. These glandular tubules run parallel 
with the long axis of the uretlrra, l)eneath the mucous mem- 
bnine, in the tnuscutar wall. They vary from three-eighths 
U) three-fourths of an itich in length. 

The Hymen.— The hymen is a ereseentic-fihajied fold of 
mucous membrane whose convex border is attached to and 



42 



KXTERSAL onOANS OF GSNICRATION 



continuout? miU the posterior wall of the vasriiial orifice, just 
iuside llie f'ourclietle. lU shU^ then rmi upwjirtl to terniiiiute 
iu the horiKsof the creseeiit, wliieh liu^l !»re iinitiHl l>y Ma urnerior 
concave border- It varie,s in form iti (liferent women. Sune- 
times the hornn of the crescent, instead of coniin'^^ to a jx.>iiit, 
are eontinned as a narrow band to tlie anterior vat^inal wail, 
where the ends join each «»ther, leaving n eircnlar or oval 
c>|veiiing in the centre (/'aonnlar hynieu " ). Oceibsiotmlly it 
covers the oritiee of 1 he vagiua entirely ( ** impct^furate hymt'n^^ U 
or it may j^re^senl a uund>er of \\^v\ small oj>enin;y^ {^'rrihri- 
form hijmt^H '* ). Jt aiso varies in thickness* ami streiijtjth. It 
is usually ruptured by the lir^t act of coitus, thoug:h nol 
always, ami nuiy be torn by other eauset*, so that it is by no 
means so syre a sign of '* virginity'' a^ was formerly snjiposed, 
8ornetinies tlie inner border of the hynifii has a fringed 
ap()earauce, resendduig the end of a Fallopian tulie ( heuee 
calle*:! '* hymen findiriatus") : thi.^ might be mistaken for a 
normal ly ruptured hymen. Moreover, it is sometimes aliment 
altogether. 

The Myrtifonn Canmcles { Canmcul® Myrtiformes), — 
Formerly these were said to be shrivelled, (>r«>jei*ting remains 
of the rnjjtnred hymen; subscHpiently they were 4*on sidereal to 
l*e vas<'ular, membrunons prorninenees placed immediaiely 
iK'hind the hymen, and *|uite independent of il. More recently 
they have lieeii as^Tibeil to ehildl»irth. |>ressure of the child's 
head iluring labor causing ne<Tosis and sloughing of the |>re- 
V iou si y t « » r n hymen , of w h i c h , t heref o re, t h ewe so-i *a 1 1 < d ra rn n - 
des are the only visible remains. This last view^ is probably 
a^rreet, ami explains why the earuueles are often ul>scut. 



CHAPTER IV. 

INTERNAL ORGANS OF GENERATION. 

The interna] organs of generation are the vagina, uterus, 
Fallopian tubes, and ovaries. 

THE VAQINA. 

The vagina is a membranous canal extending from the 
vulva to the uterus, hence sometimes called the "vulvo- 
uterine canal/' 

It is made up of a mucous membrane (covered with pave- 
ment epithelium) continuous with that of tlie vulva and uterus. 
Outside the mucous coat is a thin, muscular layer continuous 
with the uterine muscles, whose fibres run, some longitudinally, 
gome in a circular direction, and others obliquely. The mus- 
cular coat becomes thicker during pregnancy. It is extremely 
vascular, its vessels being so dis|K>sed as to constitute an erec- 
tile tissue, especially toward the vulva. Cellular and fibrous 
tissues also enter into the com|x)8iti()n of the vaginal wall. 

Underneath the epithelium of the mucjous membrane are a 
large number of vascular papilla?. Along the median line of 
the anterior and j)Osterior vaginal walls there is a vertical 
ridge in the mucous membrane fthe "anterior and posterior 
columns" of the vagina), and diverging from these, laterally, 
the mucous coat is thn)wn into transverse ridges which admit 
of dilatation of the canal during labor. 

Its posterior wall is about three and a half inches long, its 
anterior wall about three inches. Its diameter is a little alwve 
an inch. At rest, the anterior and jK)Sterior walls are in con- 
tact with each other. 

With regard to the exact situation and direction of the 
vagina, the descriptions and illustrative plates of anatomists 
differ widely. Roughly speaking, according to Leishman, 

4.3 



44 



INTERNAL ORGANS OF OENERATION. 



"it lies in the iixis of the pelvis, l>ut its axis is* placed ante- 
rior to the pelvic outlet, m that its lovvt-r [jortion is curved 
forward/' 

Its attachments to luljoiuing organs are sis follows: the 
pastcrii>r wall is ('omiet!ted by iti? middle threr-Jifthi* with the 
rectum, the united walls* conHtitn ting the rectD-vaginal .septum ; 
itii fow*'r Jjffh i.s Si* pa rated fruru the rectum, aud is? in contact 
with the }ieniieal liody ; while \t» npptr pph is iii eontaet with 
the fold of pcritojiciirn which desccmls behind the wondi to 
form l>oughLs's miMe-mic, Its auterior wall is uiiite<l hy con- 
nective ti&^sue with the |>oslerior walls of the bladder arid ure- 
thra, cfmstitutini^, rcspe<*tivelyt the ve^icii- vagina I and urethro- 
vaginal ?ie]>ta, (t-^ee Fig. 7, |>age 4'>. ) 

The up])er extremity of the vaginal cylinder i^urrouiids and 
19 attached to the neck of the ytcrus : it is called i\w (ont'ix. 

On each side of the iiritice of t lie vagina are the Indhi vt Mi- 
hull already dcscril>ed. Immediately heiieath and behind the 
|j08terior round extreuiity of this bulb of the veF>tiliule is 
placed* ou each i»ide, tlie vufro-nujinal gland { analogue of 
Cow|»er's gland in the rmile, aud variously called the gland 
of Hugnier and of Bartholin). It is a couglomcratc gland, 
varying in she from a horsse-bean to an almond, and ticcrctt^s, 
during sexual excitement, an exceinlingly viscid nincns, which 
Ls diseharged from the oritice of the glaud-duct into the fosga 
navicularis. 

The vagitui is abundantly supplied with iiervcB, ei*pecially 
toward its oritice, where it i» endowed with a peculiar »en«i- 
hWxty. \U arterial supjdy is derived from the uterine, hyjx)- 
gtistric, vciiical, and pudendal arteries: and its numerous 
venous plexuses coutiuuon** with tho*^ of the vulva, clitoris, 
and uterus, terminate in the liyp<jgastric veins. The vaginal 
veins have do valves* 



THE UTEEUS. 

The uterus is a thick- walled hollow organ, in the form 
of a truncatefl cone, .^lightly fiattened antero-f>osteriorly, situ- 
ated in the middle of the j>elvic cavity, its upper end being a 
little lielow the phuie of the suj>erior strait. The bladder is 
in fn»nt of it, the rt^ctum behind, and the vagina below it 

The small intestine rests upon it from above. In Fig. 7 the 



THE UTERUS. 

Fio. 7. 



45 




Female i^tienittTe orgun-. .. „^l. . ,, tudhml scctii>nthrouph Cbe median 

line of the body. 1. Bwly of utenis, 2, 1'uvity of body, a, CervU titisri. 4. 
C»vity of cervix, &. Os uteri. 6. Cftvity of vAgina. 7. Viiglnal orifice. 8. Blad- 
der, t. T'rethra. 10. Vesico-vafnnal septtiin. IL Rectym. 12. Cavity of rectum. 
Ml Anus. 14. Eeclo-vaglnftl septum. 15. Perineum. Ifi. Ve*lco-ulerine cul-clo- 
iac. 17. Rncto-vasrinal cul*de-Bac, or eul-de-juif of Douglas, 18. Pymphysla publa, 
1*. Nytnpha. 20. Labium majua. (From Bakniss, after Tarkicr ani> Sappky.) 

relative position of the uterus ii* shtnvn with tbe liladdtfr and 
rectum distended. When tWse orgaii** are emptif, the relations 



46 



INTERy Al ana A a\S of aEMCRATlON. 



of I lie parts are mi>re exactly represented, as in Fijp. K The 
liter Ui* hilt? three roafn: (Ij a serous «*4>!U { |Kn*itoiieum) on the 
ouLsiile, ( 2 I a Tiuij4tnilar cunU wIiiL-h •^ivew thirkiifSf? and ^>litlity , 
to the uterme wiills, and is compoaed of you-s?triated njiis<ular 



Fi«. 8. 




RcUttvc |io»lUoii i»f pelvic organs when t»U«Mt?r arul rctturo Arc emply. 
(Alter liKKlNsoN.) 

fihrefinrraiigCHl id Inyers, hnvin^rdiflTercMit directions, cmnilnrly, 
loDicitudiimlly, iind f^pinilly, uldch are chjsjely adherent lo 
untl deeussiite wlifi eii(*h other ; (ll ) a nnK*t>it« lining continuous 
with that of the vagina ami Fallopiiin tula's, and covered with 
ciliated, ndtirrinar e|)ilheliuiiL Wh«^n a new mucous nuni- 
bnme Ik'^Hhh (h form in the ult*riii* after menstruation the cells 
are vifhout cilia : Init the mature cell;* are ciliated, whieh 
acc<nints for **orrie cdwervers OKHerluig tliat thei>e cclb are cili- 
ated and others that thev are not- 



77//V UTERUS. 



47 



That [Kjrtion of (he neck of the uterus whicli jnYyect^ intu 
the lci|> of the vti^itm h covered extt*nially with paveiiieut 
epitheliuTu. This? ltii<t joius \\w coluinimr qiithelium of the 
iiiterinr of tlie uti-'rua just within itK* extertiaJ os uteri. 

In k^uL'tli (rt)UMling i\w tliickiieas of ns up[itT wall) it is 
CnJUghly) aljout 3 iurhe.^ ; the length of its fmift^^ from tiie 
extemul oa to the top of tht^ fundus {not ijiciu^iiug thiekneas 
of u[)[jer wall), is 2i inches; its wi<hh, traui?ver»ejy uero.ss ita 
wideist up}>er part, is 1 i inches ; aud its greatest atiteropudterior 



no. 9. 



Flo. to. 




^cctJaii «if the uitniM bcfurc chtld- 
birth, a. Ciivliy ofccrvU. c fiivlty 
of body. M. (iH iuUTTnim ». Itcriiic 
Willi, (Protn BAKNia^, M/ttr Tahniku-J 



n, 



•/. 




Section of nUfTUB aAer ehlldblrtli' 
The Irtlcr* have tlifi luiuie tii«;Atiitii; 
M In Pi«, 9. (From Bakmss, nfler 



thiekneHB 1 Inrh, At tlit* cw\ of prejjnancv it attains the »\m 
of n foot iir more in h^nirtli, and 8 or 10 inrhes transverwOy, 
It is* <Jivide<l hy an}itorait*t,« into fundus, IkmIv, ami net*k. 
The. fun ffuji \n iiU that rounrhnl |K>rticm plac*Ml a]>ove a hori- 
Zi^ntal lint* ilniwn throuiih thf antrle^ where the Fnllopijui 
tubes r»pen into die wornh: llie hofhf\s nil thixt ^Hmum hetweeu 
t!je fund us and I he neek : arol the Htrk is nil that part helow 
a line drawn horizontally through the organ at the level of 
the internal ^jh uieri. 



48 



INTERNAL ORGANS OF OENEnATION, 



Ita cavity is divided iotej tbe cuvitv of the Imdy and the 
cavity of the neck. That uf the budy is triangular and iliit- 
teued anttro-posteriorly ; il has thrive (»|!euingF, thoee uf the 
two Fallopiuij tubes ab<»ve and thai of the m iiitenium lielow. 
The cavity of the ueck m barrel -^^ Imped or futJifonii, and eom- 
(Miratively narrow ; it U cuu^iriLted alKJve by the iniernai o&, 
that separates it from the eavity of the liody, and gnmi^ nar- 
raw again at iti* terriiiuation in tbe exteriral os uteri. After 
chihJbirth the coti4*lrietionHof tiie internal and exteroal oe are 
le^ marked, (See Figs, d and 10, page 47. ) 

Microscopic Structure of tlie Uterine Mucous Membrane. ^ — 
It i» eunipo8ed of imirt^y^ follicles (*'ulricuhir glands'-) 
placed jx^rpcnHlieuhiriy to the internal surface of the wondi. 
Their moutlw 0]>eo into the uterine cavity, and they ternd- 
nate hy rounded, hullMJijs extremities (some of which are 
bifu recited ) np>n the nuisfiuhir coat. The follicles are lined 
with coluniriur epitlieiiiim ; and some idea may be formeii of 
their size (-^^.^tb of a line in diameter) by remembering that 
tliere are alwnit ten thoumnd of them in the mucous ineni- 
brar*e of the eavlttf of the Jiert alone. 

Broad Ligaments of the Uterus. — The^e are simply fohls 
of ]»crit*>neum covering the extcrtial surface of tbe wimd>. 
Let us imagine a line drawn acrot* the outj<ide of the top 
of tfie fundus and prolonged transversely until it reach 
the sides of the j>e1vis. jiegimiing at this imaginary line a 
broad layer of jieritoneiim pasties down over tht- anttnor wall 
of ihc womb to tl»e level of a |Kiint irndway liet ween the inter- 
nal an<l extcrnsil oh, when it tnrns up and is reflected over the 
posteni>r wall ni* tbe bladder : (his is the nffterior broad liga- 
ment. A simibir fold juis^t^s down over tbe pisterior wall of 
the woniln going low enougli to cover tbe upper one- tilth of 
tbe po*iterior mfjittttf wnW (as nlready exj)lainc<t )» when it 
lurnn u|»am1 is reflected over the anterior wall of the rectum : 
this is the posterior broad liganrent Thus the uterus, with 
( a n d I »et ween ) i ts two 1 1 roa d I i ga m en ts, f< inns a so rt of t ni m»- 
verse jiartilitm to the |>elvic t^avity ; the bladiler, urethra, etc., 
lieing in the front com[iartmen1, and the rectum in the back 
one. The lateral borders of this double ligamentous curtain 
are attached to tlie sides of the jHdvis. and hence the**e liga- 
ments are sometimes called " right '* and ** left/* instead of 
"anterior" and ** posterior/' as above. 



OTHER UGAMEaSTS OF THE VTEllVS. 



49 



Other Ligaments of tlie Uterus : 

Fifuf. The round iufavunif<, which are ^hro-mnmuletr uords, 
4i inches long. They Ijegin iK'tir the ifuperior angles of the 



Fi.,. n. 




AiiUrrlnr vUiw of IntemAl «t?ncnitl vt* r*rgiiti*, 11gniin?lil«, ek'. X%f\ «if Ihe l>rn»d 

lip liy n contml ifu Jsion. f *. ( »!rvtx UUrl /,. Hn^Mulliifuineja of Uft sldi'. //. 
BromI liKiiTDi'iit of Hglit KtdLv ♦/. rtirrMiviirMn hirnnn'ul, o. 1 a* fY nvitry r/. 
Right ovnry, /*. F»mbnnto4 ci»4 ^f Fallopinii t*ibe. Vf. Uouiul ltg:iimffit of tcfl 
•Jdc, U*. RoiiiuniunnuiU <»f Huhtsi*Uv T. l.vA nvlducf. T, Rlifht ^'viduct 
ptillint dov^ii (fi hhnw ovury T rt4^niK. I', V'fmrirm, I", I'oaU'rlorcolumtMif 
vRfflrtii. 



womh» and pass between the two foM^ of the bmad li^amente, 
sucoeseivelv out ward, ftirwartl, and then inward, to the inter- 



50 



lyriCRNAL OHO A AS OF GENERATION. 



ut\i iiiguitial ring, and ihruugli tlie iuguiiiul ("aual^ Uieir t^r- 
Tiiinal Hbres heiug loHt in the mon^ Vreiterls anil labia mtijura, 

Stroud. The vem-o- uterine ligarueut-s : semtluirar-i^liapeJ 
folds of [K^ritciyeiim pajti^iug t'roni the lower (lart of the \mdy 
of the uterii!+ to tlie tuuiiii.s of the hUnlder. 

ThinL The ufcru-Mcral lii^nimiuis: erescentic-shapeflfbkla 
of pcriloiH'tiiu [laSv^iim fr<HH the lower part of the liody of the 
uterus lo be bjierte*! into I he thirii auti fourth sacral vertebrae, 

Fjo. 12. 




fienemllvt' orsraiiR st'vn fnmi alK»vc. m Vnht-t. a. A 4lti fmnti. Rematndor 
of hyK»ffiistrk' nrterit's. a, a ilk-hind). S|M>rnmtic veMols nntl ncrrea. ». 
BlAiUler. L, t. RoiiiuJ llKutiicnt}^. i Fiinflm ut^?ri. T, t. FnUupI&D ttibes, o, o. 
Ovarh**. u Itectiim. **, Kljfht ur»'ter rifiittiiK on thv iwoas muscle, C, rioro- 

Fourth, There is i^till another short ennl» containing many 
smooth njiiH'ular filu'c^. extending from near the up|)C*r angle 
of the uterus to the inner extremity of the ovary. It iHulwut 
one inch in length, and is called the ntfiro-omrtan ligan\ent — 
gometinjcj^ the ** Ntjainmt nf Ihf ovnrij'' All the ligan»ent» of 
the nlvruH (xtntain mnie mnn^'ulnr tissue, which in increased 
during pregnancy. ^ >V*e Fig. 11, pnge AS\ ) 

The relative |KHition of the utern? atid its ligaments^ with 
adjiu^nit organ;*, when seen from above* iii aliowo in Fig. 12. 




ARTEItiES OF THE WOMB. 



51 



Arteries of the Womb* — The ntcrine artery (one od each 
—lie ) is ^Wi'u oti' Irom i\w unltTiijr branch of the iuteniiil ilisu% 
tl (lejieemli* l>ehiiHl tht* ]>erit<mc^ijiii to the to mix vagiiiie, where 
it* piilsitilicHi nmy h« tilt withlhf tiugt^rduniig pregnancy, and 
then iUieen<i.s between llie anterior and jK>sterior ioUh ni' the 
broad ligament, alon^j; the side of the cervix and cxjr[ni« nteri 
ftu l»olh of w hie 1 1 it gives off' nnmy deeply ^le net rating 
branches)* ami, tinally, its main trunk beconica direitly con- 
tinuous with tJje ovarian arterv. 



TU9AL VCSSCLS 



Fig. i». 



APtASToiiOBi* or 

UTCR«MC AftIO 
OVARIAN ARTEIIICS 
HCLICINC SHANCMCS ] 



line ¥Cfious rtcaui 



•>! 



^raT 



»AM >'* 
OUHO UOAMCNT 



UTCHmC APITtllT 



MINAL VCMOy« PL! XUS 



V. 



(fntOn VAQINAk 
ANTCRiC* 



OS UTCAI VAGINA CUT OWtH ftCMmO 

Blood iUpply of uteroa^ (A Iter TKKrirr.) 



The owirian artery (one on each side, eorreaponding with the 

pmiatie artery »if the male) is ^jveu off from the aorta 21 

be h es a bo V e i t** bi Aj rea t i o n . ltd eiseen* b i n t o t be { le I v i c ea v i ty , 

"and then a^srends beiween the two fohi?^ of ihe brnad ligament 

tu the Falloj»itni tube» irvnry, and fim<bi?j nteri, ami lerminatea 

by nna>1om<h<is wi()j the literine nrterv jii^<t dei^*ribed. 

Al the junction of I he IkkIv and cervix nteri ij^ a circumflex 
branch which unitee the arteries of the two sides, and which« 



52 



INTEllNAL ORGANS OF OEyERATiOS. 



when rut <lyritig siirji^ica! operatiuiis, Meetls j>roiyseJy- The 
arU^riai brauchess in the uteriue walls are reiniirkjilde fur their 
numerous anast^jnioses and s^phal course ( hence en J led Itf/lf^hw 
arteries), the hitter ijyality pruviding — it ii?tiup[xij?t'd — ihr their 
loogitudinal extenniun during |>regnanev, ahypjMJsitiou that is 
very materially weakened hy the tiiet that the arteries are more 
lortyoue during pregnancy tliau he to re. Jioreuver, the arleries 
of the ovary prc-^eyt the name spiral course. 

Veins of the Uterus. ^Thene hegin by small brauches 
eonttnuinis with the line plexut* of eafiillarie.^ into wliieli the 
uteri ye fiW/rrV;^ divide iu the internal lining <»f the organ, and, 
im>i*culatiyg freely with each other, unite t<^ form larger veitia 
(always! uithout valves) in the sybbtance of the uterine wall, 
whence they eventually pasB out toward the folds of broad 
ligament, where, joining the ovarian and vaginal veins, a re- 
markable venou!? network is formed, knowti as the *'pam/;Nii- 
Jonn piexu^.^' ^See Fig, lo» page 51.) On each side of the 
titerys, near its junctiou with the top of the vagina, the greater 
number of vessels in this plexus jRatr their hlooil into a trunk 
of considerable size— theiyttrnal »[)erinatie vein — which emj>- 
tiesou the right side into the vena cava ayd on the left into the 
lefl renal vein. 

Nerves. — The nervous supply of the uterus is received 
chiefly from the s\^tij)athetie system — viz., from the hypogas- 
tric, renal, spermatic^ and aortic plexusei^ 

There is no hmger any dtiuht that it also receive^ bratiches 
from thecertdu*0'Spinal system, derivetl clucfly frnmtliesecond> 
tiiird, and fourth sacra! nervea During pregnancy the nerve- 
fdires increase in size. 

Lymphatics. — The womb is nimndantly supplied with 
lymphatics and ils lyin|duitie vessels terminate in the |ielvic 
and lumbar ghiuds. It is chicHy thnmgh the^<e lymphatic 
channels that septic imttters are taker* up from the cavities of 
the uterus and vagina, trans|K»rted to ot her organs^ and curried 
into the blood, thus pnidn(*iiig sepiiciemia. 

Ftmctions of the Uterus. — It is thea*iurce of the nien- 
strual discharge; it receives !*pernuitic fluid from the male, 
and the gernwell^ whet her imprcgimled or not — IVmn the 
fcrmde ; it prt>vitles a place for the f«Hus during its develofi- 
mcnt, and is the source of its nutritive supply ; atid it contracts 
at full term to ex|>el the child. 



FALLOPIAN TUBES. • 53 

During gestation all the tissues of the uterus undergo a 
decided physiological hypertrophy. After delivery they go 
through a sort of gradual physiological atrophy — back again 
to what they were before conception. The enlarged muscles 
especially undergo fatty degeneration and absorption — called 
" involutiony'' in contradistinction to ** evolution *' or develop- 
ment The process of involution requires a month or six weeks 
for its completion, sometimes longer. 

Mobility of the Uterus. — The womb in its normal con- 
dition is not fixed or adherent to any part of the skeleton, but 
enjoys considerable mobility ; it is simply 8us|)ended or hung 
in the pelvic cavity by the tent-like aprons of |)eritoneum and 
other ligaments attached to it, as well as by its nerves, blood- 
vessels, and vaginal attachments. A full bladder pushes it 
backward ; a distended rectum, forward. It changes its posi- 
tion, by gravity, as the female changes her |X)Sture. Viewed 
through a speculum, the vaginal j^rt of its cervix may be seen 
to rise and fall with every motion of the diaphragm during 
respiration — an observation becoming still more apparent 
during the violent diaphragmatic motions that attend laughing, 
coughing, etc Forcible injection of the uterine arteries after 
death causes the uterus to rise in the pelvis and execute a 
movement resem Idling that performed by the penis during erec- 
tion, which leads to the 8up{)osition — difhcult of pnwf — that 
this actually takes place during life under venereal excitement. 

FALLOPIAN TUBES. 

Given off from the uterus, at each of its superior angles, 
is a tube whose canal is continuous with the uterine cavity. 
These are the Fallopian tubes (sometimes called "oviducts"). 

Each tube is about four inches long ; near the uterus its 
diameter ( .j\ of an inch ) will just admit a bristle, but increases 
in size in its course from the womb toward the free distal end 
of the tube, where it is as lar<re as a goose-quill. The tul>e 
passes from the uterus in a somewhat tortuous course, l)etween 
the folds and along tiie upi>er margin of the broad ligament, 
toward the side of tiie pelvis, and terminates in a dilated, 
trumpet-shaped extremity, the free margin of which is, as it 
were, fraye<l out into a number of fringe-like processes called 
"fimbriae" ; one of these, longer than the rest, is attached to 



54 



ISTEMyAL ORGANS OF GENERATION: 



the outer extremity u4' the ovtiry. Some uf the rringeil (iroo- 
esses are eon t in net 1 tis tliiii, leaf4ikt% loiigitudiiml UAds of 
mucous memijraue into the ditatcd eud uf tlu^ Luljt% which 
grow uunuwur ius tbcy aijpioiich iu* uterioc einl, jis i^iiovvo iu 
Fig. 14. 

Like the uterus, the FttJlopiau tulxis are cymjtofcfid of three 
enrnU : 1. A .ieroaa ( i>crilLiueul j oout uu tlif out^iil*/ ; 2. A imui- 
euiar cout com|x)seti uf twu layers, viz^ circular hljrc&5 (inter* 
na!lyj aud luiigitudjuai mws ^cxterimllyj ; ^. A mui^oui* coat 
continuous with that of thtj uterus and lined with eiliiited, col* 
umnur ei*itheliym. At the ilistal end of the tiilw the luucoua 



Flo. l«. 




The fivHry anil ov(*1nrl, 1. 1, Ovftry 2, 'i. Pnrt of ntonii?. 3. nvariun U^m- 
mrnt. I. i Ovfdnot. Its wnU op<'tHf1 by a lofijrUintiiuil inrls^ion to sli*«w the 
U»nidtn(1tnn1 (uUUitt UxUninic membmiir. 5, f.. PiivUioTu fmrn lnl*miftl Niir- 
mt^tv r.. Ck Fimhrlii nUiirhi'c! to ihi* oviiry or rubo-oviiHttii lignment. 7. 7. 
LoQufttudiniil folcift R IntfTTiHl end of the ovldnrt. 



coat is ci>ntinuous with the peritoneum^ and furnii*hes the only 
instance in the luMly w4iet*e a serous and a nnicou** rnemhrane 
are thn>« joined. 

Functions of the Fallopian Tube. — ft rr>nve\'fi! sjjenuatie 
fluid from the uterus to the ovarv and conducts the |rerrn-eell 
from the ovary to tf»e uterus. When the ovule f ^'erm-ccH) 
is ahont to lie 4li8charjre<l from the oviMuc, the tinihriie of the 
tube *?rasp the ovary, so na^ to promote the iiafe entnihce of the 
diminutive germ-eel I into the trum|>et-shiii^l mouth of the 



THE OVARIES, 



65 



tube, whence it is conveyed, by periistaltic motion of the canal, 
into the uterus ; this trausniissiou of the germ is also assisted 
by the cilia of the epithelium, which wave toward the womb. 
The waving of the cilia is said also to produce a current, 
toward the tube, of the fluid covering the inner surface of the 
peritoneum near the fimbriated entrance, so that the ovule, 
when not at once received by the tul)e, may passively float 
into it aiterward U|)on this moving fluid. 

Fig. 15. 




Relations of ovary with uterus and Fallopian tube. The two lines inclose a 
V-flhape<l bit of the ovary, which is represented, largely magnified, in the next 
figure. Both figures are, of course, iliagranimatitr. 



THE OVARIES. 

They are two in number (rarely three), and are placed 
one on each aide of the womb, ])ehind and l)elow the Fallo- 
pian tubes. Formerly they were thoujrht to l)e situated between 
the anterior and posterior folds of the broad ligament. This 
is incorrect. The ovary is really set *' in a hole in the posterior 
layer of the broad lip:ament, as a diamond is fastened to a 
ring." The part projecting posteriorly, above and beyond 



66 



INTERNAL ORGANS OF GENERATION, 



the surrounding margin of broad ligament (as the diamond 
projects above its setting of gold), is therefore devoid of any 
peritoneal covering, the free surface thus exix)sed being the 
columnar epithelial layer of the ovary itself, as shown in Fig. 
14, page 54, where a distinct line indicates the transition 




Triangular bit of ovarian stroma out from ovarj*. Magnified to show Graafian 
follicle and ovule. 1. Epithelial covering of ovary. 2. Tunica alhuginea 
(fibrous). 3,3. Diffentnt parts «»f slroniu. 4. (iraafian follicle (tunica fibnusa). 
5. Ciraafian ve.sicle or ovisac. f». fi. Tunica granulosa. 7. Liquor folliculi. 
H. Vitelline membrane, or zona iK-Uucida. '.». (iranular vitellus, or yolk. 
1». (ienninal vesicle. 11. (ierminal siMit. 

from ])eritoneiim to ovarian epithelium.' Tho ovary is approxi- 
mate()' almond-sliaptMl, hence it has two ends, one of which is 
connected with the angle of the uterus by the fibro-muscular 
"ligament of the ovary," while the other is joined to the 
trum|)et-shaped end of the Fallopian tube by one of the pro- 
longed fimbria, known as the tulMM>varian liirament, or fim- 
bria ovarica. The ovarian l)loodves.^el8 pass u]) lietween the 

1 In Fig. 14 the whole (ivary is n'prcscnt<Ml pu<li<Ml up out of ]>lace. If pushed 
down au'uin t«» its normal iMisititiu. it would b<- /•//»>»/• the Fallopian tube, as 
slutwn diau'rammaticallv in Fig. l'>. 



sTitvcTunj-: of the oi:iRy. 



57 



fwo fol<ls ijf l>mad I imminent ariiJ eiik-r tht* organ in a little 
ilepreiwion culleil th*^ In/nm. Each uvary t^ alHHit one mvh 
and a half in leiiglh, thre<>!|U artel's of an inch wide, and uue- 
tbird of an inch thick. Weitj^lst, mw or twu draclinis. 

It:? function is ovu hit ion— Unit i^ to sjiy, the produetion, 
Uevclopment, matumtioiu and dUcharge of ovules. Hence 
ihe ovarie>s are the e^^entinl orgaui^ of geiioratiou in the female, 
ns the teslicleis are in tht^ njale. (Fig. 15, page r)5, shows 
relations* of ovary vvitli uterus and Falloj>ian tnhe. A triau- 
guhir hit of ovarian stroma, showing ovuin magnilied, is aeen 
in Fig. 16* page 6G;. 

Structure of the Ovary. — Tht* ovary is tMn-ered externally 
with a hiyer of colli ninar e|>itlieliuni, tlie cells Ining like those 
lining the Fallopian tube, execpl that the ovarian epithelium 
i» HHciliatciL This siirfrtce-etittbeliuni is sonietiines CJilled 
**germiDal epithelium,** since some of its cells become, iluring 
ftetai life, dee[>ly emherlded lie low tlie surface, in the solid 
fiuhetance of the ovary, ami thus constitute ovules. 

Immediately iKuieath the external covering of epithelium 
is a thick coat of white, hUrous tissue, the tufimi ttihtujuiea, 
liiHide this last we find the S(did substance »jf tlie ovarian I>ody 
{the kermd of the ovarian nut, so to s[ieak ) — the iifroma — 
coni|s»st^d for the mast jmrt of filimusatid muscular tisane, and 
traversed by nutrierous blmnl vessels, 

Dotte^l al>out in various |>arts of the stroma are little, round 
Ciivities, called **Gra4ifian ('(r^///r/*^K/' The wall of these glolni- 
lar fcdiicnbir cnvitif*s is made up of the stronn* suhstjince itself, 
iH'ing in tact com|>ost^d of a dense layer of the stromsrs nm- 
nec<ive or iibrons tis'sue, and is therefore s^onietimes called 
^'ifittim fihrom/* [t is imrneiliately surrounded on all |jart^ 
of its |ieriphery witlr an elab(»rate network of ca|nlhiry Idood- 
vesseh. Fitting close inside and completely 111 ling the 
**(Tpaafian follicle" is the '*(iraafian veHtflf/^ or '' ovihuc^** 
sometimes termeil, in contra* listitiction to the tutnca fibrosa, the 
** tnnlcft propna.*^ Ijwjsely adherent to the iusitle of the ovisac 
all an>und is a granular layer of epithelial cells, the ''tnnira 
(jranuloMay Insitle this is the *' fltinnr fttlfirit/i " (or fiuid con- 
tend* 4if the ovisac), in which tloats the hittnnn njg, or i^t'ulr. 
It is only a yolk ; there is no white to it, so that the next 
fneml«rane we have to encounter is the zrtnn pt'/htcith^ or 
ejiernai membrane of the egg, while next inside of this l» the 



'U 



lNTi:JiyAL uliOAXS OF aP:NERAT10N. 



iniemal or vitelline mrmhrant' ; between tlifi^e two i^ a little 
gjMice (X't'upietl by ti Hyid, ualletl tlie peri- vitelline space. The 
egg t!ml>riiced hy the iiitLTiial or viteliirie tiieiiiliniiie tltml?^ m 
the rtuitl of tlie peri-vilelliiie sjmce witlnii the xouu ]>ellucidiL 
Knilvethled in the ^ult>;tanee ttf the yolk is the *' fjeriniual 
irenicle^** «nJ liiside thaf the *' (jt^rminal ifjiot,*^ Besides the 
tunica graiiidoiia wneririg the insiflf ot tlie ovii^^c, a reHectod 
hiyerofit i^ di^jiosed all around the outMidt of ihe /,011a pellu- 
cida. At birth it is said each humati ovary really routaina 



Ki<i 17. 



mmr 









Vertical soctlon thmugh ovary or human fcEtus, g. Germ cpttbt'llutn. with 
0, o, developiuK^'Vulc* Jn It. t. *. Ovarian »lf<jfna rtintalnlnit *\ *% ^i^ifo^nl con- 
nect ive-tianuc corpu»cltr<4. w, v. Caplllan* WiHjdvesaels. In ihc cc-nlre of MpjHtr 
snrmce of litrtire an iuvoUitfon of Ihe germ epllbelUim is shown; anU at the 
lowtT k'R liidc an Isolateil primonilal ovule, with conneclive'tlasne cell* rang- 
ing themaclves round It. (From Playfaih, afl*?r FfHXisO 

about .^0.000 Graafian folHeles, with their coiiteuli? ; but tmty 
the few that lire approacbinjr nialiirity are hir^^e enou^di to be 
st»eu with tlie naked eye, Theovuleii are therefore formed, for 
the Tiiost part, before hirtb. tlunifrh their formalirni i^ thought 
to eontiiiue in some instances two or three year^ later. Early 
in f<«tal life the ** primordial ova" were simply enlarged epi- 
thelium cells — uern* e[>ithclium — ujwn the external surface of 
the ovary. The way in which they be<^oine, later on, ijsolated 
ovnle8 buried in the ovarian stroma, is ai* follows : Cylimlrical 
inllection^ «»f the epithelial covering of the ovary turn in and 
dip down into the 9ul»Uinee of the atroma, forming a sort of 



STRUCTURE OF THE OVARY. 



69 



lie (like the follicle of a nHii!(uis iiitMiiliruiu*). The**** are 

nown lis ** eggK'orfls, " nr Ptiujurersi lubt^. The hegmuing af 

fiueh a ftihliiig^iu of the germii\Hl epitbeliuni is showu in 
Fig. 17* 

AVhile tha*e iutlectioiig of germinal epitbeliym dip down 
into the ovarian stroiiia, the ctmnective tissue of i\n* stroma 
itself grows up around ihem, and timilly unitet«, cutting off the 




Section through pAil ofii nmmniAUnn ovary (after Wirdkhsheim), KE. Oer- 
mlntLl pf.llhclhjrn. PS. ItiflccUHi stirfaee ofeplthiiHQm. fomiinjc tubuk* or ckk- 
eofil. r, PHmltlveiiVA, i?, liivf^ting cells. A'. Germ iiml vesicle, >\ foUi*'- 
tiUrnivity i4ri«iiig Itl om^ nf the ohler fnllteles, //. FoUlciilar onvlly more 
cnlttf«ed. £*f. Noarly rnnlurv ovum whfeh hn» ik*vt<U>jtcr1 unmnrl H Iht* jton* 
p%!>nu(<lUjt Mp. .Vr/. Mt'inhmnii grMtiulortn. p, Prollgirrous dtsk. So. t»varii»n 
**trtjniii, Tjr OnwflAti rolUeUv g. Mt:»ortve«afIft, 

iieek^ of the tubules and fhiiM burying them in ibe gubgtanee 
of the ovary, where they ljt'(Mniie ovi«ii«. The several stages 
«>f the f^roceee are shown iu Fig, IS, 

The wiiy in which the ovule fegg, gernwtdl ) gets out of the 
ovary is as follow.^ ; A-i the Ctranfian fi>llide reaches ninlurity 
it approtiehes the surface and begins to cause a protul*enince 



60 



JXTERKAl nnajXS of aJCNKRATfOX. 



(like a Jilfle Imil ) u|»uii tlic oubitlo of the ovary, KvonliKilly 
tlie epitlieliiil t^xtrriiiil er»iU, tlu- tunica iill>wgim'a, llit* wall of 
the Gniaiiiiu iollirle (Uiuita hhro^sa), and the wall of the 
Graafian vc^iiele ( ur uvisnc)^ all hiirsl at the sniiie ixjitil. ami 
out t'ome*H the vitelline nieniliraiie, Kife and whole, with its 
coDtents anil clincclnir ar^niTul it a loose, irre^nilar massof tl»e 
'* tunica grauulosKi," callefl the *' iiroiiijeroa^ dUL'^ 

Fjo.10. 




Section <rif aviiry, showing tH»ri>iis liittMim tlaree weeks after mens tnmtlcin. 

(Aavrl (ALTON.) 

At the monieut of rupture of the fijlHde, or j^hortly after- 
wanl, the ovule In receiveil by the Fallojiiau IuIm:? ami after 
fionie Jaya ia conveyed to the uterus. 



THE CORPUS LUTEUM. 

After dit*ehar^e of the ovule, together witli the liquor Co]- 
lieuli and that part of the tuniea j^-ranidoKa eliupiuir to the 
ovule, the eni|>ty. deserted oviwie filljs up with a ehtt of l*itHi«l, 
to wbieh are t*uhse(piently addeiJ uewly pn>liferate*i I'ells of 
the Fuemiiniua ;L'rnuuh»8a ; wanderintr wfute eorpiiBele.^ from 
the Idood ; and a *' vitelliis-like suhstaiu'e ^* tA* a jft'/iov eohtr 
eoutaiuing p-rauulen ami Ldol*ules resendjlimr those of the vitel- 
lus. The while Itltiod-rorpujieles afH'imuil:itin*r near the wall 
of the vesicle pregs the remaiuinir conleuls toward the centre 
of the cavity, while vascular pa^iilhe projeet mi all sides 





THE CORPUS LUTEUM. 



61 



toward the centre. The krjyrcr vessels iiuleuthig the yellow 
miLsw iinpiirt to its fxttriiir a folded a[)f>earauce, ionnerly 
a^scrilK'd to eoiivolutiuiiH in the wall of the ovii^ar. Event u- 
ftUy the contents of ihe ^ac are alj^orhetl, uihI the follicle 
shrivels and contracts into an in8io;niiirant eieatrix or dimple. 
The yellow^ ctilor of the content.s of ihe uvi«u' has caused the 
Bile of the iiischaffrcMl ovnle to he called ** corpus lulenm *' 
— yellow hody. Corpora lulea are of two kinds, *' true ** and 
*Malse.'^ If the ovale he inipreguatedi a true eoq>U8 luteum 



Fig. :)0. 



Fig. 21. 




CurpiiH tiitcum of the fourth month of preg- 
nancy. (After I> ALTON.) 



Corpus lutcum of prcfomncf 
nl torm. i\(tvr Oai.tos,) 



is dcvelof»cd ; if iinpre<rnation have not taken place, there 
rwnltfcj n fnlsr iHtr\nm UiteoTn. Tiie s|»eeial (chief) difler- 
enrf^ hctwecii the two are a.H follnws : Ij^I. The false corpus 
luleom increa><ett hi 8ize for three weekn ojily Oi'e Ki^^ 10): 
the trne tine continuej^ In grow for alxnit ftnir ninnlhH (see 
Fi^. 20 J. 2d. After three weeks the false corpus lutenin 
*leclii»es rapidly in size, and is redueefl to a cicatrieia! dimple 
at the end of two months; while the true one, having grown 
so larire as lo <HxnipT the jrreater part of the ovary hy tlie 
fotirti* nr fifth nmnth* remains ahont the same s^ize dnriii^ the 
fifth and sixth niontlis. then L'nnlniilly declines during the 
stnenlh, ei^'-hth, and ninth nionth.^ ; hut it is uni rednctHl to an 
insignificant cicatrix until oue or two mouths after delivery. 




62 



ISTEESAL OIiaAXS OF UEyERATlON, 



3d. A true curpu5 luteum is single j a false one will be ac-com- 
paiiied (eitiier in the ssuiue or tfie ini|K»site ovury j liy the visi- 
bly evidt^iit rL^ijmiuii of m jjrtHleeeH^r. 4th* The eiciitrix 
reanliiiig from a true coqius luteum lij mare distitietly stellute 
than the eiemtrix uf a faliie one. 



Flo. 22. 





Oft. PHmvrtriiim, ft. Remains of the upt^^'^^oet liilw* <vf lheWt*inii»n l»*i4ly. 
e. Mldilk' lii't of hiIh'* formini: |tiiiro%-iinum. d- Ijowvt iitn>phte(l Uiln-s, 
«. Alrophted rtsmahiM ♦ir\\S>tm«n *luct or (iiirlner'* cjinAL / Tho terminal 
hulb or hytJutid of the WoltB«n tlucU A, The FftlltJi>lnn lube. i. Ilyantld of 
Morgo^tih l. Ovary, 

THE PAROVARIUM* 

The purovarium (fw^nictinies called the orgfin of Rtm-n- 
muiler) is the rein»iii!« of Hip Woiffinn hofhj of ftutal life, 
aiitl cfirre8p<)iidH to the e[>ididyinis of the ntsih-, IMam'd in tli*^ 
p«»f<tenor fi>ld of the liroud iJL'^anient, wliere it may he m^n l»y 
holding np the latter and lt>i)king thronjrh it liy tranHmitteil 
light, it consi*4ti4 of from ten ta twenty lortuon?i tubes arranired 
in a pymmidal form Hike the ribs of a fan K the ha^e of the 
pyramid, surnmnnied by a tnins verse tube with \vhi<*h the 
others comnmnieate, bein^ toward the Falhipiaa tube. it>* n\wx 
lo?t on the surface of I he o%'iiry. The parovarinm has t»o 
cxcTeti>ry du<*t and n*> kuf^wn funetiun. It h chiefly «>f inter-. 
est in that tVie aecumuhition i»f Huid in 11?* tuhe« h often I he 
l)esjirming of cyitic tumor of tiie broad ligameut (see Fig. 22). 



THE MAMMARY GLANDS, 



63 



THE MAMMAEY QLAKBS. 

The mammary glumis, wht>8e timctiuii it is to st^rete milk 
fur the sustenance of the chihl after hirtb, projKvrly lielong u* 
the reproductive system. In t^hj4>e the giatid is a tb»t, nmie* 
limes* very tlat, heniif:|>hi'rt% its ha^^e resting iij)on tlie peetoralis 
majur mysjclei between the third and sixth rihs, iW cutting a 
large omnge transversely through its equator eiich half would 
give an approximate idea of thetihaiie of the gland, and on the 
cut surface will be seen nidiatiag trabecule between which 





Y ^ Lj ^ ^^^H 


^B 


^^r^ 




^^^B 


^Hro n 




^^^^H 




o"""'. 


' '^^1 






^Co'J 


■ '^"^' 


O ■} '- 




K^'^^Ai 


tfe:v3?5&^ 


. j 


^^K ^"^Wi 




^^^Kjn^^^l 




^ 


n 



Globules of healthy milk ; fourtieti iiiiuuh i i ' ^n. 

the pulp of the fruit is placed, that fairly reeemble the radi- 
ating trabendiP iif fibrou** tL«sue, fifteen or twenty in number, 
lH*tween which the aoealled *'hd>e8^' of the secreting sul)- 
irtanoe of the manunary gland are contained, and which are 
eontiouous with the circumferential fibrous cnp*?ule cjf the 
organ. The lobe.^ are murle up of InbulcvS and the lohnlciiof 
terminal fuU-de-sjicj< ( aeini ) lined with columnar epithcHura, 
Each aeitiU8 eniptieis itj* secretion (the milk lieing formed by 
de,squamation, fatty dcLM^ueration, and rupture of the e|iitbe- 
IibI cell^t) through a little duct, which unites with other* to 
form a larger duct for the lobule, and the lobnhir ducts unite 



til 



jyTERXAL ORGANS OF GENERATION. 



io tenniuiite iri a stiH larger tliift for each lobe» termed the 
gn/netopfwroiis ditcL Tht^ g:iilaolophorou8 duct*, Htteen nr 
twenty m luinibnr, one for ent^h lohe» converge loward llie 
tiipjile, lieeomiiig widely dilated its lliey approarfi it, l>ut nar- 
rowing again as they at-tnully entiT it, Tlte main <]uc1s? have 
fion-striate<I nui^cular fibre,s in their wallw, the coutraetionn rjf 
which ^kunetinjes cause spurting of the milk from the nipples. 
(Bee Fig. 24,; 

rm. 34. 




1 ^ictifvrouf or gnlACtophorou^ ducttt. 



Viewing the hreai^t externiilly, we s*»e the «|it*x of the mam- 
mary pnijeeiion surronirded l»y a pink iWi^k of »«kin ealk^d the 
art'oUu From the centre of the areohi projects the nipple^ and 
bi^neath the dij*k is u eimihir band of miiH;ndiir tibrcs whicl^ 
in contracting, aR^intfl the cxptil*^itpn of milk. 

As alrc*idy .*tafe(h milk i.«^ formed by breaking duun of the 
cell wall of the cpitheHal eelli* lining the acini of the mam- 
mary ginmis, and lil^eraiion of the cell contents, conHi.«ting 
of fatty grannies and lifpjid protophism. The *iecretion thus 
formed iB rendered more Huid by a watery transudation directly 



THE MA MM Any (iLAXDS. 



6fi 



fruJii the bliKKl vessels. The frt-e falty granules coalesce and 
tiggtegate together, and thus torrii hirger masses ealled iiiilk- 
giobulet*, which are still j?o small as to Ik* mien)«cc»pic, and 
caumtute a fatty emulsion with the more fluiil |jortiou of ihe 
milk in which they tioaL (See Fig* 23, page 63,) 




Sbowin^ eolustriim nud urdirmry milk glulmles. first duy tidet IjLbor; 
phmipiira, age<l Id, {After Bajisallj 

During the firs^t day or two of lactation, however, the par- 
ticles of fat are held toLrether in masses of ronsiderahly larjrer 
size, having a granular af)(H*armK'e. and called "* colostrum 
corpuscles," as seen in Fig. 25. 

The mammary glands receive their blood-supply from the 
internal mammary and intercostal arteries. Their nerves are 
derived from the intercostal and thora4nc hranches of the 
brachial plexus. They are also abundantly sypj>lie<l with 
Ijinphatic vessels, which ojjen into the axillary glaoda. 



CHAPTER V. 

MENSTRUATION AND OVULATION. 

Menstruation is a mouthly hemorrhage from the uterine 
cavity. 

It is called '' catamenlal ducharge,^' ^* menses,** ami ^''men- 
strual JioiVy** or in common pariauce the ^'monthly sicktiessj*' 
the ''JiowerSy^^ the '' turns,** the ''courses,** the ''periods** ;or 
the woman is sjiid to he "unwell.** 

We have already defined ovulation to be the development 
and maturation of* ovules in and their discharge from the 
ovary. What relation has this process to menstruation ? 

About the time when an ovule is ripe and soon to be dis- 
charged, the reproductive organs, esj)ecially the ovaries and 
uterus, receive an extra amount of blood — they become physio- 
logically congested in anticipation of impregnation taking 
place (for the menstrual period is really analogous with the 
peri(Klof ** heat "or "rut** — "(estruation *' — in other animals); 
but in the absence of impregnation the extra blood-supply, 
which was desigiu'<l to prejmre the organs for the reception 
and devel<>j)ment of an imprefjnafed germ, fails of its natural 
])uriH)se and is discharged in the form of menstruation. Men- 
struation is therefore depc^ndent upon and more or less coin- 
cident with ovulation — this is the " ovulnionj iheorij** of men- 
struation, so called. Objections have l)een urged against this 
theory. FirM, It is «iid the menses have recurred after re- 
moval of lx)th ovari(»s. (Answer. This is extremely excep 
tional ; the removal may have been incomplete ; there is some- 
times a thirtl ovary;' thespaye<l women used as guards to the 
harems of (Vntral Asia do not menstruate; finally, the men- 
strual dis<*harge, having been continued for years, may persist 
fnmi hithif, even after the original cau<e, viz., ovulation, has 

'Small su|M'rnniin'mry «ivHrio>* Imvc Imm-h found iwcnty-throe times in five 
hundred Ixxlies. itJarri^ue"*, jjuoting lU'igel.) 



cjJAyGJ:^ ly the UTEnimc Mrcous MEMBiiAyj:. (i7 



t!t*iised to recur.) Serotift U is alleged iUtii wooieQ ilo not 
allow ooitus aud I>ec'oine iinpregiiiited ttt the lueustrual jieriuds, 
hut ahviivs hetwenttlw per'nnis, i'roni which it is interred ovu- 
laliuri is not roincideni with nieusiruatiaD. (Answer, The 
hutiiaii female, like otlier aiiiiual^, m really more liable to im- 
pregnation when cohahitiug" near the meuptrnal pericHl^ and the 
SHUJe greater lialnlity |>roimlily <-»l>tains ul the period did not 
the How prevent ctihahitation ; nmreover, tbi* uuifin of the 
germ-eell with the spernmtic tltnd of tlie male may take place 
at the ovulatory period fruni thenurvival of sjierinatozoa intro- 
ducetl l>y coitns* a week «>r mm-e beibre ovulation ; the ovule 
ali*o may renniin after being discharged from the ovary and 
be impregnated a week or more after menstruation.) Third, 
It is 8tated that ovules are djs<dmrge*l from the ovary without 
any accf>mpanying menstnntl flow, (Answer, This may be 
admitted and exphiined without fatally convicting with the 
theory, Jt is* however, exceplioiml. ) While some recent 
writers regard the ovniatory tlieory of nicir^truation nan thing 
of the past — ^of only historic intercj*! — it cannot be thus i*ym' 
iimrily di3ix)«ic-d of at |irrsent. True, thm: who have had 
large exjierience in removing the ovaries and Fallcppian tnliefi 
iitid jx?rhat>9 '^Imiidred^ of <'ai4c*s'' (an ftpittmutthj eonvincing 
tfXpreewiouJ in which menstruation continued after this mutila- 
tion, hut ail these women were so far ah)t4inmf/ a.« to recjuire 
eurgical interference. There are *' luHidredi* of millions* ** of 
vitmuil women in whom we have every reason to believe the 
functions of ovulation ami rneLJtitruatiou are ns intinuitely 
rchited as they were thought to lie before the days of riK^dern 
abdominal surgery, In fact the sexual an<l reproductive 
functions are taio|>crcd witli in ho nniny wavK by the usages 
of civilizatitai, that it may ]>e actually true that really ttonnal 
c'ascs are in the minorily, in^^read of coTu^tituting the majority 
which those who deny the ovulotcny tf;eory of menstruatiim 
c«Hit*ider t(» V)eiiynonymous with imrmjilily. The nnijority may 
Ik* fl/juormab On the wbf^le, the ovulatory theory of men- 
gtrnatioii m the bt*«t yet (U'ujxtnnded. and mnsit be rei-eived, at 
lea^t for the pre^^eut. 

Changes in the Uterine Mucous Membrane at the 
Menatrual Epochs. — J u^t before the fli>w the mendirane 
hecuiue?^ nnich thicker, eimgested, and thrown into J!*hallow 
fobls. Then it undergoes disintegration by fatty degeneration, 



68 



MEXSTR I -A TlOy AND O VUIA TfOX 



and is tliruvvri off' with the |jlr>o(l tliat H<j\v\s fruiu the c^p^ned 
ciipilbiry l»] inn 1 ve8.se Ls. There exbLs sunie ili8tTCpaiH*y of 
opinktu OHi to how much of tb« riiiR'uii.< lueiiihnine is thrown t^tf 
every moiitbt l>ut no iloubt exiisti* as t«j the Ikct ui' jt.s Ijerdining 
|>hy?iioh-»jLrit*{ill y hypertrophiecl just htfore the n»eiises» noJ of ita 
iiriderg«jiiig n eertuiii ilegree of fktty nljophy utid degeiienitiuQ 
during am! iiuuKHliately aiter the {tericxl Shortly after ruen- 
striiatiou a uew mucous nieiohraue is already iu c<mn*e of 
]>rej Miration. 

Some writen* atHriu that the ovule dwchargeil at a gi%'eo 
menstrual }x*nod does not really belong to tluU jjerifKl, but to 
the next aukserjiient one. that is to «ay ; the nien^^tryal prm_*ess 
{de(*idiial degeneration) oe<*urring, ex. ijt\, at the iinddle of 
February, i.n the i>reaking up i>f the deehlual niembrane.s prts 
pareil for the ovule set free a month before, at the middle of 
January. This theijry, intlorsMgd by high authority, is prob- 
ably eorrect. 

What Becomes of tlie OTUle?^Whet! not impreguated 
it i.s Jost and disM^uirged with the menstrual ilow, either before 
or at\er tt,sdi.sirjtegralion. It Is tew j small to be s^een ; the vitel- 
line memlirane is a mereeelK yX^ of an iiieh in <liameter, and 
ita contained germinal vesicle measures .Ji^ of an meh ; the 
germinal Hjwt alHiut r^^^^j^- The ** vesicle " ij» the nueleui* of the 
cell \ the ''spn " the nueleohiH; ihe eutire egg simply a nuiss 
of |irotopliL*im. 

The First Menses and Puberty. — Memirmtntn begins 
at about fourleeu or tift*M'ti year?* of a^e — the *^ atje of puherfy^^^ 
s<j i^allctl. Thi.s ]>ericMl is* jireceded ainl attended l»y what are 
called the tfiym^ of puhrrtij. They consist in the development 
of womanly beauties, physiiologically designed io attract the 
male ; enlargement uml growth of hair n\yin\ ihe mons veneris 
umi labia nmjom ; growth of hair in the axillte; erdargement 
and increased rotundity of ihe hi|w and l>reast ; the vulva is 
drawn downward and baekward. sothtit in the erect pjKtnre no 
part of it 18 vi.sible anteriorly, as it is iu children ; striking 
change:? ali^* o«*<*ur in the inelination.* and emotional suscepti- 
bilities^ of the woman. 

(Ireuinstancei* modify the age at which thefir?»t menstruation 
takes place: thus, tbi' meusej* nptiear earlier in hot c/n««/e«» 
but the difference In-tween the hottest and *?oldesl climates is 
only about three years; the intlueucc uf raccy which remama 




SOURCE OF THE FLOW. 



69 



ptjtCDt 111 .^|>i{e of eliiimtic uhuiige:^ ; orrttptttiou and modt nj 
lift:: luxury, sliniuliiuts itidoleiiee, hut rounds pryriciicy of 
tuoiiglit, ek'., reudtT tlie woniau jyreojcifiu?!, wlrjJtMij)jxte*itt" t'ou- 
diliojjs retard tlif lueui^it^ ; jj^eneniJ roliUHtiicLss i»f t'oustitutiou 
and vigorouK hetiltli promote the iJevelojJineiJt of OHniistruatioii, 
aud it is deluyod by feeblfiifai^ and dehility. Ou the other 
huiid, a very tail wonmii with large Ixmes and mu&cles will 
require more time to complete lier growth, and heuoe the 
repr^Hluctive fuuctmos will be belaUnl 

The very rareaud iiui*jue easses, indiaputahly luilbeuticaled, 
iu which childreu one or twu yeans old have |>rei*uted the 
external nmitoniieal evidences uf pul)erty, and have then nieu- 
struated with more or less regularity, and have fven h-eeonie 
fijutherx before they were ten years old, are wwn: medical 
cu^o^itie« — (uhh^ fintttra — of but little iiiijx>rt in discussing the 
jihysiology of ihiij i*iibject. 

Sjrmptoma of menstrua tioE, ni>t always present, are las- 
i^^tUl^t^ and thprcK^ion uf i^pirits, hcailache» backache, cbiiline^s, 
weight in byjiugastrium and ]>prineum» nausea, neuralgia, hys- 
teria, |>erlui[)H slight febrile cxfitcmenl. They vary in kind 
and degree in thtterenl imliviilnals, and are generally relieved 
liy the fliiw. The fii-st few |»erii>ds are a [it to lie irregular 
in their recurrence, ami the diecharge is slight in quantity 
and com|x>se<t nf muctH with but bttle blooil. 

Quantity and Qualities of tlie Menstrual Discharge, — 
The qimrtfitij ui' dfs<:*harge, when the function ha« becnme reg- 
ularly *U*8tablished," i.^ from one to eight ounces, the average 
being aUait tlve ounces. The duration of the |»eriod is 
fnvn one io eiglit dayn, tire average lieing f)\e *lays» heui*e 
average dady rjuantity during (hat jieriod, one caince. 

The menstrual bh>od ihii\s not emigulate, owing to admix- 
ture with vaginal mucus, which contains acetic acid. If the 
flow W very profuse, coagulation will tx'cur, be* *a use the net ion 
of the vaginal mucus is then insuHicient to prevent it. Mucus 
of artfj kind, in gntticient rjiiantity, will prevent nmgubitiun. 

The discharge also dltfcrs at different [larts of the (KTioch 
Tt>ward the l>eginning and end of the e|HH'h it contains more 
mucus and Irss bloo<l ; at the middle <if the jieriod im>/* vrnm. 

Source of the Flow. — Thai the How comes from the 
Uterine cavity is absolutely proved by the following facts: it 
is fouml tUer^, pout moriem^ m tbnee who die during mengtruap 



70 MENSTRUATION AND OVULATION. 

tion ; it is seen to issue from the os externum uteri in cases of 
procidentia of the organ ; it has been seen oozing from the 
uterine mucous membrane in cases of inversion of the womb ; 
and when there is mechanical obstruction of the os uteri the 
menses do not appear, but accumulate and distend the uterine 
cavity, 

VicaiionB Menstruation. — This is a flow of blood from 
some other organ recurring at the monthly periods and taking 
the place of menstruation. It may occur from the hemor- 
rhoidal vessels, the lungs, the skin, the nails, the mammary 
glands, ulcerated surfaces, and many other parts. 

Normal Suspension of Menstruation. — It is temporarily 
suspended during pregnancy and lactation, and ceases per- 
manently after the so-called " change of life." at about forty- 
five or fifty years of age. Numerous exceptions must be 
noted to each of these statements. 



CHAPTER VI. 

MATURATION, FECUNDATION, AND NUTRITION 
OF THE OVUM. 

When a woman reaches the age of puberty, the ova that 
have remained dormant in her ovaries since infancy, l)egin one 
by one to grow. When full growth is attained, and the ovum 
is ready to be discharged from the ovary, it presents the struc- 
tures shown in Fig. 26, page 72, viz. : the delicate cell-wall 
("vitelline membrane") with its contained vitellus, germi- 
native vesicle (nucleus), and germinative spot (nucleolus), is 
not only surrounded by the zona })ellucida, but the zona pellu- 
cida itself is surrounded, on the outside, by another layer of 
cells, which from their shape and position constitute the zona 
radiata (corona radiata). Seen with a high magnifying [)Ower, 
radiating striaj may be observed passing through both zones 
— supposed to be minute canals through which the ovum takes 
up nutriment from without. 

In the very limited peri- vitelline 8j)ace between the vitelline 
membrane and zona pellucida, is a fluid in which the ovum 
really floaU, as is demonstrated in fresh specimens by the part 
containing the nucleus always turning uppermost. 

Inside the vitelline membrane is the yolk, composed of two 
different materials — protoplat^m and deuiojdnmi. 

The protoplasm forms a fine network throughout the little 
mass, while in its meshes are contained albuminous and fatty 
granules constituting the dentoplasm. These occupy a central 
position, leaving a peripheral zone of protoplasm from which 
they are absent. 

The nucleus is large and round, formed of a limiting 
membrane which contains fluid and a reticulum of chromatin. 
The nucleolus is conspicuous and exhibits amu'boid movements 
which have been observed under favorable circumstances for 



72 MATUEATION, FECUND A TION, AND XUTniTfOy, 

several hours after removal from the ovary. The ovum 
ghowuia tiie figure wiis cilitaiiied hy ovariotomy from u wtiman 
of thirty years, atitl ^irawii while fre.^li in tlie liquur folliculi. 
It represeDts a fnit-ffrown ovum brfore matunitiou. 

MATTJEATION, 

This tt^rm — meaning n'pfiutnf — slumhi lie aliolLshed Tlie 
idea of an ovum getting n|*e (like a frnit) has no projier 
foundation. Hetenily the ternj Ims htteii ret^trieteil to the prur' 
es8 hy whieh the fnll-gn»wn nvnm diiH-harges its |*olar gloli- 
ule^ ami I»eo>mt*H a female [irimueleys ready to miile with the 
sperm element. Maturation ih tlierefore the pre|>artttiou of 
the ovum ior fectiudatiou. 

Fta. 26. 




FuU grown hunmn orum. 



The pro<*e*«e w as follows : The nucleus (germinal ve^lele) 
of ihe ovum iiii^tead of remnining near the c\nitre, moves 
toward and re^ehes the vitelline meadirane. Then the 
nucleus divides, by the uaiml pHM-eeding of njito8i«, into two 
very une<|ua] partis, the smaller part heing finally protruded 



FECVKDATION. 



73 



brougb the viu^lline membrane iiiln the peri-vitellitie K|mce, 
whert* it remains outside, ci>Tii|»letf ly st'itarateil froTii the larger 
(>art«it*the imeleu:*, which moves back aj^^ain toward the eeiUre 
of the vitellus. The ^smaller extruded [»art \^ known as a /War 
gtobuk. Then this prot'i^as is rej>euteii : the nucleus airaia 
approaehe^ the vhelHue mend>raue, aod again undergoes the 
«ime «rie*jual mitotic division with protruision of the smaller 
part into the |3eri- vitelline spaee^ and the consequent separation 
of a i(cconfl polar globule. Once again the nucleus rece<les to 
its central |K>iition and is now known qm the f emu (r promidrus 
or "true female sexual element'' (Minot). It is ready for, 
and capable of impregnation : union with the male sexual 
element 

racITNBATION. 

Fecundation or impregnation is the UDion of the germ cell 
of the female with the 8[M*rm cell of the male, A^ the germ 
cell throws off* its |3ohir glo!>ule« to hen>me a fenude prf>- 
nuclenr^ l>efore it is ready for this union, hj the Hj>erm cell 
thr«jw« off a part of its structure lo l>ecome a male i)rouurleus 
tor the fuime purjxitse, i\s will now^ he described. 

The «[>ermutic fluid (ttprrm^ f<rmf*tij iifminal fnid ) contains 
milliouj? of histological elements s*<miewhat re*«embling ciliatefl 
epithelium e^lls» called 8}>ei'nmto!M>a (sf)ermatozoidH). By 
"raving of its long cilinm the sjHi^rniatozoon moves about at a 
dte, it is e»<tiniateil, of one inch in M'veii and a half minutes 
— a j>ower it may retain for eight or ten ilays after lieing intro- 
dace<l into the female genital organ!*, and upim which the 
fecundating potency of the semen chiefly dcfiemls. While the 
j«f>ermato7/K>n has long been known to |to«i^esi* a (so-called) 
head, hotly, and tail ^Fig. 27), recent and improved methods 
of observation have shown it to be a much more complex 
structure. Attachecl to the body and tail is an extremely 
delicate ^iral membrane^ which, when the tail niovesv inifiarta 
to the whole orgatdsm an axial rotation ; while from the an- 
terior enti of the licjol tlierc |iroj<'ct.s a )*pt(tt\ twi<-e as long as 
the htmd, and having one barb, something like a fine crochets 
needle. fSee Fig. 2K. ) 

Jn Figure 2H (from Cunninghanj*** Anniottuj), representing 
diagrammatically the structure «d'a sj)ermalozoon, other |»arts 
are seeo which neetl not be de«cril>ed in detail. 



74 MATURATION, FECUNDATION, AND NUTRITION, 



No one has ever seen the meeting of a human ovum and 
spermatozoon, hut we assume it to he the same as in other 
mammals in which the process pio. i>8. 

has heen ob8erve<l. During 
coition the cavity of the uterus 
(and probahly the Fallopian 
tubes also) receive the dis- 
charge of seminal fluid from 
the male. In other placental 
mammals the point of meeting 
l)etween the ovum and s|)ermat- 
ozoa, where impregnation takes 
place, is the Fallopian tube, 
somewhere near the junction 



Spear- 



Head- 



Neck- 



FlO. 27, 



Bodf- 



Basal body of 
-Spear 
-Head cap 
-Central body 



-Protoplasmic 
remnant 

--Axial filament 

'Spiral filament 



Hood 



Body 



Toll 



Tail- 



Spiral membrane 
-with marginal 
filament 



-Knd piece — [ 



A h 

Hunmn 8permut«>z<Mi. 
(After KETZirs.) 
A, Si.h? vlt'W ; B, Front view. 



Structure of a siwrmatoroon 
((iia^^ammatici. 



of its outer and middle third — that is, one-third of the way 
from the fimbria to the uterus. **The exact s|K)t is remark- 



CHANGES TAKING PLACE AFTER FECUNDATION 75 

ably constant for each species" (Minot). It is presumably 
the same in man. 

Usually only one spermatozoon enters the ovum in a nor- 
mal impregnation. Numerous others surround the ovum, by 
which they seem to be attracted ; some get into the peri- 
vitelline space, but only one penetrates the vitelline mem- 
brane, and enters the vitellus. At the point where this 
entrance is about to take place the vitelline membrane has 
been seen to protrude itself into a little elevation which is 
afterwards withdrawn, leaving a slight hollow or depression, 
into which the spermatozoon enters head first ; and the head 
having entered, the locomotive tail is left outside in the peri- 
vitelline space. It is yet unsettled as to whether a jxirt of 
the tail enters with the head, hut, however this may be, every- 
thing except the head soon disappears, and the head itself, 
rich in chromatin, grows, develoiw a network appearance in 
its interior, and (in some animals) surrounds itself by a mem- 
brane, and is thus transformed into a nucleus-like body, the 
male pronucleus. 

The two pronuclei (male and female) now exhibit active 
amoBl)oid movements and lx)th travel to wan! the centre of the 
ovum where they eventually meet, fuse together, and thus 
fecundation is complete. In the rabbit and mouse one pro- 
nucleus has been seen to assume a crescentic shape and embrace 
the other before fusion takes place. 

The whole ovum, after union of the male and female 
pronuclei, is called the '^ooi^perm'' (ujov. an egg; ffTTspfia, 
seed.) 

Ohanges Taking Place in the Ovmn after Fecundation. — 
Our knowledge of the earlier stages of em bryological develop- 
ment is based entirely upon observations on other animals. No 
one has ever seen an impregnated human ovum earlier than the 
third day after fecundation. In three days immense changes can 
occur. In the egg of the chick after only about one day of 
incubation (27 hours) the medullary groove has been partly 
converted into a canal ; primitive segments to form the bodies 
of the vertebra) and traces of blood vess€>ls can be distinctly 
seen. In the Amphioxus (a fish-like organism) spawning 
and the union of ova with the s})erni cells always takes place 
in the evening (5 to 7 p.m.), but in eight hours (4 to '> next 
morning) the vitelline membrane bursts, the embryo esca|)e8 



7tj MATURATION, FECUNDATION, AND NUTRmON. 

and i>et!onies a free iiidepeiitleiit iiuHvulual swiniuiiiij^ aliout 
OD tfie surluce of the watar hy the waving of eilia on its 
ectiMlernml oelli*. 

l^ickiti^ ohservatious upim the human ovum it^lf^ the beat 
we cao do h to asnume that the earliest lie^ioniiitr of the em- 
bryo and its apfienda^^es miLst he more or lei?s the same in 
man m in other animals uearly allied to him. 



SEGMENTATION. 

Development begins with ileaviige of the yolk — gegmen- 
tation of the vitelluH— uot uf the vitelline memhrnne (which 
remains entire tor the present as a sort of egg-shell ), hut of 
the vitellus with in iu This division or segmentation is aeeom- 
plished by the n^tnal proeess of karyokinesis (mit»Ji3is) which 
need not here l>e descrihe^J, The nnrlens divides* then the 
celL The two cells thus forined divitie into four, the four 
into eight* the eight into sixteen, and so on, uulii a great 
numlier are produced. This mass of cells when viewed ex- 
ternally^ ^imewliat resemltles the outside of a mulberry in 
sha|>e, hence it has been called the moruh or mulberry mass. 
(8ee Fig, 2H, *' </* page 77. j 

The two cells resulting from the first segmentation differ in 
»izf and fippfnrancc^ as well us iu llieir inherited endow tnent« 
and future de^ttiny ; and so do the two groups of cells result- 
ing from their ^further subdivision, and these groujis again 
differentiate into cells or groups of cells with still diiferent pro- 
clivitii^ and destinies; and with progressive development 
this process of ilifftrfu flat ion is constantly going on ; und af 
veccHitity, for only in this way is it |>ossible for these primitive 
celb of the ovum to l»ecome, as we know they do, the almost 
infinite variety of cells composing the tissues of the human 
tiCMly. 

At the morula stage of di'velopmetit two distinct groups 
of cells are distinguishable, as i^hown in Fig, 29, page 77. 
These are: fird, the t^ptbiaM or eetof^vrm cells which will form 
the ejtienml c*»vering of the boily, rmd utToud the liifpohfaM or 
entoderm cells to bet»ome the epithelial lining of the infrrior. 
The relative arrangement of these two groui>8 of cells is shown 
in Fig. 2y. • 




SKOMEXTAriON. 



77 



A Jittle later the eiittKlerni nells form a Pomewhat central 
iiuias, while the ectoderm cells close in ami isyrnmnJ them* 
exce]»t at one [loint called the Ulaiitoj»ore. (See Fig. ^iO.) 
The bl;iatojj<jre however will i^ojti clothe* then the entoderm 
mnsa of cells l>ecome,s eutirebj syrronnded and ctieIos<e<l hy 
ec^toderm. Between theent^jderin and fctoilerm u little Huid 
Ije^ns to accumulate, indicated bj the light space shown in By 
Fig* 30. 




Flwl five stui^cfl of iie@rnientatli>n (nibbU*s ovtiiw)— a, b, <*, rf, mii f. In q, b. 
Slid r thi' i'(4bliLs{ tellti are li»rjfc*r tliiin th<* hypohliistk* onfs. In r ilu.' eptblhtil, 
cell*! hiivo beromv itiniilU'r hihI ruoru numerous tliHii tin* hy|wjhln»tH. mid ihe 
eiUblttMtlo !*plu*ie8 lire bf^innln*; tit fnnTouD4l mu\ lUnk* in llic liyiwiblHAt cella. 
sii. ZoiKi iM'llueiilu. p, j^f Polar globule*, m. f'-lrsl eplblnAl cirll. i. First 
liyfMjbU.st <;elU 



This flultl increases and beg-inss to ^parate the hr|Kihlast 
cells from the surroundinir epihliiM, except at the mte of the 
former, hut now «d)literaied, hlii9top<:)re. By further accu- 
mulation of tiuid tiie ovum be<x>ine8 distended into a vesicle — 
to l»e known as the blantodtrnnic vesicle, or blustuia. 



78 MATrnATioy, fecundation, and NirrniTioN. 



As shown in Fi^^ .'U, the iiincT nmsaof etitudfrui ( hyiw)hJai*t) 
cells 18 compresw;-!! ai^jiiiLst the epil>la?it (ect^Mlerni) layer, by 
the rtuid uf the hlai*tu(krniic vetticle, m that it aBsiimets a cres- 
ceutic nhajx*, Hniug only a part of the surmiiiNiing and en- 
elosiiitr epibhisl. Thi** jwirt will iiKlk'ate ilu^ * mhnjouir orea — 
wherp the ImmIv of tht* eiiihryu will hogin to Inrm — while the 
reitiaiiiin^ htrL^er jM>rti<m of the MasttMlenuic vt^sifle must be 
knuwu aiS the jiOM-enibryouic or t\rf ni'tmbnjonic j>t»rtion. 

Fio, 30. 




Two further KlOKi's foUowtnfc Bt!frnn*iitAtIf»»i (rnhltii'^ ovum). o»\ Ei^blast. 
it. HypoblMt. bp, Opculng fn cpihln»l (bliwtopejri') in 4 yvt rUiscd* In H tliia 
openliig ha» cloe>e(l« 

As development })roceeds, the limiUHl ere.s'enttc muss of 
entoderm cells will however extend itself in every direetion 
until It compkteht \\ue» the entire iutenor of the epibln>!t — 
einhryonie and non-endiryotne pjrtiQiis both. While these 
[>riM*e*^e8 have never been i deserved in hmmin emhryos, there 
w no rea^^on why another explanation^ sn^^ested by jsonie oh- 
j«erven<, s^honld not be accefite<l, viz.: that instead of the liorns 
of ihe enlmierm ereja^ent extendi»iL' round the ioterior of the 
ec*to<lerm, fluid first lK'«;in!« to form in the centre of the ent»> 
dennie mass of eel Is, and hy aerumutatton ilit^tends the ento- 
derm eentrifntrMlly until it romesineontaet with the surrounding 
epihlast* Whichever nuwle of pnttlucthn is etjrreet, what we 
want to re-alize is the !<imple far/ that at this stnjre the blasto- 
dermic vesicle i^ a two-layered strueture — a layer of epiblae^t- 
eoveriug on the outside, and a layer of hyfKihlast-liuing on 



RAUBER'S LAYER. 



79 



the inside, and these two layers are in contact with each other. 
As Miuot expresses it : ** The mammalian body may be defined 
as two tubes of epithelium, one inside the other " — hypoblast 
(entoderm) inside, epi blast (ectoderm) outside. 

Rauber's Layer. — Thus far we have regarded the ectoderm 
and entoderm as being each composed of a nngle layer of 
cells. The ectoderm, however, by a rapid multiplication of 
its cells soon splits into two layers — a superficial layer of 
small cells, and an inner layer of larger ones. The super- 
ficial layer extends all round the blastodermic vesicle, and is 

Fig. 81. 




zp. Zona pellucida. ejy. Epf blast, hy. Hypoblast. 5i'. Cavity of 
blastodermic vchIcIc. 

known as the covering layer of Eauber, hy whom it was first 
described, but the inner layer is limited to the embryonic area. 
Over this latter area the covering layer of Rauber will soon 
(sixth day) disappear, leaving the inner as the true ectoderm, 
as shown diagrammatical ly in Fig. 82. 

The significance of Rauber's layer is unknown. We may 
here dismiss it from further consideration. Leaving it out, we 
again come back to regard the ovum as composed of tivo lay- 
ers : ectoderm and entoderm, as before stated. 



80 MATUIiATlOX, FECUNDATION, ASD NLTniTlOX 



Fio. sa. 



From the^se two layers, and between them, a third layer 
will sH>oii <Jevelo]i, vix.^ the memhfttd or meaudtrm. h U 
yiineec^^iry here to *iwell upon ihe ^rA l>egiiiuing luiiJ eiirly 
devclojiment of the mesoderm ahuut whieh I here iis sot tie dis- 
pute. Suffice it to say that it lK*gins to appear towards what 
will lie the pi^terior or caudal re^non of the enibrvouic area 
and gnidiially s[>rt*aik circuniferentiayy iu all directioni* until 
eventually it extends completely around the Idawtodeniiie 
Ve^iele whit*h thus be<*ome?i £r/daiiiiriar i it hat! ^/iree layers, 
ectoderm on the uuli^i4le ; entoderm on the inside ; mei*oderm 
between the two. 

Keniember tlmt these chaoge^ have all taken place inside 
the vitelline membrane, and while the ovum is yet in the 
Fallopian tnlie. The growing ovnra 
IS of course constantly increasing iii 
xizr, which causes tlistention and 
thinning of the vitelline mcml»rane. 
Jiy the time the ovum hjLs paasetl 
frniji the tube into the uterus and has 
renrhtHl the >*pot on the nn-rinc nni- 
cons mendirane where it will remain 
emlH^hJeil to continue its ftirther de- 
velopment, the vitelline membnme 
has lieeome m extremely thin that it 
now melts away and ilisapi^ears. It 
may be siiid the human e^:^^ has now 
*' hnirhtur* by the breaking up and 
disti|i|>i'a ranee of its vitelline mem- 
liranonss ** mhefL'* It is imp<*rtant to 
know for reasons hereafter stated J hat 
this lilieratioti of thenvum fronj thectjvity of its vitelline mem- 
brane only takes place when the ovnm has reached its point of 
anchorage on the nterine mucosa and not brfore. If it did take 
place liefore, the ovnm would then be<Mmie aneh<ired to the 
mucous membrane of the Fallopian tube and a tubal pregnancy 
resulL The time after iin|*regnfttion when the ovinn [lassea 
from the tuW to the uterus is unknown in man : it is thouffkt 
U) Ik? several day^ : r>r something le.*<s than a week. 

Starling out now with the three layers — t^ct/iderm, mesoderm, 
entcMhTni^ — it is from these that all fiartaof the future embryo 
will \ye evolved. 




MammaMttti itlaKtrxUTmie 
vesicle r rp,' noti I'mbry-iiifL' 
cplhlaj^t cXteui) I tJK aI I nnnj in) 

lilitNt f!otifiri«?ii 111 t'tiibryotilc 
uren, ovtT whioh ri/ (tlie 
liiycr of tinuUrii will «oon 
c1iBappi*ar: Atj/. hTiN>hlnHt or 
4$nii>derm ; j/.ir^ yoll 



Ik Aiick. 



RAVBEB'S LAYEB. 



81 



Exactly what organs are developed from each layer is some- 
what LiD&ettled but ©uough U knowu to warrant the following 
statement : 

The edodenn ( epililastj Ibniii* the epidermin and its append- 
ages: hair and naik ; its gland&i, induditig the niaminary 
glands; the nervous system : bruin, spinal cord, ganglia, and 
nerves; the organs of 8|>erial seiine; thti mouth and anuB. 

The jtieaodenn forni« I lie t^keletun : hones, t'artilages, liga- 
ments, €<jnnective tins^ues and Imne marrow i ihe heart, hlood- 
veaseb, and blood ; the muscles ; the »pleen and lyinphaticfl ; 
the serous* membranes: (>eneardiuni, pleura, and peritoneum, 
and the genitt)-urinar}' organs. 

The enMenn (hypoblast) forms the epithelial lining of the 
digestive tract and its glands, including liver and pancreas ; 
also of the reapinitory tracts larynx, trachea, and lungs; and 
of the pharynx, toiii^ils, Eustachain tui^e, and thymus and 
thyroid glands. It als^o forma the noti>chord ; and the 
epithelial lining of the bladder and urethra. 

Finally, all three of these me nd> nines, as we shall aee, 
contribute to form the hetal apjjendages, amnion, chorion^ 
placenta, etc. 

It must be underatootl that no organ in the bmly ia formed 
ejvhmvely of any one of these three gt^rm-Jayers. What we 
mean is that tlie several strueliirc* nameil have their (irtifln — 
their embryonic bftjltnunfj — in the s|>ei^iji] layer referred to. 
Tjater on, more than one hiyer heromes involve*^ in the 
development of the completed ortfjuu Thus the brain and 
mammary glamk originitte from the ectoderm but they must 
also have bloodvessels and blood and other tissues, deriveiJ 
fnim tije niesoderm. So of other orgiins. The lung derives 
its epithelium from the entoderm, btit its muscles, vessels, and 
pleural covering ctnne fnmi the mcHiderm, 

In now studying embryonic development from an ol>stet- 
rician*s [viint of view, it i» with the structures concerned in the 
mtfrilion of the (jrotvhnj ovum that we are chiefly intere.sted. 
When a child is Ivorn, we ol>serve (tir^t ) the infant itself, and 
(second) its apf>endagcs — the undiiHcal cord, placenta, 
membranes and liquor am nil. It is with these last that we 
are chiefly concerned, but to understand their origin and devel- 
opment some knowledge of the eiirly stages in the development 
of t he em bry o i tsel f w i 1 1 be req u i rc< 1. 
tt 



82 MATURATION, FECUNDATION, AND NUTMITION. 

The Embryonic Area: Embryonic Shield* — Thus far we 
have re|j:anletl the growiiig ovum us ti tnlumitmr vesirle — 
the Mui^tudtTinic ve>vk'le — a minute glulmlar ^iv ur cy^t tom- 
pjjsed of the three Itiyera : eckwlerm, me*<od<^rm, iiii<l eiit<xlerm, 
with nutritive |ja])ulitiu (yolk) io the eeiitnd cavity. Only 
one small part of this trilumiiiar vehicle will form die bculy 
of the embryo — we call it embryoiiic area ; from its shield ^hn[>e 

Fic. ya. 



'jM^^jk 




8iirflice rieir of the erabryonJc shieM of the blanl<jderrolc vefslete of a tlog 
ISto I'^dayfeold— preciKu <ig« urikfiowir Sh^ Embryonic shield. A%i. tli'ii»eii^i 
knul, p.tr. Primitive strenk, 1()0 dhuneters, (From Mmc/r, nftcr BoKMOf,) 

it is also callefl the emhryonie shield. The surrounding 
iniieh larger part of t!ie hhtstodermie vehicle, ^ — /if>/ taking part 
ill forming the emhryonir IkkIv, — is the nou-emhryonic or 
extra-enihryonie [portion of the ovtnn* If we inuigiue for a 
moment that this terrestrial glohe on which we live were 
nearly all ocean, with no jaiul formaliou except Australia, 
then i\ui*tralia would represent the emhryonie area, and the 
remaiulug ocean the extra-embryonic regioDS. 




TIIK EMBJIYONIC AREA. 



83 



Near the ceotre of the enihryniiic area first appears a cou- 
den^il knot of cells (the kuut of Ileiisen ) which imlieateiJi the 
place where the edotlcrni ami eutodenn hiive united together 
Itoorrespurnls! with the s|n>t where the iiiner must! of entodenn 
cells tirst formed inside the ectoderm. The mesoderm has not 



FIO.34. 




OruB^^iectlon of embryo In the dorenl fi-gion, thowring tx'glntilnir of iDeduL- 
liiry fold* and ifToave. m, m, MetluUitry r*>ldg, g. Med unary groove, fp. Epl- 
blMt 11. Notochord. A* Mypobloat. f. i. l\Tipheral p\att>» of ini'^oblA.^it. 

Flo. 35. 




Ci«iii-4i«cilonof embryt) in dorsrti rt-^rton, sliowlnir e3tti»niilon of meaoblast be- 
r twevn epideraiiil t'plbliii^l atid involiitfKl portion ctf oHMhj^I lliiiniiiMncunit eaiiol, 
fjip. Kpideriiittlcpitd«'*t. 3f Kpiblast llnirii^ neurnl fflniil. t'V. rmlivided part 

of iju*»-*>bl<mt. P. MesiohliLMtlr liiy*.?r ff^rmintf lM>dy wtiJl {Homutopleiirt'^ l>fP. 

}A*f«nhlH^iiv liiyer formiug hitfi'^diwil whUm «^platK'll^'»lde1lre), X Jtotochonl. 

PP Commencing plcuro-iKTitonual cftvity. 

yet obtruile^l itself hetween the entoderm and ectoderm at this 
poiiit of nnion ; hut it will do s<j later on. Extend inj^ from 
Heneen's knot towanl the periphery *>f the endiryooie shield 
ttppean? fir^it a streak which tlcefiens into a shallow grcxive in 
the eetoilerm» known as the prhnUive atreak anil primitive 
t/rooir, 

Shortly after the formatioo of the primitive streak there 
appears round tl»e aoterior end t>f it, and extending a con- 
siderable distance heycnnl tlie end, a thickening of the 



LATERAL FOLDS. 



86 



eclrHlenn known fi» the meffnlfartj piak. In the central axis 
oi' tli!8 [tliiie n lonLritnilinal furrow (tbe dorsal furroiv) 
a[)|)eaM, wliich deepens* into u jtrroove (the mtdnilanj tfroove)^ 
and thia gnwne is ^till fnrtlier fjeei>ened by foldsi of the 
meduliary [ilate rising up on the two sides and two ends of 
the groove, until the fold:* tinally meet and joim convert iug 
the medullrtry gruove into a canal — ^the meduUarij canaL 

From this medulhiry eanal the entire central nervous sy intern 
is produced ; the anterior end enlarges to form the hraiu» the 
renminder elorigates to form the spinal cord. The caudal 
end of the medullary canal is the hist to close. Some cells 
migrate through the wall of the canal to the outride and 
beeome converted into ganglia. 

Thus we have seen how the nervous system is derived from 
the epihlast t from the external germinal layer) the medul- 
lary or oeunil cainiL when first eloped in, it* lined hy epiblast 
ceIJ» : the.se in time differentiate into nerve cells. The several 
stages iu the formation of the nieflnllary grotive» medullary 
foki*, and 0iedullary canal are showa diagrammatical] v in 
Fig^. 34, 35, and 3«, pp. 83 and 84. 

What l>ecomes of the prhnidre Mrenk {prmifh'e ijpoove)^ 
It disapjiears. This groove i^ distinct from the meiJulIary 
groove. While the pouter ior end of the meclullary phtr^ by 
a sort of bifurcation, is seen to extend on each side of the 
antrrior end of the t)rinjitive streak, at a pnnt corre^iHiodi ug 
to the knot of Hensen. and while the two gnK>ve8 are more 
or lei?s iu line, the one \s dis?tinct from the other. The 
medullary gnx»ve grows into tlie uiednllary canal, the 
prinntive streak dii^appears. The one does lud. develoj* into 
the other, as was frujiierly suppoj-ed. 

Lateral Folds ( Abdominal Plates ); Formation of Abdominal 
GaTity and Umbilical Vesicle. — In ordc^r \o understaml these 
it is abHolntely necessary at this |x>int to intnwlnee a further, 
i*omewhnt complicating stateriient^ the full recognition of 
which however will greatly as,sist our comprehending the 
matter under cousideraticm. This tJtatement is that the 
mestMierm f<p/d}* hdo two coneentrie fatferi^^ one inside the other. 
Thus our blast odenidc vehicle really becomes /br^r-layered : 
ectoderm on the outside, entoderm orj the inside, and between 
them the two layers nf nie^Kierm. This fact inui^t be emphasized 
and remembered ; otherwise we cau under^txiud nothing. 



86 MATURATION, FECUNDATION, AND NUTRITION 



III ortler t<j foruj tlie bi^Jy of the einhryo ami tu pruvitle a 
cavity for the iiUernal organs, the emhryoiiic area cannot 
remain spread out as a tiat shield in line with the gloliular 
snrface of the hlastwlerinic vesicio of which it is a part. 
Nor ihie*? it. On the contrary the ynanjius of the embryonic 
area — its peripheral borders — seoop inward and fold toward 
each other in an mtf trior direction, nm] will evenhially nieet 
and join in front, at a fMnnt that will linally hecoine the 
jucfUan iiuf of tit*' ttfjthmf^K The?ie folds of the hlas^toilcnnic 
vesicle are therefore called nfHlomitnil pinfryt, or lateral jnkLs 
one on eiich mdc of the ftbihnninal cavity. The linnill 
emhryonic area becomes, therefr»re, jjartially pinched off from 
the larji:er, extra-embryotuc |Mjrtioii of the bhistodermic 
vehicle. This pinched'oH* part in to hr, and already in, in a 
rndinientary form, tlie Inwiy of the emhryo, while the remain- 
ing f'j-//vt -embryonic area will develop into the f<etal a|v|>end- 
ages : the uiembranes, placenta, an«l cord. In Fig, ;>7, No. 1, 
the thick idack line from ** ft "' to ** 6/^ indicates the samll 
embryonic area of the hlaatoilermic vesicle Ix^fore the pinch- 
ing ot!* process has begun ; the dotte<I line ehow8 the margin 
of thi» area on the distal half of the hjsected vehicle. On 
the lop ig 8een the medrdlary canal formed of ectodernnd 
rnednllary fobls, i\» alrendy exphiineih Fig, H7, No. 2, shows 
the margins of the embryonic area approaching each other, 
a contiguous |>art of the .surrounding /rr^/t-iMnhryoiiic area 
iK^iiJg of ne(*ei^"ity aUo drawn in. The fohU»d otf porti*m — 
the endiryonic area^hies not, however, stick out like a 
projecting knob on a level with the original contour of the 
Idastodermic vesicle, as repre-^euted in No. 2» A further com- 
plication arises ; the real condition Iteing !*hown in Fig. 37» 
No, 3, where it is st*en the fidded efuhryonic area recedes or 
sinks in toward the centre of die blast" wlernric vesicle, while 
folds of the adjoining non-embryonic area iK'gin to rise np 
ad round \l These last-named fold? will form the amnion 
and chorion I as explaine*! further on. 

The etnhryonic \hm\\ now consists of two longitudinal 
c^malt* or cavities, one above the other ; thcnp(ier and smaller 
one bt*ing the medullary caiuil, in whicli willtlevelop the hniin 
and spinal fH»rd ; the hiwer ami larger one being ihealnhmiino- 
thonicic cavity, in which will develop the thoracic organs and 
abdomuml viBoera. The medullary canal was formed from 




THE UMBILICAL VESICLE. 



87 



be ectodemi : in the formadon of the abdonnual cnvity rd*! 
it^ orgaus^ all four germinal invert — eetofhnn, entmlertfu and 
the two laijer:i of intmtdertn — are iiaiaied lately coucerned. 
AVhile these four layers were ali lb hied in at the pjint of 
pinched const ri<*t ton, the risirif!; iohls of the ?fo//H:-nibryonic 
area that Burrouml the enibry*>ixir body cotii<ii?t oaly of ecto- 
iierm aufl the outer oae of the two hiyei*s of nie.soderm. This 
iiiiplie!:? a i*ej»uralion of the two ine?H)denn hiyerjs from each 
other, and the fornmtioii of a cavity i>etween them ; and 
this, of e(»ui>ie, occurs. The huicr layer of the mesoderm 
mu^t now he known an the i^planchnoplctire — the »plauchnic 
layer^ — (from uTrhiv/ja, vij^^era K hern nse it for mi* the i«enm8 
n»verin^.s q»ericardinin, pleura, and ]>eritoneum) of the 
internal orirauH an well aw their murwndar walis and blood- 
ve-SfielH ; while the o»/rr layer of the meHHlerm will he know*ii 
as the mmtttophure — the stjmalic layer — (from *Tiutia^ the 
ImmIv ), heciiui^ it forms the l>ody wall ; the muscular and 
l>i>ny wallii^ of the chest an<l nbdomen, togetlier with the 
pleura and [>eritoueum, lining tho^ walls inside ; and the 
111 ood vessels. 



8 






FoMlng off of embryonic body. 

The lartre Bpace In^tween thej^ splanchnic and somatic 
layers of the mej^oderni is called the etrlum (from xtiikw^ta, a 
ravity) ; that part of it enrlosied within the endiryiinie ho<]y 
l>ec?omes, of eoun^, the jileuro-jicritoneal eavity. wliieb at lir»t 
i^all one, tlie diapbrntrm havJ!!;; ui»t yet develoix*<l 

The Umbilical Vesicle. ^ — Wliei\ the tVtur L'-c^rminal layers of 
the embryonic area became fohifd in tr» form the abdominal 
cavity* it is eviilent tlmt only a t*mail pfxii of the entire /'«/o- 
ihnn was enclosed within the cavity, the ranch larger portion 



88 MATURAT!ON, FECUNDATION, AND NUTRITION 



renminiDg as the innermost ( eiitociermal } lining oi' the non- 
enihrycmic part of the blaatdciermic vt^aifle. This excluded 
part {not within the abdomen ) is the umbiUcal vci^icie. Note 
that it is lined by etitodenn — the epithelial layer — which is 
oontiiKiou.s with the same layer lining the primitive iilinientary 
cauai ; and that over thii< is* the s|ihmrbnic' layer of iiieso<ierm, 
coutinniius with the s^anie layer tbrmiii^r the serous and mus- 
cular eoat8 of the alimentary organs. This undiilical vef«icle 
(calle*! also '^ yofk-mc^' } contains some of the ori^nnn I vitellus 
or yolk, but the contents of the vesicle (whether old yolk or 
new) rapidly increase, so that the vesicle itself is enlargetl 
aud distended, reaching ita largest size during the fourth week. 
By what means this mass of untritive pabulum is thus 
increased we do uot know ; but we do know that it forms, 
while it lasts, the principal storehouse fnim which the ^^JTrow- 
ing embryo derives its nourishments The constriction between 
the abdominal part of the entwlerm an<l that |>jirt lining the 
undiilical vesicle is not yet nnujilcte ; a passiigt' is lefi betwc^en 
the two ( tlie ** vitelline duel'' )^ throngli which fomlstutf can 
p«i»s from the umJiilical vesicle into the alimentary canaL 
Furthermore, in the splanchnic layer of mes^jderm covering 
the nmhilical vesicle, l)h>odve**sels s<^on ap|>ear» and thus con- 
tribute to al>stjrb nntrijjient from the yoik sac and convey it to 
the body of the endiryo. (Gradually the nmliilical vesicle 
grows smaller ; it^ contents are being alisorbed, until finally 
(at alxiut the twelfth week), the vitelline duet has become a 
scarcely visilde thread (the yolk-stalk J. at the end of which 
there remains a mere pin-head cavity — the last remnant of 
the undn lical vesicle itself 

The Area Vasculosa. — The Id ood vessels in the wall of the 
umbilical vesicle (iibtivc ineutioned) are the first bloodvt^sels 
tu apfiear. atal since in the chick, in which their develo|inieut 
has Ifreen observed, they oidy occupy a p*trt of the nnduliral 
vesicle innuediately surrounding the emliryo, this ]mrt has 
lieeu termed the urea rnHfuhm. In the human end»ryo the 
^* entire yolk sac becomes vascularized througboul " (^Iim>t), 
While never »een in man, the vessels are prt*sume4 to develop 
as they have lieen td>serve<l to do in other animals, thus a 
network forms in the spbinehuic mesoderm which soon exhibits 
yellowish sfKJtii, calleil bhswl-islatids, liecause the cells in tliem 
will become blood corpuscles. The network is al tirst solid. 



THE AREA VASCULOSA. 



89 



Imt later on the strands forming it l>e<^onie liolknv tiil)ea 
(primitive bkMKlvesi*elK), am! the clusters of oeUa in the interior 
break apart and IxK'ome t'vee m the cavity of the vessel, thus 
proiiucing the fir^t blocul eorpn^H^les, whieh muUiply hy mitotic 
divUiou. The vesweLs are all about the mine Mze, except that 
the vascular area terminates peripherally, in one larger vessel 
— ^the so-called sinuH term tnaliit. As yet there is uo circulation 
in these vessels. They form during the fii'Ht and second ilays. 
The heart has not yet formed, hut it is beginning to develop 
aa a cloned hollow tube. The vessels are as yet ^jf/ra-endiryoiiic 
as is, uf cour!*e, the umbilical vesicle hi which they f\)rm. but 
they proceed to extend into the ernliryo toward the heart and 
Hnally reach it, then the surfaces of contact between I he heart 
and the vessels melt away, the cavities of the heart and vessids 
join* and the hearty already pulsating before uniting with 
the vessels, still beats on, and the blood circulation begins, 
kThus, the first circulatory organs do vol begin from the heart 
lilB a centre and branch out^ as one is apt to snp]M>se» but the 
mitiute vessels begin in the area vnsculosa and project their 
larger stems inward to join the heart* 

When the umbilical vesicle, with its contained nutritive 
pabulum^ disappears, or dwindles? almost to nothing, the blood- 
vessels disappear also. This source of nutritive supply for 
the embryo having thus become exhausteil, a new device for 
the same purpose is provided by the formation of the anmion 
anil chorion, the development of which has been simultane^ 
nusly going ou, 

Tlie Otorion and Amnion, — We have seen that, wfien the 
pinched <>r "folded olf" embrynnic area sank in toward the 
centre of the blastodermic vesicle (st»e Fig, 37, p. 87 ), the 
surrounding non-embryonic jK»rtion of the vesicle began to 
ris*^ up, in a double fVdd, €ill around the emliryonic body. 
The two gcrmiual layers that form these rising folds are the 
tctodenn anrl the mmiatic laver of the m^'mdenn. The fohls 
arc known as amniotic folds, the fidrls of the amnion. By 
reference to Figs, l^ and 4, Plate 1, it will be seen these rising 
folds arch over the hack (»f the embryonic body, and tinally 
meet above it. When they meft and toKvft each other, the 
surfaces of contact nn^lt away» but the inner fohl of one side 
uintes with the inner fold of the other, and the o}drr fold of 
one side unites with the outer told of the other. The inner 



mj MATUIIATIOX, FKCUyDATloy, ASD yUTIUTION, 



UEBCUIPTIOK OF PLATE 1. 

The germinal layers ure sliowu with wIdL* iiitervenliii; 8pac<?a simply 
clearness of dt'iinnisitratloii. Kiiitjclvnu, grt'cu ; mesotlemi, red; ectodi 
Ulnck, 

Fill. I f»imi»ly hhows tlif thtcc—feuliy four— sennit ml Ittyt-rs with tliu »epii«j 
mlioti of iUv iui>it*U'Tiu iuio ><)[tmlupicurc iukI si»laiichiiy|»leunc. Il Is aq 
f II ti ru II y a rii lie ia I < f i r» vrrM iii 

Kui. 1— lltTt i ' rin hii-i fylUed hi lo form m i\, Uie mcchilliiry ('anjil«l 

mid II |Mirt of 111 I htui Itecii ftiuehed (jtllu f<iriii the Tiotfjchoni ('*'***/. ♦|1 

with which wv ^i ..utiiiug lo do. The iufsoaerui hu* not yet milled I 

to uover in the em i iv \ « > j< jc («t'« |*«jjt* 83^ bul JL iviii tioim lio so, thcu Ibc four| 
layers will l»*?come coiiipleie us lu i' ii?. 1. 

Fitj. 3.— Thv fohlliiK ort' lm% Ugun, »il<!o (jinking of the embryo toward itiaJ 
centre of Ihc bliwim^lL-rmle vc*ieio> mid rlwing up of the iimniulie folds. Kt'L I,] 
ei'ttrtlerm covuriuf^ binly of t^iUiryu, ttt. 2, eoliL«ierra furnilng tiraiilotic folcf 
aceomiMinicd witii *iomiitie hiycr of ine^vidi^rm, mm. ; I'ti., vtvium or t-iivity iol 
lH*i>ume i»k*tjro peritoneal CHVity. Vvtb. fc*.^ uiuhllicnl vesiele ; ilJ> npj*i'r imr-" 
riiW jwrt to iKLHumnlinieulury eaual. Tbia vehicle iuiic^Hjuipanicd by !i|>lanch* 
nie layer of mesioderin {njtfj. 

Fio, 4,— The uumlotie fold* have Hrelu'd over und united to form a.n,. thoJ 
amniotic itaviiy, Tiie friMiii^ In of the ub^lominul whHm ilakrml (ihites) haa | 
prugrt-'swi'il nuii will snM>n be^eome comjtlclf, eouvt'rtinji; h jiurl of at\ into p,p.j\ 
Ihe pleuro-].ieriloneal t-HVlty. Note thnt the rj-Urnat Inyer of the dtmh4r fnhl of 1 
amnion lin tiK 3) has united wliU ita felhiw in FIr. 4 and become rontliuiougl 
with the orimnai external eovering of the bliuitodernile vesicle, to U; now^ 
called the clutrion, 

Fui. .>.— The «l«iouiln*il walls have united. cUislnK in the jirfmitlve alimcn 
tary eaiml and pleiiro-[»erlloneal eavily. The umblliral vesjele Is sup^M^f'i'''^ fO| 
have disrtpiiK'aretL tri\ Ectoderm of \^*i\\ embrytmie and non-em) i 
t ion of bliLslodermk- vn'^victe— noH the ehorion. ' <rf. i. Eet-Klerm I* 
offinbryo. Ert.'l. trto*ienji Ihiini; ravltv of iimnion. ,S/*^, SplHin 
tlerm to form vest^elj*, witli i and tteritonriil eoats of intent t 

Three dilTerent layers of jtiM \Mim:\ are *eeu : one liidnn the abdoin*] 

nnl t-avitv to form ft«; mn- , *»rK' in the iiinribitie Mtjlt : nnd nne ill 

tl»e ehorfon. oi i ihr jiniTiiutie eavity with ils i. i mbryol 

appe^ir*, in thi*i ; < etton, to i»e entirely i ut oirfri.m 

Fn;. fi — l>fin« Hon vhowiujf ^>j«.. Ixwly stidk. und dloiil 

Into it *)f cntoilrniiir t.Mjrh of iillant<r(s conttnuoit» with alinHjiuary eanaU' 
The cavity of the nninfon fti.*!.) is expnn<|]iic. ho Ihat m the colum^ will tinnnl 
be oljijterated 1>y the amnion cominK in cuntaet «i)d unititij^ with the chorion,! 
Bj» »een in Fig ^. 

Flo. 7. -The f*Hu« hrts ehaufre^l ft» utmtkm-, instcrid ori«i-inp hofi^^onUl and I 
iiupp<»rt«'d only by l(- ♦ jnnlul body slnllt, its tunut ha** dt^ceiided and body-«tallt J 
baa p^rownto n i ^d posithn* mi the wlHlomen. where th*; uutbiitc ' 

eord will npiwii 

FlM, H. Her' i Iihh receded frcnn (be sttuTiili* 

eord. The eetoiit-uu ni the amtufffj il 
idaeenLal end, Whil<' (o ^bow thin H 
mut <hi'n\h,\[ N In H.-nlit^' >b^-iir1i»il b'. 

Willi I ^ ■ 

byti, 

of nu^iiMle: lu to Unui U*. \ 
longer on*"* um the left) vi I ; 
wUh ll<iiit«r nmidi ; •!/ th*- 
drnii eov4!rlMtt vlneem N/V. i, - 
T\ii». 9 <*nd to uliow how ciiv 
envilv. Flc *} U nn etomfatf'd r^ 



.ioi,-„tb. 



iHcenta 

I iOii»n 



i^Uot U't \ iUi « k 
a. lit tbi* ami 



.rihel 



idbdi 

ine.HO 



irer*^ 
the 

fwTfiJo!,! ikl eii\ 
\hv Innr* and 
llnlnir of th 



with protrndtOR bod? 
• leurnl riiv1tie4 i *'h" 



r j.l 



reirar^d i* iiaid to atieituioit ui Lu{{i:ctiicn, 
cyT/Af t^nwi layer*, nothlni^ else. 



'■neall 
fourl 

in n uud -'j. In I'iji:. \*\ '" n" Wiv^ \nnnn^\ 
hn*i l»*'<H»mc th<? alimentary ramd and ] 

id. Tiie epltbeiluUlrii -niMtf-J 

ilnnotf. Ju<l a* In »h* d llie | 

1, etc. to be »o. in ni Hlilo 

The obJ«»ct Ik to show the uUaUmvi 



7 



THE CnORION AND AMNION, 



91 



fold will now be called the amnion^ lur it haii enelosed the 
anmi*itio cavity wliirh k to till up \\*nii liquor iiniiiii ; the 
uuter fold will he kmiwii as the chofiou, 

Ol»serve tlitit tlie hmer and outer foldsj have liet'oiiie etym- 
pleUhj Hf'parated thnu each other, aiui that the endjryo with 
its amnion (a,** show n in Kigi^. 4 ami -'j, Plate 1 ) ap(K»ars to be 
entirely eutoffirum the re^t of the hlastodernne ve^iele and 
cl J u r i oiu I fiay the e n d » ry o ftpj*ea rx to I le i 1 1 u t^ eo n i p 1 e t e 1 y e u t 
off. lin it really h(»? J t can not be. If it were, the ind^ryo 
would die like itu ajoputated liinh. What then 18 the actual 
i*on(litiou ? Observe tliat in the ligure:^ we are looking on 
the cut surface iif /mj?.'*(r/"j<^* seetioiiH of the enibryotiic Ijody* 
We might nuike hyoilreds of such seetion.s l>egirining at the 
head and prtweeding toward the taiWnd, and thcj would all 
show the Bame ** cut off'' condition. But if we [mR'eeded 
further, utid made sections through the tail-eiHl it?jelf, we 
should there find the rising folds of anmioTi tlid not nietH each 
other ut»d melt away. On the contrary, thi^rc would be seen 
lietween the two riHing folds a solid stalk of mej»oderrD 
by which the inner fold (the amnion) remains united to the 
outer fold (the chorion). The luwly of the end>ryo, therefore, 
y ftot entirely cut uff; it hantrs by this (j^tMalled ) ''body 
stalk," or hauch^tieh projecttHl from near itw caudal end, and 
thii? Tnaintains its connection with the outer fold ( chorion ), 
througli which nutriment is to lie taken in from the exterior. 
This will l>e readily understood by refererjce to Figs, ti and 7\ 
Plate I, ix'presi^ntirig lonfjitudinal i^evlkms of t lie cTobryo. 

It should t>e ijott^d that the outer layer of the rising anuu- 
otic folds f which we now call chorion > h perferffij cfrnfitntauH 
with the remainder of the non-enibryonic |>ortion of the blasto- 
dermic vesicle, from which the '* rising folds'* theniselvea 
uriginallys|»rang. There is no division between the part that 
tiifl rise up over the stnikcn embryo and the part that did jtot 
Thiis the mouth of the little well into which the embryonic 
fimly sank, m to s|)enk (see Figs. '^ and 4» Plate 1 ), has lK*en 
archerl over by tlie united folds of chi^rion, and the globular 
contour of the blastodermic vesicle becomes once more restored 
and complete. Xotr. Id us emjjhaHize that this entirf contour — 
coiuinuous and complete* — is alf t<i be known as **tht' chfmon,** 

The chorion is com|H>sed of ectoderm lined on ibe insifle by 
II Boaiatic layer of mesiHlerm. (Bee Figa. 4, 5, and ti, Plate L 



92 MATURATIOS, FECUSDATION, AND SUTEiTION. 



mom, kind ed.) The s[ilaiKllinie iuu\ somatic riie?<Mlerm layers 
have hfconit^ wick-ly" iit'purtiltMl in the nuu-t^mbrvonic part of 
the hhisttMlertnir vesicle* The somatir layer lines the ehorinii 
imuh ; the wplaiK Imie layer covers the unihiiical vehicle 
on ir,H outwitle, ( 8ee Figs. I^ atiti 4, l*lute 1^ ^y>/. ) The 
large B|jiiee l>etweeii tbem is the ariitm or body eavily (k> 
caUeci). It isoeeupieii hy a fluid. That part of this* cxehini 
etirlosed by the lateral plates (abdoiiiitial platej^) within the 
embryo is the perieardio-pleuro-|ieritoneal cavity, to be after- 
ward iJivided as the name innilies. 

When the ovum enters the uterus and tlie vitelline oteuj- 
brane melts away, the chorion bt*comes the exterual covering 
of the bhLstodermic vehicle, with which it comcti in contact with 
the nterine wall and ubtMjrbH niitrimenl. To fmrther this 
ab.'sorptioii, villi apjiear. (n'ojccting outward from the external 
surface of the choriiin, and each vdlus receives a capillary 
liH^p of bloodvessels sup[died bv the mesoderm. (Bee Fig* 8, 
Plate L) 

Tbe amniotic cavity, more and more distended with liqyor 
anmii, will eventually CKiiie in n>n- 
tact with the choriun and unite with 
it, thus ctanpletely olditeratiijg the 
CJtvity of the cadum, which previously 
exijittMl between the amnion and 
choriiirK ( Fi^'. 8, Plate 1.) 

ThiH double membrune— the united 
amnion an<l chonrvn— i> the mendtrane 
which forms the *' baj; of waters" that 
Imj-st-s in child-birth. 

Some time /hiring the third tuonth, 
the villi over a greater [lari of (be 
chorion atrophy and diitnjtfH^ar, hence 
thiH part y called i\w *^ ehoriou lirvf i 
while the villi of the remaining ?«maller 
part ( choriun fratuiottHm i grow larger and e<mtribute to forni 
the placenla. (Fig. H, Plate l.j 

The early villi liegin to ap|>ear alumt the end of thesectmd 
week, and !^K>n cover tlie entire *'horion, giving the ovum its 
tH>-cri1le<l ** nhair gvfvmt^" a? ^eeti in Fig. 38. At two months 
the villi of the chorion lieve begin to degenerate! and in a 
month or two tnore they havt5 gone. 



Fiaas. 




Hutniin o¥um, with eon 
tiUnt'tl rinl»riii», iihKmt tlic 

KdM.lKKR. Mflcr Allkn 



THE A L LAS TO IS. 93 

Tlie Allantois, — In the human emUryo there is tn> real 
alhinluJH, f^ucli im U suoji in ihcrhick, the ciilf, and oilier mam- 
mals ; but there is a rudiiueutary modiiied form of iilliintob 




Ddrelofonent ittlll more advanctnl. a, a. FoUlt of aTnnioti about tu toy eh 
and joiit eiurh nlhcr. p. CVjnuncncciiieiit of allantob. 

Fio. 40. 




1niti«nPtk»n f»f amniotic fuMi-nta. m. t'mbilicnl vesicle p. Pt'diolf of 
ft)Uniot>i. The itrojwtiiin foldH of the allatittils, ptis^in^f rournl ihe cmltryo and 
fTillowJnif the folds of the iiuiniVm, will sfjoij join and uullc, complctiily iiur 
rounding thc^ ovum, 

— nllnntoic stalk— eonstitutintif ii part of the "ImmIv ?talk,** 
previtJUMly ineutiouetl ( )»age 91 ), hy which thu emhryo retains 
iifl oooiiet'thm with I he ehorion. One uf tlie functions of ihe 



94 Jfjrri2.tr/0A; fecundation, and nutrition. 



allanLi>it' sitiilk in to stretij^then and jH^rpL'tuate this coiuief'tion 
\\y L'otivt'yiii^ l>lot>(lvejsj*els from the emhiyo ti» the chorion, thus 
coniributinfi ti» Ibrrii tht* Quihilieal eonl ami phieeiitn. We 
can best yndcrHtaiul it by tir^t describin^'^ the alhiiitois as it is 
seen in the chick. Here we tiuil a tiurt (d' firotriision or 
divert ictiUim of the entoderm project injr itnelf otit of" the 
embryo, just befdud the stem r)f the ymliilieal vehicle or yolk 
sac. The entodermal liiuiig of tbii* diverticnhim is roiitiuuous 
with the entodermie lining of the primitive alimentary t^anal : 
its Vavity is eontinuous witli the '^hiud-giit '* of that canaL 

Fiii. 41. 




Showing fold* of allantois complWely uiiiud, mid thefr two lAyen» in PouUrt 
wltti eplMrt*l AtiJ viU'lline membraiH'. to ftirm ilntrion wild it» viUl I. Vllrl- 
lluL' mfiabniiii. 2. P.pJbluj^L 3, Allantois 1 rmbiliciil vtrisirle. h, Amuiou 
«iU internal layer, coutalninK llqnof am nil). 6. Bt»dy of flctiis, 7. Pedicle of 
ftUantoij^, Ut become ihv umbllicttl cord. 

It is covere«1 on its outi*ide hy a splanchiiic layer of tuesoderm 

(in whicli develop its bloodvei?$!el8), a eontinuation of ihe same 
splanchnic layer of menoflerm which forms the veii-sels and 
mnwndar coat of the intc*stine. The allantoii^ beirins as a 
hidlow jKHieh. a** «ihowii in Fi^. 3fK and hmui frrowsand spreads 
cireumferentially, as a jjlolnilar flattened |K>uch, all round the 
i^ndiryo i Ftj: 40), until it^ borders meet and juin» m v\m>M\ 
m ¥'v^. 41, A% shown in this bist figure, the vainU} of the 
jM>ueh is gt^tLing smaller^ and will 9^m\\ di8ap[>ear altogether 



THE ALLANTOIS. 



by the inner siirface.s of the cavity ctiiniug io contivet with each 
rjther lunl uniting f(i lorni n incmlvrane. This mcnibranc will 
ilistt*ml until it coinea n\ runtact nnd unites with I fie cliorioii, 

Keturniiig now to ihe huniiin euiltryin we fitnl the allantoic 
pouch of enUxlerm only extent Is a wrij nhoH, diMance into the 
Ixxly stalk of mesiiileriu (i*ee Figs. i> and 7, Plate 1); the 
Htalk» therefore, is eoTnjM>sed of niesofierm alone^ without uiiy 
euttKlernial cavity continuous with the intestine, as ^een in the 
chick. Note also that tlie body stalk JtM-lf is rery nhorU ^ 
that the anterior (aVwloininal ) surface of the embryo ij* ek«*e 
to the inner surface of the amnion. It will not remain m. 
The stalk will grow in length, a.* if it were projeeteiJ out of 
the umbilicus of the endjryo, until it become a f<M»t (and 
sometimes i^everal feet) irj length. (Set^ Fig. 8, Date 1.) 

Observe tlmt the ectodt^risml layer forming the skin of the 
embryo atops at the hetiU end of the eonl and also that the 
et^tcMlermal layer lining the amrnori i<tof)ft5 at the |i!acental em\ 
of the cord. The cord itself, therefore, is md covered with 
amniou, as wn.s formerly supjxjsed. In Fig. K Plate 1» the 
oord is rcjiresented as consisting of me?^)derm alone ; a naked 
Stem of mciioderni without any sheath or coveriug^ And so 
it would be if it had to get one from the amnion, for in 
recedmg from the child's alnlonien, the amnion leaves no 
sheath liehind it for tlie cord whatever The eord^ however, 
^^U its sheath from a tul>e of et*toderm and 8t»matic mesoderm 
which Jo Ho icj< t he le ngf hen i n g Ix m1 y stal k . A s th e sta I k grows, 
or' seems to be projected nut r»f the chihFs abdonien, the 
sheath of body- wall and eettMiemi grows with it and makeM its 
fiheatK The external coat of the cord then is ectmlerm 
conttnnous with the chihTs skin : on the skin itself the ecto- 
derm eelln dilferentiate into epidrrmi^ : on the cord, the ect*h 
denn cells diH'erentiate into the smooth n^emlirane with which 
the cord is 4'overeii no matter whether we call it mmlttie^l 
epiderndii or any other name. Inside this ectodermal covering 
is a poorly-developed i a differetitiated or modified) layer of 
si^nmtic me^^oilerm continnous with the somatic layer forming 
the nmscuhir wall of the child's alxhmien. In the sheath is 
the central core of splanchnic mes<Kienn and its bloodvessels 
carried there by the allantoic. If the sheath were empty, its 
cavity won hi be found ctmtinuous with the cavity of the 
embryonic ccelum which is to become the pi euro-peritonea I 



96 MATimATlON, FECUNDATION, AND NUTRITION 

cavity, innl thus in the cavity, we liiul the remains of the 
uiiihi Ileal vesiele aud of the rmlimenttiry allantoie [louch, 
Imth uf which, as we have i?*eeD, were eouthiiioiiT* with the 
eatmienii of the uliineiitary cuoal, and were covered with a 
s^>laoehnic layer of the niej^mlerm, and hoth [irotruded into 
the etplum. Thus, also, is ex|>htined the i.»eeurrence of 
unihiliai! hernia, when a pieee uf iuteistiae jirotrudes into the 
cavity of the ei»rd at itn root^ its eavity being really a con- 
tinuation of the jwritoDeal cavity » 

The formation of the tubular sheath of the cord may per- 
haps lie made more intelligible by comparing the bwly of the 
embryo to a wound-up tafK?-meiUJure. I^ct the ta|je represent 
the conl and the little metal ring that serves us a handle 
with which to puH it out, represent the amnion. Now pull 
cmt a foot of the taj>e : it it* Ljuite naked, so far as j^ettiog any 
sheath from the recetling anndon is concerned. The sheathe 
therefore (if there were any ), would come out of the meai^ure 
itself, and be fHvntinuous with the box in which the ta(»e was 
ci»iled, 8<j the sheath of the cord comes out of the embryo, 
and is continuous with the Hmratic mesoderm and ectoderm, 
forming the wall of the ahduminal cavity. 

In Figs. 9 ixjul 10 of I'hUe 1 I have endeiivored to show 
how the cadum^the space l>etv\eeii the splanchide and somatic 
layers of mesoderm — becomes the pleural and |>eritotieal 
cavities. In Fig, 9 we fiml the four germinal layers, just 
as in Fig, 1, except that at the |xnnts '* a *' and '* />'* in Fig, 
9, hyclding dilatations are begin uing to project. With con- 
tinuous development the bud *'a '* Viecomcs llie lungs and the 
bud **/r' the alimentary '*anaL The sim^'e marker J by red 
crosses, al>o%'e dia^ the iliaphragm, is the pleural cavity ; iiclow 
the diaphragm it is the [)eritoneal cavity. 

The Placenta. — T«> understand the develojaiient of the 
|»lacenta we must examine the progressive changes tfiat take 
place in the mucous membrane (mucosa) of the uterus after 
im[iregnation. We have seen that even before impregnation 
when an ovule is expected to enter the uterus, the uterine 
mucosa be<*omes much thickened, convoluted, and more vas- 
cular. This normally hY}H»rtro|)hie<l mucosa in the absence 
of impregnation degenerates aud h thrown otF with the nien- 
gtrual discharge, hence it is called 'uiecidua menntrnaiiM,^^^ 

1 1kndmt in dcrivetl f^im ** tifHduu4,** ft fkUlng uflf; \>Jle,fhHn ; oaulcre, to HiU), 



THE PLACENTA, 



97 



When impregnation hm occurred, the exuberant growth 
and vascularity of the uterine mucosa continues^ in the 
manner to he now descrilwd. 

The entire inucous coat of the whole uterine cavity, from 
the 08 internum to the orifices of the Fallopian tuhe^, when 
th U8 thic k en ed , i s * 'a 1 1 eti the dcf^id u n vtrn {or nt er i n t: d ec i < I u a ) . 
When the ovum enters the uteru«^ and reurhes the spot where 
it ia to renuun, the tkx^idtia vera &entls over it reflecte<i folds 
tliat cover ami enclose it, these relitMied folds of the vera ure 
known aj? the deeldufi rcfiexa (or ovular deriiiiui, or Hecidua 
capmlarh). That part of the vera vvhieh lien hctween the 
ovum and the muscular wall of the uterus, and in which the 
placenta will develop, is known as the deeithiu tierotina (or 
/j/acm/a/ decidua, or decidua bamliH), (See Figs. 42, 43, 
and 44) 



Fio. 42. 



Fia. 4S. 





Formation of de«i<luii vcfH, which U 
r«pn.'AtiuUM] by bltick c<»lorliii;. 



Formation of foltls of Jecidtim reflexA 
growing up Around ovum. 



When the fecundated ovwni enters the uterus it is still 
surrounded by the vitelline nietnlrrane, l>ut, having reached 
the situation where it is to retnain in the uterine mucosa, the 
vitelline membrane melts away and the ovnni is free, (See 
ptfe S)90 By this time the ovum has of eoiirae become a 
idastOilerraic vesicle, ami is covered by its external germinal 
layer, the ectodenn. The vitelline membnine having dis- 
ftpfieared, the eiloderm would, therefore* seem to eome directly 
in contact with the decidua vera. So it does in a way, but 
the contact is not tlius simple^ for the outer surface of th« 
7 



98 MATURATION, FECUNDATION, AND NirTRfTIOX 

ect<jderm hm l>e€otnt5 covered witli an additional Inyer of 
ee\h, known iii^ the tt'ophobluj<t (^or trophtxleruj;, whieli iiju>t 
Duw rei't'ive our alteotioiu 

The TrophoMast, — ^Iti tlio tliuij^mriH we have represeoted 
the geruiiiial hiyefs as beiug comjxjj^d of oiUy one row of 
cell^ or layers ooe row thkk. Of course they do not 
remain so. The Wdy-s^tiilk, we have seen, is conijmsed of a 
mius of niescKlerm cells, and llie body of the embryo is niude 
up of many layers. 




Jolnlncof fold« of deriilua reflexn anmnd ovum* and tblckenlng of det'ldua 
«vpunifi where the iilaceula will «levL'h>p. 

80 we find the ectoderm does not remain a single layer, but 
develops upon its external surface an additional, quite 
thi<*k eimt of cells, known lus the trophobhaf. And thin i^ 
diviMible into two ilistinxU layer*^ : fimt, an inner hiyer* matle 
up of well-defined cidHndal or round ceils, known ius IjanjLT- 
hair^ layer ( Jjimtrhan lir*<t ileserilx^d it ). and, /**(v>in/» an outer 
layer, in whieh no cell-walls ciin he secri, or if there were 
nny original ly they have melted away, leaving a granular 
mass of protoplai«ni dotted all over with scattere<l uttrfel: 
this is the nt/nciffium, or syncytial layer. The frffphohlant 
(com|K>seti of the Langhnn and j^ynr-ytial layers) already 
exists lH*fore the vitelline numihrnne disap|»ears: it is, there- 
fore, a ftetal structure. When the ovum reaches the 8p<»t nu 
the decidua vera where it h to remain, the vitelline niern- 
hraue di»jipjx\nrs, and the lil»erate<l ovum, elothed with trcipho* 
bla^t, couieA in ci>ntiict with the vera. And now* occurs a 




THE TROPHOBLAST. 



99 



mo5$t reinarkablt! and iuterestiug eveut The cells of the 
gyiicytiuni are phiigtK^ytie ; hi coiitia^t with the uterine mufosa 
they begia to de^tnjy and eiJFusume the decidua vera, imd 
thus, BM it were, eat a bole m wlueh the ovutu really huries 
itself. Tbu« ocrurs tixatiou atul ** impfanUdhn " of the 
ovum in the suljsiituuee of the vera. Over the poiut of 
eiilrauce, folds of the vera ris^e and joiu, fonniii!^ the tfreifltta 
Tt-fiexii. Betweeu the I rtt|ihol>hwtie covering of llie ovuro aiul 
the muwndar wall of the uterus, tluit is to say, at the bottoiu 
of the little eavity, there still remnius uneonsumed vera, ooa- 
slitutin^ the deeidua eerotitia. 

We have uovv to eoiisider the relations of the eliorioiue villi 
(covered with tr(j|diohhMie eetiMlerui, i>f eourw ) with the 
de<:idua, aud the ehaii^^es in hoth whieh lead to the develo^v 
uientof the plaeenta. It must tirst he iioteil that the decidua 
itself, durini( preiruaneVt does unt n'riiain a (>m--hiyivred struc- 
ture. Three layei-s can he rei"otrui/>ed. 

Fir»t, — ^A su})ertieial, thiu hiyer (faeiug the uterine cavity"), 
ktiowu ns the dratum coin/tachtfti bei*aiiHt* it is more eoiuimct 
ia structure, from having a greater amount i>f interglaudulnr 
ccmnet'tive tiasue and a very moderaft' dilatation of the gland- 
ular follicles. 

SecontL — A much thicker layer immediately hehnv the tirnt, 
in whicli the tubular glands iH^eome e norma uahj dilatetl, and 
even j^iuefl ti»gether» wj as to form an irregular network of 
intercom municating gpHcej* with Init little intervening c«)nncr* 
ive tissue. It thus acquire** a sptytujjf chanicter, and is known 
i the nimtHin spongwHurn, 

TliirtL — Still l>eneath this s|»ongy layer, next to the mus- 
cular wull, i?i a thin layer known as the bai^a! or nnchaiiged 
layer, heeause it remains wUnit jis it wus hefore pregnancy. 
It is eoiir[Josed chiefly of connective tissue. 

During the early weeks of j^rrgnsjnty the enfir^ chorion* 
that is, the entire external surface of the IdaHtodermic vesicle, 
i« [irovided with projecting villi, which hegin as mere ecto- 
dermal hnds witliout any hUxKlvessels, hut very Skxm each 
villus (as w*e have seen) receives a vascular core of mesoderm 
which Carrie*! a ca[)illary hlooi^veiis^d. At first these vascular 
villi project into the rcflexa. as \\v\\ as into the de<-idua sero- 
tiiu\. Dnrini; the senvnil riioruh the ves^sels m the villi of the 
rt*llexa hvijin to dinapfjear, and a(ta' two nmnths the circuiatioii 



100 MATURATION, FECUSDAT10S\ AND yUTEITION, 



w the cliorioii is restrktefl tn tht^ Kerotiiia wliere the j>]ju;eiita 
W tu tlvvt'loji. Ojiucidf iitly, iIr' rUft uf the retk^xa ntn^pby luui 
djf*!i|>pear ; uikI the reHexu itii'If* I h hi tied by iliiitenlicm nt' its 
growing couteiiLs, and hy llit* |)hag**<*ytit? artiuii of Hl4M^frnml 
tnj|iht)ha8t» cuines in t^^mtact, alMiiit thi^ end uf the third tnoiit!i, 
with the vera lining the rei^t of the uleriDe cavity* when it 
beconies suhjeeted to prfauiuj'e on Inith of its surfaces, whit*h 
reduces it to such extreuje thiuncsH that in fdaees it quite 
fades* awaj^ leaving the chorion in eontftct with tlie vera. This 
procevss goe^ on utiti! during the fifth nionlh the entire reflexa 
CO n I pi ete 1 y i I isa | i]>ca rs. 

We may now, llierefore, di-^misw the reflexa and return to 
the serotina where the placenta ij* to form, 

The ]ilnn of couiifruetion in a eornplcte phu*euta is Hiniply 
thin : ('avitic^ form in the decidna jierotina, into wliich 
maternal l^liKid i\m\s in and out. Fmjecling into iheee cav- 
ities eonie the cl^tnal villi with their hniuching vat^cular tufts 
to he constantly Itsilhed in tlic ehl» and fiow of rnatcraal hlomh 
ju:<t Jia an aijuatic [dant projt^is its nlem and hriinches from 
the lx>Uoni of a j»ond, to 1k^ constantly hathcd in the surround- 
ing water. The niaternul tunl fo-tal lilood^ do not mix : the 
hlowi condng into the ciivities from nniternal vcs4tels returoa 
by inalt'rnnl vejjiwel^ and the ftctal bhuwi in the chorial villi 
etmic^t and returns hy ptial vessels. 

The nuiteninl I>1ock1 cavitieii are variously known n» lacttnm 
Clake^), i<inu**e8, and ** intervillous spaci's/* because they 
iX*cu|»y the sjmcen betweeti iTcigh boring villi. The mode of 
their formation is not ahsolnlcly >;ettled ; two ex[danati<m8* are 
^iven. Oneifj that the nialernal capillarit-s thcmselvej* dibite 
into large i<inuj*e.s (we might think of them us normal varicose 
or aneurismal dihitations > into whjrh the growing villi pro- 
ject The other i.s that in the thick hiyer of trophoblast 
c*o%'ering the villi* | witches of degeneral ion tx'Cur in the tropho- 
hlast cells, thus leaving empty Mpaces* into which maternal 
bliHwl gaifis fldmittancc, by the phagm'vtic cells of the tropho- 
Idastic syncytium having t'fi(rn tht'w unij inttj the walls of 
maternal hh»f>dve.^!^di*, thus jjcnnitting an actmd extraviisation 
or hemorrhatre into the sjMices whence the tropholdast cells 
h a ve i I isa p | M*a red. T h e h h m wl t h uh c< j rn i n g i n t^ » t h c spa< 'cs. g< le^ 
out agaiu hy i>ther o|xMting8 made by the i?ame phagocytic 
action of the trophobhii^tie oella Iii »ome instances the tropho 



THE f^LACEXTA. 



101 



billet completely HurronndH tlii- 1j1uo<1 f*|*iice f si mis), ixuA then 
eiiLs iiwiiy the inaternul wall eurlosiug it, thus ihe hloud that 
Wiia enolo«e«l hy and in nuiUR't with a matrrnal vaik'uhir wall 
is now enclosed liy ami in con tail with a j\rktl wall ; viz., 
tr<i|>hi>hlitst, or fhorioni** ectoth-rm, llaviujir I'unMimed the wall 
of the sinus* the bnnifry trujiholdustie fAh pruhahly jirot'eed to 
corusume the hloncl iLnelf, but they cuunot consuine it ulh tt>r 
the supply in con^tautly rent^wed by the eirculatiou. Projeotiug 
into the^e ponds of maternal hloorl come.the ntems and brauches 
of chorial villi with their ltHj|is n( wtpilha*y vessels. Fig. 45 

Flea. 45. 




Vt'rtjtMil ?j<*<!tJon of H pUccntn. showiiitt ^nwulur ttifts of chorion nnd blooil 
Xmkvri of (tUecDtA. a, o. Chorion, b, b. Il^cklim, «*♦ r, <\ <*. Oriflcea of uterine 



— an old diagram from Dalltni^ — shows very well the jdan of 
COQ«tfU€tion ik»-Heribed, the lihick .*ihadin^ ref^renents the pmd 
of mttternal hhwxl which eome.'S at hI *;<»*-« throutrh th*^ ojx^nin^ 
c, c, c^ L\ Observe that tin* lenninal ends of scuoe of the villi 
join die deeiduu, thes^e nn^ known as ** fastetjin;: villi ''; others 
dantfle free in the intervillous spjiees withcnjt any sueh fasttMi- 
iui<. Note, too, thttt between the fcet^l and nmternal blood 



102 MATUKATIOy, FKCUyDATIOy, AND yUTIUTIOX. 



tilt* re always exists the strurlure of I lie viUus itj<clf, which, 
thuijirli extreint'ly thin, KUll t'oiij^isl^sof the eutlotheliinii lining 
the tirtal tmj»i II lines, and the eeNwierrual layer of trophtihlast 
ixn'erir^g theru. Through tbese atruetures the iaterehauge of 
material, iiicludiug oxygen and earhoii dioxide, lakea [daee 
hy mnnma. 

As the villi braQch out, enlarge, and communicate with each 
other, their pbugoeytie eovering of tro]>hi»hUiHt!r eetodernial 
eelL-^ ha.s continued to consume and uhwirl* the uterine tissues 
of the serotina^ so that eventually nearly the whole }daeenta 
consists of ftetal villi and maternal hltwd sipaees, w ith their 
contained materual liloud. S<mie strand.** of the inter^'lan*!- 
ular linsue of the s^erotina, however^ alwayt^ j»ersi8t, and extend- 
ing from the thin btusal layer next the mm^'ulur coat to the 
stratum e<jm|>aetum facing the uterine cavity, they eiioFtitute 
the fibrous bantls, or R'pta, which divide the plaeenta into 
Itibular areas, seen on it^i uterine surfaee after delivery. 

Our knowledge of the eimiplete jilaeenta has been aetpiirtNl 
by direct obs<^rvation, hut during the early day a of pi areata 1 
development very few human ova have been seen. The 
youngest yet known was de7?enhod hy 11. Peters in IKJJIL 
It is thought to have in^en fn)m three to six days old. Sections 
of this s[H*einjen ap]>ear in all our rt^'eut text-books, but no 
two of tliem are exactly alike, I have ventured to intra- 
rluce a rectaist meted illustration, riate J I, whit^h is a sort of 
eom|n»site !!iodi!icatio[i of tho»e given by ^finot, Williams, 
Rol)in8on, and others, which I ho|*e will be understooth 
The entcMlerm, meso<lerm, and eetoderm have the same green, 
red, and black eoloring, res|H*ctively, as iu Plate 1. 

To agree with this jdate, I have taken the rather unwarrant- 
able liberty cjf lining the anunoth* cavity with e<'todennal 
eella continuous with the back of the embryonic shield : but 
the n»ore highly magnified Fig, 4H, immeiliately following^ 
hIiows this to l>e untrue. The fact is, this early humiin sj>i*ci- 
men differs from, and cannot be made to agree with, the 
couilitiouR obs**rved in other animals on which our knowledge 
is bai^Mb as will l»e explained farther on. 

Another early human nvnm is that of Oraf Hpe, shownt 
in Fig. 47, a section of whieh apf>ears in Fig. 48. 

In the^e and all other sfiecimens of early Intmrtn ova, the 
amnion is always s^'Ct* m a sac alreadt/ dmtd^ so that we know 



PLATE II. 




Am c 



^Mus 



Clot 



Tro, 

BI Ibc 



_MUS. 



Tro. 



/ 



■■■■«■..■■■•'■■ !# 



Bl lac 



Ut ftp 




Conn 



Bl. IftC 



THE PLACENTA. 



103 



notliiiig as U) the mode of it« fommtiofl, but, w^ Ballni^tyne 
remarks, **the fact of its heing clctstNl suggests the (jiiestion 
whether it was ever o|)eii. Pruluilily the nniiiion in the human 
snhje<»t is Nv/r fonneil by the uphetivnl uf ihUh of extra- 
embryrinic ?i<nnatopleure at all, hut by breaking thmu of 
ejn blast tissue to fortu a eavity ( lierry Hart }, ur by iii version 
of the bliu*^to<lerni (Mall)/' In MalF:^ early nvum the 
aruniiJtic t^ae a[»[M'ared l>efore any embryo or priiuitive trace 
cuuld be discovered. 



--eot, 




ines. 



Pivrtion of Fetera* oTom, hlfrhly magriffled, showing e«rly sUg« in devvlop' 

TTirnt ..f ijmbryo. lAfltT Wii.ua Ms.) ^.Amnion, r. rhorion. ««. Kctoderm. 
^ !:r!U>i|rrtn. meiL Me«idenii. E.S. EiDbryonio shlelil 1%H, Yalk^suc. Sp, 



Ileichert*8 ovurn» supjuK^eil to be thirteen days* old, and 
repre<»ented four timt*!^ iti^ naturn! size in FigF*. 4y and 50, wim 
found in the wnrub of a woman who eommitted «tiieide. It 
W416 flattened from side to side^ doinewbat like a biconvex len3» 



104 MATURATION, FECUNDATION, AND NVTRtTlON. 

the surface faeiuj; ibe reflexa (shown in Fig, hi)) being more 
convex than Lbe other, Friug<53 of villi projei-tfti ouly iVoiii its 
borders, the central fiortions of b*>th surfaces being bald and 




^cm. 



Bf>ef'N huraAri ovum, t-mbryonic iireKtO.4 miUimetre long, y 24. (Wuj fAMa) 
4. AinriioiK ii*. AMoininiLl fierltde. <7< Chf>rioti. r, r. Chorionic fplUivlmm. 
cm, Churioulc mefiodunti. r« Ohorioutc villi. Y. Yolk-sac. 

Ft8.4a. 




Beetton throairh Spec'i yotiTiRfsi ovum, shown in Ftif 47. x 24. rvV[tLui(J».) 
*, CSiQriotifc memltranc, rd. Ectoderm* m^f. M»'*od<?rm. *ttn. Amnion, f. 
Beiriotilnf c»mbrfa. bit. Abdomlnat pedicle. aU. AUnntoUi. |^.«. Yolk-MC, 

dreujar* that toward the iitern? ex lii biting n\m a smaller cir- 
cular central space. It contained no trace of a fietus. A 



THE P LACES T A AT FULL TERM, 



lorj 



[iiiman ovum^ faurteeu tiiiys old, with eryliryo, miigtiiiiwl 
tweuty dia meters, mid ohtuiiied liy Hly, is 8hi>\s q iii l^'ig. .rl, 
p, lUt)| aud aDother l>taweeti fifteen and eigbteea days, de.*H riljud 
by Coete, is i?hovMi, largely niugoitied, in Fig, 53, p. 106. 

Disapjioiutiug as it !=> to Mod ihese diiierences between early 
human ova and the ideaa we have obtained from the study of 

Fig, 4i> 





Showitig 



eiarjryj. 



rif lUlehert'a 



8huvvin^ side vIptv of \U:\rhvrV» 
ovuui. >. I, 



' animals, it is gratifrinicr to know that the final outcome 
is the .name ; that it* to say» whatever the l»e|i^iniiingt in tlieeml 
the placenta and memhraiie.s come ont tin we have destTilied 
ihenu With the .stndent I deplore tiiese discrepaiicicH, hut 
he will understand that, with regard to them, the rest of the 

FUi, 51. 



/ 




Th*i samt! In dliMrraminAtlc section* fHwO X 5, <i* Afen germlnnHv*. 



nlwtetrieal worhl ia no better off than we are. To remedy 
the difficnlty we tnu*?t await more Hi>edmens ami furttier 
Investigation, 

The Placenta at Full Term. — Tlie placenta at full term 
is a sofl^ Ff>onpy mass, irregularly sa nee r-sh aped, j^even <»r 
eight inehe^s in diameter, (hree-quarters of an inch thick near 
the centre, and from one-eighth to one-fourth at the edge ; 



106 MATLlLiTloy, FECUNDATIOS, AND M'TRJI'IOK 

VIG. D2. 




Hit*! ovttm, wen fVom fight side, x 31 Mi<intoi» eon- 

ner^tliii^ wllh Ck, a. jMirt of Ihr ehorUm. Ji. iknrl. \. Jtl«>udvc*istila of T*,, 
yolk&rtc, or umblllcul x'i^^iulu. N. Neuml gn>t>vc for i»pltial c-uiinl. 



Fm.». 




nittnuti mMim during thin! wvtk. A> Amnion. A,», Allanlnlc stjilk. II 
fleart. W lUoodvcs^cU of V. t., the yolk s«c, or umbUiCAl vc«iclc. I^Fruin Hm, 
After C'OSTK.) 



THE PLACENTA AT FULL TERM 



HJ7 



average weight twenty omices. It varies mucb in all them? 
particulars. 

Oil insiiection after delivery* the uterine or external sur* 
face presents a dark-red, rou^jh, and uueveu appearance* with 
irregular fiasures dividiug it into bbes, as seen in Fig, 64 



Fig M. 




Uicrititf surf^^e of the plaecntii. 



The internal i)r f<etal surface is eniooth an«l trlisteniTip, 
while large hliM >d vessel !« may be seen and fell Wnieiith it,s 
aniniutie cf»verinp, a*? ^hown in Fi^. 55. The placenta is 
iwnally Mtunh'tl im the |M>sterior wall of the uterus, hi^h up 
near the entrnm'es of the Falh>pinn tnhes. This is the rule; 
exceptionally, there is nu fmrt of the uterus to which it may 
nut l>e attached. 



NUTRITION or FCETVS DURtSG PREQ NANCY. 109 

The Umbilical Cord ( Navel-strmg, Funia). — At fir^t 
it is the nxit of the ullautnis, or llinl portion of tin* ullnriloij* 
extemliui; inmx the hinly uf the tVt'tus to liie ihorioih Later 
it reiuaitis^ the eotuieetin^ link lietweeu die iilnJomeii (uavel) 
of the fa^tus aud tlie phieeiitn. ll eon tains two urteries, whieh 
are eoutiuuatiorti* of die f<etul hyjMj^jistrie arteries and cme 
vein — the hitter without valves', ulthuujfh erei^eetidc-shaperl 
folils oeeludiJi^ two-third:* of the eaiial of the vein, and thns 
tJonMilutiiiu irnjierfeet valves, have been dest^ribed. The 
umbilical arti^rie^, at tirst jitnvight, beeonus later, twij^teii 
around the vein* The ves^gels are iinbedded in die nwalled 
, gelatin of Wharton, and the i'ord is eoverwl exteriialiy by a 
> »[teeial layer of e[ (it hell inn derived fronj the faHal eelo<lenn, 
and not hy a wheadi of amnion a» was formerly i$u[)poj»eii. ( 8ee 
page 95). 

The eord ij* Ui^ually attaehetl mar, but not t-xaetly i';/, the 
middle of the plaeenta, Smiedmes it i?* iiiR^rted rlo&e to the 
jdaeental margin, aud is ealled dien *' battledore placenta" 
and ** in»rrtio marginniitt,'* Very rarely it is inserted ontside 
the plaeental ln»rder, iiito the nnvrtibrane^, the ufuhilifal ves* 
s*ds .^nlMlividiiiir and spreading out their branchew before 
reach lag the placenta — '** hij^trh'o vrinmnitoHn,*^ 

NUTRITION OF FCETUS AT BIFFERENT PERIODS 
OF PREGNANCY. 

1. At firsit the ovum alwHirlis nutriment simfily through the 
vitelline membrane, while |umdng through the Fallopian tnl>e» 
The nntrient material is snpplie^l by the secretion of the tube 
itself, or may eon^^t in (rnrt of jieminal fluid iritrixlyce<l from 
without. 

2. The vitellus is absorlied by the entoderm lining' the 
undiilical vt^j^ieh- aud alimentary caiuib uitd later it in absorfKed 
and conveyed into the body of the endiryo l»y the blood vei^s^da 
of the area vasculo^aa. 

3. When the eontentj* of the nmhilical vesicle are exhausted, 
the ehorial villi a[)(w?ar and take up nourishment from the 
uterine deciclua, with which they are in contact. 

4* With the disa|>)Kninince of villi in the ehi»rion Iseve* the 
villi of the deddua i»erotina develoti iuto the placenta, where 



110 MATURATION, FECUNDATION, AND NUTRITION. 



they take ii[) iiutriineiit from tUe juatenml blood with which 
they lire HUrrmiri(le<l 

PEHctions of the Placenta.^It itm only nffnnh nutriment 
to the ehihl, hut i;^ ul^i its frsplmtorii orr/an. The uiuhi Ileal 
arteries earry hlue ( vemuHj IjUhxI to the plueenta* where car- 
bouie acid ^as ia given off* to the matenuil hhwid, and oxy^^en 
taken hi from it, m that the uiuhiljea! vein hringj* baek arterial 
(red ) bhxtd to the tietu«. The |ihieenta is also an orfjrut of 
e.veniioti for the infant. Keceotly the |ilaeeiita ban In^eu 
credited willi a jiflf^Hhr funetiou, by wliieli it has iiower to 
j»ele<-t froiri the niatenial bhiiKl sneh niateriaU m may be 
re<[ Hired by the tVetiit^ at di Cerent [KTiods of pregnaiKy. 

Tmtal Circulatioii. — The nrnbilieal vein after entering the 
nnihilieu« sends two hranehei* to the liver, while hs main trunk 
(the dncfuA rmoMttj*) emjities directly into the luseendiii^ vena 
cava. The blood returnetl frt)m the |ilaeei)ta by the iimbilieal 
vein tft>e.s, therefore, part of it to the liver, whence it isreturne^d 
by the hejialir' veiiifj into tlie asreiidin^' vena cava jiu^t above 
the eutraiire of the dmliin venosiif* to join the cnrrent from 
this latter vesrwd. The blood from the lower extreniities of 
the ftetus eome?^ up throuL^di tin* vena eava, and tluis mixes 
with the return bhM>d from the plaeeiitxi. 

Early iu pre^nauey the greater [jart of the bltKMl in the 
litubilieal vein goes throngb the liver, l)nt toward the end of 
pregnancy the hulk of it gix-s^ iliri^'tly into the as^^ending voiia 
ciiva throngb the duetus veuosns, the flnet having beeome 
enhirgeti for thin ]jnr[M>.-*e while the portal j^y>item hai* beeonie 
insuffieient to transmit llie inereitsi'd ijuantity <»f IiIikkL 

The luseending vena eava |Kiurs its blood into the right 
anriele of the heart, whenee it ia diret*tetl by the EustiK^liian 
valve through the Jttr a men nvnlt* int<> the left auricle* From 
the left auriele it goes to the left ventricle ; tVom the left 
ventricle to the aorta. The great bulk of this aortic stream 
passea thniugh the large arterial branches of the aortic arch 
to the head and up|>er extremities. From these the bhx>d 
returns by the dcj*eeinling vena eava to the right auricle; 
from thence through the tri(*uspid valve it p4wse*J int<j the 
right ventricle; ami then it enters the beginning of the pul- 
monary artery, hut llie two brunches of the pubnonary artery 
going to the lung** cannot receive this c<iluniu of blooil before 
respiration is establishes I, so tlial there is a special blucKi-iluet 



APPEARANCE OF THE EMBRYO, 



111 



i 



(the dudua urteriomin) pnjviilcnl for carryiiig the stream from 
the trunk of the pulmonary nrtery iuiu the *le?<t:eiiiliiig iiurtii, 
from whence piirt goes to the lower extremitie^i, to come hack 
l>y the a.*ieeniiiiig cava, whi!e another [Kirtiou puJ■*e^^ ahmg the 
umbilicfd arteries to the placeiiUu The iimhiliciil arteries? are 
eoDtituiatioths of the hy[Kjga.Htne artiiries given otf from the 
internal iliuej?. 

Changes Taking Place in the Circulation after Birth. ^ 
There i^ no longer any eurrent of Kkxxl through I he uiu hi Ileal 
%'ea&eli*. The navel j^tring ilries up and falls i»tf. The iimhili- 
cal arteries iu.'fifie the alxlomert renniin pernninent in a jwirt 
of their eourse, constituting tlie Huperk/r vf'm'nl ndtrien. The 
ductus veuoi*us and ductu?? arteriosus no longer adniil Idood, 
but shrivel up into tihrous e<irds. The ioraiut^u ovale eloties» 
%o that there i;* no longer any pa.s^sage froiu ouc auricle to the 
other, and when the lungs are exjiauded hy respinitinii the 
pulmonary arteriei? receive tlje Idood which Ik fore went through 
the ductus arteriosus^ and convey it to the lungs. 

Appearance of the Embryo at Different Periods. — Since 
it may iw im|>ort:uil to ascerlahi the prolmhle duration 
of pregnancy when the |>roduct fd' c<mcv|itint» has lieen |ire- 
malurely dificharged, we conclude this chapter with a brief 
reference to the size and apf>earanee of the growing ovum at 
different peritwJs, 

For the first two weeks at^er fecundation the ovtmi is simply 
called an omnn. From the en^l of the secomi week until the 
end of the fj'fh, it is called an rmhnjth From the end of the 
fifth week until full term it is called a fniuR, But tliis rule 
is not rigidly folhwed in the lKK*ks. As we have seen, the 
genn-cell lives in the ovary years before im|>rcgnatiotL Bul- 
la ntyne calls this the ** tjrrminai ptnod'' of its life. 

At first the develo[)imr end)rvo is comjMitsed almost entirely 
of »ra/rr. The analyses of Fehling and Michel give the jht- 
centage of water at two ami a half mouths as 93.82 ; from 
thinl lo fourth nmnth 89,95 ; and at seventh month t*^4.7''), 
the remaining constituents lieing alhuminoids, salts, and fatij 
( Williams K 

The different membnuies with their ciivities fille<l hy watery 
fluids wouhl suggest, our regarding the early enibrvo as a sort 
of compHcatt*d ^ij^trni of ry/»/x^ an<! such it really is. It con- 
taing no vacuum and no air-cavity : ulf sjKices are iKM-npieil 



112 MATUEATIOy^ FECUyDATWy, AND NUTRITION. 



by a watery fluid of some sort; the Hiiids of ditferent cavities 
probably ditieriu^^ io ilinsity and m their rlieioirul and elec- 
tririil [»r(i]tertiei*» tiot yet »ii^'ertaine<L 

It may be noted that iii all the i^ectious of early end)r}'os — 
of whatever ardojal — represented in the lx>ok^, the tlorMn I sur* 
faee of the ernljryonie body i*? almii/A directed towarii the 
uterine walb toward the decidaa Herotma, When the folds 
of the amnion areh over the l>ack of the erabrvo, meet, nnite, 
and 8e[uirate into amnion and ehoriou, the baek of the ernbry- 
(Hiie Ijudy bfeomew eut off ( a*^ we have .seen, page 91 ) fronr its 
ju net ion witli the uterus at all point i^ exeept the biHly atalk ; 
thus it ran no h>n|rer maintain its orij^noal (Mirallelism with 
the nteriiie syrfaee, tnjt the heiid and body «d' the embryo, 
suqx^nded only liy the enndal Imdy stntk, tdiauge their rel- 
ative position in Hueh a manner as lo bring the abdoifiinal 
iisj>eet of the end>ryo toward that |«irt of ihe uterine surfaee 
toward wliich the hack was^ ori<nnally ilireeted ; that is to say» 
the naveb with itj? yet ^hort nndiilieal cord, fares the uteri oe 
surfaee : originally the (Mck faeed in t inn direction. Whether 
thii« change lie <lue to gravity or other i'riuf*ei* in not determined, 
though the curving forwanl i*f the caudal end of the etnlvryo 
during the third week undouhtetlly eonlributeM to firing the 
hotly stalk more to the fnmt ; a jjroeespi whicli becomes "itill 
more pronouncetl during the fourth week, when the caudal 
and cephalic emlt^ of the end>ryo approach each other, some- 
thing like the two endt* of a capital C 

During the third week, however, the embryo presents a 
remarkable "dorsal flexure *' in the ojtpQifitr direction, ^hnTply 
convex in front with a corref^pmding sharp sulcus in the buck. 
Tins cimi]>letely disap|>ears during the fourth week, wlieii the 
rudimentary ^'pirjal colunm l»econie^ continuously rounded and 
convex [H)steriorly, as we tintl it later in the i!etus. Tliis for- 
ward *^dor!?al flexure*' of the third week is thought to lye 
abnormal, ()r acci<lentally pruductnl during examination of the 
9|XHnmens in which it has been ohserve<l, a point as yet 
onssettlal. 

Size of Embryo and Foetus. — There are different ways of 
measuring the emhry*!. When the ^'tiormijlexnte** has di&- 
flpjieared, the forward km«>itLtdliml flexion of the eudiryoinc 
iKHly beconu'S ^<i pronounctnl an to liri ug tlie head «nd tail 
euds ahiiotit iti contacts thus producing a decided hump just 



SIZE OF THE EMBRYO AND FCETUS, 



113 



behind the head, known as the '' neck-bend," which reaches 
its extreme development about the end of the fourth week, 
after which it diminishes as the body lengthens and the head 
and tail recede from each other. 

The measurements of Prof. His (quoted in most books) 
extend from the neck-bend to the caudal-bend. (See 
Fig. 56.) 

Measured by His's method (from neck-bend to caudal-bend) 
the length at different periods is about as given in Fig. 56. 

Pro£ Minot disregards the neck-bend and measures ** the 
greatest length of the embryo in a natural attitude along a 
straight line," the limbs not to be included. 

Since embryos of the same age differ much in length, an 
eiTOk^ standard of measurement is unattainable and unnecessary. 

Measured by Minot's method the length of the embryo at 
the end of 

4 weeks is 1 cm., about i inch. 

8 weeks is 2i cm., about 1 inch. 
12 weeks is 8 cm., about 8i inches. 
16 weeks is 15^ cm., about GJ inches. 



suggests the following rule : During first half of 
pr^nancy, squaring the number of the month gives the 
length in centimetres. During second half, multi{)lying the 
number of the month by five gives the length in centimetres. 
It gives approximate results as shown in the following 
table: 



1 cm., about 

4 cm., about 

9 cm., alx)ut 

4 x4 = IG cm., aUiut 

5 X iy-r 25 cm., about 

6 X o =80 cm., about 

35 cm., al)out 

40 cm., alnuit 

- 45 cm., about 

End of tenth month, 10 y. 5 - 50 cm., about 



End of first month. 
End of second month. 
End of third month, 
End of fourth month. 
End of fifth month. 
End of sixth month, 
End of seventh month. 
End of eiffhth montli. 
End of ninth month. 



1x1 - 

2 X 2 - 

8x3 

4x4 

5 X 5 - 

6 X 5 
7x5 
8 ■- 5 
9 



J inch. 

ij inches. 

8 J inches. 

Oj inches. 

95 inches. 
Ill inches. 
13} inches. 
15} inches. 
17J inches. 
19} inches. 



The measures in this table during the later months are 
supposed to extend from the top of the head to the soles of 
the feet 
8 



114 MATURATION, FECUNDATION, AND NUTRITION, 




SIZE OF THE EMBRYO AND FCETUS. 



n 



His^s Measure Line. 




& 

< 
3 

a 
I 



s 






17.5mm: ■ 




m 



i 

E 



o 



, IS-Smm."" "^ 







116 MATURATION, FECUNDATION, AND NUTRITION. 

The child at full term measures in this way (when the 
lower limbs are extended) on an average about 20 inches. 
Its average weight is 7 pounds. Quite healthy children at 
full term may weigh only 6, or even 5 pounds. Below 6 
there is usually some abnormality; on the other hand, chil- 
dren of 10 or 12 pounds are not very unusual ; those of 20 
pounds and upward are extremely rare. 



CHAPTER VII. 

THE SIGNS OF PREGNANCY. 

The signs of pregnancy require particular and careful 
study, for several reasons : 

(1) Because unskilled persons very often, and the most 
skilful physicians sometimes, make mistakes in stating that 
pregnancy exists when it does not, or vice versa, (2) The 
question of pregnancy may involve character, as in unmar- 
ried females. (3) It may involve the legal rights of offspring. 
(4) It determines medical, surgical, and obstetrical procedures 
often of the gravest import. (5) It concerns the reputation 
of the physician ; his errors subject him to ridicule. 

Classification of Signs. — They have been divided into 
presumptivey probable, and poaitivey according to the degree 
of reliance to be placed in them as evidence of pregnancy. 
They have also been called rationaly or such as are evident 
to the sensations of the patient ; and physical, such as become 
apparent to the educated physician by physical examination. 
Probably the most practically useful method is to divide them 
into thoise that are certain and those that are not : hence, first. 
Positive signs; second, Doubtful signs. 

The duration of pregnancy in the human female is forty 
weeks, or two hundred and eighty days, or ten months. In 
using the term " month " in this work it will be understood to 
mean a lunar month of twenty-eight days. 

How Early during This Period is it Usually Possible to 
Hake a Positive Diagnosis of Pregnancy in DoubtAil Cases 
Where Important Interests Are Involved ? — It cannot be far 
from true to assert that the majority of general practitioners 
of medicine are not sufticiently skilful to make a possitive 
diagnosis in such cases before the pregnancy is nearly half 
over. Even the most skilful can hardly obtain absolutely 
positive signs during the first sixteen weeks. 

117 



118 



THE SIGNS OF PREGNANrw 



But liMl*^ reliance cmi h^ |iliice<l \i\yim the slatemeots of the 
woman liersi-lf. Without biing conjiciou^tfy untrythful, she 
nmv he tlewived l>y her own .seiisiitions ; and in otlier cai^ea 
may wilfully inisleail the exiiminer, even denying the poml- 
btiify of pregnancy almi*!^t up to the time of delivery. 



POSITIVE SIGNS. 

There are only four signs tliat are ahmhtk^lij positive, VJ7* : 
L The firtal heart sontid. 
2, Quiekening, or active motions of the ehihh 
3* Ballotteiiient, «>r (wussive hn'omnti^m of tlie cfiihl. 
4 Reeognition of lU4al part*! by alnhoninal puljiation. 
Three others, thougli nut m valuable, are usually classed 
with the fKj.-iitive sigosi, viz, : 

5. The uterine muriour, 

6. Inteniiittent contractioDSof the utertie. 

7. Hegar's Bign. 

L Tlie Pcetal Heart Soimd, — ^The |Hikation of t!ie heart 
can seldofu be heard before the twentieth week (the middle i»f 
p reg nan ey ) . A p r act inet I , s k i I f u 1 ear Hi ati reci^gu i ze it two or 
three weekn earlier. As pre*:^naivey advanee.*^ the wniofl gets 
Jouder and more ea«y of re<*og(dtion, resend>ling that mnde by 
the ticking of a wattdi heart! through a featJier pillow. A 
gocMi imitation of it may be pnw bleed hy pretdng the jialm of 
one hand strongly a gnius^t the ear, w bile ou the baek or eubital 
Iwrder of it a ?w^rie:? of gentle lonehes, iu <|uick suct'esi^ion, are 
ma«le with the tip of tfie middle linger of the otlier hand, pre- 
viously moistened with sidiva ; or a l»egitiner may learn the 
9(»uml by listening ro the heart of a newd>(»rn child. 

Failure to hear the heart sound?* during ihe later months 
tiot^ not jjoftitively negative the existence of |»regnaney» for the 
child may Ix? *lead ; ur the heart t^imndt* may l»e very feeble ; 
or thick tunjors, etc., may intervene lietween the uterine and 
aHdomiual walls, interfering with the tranamisj^ion of the 
«ouud ; or the au.«cultator*i* ear or *jkill may l>e at fault. 

The /Vf//«r7»rv uf the fcetal heart ?iound.H l>ears no relation 
with that of the mother's heart. Tlioy are inde[»endent of each 
other. The ffotal heart beatj* from oue hundred and thirty to 
one hundred and tifty time?* n minute. It is generally a little 
less frequent in large children than in small cues. Very large 



THE FCETAL HEART SOUND. 119 

children are usually niales. Hence, attempts have been made 
to determine the sex before birth by the heart sounds, but little 
reliance can be placed in the method. 

It is barely possible to mistake the sound of the mother's 
heart for that of a child in utero, as when, ex. gr,, the mother's 
heart, from fever or other cause, attains the same frequency as 
that of the infant ; but this mistake could be avoided by 
noting if the mother's pulse beat simultaneously with the 
abdominal sounds. 

When the sounds of the pulsations of the foetal heart are 
distinctly heard, while the womb is found too small to contain 
a foetus of sufficient size to yield a heart sound, and especially 
if the womb l)e but little larger than an uuimpregnated one, 
it indicates extrorutsrine foetation. 

Method of Examination. — Owing to the flexe<l posture of 
the child, the sign is transmitter! through its backy which is in 
closer contact with the uterine wall than are the other parts 
of the infant's thorax. The back of the child usually lies 
against the lower part of the uterine wall on the left side. 
We listen for the sound, therefore, on the alxlomen of the 
mother about the middle of a line drawn from the umbilicus 
to the centre of Poupart's ligament on the left side, or the 
r^ou thereabouts. Failing to hear the sound there, the 
same region on the right side may l>e examined, and, if again 
failing, the whole surface of the alKiomen may Ik; explored. 
The sound may be rendered more distinct by pressing the palm 
of the hand on that part of the uterus op|K)site the child's 
back, so as to force the dorsal asj)ei^t of the infant against 
the side of the uterus to which the ear or stethoscoi)e is 
applied. 

In breech presentation the sound is heard al)ove the umbili- 
cus, and in transverse cases low down near the symphysis 
pubis. 

Before the last tliree months of pregnancy we may hear the 
sound better over the median line in some cases. 

In auscultation of the abdomen a stethoscope is used (the 
double one preferred), or the ear alone, one thin layer of 
clothing covering the surface in the latter method for the siike 
of delicacy. For various reasons the stethoscope is l>etter. 
The patient must lie u|K)n her ]>ack, her limbs extende<l or 
moderately flexed, and the room be kept quiet. PVeble sounds 



im 



THE SIGNS OF FREGNANCV, 



are sometimes diverted by the fingers* oo the stetiioscope. By 
wetting the mouth uf the iii8trurtieiiti 3*i> that it will 8tit-k tn the 
i^kiii, it may be held in |>ositioo hy the head of the examiner 
while the tinsel's are removal. 

2. Quickening* — This lenn orifjiuafed from the erroneous 
>n|>]H:isiti<m that the child In^caoie '^tpdck,'' or alive, only after 
it betjan to move. It simply mranj^ active niusinilar mtJliona 
i>f the chiUFs limbt? or body. The period at which foetal move- 
ments may l>e tirnt re<-*ogrd7j«3d %'arie8 very much ; but to make 
a practical Rtatcmcnt, and ooe easy uf reeol lection, we nray i<ay 
almnt (hf middlr of pregnancy. Then, and afWr then, i\n 
obetetrieian of ordinary j^kill may feel the motions of the 
child, but the mother tnay be eogniwmt of certain sensations 
in tlie ahlomen (described as '* fluttering," ** pulsating,** 
*' creeping/' etc.), whirh she calls **fpeling life," as early as 
the sixteenth or eighteenth week. ( Jcnisionaliy in examining 
the abdomen the physicinn, at I Ins early ]>ertixb or even 
l>eforc, may feel, or hear with ihestethoscojie, eertain motions, 
whieh he ^tij^poHet* arehetal movements^ but these are stiircely 
reliable, 

I^ate in pregnancy the motions, when violent, prod nee dis- 
tortions and projections of the alKlominal wall tlmt may ite 
seen as well as felt. 

The motions are of two kinds, viz, : a slow, difl'uaed, heav- 
ing motion pr<Kbiced by movements of the child's body ; and 
more forcible quick rtvotions jiroduced by movementi^ of its 
limliflw 

Failure to recognize these movements does Kin negative the 
exbtence of pregnancy : the child may l>e dead, or it may 
retain life and vigor, and yet fail to move, even during the 
physician's examination, 

Ointractile musi'ular motions in the abdondnal, uterine, or 
intestinal walls, the movement of gas in the intestinal canal, 
antl the pnlsutinns of aneurisniH and large arteries, may, it is 
just i>c:>ssible» be mistaken for fretal movements by the inex- 
per ien ceil. 

Method nf Ej'amiuafwtK — I^atein pregnancy ftptal motions 
may often l>e discovered while the woman is sitandtng or sit^ 
ting, but it is best to place her on her back, with the thighs 
flexe«l» so a» to relax the aUlominal wall. All chillving, es}Hv 
cially corsetfi and waistbands, should )>e renioveil from the entire 




4 



BALLOTTEMENT. 



121 



abdomeo. The blfi4(Jer aiiJ rectum must be enijity. Plufe the 
vrimmii iiear ihe si«le uf the \wd, and lei the examiner etautl 
€l*ji*e to her side, but facmg her t'eet ; hb handu to l>e placed, 

fitthijs together, a»^ showu iu Fig, b>^, their ulnar iMirders 
K'injr gnidually Bejni rated un<i pre8!*e<I duwn on each side 
of Ihe uterus until that organ \a held between them. One 
hand should now reinaiu t^tilj while the other manipulates the 
womb, feeling for any inequalitiea or projections produced by 




the foBtu», Prt^^ure thus applied, first on one side, then on ihe 
other, will usually cause fcetal motions, during which Itofh 
hnnd$ i»hould be held stilb thus enabling the examiner to dis- 
tinguish lietweeti active niovementa of the child it^H and 
po^ive in<tvemcnt> pnHlijceil liy his nwti mnnipuhiti^m. 

3, Ballottement— Pa^ssive Locomotion of the Foetus. — This 
is rt sudden lo(*oriii>tiiUi of the child iu the uterine cavity, pn^ 
dHf^H and felt by the phy<^iciaa. 




122 



THE SIGNS OF PMEGXANCi\ 



Method of Examination, — The wunuiii is placet! in a position 
wliich will muke the trliihl settit\ by jj^mvitatioii, towiwl ihiit 
part (if the uttriis where ihe i-xaniiuiiifj: iiuger i^ iu he applied 
per vttfjinam. The I test plan it* to Itt her sit on the etlge of n 
1<TW he<l or ehair and then lean liack againnt pillovvss m» n» U> 
W midway lietweeu sitting and lying. The finger is now intro- 
duced atnl })larefl in front of the cervix, clo^e to its junction 
with the buily of the woinh, (See Fig. 59. j 

FlQ. 09. 




' 1 
f Dtcmiil ballot tcme lit. ftctui-rccMimbcttt position , mt sixtb mnttib. (J Rwnr. ) 

The other hand steadier the fundus uteri. A sudtlen u|v 
ward, jerking, hut not violent niolion ig now extx^uled hy the 
exaniiuing }inger» whieh will eattse the fcetus to himud slowly 
upward to the fundus, and ii^ it eonies back again the finger 
will tee) it knock against the neck (>o to 8j>€»ak) i»f the utiTine 
bottle in wliich it floati*. The nianipulationi* may Iw re[H^ated 
»everal tiriiei* to insure certainty. The [Hisition may lye 
changed to a lying or Mandiirg one, and the finger pnl behind 
the ecrvix uteri, if the fiiNt examinalitin be not KitiHiactory. 

The s<tandiug [x>!fition— the woman jdaeing one foot on the 
lower round of a chair and the examiner knc^eling in front of 
her— though indelicate, should always be trit*d when we fail 
to recognize ballottenient in other | postures. 



THE UTERINE MURMUR, 



12a 



If tlie abdominal walls be tbin, external halloitemeni majr 
be i)erforn»c(L Tbe womiiii lies im ber M(le, tbe abdomen 
slightly over tbe edge of the l>ed, iiud witb a baud uii eiieh 
side of the womb the oj>erat*>r endeavont to mo^'e the f<rtu8 up 
and down for the purpose already indicat^'dt or he niay a|jply 
bi^ bauds to tbe wund^ in tbe manner just previoy.sly flei^'ribed 
for dis*3ovenu^ tletal ruovenientj? — tbe woman lyin^' ii[ioii her 
haek, when* by gentle lappiiitf witb tbe tin|rer-tip8, tbe boun<l 
aud rebound <if (be tloatiug fielim may be jR'rceived. 

Bullottemtiit may l>e reeo^j^nized earlier than any other of 
the poi^itive .signs, viz., from about the fonrteetith or fifteenth 
week, atid until within six or eight week:? of tuU term. 

Toward the end of pregnancy the ebibl t*o uejirly bll& the 
uterine cavity that it cannot be iwoved about In multiple 
pregnancies, or where there it* defieieney of the liijuor amnii, 
be si^a is unavailable for the Kime reas^m. The ehiid may 
Sso be immovable when it it* lying crosswise in the womlh 
Again, the operator may la*'k *?kill an<l acute tactile geusi- 
bilily. During tbe hr^t jnirt of [»regnancy the child is ttK> light 
in weight to \w felt with the fhiger through tlie uterine walk 

A tiilculiLs in tbe bladder, a })eiliculated sybperitoiieal 
fibroid tumor of tbe uterm?, a prolapsed and slightly enlarged 
ovary » and a nuiltiloculur ovarian cyst may give rej*uUs re- 
sembling ballottemenl, but they are found to be otdrnfe of 
the uterus — not in it — as niiiy he discovered liy tbe bimanual 
examination. 

4 Recognition of Foetal Parts by Abdominal Palpation. — 
During the later inontksot pregnancy llie head, breeeb, l>i*ck, 
and movable small parts of the child may be recognized by 
(»i]J)iation fs^ee p, 244), when the conditions for so doing are 
favondile ; but caution must be taken not to miHtake hbroid 
tumors of the uterus b>r thecbikr** bead and peiliculatcd sub- 
peritoneal tumors frjr ihe movalde small |mrt8. 

It may here be added tbid a piisitive diagnosis of preguaucy 
during tbe biter nun rt lis is |>ossible from skiagrao^s made witb 
tbe R<intgen rays, 

5. The Uterine Murmur, — This has been called pfacefttal 
mnrrnur — placental sonfHe, or bruit ptarentalre because it 
wiUi thought to lie produced liy bluod rushing through tbe 
'* placental sinuses"; nterine mn^r or murmur, on tbe suppo- 
sition of its being caused in tbe san*e way in the arteries of 



124 



THE SIGNS OF PR P:G NANCY 



tlie littTiis ; nhdnminnl souffle, bei-ause it was believed to <KTur 
frtiijj prt-iisiire of the gruviti wumli upon tiie iiir^e ve^sel.s of 
the alwJojiieo. It tm,s lilH.* lieeii rt^ferred to hhMMl-rliar»ge«, 
like thoi^e (KH^urriiig in |inifyun(l ajULiiiia , and U is m'ul a 
80 tuevv hat similar HJiiDiJ has heeii prmhireil by jiressure of the 
stethnsai|>e upni the epigti?*tnc artery iu the abdominal wall. 

These tbeoriesi are htill unsettled. The one most generally 
received is that whicli refers the sound to the itttriite Idood* 
channels. Tbe miirmnr has been lieard several ilays after 
eomplete delivery uf tht* phit-enta. and there is no snljstaiitial 
pr^jof of its produt^tion in tlie vt'«i8el8 of the alHloriien. 

The numi striking peeullaritieij of the uteri tie murmur are 
as fi>lh)ws ; 

1. It is a maternal wnind symbrunous with the mother's 
pulse. 2. It is remarkalily capriciuus or eoqnettii^h in ehar- 
aeter, ehanging often in tone, pitrh, intensity, duration, and 
hK'ution, even while we listen, or it may be absent and again 
retnrn, A. It btM^onn^ stronger at the begin nmg of a labor 
[Miin, ceases aitogether at the at nie of the pr»!u» returns loud 
ngain as the pain goes otil tiiul, alk-r that, resumes the char- 
acter it had l»efore the pain hegari. 

It is nujst ysnally recognized near the lower part of the 
abdomen, and necessarily so when hrst auilible, beejvuS'e the 
womb does not yet extend high up iu the abdcjminal cavity. 
Towanl the end of the |>regnancy it may be heard f*f course, 
higher up. The stethi»s<:<i|>e shnuld be placed on the sides of 
the uteriis, over the uterine arteries. It rannot generally be 
re(x>gni/.ed l*efV»re tUr mjrtreuth w^^ek, exvf^\\t by ears ex eept ion- 
ally acute and skilled. It remains afterward till full term, 
urdess temporarily aljsent, »s In^tore exphiined> It is not on 
ahmtiUeli^ positive sign of pregtifincy, l^ecause a sound resem* 
bling it may lie heard in I urge fibroul tumors of the uterus, 
ovarian tumors, and other cnnditions. In fact, this sound 
never ought to have been rlaast^d with the positive gigns. As 
years go by it is accord e<l less and less vahie. 

tt. Intermittent Uterine Contractions.— From alnjut the 
twelfth week of [►regnancy ( when the womb has grciwn sutH- 
crently large to lie felt by tlie hand through alidoimnal wall) 
until it-* termination, the uterus is i*(ai!?tantly Cimtraeting at 
intervals c»f n few minutes. Though a valuable sign, fnmi the 
early f»eriod at which this may l)e recognized, it is not an 



4 
4 



INTERMITTENT VTERINE CONTnACTtONS, 125 



absfAuUiy pontive one, becaiisre the uterus may contract in a 
similar manner m its etf<irt!s tu expel hlood'ClutB, polypi, 




. Pc&ivihaped virgin uterus, b. jQg-sbnped n terns. The thmniM) segmeni 
Is defined by ttio dotted lines. (Dlagmiumatic.) 



Fic. 61. 



Fici, 62, 





Ljlhft.pe of nonprcKT^Ant nunis. 
(Frnm Uiii«T« after Uvdiso 



Bhapo of uterus in csriy pwg- 
uAncy. 



retained mensc^s, fihro'ul tumorsi, and other prodnct'^ not con- 
nected with prej^'nancy. It is nf ^reat diatriiostic value^ 
however, as a corroborative sign when considered in relation 
with the history of tfie case. 





THE SIGNS OF PREGNANCY, 



The rimtractioDS of a iJMemled l>lad«lrr, wlicu it^ walls are 
umrh lliifkeiied by hypcrtn»[)hy, iniL^it jmi^ibly l»e nibtttken 
for II con t raei lug u t e r u h. En 1 1 it y i ng t h t^ I > la dt 1 er hyk a cat heter 
would readily settle thiri diffieyjty* 

Method of Ej'ami nfd ion. — hel one band ^^rasp the fyndus 
uteri and reiiiajii 80 doing for fnyni Jive io Jiftttn or eren ht'eitfif 
mitttitf\<f. It will feel (be \voni!> harden (by con trad ion) in a 
very cbaraet eristic nrnDoer, The contractions hu^l frurii two 
to five niinutes. SbouliJ I be external exatinnatbni alone fail 
to recognize tbe enbirged uterus, tbe bimanual metbod tiiay })e 

Fig, 63. 




DemonBlnitJioo fif i[e^r't< t^igit hj bimnminl exAmlnatloii, the fiuulus being 
iurllinenj backward. {HoNTfTAo.)i 

enipb>ye<l, one or two fingers of tbe otber band bein^'^ |>as8ed 
into the vagina to elevate tbe uterus toward tbe haritl already 
on tbe abdonien. It h of tbe greiUest importance that the 
abrlominal wall be relaxed liy Hcxion of tbe lower lindiF<, the 
woman lying upori her back^ and all elolbing and waistbands 
removed. 



p 



hegar\s sign. 



127 



7. Hegar's Sign.^ — ^This is a clinuge iu the shape and consist* 
ency of that part of tht* ho«ly of ihe uteriid jui?t ahove the 
cervix. The ** j>ear shape " uf the uuiiupreij^iiakHl uterus is 
chauged to that of an ** ohl4u.*iliioiied, fat-lveilifd jug " ; llmt 
is to say, the lower ^eguieut of the iHidy of the uterus, instead 
of widening (jradaalhj above its junction with the cervix, 
widens .fuddody like an inverted round'Shouhlered demijohn, 
the neck of whidi may he ctmi|mred to the neck of the uteruis. 
(*See Fig. 60, pat^e \2b.) T*>gether with change of «/iay>*', the 
segment of thf uterine Iiody ijjnuediately above tlie cervix (the 
ri>und shoulder yf our fat jug» to continue the simile) becomes 
m>fU thiiK yteldiutj, and rlnMic in nmsiMtncy, w bile ulK>ve this 
yielding part there retoains a harder, resisting portion of the 
uterine body. 

Fig. 64. 




atmtlon of Hegar'a al^n l»y bimimiinl examination ftt .Nixth week, the 
fuiKiuB being lucUned forwnrd. (Jkwjstt.) 

The change of «hape, m recognize<l hy the examining finger, 
is wel! shown in Figures 61 and 62, page 12/i, 

Mtthod of Examination. — If thi- vagina be spacious and the 
bdominal waih fax and thin, HeL'^ar's sign may be denam- 

ate<J hy paasting the finger ot tnw Itand into the vagina high 
up behind the cervix uteri, while the finger-tip^ of the other 
hanfl make pressiire externally above and behind the pnbes* 
OB Rhown in Fig. 63, page 126. In cases where the fundus 
uteri inclines forward, the intra- vaginal finger should go high 



128 



THE Slays OF rREONA^CT. 



up in front of the cervix, while the iingers of the other hand 
make pressure externally behind the fuDdut^i as shown in Fig. 

In cases (chiefly nullipuni^) where the vagiua is not suffi- 
ciently spacious and ihe ahdominal walls not sufficiently lax 
and thiu to allow of this dt^moost ration hy the niethod above 
doi<"ril>ed, let the iiKiex-fin^a^r «»f one tjaud Im? pi*s.setl into the 
rrrtttm high np, above the attach men f of the ntcrfymrrni lif/a- 
7tutitf<, the thuml) of the mme hand going into the vagina in 
front of the cervix uteri, while the fmgers of i\m other hand 
make pressure externally behind the pubea, as shown in Fig. 
65. 




Demofistnitlon uf Hegftr't rfjini hy r^to-vAgiiml czftttilnAUon. (Sonstao.) 

Another methocj 10 to prens the whole tttenis dnwn with the 
external hand, while thefin«^er h in the rectum and the thumb 
in the vajirina, at* just rotated. The tissues just above the in- 
ternal OS uteri may now \>e compressed lietween the thumb 
and finper, and their thinness and elasticity demonstrated. 
Sometime* the interveniuir tissue* feel us ** thin €l* a visit ing- 
card^'* or the feeling may convey the imj>ression of an apparent 
iie|m ration or loss of continuity between the cervix and body 
of the uterus. 



ADDITIONAL rUYSICAL SIGNS. 129 

Very rarely it may be necessary to anaesthetize the patient 
and draw down the uterus with a tenaculum or vulsellum 
forceps hooked into the vaginal portion of the cervix, in order 
to bring the thin portion of the uterine wall within reach of 
the examining fingers. 

Hegar's sign has been recognized as early as the sixth or 
eighth week, and is of great value at this early date. In dis- 
eased conditions of the uterine wall it may be absent or 
unrecognizable, even though pregnancy exist Some skilled 
observers assert that they have ventured a positive opinion 
from this sign as early as the fifth week, and which subse- 
quently proved to be correct. The sign obtains more and 
more value in proportion to the greater degree of thinness and 
compressibility of the tissues concerned. When they can be 
so compressed as to yield the impression of an apj/arent sepa- 
ration between body and cervix the value of the sign is at its 
best In a few instances this a'pparent 8ej)aration has led to 
the erroneous diagnosis of extra-uterine pregnancy, especially 
where the cervix was hypertrophied, the enlarged cervix 
having been mistaken for the body of the uterus, while the 
enlarged body of the pregnant womb was taken for an extra- 
uterine cyst A pre-existing lateral flexion of the uterus would 
increase the liability to such a mistake. Caution accordingly. 

Nearly allied to Hegar's sign and often associated with it 
is the detection of finctuation in the thin uterine segment, 
especially of the anterior wall. It is best recognized by pass- 
ing two fingers into the vagina, and manipulating, first with 
one, then the other, while the womb is steadied by the remain- 
ing hand outside of the abdomen. It may be felt as early as 
seven or eight weeks, but ro<|uires an erlucatetl finger. The 
bladder should have l)een previously emptied by a catheter. 
It was first pointed out by Adolph Rasch. Sometimes the 
Bofl segment of the uterine bodj/ seems to overlap the cervLr at 
the anterior fornix of the vagina, thus presenting a sort of 
ridge or fold easily felt by the examining finger. 

Additional Phsrsical Signs. — In addition to the forego- 
ing seven positive signs, auscultation may reveal one or two 
others of less value. These are : 1. The /?///?> or umhUical 
Bovffle — an intermittent, hissing sound, synchronous with the 
finetal heart, supposed to come from the umbilical arteries 
when the funis is coiled around the chiUrs body or neck. 
9 



130 



THE SIGNS OF PnEUNASCr, 



2, The *\ffrtal iihofif^^thm foiivcya Uj I lie c^ar a comhmea 
SfCSiitiim uf jtlifK'k ami m>iin*i, and is |>rt»liiilily jiroiiiic:t*cl hy 
the prt'sssure of the i^tt^tliosooi>e moving tbo fieiiii^ jiiissively. 
It is huHoUfmriit rticoguized by the ear, ietiteaii uf the Jitifjer, 

3. Sounds |>rmluced by active motiuus of the chihh It is 
** quickcuinrf'' recofniized by the ear, iiii^tead of by the hand. 
This Jast is of 8t>mc value, since it may be »x^'asiouaUy reci>g- 
niz^etl earber than the other ausicultiitory si^u^ — viz., by the 
end of the twelfth week. Neither of thcvse three additiouul 
si^ni!^, however, i-* comparable^ in practical value, with the 
seven previously mentioned. 

DOUBTFUL SIGNS OF PREGNANCY. 

These are difficult to define numerically, but for conveni- 
ence of recollection we may enumerate fur that an^ easy of 
recognition and fire others that are somewhat le,s,s so. Kaeh 
of thene lea signs however, inelutles a variety of pheuomeua. 
They are as* follows : 

Fird Five, 

1, Suppression of the nieusei^ 

2, Changes in the breasts ami nippleSp 
H. Morning' »irkiH*ss, 

4, Alurhid longuij^ ami dyspejisia. 

5, Changes in the size and shu|>e of the alKJomen. 

Second Five, 

6. Rofteniu".' and euhiriremeut of os ami cervix uteri. 

7. Vi<>let iMjIor f)f vagina. 

M. Irritahility of the blatlder. 
iK Piirnientury depcxsits in the skin* 
10, Mental and emotional phenomena. 

Ik^ide these there are a few residual odiU and ends ly 
W'hicii the list of p^esitation si'^nal»J may he ci>mpleted. 

L Suppression of Menses.— Menstruation in 8U[>preR8ed 
durin;^' [nv^fnaney, becaujie wlial would have b«*en mm^rual 
hUnnl in the nb>jcnce of impn-jruatjon is* now* appropriated to 
the development of the tivum and reprij<luctive or^nn. There 
is no ovulation during preguauey* Buppresmon of the meuses 



CHANGES IN THE BBEASTS AND NIPPLES. 131 

is a very doubtful sign, because, exceptionally, menstruation 
(and even ovulation) may occur during gestation. Cases are 
seen, very rarely, in which menstruation occurs only during 
pregnancy. Suppression of the menses may take place from 
cold, mental emotion, and many causes other than pregnancy. 
Again, the sign may be unavailable in cases where impregna- 
tion occurs at puberty, before the menstrual function is estab- 
lished ; or during lactation, when it is absent ; or in women 
whose menses are wanting from anaemia or debility. Finally, 
the woman herself may be untruthful, asserting that menstrua- 
tion continues when it has ceased (or vice versa)^ and may even 
stain her napkins with blood to mislead her family. 

When menstruation occurs during pregnancy it seldom 
recurs every month throughout the whole period ; more fre- 
quently it ceases after the iirst three or four mouths. In the 
latter case the flow is supposed to come from that portion of 
the decidua vera with which the expanding decidua reflexa 
has not yet come in contact. After the contact named takes 
place, there is no further menstruation. 

2. Ohanges in the Breasts and Nipples. — The mammary 
glands become firmer, larger, more movable ; their blue 
veins more easily visible ; and sensations of weight, pricking, 
tingling, eta, in them may be noticed by the patient. There 
are also a few light-colored silvery lines radiating over the 
projecting breasts. 

The nipples become enlarged somewhat, and more distinctly 
prominent, or erect ; and a sero-lactescent fluid oozing from 
them dries into branny scales upon their surface. 

The areola, or disk, surrounding the nipple and the nipple 
itself gradually become darker in color, varying with the 
complexion of the individual from the lightest-brown tint to 
black. Uf)on the surface are seen ten, twelve, or niore vnlarrjed 
follicles^ which project one-sixteenth or one-eighth of an inch. 
They vary in size, and contain sebaceous matter. 

On the white skin just outAde, but immediately surrounding 
the colored disk, the secondanj areola subsequently ap|x^ars. 
It consists of round, unelevated s|X)ts, of a liffhter color than 
the surface on which they rest ; heuco they are said to rewm- 
ble spots " prmluceil by dro[)s of water falling upon a tinted 
surface and discharging the color." There is one complete 
row of them placed close together round the dark areola, and 



132 



THE SIGNS OF PnEGNANCr. 



other geattering ones a little further off that are less ffistiuct. 
iSt'crHion of Milk. — In a w*iiimii whr> has tievt^r I'l^tni preg- 
nant before?, thit< b consi(KTe<l a xtTV %'iiliiahle cnrrohc^nitive 
sign. Milk, iriexceptioimJ HLstan<'e>, roiiH tVoni the breast weeks 
t)efure delivery, aud a drojjof hietets+^'eul fluid may he Kjuoe/ed 
from the nipple as e^rly as the twelfth week of gestation in 
some ea^es. 

The dates at which thej^e si^veral breast signs appear are as 
follows. The ffecondnnj avrofa does not l»t?eonu* visiihle till the 
twentieth or twentydburth week; i\\v Atfrny lint-ft do not 
appear till near the end rtf |iregnnnry ; nnd nvarly iill the 
other «gn8 on lhet>e purt>^ coiumenee fninr the light h to the 
twelfth week, and then l>eoonu' more pronounot'd m pregnancy 
got^ on. 

What I)f(jrec of (Wtahtfif Om hr Aftarfwd to the Bread 
Sitjn^f — They are totally unreliable, taken aiune. Jn e*>u- 
junction with ntlier early f*igns they njay lead us to fjng|>ect the 
existence of pregnaney, but such a suspicion *>hould not be 
cry.Hiallized iulo mi expre^j^nl opinion until more pi*i?itive 
stigns apfK'ar. Their alinenee docH not negative pregnancy. 

CoUiJitions rcNentbling tbem may rx'cur fmm uterine or 
ovarian di>sea.*es independent of ge>itation» Many of llitni 
continue a long time nft*/r delivery » and ndglit lUm be ei ro- 
n<xuii*ly attributed to a suppifsed succeeding |*regnancy. 1 on- 
fioiiou of this ti<»rt arises when pregniuicy is suiipected during 
laetJUion^ or afler a concealed or unknown alMirtion. The 
Hi'rretion of nulk has been pnKluccd artificially, not only in 
feimde*s but even in nuilen. 

In f/rim f parous ivomtii the oi^cu rrence of the secondary 
areida, the seiTetion nf milk, and the faet of our being able 
to foree a dro|i of lacte^cetit <biid fn»ni the nipple, deserve 
great eon.^ifltrafion ; but in multipara- they mui^t be taken 
rum (fvnuo h<i/m. SttpjtrrAHion of the nidk «H*retion m n lulling 
women is of ci»nsidenible value as a corroUvrative sjgiu 

X Morning Sicknesa. — This cotiai^ts in nausea, which may 

may not Ik* in'rompanied by vomiting on first rising in the 
ftiiridng, or it may take f>!ace at or after the morning meab 

It ii^unlly begins al>out the fourth or fifth ueek and lasts 
until the end of the Hxteenth, or later, Stnietimes il conies 
on rt few days after impregual*on» and continues throughout 
prei:naTK'y. 



CHANGES IN SIZE AND SHAPE OF ABDOMEN. 133 

It is a sympathetic disturbance, most likely due to a degree 
of congestion of the uterus beyond the physiological limit, and 
for which it is, to some extent, a natural corrective. ISexual 
excitement after conception is probably a factor in its pro- 
duction. 

It justifies the suspicion of pregnancy only when it occurs 
and persists without any other special cause and in a woman 
who is otherwise healthy and well. 

In some pregnancies it does not occur at all. 

4. Morbid Longings and Dyspepsia. — Some pregnant women 
have an unusual desire for sour apples and other acid fruits 
or drinks, and salads prepared with vinegar, etc., or there 
may be a liking for substances still more unpalatable, such 
as chalk, ashes, lime, charcoal, clay, and slate-pencil ; even 
putrid meats and spiders have composed a part of the chosen 
menu. Occasionally there is entire loss of appetite, or a 
disgust for particular substances. 

Heartburn, pyrosis, flatulence, and unpleasant eructations 
are of common occurrence. 

These dyspeptic symptoms and morbid longings begin about 
the same time, and have about the same diagnostic value as 
morning sickness, and their duration is equally uncertain. 

5. Changes in the Size and Shape of the Abdomen. — 
During the first eight weeks of pregnancy the abdomen is 
really flatter than before, and presents no increase in size. 
This is due to sinking down of the uterus, which pulls the 
bladder down a little, and the bladder, in turn, by means of 
the urachus, draws the umbilicus inward, so that the navel 
and its immediately surrounding abdominal surface appear 
drawn in instead of prominent. Hence the oflKj noted French 
proverb : ** En ventre plat, enfant il y a,'' 

" In a belly that is flat, 
There's a child— Ikj sure of that." 

But you cannot be mre of it. 

By the twelfth week tiie fundus uteri begins to rise al>ove 
the brim of the pelvis, where it can be felt with the hand over 
the pubes. The navel is still sunken. 

At the sixteenth week the fun<lus has risen about two inches 
above the symphysis pubis. The navel is no longer unusually 
sunken. 



134 



THE SIGNS OF PREGNANCY, 



So the vertical enlargement progresses at the rate of about 
one and a half to two inches every four weeks, until the 
fundus, at the thirty-eighth week, almost touches the ensiform 
cartilage. During the last eight weeks the umbilicus pro- 
trudes beyond the surface. 

About two weeks l)efore delivery the womb sinks down a 
little, the abdomen becomes less protuberant at its upper 
part, and appears smaller in size. This is generally ascribed 
to relaxation of the pelvic ligaments and soft parts. 

FiQ. 66. 




Size of litems at various ihtIihIs of pregnanry. 



We may more easily remember the |x)sition of the fundus 
at different stages of pregnancy by dividing the whole term 
into thirds, as follows : 

At the cn<l of the/r/t< third the fundus rises a little above 
the |)ul)es — say it is at the pul)e8. 

At the end of the second thinl it reaches the navel. 

At the end of the thinl third it rojiches the ensiform 
cartilage, aHowing for sinking during the last week or two. 

Hy sulnlividing the intermediate s|)aces into thirds, and 
allowing one-third of upward expansion of the funds for 



CUANQES IN SIZE AND SHAPE OF ABDOMEN 135 

eneh four weeks we shnll atlain aj>proximati* precisioD sufti- 
eitjnt fur practical purpu«*eis, for there are great diflTereuees in 
dirterent eases. 

The principal ciiaraeterij^ties liy which eiihir;L^enient of the 
abddmeti from pregoaiicy may be distitigui^hed from other 
kimJ^ of abdomioal swelliiiji^ are as fiillow« ; The pregnant 
womb is usually symmetrical in ahape ; it ie; lontjer veriiculhf 
than tninsver»ely ; its contour is smooth and even ; \i possesses 

Fio. C7. 



y^ 



Pnipatlng the uterus (PAEvm ) 



a f^e^'ulinr, stiff, flnstir ronf^isfrnry, and nray be felt to eoutraei 
fiufirr im/paiion. By careful^ firm pre;wure it may also be 
felt to eontnin a mo\mhh\ floatmjj Holiti body — the fcetua. It 
t!» not eft!4y to dii?tUJguiBh these |Tet'uliaritte8 by ]>alpation of 
the alMh)rneu. The sense of touch must first Jk* e<lucnte*i by 
long practice, and oven then* ui doubtful cases, tlie /iiV/>ry, 
ofitjin^ duration, and acrom^mnifing inymjttoma of the enlarge- 



136 



THE SIGNS OF FUEONANCY. 



merit must be fully studied before we can attach t*j them much 
di u^^-i lOi^i i c I ni f X > rt un c«, 

Mdhod of Exitminatiott, — To iisf'ertuiii ilie size and other 
chanieteristk^ of (be ^'ravid womb hy |iai|Miti(m, either the 
mmle of maujjiulution alremly mentioiieil under *' (Quicken- 
ing " f |>ii)|e 120 ) uiay be used, or one iinud may he ]>laccd u|K»n 
the abdomen, lu* t^hovvu m FiL% Im. lu tliii* iHuHtmtion the 
left hand is used, the examiner .suuidiri^ to the right ot bis 
[lalient. The hand \s^ curved lo JiL the titintuur of the uteroB 
and |jhieeil, at tirst, low down over the hy[H)^astric re^^^ioTU 
Jnlermitteut pre>*8ure is now made, and ihiring eaeh intermis- 
sion ihe bund iH eiirried L^radunlly hi^dier U|>, tlie pressure 
lieiuL^ ^^reater at the ttltmr bunlcr «*f the ham I, s*» tbut when 
tbe t'miflus of tlie womb is reached tlie ham I at onec reco^xnizes 
the liiniinisbcd resir^tanee and sinks «h'e[x^r into the ahdimnnal 
space alxjve i\w uterui*. Detection of the enlargeil uterus* is 
easy late in |>re|;naucy. Durinjt^ the earlier month**, when the 
tumor is not well above the jielvic bnm» it is more difficult. 
In the.«e latter cases let the lower liml«* of the woman be 
cxten«le<l ami sliij^htly j^cpnrnted ; then |)hue l>oth Imnds flat 
UiM/ii the abdomen and make continued Hrm [pressure while 
the vvonuin takexHt^veral dee|i inspiration^^. During'' theconse- 
*|Urnt expiialions the re.^islance of the alHlomnial walls will 
tinally yiehl, and the hands be enabled to ex|>)ore thi» rejjion 
of the |K hie lirim and demonstrate the enlargeil wondh 
lieware of miHtukin^ a distended urinary bladder, or one 
whose walls are hypertrophied ant I in a state of contraction, 
for a eonlracling pre^^naiit uterus. Fibroid and other 
tumors of the uterus; cystic and other tumors of the ovary ; 
dit*tent»i»n of the womb fn^m retained mens**s ; accumii- 
lations of Huids or <rast*iJ ; obesity; jjseudfK'vesis ; enlarge- 
ment of liver, spltH^-n, and other of the alulominal viscera, 
etc., may lead to enlargement of the alKlomen simulating 
preg^naney, The [ji*itory and duration of the swelling, 
together with accom[«uiying sympt<mis, shonhl prevent its 
being mistaken for gestation. (See Differential Diagnosis, 
page 14t>0 

ij. Softentag and Enlargement of Oa and Cervix Uteri. — 
In making a digital examination per mf/htam the rliHerences 
to be noleil between a vinjin uleruw and an impreguateil one 
are very characteristic ; but between the impregnated iuid 



VIOLET COLOR OF VAGINAL MUCOUS MEMBRANE 137 

unimpregnated uterus of a woman who has already borae 
children the differences are less marked. 

Scarcely any change takes place during the first few weeks 
of pregnancy other than the alteration of position in the womb 
already noted, together with increased weight and consequent 
diminished mobility of the organ. 

The chief characteristic of the virgin cervix uteri is firmness 
of consistency. Very soon after impregnation it begins to 
soften and enlarge circumferentially. The lij^s of the os ex- 
ternum become wider and puffy to the touch, and the fissure 
of the OS becomes rounder and larger. The softening begins 
at the outside (vaginal surface) and lowest part of the cervix 
and gradually extends upward and inward until the compact 
nodule of the virgin cervix is converted into a soft, elastic 
projection whose length is apparently shortened by increase of 
width and diminished resistance to the examining finger. 

These changes begin soon after conce{)tion, but scarcely be- 
come easy of recognition till about the fifth or sixth week. In 
sixteen weeks the lips of the os are softene<i ; in twenty weeks 
half the cervix is soft, and the whole of it has undergone the 
same change when the " term *' is within a month of comple- 
tion. 

After one child the cervix never goes back to its pristine 
virgin firmness, nor does it recover the i)erfect smoothness of 
surface and smallness of the external os characteristic of the 
virgin uterus. 

Again, during a first pregnancy the os will not admit the 
end of a finger; during a subse<|uent one it generally will. 

The diagnostic value of softening and enlargement of the 
cervix uteri is only relative; their absence would general ly 
negative advanced pregnancy ; but as they may occur from other 
causes, the affirmative evidence they furnish is not reliable. 

7. Violet or Dusky Color of Vaginal Mucous Membrane. — 
By Jacquemin (who first discovered this sign in examining 
the prostitutes of Paris) and others, it has been considered to 
furnish positive evidence of pregnancy, es|>ecially during the 
early months. This is an error. The discoloration is due to 
venous congestion, and conditions closely resembling it may 
occur from uterine or vaginal congestion inde})endent of preg- 
nancy ; as it can only be observed by inspection, it is not 
always available. 



THE SIQSS OF PREGNANCY, 



H. Irritability of the Bladder.— FnHjuen I inicturitioii from 
irritable liliiddtT \^ so comiiiou (hiriu^ the firM three months^ 
of pregniiuey that it is ret'ogiiixefl w^ one of the signs <tf gesta- 
tion, It is eauHe*i In' prea<ure of the normally proln[tse(l 
uterus U)>oo the liladtier. Wheti the utenis rise^* <hirin^' the 
fuurtlt month, the sym[rtoni iisyally iliisajipeiins. Il nmy he 
iieccini|mnieil hy Rlijjrht invoiuntar}' diselmrges of iinne '^vhen 
the jKitient nnijLrlis, huigbs» sneeze.^, or vouiits. 

i>. Pigmentary Deposits in the Skin.^-Be.^^irles darkening 
of the areola of the ni[>ples Itefore nientionerl, there is oeea- 
sionally a brown, are<dous Iduf^h around the und>ilieiii», whieh 
may extend along the median line to the puli€s. It varies 
with the eomplexion of the patient. In rare instances the 
color eoverii tlR* wfiole nljdomeo, and eai^e^^ are recorded of it.s 
s[»readinL^ over the entire Iwjdy. 

Irreirular putelu^ of pitrment (ehloasmata) alfto appear on 
the fare, with dark rinpi under the eyes. They di*ap|»e4ir 
ttiYer didiverv* Hunielinie?* RXiiier, 

10, Mental and Emotional Phenomena, — A marked ehaii^e 
of teni[K'r in the woman, a8 from amiability to |»eevislniesi8, 
from eheerfidnetis In nielanrholy, etc,, or exactly ap|x»site 
ehan^ei*, nniy cKYiir* In some women the moral mm^e h 
depraved or elevated ; and inivfltThml jtowcr may he nio<Ufied 
ill degree. 

Tliet^e signs are only of ("orrfilitjrative u.se in diagnosis. 
They are generally more apparent tt» the household than to 
the jiliyi^ician. 

Additional Signs. — The following atlditional signs may be 
hoUmI : Toothache or facial neuralgia, or actual airies of the 
teeth, during siieeefisive pregriancie.'=« ; salivation without mer- 
cury ; a tendeticy to synci>pe in women not dLH[Mjsed to faint 
when nu impregnated- Some wonicn date impregnation, arid 
oft4*n eorrwtly, fn>m uniiBiml gratiHcntion during a particular 
at*t of cHMtion, 

The intrcKluction of a clinical thermometer into the cervix 
uteri h niiul to indicjite au elevation of ten)i>erature ( P or 2*^ ) 
when |treirnan<y exists. 

None tif these iiuiientious are reliahle. 



SIGNS DURING EACH MONTH, 139 



SIGNS DUBma EACH MONTH. 

The different signs recognizable during the different lunar 
months may assist the ohstetrioiau in judging the duration of 
an existing pregnancy and probable date of delivery. They 
are as follows : 

First Lunar Month. — Absent menses. Gastric and mam- 
mary signs may, rarely, begin thus early. Tip of cervix 
begins to soften by end of month. Slit of the os more cir- 
cular. Uterus sinks. Umbilicus depressed. 

Second Month. — Mammary and gastric signs usually begin. 
Uterus sinks ; hypogastrium slightly flat ; umbilicus depressed. 
Softening of cervix extending higher. Menses suppressed, as 
during remaining months. Hegar's sign perceptilile. 

Thkd Month. — Gastric symptoms continue , mammary signs 
increase. Womb still sunken ; os low in vagina ; navel still 
hollow ; hypogastrium still flattened ; progressive softening 
of 08 and cervix. At end of this month womb begins to 
rise above brim of pelvis, with consequent higher position 
of cervix and less flattening of abdomen and sinking of 
navel. 

Pourth Month. — Giistric symptoms commonly subside. 
Breast signs further develop. Continued ascent of uterus, 
hence cervix higher in vairina, navel less hollow, abdomen 
less flat, or beginning to enlarge. Fundus uteri by end of 
this month is two inches alwve pubes. Progressive .softening 
of cervix. Women may " feel motion " toward end of the 
month, when skilled examiner may also detect ballottement 
and intermittent contractions. Uterine souffle audible by 
stethoscope. Very acute hearers claim to hear heart-sounds — 
very iznusual. 

Fifth Month. — Breast signs increase. The ** secondary 
areola" appears Quickening conmionly occurs. Gastric 
symptoms entirely relieved. Ballottement easily recognized. 
Heart-sounds audible. Uterine murmur. C-ervix softer, and 
apparent shortening begins. Fundus midway between pube^ 
and navel. Alnlomen visibly enlarged. Umbilical depres- 
sion diminished. 

Sixth Month. — Ballottement, heart-sounds, fcetal motion, 
and uterine souffle more distinct. I^wer half of vaginal 



Uo 



THE ^sKfSs OF riijEusAycy. 



cTPvix N>flt^ut'*L External o:* iiiuy jiii*t iidniit tip of finder 
by t'lul of tliKH rncmiJi ; tins iluulitful in priiiii[>nrn, ihnugh 
iuhit |HJHHil)le. llreaM si-j^ius auil '*secoii<]ury areola'* iricrea?*i*d. 
I'liibilical depressifiM alniost effaced. Uterine tumor distiiict 
FuuiiuH up ti» or just alK»%e tiavel. Aj^jMireiit shorteuiug of 
irrvix iuerca^i'd. 

Seventh Month.— Ball otteni en t ct>ntinue?i ; nu^cuIUtnry 
Mi^jis fttdl mure uudilile. Furidni* two iaflu!* above undMjicni*. 
Uejiressioti of na%'el unjl-niiiii or <juite efiared. Vaginal cervix 
appartntly redueed ojje'liulf in leugtli ; l«jwtr twi>tliirds of it 
wjiVened. Cervix *Jtill hijLrlier in vagina. Brea^^t ►•^igtus in- 
crcaned. External o8 nuiy admit tiiJger-f*/> eveu in primipara, 

Eighth Month. — Ballottenient doubtful; oilier physieul 
Bij^ns more au<lil»le, Grejiter fwirt of cervix tiofl, and ** apjair' 
rnf* *<hortening increaseiU A bdomen distended, and distinctly 
pyriform ia sihajxi. Umlulical de|)re^sion gone. Fumlus 
midway l>etweeu navel and cubiform cartilage. Os higber 
anfl difficult to reach. Brea^l ^igns iucreiUstMl ; milk maif 
be Hecrcicd in some fpiantify in nKiltiparte. Umbilicus may 
begin to pn (trade toward last week. 

Ninth Month. — JSalloitcmejjt abnent ; other physical wigns 
more dintincu Und>iiicui* protrudes beyond f«uriace of alido- 
luen. Fundus still higher than lawl month. Exienuil t^ will 
eiwily admit tingcr4i|i; and, in mulliiiara\ oh and cervix will 
admit finger to fee! fu*tal head and njcridirane^. Lipj^ of os 
tliick ami soft, and apparent shorteulng of cervix rapidly 
progrt^'siic?!* 

Tenth Month.^ 11 eight of m and fundus and [iromincuce 
of inubiliinii^ reach their miixianim aboul middle of month, 
and tfn*n Iwgiu to IcKsen, ( ervix uteri obliterated by retii 
Khfjrtening dnring thirty-ninth and fortieth \vt^*k. Lip of 
OS, in pnmi|»ane, l>econie tliiiiner , in mnlti|Mira\ retain more 
thickueiis till I he end. Presenting part low down. Oh uteri 
eitMily reached, riiy»«ical signjs distinct, Symptonist due to 
pre*s>*nre di>«apjM'ar. There may In* iHletua of legs and geni- 
tals, with pain and ddhcully in walking. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY, 

From Ovarian Tumors* — In ovarian tunairs (cystic degeii^ 
eration of the ovary) the j»o!4tive signs of prcgiiaiu'y are 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 141 

absent ; menstruation ^e/iera//// continues ; there is fluctuation ; 
history of tumor shows it to be of longer duration than preg- 
nancy, and to have begun on one side of the abdomen ; cervix 
uteri not softened ; woml) not enlarged, and can be moved 
without moving tumor ; or, when tumor is rolled to one side 
by abdominal palpation, cervix uteri does not participate in 
the movement, as demonstrated per vaginam. When the 
tumor is large there is emaciation, es[)ecially of the face, and 
failure of the general health. Exceptions to be borne in 
mind, e. g,: 

Pregnancy and ovarian tumor may coexist, when abdominal 
palpation will reveal two tumors of different consistency, with 
a possible sulcus between them. Diagnosis difficult, especially 
when associated jvith dropsy of amnion (excess of liquor 
amnii). In the latter fluctuation is more superficial ; cervix 
uteri enlarged and softened ; womh does move with movement 
of tumor. After having decided to of)erate for ovarian tumor, 
should any lingering doubt remain as to pregnancy, the womb 
may be measured by the uterine sound, or the os dilated to 
admit examination by the finger. 

The practice of as[)irating some of the fluid in these cases 
for examination has been given up. There is no morphologi- 
cal or chemical element in ovarian tumors by which a diag- 
nosis could be made. 

From Fibroid Tumors of Uterus — Fibrous Tumors, Fibro- 
myomata. — In uterine fibroids, tumor is (comparatively) 
harder and more inelastic ; it is unsymnu'trical and nodular in 
outline ; of much slower growth than pregnant womb ; is ac- 
companied with profuse menstruation ; cervix not softened, 
but may be unevenly enlarged. Positive signs of preg- 
nancy absent, although the uterine souffle may sometimes be 
heard. 

Rarely fibroids may coexist with pregnancy. I)ingn< sis : 
by physical signs of pregnancy and results of time. Labor 
will come on, and may terminate naturally, provided tumor 
does not obstruct i)elvis. 

From Distention of Uterus due to Retained Menses — Hsema- 
tometra. — In retention of menses there is a history of jmin at 
the menstrual jxTiods ; uterine tunna* groNNs by sud(len en- 
largement at each jH^riod, with some decline in size afterward. 
Uterus more tense and resisting than in pregnancy. Vaginal 



II: 



THE SIGNS OF PREGNANCY. 



examination reveals niechunical oJ>8truction, either m vag^i** 
or LiteruK, preventing' egress of nu^nKfj^ — ihia iimy be nmgen- 
iml, or a<x|uire<las reeult of intijiniinatiou, ndiie.si(>n, etc. The 
breast aiij^n^ and jxi^itive signsj of i^regnauey are abseut. 

From Distention of Uterus due to Qae — Fhysometra.^ — Tliis is 
really a tijmpanUeM of the uterus* Tfie gas, retained hy mme 
olkitructiou ILL the cervix, is due ti> deeutiiposuiou of lualters 
u ithin the ut^riue ciivitj. Wumb en hirges niore Hloniif, and to a 
ItsM degrrr than in pregnane v. When hirge enough to be |^er* 
ensscnC it is vtmHUnL When liiled with the linger, ^^tr vatjlnanu 
it is bghter m weight than Its size wouhl indieate. Fetid gas 
in ay esej i \ \e in 1 1 1 1 v ivji n a . Fosi t i ve ni gn.^ of j n egu a n cy a bseu t. 

From Distention of Uterus due to Watery Fluid — Hydro* 
metra. — The tiuifl aenirnnhites in the nlerine cavity, owing to 
obstrnetion iu the cervix. Womb sehlotn larger than an 
tirarige, and gruw?^ slowly. Most apt to oeeur aller '* change 
of life/* Fluctuation may l>e detected. Absenee of jxisitive 
signs*. Hydrometra atid phyi*t:nnetra are extrenn?!y rare. 

From Obesity,^In enlargnient of abdomen from fiit, other 
partH of the body are enlarged: l>elly is si»fl aiid doughy to 
tuneh, and without any central (uterine ) tumor. The |K)8itive 
signs of prei^iiancy an<l most of tlie ^igns alwut tiie bre^ists, 
etc., are absent. The txTvix uteri remains suiall and uti.soft- 
ened. The uterus itself is not increased lu size or weight and 
retains it« uwual m^dM'lity, 

From Abdominal Dropsy— Ascites. — In dropsy there is di»- 
tinct fluctuatinu and uo utertrie tumor, Re^Honance on perciiii. 
sion of alKiomeu cliani;**^ it** btHuidary line ( hori/outally ) by 
chan^fitig jMwition of woman, »nying to floating of intestines ; 
cervix uteri unchange^l , physieat signs of pregnancy absent* 
A»citt»s and pregimncy nniy coexist. When tlie aMcitcM h evi- 
dent and thi" pregnaiiey donlnfub removal of the a.«<*itic Hiiid 
by tapjiing will rc^nder the enlarifed uterus and other signs of 
pre*rnancy more ea5iily recognizable 

From Amenoirhcaa Associated with Congestive Enlargement 
of Cervix Uteri.— This? i.« aci^tmpauitMl with symptoms of uterine 
inHamniatton ; backaehc ; pair^s* in the hitKH, alwhnnen, etc. ; 
WtMght iu pi*rineinn : difKridty in walkiun' ; and, on exanvina- 
tion, the €*ervix uteri is tender to I he touelu Time will el ear 
up donbt. If firegnancy cxii^t, enlargement of the bodij of the 
Wond> will HiHm deelari' iL 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 143 

From Pseudocyesis. — This means "false" or "spurious 
pregnancy," Women who wa7it to be pregnant, and single 
women having reason to fear pregnancy, are apt to imagine 
themselves enceinte when they are not. 

It occurs most often near the "change of life," when cessa- 
tion of the menses, obesity, tympanites, and various sympa- 
thetic phenomena appear to lend color to the false impression. 
There are hysteria and involuntary projection and contraction 
of the abdominal walls, simulating the enlarged womb and 
foetal movements, so-called ** phantom tumor." 

Diagnosis : anaesthesia by ether at once disperses the ab- 
dominal signs, and vaginal examination reveals an unchanged 
cervix uteri, and an empty, unenlarged uterus. 

From Tympanites. — Tympanitic distention of the abdomen 
gives tympanitic resonance on percussion. Physical signs of 
pregnancy absent. Uterus not enlarged. Tympanites and 
pregnancy may coexist. Exclude the latter by making con- 
tlnuous firm pressure upon the alniomen during several suc- 
cessive respirations, increasing the pressure during the expira- 
tory acts, until the examining hands — one placed ujkju the 
other — feel the spinal column, and thus denionstnite the 
absence of any intervening enlarged womb. The abdominal 
enlargement of pregnancy is chiefly in an antero-posterior 
direction during the early months — not from side to side — 
while in tympanites it is in both and all directions. Normally 
the folds of intestine remain above and behind the uterus 
during pregnancy, hence there should be no resonance on j)er- 
cussion in front of the womb ; such rew^nance, however, occurs 
when the tympanitic intestine is forced between the uterus and 
abdominal wall by its own distention with gas. 

From Subinvolution. — In subinvolution there is a history of 
previous pregnancy (which, however, might not be acknowl- 
edged). Patient has not been entirely well since her last 
lalwr or abortion ; has suffered from pain in sacral, iliac, and 
lumbar regions ; feeling of weight in the |)elvis ; leucorrhcea ; 
menstrual disorder, together with nervous, digestive, and hys- 
terical symptoms. The uterus, enlarged by pregnancy, be- 
comes rounder and wider, both transversely and in an antero- 
posterior direction, while in subinvolution the enlargement is 
chiefly vertical, the length of the organ being increased more 
than its width. In pregnancy the cervix is softer, and the 



144 



TUE SIGNS OF PREGNANCY, 



body of the uterus more elastic than in subin volution ; and 
the cervix, vagina, and vulva are more likely to present a 
violet or purplish color. In subinvolution the size of the 
uterus never exceeds that of an early pregnancy, hence in 
doubtful cases time would settle the diagnosis. 

METHODS AND ORDER OF EXAMINATION. 

In examining a woman for suspected pregnancy the order 
of 8e(|uenoe in the several steps of examination should be as 
follows: 

1, Oral examination as to history, symptoms, and duration 
of the case. 

2. Examination by (a) inspection, and (h) palpation of 
breasts and nipples. 

»']. Examination of abdomen by, successively, insjiection, 
palpation, p(^rcussion, and auscultation. 

4. Vaginal examination : («) digital, (6) bimanual, (c) by 
inspection if necei*sary, 

5. Digital examination, jwr rectum, if required. 



CHAPTER VIII. 

HYGIENE AND PATHOLOGY OF PREGNANCY. 

To anticipate the pathological phenomeDa of pregnaDCj 
without surprise we have only to recall the physiological 
changes that must necessarily take place with every gesta- 
tion. Processes of change — of structural evolution — whether 
progressive or retrogressive, and whether occurring in man, 
woman, or child, are alivnyn liable to be interrupted by slight 
disturbing causes, and thus develop pathological phenomena 
of more or less gravity. The physiological changes incident 
to pregnancy are without a parallel, in their degree, in their 
number, and in the rapidity with which they occur. In a few 
months the uterus increases in dze (from 3 to 12 inches in 
length; from U to 9 in width) : in weight, from about an 
ounce to about two }x)und8, not including its contents. The 
capacity of its cavity is enlarged 519 times (Lusk, after 
Krause). The area of its external surface is increased from 
16 square inches to 339 square inches. All of its tissues : its 
muscles, ligaments, arteries, veins, lymphatics, nerves, and 
nerve-ganglia, become tremendously hypertrophied. The 
uterus itself changes its poi^ifion, prola))sing during the first 
two months, and gradually rising after the third. Later on 
(owing to distention of the rectum and sigmoid flexure of the 
colon), it l)ecomes twisted on its longitudinal axis so that its 
anterior aspect looks somewhat toward the right, which brings 
the structures in the left broad ligament more to the front, and 
tilts the fundus a little toward the right side. Correlative 
changes in the abdominal walls, and in the position of the 
abdominal viscera, must also occur to accommodate the en- 
larged womb. The vagina and vulva undergo a somewhat 
similar hyj)ertrophy, thou<rh less pronounced. Chancres also 
take place in the foMs of |)eritoneum and connective tissue in 
the pelvic cavity, as well as in the ligaments, cartilages, and 
joints of the pelvis itself At the same time the mammary 
10 145 



1 lis HYGIESE AND PATUOLOaV OF PBEGNANCY, 



glaii*Iii are going throygh u. Iijjjertrophic evoUition pre|mratory 
to lacUitioiL 

With thei«e local jjheuomena must Qeeessarily take place an 
extetisive m<H]iticuti<in in the tjeneml system of the wonmu, 
espt^tnully vsilli rt'leivui't- to iIjl^ gt'iiersil iiutritiop. She jjro- 
vi<Je.s the iiutrhive pabyhiiii In* whii'h lliegrowiiig orgaii.*^ are 
iiiistaint^tl, luiil hy wliit-h the Ik'tus, with its »]>|)eiiJa*i;t« and 
\m\\i i>i' waters, \^ l>inU up* She must tliereibre form more 
Ijhxwi, ilige?it more food, aufl incrciusc the activity of her ex- 
er e ti »r y a n d »ee rf^to ry o rga 1 1^. T h e e x t ra h I oi h1 m u st 1 le pro |^ 
t-rly circulated, not only thmiigh the byt»ertroii!Tied ve^ssels of 
the enlargeil reprotlm'tive organs, but alai tli rough the pla- 
centa \ JieDce, In jiregnauey, there occurs, normally, hy|XTtrf> 
pliy of the left ventricle of the heart, which disapixnii-s after 
delivery. The elimination uf carlion fHoxidc by res]>iration is 
inereastMi In sliorl^ the prt*giiant WLmian !ia.*i to provide nutri- 
ments to brealhe, to circulate l»h>od, to secrete and excrete, for 
iiVii in<!ivitiual> — lierself and her foetus. 

The sn«pen!=!ion of ovnbilioii and meimtruatiou duriug preg- 
namy cons'titutes further ehiingcs of function, i/vhicb, while 
natnni! enough, must add Bornething to the expenditure of 
vitnl \hvvi\ 

Wiih thet^^ varietl and uunierous structural and functional 
changen*, and with the necessary incrcaH<^ of work imjx>8ed on 
the general irutritive syt^tem of the pregnant woman, it is 
scarcely to lie ex[ie^*ted that gesUiti(ui, e.H]MH*iaI]y in women 
w*ho?se lives and habits are artificial and nnuatnral in many 
n^fK?cti4, fihould be altogether ItiUnt and free from unplea&«ant 
tiymptonii*, if indeed it be unaccom|>anied with seriiHis disease. 
The wonfler is rather the other way, viz,: thatsutferin^is not 
grt*aler and diKeru-c?^ n»ore frei]UeiU and severe than we find 
thenL It may 1m? well saifl ; to breed easily is a gnod test of 
iKMlily *j(nind TICKS, 

The abnonnnl snrnmndings and hahits of pregnant women, 
especially in highly civilized tTimninnitici', are more account- 
able for Muffering aud diMtnmiftirt than i8 the pregnancy itself. 
Faulty hygiene, either frcjin earele-** neglect, nr ignorance^ ig 
often the real cause of disai^ter and distrcK**, To iire^ierve 
health y eai^ier jnid l>etter than to cure iliiieaj^e. Witli this 
in view the following directions will l>e of service. 



MUmULAR EXERCISE. 



147 



HYGIENE AND MANAGEMENT OF NORMAL 
PREaNANCY, 

I^et every pregnatit women l^resilhe pure air; heuoc^ the 
atinoi^phere uf the country i^ i»t4ter ihau iluvl of a cit)^ ; oiit-tloor 
lite ( climate ami weather [leniiittiri^^} belter than iinloon^, 
K<H>m8 to be well ventilated l>y havinj^' one or more windows 
dowu« even everf?u little^ jVowi thr top; nUnosuheric imimritieJ 
I isuai 1 y ace u in u 1 a t e to wtir< I the ce I lit uj. ( ' ro \\ 1 1 1' 1 1 a j la rt m en t s, 
theatres, churches, etc., ^honhl he av»iided. Many prepiant 
women l>ecome peculiariy ?^en^itive to disagreeable oiloni ( hijpti'' 
o»mm has been noticed jls o»e of the ^^ign?* of pregnancy ), as if 
nature bad proviiied ihem with a sprtial instinct to detect and 
ei?ca}>*^ infected atiniw^pheres. Throu^^hi>ut preg^naney the 
eiimitiatiou of earlxniic dioxide i« increas^ed almut 25 jier 
cent, and ilurinj; the later months the encroacbmeni of the 
enlari^ed uterus toward IIr- diaphrngm imftedes rej^piratiou ; 
hence ;>im>- air Ifcciunci^ a prime iieceNsity. rufortunately, 
respiration \^ further restricted by f//'t*^A (notably rormih } aad 
by muMrttlar iwfffff^urv, (_Vu"Hetii s^honld be clincarded altogether 
liuring the later n»*mtb.s or w«jrn loo5<ely, or, d' |iersi8te<l in, 
their *' rihs of j^teel " should be interrupt eil w ith spaces of 
elastic faljric^ — a method of amstructioo coauaouly provided 
by »tavmakej*8 fi)r pre^jrsant women. Avoid waist-haodB and 
girdk* rtuind the abihmien ; let the wei^^ht **t' skirti* be sup- 
pfirted l)y sm^penders from the sbrtulders, (jarterp, wliether 
above or below the knee, imiy produce O'dema of the ivi^t and 
varico^' veins* in the Ic^:. Amoii^ other vicei^ of costume are 
bi£;b-heeled shoe^;, which impcile locomotion ami produce 
Ptundding, with iti? sometimci^ di.^i.Htrone consciiueoce^. All 
clothing: should be comfortably warm, the lower limbs espe^ 
cially beinp protected froni cold, Ex]iosure to cold and wet^ 
<-8pecially when over-fieated, may lead to renal couge4*tion and 
nej>hritis. 

Muscular Exercise* — The best exercise for a healthy preg- 
nant woman, even up to the day of her lyin^r-in, i^ vafkhig 
in the optm air. At no period of pregnancy netnl i( be in- 
terdicted, if kept within the li(nit of moderate fati|rue. It 
increases^ re.'? pi rati on, appetite, and dijcrestiou, and promoter 
sleep. Violent exercise and muscular stnxio of all kinde, 



148 HYGIESE ASD PATWHJUiY OF PnE(f\\ANCV, 



es].ieeially litling, must lie avoidt%L Itiiluij^ an horR'lmck, on 
biovcles, and in vebirle,-^ wkhout sprin^i^ ovt^r r*(u;i:li roatls are 
injurious ; jM^r confra, exercise in mmxillily rutiniu^r eurria^^^*^ 
up>n level roads is a<lvii*ahle. Mueli <le|*tulH ujxmi the 
woman : one iimy withstand ftlniosi every sort of jolting and 
rou^h U3a*i;e without any ill elfect, while anutlier^ — more 
uervouf*, delicate, and excitalde — will sulfer, even to the ex- 
treme of al»orti(>n or jireniatyre lalmr, from very sliy^ht n\e- 
clianioal disturbanceK. Use care in all. Hailroii<l an<il stn^et^ 
car tnivel nniy or may not he ipjuriouB, as the mechanical 
jarrinpf in great or small ajid the wonjen more or letfs excit- 
able. They sbonld he avoided during" the last few week^ of 
prefjfnaucy in all caseii, Nc» |iretrnant woman w ho in snliject 
to sea-sieknt^ ahoiild risk <H?eari travel, and lho«t^ who suffer 
in the i^ame way from the swinging of railway carriages should 
not travel liy rail. One great virtue of out*door exercise 
is to <livert the winnan's mind from dwelling uj»ou her com- 
paratively trifling ailments and magnifying iheni into hi>rrorH 
of infirmity, with a liability to drifl into chpmic invalidism 
aral hysteria^ Ia^x her Ik^ }>ersuaded t<» re,*^ist languid hdliiig 
upou iier much aufl set^k refresihincnt and exhilarati+jn in the 
gun and air, provided, of course, there lie m> real e<niditioii 
rtvy«tVi«ijf rest. 

Pood. — ^There h no rejisou, as a ruk% why a hruHhij preg- 
nant woman should make tiny great change from her ortlinary 
diet. With fresh air, exenMse, mental di version » and free- 
du»n from the mechanical jireasnre of ctistume, her a|»i>etite 
ami dige-stimi nniy bt* gooil during most of licr gestntioiu 
ifiwlerate morning sickness may interfere with her lij-st daily 
meal early in pregnum-yt ami the growth of a large uterns 
encroach upon the j*tomaeh during the later montlis, hut 
in spite of these drawbacks na^st women manage to a^imihite 
i*nough food to gain flesh and impmve their general nutriliou 
nither than othervvis<\ The woman*** tasten — her likens and 
dislikes— nniy usually be indulged with advantage, at least 
in m far vlh they refer to or<linary foods. Wines iiml alco- 
holic <lrinks» together with tea (which consti*|(atcs) nird collee, 
should be taken with L'real moderation, if at alL Kip: fruits 
of all kimK and dried frnits— notahly pnmf'i*^ of which ntnny 
pregnant women beconu' fond^ — are of service in cornnling 
constipation. While milk and chiK^olate may be taken when 



DISEASES OF PREGNANCY, 149 

desired, the one driuk — raost important to every function of 
the body — which many women neglect or refuse to take in 
sufficient quantity, is common water. The habit of disliking 
water may be overcome by a plentiful use of common saU, 
which produces thirst. Late in pregnancy, when there is 
little space for a full stomach, the meals may be small, but 
of more frequent repetition. 

The Skin. — The skin must be kept clean by warm baths 
(not hot, not cold), taken at least three times a week. Sea- 
bathing is objectionable, yet some women enjoy it without 
injury. When, late in gestation, the woman becomes too un- 
wieldy to undertake a bath, the external genitals may be 
cleansed with tepid water twice daily, and the skin rubbed 
with a wet towel. During later weeks of pregnancy the 
nipples should be kept scrupulously clean, free from pressure, 
and softened by applications of borated vaseline or cocoa- 
butter. 

Sleep. — Sleep is important. If practicable, a pregnant 
woman should retire early, occupy a bed by herself, and sleep 
eight hours or more. While coiUm after impregnation is a 
physiological alxsurdity and ought to be avoided, it will usually 
occur in spite of any advice to the contrary. Indulgence at 
times corresponding to the menstrual |)eriod is liable to cause 
abortion in those predis{)osed to this event, If abstinence ])e 
refused, enjoin moderation, and brief instead of prolonged 
sexual excitement. 

Under all circumstances encourage the patient to refrain 
from anxiety and fear of her approaching travail. Substitute 
industry and social cheer for indolence and solitary' brooding, 
avoiding always emotional excitement. 

DISEASES OF PREGNANCY. 

The diseases incident to pregnancy are numerous and 
varied. 

Let it be remembered that most of them are due either ( 1 ) 
to sympathij — other organs being disturbed in consequence of 
the tremendous changes going on in the reproductive system ; 
or (2) to prcsi^Hre — the mechanical pressure of the gravid 
uterus upon neighlM)ring ])arts ; or (8) to toxivmic infection — 
produced by deficient elimination of the excreting organs, or 



50 HYOrENE AND PATHOLOGY OF PREGNANCY, 

by other CHij^es, Syiniuitlictk" ilisturlmticeif jirerloiniimte 
fliinn*; the earlier niontJi*?, inechaninil ili^'^lurhauce* during 
tfjL- Inter oiien. The opposite hUnul <roii(liti«>ii8 of ancmh and 
jilrthttra al^j \^^^^y ii^i ijnj)orUnit rhfe \n determining i\w eluir- 
aetcr and treatment i>f the.se diseases, 

Aguin, geiRTiilly i*j)euking, the nirwua tfiji^fnn /.•< more mis- 
crptible to imprr.^'^i.tmH drinnif itietpHinctj thmi nt other tiniee. 

Finally, some of the patholopfieal conditions ttj he stndied 
are simply exag^^eratioiisof tlie physiolopeal jiheiiomena ordi- 
narily luinilK'ied \\\i\i the usual Ktgth^ ni' pre|riianey. 

Classification of Biseasea. — Noehi^ificiition of the di^af^es 
of pre^nnin<y yet deviseil is |>erfeet ; all are arhitmry. For 
rotivenieuee sake we may grouji the several afleetions to l»e 
coiisi<lered leontiiiitig the liift to ihufc^e actuuHy due to pmj- 
nancy) as follo\>s: 

L I > i seast's i *f t h e Di fjeFt i v e O rga n s : 

«. Salivary g lauds. r. Stomach. 

b. Teeth, d. Int<'Stines. 

2. Dij*eajse8 of tlie IVinary Organs: 

a. Kidneys, k Bladder. 

3. Diseases i>f the Reproduetive Organs: 

(L Uterus. c. Vtilva. 

k Vrtgina. d^ Mammm, 

4. I)i8i*a.«es of the Circulatory Organs : 
a. Heart. e, Bloorl ehanges, 
Ik Veins, 

5. Di&eases of the Rt*8pirai<»ry Organs. 
6* Di&ease*i of the Nervoni^ System* 
7. Diseases of the Skin. 



DISEASES OF THE DIGESTIVE SYSTEM. 

Salivation of Pre^aney* — Stfrnptoniff, — ^A conBt^mt drib- 
bling of sjiliva, day and night, I nit no oflTensive breath, as in 
mereurial smlivation. Oeeur? usually during the tnirly monlhss 
but nmy eontinne during the whide «>f [iregnancy. It varies 
greatly in ihjratitm as well m in degree* lluecid mucous 
meinbraue may Ik* red and tumid ; the tnubmaxillary and 
pfirotid glamls tendt*r ami enlarged. The water of the saliva 
h iriereaj^ed ; it^ soluls dimiiushed. Ptyalin may Ik* deficient. 



DENTAL CAEIES JA7j TOOTUAillK 



151 



and dij^estjim cunsecjuenlly injpainML (>ceai*ionai ly (fingwitis 
cKt^urs ihe gurus !n-iii^ red, swullru, teiitler. i^tJiiielimei* liloed- 
iiig on pressure mid retracted froiii the teeth, whieh liectmie 
lomtu with dijfieuh nod |jahiful luat^itietttion* 

PrognoHU u douhtiVil as tu cure iK^fnre deliverVi Init no 
serious ednseciueneei? iiee*! he apjjre headed further thnu anxiety 
and annoyanee, 

C<iHm.- — It is tme of llje stjmiHitbt'fle afflrtioust. The sym- 
|mthy between the riidivary irhiinlK and the generutive t«yhtem 
18 well known from the plienoniena of nuiriijis, coition, etc. 

Trentment. — J^v gentle saline hixiitivi^t which di\'ert tlie 
exeest{<ive secretion to the inte.-«tinal glands*, and by astringent 
mouth-washer of tannin, alum* j^suljihate of xine, or pitiiKsiura 
chlorate. Counter-irritati(jn l>v tincture of iodine or i^rmill 
blisters externally, over the parotids. Extract of helhuhmna 
(gr. It three tinu's* a chiy), or eijuivulent d<i«es of atropia, nniy 
lessen the disehnrge. PihM'iirpine ( gr* |'i ) and tinid extract 
of viburnum have been rwom mended. The following gargle 
may be Ui^etl two or three times a day : 

R. 8mlii bciracis glyeerini, f.yj ; 

♦ Aqme roste, vel aqute, f^vj.^ — M, 

Bromide of |iotaj*.sinm has toured some eaw*? ap|>nrently. 
Iron ami other tonicj^, with generouH diet, are im|M>rtanL No 
treatment is reliable. 

Dental Caries and Toothache, — That pregnancy actu- 
ally eausieiS the teeth to dway is a widei^preafi belief among 
physicians as well ai* hiymen ; hence the poverb, ''for every 
child a tooth." It has been ascrilii'd to aeiility of the oral 
secretion from <ly8j>ep.sia, but quite as likely it is ilue to nml- 
ijutrttion of the teeth from certain eonimituents of their com- 
position having been approfiriateil to nutrition of tlie end»ryo. 

Treat mrtit — In recommending operative finx^eilures np<»n 
carious tt.*eth (birintj jireirnancv, the degree «d' **nervtHii*neas" 
or emotional ?<u<ceptiliility of the fwident, and the seventy of 
tJie re^juire<l nf)eration, should enable the phy.'^ician to jmlge 
whether the menial .slitx'k or physical 8U tiering lo be incurred 
would l»© likely to bring on abortion. Cf>nclusion accord* 
ingly. 

in case no operative procedure in agreed to, a Aam of 
morphia may be administered hypoderndcally for hnmedictie 



152 HYGIENE ASH PATHOLOGY OF PREGNANCY. 



relief of the jmiii, k» be followed byanmlyiie^ and quinine in 
Jail dosea tlius : 

B* Qoiuist* sulpL, gn xxx ; 

Morpli. syl]»lj., gr, a-^i; 

Extr. iRdladiiiitite, gr, isa j 

A fid. >tul|ilL ammat^ q. ?. i^. |>il. vj.^M. 

8ig, — Take oue every Jour hours. 

Other renie<liea are : Fid, exL gel8ertiiuiij» ^il. iij-v, three 
t i ni es a d jiy , u ii ti I si ig h 1 1 j toi^i h tRe ti r.s. ( ' r< itou eh I o m I , gr. ij-Vj 
ev«ry hour, until not nu>re than fifteen grnin.s are taken. 

Externally, warm apjdkatioii.s and arjtwlyne linimeuta (of 
camphor, aconite, laiidtinym, Lddorolonn, ete* ) may iiiford 
reliefl Neuralgia of the hne {iir douiuareHx) retjuins the 
fttime remedies. F*aeeacbe, heiidaehe, lotento^tnl ticnnil^^ia, 
and other forms of the same diseiLse, wlien eaused by ant mint 
r<H|tdre iron, to whieh arsenic may be profitably added, as in 
the following formula from Lusk : 



H, Fuh^s ferri, 
Arsenic, 



gr. sV— M. 



To be taken in pill, three tim€S a day. and ei»ntitiued several 
weeks ; or. 



gr. V ; 
5j. — M,, 



Ferri et quiniffi citraa, 
Aquae, 

three times daily al meal hourt*. 

To arrest eariei^of the teeth during pregnancy, Hirst recom- 
mcnda syrup of tlie lacto-pho*iphate of lime, one dram three 
times a day- 
Derangements of the Stomach ; Excessive Vomiting ; Per- 
nicioufl Vomiting; Hyperemesis Qravidarum. — Sifmpiomj^. — 
Exaggeration of ordinary " mornint^^ sk'ktieK^." Vomiting 
increased in severity, duration, and frtMjuency. May come 
on at all tinges, day and night. Ejected matters contain, 
auccesBively, food, ciejir niucui', and regurgitated bile. May 
be severe [lain in the stomach from contiruie<l retching ; 
apt to continue weeks, ijr even months, in spite of treat- 
ment; then follow constituUfmal tttjmptomji^ fever, or sub- 
normal temperature, cmaciatiotv restlessness, exhaustioUp and, 



DERANGEMEyrS OF THE STOMACH. 



I 
I 



ftler, fetid breath ; ihy\ Uniwn longue; feehie and frequent 
pulse; uigbt-sweats and io.si>niiua. Still later, in the worst 
CHiefli, vumiliiig sttjjjrt ( t'rt>ni exhiiLJ.sti»>n of reHex jxiweruf the 
Bpinal cord), aud uervotis .syiiijJtomH ajjjx-ar, viz,, delirium, 
rtu[K)r, eoiiia, and rarely, very rarely, death. Vimiiting of 
l»lo(jd, even severe heinorrhage from the stomach, may occur 
in c^ses of gai-trie ulcer or uiueer. 

Protfmm^, — Cask\s appareutly hojicdess s<jmetimes "turn a 
comer," as it were, and eufl in recovery wheu it is Icastt ex- 
|Mscted. The symptoms may stop fT«)m i^u/fdeu mental emotion* 
or the oc»currence of .spoutaneoiiji ahortiou , or, again, a uew 
mcxiiciuet or sotue sfK^ial article of tVMjd or drink may suc- 
ceeiJ after many otherjs have thiletL The gravity of the prog* 
oupis increaj^s in projM>rliou to conMutional s^ymptoms and 
failure of general nutrition. It is worse in th<j^ causes compli— 
eate<l with s<jme gastric or intestinal diseiii<e previous to preg- 
nancy. Pernicious causes occur ahout once in 1 000 pregnancies. 

Causes, — ^I^jst cases of moderate severity may be attributed 
to reflex nervous derangement, just as v<uniting attends dis- 
eases of the uterus, Stretching of the uterine mnwcular fibres 
by the growing ovum; flexions and ver>^ions of the womb; 
inflammation of the uterus, either of its body or neck ; old 
peritoneal adhesions binding down the uterus ; or st»venil of 
t h ese coi ij o\ n 1 1 y , in ay con st i t y te et i o 1 * »g ii-n 1 fa ctors. Pre v i o u s ly 
existing gastric catarrh, ulcer or cancer, and old intestinal 
lesions may explain s<jme uf the grave cases. 

That in many cases the disease is a pure neorosts is evident 
from its being suddenly cured by Home decided mental imfirest- 
mm made by a new medical atteiidaut who jK^rhaps informs 
her authoritatively that the vciniiting will stop at a giveu time 
after a given remedy ; or he may alarm the patient by the 
dangers of impending altortion and thus stop it. 

In every case it must be ascertained that the bowels, liver, and 
kiflneysare not impaired in their functions, otherwise toxandc 
vomiting may <M'cur from retention of toxins that ought to be 
elimiuated by these organs. 

Trrabncnt. — The remedies are '*!e£fion.*' Wheu s<mie fail 
others must be tried. What will cure one case may be futile 
in another. 

IHcL — Total altAlinence from focnl or driak may be tried for 
a whole day, or even iwn or mure complete days — a mmle of 



154 HYGIKSE AND PATHOLOOY OF PREGNANCY. 



treatment ea«y of aiiplicatiou earbj^ nut s<i hdei\ when the 
pfltieot ts exhaiisteth 

Uquid dltK in sinull rjnantilie.^ fre4juently re})eated, in pref- 
erent't' to ^iiTnls, the onier of ^elet'tiun us? tbilows: 

Milk ; milk with soda-water ; koumiss ; buttermilk. 
Icvtl milk. 
I^Ieat H(Hips ; either 
Bct't; 1 

Ciritken, - carefully freed from gteemm 
Mutton, \ 
Well^codkircl fariuftceoua liquids: 
Bur ley* water, 
ArrownH^t. 
Hiee- water. 
Corn-starrh, etc* 
Should these faih and the patient avow a demre for some 
appttrenthj iinsuital^le article, give it to her ai* an exiTeriinnit, 
and put the !s|f»ji« asidi\ 

iMitin^ir ordinary **|io|i-eorn'* will simietinies F«top it; 8*^1 will 
chewintr spryee )ium. 

Ice-* reuiiu cnieked ice, ice* water, aod water-ieea may do 
gooil service. 

Wake the patient at midnight, or in the early morrdng 
houra» and give her (while recnml>eiit) trw^st and rottec, or an 
egg, (hen quickly put out the lights and leave her alo!ie to 
slet^p again. Fo<»d thus given may Ite retained when it would 
l>e rejected at other tinu*?*. 

Scraped heef, kan and ran\ spread on i^nj thin I j re ad, is 
wortliy of trial 

In ea'^eri where no iVtod can he retained and the general 
nutrition In^gin:? to laih the patient may hcsusurvned, for weeks 
together, hy rcM^'tal alimentation ahme. Peptonized heef tea 
and other animal hrotha, pc*ptonized milk, white of eggs stirretl 
in water. etc.» in quantities of four or five ouneesi, three times 
a day, naiy Ih^ injected. Tincture of ojnuni, or |Ritas8ic l>n>- 
niide, or hnindy, may he added to the enemata aj« circum- 
stanees may recpjire. Diarrhtea and rectal intolerance^ by 
preventing retention of the injectiont*, may exclude the use of 
tlii^ treatment* 

The enema should he slowly introduced high up into the 
bow^el through a loiig sotl-ruhljer tuln* or catheter^ the rectum 



DERANGEMENTS OF THE STOMACH. 155 

haviDg been previously washed out by irrigation with warm 
water. To secure retention of the injection, the patient should 
remain absolutely still after its administration, add pressure 
with a napkin against the anus should be maintained for a few 
minutes until the desire to evacuate passes off. 

To relieve distressing thirst, a pint of normal salt solution 
may be injected high up into the bowel twice daily, the rectum 
having been previously cleansed by irrigation. 

Medicinal Remedies, — Of the various medicines used, it is 
impossible to say which will suit any one case. For con- 
venience of- recollection they may be arranged in groups, as 
follows : 

1. Purgatives. — A brisk cathartic pill, or laxative enemata, 
until bowels are freely open (especially if there have been pre- 
vious constipation), will "work wonders" in relieving emesis. 
Accumulated toxins in the intestine, which may have caused 
the vomiting, are thus removed. 

2. Reflex Sedatives and Anodynes. 

R. Potass, bromid., gr. x-xx, in some aromatic w^ater three 
times a day. 

B. Chloral hydrat, gr. v (a small dose), given in solution, 
every two hours. 

B. Pulv. opii, gr. j, given in a single pill with as little fluid 
as possible. Not to be repented. 

Should the stomach reject all these, 

B. Potass bromid. .^j ; or 

B. Chloral hydrat. gr. xx; or 

B. Tinct. opii, f^^s 

may be administere<l in a nutritive vehicle j)er anum. 

Morphia — preferably the l)iinccunate — given either hypo- 
dermically or eiulermically (sprinkled on a blistered surface). 

Anodyne plasters and liniments or ether spray, ap])lied 
over the epigastrium ; also counter-irritants e, g,, mustard, 
4»ntharidal collodion, or blisters of Spanish fly. 

3. Alkalies. — Ks])ecially suited to cases of acid stomach, 
heartburn, etc. Give acj. calcis, .^ss with ^s^ of milk, and 
repeat every fifteen minutes; or Vichy water; or magnesia 
with milk ; or the aromatic spirits of ammonia (dose, xx 
drops) in ^ of some aromatic water ; or bicarbonate of soda. 



156 UYOIESE ASD PATHOLOGY OF PIlKGIiASCY, 



4. AtmU, — I>enji>ji-j uirt\ iiraii^H^-juice, or the adtl. jiulphiiric, 
aronialic, (clf*^, x-xx dropf^) in ,^ of wuter, (1ln<* ncid 
{mjiHjh itrnli cilriru V.^. P., f^KSi. farlnitiir acitl (jras)» as 
ill siwlft uaftT, or the etiervesciiig lirauglit of the L . K P., 
etc-. One or two ili'ci|j6 of the dUnle bydracyauie acid may 
be addeil to the latter. 

5. Aromatie Bitter Tonks, — TiiuU, eardawioriL en., or tinct. 
gentian, eo., or tiiiet. drjchou. in>., or timt. rhei <Jide. (dose 
of each about ,^ j, or the iiifiis?joii of ealiiiiiha with aromatic 
etilphurie acid. 

6. luinxit*itting Ihnn/cs. — ('harnjiagne ad iibiinm* Freiirh 
hrai)dy. sherry, wliisky, kuf^rhtvasxer. Either may he tried 
in s^uitieieiit *juau titles to produce slight intoxication. Ti> he 
resorted to only after a trial of le*ss ohjectiuimhle methods of 
treatment 

7. Unrhumjied Mtmedit^H, — Given empirically : 
Bismuth ^ubnitratts dme, gr. x-xx, l)efore each meah 
Salicine, gr. v-x, three timei* a day. 

Potajis. iodi(L, gr. \\ three time.* a day. 

Oxalate of cerium, gr. v to x, before nite&l& 

Vinnm ii>ecac., gtt. j> every honr. 

Creo>Kjte, gtt. ij* in aq. e4ilcis, ,^s<. 

Phoi^phateof lime, gr. xv-xx. in water, three limei^a day. 

Tinct. i*j<Jinii rowp., gtt. x-x\% fliluteih three times a day. 

Fowler's ,'w>lution of arsenic, gtt. j, three times a day* 

Tinet. aconit, nid., gtt. ij-i\% three times a day. 

Tinet, nnciyi vom., gtt. x» three or four times daily. 

Muriate of cocaine — three |>er cent soIutioD — dose, gtt, 
x-xx. 

Pyroxy lie spirit, gtt x, largely diluted, t i. d. 
In all i^evere eases the patient i^bould be kept at rest in l>ed. 
Htill other remedies may I>e neee*^ary, as the restoration of 
a di^plaeed or flexed uterus and its support by a jiessary ; in 
cases of iutlamed cervix uteri for even when no such intlam* 
mntion exis^ts) (KUjr a leu [>er cent solution of argentic nitrate 
tbrough a glass sf»t*cnhim int^i the vagina until I he vn^nnal 
pcjrtion of the cervix is eom[)!eti*ly submerged ; let it remain 
ten or tifteen minutes, then di^ejint it: to be rejM-ated two or 
three tinies, at intervaln i>f a few day*'. Relief ia Hjmetimes 
obtained by applying anodynes to the cervix and vault of the 
vagina; a Jtfteen f>t*r cent, solution of muriate of coeainPp or 



DERANGEMENT OF THE INTESTINE, 157 

the extract of belladonna, or Battley's sedative, may be thus 
applied with a probe and cotton wool, or carael-hair brush. 
Dilatation of the os and cervix uteri with the finger will some- 
times afford immediate relief, but care must be taken not to 
produce abortion in this way unintentionally. 

A bag of cracked ice applied to the cervical or dorsal ver- 
tebrae for half an hour, two or three times a day, will some- 
times stop the vomiting. Pencilling the fauces with a ten per 
cent solution of muriate of cocaine has been lately suggested. 

The (at best unphysiological) practice of coition during 
pregnancy is probably one of the causes of this vomiting, and 
should be interdicted. 

Should all means of relief fail and constituHonal symptoms 
of a grave character arise, the last resort may l)e adopted, 
viz., the induction of abortion or premature lal)or ; but the 
cases requiring it are very rare, and it is not to be employed 
without a consultation of two or more physicians. 

The best means of inducing abortion in these cases is by 
dilating the cervix uteri ; but as moderate dilatation with the 
finger, as just stated, will often stop the vomiting, this should 
first be done, when, if the vomiting cease, further dilatation to 
produce abortion will be unnecetssary. This mode of arrest- 
ing vomiting was discovered accidentally by Coj)eman. The 
method bears his name. 

Derangement of the Intestine : Constipation. — Constipation 
is very common. I^ess often diarrhoea occurs. Constljtation 
is a symi>athetic affection during the early months, and due to 
pressure of the enlarged womb during tlie later ones. 

TreatmenL—DxxT'm^ the early nnmths mild saline laxatives, 
taken largely diluted before breakfast. After their action 
instruct the patient to visit the closet daihi at a regular hour, 
and use gentle inanrnfje of the abdomen while there. Oatmeal 
jwrridge, and brown bread, l)ran bread, or cornmeal bread. 
Cool water to be drunk every morning before breakfast, and 
again the last thing at night.' Grocer's figs, dates, prunes, or 
tamarinds at night before drinking the water. Forbid tea. 

During the later months, when masses of scyba la are liable 
to accumulate, castor oil with tinct. opii may be given, and 
injections (daily if re(iuire<l at a regular hour) of soap and 
water ; or hot water and glycerin, equal parts ; or rectal sup- 
positories of pure glycerin. 



168 HYGIENE AND PATHOLOGY OF PREGNANCY. 



Slitmlil stronger inedicines l>e uecessary, either early ur late, 
tmuum inny be given, ur exlraet of cui<x*yijth with extract of 
beJludoniiii, or an oeeui^ioiml lilue pill with soap and iit<iiftet»dH ; 
or u teusjiKKmful of eonj|K»unil li<|Uoriee [lowder at nig^ht ; or 
H, Kxt. eulot*yuth. eo., gr. ij, pulv* rhei, gr. j, ext. lieiladonnie, 
gr, 1, ext. liyuKTumi, gn s8, in j)iil, at hedtinie; or li. Aloin, 
gr. }, stryehniM, gr. ^^, ipeeu<\ gr. ^^^, ext. helladonnM', gr. i, 
iu pill, at night 

Impacted fecal masses wjnietimes rnjuire removal by mo 
cbanieal means aud advent enema t a. 

For chninic cotigtijjatioii direct ina.<-«age in the closet, thus : 
When seatcil, let the [laticiit place her arms *'tikinjho," the 
thyrnh?^ direeteil hacksvard aii<l plunged into the npace on eaeh 
tiide nf ihc lund>ar spine beluw the rihs, while i\\v hands are 
s|iread out I»elow the ril)s laterally, and so mtived aliotrt in a 
cirf*lc nuind the hudy, the entb of the thiunhs and hngers 
nniking intermittent pressure. 

Dlarr1i<Ea. — If it have becti [ireceded by cotijitijiatitui, and 
the evaruatioiif* cimtain l>ut little fei*al matter, and consist 
i'hicHy f>f miicn8, give a gentle laxative of eai^tor nil and 
bindaritiui, or a dos*t? of solution of citrate of magnesia to 
eleaniHe the lM*weL 

ADer being sure that no accumulation in the bowel re- 
mains, and in castas where none originally existed, give vege- 
table asiringents with opiates, ex\ (p\, the tincturea irf kino, 
catechu, or krameria (ihrn^ of either ^]), with liuet. o]»ii, gtt, 
X, in 5S8 of mist, cretas three times a day. Or pills contaiu- 
ing acelale of lcad» f>}>ium. ara! »|>eeac may Iw [irescribedj or 
t?ynrp *d* rbidmrh with hicnrbonate »if soda. 

In inhlili'ai enjoin niys<*uhu' rest and the recnmlient jiot^ture; 
inustarrh followed by warm rata[dasms to alMlomen and milk 
diet with well-ccK>kcd rice-floor, arrowroot, or com-starcb. etc. 

The occurrence c»f diarrhtea during pregnancy must n*»t Ik» 
neirleeteri. Uttlesj? cheeked, it niay lead to aliortion f>r pre- 
niatnre delivery. It slionld he treated with great earf% ei*pe- 
eially if accompanied with tenesmus f>r other signs of enteritis* 

DISEASES OF THE UEINAEY ORGANS. 

IHBeases of the Kidney : Albumitturia ; Uraemia ; Toxaemia ; 
Eclampsia. — Uecetitly much pn»minenee has been given to 
the «o-culled ** ToJramia of Prey nancy ^'^ or ** general loxienda," 



DISEAiih.S OF THE CIUXARY OUGANS. 



150 



riHMjgtiizeil Hsu iin flf^/fo-iivtoxieatiou <*rig^iiifttmjr not fn>ui witb- 
ouu liUt ill the wutiuio herselil Many difiVrt-nt llieone.H are 
giveu to exi>ljiiu tliis tcLxainiu tA' |>rej^otujt wununi, but the 
treatment cle<(iic'il)]e trotii M t*f tlitmi i.s nearly the f*anie, vix.» 
elimintttive tretitnient, to aid in g-etting rid of the toxins through 
the excretory cirgans. It is for tde most part inudefinate 
functional activity of the^ orgatj« li[*oli whit h the retention 
of toxins and toxaemia have their origin. 

In a large nuijority of cusej^ ( tHJ i>er cerd. or more) the kid- 
nt'fjii are the <irgans at f?inh. From dtticient functional activ- 
ity of the kidneys excreincntitiouH matter>i that ought to Imve 
l*een elimimtted in the uiine are retained ; then follows^ iinemia 
or some other kind of toxaniia, whicli, when it hefomes* t*iifti- 
ciently hUenHc, jiroduecs convul8inn*s (eclampma), and in the 
w<)rj*t cai4es r<mui and dcalh. A co!nmt>n and early symptom 
of this troulde is afbtuftitiuna, but alhnn^en in the urine is a 
gympton* onhj; >vo cannot regard it ii8 a disease in itself, hut 
only a sign (jf renal dit^MK«e. Hence hai* arisen the now uni- 
vernal [practice of examining the nrine for tdhuinen in ail 
|iregnant women ; and ii nncros^copic examination for tuhe- 
cnsts, bloiKl corpuHeU^s, and renal epllheliym at* further evi- 
dence of kidney diFcase, should iiho instituted. 

The fref|uency with which albumen ocx'urs id the urine of 
pregnant women has l)een %^arimisly estinnited at from 2 to 20 
jier cent. Probably tho,«ie wlio ubtain the higher percentage 
use exacting testis by which vtrrf trace.^ of albumen are 
ileteeted, wiiile the lower percerdage ii* olitained by ortliuury 
and rougher tc^ts when the tjunntity of allmmen is greater. 
Slight traces of a Mm men may occur from the presence in the 
urine of mucous ilischarges fn^m the vagina, urethra, and 
bladder, witlmut kidney dist'ai*e. Bad mm^ of renal disease 
going on 10 convuhiona only occur once in alxiut 500 preg- 
nancitfpi 

Etiology and Pathftlotjif, — Nothing is more unsettled tlmn 
the caufH^ and pathology of the renal troidrle.s «jf [iregnancy. 
All known lesions of the kidney — every variety of nci»hntis — 
may mrur in pregnant women ff-* tit titht*r ])er.*(m^. In t^oine 
women renal liiscai^e is present when gestation bcgint^. While 
sonit* ca.HCH are thus acctmnted for, tliere are others in which 
renal disease only begins during pregnancy and ilisn (ijx^ars al^er 
delivery. It is these last that are diHieult to explain. That 



!(>(» IIYQIENE AND PATHOLOGY OF rREGSANCr, 



tlie tuortiiJ t'oiiflitions obncrvefl lire in some way |>n>diired by 
jireiriiiHK'y €Jitirii»t he il«*uf>tetU ami tbut previously existing 
rrinil "lisi'iLs*^ is made worse by gestiitioii is etjually true. 
Theoretical t^xpliiiialions that explain s<ime cases fail to explaiu 
others. The etiologiail faetorj* j*roliably vary in kiu<l and 
uutnljer in flitfereiit vtvsei^. Sitae uf tht^^e factors (the relative 
(M^iteacy and freijiiency t*f whieli it if> tiiftieuh to detiiie ) are 
ai? follows : 

1 . Ol )8tructioii t4» t he ureters owing to i hei r being *' stretche<U 
rtexe<l, distorted, or ronipre.<seii " Uy tbi' gnivid nlerns. 

2, Sudtlcn hypereniia of the kidneyii, |>rodueed by cold and 
c*>jj?^e4:{uent suppression of persj>iraliou, 

8. Iiicrea^^nl functional activity of the kidneys, required 
during pregnancy tn excrete waate pnj<luct5 of the fceUiJ*. 

4. locreased blood jircKsure in vessels of kiilucy from gen- 
eral arterial tenHiini thrtuiiihrvyt the body, owu^^ to eartlia^ 
hy[nTtri>phy (physiological hypertR*phy of left ventricle} in- 
cident to pregnancy. 

*). Mechanical [ire*«ure of the gravid uterus Ufwin IiIixkI- 
vessels — either veini*, arteries, or both^ — so as to elisturb the 
renal circulation. 

G. (jeneral increase in intra -alxlominal pressure owing to 
teimon [iriwluecd by expanding pregnant utenn^, and pri>- 
dncing venous stasis in the kidneys 

7. Keflex vasomotor s[iasm i»f the renal arteries (and eonse- 
ijuent renal amemta ) origimitiug peri[ihernlly frrim the uterus, 

H, The alleged hydnemic condition of tlie IdmMi incident to 
pregnancy. 

9, Anomalous distribution of large bhwjd vessels in the 
alHlomiual cavity, such et?topie hlrMxlvessels being more liable 
to mechanical pressure by gravid uterus than vt»ssels normally 
diHtril>uted. 

10. Alisi^rption into the IdiHid uf toxins from the intestine, 
owing to defifient atiion of the liver failing to eliminate theae 
toxic materials during pregimncy. 

1 1, It is pisnible the kidneys may participate in the vascular 
<!onge!*tinn of the genii o-uri nary system incident to sexual 
excitement, A 1 1 coll tin after in»(>regnation m lonuiturab ThiB 
would help lo ex[»lain the grealer liability to renal dineaifie in 
primipane. Social cnsttmvs jind the laws of physiology are at 
variance iu the sexual lifeof civiliz**d jieoplei** Noneof the»e 



DISEASES OF THE URINARY ORGANS, 161 

views has been conclusively proved ; most probably a plu- 
rality of etiological factors acts conjointly. 

The lesions of the kidney vary, depending largely upon 
the existence or non-existence of structural changes prior to 
gestation. The evidences of nephritis, acute or chronic, inter- 
stitial or parenchymatous, may or may not be present 

The condition known as *^the kidney of pregnancy'' consists 
of anemia of the organ with fatty degeneration of its epithe- 
lial cells ; but without nephritis. It is of frequent occurrence, 
but of less import than nephritic cases ; its symptoms are less 
pronounced, appear later, and disappear more promptly after 
delivery than in cjises where there is inflammation." The treat- 
ment of both conditions is practically alike. 

Syniptoma and Diagnosis, — The urine of every pregnant 
woman should be examined at short intervals, especially late 
in pregnancy, both chemically and microscopically, for evi- 
dences of kidney disease. Albumin is detected by boiling 
the urine, which coagulates the albumin, as does also nitric 
acid ; but heat will give a precipitate resembling that of 
albumin if phosphates be [)resent ; this, however, is imme- 
diately redissolved by nitric acid. The amount of albu- 
minous precipitate may vary from a barely j)erceptil)le 
oj>alescence to apparent complete solidification. Albumin is 
not always continuously present ; it may be absent one day 
and appear the next, or vice versa — hence the examination 
should be repeated. 

The quantity of urine passed in twenty-four hours should be 
collected and measured, and the total amount of iirea it con- 
tains be approximately ascertained. This can be conveniently 
done by using the ureometer of Doremus with the sodic 
'hyjx>bromite solution, which jrivos the grains of urea in each 
ounce of urine. The total quantity of urea excreted daily 
should not be less than 400 or -lOO grains. 

Examined microscoj)ically the urine exhibits renal epithe- 
lium cells, tube-casts — either hyaline, epithelial, or fatty — and 
perhaps red blood-corpusclos, the presoiK^e, number, or alv 
sence of these elements varyiiii^ with the kind and stage of 
kidney lesion. Casts may be present without albumin, and 
mee. versa. 

The urine may be deficient in quantity, and of darker color 
than it should be. 
11 



162 HYGIENE AND PATHOLOGY OF PnEGNANCT, 

In nK>fc«t cjij^es there Is mlcma^ puffine^s of the face and eye- 
lub ; also of tlie hands, m that finger rin^^s bcromo tiglit* 
(Ivleinatons .*twelJing uf the feet h eonimou, \ml ttf leiss signifi- 
cauLv ; it oeciirs in miiny j^regnant women witliDiit kiilney 
tn 111 hie. In some easej^ genenil ananurra oeeiirs, iiivulving 
the cellular tit^ne of the whole hocly, and even the i^erous 
eavitia^. Stich a very extensive flro(»!sy Ht*t"in^ in tionie eases to 
he ht'nefieiaL 

Willi thes€* nrinary and drop^sieai pyniptunis only, many 
wtaaen. under |>roi>er trt-atrnent^ nniy go on for weeks and 
even inontbw, without any olfier and more t^riou.^ Hyniptoma^ 

But in every ctut% whether mild or severe, tirere is aa 
always to he dreadeil darker i^idv to i]m elinieal picture, from 
the liability to iox:entia or unetoit^ iuttjxiention. 

The new set of syniptoai.s indirating this unemie poisoning, 
the early re<'ogiiitiiin of whieh is *A' the greatest iinjiort, are 
as follows: Imuhche, ntiUHea and mmttuKj, vphjaMrtv /i«in, 
vevihjih ring in fj lit the ran^, Jiashe'* of fiffitt or darkhtfiH^ double 
vimotu bliminesH, deafntHM^ mt^ttiui di^t itriMince, dejevtite mftnor^t 
mmtwlmer ; i*ym[itoms easily explniued by the eirenlntion of 
toxie Idood through the nerve centres. These may he pre- 
ceded hy la?sitiide» and ai'convpanied hy const i pal ion. or by 
tliarrbiea (ura-niic diarrhiea >. jlrudaflw is [leriiajus the most 
fiignifieant and ciminion warning symptom. In had cases the 
nrine is rtHluced in qnantity (almost suppressed ), very ihirk in 
color, its albumen greatly iDereased, so tlnit it he<Tinies solid 
on hoi ling, 

Next comes the final aitastropheof m^a'i/7^/o?M i eefam/ma)^ 
The <**nividsive fit begins with tvs itching of the facial ninsi^lea, 
rolling and Hxatifm of the eyelmlls, pnckering nf the lips, 
fixation of the jaws, j)n>trnsi<ni of the tt^ngne, ctc\^ soon fok 
lowed Fjy viobmt spasms of the miis<di's«»f the trunk and limli«, 
including tliosc of respiration : hence lividity of the face and 
stertorous breathing, liiting of the tongue, ojiisthotontjs, etc. 

The fit hists fitU'en or twenty seconds, ending in partial or 
coajplete romn, p>ssihly death ; or consciousness nniy return, 
to tie followed hy other convnlsions. 

Premature did i very nniy <M*<'ur, or if the cast> reach fall 
term without nnivnlsions, they may l>e bM>kcd for during 
lalH>r. In some casi'S they con»e on aficr delivery without 
having previously occurred. 



DISEASES OF THE URIXARV ORGANS. 



U 



After laljor the ])iitiviJt iiiny recover ; or after purlijil 
recovery may die later fffMu Brit; lit '?« disea^ , or rvmiiiii 
niore or less liisabled from paralyj*is or mental deniuge* 
meat. 

Pfofjnmifi, — This will largely depend upon the d^ree to 
which the unemic toxa^niiu ha^ progressed. i\Iaiiy ease,^ with 
allniiiieii, castn, and aHlenia, under proper and tinvely treat- 
ineut e^ic-ajK? toxaemia entirely, and j^o to term without further 
tnjuble : in fathers, the alhuiiien uml exists inerejuHe hi sopite of 
treiitiiient, lieiiee toxi<» symptoiajr ami eelani|**ia are likely fu 
fX'cur. The outlook is iimv nnwt grave. Tlie maternal 
mortality after etdampsia is almut 20 |M?r eent The ehihl 
otWu dies, either from premature birth or from tlie existing 
toxiemia. Death of t lie child hi ufero ia sometimes henetii*ial 
to the mother: lier toxiemie sym]>toms improve ; 7inp|K>?ie<lly, 
heeaui^e the metulxilie |>rfH*e^'*es of t'<etal life oi^ase to produce 
toxins injurious to the woman. In twiTis there are two ehil- 
•Ireii whos4* defertive metatKdism may |iroduee toxins ; hence 
a graver prognosis, 

(tenerally iipeaking, reintl .sym^itiHus a|>pearing earhf in 
pregnamn' are worse tlian when tx'eurritig latter; the woman 
hiLH longer to go before the relief of delivery. The entire 
ab;^enee of iixlema is nnfavoriihle. When (convulsions oeeur 
the ilau*i:er iaereases with their luimher and freijueney. One 
Hi may be fatal ; ett^es have, however^ survived nfter fifty 
convulsions. The majority i»f cast's iK^eur in prirniparie, in 
whom the fn'ognosis is less favurnble» owing to their hdmrs 
being usual ly slower and longer than m multipane, 

Tt'eafmenL^'TU^ main prhtinpif* of treatment is elimtnatitm. 
The excretory functions of the ImiwcIs^ j<kin, liver, and Inugs 
must be increiLseil to take the phice of inaderjuatc ebmhnttion 
by the disjildeii kidneys. In this way toxamiia is prevented, 
or when prewnt, may tn* relieved. FIrnct\ first, /iiAry^Wnv/^ 
(fivepulv. jalap, co., ;^ss ; or cahancl and jahip, of each, ten 
grains; and keep tip a free action of the bowels with a daily 
pill contairniig extract of aloes and extrant of colm-yntln of 
each threcH^uarters of a grain, tnken in the morning. In had 
eiuies with symptoms of impending uraemia, elaterium mny Vte 
given, hut with care to avoid exhaustion and production of 
premature labor by its flnistic etlect^. 



4 



< 



1G4 iiYiiiESK Asn I'ATfioLoar ar rnEGyAycv, 



R. Tritiirttt elaterini, 
Extr. Im*i^yain., 
01. earyuphylli^ 






Wheti a mikltif piir^e is dosiral>le, ^I'lve a daily dose of 
Etwsoiii i^ah : or a satunitt^d mdiitiou of llic same in ilusi^s of 
a tiddes|KJoidnl^ two or tliree timers daily — enough to secure 
twi» or iiitirt* liHwe Hlm>ls every day* 

Next iti ianHirtaoct; to |mr^atioQ is promotion of excretion 
by the A In. Keeji the |uitient wjirm in bed ; or, if nh!e in \vo 
U]K let her wear warm uin>1( a rlolliin^'^ ; avoid expo^ftire to 
CiM, and take a daily warm hath, followed by lyrisk frictiou 
with a tovvt L 

Iti eascj* of toxienda, with iniiiendiu^ e^*l!impi*ia, j^obmer^^e 
the patient, all hut the head, io liath-tnb of hot water — lU^"* 
F,- — <*overed with ii blanket. Ijet her h*> remain thirty minutes, 
the lem[>eratnre of the water beinjLT 52rrad*ijdly iiii- reaped to 
] 1(»° F. On removal from the hath, wrafj the patient in a 
hot sheet, phiee her in Ikh] betweiii thiek wo<deii l>lanket«, 
atni cover nji all but the face. Dnrin^jf the hath cold wet 
clot hf? may he applieil to the head to relieve headaehe, ete, ; 
water drarvk freely t«> promote dhiphore^jis, and a ghi.-s^j of wine 
given if fainttieiiH cx'eur. (iuard agahist ex|Kisnre while cool* 
ing off, rising from iK^d, and dressing. Hath may he repeated 
oijce or twice daily. It ha-s one drawback, viz.: the liahilily 
to hrit»g oil uterine contraction and labor. I'^hh^rnl and the 
bromides may jirevent this. 

When the waterdiath is not avaihilde use the hof-nir htith, 
tints : Place a 8[iint lamp on the fltior near the bed ; over it 
arrange a lari^e tin fnoDel, the hmg ImhiX beak of wfnt'h, i»biced 
Iwnealh the l>e<lelothet4. conducts the hot air to the >?pace uccu- 
pietl by the patients It iiuiy be coutinueti half an hour, and 
repeated daily. 

The n*^ of jaborandi and pilocarpine as diaphoretics is not 
advisable, froru their liability to tlejiress the heart's action, 
pniducc pulmonary oMient/i, and bring on Ial>or. 

It should be remembered tliat i*tt*ra( hi tj nii*\ pitrfjtn(j, if con- 
tinuech will fh'[ilele (he Hvstem much in llie name way that 
bleeding would, and llms pnMlnre feebleness and frefpieticy of 
the pulse, which may rei^juire stimulants (i»ratidy, strychnine, 



: 



DrsrjsKs OF TuicjuciyAnv onoANs, 165 

p.), Ui keep up tbe acetic m of the heart. It is under these 
circiim8lan<'e>! that the ntirnial suit siiluhon (*see lielow ) serves 
the double |jur|Hjse i>f luiiug tia a ditimtir and as a cardiac 

Le?«en eouge?ti«m nf the kidneys and pnmirjte their secretion 
by extent*ive ilry etipjnnj^' with tiunlder ghi>5sei< or liirjye eufis 
over the loins, tidhwed hy the appliention of a riiuslard piaster 
to the sajne part ibr tifleeu or twenty ndimtes ; theij hot 
imultices t»u8tantly applied and changeil every two hours as 
they get eooL 

Diuretics. — The best diuretic is ordinary water — two or 
three quarts daily. Viehy, ToIauiU or Hutfalo lithia water 
may, however* be given, or tlie eitrate of lithia lo five-grain 
doses* with iuftistion i»f digitalis; i>r the lithia salt may be dij=u 
scdved ill water and taken with one or two droji«< of jiuid- 
tJttraH of digital i.s — more reliable thjui the thiHftre. Bitar- 
trate of potasi?ium, ,^j or ."^ij, to a pint of water, with lemon- 
juiee ami a little sugar, is a ]deasaut diuretic drink. 

The diet should i^e chieflyt «iid in bod cage** cirhmvely, 
miff: — two quart:^ claily. Milk itirielf is a diuretic ; it is 
fjidily as?.'imilateil, and leaves but little d^-bris in the knveL 
Cases <»eea8iouully or(nir — prolxiibly from personal idiosyncrasy 
— where milk thn^s not «ii;/est ea^^ilvi and where it doeA leave 
masses of undigej*ted matter in the intejstine. Here it should 
be diluted with water, half and half lu mild eases fruits, 
ailads, and light vegetablej?, with h^^h. toast, and bread-and- 
butter may he allowed. 'Meats should he forbidden. 

In anremie ca^e^s give inm — '*Basham*8 mixture'' — the 
Uq. ferri, et ainmonii ace tut., ,>«h, t, i. d. 

In toxa*mie eane^ one or two quarts of normal salt solu- 
tion ' may be injeiled under the mammie ; or ioto tlie nui- 
neetive ti^^ue f>f the nates nr abdimiinal wall. 

The only way in which excretion by the lung»Qm\ be made 
to ai<l the disiibled kidneys is by securing free respiration in 
pure fre>«h air. Remove waistbands nnd corsets. Ventilate 
rt>onk«. 

Auxiliary excretion by the /trer is accomplinhed indirectly 
by the mercurial and i>lher purgatives already mentioned : 

♦ Trf^pfiroit hy pntHntf 100 errtinR fnpprfi.xlinatel>' ont*ttiiHp«ionralj nf t'omtnitm 
»iU In a qurtrt'of WHtir untl bolUnp ff»rfivtMnlniiU« ; ninre<»xactly,ain"iiln«t>f 
iftlt lo one tlulilotince of wiUer, which uiuke» ii sU't«ntbs of 1 \>vt ct^ut, volu- 
tSoo, 



166 nrOIE^E AND PATHOLOdY OF ^I^EQ^'ANCr. 

they probahly net by lesseiiniLT ioii^^t\^h«>ii nf ihe |iurhil veuoiig 
gysterii, No jnedieitie m jmHtiive/if knoivn to iuerejise I lie iMXTe- 
tiou of bile. Never! hele^8 the old pill of Niemeyer contiiiniii^ 
one jjniiii each of niasjj. hydrur^., |iidv. ditjittdii*, aii<l pulv. 
aciUa\ given three times a day. hits beeu pn>ved by lnii<; exjHTi- 
ence to l>e useful in these ciLses of iiiade(|uate khhieys. 

Observe that* h^ivve%^er the irieiius iiiiiy ^litfer, the priaeiple 
of t r en til) en t is ithvays the miue, viz.; rej*tore fuiirliini of tlie 
kidneys, or aid them by ineri^used eliminatioD throngli olher 
organs, ehietly Hie imnef^'* and j<kitt. 

When albumen and tube east.** increase in spite of treatment, 
and ei^ptH^iully when headaehe and other ^ymptoaii* uf tox:emia 
be<rin, abcrrtiori or [>rematnre Itibor should be iodueed. 

The treatment of ee lam |jisia liy mor[dua, eldoroibrm, etc., and 
the (ibstetrieai manat^^ement chiring hd>or will lie considered 
in Chapter XXXIIL 

Diabetes { Mellituria ; Glycosuria), — Bugar may he found 
in the nriue of pre^niant wotuen with(»ut any syinptoms of ill 
health, and disapjiear after ilelivery* ttr after laetatitm. This 
so-ealled ''}jhysiolo^ieul prlyeosuria" is of fretpient oeenrrenee. 
Again, women wh(j are already the subje^'ti^ of diabetes may 
beeonje pregnant, anfl the pregnaiii'V g'o on to term williout 
any neec»s,sary afiparent interferenee. 

Itnt «babete8 complieatin^' preLmancy may he seriooHt or 
even fatal to Ijnth mother and ehild. These eases are very 
rare, es|M:^eially so in primipane. The ehihi Hunetimes dies 
liefore hirth ( dnriu^r the hitter njonths of prepnaney ), or s4k*u 
afterward. The maternal deat!»s thus far iiote<l have i^ceurred 
aft^r delivery ur [>remature lal>or. 

DktffnoAiK. — Detect sugar by ehenxieal tests fTrommers, 
Fehling*s, Mixire*s, etc. ). The vv<mih nniy be over-large from 
drojisy of the amnion, or from the ehihl iK'ing ein>rmous in 
sixe, owing to dniftsieal iufiltrntiou. Lialvibty to abortion or 
premature delivery. IVuntus of the vulva Is apt in iK'r-ur 

^Vf«/7n^/*/,— The dietetic and medicinal meani* em|>loyed for 
diabetoj^ without pregmiuey. Should these fail, the fjuestiim 
of itidueing premature labor miiM he eonsideretl as a hist 
resort. 

Bladder.— I rritahility of thra organ is indicated by fre- 
quent ih^ire to micturate. It f>ccnr? as a sympathetic affec- 
tion during the turli/ mouths, causing (li^tress and sometimes 




BLADhER. 



Ifi7 



difiturbing rei*t at ni^^ht. ^Any also l>o produced by prolnjise 
of tlie uterus tluriti^^ liie Hrst three nioutlKS relief &ii«>nUme- 
ously occurnug us the womii rii?<'« during the fourth niouth. 
The w(»rst ea.'^ei^, aeeoinpnnieLl iBonieiinu^ l»y serious eystitis, 
are coimuonly clue to retroversion of tlie uterus. In iiny ease 
of irritable hhubler il m im|M»rtaiJt to kuow wh€4her the troulile 
Ik? purely uervous, or ou the coutrary, due to cyst i tig. The 
urioe telli? : in purely functional rade43 it is clear ; iu cystitis, 
cbnidefl with mucus or pus, wliich may \w. detected with the 
tnien»ftco|>e or observed iu vi^?iblc strings or niasses when the 
urine* after ftettliug^ is [H)ured frurn ooe vessel to auolher. 
Tbe fKJSsibility of gouorrhcea should be reinend>ered. Iti cys- 
titis the bladder is sensitive to alKlonunal preA^^ure. 

Late in pregnancy irritalde bladder occurs from prei?eure 
of enlarged woud>» es{)ecially when the child's bead is large 
froni hydrcK*e|>hjilus. Cniss*p reset itat ions sometimes drag the 
bladder out of place and prcKluce fnnetioual irritability of the 
organ, to be relieved l»y abrlomiual [nilpation restoring the 
child to its Dorninl position. 

TreatmcnL — -In nervous or functional cjist^s, without cystitis, 
rectal suppjsitorics of morphia and atrnpia at night to secure 
rest. The following is an eflicieot ami convenient remedy : 

B, Ext buchu, fld., 

Tinct. iipii camph.| iia f.^j,— M. 

Sig,— Teas|KHiiiful (or more j every two or three hounu 

Give bJand mucilagitious drinks (flaxseed tea, coUl infusion 

of sb'piiery elm bark, etc. ), infusions of uva ursi» or triticum 
re])enH, c^unhined (if the urine lie over-acid ), wilh liij, ]xitassa 
or (K)tas!*. bicarb. Balsam copaiba and tinct, belladonna inter- 
nally may be tried. 

In cystitis, beside the foregoing remerlies, the cavity of tlie 
bladder should be daily washed out with stime warm antiseptic 
solution, viz., creolin, 10 dro|)s to a pint of water; or either 
thymtd, galicylif acid, or ]M>tass. pennanganate^ in the profK»r» 
tion of 1 to fOOO of water, or boric acid, 40 to 1000, 

In all cases be sure the l»Iaddcr completely emiJlies itself. 
If necessary, use male elastic catheter. Restore the uterus if 
dispbwed, Tlie knee-elbow position may enable the |witi€»nt to 
e m pty t h e b 1 ad d <^ r . W hen the w o n d » i n c 1 i n es fo rw a r( I , press* 
ilig UfM>n tlie blaiMer, punh back and stip|)ort it witJi wide 



168 HYQtENE AND PATHOLOGY OF PJ^ EG NANCY. 

ablfmm»iil liaiKlnge. Kt^ep iJie liyvvt^b free from jut emulation, 
ihuTi leiivinjLi^ iiiori* rtHmi for the uterus nud l>la(Jder, 

Hematuria i Bloody Urine ].— May <R'cur froru (*toiie in the 
bladikr, in wlik-h case tlie crileylus fjluiultl l)e removed by 
Burt.'i<u] o|)eratioii duriu;^' the h4 m oh fit tif (ire^nuuiev, thus 
jej^seiiing ihe danger to tlie ehild IVuni premature lal»<M% should 
lliiit laTiir Irfim the 4»peratHJii. lleneaturiii also resuh^ froiri 
aeute cyslilia aod uejjhritis and from preHsurt- of tlie ^n'avid 
uterus produeinjj^ eougei«tioii and disltuitiuu of the hliH)d- 
vesi^ls of the I) holder — fio-ealled ** tr»iraf hevkorrhmihy lu 
this hiht ease heiiK>rrba;ze nuiy hesuflieieutly .severe lo re<|uire 
a.strin|i^^nt iojeeticms into the Idadder ; aial utenoe pressure 
shouhl he relieved hy the kneeH^hest |io44ture. or Sims [wsitiom 
Laxatives if required, 

Incontmence of Urine. — Small and frequent ii^volnntnry 
li isehii lyes *^f urine a re often assoein ted with o ver-distei i { ion of t he 
Madder find hu^s of lone in its mnsinihir wall. There amy also 
lie paresi.M of the vesa'al sphiiicten The How of urine orrurs 
during eoughing, laughinju% snee/ing» ete., hut also at other 
times. It may he prtKlueed hy uterine di^jilaeements ; \mA\\ 
nute version, retroversion, and pndapsus, 

Trtrttmcut — ^Iii eases of detietent musenlur tone in the 
hladder i^ive tinet. itueu^ voniiea; ; or stryelmia ; or tinet. 
ferri ehlorid. for some ilaysor weeks. For a shorter time, Hve 
droj^s of tinet. eantluirides in ^j of flaxseed tea nniy he taken 
t. i. d. FrtHpient ahlulionH and sini|ile ointments may l>e re- 
quired to relieve or [prevent exeoriaiions of the skin. A dis- 
tended hladder will of course require ft catheter. 

Retention of Urine. — I'sually due to retroversion of the 
uleriia. Use catheter and treatment for retroversion (which 
see). 

AFFECTIONS OF THE REPRODUCTIVE ORGANS. 

Prolapsus Uteri i Falling of the Womb ) during Pregnancy. 
— It usually rights itself when the womb rines durir»g the 
third or fourth month, hut, failing in llus» the condition may 
lieeome s*'riou8 from the gnnvitjg uterus getting jammed 
hetween the l»ony wtills of the p«»lvis and pressing ujioii the 
blndder and recniim^ or leading tu ahortion. The pressure of 
the growing uterus may eveti jinj^luc'e sloughing ami gangrene^ 
either of the wuuib itself or of the origans in contact with it. 



RETROVERSION OF UTERUS. 169 

Treatment. — Rest in the recumbent posture, with the hips 
elevated on pillows, pushing up the uterus by gentle manipu- 
lation, and, if imperatively necessary to keep it there, jKJSsa- 
ries. Continue treatment until uterus gets large enough to 
remain al>ove the j)elvic brim. Should impaction occur and 
obstruct discharge of rectum or bladder, the induction of abor- 
tion may become a necessary resort to siive the woman's life ; 
and if the tissues of the womb be infected the entire organ 
should be removed by vaginal hysterectomy. 

Setroversion of Uterus. — The fundus of the organ falls 
over backward, while the cervix is tilted upward and forward, 
toward or over the pubes. 

Symptoms. — Pain in the back, numbness or pricking or 
unsteadiness in the lower limbs, and difficult or very painful 
defecation and micturition. The diagnosis is made on finding 
the fundus uteri in its malposition by a digital examination 
per vaginamy while the os and* neck are tilted high up toward 
the pubes. 

Prognosu. — Usually favorable from gradual spontaneous 
replacement as the womb increases in size, but serious or fatal 
consequences may arise from impaction of the growing organ 
(as in prolapsus) if it be not replaced during the earlier months. 

This so-called "incarceration'' of the growing retroverted 
uterus, apt to occur when sacral promontory is unusually pro- 
tuberant, and in deformed pelvos. 

Ulceration and sloughing of the bladder may occur from 
prolonged retention of urine with conseijuent unemia ; and 
obstruction of the bowel may cause absorption of poisons from 
the intestine and consequent toxtemia ; the bowel, vagina, and 
bladder may ulcerate or rupture from pre.««suro, and peritonitis, 
septicaemia, and pyiemia follow. 

Treatment must not bo delayed. I]mpty the bladder by a 
male elastic catheter. If this be impossible, aspirate the blad- 
der. In using the catheter it should be remembered that the 
urethra is sometimes eloiujaied to the extent of four or five 
inches. Empty the rec^tum. Place the woman in the knee- 
elbow ])ositlon, and restore the organ by gentle digital pressure 
either by vagina or rectum, or both conjointly. 

Should manipulation fail, make gentle, prolonged pressure 
by distending a sofl-rubber bag in the vagina, or a Barnes' 
dilator in the rectum, the pressure thus induced l)eing kept up 



170 HYUIENE AMt PATllOLour OF VREUSANCY, 

fur ^'Vtnil lumr^. After ivpbiremcDt h HimI^c jiuh-aufv may 
be retjuireil to n'tniii the \voiii[» in \\s riitriiml jMii^ilioii, tir tarn- 
|j<3i»H of iiseptie wool pliiL'tMl Ijeliiiid tlie *^ervix in tlie ]»<>»iterior 
vaginal loniix may I*e used f(*r that piirjiosv. 

Should nil tltef?e lueiitit^ fail, tlie idHioiueu mny Ue o|)enecl» 
aud a Latid [Mi^ssed iu througb llie inrisioti to lift (iu; uterus 
out of tlie pelvis buck into its proper place up iu the aluloiuiual 
cavity. TJjc iuei^iuu iR'iu;:: I'hised, pre^'tianey luay jro mi to 
full teruL 

h\ \A\ivv of this method, iil^^^rtiou or premature lahor may 
lie iudut.'ed. 




Rntroveritoii At about twelfth wwk. 



If the uterine tlssuet? are infeeted, inilai»ie<1» ulcerat£*dj or 
gaij^reuouji, vajfiuRl hysterectomy may be done. 

Fig. ri8, from lx*ii*hman (after S'hultze ), showj* retrover- 
sion of ^jravid wondi at almut twelfth \veek» with retention 
of urine and enormous di&flenticjri of bbi<!dert owinj; to the 
urethni Ikmu^ dragged up and ei>mprespied \%y ilie displaei^J 
cervix uteri. 



retroveesWaV of uterus. 171 

Retroversion of the uteru.s is frequently associuted with 
some degree of retro-/?/ j/on — ^a bending of the iixi« of the 
wonj)>» iii which tlie os exteniufu and va^'iual jiortioti of the 
cervix iipf^ear to niaintaiti their nornnil [Mi?siticai, wiiih- the 
fund UK i.s bent liaekward toward the ^uennn (Fig* 69); hnt 
the dLHiistrourt results are the f^auxe its in simple retroversion ; 
60 18 the treatment 




fiASiTo-^Jtrxion of gravid iitenifl— dxtceiitli week. (ScurLHEE.) 

In the e»me of retroflexion it oc<»!isinnully hap|ien8 that the 
womb l)eeomei§ ilihited into ii sort of dtnible sae, one jiouch 
of it l>eiii^ above and tlie otlier lieluw the jielvie brim, ae 
i^hown in Fiir. 70, fnini Hanias' work, Iin|>a(tioij and dan- 
gero(i8 pressure npot» lihidth-r, etc., in the pel vie cavity, are 
tlojs rebeved. Both [Kiiirfies may iilsvi ni*e alwjve the brim 
^[Kirrtaneously ai* preirminey proceeds, juvd fhe ije^tation reach 
full term ; or, the l«»vver |wn)cti reniaininir ni the })elvii*eavity» 
full tern» nniy still be attained, Imt delivery i:^ im|K>j?.'*ihre» 
owing to di)*[jlaeetnent of tlieosnbove pubei*, and oei^-iipation of 



172 HYGIENE AND PATIiOLOar OF PIlEGNANCr. 

I he jit'l vieravity ]>y tliu lower |KJUcb» uoleas ibe latter In^ |tu^lied 
U|» liy luiumul pressure per i-ofjinam mn\ the t** uLeri brought 
<iown, whieli js tlie jH-oper Ireatmeut «tiiriiig both preguaiiey 
and hilH>r, Shoithl iliis inethiMi fail, the last re^^urt is viij^iuai 
liyslerutoiny and e.vrrneUon of I lie eliihl ihrougb the ineiKion, 
Anteversion of Uterus, ~8iiiee the iiuieriur iK-lvie wall 
is ouly uiie-lbiiTil 3^ <.leep lu? tiie posterior one, there is far less 

FiQ m 




BUncculiitotl iiioni»— fnoimpfrtc retroflexion. R, Rectum* Or, Os uteri. 
B. I'nlhra mul l>latlder. 

flirtirutty in the fundus uteri getting: aliove the brim when it 
18 f1i8pbice<l anteriorly (anteveriiioiO than when retroversion 
ocrnirs. But when abmr tlie lirim the womb may 8till remain 
anieverted and press^ upon the hladtler, as iX'ciirs chiefly in 
ileformed women ffxdvie deformity), or in caitcj* of ventral 
hernia, i>r m t}n»*e whtwe ubd<irninsd walls liuve beeome relaxed 
and |)en<hiliMis from frefprent rhibUH'ariri^'. 

l)tatjno)itM IS made by vatrinal examination revealing the oa 
and eervix ntpri far hack, while the funduH, thrown forward, is 
felt tbrijugh tlie anterior vaginal wall. 



LEUCORRIKEA, OR ''WHITES:' 173 

Anteflexion. — Anteflexion of the viomh— bending of the 
uterus so that the fundus and body are curved forward toward 
the bladder and pubes — may or may not be associated with ante- 
version, just described. It is apt to occur in women whose uteri 
were anteflexed before pregnancy began. Rarely the fundus 
mdy become locked behind the pubes, but it is far more easily 
replaced than retroflexion, the pubic bones ofl'ering no project- 
ing promontory like that of the sacrum. Recently, however, 
ditiicult cases occur from the anterior wall of the uterus hav- 
ing h^n fixed forward (before impregnation) by the operation 
of stitching the fundus to the abdominal wall for the relief of 
retroversion. When such "anterior fixation *' of the uterus 
has been done, the enhirgement of the gravid organ go^s on 
chiefly by expansion of its posterior wall, while the anterior 
wall, tied down by adhesions, remains thick and unexpanded ; 
hence irreducible anterior displacement. 

The symptoms are irritable bladder, frequent micturition, 
increased by the erect posture and mitigated by recumbency. 
Vomiting excessive and troublesome. Pain in the hyix)gastric 
region and pelvic cavity. Diagnosis by the same means as 
anteversion, except that in anterior flexion the os and cervix 
may retain their normal position. 

Treatment — Replace the womb, in easy cases, by digital 
pressure upon the uterus through the anterior vaginal wall. 
Rest in bed, on the back. In cases of weak and {pendulous 
abdominal wall, put on abdominal binder to support the 
womb from tilting forward over the pubes. In difficult 
eases with anterior adhesions, use jn^rsistent digital massage 
and vaginal tampons, to stretch or break up the resisting 
adhesions. 

Leucorrlioea, or " Whites." — It consists of an excessive dis- 
charge of mucus from the vaginal canal. It is liable to irri- 
tate the vulva and produce itching and excoriation. Con- 
dylomata may exist, or granular ])apillary projections consti- 
tuting granular vaginitis. Generally the disease is sin»ply 
a hypersecretion, due to congestion of the vaginal wall or 
cervix uteri. It may be due to gonorrhoea or to endo- 
cervicitis. 

Treatment — Avoid the use of injections for fear of ])roduc- 
ing abortion. Fre(|uent tepid emollient ablutions are indis- 
pensable for cleanliness, and to prevent excoriations, etc. 



174 HYGIENE AND PATHOLOGY OF PUKd NANCY, 



Luxjitives to ]jrev*^nt cnrL^tipHtiou, If the <lis^4mrpe l>e 
fiulikienrly prutune lo rv^nttre mcHleratiug by as4triiJtJ:eiit, use 
vagitial supiKJsiturics of Lauiiiu, alum, etc. 



H, AcicL taunic, 

(_)L iheulmmL, 
Fiat s^u|>i>03*i. iju. vi. 



a; 

Cst' one tvvire diiilv. 



A musliu Ka^» lar^e eocHij^'h tu contain iwenty grains t^arh 
tif alum and liit^iiHith snbnitratc, may In? introcluee<l dry into 
the u|»|Kr jmrt ctf the vaginit, and withdrawn liy it.^ atlaebed 
strinj^ after twelve houn«, 

lnj*teati of astrinffeiitH, a sinjtrle afiplirathni of a HO per 
cent, i^olutitm of carlHdie aeid in ^dyeerine may i>e made U) the 
vapnal rmieon.< mendirane and eer\'ix nteri. 

In ^^^onorrhieal en>i.*H aj>(iiy a 2 i)er eent. H>lntinn ofari^entic 
nitrate to crfn/ pttrioi' vairJnal nuietmi* niendiraiie, with hrnsii, 
tbroijLdi s^peenbim, daily. Kee[i the parts clean with mild 
bii'hloride of nierenry lotioiL 

Pruritus Vulv®. — Intense itching of the vulva is of fro 
f|uent oeeurretiee during pregnancy. There is an irresistible 
<ie?^ire to rub the parts, i^onietinu^ even daring sleep, which 
may lead to excuriatimi, Knobbing, ulceration^ etc. Itching' 
may extend over thigh:^, alMlonien» and other parts (tf the 
IhmIv, In l>ad cases, suffering, worry, and insomnia may 
lead to mania and insanity. 

Catt.nti, — Irritating vaginal iHscharges* with la<*k of clean- 
lines?. (4lyeosuria and [mrasites nuiy [iroduee it ; als^* ingrow- 
ing hairs, and migration of seat worms (futrariile^) from 
rectum. It is sometimes a oeurosis, whieh» however, may 
depend rai toxiemia. 

Trrftfiitrtit. — In the eommoii ciist^s due to vaginal discharges, 
the princifile of treatment in frerjuent rb^an>*ing t»f the vulva 
with HMvthin^' and antisi'ptic sobiti*»ns or ointiiieuts. After 
washing with tepid sterile water, the best appliaitions are a 
snintion <»f rarroMh'*' nithftnutii% 1 to 1000, or if this irriiatt^ 
ust^ a 1 to 2000 solution, and follow it liy warm salt s<ilution ; 
earholiv nciil, ^ij to *Mie pint of water or oil ; or ^ of the acid 
to ungt. rmsc, 5iv, Paint vnlva with itih^er nitrate sM)lution, 
gr8. XX to water, ^. Applications of lysob resorcin, thymol, 
iodoform, or bonicie acid, may l>e tried in suceej^sion. 



i^ISKASES OF THE BLOOlL 



175 



For anofhjtw nmAwnUmn^ tise u 4 jkt cent. s<ilutioii uf 
coctiicitj or uu uiiitmt*rit of siuiie strength^ ur the followiug : 



R. Ciirnplior, (^ 

Chlontl hyilrate^ j 
Ungt, aqua rosa.% 






or infusion of t(>hiie<;<j (3^8 tu wrttt^r, O j ) ; or soda Iwrat.M ;j 
to wat^r, Oj ; i>r ihist with a juiw<ler eoiUuiuiug jnm*lereiJ 
start'h four |wirLs lunl t:anjplior oiji^ [uirl. A|iplirjiticoia tt> thi? 
tvtj/i'mit rnav Ims trknl ; a *sruall taiij|i()ij Hoakt'J in a o to 10 jier 
fieiit wlution of lysol may l>*^ placed in the j>o8tt;rior vagitjal 
fornix and reinaiu for several fitmr^; or u nil vtT nitrate wjlu- 
tion (20 grains^ to ^ ) may Iw ].x>urefJ into tlie vagina tbnmgli a 
ghisj* cylimtricul speeiiluni atnl niark^ to cume in contaet with 
every part of \\w~ nmcoiift snrface, when it is waa^hed oul by a 
sterile salt solntion. 

^[aiiy other reniedie«« have been iiseil in relKdlioiis (*im.*s, 
Smoking a cigar lias been known to stop it, Exii<tiug toxienna 
mii?^t Ik* relieved ]>y elt mi native treatment. (See Urivniia^ 
page l*>'i/) Diahelio earns require dietelie treattiient. In- 
growing hair must lie removed. Rectal iiTJeetions of iufuaiou 
of quassia for aiscarideH, or a tive«graiu dose of santonin at 
night and a laxative of Kot^helle salt in the morniug. 

If ideere exist, remove sciibs by warm pjiiltices, then apply 
silver nil rati% grs. xx to water, .^|, to la* fitlloweil liy ointment 
of calomel, ^j to vast' line, t^. 

PainM Mammary Glands. — Breasts are the seat of pain of 
a neuralgic character due to rajml development. In pletlioric 
women relief may be obtained hy the derivative ef!e<1 of saline 
laxatives. In amemic, tiensitive, nervous women, give iron, 
quinine, wine, and good fowl. In either vtisv applicatitni of 
Ik'Iladonna ointment, or the tincture wjirinkled on a l>read 
poultice, or anoilyne liniments of olive oil, camphor, and lauda- 
num, will atfbrd relief. 

DISEASES OF THE BLOOD AND CIECtFLATORY 
ORGANS, 

Palpitation of the Heart. — Pa I |»i tat ion (if thi heart may 
occur either Hym]jathetieally during the early months, or later 



^m^ 



T(> nVaiESE AND PATHOLOGY OF PRKGNANVY. 



from eiicroaeiiMieul tif tin etilar^feil uterus |niiihiiJL'' ii[i tlit* dia- 
plirujLjHi, anti €uilmrni.Sfiiiig the btMirt » action, 

Tri'ittmeuL — The syiupatbetic trouble is usually H^stniuteil 
witb nervous di^hility due to luurDiiii, uud tberet'ore requires 
iron, quiuiut", p>imI diet, au4 a little wiue* A pbi^^ter of bella- 
d*Hina over ibe cardiae rei^noii. Direct relief may l)e obtained, 
tenHKirnrily* by iusafa4ida, byoseyaiuus, luid oiber iuiti*s|iii;s- 
tnodies. 

The o|i|M>site state of plethora mat^ exkt, wbeu re^t^ laxa- 
tivi'H, low diet, lunl, jwriinps, Moodleltiu|Lr wiil in} riMjuired. 

For ibe njet^bauieal eud)arr»S!*nient,s of the later months, 
little eau Iw done further tbun [^filiation by autijipasmotht^ 
and altentitai to the g'unerul health and excretory fuuetion^; 
but the ]>atieut may be eonstjled ^\itli the hrsu ranee of relief 
when the womb sinks «invvu prior to df livery. TeiijjMjrary ease 
mav In? attained by belladoiuia phu^ters over the |n'a'<*ordiuuu 

Syncope, or Fainting.' — The attackn may re<'ur 8i'%H'niI tinies 
a dav. The pulse is feeble, piijiils dilated, eonsciousneisi^ partly 
Itij^t, and there may \iv liyt^lerieal plienomena. 

TrratmenL — lieeumbeuey with the head low, the a[i|iliea- 
tion of ftinniotiia to the nostrils, antl diffusible stimulnnti*, 
valerian, ete., durin^f the attaHvs. In the intervals, iron, 
fix)d, and bitter 1oiiie>j. Bromide of pnta.s^^ium, ^'^r. xx, tliree 
times a tlay. Remove enrsets ti^ht-iittin^' elothes, and all 
Indl^, waist-Mtrin^^ss and Indly-liand*. Avoid ero\vde<l rooms 
and impure air. ^ . 

Anaemia. — The txaet bloml-ehan^^es of pregnancy that oc- 
cur nornmthj are still nnsettled, but the teiideney ^^enenilly is 
lowanl itutrmia, wlneh may be<.*ome i^io prouounee<l a^ to re- 
quire treatment. It is nu»st apt to oeenr during the later 
morrtlis, when the red eoqai?Mde4» and albumin af llie Idood 
are dinnnishe<l and its tihriu inereast^d. 

When i^reM^nt before pre^a\nncy bejrins, i< gets wor8i% and 
may rarely projjress to ptrntriftHn anaemia — Kanetimei^ a>«y)ri- 
ateil with lenkannia — and go on to iHjmplele exhaustion and 
death. Aliortiitti or premature labor may rnTur and the t*rtu8 
die from inanition before birth. In jHTnieiouH eaws, besides 
the usual >ryw*y*/o»w r*f anaemia, there it* a teitdemT to hemor- 
rhajfe fr4>m tlie no«e, Fttomaeh, and other organs, v^ith pro- 
nouneed eniaeiation, pall«»r» exliaustion, faititfiess, and verlii^o. 
The protfitositi is here tnogt grave. 



PLETHORA. 177 

2Vea<wi€n^— Laxatives (if constipation be present) followed 
by iron — preferably the solid preparations, viz. : Blaud's 
pills, iron by hydrogen, or carbonate of iron. Bitter tonics 
(elixir of calisaya, or tinct. gentian, co.) before me^ls and 
iron afterward. Arsenic is valuable, Jj^ of a grain, with 
pulvis ferri., gr. ij in a pill after meals, t. i. d. 

Give a meat diet — lean, underdone beef, or scraped, lean, raw 
beef; together with meat soups, milk, eggs, fish, bitter beer and 
wine. Sunshine, fresh air, exercise out of doors if practicable. 

In cases with hydrcemia and adema of lower limbs extend- 
ing to thighs, vulva, vagina, and uterus, the labia may be so 
swollen as to require small punctures to let out the fluid, 
under an aseptic technique, of course. 

In any case progressing from bad to worse, despite treat- 
ment, abortion or premature lalwr may be advisable to save 
the woman's life. During labor septic infection is doubly 
disastrous, hence rigid asepsis is imperative ; avoid corrosive 
sublimate as an antiseptic. After delivery some may recover 
under arsenic, iron, food, etc.; others not. 

Plethora. — Plethora during pregnancy is rare ; it may, how- 
ever, occur, or simply constitute the continuance or increase 
of a pre-existing plethora. The xymptoms are opposite to those 
of anaemia, except with regard to headache, giddiness, flush- 
uig of the face, and ringing in the ears, which may occur in 
both ; but the general appearance of the female, together with, 
in plethora, the strength, fulness, and slowness of her pulse, will 
render diagnosis easy. Many plethoric women present a pre- 
vious history of profuse menstruation. Uterine hemorrhage 
during gestation, and conscfiuently abortion or premature 
labor, may occur, unless relief he afforded. 

Treatment, — Saline laxatives to produce watery evacuations 
and thus lessen vascular tension ; or a more decided cathartic 
to begin with. Avoid animal food, meats, eggs, milk, as also 
highly seasoned dishes, condiments, and stimulants. Restrict 
the quantity of food, and let it consist chiefly of vegetables, 
light soups, and cooling drinks. Immediate relief may be 
aff()rded by bleeding, even though the (]uantity of blood taken 
be quite moderate. Leeches or cupping will he preferable 
w^hen, coupled with general plethora, there is local hypera^mia 
of some particular organ, as the braiii, kidneys, or uterus. 
Sexual excitement and coitus must be prohibited. 
12 



fYGlESf: AMf VATHOLOUY OF riiLiiyASCW 

Varicose Veina, Hemorrhoids, Thrombus, etc* — i*re,^sjjret)f 
Uic* utLrus iqwrn llir Inrgv veuuiis trunks t^iius^ejs d»i*teiJtiou aiul 
vnric(»^ tlihitiidoQ of the veuuiis branches below them. Hence 
opdernsi unci %'arieose veins of the legs, heniorrhuids^ dilatation 
mid rupture of the veirw of the vagina and volvft* witli exter- 
nal [deedin;^:, or fonnation of thri>nd»i. 

Trtalmcnf. — Rest in the reciitnlient tM»i?ItioD, 8Up|Kirl of the 
uterus hy alMJonrmal baudages, anpi>urt of the veins of the 
legs by elastie j^loekings or weM-a|»|4ied roller bandages. 
Rupture of a varicose vein niay occtU'snai falal Ideedin^' ; 
betU-'e supply the [jatient with conipreis^ and bandage, and 
teach her how to use them iti ea^e of ueed, 

Htmorrhuids retjuire, in addition, bixativea to eorreel cim- 
stipahon, cool-water enemas before j^lotjlt*, and the avoidance 
of all sirainioM: efforts. Cold ablutions to the auus*, ibl lowed 
by astringent ointment, ex, j/r.: 

K, r.i- Kalhe, | . _„ 

Vn^r. strauaniii. i *** '^' ^^* 

Sig. — A[>ply to anus, inserting some within the .«phiucter. 

The ungt, j^alhe euni opio (II P,) mny be nt^eil in the same 
way with excellent effect. Snp|)oi^itories, each nnitainiii^ 
iiMlntbrni, ^m, v, ext. belhnhinna, p^r. .ss, glycerine, .qy, are both 
soiithing and laxative, Tlie confts-tion of snlphur is a uikmI 
hixative in thejie i:iises, and, contrary ti> fi»rmer exi>erience, 
alws ha** been found benefieial, a« in the following formula 
by Fonlyce Barker : 



B. Pulv. aloeii soc, ) 

Ext, hyo5*t*yami, 

Pulv. ifiecae*. 
Ft, piL no. XX* 
Sig, — Take one night and morning 



oa 9j; 



gr, v» — M. 



Thrmnhi of tlie vulva or vagina, if sjuiall, may Ih^ left to 
nature for absorption to take place* If large, caut«ing pres- 
sure on mirr^nnidtng part5 ami threatening rupture, the only 
trentraent is free incision and i-areful renioval of the amtained 
clotj^ folltJWed by antif^ptic washing, deardines^s, n^st, !«ty[itie 
applications if nei-cAsary to prevent the rerurrence of future 
or stop ejtisting hcmorrliage. The |m)gno»is in Buch cases is 




NERVOUS DISEASES. 179 

doubtful. In all cases absolute rest should be enjoined to 
avoid the occurrence of embolism. 

DISEASES OF THE BESPIRAT0B7 OBQANS. 

These comprise, chiefly, functional disturbance of the res- 
piratory actSy manifested by two symptoms, viz,, cough and 
dysjmaa. The acute and chronic organic diseases, pneumonia, 
pleurisy, etc., occurring with, but not on account of pregnancy, 
may be excluded from simple functional disturbances by the 
absence of their characteristic i)hysical signs. 

Cough and dyspnaa occur during the early months as ner- 
vous or sympathetic troubles, when they require anodyne and 
palliative remedies, counter-irritation by sinapisms, reflex 
sedatives (notably the bromides), and antispasmodics — vale- 
rian, camphor, morphia, dilute hydrocyanic acid, etc., as in the 
following combination : 

B. Elix. amnion, valerianat., f^ij ; 

Spts. ictheris nitrosi, f^ij ; 

Liq. morph. sulph., f ^ss ; 

Acid, hydrocyanic, dilut, gtt. xij ; 

Aquie camph., ad f ^iij. — M. 

Sig. — Tablesjxwnful every four hours, until relieved. 
In cases of obstinate and |)ersistent cou<^h, ten drops of the 
oil of sandal-wood given with a dessertsjwonful of the emulsio 
amygdalae, three times a day, will sometimes afford relief 

During the later months cough and dyspnoea result from 
the enlarged uterus encroaching upward upon the diaphragm, 
thus interfering with a deep inspiration, hence the breathing 
is shallows frequent^ and unsatisfying. This is most observable 
where the womb is very large, from twins, dropsy of the 
amnion, etc. Treatment by palliatives, as in the sympathetic 
cases, but with little assurance of success until the womb sinks 
down before delivery, when we may anticipate spontaneous 
relief. Laxatives mitigate the suffering. 

NERVOUS DISEASES. 

Exaggerations of the mental and emotional phenomena 
already referred to as signs of pregnancy may o<*cur. They 
lead us to apprehend insanity. The time of their most fre- 
quent occurrence is from the third to the seventh month. 



180 HYiilENE AND PATHOLOGY OF PREGNANCY. 



Tnatmifd cim^isU iu tlie itromoiion of sfecp hy hroriiide** 
iukI chlcn'al hyilmte; laxatives; nio<K'nile txen'i8(% clieuri'ul 
siK-'lety* ami rlumge of scene ; lugetfier with nttenlmu to diet, 
untl tbt pn^MT clige^tiLm a ml u>j<iii>ilutiori of fu<i<]* 

Cliorea.— -C'lioren tlurin^^ [>re.«:uatH'V is rnre* J t owurs oliielly 
in llicijie vvhi> have previous^ly isuliered fr(»ni the tlii*easn'» and 
1 ti( i8t ly i n I iuni \ pii nv. Its* raut<es ( a* 1 iiirti td ly oIik- u re } em 1 iraee 
liereditary |)redis(Kj?^jtiLm» the heart Ir^ioni? of rheumatism 
uiid eoiijsecjijfui embolic j>nx*ej?i*eti ; rina.M«m, fear, sorn»w, 
anxiety* and penpheral st^xuui irntalii>ii. It is apt to \w^\n 
coiycidentiilly with the early fuflal iiajvements. Il W a s^erious 
cx»m]>licatioii, soraetiiiiea ending iu infinity, premature lalM»r, 
fttuK iu about oiie-third of the easea, death. The child is 
ijometiiues atfei'ted with the disease. 

Tn'alnunf, — The hromides and ohloral tn pnnluce sleep and 
le^ijen the movemenlii. Mental ijuieloile ; res-t ; avoidance of 
exi'ilement ; changes of j?4.*eiie and pleasant surroundings, 
ArHcnic* iron, and Ivitter tonics. S<Kliuni salicylate in rheu- 
nuitic cases, Ai* a last resttrt iufluction of jirematnre hd>or or 
abortion. Prior to the latter prtx-eediug moderate digilal 
dilatation of the o6 uteri ii* worthy of trial. 

Sciatica. — l*ain In the jielvi.s t^hooting down the thigh, 
fwmictinu^ accoinpauie*! witb cramp, and tenderness on preft- 
sureover the s<*ialic nerve* are usually due to const i|>at ton and 
pressure of luird fecal accuiriulation. May a 1st) tH*eur from 
uterine displacement — notably retroversion — ami fniin the 
pre~«sure of a large and heavy child, 

Tfratmnit. — Dixativc!* intcrnallyt and large rectal injec- 
titnis ci>ntaining castor oil turpentine, soap, and glycerine, 
until the bowel is completely empty. Sn bsecjuen I ly, glycerine 
guppjsitoriej* and the remedies pn-viously reciunmended for 
constipation (see page 157 ). A di>plaeed uterus niUHt be re- 
(ila*'ed and retained in fxisition (s^^e page ITd*). The ]*ressure 
of n large child can only be njiligaleil by the latert>i»roao 
f»osture, and h>»»s<* clothing, together with antwlvnes. 

Paralysis. — Paralysis (hemiplegia, |«iraplcgia, facial pal^y, 
or paralysis of ihe organs* <»f the sjiecial S4^ns4*8 ) fXH'asionaUy 
cKTurs. 

Determine hy uriimry analyms whether of not the ?ynip- 
tonif* are due to the retention of urea or the presence of some 
other toxic agent iu the bh>od. If so, the main element of 



GENERAL IDIOPATHIC PRURITUS, 181 

treatment will be by incre:ise<l elimination — purgatives, dia- 
phoretics, diuretics, etc. These failing, the question of in- 
ducing premature labor must be considered. 

(General Idiopathic Pruritus. — A distressing and sometimes 
exhausting nervous trouble is a general itching of the skin, 
without any visible lesion or eruption. In very nervous 
women it may lead to abortion. Is apt to be worse at times 
corre8|X)nding to menstrual jxjriods. While difficult of cure, 
it ends with the termination of pregnancy. Palliative reme- 
dies are : inunction with vaseline afler a prolonged soda bath. 
Application of carbolic acid (3J to water, Oj) ; or lin. saponis 
camph., 5v, with chloroform, gj, applieil on cloth. It has l>een 
cured by smoking a cigar. Solutions of chloral, menthol, or 
corrosive sublimate may be tried. Also linseed oil and lime- 
water. 

Apart from this nervous itching without any skin lesion, 
actual herpes may occur (herpes (jestatlonis), and return with 
succeeding pregnancies. Patches with redness, some with large 
bulla;, ap))ear on the buttocks, abdomen, thorax, feet, and 
forearms, together with itching and burning. Affects young 
women more than others. 

Treatment.— Vi^e same palliatives as recommended above 
for nervous pruritus. When eruption l)egins anoint with 
lx)rate<l vaseline or glycerol of starch ; and when eruption is 
fully developed dust the surface with |>owder of bismuth and 
starch, or sUxrch an<l talcum. Baths amtaining starch and 
bran are beneficial. Tonics, laxatives, and diuretics may l)e 
advisable. 

Another skin trouble (pitijriaAis gravidarum, resembling 
pityriasis versicolor) occurring in feeble women, and diagnos- 
ticated from {)igmentary deposits by finding the characteristic 
parasitic fungi in the scales microscopically, can be relieved 
by washing thoroughly with tincture of green soap and ap- 
plying veratrin, grs. x, in alcohol, 5 j. 

Chloasmata: brown patches of pigment U|X)n the cheeks 
and forehead, with darkened rings under the eyes. Are not 
amenable to treatment, but disapi)ear sjwntaneously af\er lal)or. 



CHAPTER TX. 



INTERCURRENT DISEASES OF PREGNANCnf. 



A PREGNANT wimian TUiiy hv nUiu'kM wilh prjeunioinft, 
measles*, small ptix, etc. Such <liseiu^\s, while iu im way tluc 
tt* prejjjuaury^ (K*cur as accitleoUil voiHcidtnees seriously cum* 
plieatiii^ it. The prognosLs and resylta of such cnsc^, with 
regard to the prefroaiicy itHelt', and U> the life or ileatli of the 
mother arnl tletu^s and tlu* rule^ tnr treatment, will here he 
brietly (x^km tiered, without atleiiniting any complete dfseri|v 
iiori of the dim^ase.s thtin^elvt'?^* The aenii:* fcvfi's — niahiritil, 
cfjutinued, and eruptive — eonstitote an iniin^rtant jL'^roii[i of 
the^e d leases first clitiniiiig our attention. They arc it 11 at- 
tended with hitjh trm/iertitHre. ('on tinned hijL^h lenipcratnre 
gerionsly imju^rils the life of the tietui^ and, in eiinsci|neuce, 
the ctjutinuanee of pregnancy. Fietal life h further endan- 
gered hy change.'* in the eoin|KJsition of the nmther's IdiwNl 
ami in the maternal hltMMl-pn^&^nre — the placental <*inHilalion 
ht^ui,' ihert^hy impaired. The child may also be iufceliMl with 
the mother's dist'M.<e, 

Inteniiittent Fever — Ague. — Pre^'naney is not, as wjis onee 
sup|M)setl, a protet^tiou apiinst aj^ne. Not only may the 
mother have it, l«ut alw> tlte rhihl in ytrro, the latter l>eing 
horn with enlarged spleen und olln^r evidt^neci* of the dipi^ano 
in eon^quenee. In many ease*i premaliire lalw^r fjciMij-s ; in 
a Kinall nuTrd>er, ahurtion. The fojttis, if not dead, is often 
feehle and ill-uounsl»cd. 

Trfnimtnf, — Quinine, or ari^4-ni<% ns in canes witliont presj* 
nancy. The fear of f|ninine proditring ahorlinn may he dis- 
misvSt^d ; the disc*a^^ i^ much more to Ix^ feared than the mrdi- 
eine. Winnen iu nulla rial dii^tricts who e8<'a|)e iiL'ue during 
prejrnaney arc lijd»!e to it after delivt*ry. The attacks maybe 
prevented by giving fjuinine durin^j; a few days foUowinjj^ par- 
tiirilion. 

182 



SCARLET FEVER. 



183 



Eelapsing Fever ("Famine Fever" ). — Neiirly all jirfg- 
iiant wrMiK-n uUiickcd with this t'tvcr abort or have prenuiture 
labor. Aburtiori jh iiiosl riininum, unci iHattfinUMl withilnngor 
of great beniorrf nitre. Heniurrhiige Iroiu the iilerus riniy pre- 
cede, and tht^n (^tintrilHite to prodiieis the iiborliou. 

Trratmeni s^houhj Ua esjR'riully tlirectctl to the control of 
this hemorrhage before, dyring, and after delivery. The 
treat me ut of the fever it^^ If should Iw essentially the same as 
in cases not conifilictited with pregnancy, aire being taken to 
control elevation of tem|)eratnre. 

Typhoid and Typhus Fevers. — Tfjftltoid fever dnring 
pregniiney i.n rare. Wbeti it dm^s (KTiir, aliortion or prema- 
ture labor i.s frequent. In tfjphufi lever only ahonl half the 
women ahort. There is less danger of uterine lu'niorrhage in 
tyjjhui? than in ty[)hoid. In both di.seuses the clnld i.*^ liable 
to be feeble, or dead, or it may die with symptom!^ of the 
niother*s fever witliin a tew days. The control of uterine 
hemorrhage and of high tenn>eratnrc const it ntes the aprcial 
element ai* trfaimrtil^ besides the n-inediescomnioldy achlreitsed 
to these fever.s when urironiplicatcd with gei^tation. The prog- 
no^is^ a8 to the mothers life^ i& grave, but the majority 
re<i»ver. 

Yellow Fever. — This is a most dangerons conTpliration 
of pregnancy ; not less than two-thirds uf I he women *}ie. 
Pregnancy artbrds no imniynity from the disease, and partu- 
rition imTcasej* the liability as well as the danger. AiM>rtiou 
and Cfmserjuent hemorrhage, snppreA^ioQ of nrine, and uramiia 
are the chief cause^s of uiorlality. In cases that recover^ and 
without miscarriaire, it is said iminnnity from the diseasi* is 
conferred npai the oHs[)rinLr. During the jirevalence of yellow 
fever, pregnant women should lie protected fnan the bites of 
mos<piitoes, eillier liy gauze screens, etc., ftr by nntntiling 
exfHKsed [uirtsof the body with spirit of camphor, oil ofpenny- 
royab etc. 

Scarlet Fever.— This is more liable to otTiir during the 
puerperal state than during |>regnancy, when it is com|>ara- 
tively rare. Both *M»nditions add irreatly to the ntortality of 
the fliHease. Kreai liability to abortion or premature delivery 
— liability varies in difierent e]>idemics, owing, pndiably, to 
the varying tyjK^ of the prevailing disease. Lyingdn women 
expused to st*urlatinal infection develop a niodifieil form of 



184 INTERCURREST DISEASES OF PREONAycr. 



pUiT|MTal fevfT, atteinltHl with pritnnitis, (Tllulitis^. ainl ^rreat 
riiort^iiity, **alltMl ** FuiTjH^rMl S'lirliitina," I>urijj^ |)n'LniaiK*y 
searluliiia is a gravt.^ tvmqjitialiiiii, hn\h Iroin aJnirtiuii ami 
from the kidiiin' irouhle t>t" the lexer aihliug to the albumiii- 
uriu and reDal lrou]>le of gi^tntion* ^^[MA^ially hi primi|>ara*. 
Ill some cases [jreernanry conihiut's, hcith mothir an*] v\uU[ 
Tvi'i\vering without i oj u r\\ Chi h I n^ii are soineti me^ hi >rn v\ it h 
de.s(|tianjaU(jn of the cuticle and other evidences of having hail 
the ilLsetL^e in utfro, 

Tn:atmrnt. — The aarnc a.s for j^carlet fever in the noii*j,^rfivi<l. 
As u nile^ pregnancy ^honhl not be artificially terminaleiJ ex- 
cept perhaps in had ciises of allnnnninria an<l unemia, Snne 
ol>fftetricians advisi^ it to save a viable clnld, when themotliers 
life is in ^rrfat jiMipardy. 

Heofiles ( Eubeola ), — Very rare dnrin;? pregnancy. 
Liability to abortion. The child may be bt>rn bearing the 
eruption of measles, or *ievelnp the disea?^ i^fiortly atter birth. 
Its ileath in utero is supposed Ut be (he chief V(in^'*e of the 
alwirtion. Danger (»f metrorrhagia (if abortinu occur i, which 
tnay be fatal to htjth child ami [laretit, liubeola during the 
pner|ieral state is frequently ctinvplicate<l with pneumonia — ^a 
complicaliim of rtmsiderahle ihniger. 

Smallpox (Variola). — Con fluent small|M>x nearly always 
eaust*s aljortion or [iremature delivery, Jiml is nearly always 
fatal to the mother, the danger niiTcasnig with the advance 
of pregnancy. 

In dincntf' smalljKix also alwrtion is very Irequenti but le4«8 
so tfian in the cniiflneiit variety, and the mother usually re- 
covens The child may l>e lM)rn wilh or without the disease, 
ftfnl, in si»nic casc/s, with pits i>r scars indicating \U having 
paaHcd tlirongh it. Exceptionally, the child may have smafb 
pox and (he mother not have it- In twins, one chdd may 
have it and the other escap*. 

Almrtion is liable to Im* attended with profuse hemorrhage. 
As a rule, th«* child, whether viable or not, is l>orn tlead. A 
Verj' few survive. 

Every pregnant woman ex|^>sed lo variola shoyld W vat^ 
cinated, unless protecte<l by [»reviims %'accitmlion of recent 
date, A re(*enHy delivered \\omini, as a rule^ should not be 
vaccinated : though it may be justifiable under circumstances 
of great exposure to a very virulent cfmtagion. As a rule, 



TUBERCULAR PHTHISIS, 185 

it will be advisable to vaccinate the child unless it exhibit 
evidences of variola. While in some cases the child appears 
to be protected by the mother having had sma]l[X)x during 
pregnancy, there is no certainty of this protection. 

Varioloid during pregnancy involves only slight danger. 

Cholera. — Liability to this disease the same during preg- 
nancy as without it. Mortality greater as pregnancy is ad- 
vanced. Alx)rtion or premature labor is frequent, and may 
even occur after the woman survives the attack. Many die 
before the womb empties itself. Mild cases may recover 
without abortion. The child dies from asphyxia, or cholera 
infection, or from pathological changes in the uterine mucous 
membrane, chorial villi, and placenta. The clinical history 
is the same as in cases without pregnancy ; so is the treatment 
The induction of premature labor — formerly recommended — 
is not advisable. If labor occur, judicious means to hasten 
it are admissible. 

Pneumonia. — Acute pneumonia during pregnancy is rare. 
When it does occur the danger to both mother and child is 
very great, and increases with the advance of pregnancy. 
During the last three months about half the women die ; 
whereas, if the disease occur during the first six months, only 
one in five or six dies. Abortion or premature labor often 
occur, and more oflen in proportion as the pregnancy is ad- 
vanced. This greatly adds to the danger. In some castas, 
even of extensive pneumonia, the pregnancy may continue, 
and both mother and child survive. 

The death of the moth(T is usually ascribed to cardiac 
failure, sometimes asso<nat(?(l with hydriemia and pulmonary 
oedema. The child dies from high temperature, deficient 
oxygenation of the blood, and imperfect blood-supply to the 
placenta,. 

Treatment, — Prevent the occurrence of abortion or prema- 
ture labor, if possible. When labor comes on, it should be 
ha.stened by all prudent means, as in ordinary cases ; in ad- 
vanced pregnancy, by forceps, etc. The general treatment 
must he directed to strengthening the waning heart, viz. : 
brandy, ammonium carbonate, <ligitalis, and beef essence, with 
quinine to reduce the temperature. 

Tubercular Phthisis. — The cases in which pregnancy 
seems to retard the progress of phthisis, or prevent it« inva- 



im IMERCUEREyr DISEASES OF rKEGSANCV, 



8100, are extremely few; tluj^e jd which it pret'ijiilales tiie 
diijieime wucl hti.<t'r»rt it?^ pn>gresffi to a flital teriiiiiKiti*»iJ are 
many- The |mer|>t'rMl ^tiile aiuJ Jiictntiyn .still fiirUKT fjivor 
ihe devi'l*pj)iiieiJt and pro<rrt\s8 nt' plithisii* iij iiitwt aLsc^s- A lior- 
tioti and [irematyre lahiir are not c<miiiioii, uiili'ss tla MMiinan's 
ccmditioii he t^xtreiiie and ehr h HyUtihrmg fVurii delk-ieiit at*ra- 
tioii of the hi<wjd, wfieii ])reniuture delivery may oeeur. The 
sul*jeets of advaueed }>hthii*i!* are nut apt to he<ijn]e pregnJint ; 
they usually have nnit'tiorrha^a, as well as lenei^rrhjeji, and 
prohiildy do not ovulate. In the earlier stag<L'8 of phthisis 
eonroption is n<»t iiiterfenH] with. The ebildreti of phthi^ieal 
nintliers are nt^iuilly >*niall iu sixe, but do not nL^'etsHjirily 
pre.M*nt any niauitl-st evidt^iiee of ilt^feetivi* dt'velopnietjt ; 
they are predisposed to the <lisea,<e, n^ well as to tnhereular 
|>erito!ntis, meningitis, ete. Tlie plaeenia is liable to he af- 
ieeled with ealeareniis de^reneralion in tnhereuhiu.* women. 

TreatmciiL — When labor rome:^ on, early a.s8it*tanee ghoidd 
l>e rendered by tbree|^ Xm fores?tall any tnereaw of pre-ttx»gl- 
m^ I *ro.<?t ration. The mother should not be allowed ti^ imrse 
the eliihl for the 8ame reason, at? well t\^ for the additional one 
that lier milk would not he projier tor it, A uet-nursi' or 
artitieial fiHKl must l»e <*btatned f tr the infant. Women jire- 
iIi»|K)8€Ml to phihitiis 8hou!d he jul vised not to nnirry, as well 
for their own sake at^ ibr that o^ their |)ro^etiy» who may in- 
herit the disease, and that of their husbands, who may cou- 
imet it hy iideetiou. 

Heart Disease. — The heart during prejrnancy un^lergoes 
a physioloi^ical erolufioit, ehietly consisting t>f hyj>ertrophy f>f 
the lefV ventricle, tlruii enablhig the orji^au to ]K^rform the 
extra work which preirnaney requires. After lalMjr, i it volution 
oceurs, the orpin returtiiuji^ to I he eondition in whirh it waj^ 
before eoneeplion. When to these* pliy?iolo;::ieiil eliaiiL'e^ i^f 
evolulion and involution are added the valvular lesions of 
dijtemse, it tHmgtitutes a serious and daiij^erous iH>mplieation, 
Mttftt of 8ueh eaM^-** are those of ehronic valvular disease re- 
gidlinj^ from rheumatie endi^canbtis. Acute end<»e4irditls may 
however, net iu during; pretaianey. or an old latent case may 
l>eeome aeute from ihe vi«denl strain imposed upon the valves 
during the exertion of lalnir. Acute perieurditiH is extremely 
rare dnriuj: pregnancy, and in the few oli^ervt^d eajj^e^* pretr- 
nancy was not iuti^rfered with. 



HEART DISEASE. 187 

Valvular disease, both during pregnancy and labor, may 
not produce any serious or unpleasant symptoms, if compen- 
sative contractile power in the muscular walls of the heart be 
sufficient to carry on the circulation, despite the valvular ob- 
struction and regurgitation. 

But if this ecmipetisatioiifailj or become partially inadequate, 
a more serious condition at once arises. Local congestions, 
especially of the lungs, occur, with the following symptoms : 
dyspnoea (increased by exertion), precordial distress or actual 
pain, palpitation, frequency of i)ul8e, and hemorrhage from 
the lungs, nose, stomach, etc. These symptoms, beginning 
moderately, increase, and may go on to distressing cyanosis 
with oedema, general anasarca, dro|)sy of the serous cavities, 
together with liver and kidney disease from congestion of 
these organs. The foetus may die from impaired nutrition, or 
from deficient oxygenation of the mother s blood, or from the 
mother's hemorrhages. 

Mitral stenosis is the worst ; mitral regurgitation is not so 
serious, especially if existing alone. Aortic lesions are more 
rare, and perhaps occupy an intermediate position, as to 
gravity, between mitral stenosis and the less dangerous niitnil 
regurgitation cases. Combinations of mitral and aortic lesions 
are worst of all. 

Treatment, — Whether a woman with cardiac disease should 
be advised not to marry will depend upon the lesion or lesions, 
and upon the degree of compensation. (See preceding para- 
graph. ) With proper care, a good many can l)e carried suc- 
cessfully through pregnancy and labor. In bad cases, with 
already existing symptoms of inadequate com|)ensation, preg- 
nancy should be avoided. 

Besides hygienic treatment — regulation of f(X)d, air, warmth, 
rest, baths, exercise, laxatives, and the like — the main point 
is to strengthen the heart-action by digitalis, strophanthus, 
and strychnia when symptoms of inadequate compensation 
arise. Epsom salt and calomel may be used as laxatives on 
occasion. If symptoms grow worse in spite of treatment, induce 
premature lal)or. 

During lal)or, spare the woman from bearing-<lown muscu- 
lar efforts as much as possible. Hasten delivery by forcejis 
or version when the os uteri is sufficiently dilated. When 
not, and hjiste is imjK^rative, incise the os or use Bossi's dilator. 



188 INTEMCUnRENT DISEASES OF pnEGNANCV 



Chlorotorni ouiliously for aii:f!*l1jesia» A i^pi^eial iluii^or occurs 
just ftjhr tlit^ v\nhl m rx[H^lk'(L Ovvitiiji iisi it would sceiu, to 
tlit^ sudiltMi reduction of hliKid i'irruIjitinjL: tbrtniL'-h tlu? uterus, 
more bli^iHl is ihrouii bitck ijjHUi (lieeirculiitiun juid the heart, 
aud ail the syuiptuins are iucreated and heartdailure a[:i|H^ars 
immiDent, Tlut* is i^ometiuieH iialuniUy ftirtistalleti by a mud- 
i^nxXv p»Btj)artuin heniorrha^^e, which if only iiiodemte should 
itfd lie ^^to[)j)cd by er^^of, uiassage, etc., lad actually encouraged. 
If no such salutar}' heinorrluige take place» aud the endnirraas- 
ineut of tlie licart be tlireatjeninij, receut ex|>erieiice prov*^ 
that relief may be oblaiued, and pcrhajiu'? life stived, hy the 
removal of halt'a pint fo a j»iut of blood liy vene?^^ctiou ( Hii'st). 

The cardiac tonics nui^t f>c c<»ntinycd, both tluring and for 
8<inje days or wi'cks alter lalror. Be.'^ide*J tho^jc already men- 
tioned, nitroglycerine may be pivcn, and for the relief of 
dyspruca nitrite of amy I h es]K^*ially etfeclive. 

Graves* Disease ( Exophthaliiiic Goitre). — Ct raven' diseai*e 
nuiy originate during jiregoaiKv mid disap|)car afterward ; but 
if previously exi?iting it m made won^* by ge.«tati»m, with a 
tendency to uterine hemorrhage and liability to foetal death. 
Goitre without exophtlialmo:^ is tilm increa.seil by pre|rnancy. 
and may ]utNinee Huiticicnt dyiipntea to require relief by 
tracheotomy. There is no Kpt^*ia]ly ^lifTerent (rcattneut for 
thcMc d incases than that cnijilciycd in the non-gravid state. 

Jaundice, Hepatic Toxsmia, Acute Yellow Atrophy of the 
Liver. — .laundiev <»cca!^ionally *k'ciji'» in pregnancy fromexttii- 
sion of catarrhal inihirnmatiou from the dmMJenum into the 
bile duct*<. It usually dL*<np|)ears 8jxjntaueou>^]y (^r atler a 
nilomel or e^aliiie purge. Every ca^e^ however, becoineH of 
serious interci^t, innsnuich as it may lie the beginning of acute 
yellow atrophy of the livcr^ — an nlnH>8t unifomdy filial dis- 
ense, which, tluHjgh rare, is Hjx^ciiilly liable to occur in preg- 
nant women. But little is knrvwn of jt.s pathology except that 
the liver undergoes a remarkably rapid atrojdiy. The suc- 
f^espive symptoms are : jaumiice, vomiting, anorexia, furred 
tongue, pain in and tendcrneiis over the liver. Hemorrhage 
from the stomach ("black vomit*') or Ironi the bowels. (Vm- 
slipation or diarrhoea. The?*** jjymptoms are stion followed hy 
pronounced nervous nymptoms due to toxaemia ; vix,, delirium, 
^tU|Kir, inctmtincnce c»f urine and ftece^ convulsions, coma, and, 
usually within a week, deatL 



LIVER DISEASE AS A CAUSE OF ECLAMPSIA. 189 

The urine is dark, contaius blood and albumen, while its 
urea, uric acid, chlorides, sulphates, and phosphates are dimin- 
ished. On standing, leucin and tyrosin form in it There 
is no treatment other than attempted elimination by the skin, 
bowels, and kidneys of the pervading toxins. Rectal and sub- 
cutaneous injections of normal sjilt solution have been recom- 
mended. Miscarriage or premature labor may occur, but 
with no good result. 

Liver Disease as a Cause of Eclampsia. — In the livers of 
those who die from eclam))sia, there are nearly always found 
areas of neeroda in the liver-cells, and thrombi in the portal 
bloodvessels. Some of these vessels rupture either in the sub- 
stance of the liver, or just beneath its capsule, producing 
hematomata. The necrotic areas, thrombotic processes, and 
blood extravasations may be microscopic in size, but some- 
times visible to the naked eye. These findings suggest that 
the toxaemia producing eclampsia is due to impaired liver 
function — to a hepato-toxceniia — rather than to a renal toxcemm. 

But there is no proof that these liver lesions precede the 
eclamptic paroxysm : hence they may l)e an effect of the con- 
vulsion rather than its cause. During the spasms, the whole 
venous system is engorged, sometimes to bursting, as in the 
brain. Lesions resembling those in the liver have been found 
in the pancreas. 

The blood in the |)ortal vein and its branches has no heart 
impulse to force it along: its circulation depends entirely upon 
the muscular movements of the abdominal walls and dia- 
phragm in respiration. When these rei*piratory muscles are 
fixed by rigid spasm, partial or complete stasis of the |X)rtal 
blood seems inevitable. Toxic blood soon clots when at rest 
Hence thrombi and necrosis of cell-areas, whose blood supply 
is thus cut off. Some of the distended vessels burst, hence 
hematomata. Thus the findings in the liver may l)e ex{)lained 
as an effect of the eclamptic seizures. 

Defective liver function must, however, be recognized as a 
possible contributive factor in the production of toxjcmia lead- 
ing to eclampsia. 

Treatment. — There is no s|)ecial treatment fi)r a hepato- 
toxajraia other than the eliminative treatment used in ura?mia 
(9. r.). 



CHAPTER X. 

ABf)RTION AND PKEMATTRE LABOR 



adi 



jf the fa'his f»ejfi 



Utble 



Abortion m itt»Jivery oi me la^nis iMjfirr it i,s ruiMe — t, 
helore the end <>f llie Ivveiily-ei^^hth week. Between this 
time aii<l full term, disclianj-e of ilie ovum ij* ealleti ''pre- 
matfire /a //or." No other division of tin* sniyeet is iieeejii^Hrv, 
thoutrh muw writers limit the term *Utftortunt'' to disehar^e 
of tlie ovnin tluHnu: the first twelve weeki? ; if it tMTur be- 
tween the iweltTh and twenty-eiglith week, ihey call it **MtM- 
mrrlmje/' Hie symfitoms, however, diHer soruewlmt during 
tbe first three months from those of the Fueeoediui^ four* as 
does also the treatment. Exceptionally the ehihl is vialile 
before the twenty-eighth week, even a montli or two earlier. 
Such emeu are rare. 

During the first three or four niontliH the fcuttis and mem- 
branes are often diseluir^'^ed in thc^ unhroken i^ae ; after then, 
when the phieenta i^ more fully formed, it is iij^ually for the 
ftetUH to e«trae first, the placenta and niend»raues atlerward. 

Frequency. — Alxmt one out of every five * pregnaneies ends 
in abortion, and ninety percent, of ehildbearmg women abort 
onee or more during tlieir lives. 

Causes, — T\w pndUi urn ttg ea uses nmy refer to either mollu'r, 
father, or ehild. 

A tlead fielus? is generally exfK^llcHi without much delay. 
IIjs ileattt may l>e due to disease of the placenta or mend^ranes, 
or obstruction in the undiilieal eorri, or external injury, or 
deficient nutrition tVoni a variety of circumstances or hdieriteil 
syphilis, or nuneral and other pois<»ng derived fr*im the mother, 
or from t he eruptive fevers, H igh temperature on t he pa rt of the 

» In fr>rm«r editions i»f HiIb wctrk llw ftiniuoncy w«s stfitcd to be one out of 
tvelvf prefrnnrirli'*!. It i^ firotmhte th** frwjinsiim' is cotitintmUy Jtii n^iislnjE with 
the ndirti'iiil hikbftA nf rlvMlPitlon iiml th« dttmiUoii of kAowkHlg« «• to meth- 
CHID of hiductnv Aliortictii among ttie Ulty. 



PERIOD OF OCCURRENCE, 191 

mother soon kills the child. When the mother's temperature 
reaches 106^ it is always fatal to the foetus, and a rise to 104*^ 
is dangerous, the danger being greater when the rise is sudden 
instead of gradual. The temperature of the foetus is a degree 
higher than that of the mother. 

On the part of the mother, constitutional syphilis is a potent 
cause. The occurrence of acute inflammation of the thoracic 
or abdominal viscera ; the exanthematous fevers ; plethora ; 
ansemia ; albuminuria ; excessive vomiting ; constipation ; pla- 
centa prsevia ; diseases and displacements of the uterus, espe- 
cially retroflexion and retroversion ; multiple pregnancy ; 
chronic lead-poisoning ; chronic ergotism from eating bread 
made of spurred rye ; the precocious or very late occurrence 
of pregnancy ; the "abortion habit" — this last, if it have any 
real existence, usually means chronic metritis^ uterine displace- 
menty or some other disease which produces recurrence of the 
abortion. 

On the part of the father, precocity, senility, syphilis, de- 
bauchery, and debility may lead to it. 

Exciting Causes, — Mechanical violenccy as blows, falls, violent 
exertion, the concussion of railroad accidents, excessive veuery, 
sea-bathing, irritation of the mammse, tooth-pulling, etc. ; or 
emotional violence, as excessive fear, joy, grief, anxiety, anger, 
etc. 

Many abortions no doubt occur from the wilful administra- 
tion of drastic emmenagogue medicines and from intentional 
disturbance of the ovum with instruments. 

The above causes act, for the most part, in one of two ways, 
either by producing death of the foetus or by inducing uterine 
contraction. 

The most decided exciting causes are often strangely inert 
in the absence of any predisposing ones. In some women 
with an apparently "irritable uterus" very slight exciting 
causes will bring on uterine contraction ; in others all sorts of 
injuries and surgical operations — even cceliotomy, removal of 
ovarian tumors, removal of fibroid tumors from the uterus 
itself, and amputation at the hip-joint may sometimes be done 
without any disturbance of the uterus or ovum. 

Period of Qccurrence. — It occurs most frequently during 
the second and third months, though, quite possibly, many 
abortions during the first month are never recognized. 



192 



ABORTION AND PREMATURE LA BOIL 



Symptoms. — Pain, iiUermittent iu clmrncter, and due to 
uUTiiie amtractioiiis — in reality* mmiuture lahor-palns ; and 
fwmorrhagt, due to |mrlJal separation of the ovum from x\m 
uterine wall. 

Chiiline^, nervousness, anorexia, ejimti, flighty pains in the 
Irack and ahdoinen, frequent micturition, and a mucuyR i>r 
wntiL^ry dii*i har);e, may oecur and continue i^ome days liefore 
** labor-pain« " and hieeding, but they are not cottimon until 
aller the third month. 

When the unliroken meriil>ranes with their contents are 
expelled entire (like a '* soft-? helled eg^")» which i& most 
likely to ha]j|>en during the first three months, the hemorrlia^^e 
may he tndy moderate; bnt when tiie hsu^ hur?:tH iind 4'olhii>^es 
ai%er disseharj^e of the fetus and liquor amnii, bleeding is 
usually more profuse. In these latter cfLse» the blee^lirifi^ and 
pains may eeuse for hours, duy.s, or even weeks, but if the 
[daeentii or membrane he retained* these jsyniptomK are sure to 
return sooner or later; and in ease the retained i^ecnndinea 
decompose there will he added a pntres<*ent odor of the dis- 
charge-, and, likely enough, a severe chill, tever. vomiting, 
general depression, and all the other symptoms of se[>tic 
infeetiou. 

Diagnosis. — Pains and bleeding having o<x*urre<], the diag* 
nosis is rendered |K>silive by vagimil examination revealing 
partial or complete dilatation of iIkmib nten, and presentation 
in it of the bag of waters, nndaliral cord» or body, of tlie 
foetus. Examine afi discharges, jireferably under water, for 
truces of mendiranes, foetus, arid elkorial villi, otherwise abor- 
tion may (X'cur without re<*oguilion. Should doubt arise from 
dis«*barges having been tlirown awny, unexaiiiine<l» it may Ije 
stiitefl as a general rnlr that if the vsond) have completely 
emptieii itself, the Hymjitoms will snbsi<le ; if otherwise, they 
will eoTilinue, or remir after a |K>Hsible remission. 

lHatjh*mA of AhtniioH from Hetuminri Menstrnation. — 
In Uienstruatioii bleeding generally relieves the pain; not so 
in abortion ; menstruatiou occurs at the [x^rirwl : abortion not 
Oaei^ssarily so. In abortion there may he a hit*ti)ry of violence 
or Nmie *»ther cause for the symptrans, and the early signs of 
[iregnancy will have a]>|>eare<L Sh(mld thgitiil examination 
nut afford s<nlhcienl evi(]ence to elesir up doubt, a jiomttw 
diagnf>sis may l>e im]H>ssihle until the os uteri liave sufhcieiilly 



DLiaNOSlS. 



193 



filiated to a<lmit tlie fiii^er-eufl, or until a part of the ovum 
hiij^ been expelled ami recxigiiiJietl 

Diaijnosiif of iHevliithle from Prevrniable Abartion, — Per* 
sisteut uQil profuse beiiiorrhage, frequency and ijeverity of the 
pains ; eou^iderabli^ ili lata Lion of the <j« uteri, which rapidly 
pro*j^re^es, an a rnle^ indicate that the almrtiou cauuut lie pre- 
vented ; but excepri<ius may occur. If the fieluis W dead» or 
the membranes l)roken, the almrtion become.'* still more inevi- 
table ; but it is not in al! ca&e^s to l^e s^ure on tbe^n^ two jxjiuts, 
and vtTtf exceptional cai3**.s i^ccur in which a dead fa*tUH is 
retained for montfia and year.s. A pregnancy baa even been 
known to continue after the niendtnined have been punctured^ 
and after pieces of thcdeiidua have l)een discharged^ following 
the intro<luction of the ut+rine ^*iirjd. Most cases follow the 
general rule Hrst above stated. 

DiaguQgU of IncomplrU: Abortion. — In cai*es where the 
diachargeji have not been carefully examined, or have l>eeD 
thrown away wit boot examiuaM<*n, and in which demonstra- 
tion that the entire ovum bat^ been exptdled ia in this way im- 
pissihle, the oidy sure method of diagnosis is to pass a tiiiger 
into the uterus and feel whether {portions of the placenta and 
membrujies* Htill remain, 

DiagnoMA of Vompfetr httt Conrealed Abortion. — This 18 
very ditticult It de|R*nds clnetly u[X)n the biston," of signs 
an<l !«ymptoras indicating prej^nuncy and abortion ; and u|>on 
the recognition of an enlarged uterus growing smaller by 
involutiott, the hn hial discharge, and sometimes the apjieiir- 
aut^ of milk in the breasts. 

Diagnosis of Ftrtnl Dctitk — The ftigns of fmfal death 
are btnguor, low spirits, pallor, chilliness, ^ierha|>s s<:»me fever» 
sunken eye« surrounded by darkened rims, nausea, anorexia, 
fetid breiith, and had timte in the mouth ; a feeling of weight, 
discomfort, an*! cohlnej<s in tbe hypigastrium ; flabhincsa, 
with stationary or diminisJied size of abdtimen, with l^m of 
it^s normal firmness and elasticity; the uterus rolling more 
easily from side to fti<!e ; flaccidity and diminished size of 
breasL**, wnth the a[>tiearance of milk in them/ These 8ym|> 
ti>ms may not come «m until mme time after fietjil de«tb. They 
may also be produced by other causes. The <xH'urrence of 
several is necessary for diagnosis, wlncb last, even then, may 
not be positive. Fetid dim-harges per vagtnnm, with or with- 

13 



194 



ABORTION AM) PKEMATUKE LABOR. 



out exfoliate*! epiileriiiis, nre mf»re reiialile. The ilt'tedion 
(jf aeet<me in tlu^ inuther's? UT\m% us? a Bigii uf iirtal death has 



prov 



ftl to l»e unreliable. 



Wlieii there is time t'i>r deliiy \\\v, best available nigti of the 
f«etus behig alive is coutimious etilargeiueiit of the uterus , 
when tlie fiEtus is ileatl the uterus censer to grow, nn*l may 
(leerease in size. The eoiuUtiou is revealed by the binumual 
exaiuiuatiou^ rej>ealed at iutervids of one or two weeks. In 
bydatiditbrni preguaueii^, hnwiver, the Wiuub may grow, eveu 
rajiidly, wheu tlie fa4Uis bus died. Fiually, while the child 
live^, the te»i[K.*ratare of the tdvna^ (as tested by a tlierujoni* 
eler in the cervix ) will be one or two dej^'ree^ higher thau 
that of the vagina; if it be uni s**, the ehild la most prob- 
ably tkad. Wheu |>reguauey has suffieiinilly ailvuueedj the 
al>seuee or cessation of previously reeoguiited beart-sounds 
auii lietal niovemeuti^ is iuijMjrtaut. ( Fur sigus of ftetul deittii 
during lalHir, at or near full term» see Chapter XXIL) 

Prognosifi, — ^Abortious ol\eu eousume ujore tiuie thau fulb 
term lubors, owiug to the long uud tiiirnnv cervix uteri, and, 
as yet, im|x^rfei't devch>|)uieut of the uterine muscles. The 
Srccuiulines are often retaiut'd hours or days after ibs+harge of 
the tcetuti. With jiro|)er treatment alu^rtion is sehlom fatal ; 
it is le,*5s dautrerous than full-term delivery, as reganJs the 
chances for life, but it is far more likely to leave chronic 
ult^rine fbst^ase and great debility frtun lieniorrbage. 

The <'bief <laugers are hemorrhage aud sej)tietemia iVom 
re tain e« I sec u nd i n es. 

Treatment, — The treatment of alK>rlion will differ much 
according ns we design to jireveut, or »>n the otticr hand, 
htL^ten delivery. 

If I he hemorrhage he only slight in degree, and the pains 
fetible, if the os uteri be not much dilateil, aiitl the mem- 
bnuie*5 not broken, we strive to continue the pregnancy; if 
opi^isite c<tnditions prevail, we cannot do so, but nuist hasten 
delivery to put the womau in safety. 

Should the ftetus he deatl* the uterus mugl, of eaurset he 
emptieii 

Treat mcjit to Prevent a Threatened Abortion when the Smp- 
ItmiH are SlujhL — Absolute rest in the re<'urnbeiit |K»sture in a 
ecM^L dark nxnn, with light bed<»lothing. Mental and emotional 
qujai. Cofdiug driuk», avoidance* <if all stimulants. Opium 



TREA TMENT, 



196 



(preferai»ly the lirj. opii RHlativu^ ^i\. xx-xxx) to arreM 
uterine coo tract ion ijinl check tieiiiorrb!i«^e ; or a sin»|Hisiti>ry 
of niorpiiia; the o|iiate to li^ re|H'ateil every two houi^« or 
as olteu ai* may l>e iiecej^sary to stop the pain.^, Hy< Irate of 
chloral ami the j^otasj^ic l^roaiiile miiy he usetj instead of 
opium. tJ. W lilt rid tj^e Williains reeonunentit* tlie following 
rectal suppositoriea to \w repeatetl every lour or six hours: 

E. t'tMlei:e siiljiluit,, gr. se ; 

Ext, hyo^yaioi, gr. j ; 

Ext. viliurni prunifolii, gr. v ; 

Oh iheobroinas q. s.- — M. 

Playfair preferred chkiroilyQe in teu-miinm dtxses every 
three or tour hour^t. 

Mild luxativei* (mlines, castor oil, or simple enenmta of 
warm water ) shou hi he used to cjvercoDie constipation produced 
by the opiates* Never use er^rot or the tamjxin ; and the 
application of cohl clotlis to prevent hcmorrha^a' is of doulit- 
ful utility ; it rather aii;j-njeot?i uterine eontniction. The 
viburnnm jtrnuijoliitm (fid. ext., .•^\ or golid ext., gr* iv» in 
jnll every two or three hours) is alleged to be a valuabh^ 
preventive of aViortion ; it rjuiets uterine contraction. Evi- 
dence in favor of it5 utility is increasing. 

Kemove any known nuisc of the synifjtoms and restore \\y 
|XJsture and gentle manipuhition any existing uterine dis- 
placement, especially retroversion or retroflexion. 

Eiforts to })rcvei}t idiortiou mnst, of course, cease after the 
ffrtus is dettii^ but of this last event there is, during the first 
three months, no unt*<fni vocal sign. Reduction in the size of 
the uterus, or its snuiUness when Cf^mpared witli tlie known 
duration of the pregnancy, is f>erhaps of raost diagnostic value 
in this respect. (Bee |)age 193. ) 

Tt'tatmeui when thf Abotiion is hteritahlf^^ — ljei it he pre^ 
niised ihot in all manipulations and oj^erative nu'iisures — 
whether digital or instrumental— res^trt cd to in abortion cases, 
the same rigifi asepfle ferhnifjue must be observed m m full- 
term labors or surgical operations. 

The external genitals, the vagina, tlie bauds of the oj^rator, 
and his rubber gloves and iustruments must he made asep- 
tically clean. (For particulars aa to antiseptics, see Lidjor, 
Chapter XII., page 241.) 



M 



VJQ 



ABORTIOy AM> PIUatATrilK LABOR. 



In must CfiiK^t* of ahurtioii delivery may he \ofi tu romplete 
Itself liy the until nil jjtnvers. This is e.*i|M?t!ially true of cases 
oceurriii«^ tluritig the tiret two luoiith?^ uf pre^^uaury, Inter- 
fereuce may l»e rajiiired iu these, aud later eaise^^ ou actM>uut 
of €xceHi*itr hemon'hmje. Thii* may alv\ays lie t^nrefy arres^ted 
by the vagiuul taui|>ou properly a|iplie(I. The taui|M>u also 
Mimulutes uterine contmvUon ami proumtes corui)lete 8<^pa ra- 
tion of ihe ovum from the uterus by cimi^iuii effused hhwHl to 
back uj) and aecumulute l>et\veeu the worub and fo'tal meni- 
hm»e». The tampon ii^a vairiual pluij» nmsititing, preteraldy, 
of iodoform >,'auze — sitripr^ two (»r three luebes wide and a» 
many yardn hui^ as may lie ri(*tH^ssary — wbirb is to lie paeked 
lighiltf, tifi^t into the cervix uteri (with rare not to ruj^ture 
the amniotic sac), theti into the va^iiud forniees arouml the 
cervix, and so ou down until the whole vagina is completely 
tilied to the vulva ; over this Ijist ao antiseptic pad. eovere*i 
by a biinda^tre, keeps the tam[Km from beiu|Lr exjKdle<Ll. To 
apply the tampon etfetttoally, a Sims s|>eeubim ia used to ex- 
pose the cervix ami va^dnal nMif the instrument iK-ing 
gradually withdrawn ns the tampon successively fills the 
upper aud lower |>art^ of the vaginal canaU A lon^r curved 
i-lrtjasiiii^ foree[)s is to be used iu placing the tampm. Other 
kinds of antiseptie ^auze may be use<l, and in eaiies of necessity 
almost any j?terilixeil and antiseptie textural fabric may be 
subistituteil for the iodoform material. The tamjxni may re- 
main twelve or even twenty dour hours. The most desirable 
result, which usually wcurs wtlhin this tlme^ is expulsion of 
the unbroken embryonic sac from the uterus into the vaL'ina, 
whence it is easily extraetetl when I he tampju is removed. 
The bladder should have been emptitnl when the tamjxm was 
ajiplied, and care anist l»e lakcn that the retention of urine 
\a not produce! I by pressure of the gauze agaiDSt the urethra, 
when a catheter may lie ne<*e8smry. 

Should the patient have a sudden relief from |>ain while 
the tampm is iu place* it may lie biferr*'*! that the uterus has 
emptied itself and then the ^^auze may be removed witln>ut 
delay. Fluid extract of ergot ^ss, every 4 htnirs, should be 
given w^hile the tam|x)u is in place, to coutraet the uterus arid 
BMmf^t expulaion of its conteut.s. 

Whenever the <is and cervix uteri are stulficieully dilatefl to 
admit otie or two fingerSt the whole contenti of the uterus 



TREATMENT. 



197 



fshiiuld he at once scooped aud scraj^ed out by digital nianip- 
ulutiou ; or ]>v a dull curette* the finger beiug usually pref- 
erable and certaiDly more safe. lu using the Hoger^ the 
patient must l)e aiiii-^thetizcd, the haud (greased with aseptic 
vaseliwe) passed iuto the vagina while the other hand niakea 
counter pressure on the ah<]oruen over the fundus uteri. The 
finger iu the uterus will l)e able to dialudgt* the foitus and 
plaeeBta, and to ascertain |Hj.«itively that no fragmeuts of the 
latter are left behind » which hist cannot po surely he doae 
with the curette. It is not uei^e^ary to remove the entire 
decidua vera ; ailer the fietal nrendiranes and pliu-enla are 
renmved, reninantis of the decidua may be letl to come away 
of themselveii. 

Finally* the uterine cavity mual be irrigated with a mild 
bichloride solution (1 to 4000); this to be followed liy sterile 
water or normal salt solution — these solutions being of course 
warm (100^ F. j, or hot (n0°-115° R) if necessary to 
stop bleeding. 

When the uterus is to be emptied l>y the curfif^ instead of 
the finger, the patient must be ansesthetized, placed crosswise 
on the bed, and her lii|>fri brought to the edge of it» The 
cervix is then seized with a %^nsell«ni forcejis^ and drawn down 
to the vulva, being there liebl s^teadily hy an assistant while 
the ojierator scTat»es every jKirtion of the uterine cavity with 
the curette until everything is removed. The hand of iin as- 
sistant, or of the o|)eratt)r himself, may steady the uterus by 
pressure on the fun«ius. When the uterus is empty it should 
l>e irrigated with hicliloride solution, and then with sterile sjilt 
sobition, as before exjilained. It is usutd tn insert and leave 
a light strip of ioilothrm gauze in the uterine cavity and cervix 
(for drainageb which may he removed in twenty-four hours 
— the gauze is antiseptic, stimulates contraction, aiitl stojifl 
hleeditig. In many cases it is su|)erflyou8^ — some ofjerators 
omit it entirely. 

In ** incomplete ^^ caseR, when the embryo has heen expelled^ 
leaving the membranes and placenta in utern^ while it is true 
that in many instances the abortion mm/ complete itself 
without interference, thi« may not ii<*cur for several days or 
even weeks, during whicli there is always danger of septic 
infection and recurrence of hemorrhage. The safer plan, 
therefore, is to empty the uterus at once hy the finger or 



198 



ABORTION AND PHEMATUHK LAIHJR. 



curette, the os and cervix hemg dilated with a Goodell or 
i*oitie other dilator for this purjHjge when ihey have closed up 
efter eximlsioii of the f*etu.s. In iie^Hftted atid didtiyed eni^e,% 
when deeuiujKisition of the seeuiidiiU'S hasl>ep'iiii arToiii|miiied 
with piUrescent odor^ irinnediate eniptyintc ^>^ the uterus is 
impf'rative, followed by a!itise|jtif' irn^':uti«jii nf the uterine 
cavity* to prevent sapneniia and septieienua. 

It hospitals or elsewhere, when ex(ierienced operuton* are 
avaihihle, the Mtirtjiral mtihod has heen recently adviseil in 
all cuma of iuevitahle abortion. Jt consists in emptying tlie 
uterus at once, with the finger or curette as previouf^ly 
dej4cril>ed, after artificial dilatation of thecervix and ana\^the>iia 
— just a^i (ine would do any other surgical o^MTation for the 
removal of a morbid growth from the nlerine cavity. This 
may be well enough under the eircumstance*? mentioned, but 
in general practice the nuijority of cases have heen, and will 
contitiue to be safely managed hy the le^s radical metbwls of 
treatment previously describe<L To the.sc latter I may add 
the method of rj-prtjision. When the cervix is pretty well 
dilated, two tinn^erj* in the vagina and the other hand outside 
U[wrn the body of the uterus nn»y thus express the iinhr<»ken 
ovum from the uterine cavity into the vagina. It requires 
eoine nkill, and if unsuccessful dot*s no harm. 

In al)ortion between the fourth ami seventh inontb.s (so-called 
** iniijcarriagc ** ) the fix4al siic iis seldom expel led entire ; usually 
the foetus a>mei? first, the seeundlnes* after a eonsideralde 
interval The pains are stronger, there i^ more liquor amnii. 
the contracting uterus can more ea.sily be felt, and milk is 
niore likely toa[i|)ear in the breasts than in early cages. The 
principles of treatment are the same as jireviously describeth 
but there may be difhculty in extracting the pbicenta which is 
generally atlhereut ami the hemorrhage may he more profuse 
than in earlier (^s*^s, hence additional care in controlling it 
by tanqions, ergot, ami prompt removal of secundincs. 

The after-treatment of abortion must he con tinned rest, as 
after a full-term labor — ten days in bed, at least. 

In women who have aborted once or more, and who are 
theref**re likely to re|>eat the pn»cess, we shoubl enjoin absti* 
uence from roiin^ for a year or more ; removal of all susjitx'tt'^ 
cauM'{^ of the accident ; when pregnamn' again ficcurs, insist on 
perfect rest in bed for a week or ten days at tiuie^ corre«ix)nd- 




TEEATMENT, 



199 



jug to the menstrual epoch. After eonceptiou, eoitug must be 
furUiddeti diiriiitr f^'^ei^tjitiuii, 

The two eojiinioii causes of repeated al>L»rtioii, viz,: chronic 
endometritis iiud reirodisjifarrment of tlie uterus, shouhl of 
course receive treatuieiit. 

Imperff'd Almrtioiu — Wlieii reiiuuints of tlie ovutu r-etniiiu 
in uiero^ a^ they may do for days, weeL^, or even mtmth^, ailer 
a supi>0!i^d complete eiiifityiiif.^ of the womb, it b termed *Mm* 
perfect" or ** incomplete " abortion. 

All syujptoms may ,«nbHtle, wholly or in jiart. but sooner 

later hemorrlmjj^e will recur, with dis(vhartre of decidual or 
fl(u*eutal ilcbrii^, wliich nmy or amy not be putrescent— in the 
"[)rmer ca.se endangeriui^ *«eptica*mia, etc. Such cases result 
froni» and also lead to, endometritis. Retained blood may 
deposit successive layers of tibrin u|ion fra^^meuts of mem- 
brane or placenta, constituting^ socalled *MibrJnoiis polypus," 
Renewal of pains and blcediiiLr ultimately result. 

Treatnifftf consists in completely erupt vifig the uterus with 
the linger or curette, and the use of aniiseptic injections. 

Mmed Ahorfum, —As, at full term, the child may die and 
renmin iu utcro wec^ks or months afterward, constitutinji,' ao- 
called ** missed labtir," s<:j, during the earlier months of prejj- 
nancy, death of the foetus may tx-cur and the ovtim still 
remain weeks or months in the uterine cavity ; this is *' missed 
abortion,^* 

In these cases the sym[)tom8 of jjregnancy are ftrre«te^l ; 
milk may appear in the breasts; the Jifjuor »nmii is absorl>ed; 
the child macerates or be<'omes *'inunmnfied'' — rolled op in 
the jdaccntaor membranes like a jMircel^ — but usually it is not 
putrid, for the unbmken membranes have protected it fmm 
atmospheric jnjerms. 

Paitis, l^lee<iin^^ and unexjiecied discharji^e of the masB 
usually result. WIh'U lids bist ch>es not occur in Mtif^pfrted 
castas (jtOHiilrf diagnosis is ilifficull ), cathelerism of the uterus, 
or dihitalion of its cervix by tents, to |>rovoke contractioti antl 
expulsion of the ovum, is the pro]»er treatment ; or tlie cervix 
ujay he rsipidly diliitid with the steel dilators, and the cr>nteDta 
of the uterus removed by the finder or curette, as in other cases. 

Kince a dead hetus may l>e discharjj:ed montlis or years after 
the death or departure of a woman*s husband, this explanation 
may be necessary to shield the mother innu unjust suspicions. 



2m 



ABORTION AND PREMATURE LABOR. 



Before conoludinii; thU rhapter on alKirtioi* it may be well 
to remind tlie readier thnt with re;^ard to (lie treufmento^ ihoae 
casti* iluu do not terininiite ^imntuneonsly, iimJ which retjnire 
iiiterft^rence eitliLT from excrsi.'^ive ajnl runtiinHMl htMnnrrhiif^e, 
or on ufT^HOit of retention of the sectnidinej*, tim mHhffds of 
pmetice huve grown np, viz, : fird^ the erpectant method, com- 
printing the use of the tanipm, ergot, gentle expression, or 
digital extniction of the phieenta wheo it ])resents in the m 
uteris reserving the more riulintl njethud of wnifiin^L'^ out the 
uterine cavity for ca^ei* in which thToinpoftilion of the khuhi- 
dines Is beginning, or in which frequently rcenrring or hmg- 
continue*! hennirrhage huj* rendered nitire active nu^zLsure^ 
ncccKsary ; j^rmttd^ tlie radiral or nrtive inethtKi, l>y which all 
cai*e,M conmdered heyuml |ire%'eutiou are treated actively from 
Ike beginning, the woman l>eing aniesthetixed, the im and 
cervix uteri rapidly diiated with Bteel inntrumentts and the 
curette used to empty the uteruti — scraping out fcetui^ pla- 
centa, and the entire det'idua hy one complete operuti<m — just 
ai* a indypui* or other morl)id neoplasm would lie removtMl hy 
a Himcwhat similar surgical proceeding. Uotb methods of 
Ireiitment have tlieir rc^^iwotive advantages and clitiiidviin- 
tages ; both have earnest adv<M'ate^ ; neither phin has been 
iiniver?<al!y ado[aed. There will prolnihly always he ctises, 
or at least circumstance*^ in and nnder which each of the two 
methodic may Ite judiciously employed. Muc!j will dr|>end 
ujwai the ex|>enence and skill of the fihypician. If he were 
always a skilful opcriUor the raflical method would doubtless 
be inK'isalde in more ca>ic,s than it is at preiH^nt, when s<»me are 
unable and unprcjiared to inidertake a curetting o|Kration. 

Treufuteut of Prnrtnlttn: lAilmr. — The managemenl of labor 
al\cr the seventh month is abont the same as at full term. 
Dihitiition of the os may lie slow, but the chihl is smaller. 
The placenta is liable to be retained, but not so long as in 
nbtirtion c^i^cs. Its delivery may be expedited by compres- 
sion of the uterus through the alKlon^en, or, if this fail, and 
the Incurrence of hemorrhage neccjssitate interference^ two or 
more fingers, or the half hand or whole hand I according to 
the degree of dilatatioti of the os uteri, autl the jieritnl to 
with pre^mmcy has advat»ce<l). nniy l>e introduced into the 
womb and the placenta |*ecled off with the fingers and 
extracted. 




CHAPTER XI. 

EXTRA-UTERINE PREGNANCY, ETC. 

Extra-uterine Gestation (Extra-uterine Fcetation; Eoctra- 
uterine Pregnancy ; Ectopic Gestation) is development of the 
ovum outside the uterine cavity. Since some cases, while mis- 
pUicedj are not entirely outside of the uterus, the terra ^^ ectopic** 
is perhaps best. 

Varieties. — The ovum may lodge in the Fallopian tube 
(tubal pregnancy) ; when lodged in that portion of the tube 
which passes through the uterine wall, it is called '* ijiterstitial 
pregnancy" Rarely the tube is congenitally deformed ; it 
enters the uterus externally as usual, but then descends in the 
muscular wall and opens into the uterine cavity lower do\\Ti. 
An ovum lodged in such a tube would constitute a veritable 
** interstitial jyregnancy" The ovum may remain in the ovary 
after the Graafian vesicle has ruptured (ovarian pregnancy) ; 
or it may find its way into the cavity of the abdominal [peri- 
toneum (abdominal pregnancy). There are several sub- varie- 
ties mentioned further on. 

All forms of the trouble are rare : extra-uterine cases only 
occur once in 500 or 1000 pregnancies. The tubal variety is 
far more common than any other and will be first considered. 

TUBAL PREGNANCY. 

Causes. — Spasm, paralysis, stricture, sacculated dilatation, 
doubling of, or pressure upon the tube, causing obstruction of 
its canal. Loss of ciliated epithelium from inflammation, 
hence the ovum does not so easily reach the uterus. The tul)e 
may be compressed by tumors outside of it, or drawn out of 
place, bent, and fixed at an angle by contracting adhesions, 
the result of [)eritonitis. It may be obstructed by small polypi. 
In twin cases, each ovum may interfere with the passage of 
the other through the tube, hence twins are relatively more 

201 



202 



EXTRA-UTERINE PREGyANCV, ETC*. 



frajyeiit in tuUal prefrni^ncies thiiu Vn titjrnial oiit^s. Fri^'ht 
dyring: i-oition ii* an alleged hut tloubttul ciiuse. Tubal |>rc^- 
uancy is more apt to occur \xfief than before thirty years of 



Plo*7L 




Pregniinoy in the ezternn) third oftlic left tnlKv (From Pahvin. aft«r Wimckkl.) 
a. OVftry. 5. Lcfl tube, e Tutml genUUon cyst. d. Adhesion* 



Fio. TL 




Titbftl proirniin^y wlih crirput iQlenm In opposttc omrf . f^rnv dedduiil 
tneiuhrtinv^ In <)iiiiK'lhii? frutn ihv inrlntui tiicni:^. (Pruiu HEYNou«jLiid NkwiclIo 
•IWt Playvaiw } 

age, nnd iilm> after |>rolo»ue<l i^terility. Occasionally a fertil- 
ized uvum from ont ovary niig^ratea acroe«3 to enter the tul>Q 



I'ROONOSIS AND TKRMLXATIoy OF TVIiAL CASKS, 203 



oi' the opimnte Mide, but it nisiy then have growo Um Iar<j;:e to 
pass«» uiid l>ecoiiies arrt^slt'd in the tiiljt\ (See Fig. 72, 
page 202. j 

Prognosis and Termtiiatioii of Tubal Cases. — All forms of 
extm-uterine |>re«rnai]ey are extretiiely dan^reroiii?. If let 
alone more than twt)-thirtk lif the atses die. By pro|>eT tre^t* 
meiit many are Faved. The ii8ual explauatioo of this fatal 
ri^ult has heeti, until reeeutly, that the tuhc is clisteuded hy 
the f?rnwin|.' uvuiii until it hiirnt.s ; then follows a flantrt^rous 
or fata! hcmorrha/j^e from the ruptured lulie. But the 
explauatiou is not thus simple. Ouly ahout one-fourth of fhe 
eaif^H end in rtiptttr*' ; the other three-fourths lermuujte in 
tubal aba Hi mi „ l>y wliich we mean disc'har^^e of the uvum from 
the tulve through il.s ahdomiual ostium into the [)eritoueal 
cavity* Here again hemorrhage f»eeiirH fnuu the aljorting 
tul>e into the peritouenm» junt as we have hemorrhage into 
the vagina from au ahorting uterus*, Neither tulail abortion 
or tulial rnidnrr oeeur trmu simple diHtenlion of the tul>e 
from growth of the ovum. The se<pienee of events is rather 
a» follows : the |>hag<K'ytie tropholitast cells of the ovum» hy 
their HCM'alled ^'-corroMtre' arlioti, eal into and through the 
tuhal uuieosii (the F'alhipian deeidua ) anil may even jveue- 
tnite through the museular coat to the peritoneum, thus 
dangerously weakening the wall of the tuhe. During this 
corrosive pnK'ess, bhod vesiteU are opettrd and hhwiil is effused 
into the tuhe, iusiuuating itself between tlie fu-tal rhorion and 
tubid svalh thus causing their sefmratioo, with still m(»re utid 
more hemorrhage and uccimiulatKm of extravasateil IiIolkI 
within the tulH/. Thus the cause of distention is not ttlmply 
growth of the ovum (though this eoutrihutes a share in the prtxv 
ess), hut accumulation (»f etfused hlood. Under these circum- 
stances, if the ostium ahdominale of the tut>e he o]>eu» the 
ovum is exj>erlled (tuhal abortion) ; if the opening of the tube 
be closed or obstructed, its rupture takes place. Mus<nilar 
e«jntractious in the wall of the tuhe ( Fallofiian *' lal)or pains *' ) 
are, of course a contributing factor in Inith processes ; or may 
be so. Tidial tibortion occurs chiefly <luring the first and 
8ecN>ud months of prei^uaru'v ; a few cases during the third 
and fourth moutlis. Thus of (il rases re^'orded by Macken* 
rodt ami Murtin, 21 occurred in the first moiUh, 2Vt in the 
second, 8 in the thirdj aud 3 in the fburth. Kupture of th^ 



2(J4 



EXTUA'UTERINE PHEGNASCY, ETC, 



tube occurs most often during tJie tbird an<l fourth months. 
A few cjises octvur Inter, inn\ mn\v! have gone on to foil term. 
When tubal ulHirtion «xm yr^ cluring the fir>;t two months, 
the emhr>M) dies, diaintegrate-s, amd *lisii|»[)ear>* by ahs<irption. 
At^er then, when the phiceiita i« fonneil and is ont detached 
from the tube, the embryo iuiiy be di»<.'hargcd (either by 
rupture or i\hortiou) into tlie peritoneal cavity, but maintains 
\U connection with the phiceutii by its und)ilical cord au<i so 
emitinueft to deveii»p — even to full term — \n the abdominal 
cavity, instituting the '* ahdommaV variety of extra-uterine 
pregnancy. This is knowu as secondary abdominal pregnancy. 

Fig, 7a 




of a i 

Tubal Abortloo. o. Ovum bet iir cjcpel led. /, raifttv^ti* toNiomlnttle. a. Am- 
puU», t Islhnjus of tutte, (From Jici.i.tnT. nliur III mm,) 

A pnviary abdominal ca<^e ii*< one in which i lie fertilized ovum 
never enters the tulve, l)Ut beyith^ its development in the [>eri- 
toneum. Recently it has been tpiestioned whether such a 
** primary " case is ].»ossd)le ; a few uud*>ubled instJuices have, 
however, been retrortk^d. 

Broad- liga m e nt Frcffu a n nj. — S< >m et i rues f " tnice i n 50 
ca^-s,"* W'diimjn^) wlien a tubal pregnancy ruptures, the rent 
occurs iu the under t^urface of the tid>e not covered liy peri- 
ttmeum, hence the contents of the tulie (ovum and extrav- 
asitti^l IdrHid } do not go into the |>eritoneal cavity, hut are 
received betwet^ii the anterior ami pwlerittr layers of the 
broad ligament. These layer*" l>eing normally united to each 
other by connective tissue, offer coTisiderable resistance t<f the 
intruding contents of the ruptured tube ; heuc^ hemorrhage 



PROGNOSIS AND TEJiM [NATION OF TUBAL CASES. 205 



is restrained, tlreextnivasiited hlood lifc^mies u liniileil, eirt*yui- 
seriberl licniut*iinn, uml i\w (hmgfer of deiil h fnnii lu'iinirrliago 
18 much leAs thnii whvn the ryjiture and ItleiMliiig go freely 
into the large [xriioiieul e^ivity. Shoidd the (iltirtMita reiuaiii 
well attached to the tidie, I hi' ease mny go on to terni ; the 
peripheral margins of the placenta extending lieyoml the 
tulje attarh themselves to the eonneetive tissue of the broad 
ligament foMs its the nrgati grows, jiut everything is ouiiflflf' 
the pet*itooeal eavity : though unthrtuuittely it mtiy not 
remain 80* for the broad liganienl tletal sae nmj itself rupture 
later on and disehiirge its contents into the i>entoneun» ; thus 
the case be^'oines finally a t^evomhiry abdumlnnt pregnancy, 
the eondition now being nuieh the same ai^ when the tubal 
case originally rufitnred intt> the |>eritoneumi n^ fireviously 
descrdved. 

Tfibo-utrrine Pt'ajtutneif.—An ovum develo[>ing in tliat part 
of the tnhe parsing through the uterine wail gra<liiaily jiro- 
trudes us it gmws, into the uterine euvity, hence part of it is 
in the tulk?. and ]>art in the uterus. 

Tnbo-ahffominaf Prrgnanrif^ — An ovum developing in the 
fimbriated end of the tube may in like msinner projeet itself 
into the pt^ritoneal cavity where it form* ad!u^ions with con- 
tiguous organs; thus it is partly in the lulve anrl partly in 
the peritoneum. 

Tulm-oinnan Prefjnancif, — -Ilere the implantation of the 
ovum was at firnt either in the tuhe or on the ovary (tlie two 
organs perhaps having been previously adherent to each 
other), and as it grows, nei'esj^arily invades both structuri^s 
and becomes attached to both t^vary and tube. 

In any of these cjise^s, what becomes of the feet us when it 
dies? Ifitdieinthe unrn]>tyred hetal sac during the first 
tivo months, it rapidly disintegrate?^ and is tthsorlnd. If it die 
there later it may l»eeoine shrunken and mummtfird ; or it 
mny be converted into a iithopfcdton, or it mny ilegenerate 
itit4) a yellowish, grejvsy, soapy snhstanee known ns adtpoct-re. 
In either of tbe.se three conditions the ovura maif remain 
dormant and harmless for months and years, even during a 
long life ; but there is always ilanger of a more dis^istrous 
events viz.: sttppuration. The fietal sac becomes infet^ted 
with micro-organisms (sirp|K»seclly by migration of liacteria 
from the intestine), pus forms, and the whole nmss becomes an 



206 



EXTILt'VTERiyE PREGNANCY, ETC. 



k'liich bursts discharging iti? contents into the vatiina, 
bladdtT, or bowel, or exteriiallv tlirongh the skin. With the 
pns eonie ihe He|»siraleil Iniiies of the tietul skelt'lotu if llit^ 
einbryoiiie <levelo|niieut have proceeded tar enough to form 
one. 

When a fuetus has l>een discharged from its rnj>tured tubal 
sac into the pritoneum ami dies, it is possible (shraild (he 
woman survive) that it may become re-€;ncy»^ted by a ca|i«ule 
of inflammatory ad}iesi<ms, where it may again remain 
(mnmmitied, etc/) liuriiig a h»n^ life, or undergo suppuration 
and Iw discharged, as just previonsly de^^erilied* 

While these events are interesting jxvssibilities, they are 
schlom met with nowadays, exeepl iji neglwli'd eases where 
the tietns lias not lieen removed by ojifratioti, as vt sbimUl be. 

Symptoms and Diagnosis of Tubal Pregnancy.'— Tii is 
almormal condition is most often cot suspected before sym[> 
toms of approaching ru|»t lire l3egin ; sometimes oot until actual 
ruj»lure hiu? taken place. 

The Mifmphim prtrtifiHij ruphtre are extremely im|KHlnnt^ 
but the diagnosis is dirticult. Tlie early signs of pregnancy 
exist The menses are absent, but rrapp^nr irrefjuhrhf uffrr 
one or fwo moitfh.\ leading the woman to doubt her snppit^ed 
pregnancy. The dis<.'harge is mingle^ I with xhtrfh of broken- 
down uterine decidua. The womb is somewhat enlarged, hut 
not as much as it should he in a normal pregnancy of the 
same duration. A tender ami |Miinful tumor (the tul»al cyst) 
is discovered on the aide of the nlerns, in the vicinity of one 
of the broad ligaments. It gnovs rapidly ; the wondi does? not 
The tumor may be detected by the bimanual examinalimi ; it 
is S4>niewhat soft and doughy, or llurtuating ami extremely 
sensitive, 

Shoubl the vaginal finger re^/ognize liallottement, the iliag- 
nosis is certain- Owing to jires^nre npm the howcl there may 
he rrctal teftrnmitn in addition lo ctjnstipation. Pressure UfKin 
vessel and nerves causes n>detna and j>aht in the fimh of the 
affecte<l side ; these cKtnir earlier and are more severe than in 
normal gestation, and may be accompained with slight eleva- 
tion of tem|HTature. The womb may lie puslied on one side 
hy the gn*wing in'uru. Eventually a severe, tearing, colicky, 
intermittent |iain iwcurs in the region of the rum<»r» produced 
by contractions of the wall of the tubal cyst ; the " miniature 



TRK.ATMENT OF TUBAL CASES BEFORE RUPTURE. 207 

FaJlopiim uterus" is irritnted to ciiiilnu-t by distent iuu ; it is 
having "painii*'; but since there may l>e no outlet for its 
t^otitenH it bursts. 

Symptoms of Rnpture.SexeTe and sudch^n alKlonjinal 
j»ain, witij ioteni*e rollnpts palhir, feebk* iiinl IVftiueiit puli<e^ 
ek\ Kajiid swelling of the abdomen, low down, and at iii^t 
on the side oci'iipit-il Ijy the tunuir ; hiter, all over The 
swelling is sotl and doughy ; it is prodnced by IiUkmI ettui^ed 
into the |ieritoneiini- Byuco[>e, nausea an*i retehing, eold 
sweats, and sidnjoniml tem[)€niture. The same eyniptorns 
iKTur in tulml ulxd'tion when heniurrhttge is severe. 




I'regnnnry In right tube. PurtlttHy tntra-lliEramenCfJuit. (From pAnviN, aRer 
ZwKiFEL.) «. Riffht tiil>e. ft. Ovtiry. r iiegUition cy»L with ftt-tus. 

Treatment of Ttibal Cases before Rupture, — When surgieal 
skill is available the |iroj>er trentnient l^ cHrliotomy, After 
thorough cleansing and sterilization tif the abrlonieii and pnlies, 
as well a>* of tlie instruments and hands of tlie oj»erator and 
assistants, the blachler is emptier! und th^ patient aoiesthetized. 
An incision three inches long is then made in the median line 
above the [tnbes thtwn to the pentonenm, any IdeecJing vessels 
being twisted before opening the peritoneal cavity. The 



208 



EXTRA- UTERINE PREG NANCY, ETC, 



peritoneum i.-? then inciwd : the intestine kept Imck by pads 
tjf eottoii or piiize wrung out of the hteriliztMl wntor : the 
o|>erak»r*s iitjgers l>rin^ tnit the Llbtcmled tube nwl ovury at 
the infii^ion sifter huviu*^ fre<^d theui t'rum any existin^^ mi- 
hesioni? ; the peclich* is then transtixerl hy a double M^Mture of 
sterilized .^ilk, and eiii'h half ul" ii tied s**eurely aceording to 
snrgieal rule. The pedicle is eut, and the entire tnaA«i- tube, 
ftetal cyst, and ovary — removed. The |>ads are then with- 
drawn and the alnJoinitml incision closed and dressed in the 
usual nninner. In c^ii^c of threatened collapse from hem or* 
rhage during the o[ienition, iJie peritoneal cavity may be 
tioo<le<l with a 1 p(T cent, sterilizt-d solution of coiumon sab at 
a teruj>cralure of 100*^ F., a fpiart of this scdution having been 
previously |irepured. It is nipidty ab.^^nrbed by the (icri- 
tonciim^ anrl actvH as a restorative — like transfusiim. 

The device of kifluiff the /wtuH to stop its growth, ami thus 
forestall further distjentioti uud rupture of the cyst — by tho 
various method.s of (1) aspiration of the litjuor amnii : (2) 
injection of morphia, etc, into tlie amniotic sac ; and (H) by 
electricity — hiis ti>r p>od reason^ been abandoned. Tlie first 
two methods are no Ioniser thonjj^ht of That of destroying 
the bfe of the fo-tun tiy elcctricitVi while inudvi>*able, nd<:ht 
still l>e worthy of cfjusidenition when surgical skill was nnot)- 
tainalile or the patient ami ht^r friends refused surgical inter- 
ference. The method of [jrm-edure is as follows : A fara<lie 
current is passed tlurough tlie cyst in a series of sharp shocks, 
and rej)eated every day tilldjiiiinution in the size of the tuiuor 
and retrograde changes in the breasts indicate fa^tal death. 
One pile (the negative) is jmssed into tlie rectum or vaghni 
and t>laced in contact with the tumor, while tlic [>ositive p<ile 
is applied (»n the ahdonien. Kle<"tricity should tud be usetl 
when there are signs indicating impending rupture ; it would 
hiLsten that unhappy event. 

Treatment after Rupture.— ('celiotomy is here unques- 
tionably the best tnethod to [mrsue. The ab<hmiinal cavity 
should lie openefl by incision, the Fallopian tuk\ with the 
cyst, feet us, ovary, arul etiused hhnxl, renjovnl, in the manner 
just previr)usly descrilied for cases before rupture, extra care 
l)eing taken, in the rujitured cases, tr> fy«*>^/r/ secure the bleed- 
ing vessels uf the rufitured lube froui further hemorrhage. 
The sterilized salt solution may he used to recufierate the patient 



TREATMEXr AFTER RUPTURE. 



209 



from (^"ollaiiscs a.* in vtiM^iy o|)erated upon Ijofure nipttire just 
prt'vioysly destTibed ; the ajx-ration tu he performed with the 
gtrietest iintii«e})tie pn-eiiutiuuH. lu forty-two ojteratiuas jier- 
formed immeduddy iifter rupture by Ijiwsou Tait, thirty- 
nine women were sav^d* Hiri*t, of Philadelphia, had twenty- 
four coiiseeutive ciLses without a death that eould lie ascribed 
to the operation it^^elf. He mivise.s, after the tul>e, i>viirv, 
and eyst are removed* that the ahch>meu shouhl be IJushed with 
lartre tpiantities of hot .sterile water and tlrained with both a 
^iass lube and piuze jnieking, l>otli of whieh art" removed after 
4K Imurs, a rnblnr tid»e liaving tirst been [laj^'^ed thron^^h 
the glass one to take its pbiee. For about ten days* the al> 
dominal eavity rei*eiveji, through this rubber tube, a daily irri* 
gation with hot tJterile water, until it eonit^ away elear from 
any tiake** of blot>d-4^1ot or deehlual <lebris. His [witieuts had 
no ft'ver, and *' every wound beahnl [iromptly within three 
weeks/' withnut any [KTsistent sinus. Ltiek of surgieul ad- 
tlre^ss, darlnjr, und skill, the want of surLneal instruments and 
antiseptie appiianees, and the dreiiil (»ro|>eratin^' ujKm women 
almost at the door of ilea tb will iloubtlesj< eoutinue, as in the 
past, to prevent the performanee of this oj>eratif»tr in many 
ca^est where it ou^^ht to be done. In Mnne eases, after o^Keuin^ 
the alMloiinnal eavity, the foetal eyst may be found so Hrmly 
and extensively adherent to adjoininii viscera ami other tissues 
an to render Its removal extremely ditfieult and dangerous or 
even impossible. Enueleation of the sac shf^uhl here in*t be 
attempted. In some t)f these eases it may be stitched to the 
abdfuuinal wourvd, emfitied of its eontetUs, washed out with a 
weak biehluride solution ( I : 2<KtUjr) ), and packed with iodn- 
form jjauze. In other cases where the sae is low in thefK^lvia 
and easily reached tbroutr]] the vajjjina it muy be o|Hnred thnui^b 
that canah cleareil of itseouteiits. washeil out, aud packed with 
gauze, leaviuK a free o|>einnL^ tor druinaj/e. In doiu^ both 
an alidominal and vnirinal o[>erali<m nu tlie siimeoccjtsiou the 
hauils (tf tlie o|>eratt»r must, of course* never pass from tlie 
va|[j:ina to the aliilomiual wouud without th<»rou*rh disinfectiou. 
It would be best fo have the abdonrinal iucision closed by the 
uneontaminaled han*is of an itssistant. Should no njR^ration 
be attempted, the otdy remain inir treatment is that of ex|>eet- 
aney — a forlorn hope. The woman must be kept absolutely 
at rest ; opium given to relieve jwiin ; stimulants to jirevent 
14 



■Ml 



210 extha-uterine pmeGaVancy, etc, 

collajxse : with ice to the alulomen nud coni|<rfstfi(m of tht^ aorta 
to control heuiorrha^ro. Tliere m a hare chatii-f tlie lileediii^ 
may stop* and the iU'tus liet'tjiue re-<:*niT?Jted l»y a wall of'iutlaiii- 
nialorv exudathm, uiid ko reiimiu haradtvss' nv hv disi'liar^eil 
later by aliscess aud hijrstitig of the t'yst*, either externally or 
into sk^me neighlioring vis^euH, as already explained. 

Ill eases of tulml prcgnaney that have advarieetl to the later 
months, we have to deal with a placenta and ?«otaetinH'>5 with a 
living and vialde diihi The child should lie reinovetl hy 
eoeJiotoniy and, if alive, the jdacerita should iie left alone, the 
cavity of the f<etal stie heiiig packed with gauze, a j>art of 
which [irotrades at the hnver end of the ahdoniinal ineision, 
for drainage. To attempt renioval of the pbuenta wonld 
endanger a fatal hemorrhage. la a few day^ (the plaeeuta! 
vetssels having now become oci'luded) the aljilominal inciirsion 
Diay Im re<>[>ened, the gauze removed and j>lacentii extriH'tcd 
with le^ (hniLrer of hieeding. Hhonld the child have been 
dead some day?: hefnte the cudiot<jmy tjperation, the placenta 
nuiy be removt-cl withont fear of great hemorrhage at the time 
the child 18 extracleiL (8ee Tnatittrid of Abtktmlttid Ksira^ 
uterine Caten, page 216.) 

INTRA-LIGAMENTOUS PREGNANCY (EXTRA-PERITO- 
NEAL. SUBPERITONEO-PELVIC. SUBFERITONEO- 
ABDOMINALu 

This y the variety of tnbal pregnancy in which the tiilie 
rupture** between the hiyers of the broad ligament — between 
two external surfaees of j>erito(ieal layers, aol into llie fierito- 
neal cavity, a.« before exphuiie<l ( jx 2(14). Tlie effusion of 
bh>i>ii is rejitrieted hy these layers of hroml ligament and the 
cHainective tissue uniting their ajiptiscd surfact\*. Hence the 
hemorrhage is le*^ likely to Ik* rapidly fatal, constitnting a 
limited h:enuitix*ele, whieli may liecome absorbed, leaving a 
lithoiMi-^lion, or devehjp into an abscess later on. The newly 
f(jrmed !iienuit4X*ele mar/, however, undergo a tteconthtrtf 
rupture through the distended bnmd ligament and into the 
|)eritoneal cavity. 

Diagnosis. — The diagnosis of inlra-ligajaentcms case,s de* 

pends ehietly u|hju the eolhipese from hemorrhage l>eing fe^ 

1 Vlretiow (Cellulnr l*atholotry, p ivjT,) fmitid the mmrles of the frHut per- 
Hedlx intact atler renuUnlQu ti^lrtf x^nm in ttic butly otthv moilicr* 




INTERSTITIAL PREGNANCY. 



211 



Hverc, and upon the refxvgiiitioD of a rapidly formed but still 
eircumscri I H^d tttmor h\dv\)innU\)t of the uterus, in which may 
Iw? felt tiuo(uiitit)u iuul [ier[iii|i;j (iulsMtir»;| vt*sst'L<* Thin tumor 
h forme*! hy vhAs of etf\isi^il hifMul rirrHmAerihfd hetween the 
folds of hroiid ligametit, tjuite tlitfcrrnt from iIk' dotjghy eii- 
kiri?emeut tiiffu.^cd ov*t the wh<*le alHloToetr when hemtuThajLre 
has taken ]4ace inside the [irriloneal cavity. Moreover, reetal 
examination shows Don^das' ri/Ai/r-x^jr to he fmphj^ while in the 
intra- [w^ritoueal castes it isjilied with efl'used l>kKMh 

Treatment. — Snrgical interference not immei Irately neces- 
sary. By re^^taiid recum henry, with treatment for the antj?mia 
following the moderate henvorrhri^ife, the effused hfood may l>e 
ahftorl>e<l, and I lie woman recover, I>ater on suppuration nuiy 
occnr, with sytnploms of sepi.s, — (drills* fever, rapid pulse, vom- 
iting, etc., — when alidoiiiinal i?eetion will he reijnired. It is in 
these hroad-li;,'!Jinent rase^ that entire removal of the cyst will 
often he diftieult and dau;rerousi| and when it will iiehetterto 
ojKJU the mv and stitch it to the ahdominal wuunil, as just pre- 
viously explained. 



INTERSTITIAL PREGNANCY (TTJBO UTERINE ) . 

The ovura is in that [>art of the tuhe [ia>v4nf!^ thn>yi;h the 
uterine wall. Extremely rare. Rupture may occur into the 
peritoneum ; or that surface of the fcetal cys*t toward the in-' 
terior of the wond> may rupture ami the ftetus esca|>e into the 
uterine cavity, and come out l»y the natural pai^sage. It is 
less fatal than tulial pregnancy, and may rarely advance to 
full term. Differential diagnosU from other varieties very 
u n ce rtn in. T h t ' w om 1 )i s i rretr u 1 a rly e n 1 a rged, and t o a g reii ter 
de^jnr than in thu cjther varieties ; the tnni<ir moves with the 
uterus ; the uterine cavity is empty. I'ossildy the finger in 
ut*'ro may recognize the bulging wall of the fo-tal cyst and its 
e*>n tents. Ahdominal section nuiy lie re*piired hefore the 
diagnosis can he rmtde ]>osiiive, 

Treatment. — When the fcetal cyst bulges in toward the 
uterine cavity, the cervix uteri may t>e dilated, the eyat in- 
eiged, and its contents evacuated through the vagina, the sac 
being afterward cleanstMl ant ise|4i rally and packed with iodo- 
form gauze. When the cyst lodges the other way, toward 
the outside of the uterus, an ulMhmitnal seetiou shouhl ha 



212 



EXTRA'VTERINE PREGNANCY, ETC, 



made ; the eyst opened mid emptied ; theed^c\^uf tbeoj^etiuig 
sutured to the wall of the alithmien ; the lileediii^ vesj^ela 
seeured and the mv tiraiiied through the uhdoniiual ineisioa. 
Hhould this* he loun*! hjipmcticahle, the ojM'uin^ made in the 
peritoaeal gurfaee of the ey?«t loay he securely .stitched up (as 



FlQ, 76. 




IntentltUl or tubo-iitorlne prc^ancy. i From I'laypaib, ail<?r Biakd Sfttow.) 



in an ordinary C«*}*arean stection oj^erafion }, a eounter-iipenhig 
havincf l>een previouj^ly made, for drainage, from the ravity 
of the cy«t into the cavity of the uteru.«, the alMlomiual in- 
eimon l»eing then elosed without drainage. The tx^rvix uteri 
fihould, of course, have heen thonnifrhly dihitnl heforehand. 

Another deviee is Porro*g operation: take out the entire 
uterus with Its eontent», by supni- vaginal amputation, through 
the al>donnnal n»ute. 




ABDOMINAL PnEGNANCY. 



213 



OVAEIAN PREONAKCY, 

Its occurrence has Ix^eu <1Lspi]t:ef1, Imt a few cafles haTe 

undtHihteiily lieen observed. The ovisac ((Traalian vosicU^) 
ruptures without the *ivule escaping ; »j>ermatoz«a euter 
through the reot, hence iiiipreguntiou and get?tation l>egiii in 
the ovary. The wall of the ovisac and stroma of the ovary 



FW.Tfi* 




OvArian pn-iynancy, left side. Only pnrt of the ovary pariicir*t€* In Iht? frcsU- 
tlon cyst. (From rAHViN, aft^jr Wincm.bu) n, Ovitrlati pri'^nimcy, 6. Lcfl 

dilate to form the foetal cyst: hut gradual distention may 
force the ovum frnrtially out of the ovary and iiitu the peri- 
toncnnn, tlit* port if >n e.«*caping heing eircuniscriht*<i hy peri- 
toneal adhe^iouis Ktij^ture ujinully occurs within three or 
four monthsv with the R'vcral results UHunlly prcKlnced by 
rupture of tubal case^* Ditfcretitial tllfiffuoMi^ well-nigh inipog- 
eible. Treaiment: practically the same ai< for tubal gt^tatiou. 



ABDOMINAL PREGNANCY. 

In these c^ij^es the ovum is neither in the womb, tube, nor 
ovary ; it ij* in the cavity of the pcril<Mieum ; it'* gn>wth is 
not curtailed by any resisting niusculajr wall. The pregnancy 



214 



ExmA-UTEniyE rnEa nancy, Era 



then^fore imiy, atid iistially does, £^o to foil lerra — a history 
Burprisiiigly iliflereyt troni Xhv rupture mTurnng in other 
varieties |>reviou!ily tlesKTilieiL The pUicenta has Itet'O fbiind 
attached, in ditlert nt cases, to all |>urt.s of the iKTitoiicmm ; to 
that coveriug tlie uterus, the bhtdder, the eoh^n, the small 
iote,*itine, the mesentery, the stomach, the kidoey^ the ouien- 
turn, the lund>ar vetebra% etc. 

Ahdomiiial preguaucy is isaid to be jfrimarij when the im- 
pregnated ovule^ tailiug to [lasss from ovary to tube, drojjs 

FlO.77. 




Utcrui iind f(«tiii tti * CMe Of abdominal pregnancy. 



down intu the cavity of the |>enlQueum» and attachiiij^r »t*^lf 
to that memfu*ane, liepn>* there its priiuary flevehipment. The 
ex»8teat'e of this variety ban been denied anil thoutjbt to l^e 
iniiM>,«dlde ; it is j«aid that the peritouenm wrudd dijrest Iheiivum, 
etc. But that jm[)re^natioo may really oerur in the alHlom- 
inal cavity Is shown in a case where the butly ami [wirt of the 
ne*'k nf the uterus liad In-en remove*!, the uvaries remaining. 
8*Mueu j)a8sed m thnujirh a fiHtuhuii* openiofir in the stump of 
the cervix, and nlidtiminal pn»gnam'y iVdlowed. 

Most castas of al>dt>miual prejjuancy are said to lie ^eamdary^ 
that is to gay, they begin as tubal, ovarian, interstitial, or 



SnfPTOMS AXD in A GNOSIS, 



215 



intra -ligamentous eiises, a ml afk-r rupture become, /femvffan'iff^ 
ftl)<dominnl caHes. The ijvum remains partly connected with 
if.s first sac, but wherever it touches the itt^ritoDeum a prolif- 
eration of connective tissue ot^eurs, and m the sac is enlarged 
and ctmtiuues to grow, forming aflhesions to various visceral 
layers of peritoneum. More rarely there are no restricting 
f^seudtj-mendirunes, the ovum, surroundefl by its amnion and 
chorion, }>ein^' free in the al>dominal cavity, And still more 
rHrely the amiuorj and chorion may afm ru|iture, leaving the 
chihl looHe in ihc? cavity of tfie ntidomen. It then usually dies, 
hut exceptionally iloe^n not, hut pursues its i level opmeot in a 
new sac of jjro life rated connective tissue. 

Symptomfi and Diagnosis. — Nothing s|x*ciiil occurs during 
the early part of pregnancy, exeejit that the uterus does not 
eidarge eorres|K>udingly with the duration of pregnancy, At^ 
tacks of pain in the ahdomen may occur, with fever, due to 
local j>eritonitis and stretching of adhesions^ and sometimes 
fjain is prtxluceil hy fietal motions. Most cases jirogrexs with- 
out other remarkahle symptoms ; sometimes there may he 
partial rupture of the cyst, with iiKMlerate bleeding and pnKh 
tnitifin^ and suhs*^<|ucnt recovery. I^ite in pregnancy the 
movements of the child are more ensily felt, and the s^mnda 
of its heart more distimlly heard than in normal pregnancy. 
The ftetal jmrts may sometimes be distinctly telt tlirough the 
posterior vaginal wall, iti Douglas' ciil-tie-Mw. This, however, 
may also occur in cases of bisaceulated uteri, but here the 
jxwiition of the os ami cervix uteri would aid the diagnosis. 
(St^e Chapter VI IL, jk 1T2, Figure 70). Rmall size of the 
utertjs |)recludes the jxjssihility of its containing the f«.etus. 
At full term tahor-pains hegin — uterine contrjictioiis— with 
discharge of the uterine decitlua and siane blood, an<l the 
foetus, till now alive, well, and nowiially developie^l, soon dies. 
It may remain for many years without change; or become 
partially absorbed, leaving a lithoinedion ; or again, which is 
mast ccmimou, the cyst iR'coraes iuHamed and sujjpurates, the 
child hreaks n[», deeom|>oses, and the whole contents of the 
abscess are discharge<! through tistnlons opeiungs into the ad- 
joining visceral favities, i>r **xternally through the skin, the 
wonmn being liable to death from exhaustion, septiciemia, etc. 
lu eases where a diagnosis is a/mod certain, it is permissiljle 
to make it quite so by pacing a linger through the dilated 



216 



KXTRA^VTERINE PREGSASVY, ETC. 



OS uteri, thus demoitst rating the emptiness of the uterine 
cavity. 

Treatment. — In ahilominal pre^nuuiry we i>fWn liiivt* to (l**;il 
with 11 !h'€ fhihl aiifl wilh !i lUnehjpfii phtrejiia, tliis hitter 
not Iteiiig attacheil to any uiuH-ulur striitlnre — lii%c the wall 
of the uterus — whieh will r<inlmrt aiiVl preveiil hleediDg after 
eepiiraticjn, henre danger of lieiiiorrhage. 

If tive chihl he alive^ an*l the woman present no very serious 
symptoms, nothing might be done unTil near full term. Then, 
one of two courses is available; either ** pnmunj ctrHoUmiy^' 



FJG.78, 




LithopKdion. (From PlatfaibO 

Iwfore the chili 1 (liesi, on* I h\ order thnt it mixy Ive ex t meted 
alive; or ^'tt^vondaiy caiiafomij'' None weeks, or even nunitli!^, 
after its death* Which it* the f>etter jdan !ms long been n 
matter of discui^sion, and Hi ill remains unsettled, fiy the 
primary operation the ehild h s*jmetime>» savecl, but the risk 
to the mother— 10 maternal *leaths in 40 eases — is im great 
(ehietly from hemorrhngi* at the placental j^ite ) that seeoiulary 
cceliotoiny has l»e<'n until recently preferred Lately, with 
improved melliodjs of o| Healing, the jjrhnary operntiou is grow* 
ing in favor, and the ebaoce of ssaving both child and mother 



TRKATMEST. 



217 



increased. When tlie child luis died* whether at term or 
bei'ore^ tJiere should he no n|R*rutiMii for at least a nmivih or 
even much hni^'^er, provided no syniptoius of st-pticteiida «rise. 
This delay ullou^ ohlitenUion of the phieeiital vessehs and 
le*3ens the risk of iicinorrhiige diiriii^^ and after the o)>eratioii. 
So lon^ as the dead ehild reiiiirmi^, however* the risk of sej> 
tica>niia reiiiaiiis also. Delay iiiiist he ine4isureit l»y the ease, 
not by rule. 8ome advis*^ the tihdonien t*i be tvpeiied **a,ss4Km 
Ui^ the plaeerital eiiTulation has eeased, x\^ eerlilied lo \\y the 
ahseiiee of phicentii I Jii ti rn i u r/ ' T ht^ operat lott { \vi I h id I aj*e] >tic 
preeatitioiis ) is ^lorie hy iiiakiii;^ an iuei:*ioii in the linea alba. 
Shtmid the foetal s^ae not l>e arlherent to the alMloniiniil wall 
it must be stitebed to the incised surfuces of the Winind before 
being opened. When o|iened the child h removed* the funis 
cut off close to the placenta, but the plaeentJi kft umliMnrfnd 
The sac \i^ packed with aseptic gauze, a purt of which is 
alloweil to protrude at the lower end of the alidominal incision, 
for drainage. In a few days the placental vessels will havo 
become obliterated, i>r the phicentu itself separated i'rmu \is. 
attach merits, when the abdominal iiicisaai may be a»:ain optoied 
and the jtlacenta removed. To attertqit s*^parali(>n «if the jJa- 
centa insures immediate and dangerous heiUfirrhage, Even 
when it is left, heiiifjrrhage may occur hi ten An improved 
mode of operating has been su<x*e*4fully practisied to avoid 
both the danger of hemorrhage and septicemia. It consists 
in exdedhtfj the entire cijst and placenUi at once, not by tear- 
ing or jieeling them away* hot by first clamping ami then 
ligating, hit by bit. all vfiscular e<mnections of the cyst ami 
phiecnta, the fiartii tied by the ligatures being then severed 
by incision. This method will probaldy sujiersede that of 
leaving the placenta undisturbed. At present the matter is 
unsettled. 

When* in neglected cases (without eoDliotomy ^, the fa?tus and 
lirptid contents of the cyst are (►eing gradually discharged 
thrtmgli fistulous oj>euiugs, the^^e ojvenings should be enhirged 
by careful stretching with steel dilators* arjttseptii' washes 
thrown in* free drainage sc^.Hired* and piti*es of hone or other 
obstructing debris removed by manijmlation. The wmnan is 
given iroii, f|uinuRs f*MHh and stimulauta to prevent exhaus- 
tion, and opiates to relieve |XiiD* 



218 



EXTRA' UTERINE PREGNANCY, ETC. 



HYBATIDirOEM. PREGNAHCY. (CYSTIC DEGENERA- 
TION OF THE CHORIAL VILLI, MYXOMA OF THE 
CHORION. VESICULAR MOLE.) 

Tb<^ i'a^tits dies early ^ tlissulv*'S, ami (lisjip|wan*, or tnay he 
fi)UJHl a.s a shrunken rt'imiiuit c»f its t'oriiii'r self, surrouutled 
hy iti^ am II urn and tlm degeDcrutftl cJiorioru The villi — the 
hulhou8 eu<is of iheir linuifheii- — heeome distended with tUiid 
inU) little &*acs or cysts uf iiitferent sizes, which continue to 
increase in uumlw'r till the uttruH Js tilled. Technically, the 
dispense is eydtr {ur Avn\Mr-m%\) drgenerat'mn of the ehorkd villi 
The cysts hun^^ hy loJig, iiarniw ix-dideH, like diniioiitive 
elastic pears, or dangle from each other, su^^^estin^ a rcscm- 
Idunce to Sfrpeat's eggs. Viewed m /ar/xx^; they look like a 
Iniiich of *rra[H\s, hut their hraiiching stalks are not derived, 
like a Imueh of gni|>e?^, from one main stem, Imt one cyst is 
joined hy its jK*clicle t*i another, and this agaio to another, 
until the final jH'iliele is trace<l to the niemhrnne of the chorion. 
Some of the cysts are half an inch in diitmeter or a little over 
— nif>st of them miicii smaller* (l^e Fig. 79.) 

The idea has hvng jirevuiled that the disease was a myxo- 
matous degeneratiiai of tlie niesohlastit^ eore in the interior of 
the villi, hut more re<*ent!y it has hcen demonstrated that the 
epithelial coi'ennfj^ of the villi— the layer nf Langhans and 
the pyneytiuni^ — are chiefly e4>iK*enied. Wiule the inner 
snlistuuce of the villi doej* undergo a myxomatous degenera- 
tion with ohl iteration of the fietal capillary hM>[>s, it is really 
the rapid proliferation and increased activity of the cells of 
l^nghans and of tlie syncytium ufwai which the development 
of a vesicular mole chiefly dejjcnds. 

The degenerated villi may |Mniotrate deeply into the nms- 
cnhir wall of the uterus, even to the (leritonenm, ami thus 
lead intlrrectly to rupture of the uterus. In sejme cases of 
twins the chorial villi of one fcetus may degeuenite, while 
those of the other do not — the latter child reaching, |x»ssildy, 
full development. In other e4iiies only a part of the villi l>e- 
eomes diseased, em>ugh remaining healthy to form a placenta, 
and the (*regnaney goes to full term with a \vell-fi>rmed child. 
The degenerative prt»ee8S usually ^f</*//x during the tin^t month 
of pregmiUi'V ; its tHinimeuceiiieot ifi seldon* |xjst|>oued later 
than the third ruoutk 



DIAGNOSfS OF TRUE IIYDATIDS. 



219 



Oauses. — It hns Ikth iiRTihed to cnnstitniioiml t^yphilLs, 
morlnd chatit^e?* in i\w (lecitlim, Hirly dtiuh i)f tbe I'liL'tus, Hc\, 
but the question is still unset iUmI. 

It has l)eeii cnlletl ht^datUlifonn ^yrcgvaurij irmu n crude re- 
eemblanee to, aod a former errontoitJi suppiwitioii that the 
vy»ts were ideutieal with, fnir hyihithh (eutozctji, acephnlo- 
eystg)* such as orcur iu the liver luid i>ther organs (jKJssihIy 
m the uterus'), I nit whteh have nothing to du with impregna- 
tiuu, or UQ ovum* 



Fio. 79. 




Hydiitidirorm degeneration of tht- chrprt&l vUU. 



RcMiinnnt8 or repeated new developments of the ^ruwtii 
may appt^ar months or even years after impre^rnation. In 
women sepiimted from their hushands^ unpleasant eompiiea- 
tioiiii mi;fht tlnjs arise, and tlie ea.s** assume ineditThleiral ini- 
jKJrtmiee. 

Diagnosis of True Hydatids from Eydatldifonn Pregnancy* 
— hi true iiydatids the eysl^s develo]i, some inside of others, 




220 



EXTRA UTERiyE PnEGNAXrV, ETC. 



anti tlie echino€i>coi bea^ls and htK>klc{8 may be men with the 
mioroscojK^. This microscopic aiifieanuice is wanting in hyilat- 
iclifurm pre^oancv, in which, n\^\ we have 8ccn the cysts 
han^ hy stalks and iricrease by a m»rl uf liudding process — not 
insitle ea<*h otiier. 

Symptoms of Hydatidiforai Pregnancy. — Tlie early signs of 
pretjjtmncy follow iinprepiatioii as ysual j but there are no 
posilive or pljysicail signs, for the cliihl dies before the tenth 
week — H)fteti nuich sooner. Then follows extreme rapidity of 
uterine eular^^ement. At i^ix months the womli is as large as 
at full-term pregnancy, ft is unsynimetrical in ><hape : it \& 
doughy or lK>iZ"gy to the tt)nch, and no fcetuw can be felt in it, 
Overdi^^tention, Ijetwt^'n the tourtli and sixth niontht'* occa^^ions 
obstinate vomiting, and eventually leads to contraction of tlie 
womb, accompanied with giishea of trutisparcnl watery Huid, 
from crushing and burst iog of cysts. Hemorrhage — ^severe 
hemorrhage — ma)" aim occur, 

IHagnonH in confirmed by finding characteristic cysts in the 
discharges, or the mass may have been previously felt in the 
OS uteri. 

Prognosis. — Generally fiivorable. Mortality IH per cent 
The chief danger u^ hemorrhage. In rare cii,*cj* rupture of 
the uterus may ^Mxair^ with conse<iucnt hemorrhage into the 
peritoueal cavity, [jcritonitis, septicicmia, and death. 

Treatment. — Empty the uterus and secure its contraction as 
soon an s,afely pracltcable. Give crgol. Open the os uteri, 
if necessary, with a Barnes or other dilator, and witl» the 
fingers or hand, or half hand in the uterus, carefully extract 
the mass. Beware of rtipturhi^; tjtr uterine wall ; it may he vrrif 
thin, especially In advance*! caiH\s with great distention. 
While the os is ililating a tam|M>n may be nci-essary to check 
hemorrhage. Jtisteud of using the hand* the mass may Iw 
broken U|» with a male nictal <*atlicler, and left to be exjit^llcd 
by uterine coutractioti, espmiilly when the os is nndilatefi, a 
tamjMju being used to contnd hemorrhage. In no instance 
t»houhi the curette l>e used, owing to danger of its penetrating 
the thin uterine wall. 

In case the child is demonstrated to 1>e allye (as in the rare 
instances of twins prevh>usly nientitnicd), an attempt may 1^ 
made to control hemorrhage without emptying the uterus; 
but should this not succoe<l, and the life of tlie woman l>e 



DECinrOMA .V.l LiaXVM. 



221 



j eopa r«] \ le* 1 , t ht^ rule i tf ' re mo v * 1 1 jx the 1 ly < 1 a t i « 1 i f b rrii m ass ni u »t 
Ire jidliered to, whether the beiilthy (»vuru lie distiirliefl or not. 

After emptying the nteriis iH <*uvity slioultl Iw^ wa^^liefl unt 
with a earbolie jiolnlion. If bleeding t'ontinue» tampon llie 
uterine envity with loilofbrm ^auze. T<j prevent reeurreiiee 
of the growth J liarne^ reetjmtnen<l&« painting the inside of the 
uterus with tr» iodin, one jjitrt, to glyeeriDt five parts, onee a 
week for several weeks. Should there l»e any ojeitxivr dis- 
charge, wa^^li out the litems willi some unti:^eptic jsolutiou and 
insert a .Hup[X)sifury of iudoforni. 

In eases where a liiagnosis has l>een made early in preg- 
nancy, or even later, but wifhoid (ttry uftTine contracttouji or 
heniorrluige^ it will be lie^t to dilate the os titeri, bring on 
Jabor, and empty the wondj, and thus lessen the danger of 
hemorrhage, wbieh inerease^? with the duration of pregnaney. 

While the aneient idea that all eases of cyaric degeneration 
of the ehorion were iiialigtmnt lias l)eeo long ago abandone^l, 
reeenl invi'.stigation h:u*9h(*wn that there ij^an intimate relation 
between nnilignant disease of tlie phuental site and ey^tie dis- 
ease «)f the chorion. Bo freijuently, »n tact, doeii tliat most 
nipidly fatal form (if eatieer — iheldtittma malitjtnim — -ftdhnv 
hydatiditbrm mole that its iweurrence should be born in mind 
a^ a possible thing in every ease. The disease will now l>e 
considered in a separate £teettt>n. 



DECIDUOBIA MALIGNUM CHORIO EPITHELIOMA 

MALIGNXJM). 

The first term implies thai tlie disease begins in thedei'idua, 
hence a mofemai growth ; the second, that it originates in the 
chorial villi, hence a Jtrtal growllu The latter is probably 
eorre**t, thnngh this is unsettled ; it may be either or botlu A 
dozen other synonynm have been used. 

It may mx'ur after labor and altorltun, but about 45 per 
cent, of the cases follow hydatidiform moU% In I2M cases 
collected by Ladinski, 51 followed mole, 42 followeil alwvrtion, 
28 labor at tenn, 4 premature Inbur, and H tubal pregnancy. 

Symptoms, — Keeurrcnt heninrrliage.s fnini the uteru^s and 
a more or less fiHil watery discharge, coming on davs^ week.-*, 
and even months after labor, abortion* or discharge of the 
vesicular mole. 



EXTRA-UTEIUNK PREGyANCY, ETC. 

A finger piissinl tlirougb the usiiully [mtolous 'w* uteri finds 
in thf enlar^jfi'd uteririt' ravily |>roj<H'tiiiif in:ia<i*s t*t'sofl tVinl>!e 
tissue that may \^ i'lmly lirokiMi ofl'iind extntcteil lor niiiTo- 
seiipiml exaniinutiatj. It m only l>y tli^j juR"ro.^L"u|>e timt i\n 
almAnlely potfitive diagnfjsi» can be niaile. The imiM>rtftnce 
of this sure method of diagn<jsis cannot he overe^ttininted* lor 
eariy extirp«ili<»n of the uterus is the patient's oiilf^ ho|>e of 

When ex|Mert niirruseopic evidence is utmvai!nhlc, there 
are other s^yrnptouis on which it would he jusliiinltle l(» do a 
hysterectomy ratlier than risk ihe wonuiiri^ lite liy defay. 
Til us hemorrluige^ and u fijul »iis<'hiirge, owing to retention of 
sei'uadine.s afVer un «u'< Unary lalwr or alujrtion, and wUhmit 
any nmiignaucy, nre pvnmitienth^ relieved by curettage ; while 
in deciduoma maligiium the uterine cavity, after being j^erapccl 
out, rapitlftf fiifs up atjuin (sonielirues even within a few days 
or weekvS) with the muligruttil growth, and the syuijitoms reeur. 

Anolher not uneoriimoii ?.yniptt>m is r=?pittiug of ld<iod 
-^hieniO[ity.sig, Tlii^ is due to metastasis of eaneer eells from 
the uterus to the hmgs. Tin- disease* is renmrkiihle for its 
numerous and venj ^flr/// metastases, thus produeing se<*oji(hiry 
growths in the lung, liver, jmncreas, (ileum, kidney, spleen, 
heart, diaphragm, ribs, |>ericardiuni, and brain. Sometimes 
se^'ondary growths are ftnind in the vaginal wall, or in one of 
the labia mujoni, prefieoting a jiri»jeeting friable mass like those 
in tht' uterus. 

Treatment. — Hysterectomy, mrhj eoniplete extirj^sUion of 
the nterus, is the only ho^)e. Otherwise, death io from three 
to six njonths. 



FIBRO-MYXOMATOUS DEGENERATION OF THE 
CHORION. 

Very rarely the interior strtima nf the chorial villi becomes 
more or les^ solid fri>m the developmetit of tibrous tissue ; thii* 
may go nn to form scattered nodule.s throughout the phieenta^ 
or give rise to one [)laeental tumor of considerable size. It 
may or tuay not be aeetm*[mriied with synqitonis requiring 
treatment by the ctirette and gauze packing to arrest hemor- 
rhuge. 



DROPSY OF THE AMNION. 223 



MOLES. 

Moles are masses of some sort, developed in and expelled 
from the uterus. If the growth result from impregnation, it 
is called a ** true " mole ; if it occur independent of impreg- 
nation, it is a ^^ false " mole. 

True moles : The hydatidiform pregnancy just described is 
a true mole. Another form — the ^^ fleshy mole " — occurs after 
early death of the fastus, from a sort of developmental meta- 
morphosis of the fcetal membranes, mingled with semi-organ- 
ized blood-clots, so as to form a more or less solid nondescript 
fleshy mass. Chorial villi may generally be discovered in it 
with the microscope. 

Portions of the foetal membranes, or of the placenta, may 
be left after abortion, and develop into true moles. 

False moles : An intra-uterine polypus, ot fibroid tumor, or 
retained coagula of menstrual bloody or a desquamative cast of 
mucous membrane from the uterine cavity (membranous dys- 
menorrhoea), may be expelled from the womb, with pains and 
bleeding resembling those of abortion or labor. p]xamination 
of the mass, its history, and absence of chorial villi, will be 
sufficient to indic^ite a correct diagnosis, and shield the female, 
if unmarried, from any undeserved suspicions. 

A desquamative cast from the vagina may occasionally 
occur. 

These are so-called false moles ; they seldom attain any con- 
siderable size. 

Treatment consists in securing their complete expulsion by 
ergot, digital manipulation, or curetting. In cases of fibroid 
tumors or polypi the usual surgical methods may be necessary 
for their removal. 

DROPSY OP THE AMNION (HYDRAMNION, HYDRAM- 
NIOS, POLYHYDRAMNIOS). 

The normal quantity of liquor aranii (one to two pints) 
may be increased to five, ten, and even twenty or more pints. 
This is hydramnion. 

Causes. — Causes not thoroughly understood. In some 
instances the cause is interference with return of blood to foetus 




224 



EXTMA'VTERiyE PnEGNAXCV, ETC. 



through unihilinil vein, eitlier irom pre.ssure ou the cnrd (asm 
twins ur tripkis ) (ir fmrn rlis^ast* uf I'lt* tal iieiirt, lyn;jjs ur liver, 
ohslriK'tiii!; ('iienlulitnj ; henro jissocmtnm of hy<lr!itimi(m willi 
By|>linitic (liR^af^tf *A' liver at' tu tus. Excessive s4.^e return ironi 
the kidneys or from the skin of the iu'tus. A en t erases 8orne- 
time-s fiillow l>low8 upon the tilnli>meii, with supposed intliirunui- 
tion (if the auuiion it.'ieif. Tljinru^s (if the mother^ lilnml 
irmy jinxluee it. There are numenius other dieoretieal exphi- 
uiitious. It is seldom oht^rve4 hefore the fitUi month* 

Symptoms. — Ahdomeu unnatnrully hir^^e from t>verdis- 
tendeil uterus ; inerease in size and weit^ht of the latter lead 
to dyspnoea and pal|>ital»on, vomitin<r, dys])epsia. hisimurm, 
lyi*! ledema iA' lahia and hnver limbs, tojiether with neuniljjlo 
uhclominal pain and tiitHeuit loeomolioih In case^ (*f fj/atlttttl 
aeeumulalion of tlui4 tlu^e sym|){oms may lie unexptrtedly 
mwlerate. Wry rarely the diseiL^^ oeeurs in an urate form, 
with fever, rapid itistead of g:ra<lual distention of the utenii3, 
and coii5e<pietit irjteuse ahdojiiinal paiu, extreme clyspnuea, 
cyanosis, and distressiiii? emesis. 

Hyflramuiou may lead to or l>e associated with ascites. 

Diagnosis.- — The nteriue tUTiit*r will i^e found, on pal|)alioii, 
ehislie and tense, with iudistiiiet tluiluation, bi^i'ominc: more 
distiuet as the distentioii iucreaae.s. The fveins is very mov- 
able, ehan^^in^f its (K)sition frequently ; its beart-Hunids are 
faint or inaudible. The hist*»ry of prejrnaney is an important 
element in ilia|rncisis ; it is sometimes overt iJH^ked. Twin l^reg- 
naney ditFers from hydmmrjios in pre^iieolin^ on jialpiitiou the 
e*>lid irreiTuhir ^irojeetiorss of the two fcetuses. An overdis- 
tendetl Idadth-r is tliHerentiate*! liy the catheter. l)islention 
fif tlie alMhinien fnuu ]>reLataney associated with eystic tumor 
of the ovary or bmad liiranient ilitfers from iivdramnios in 
presenting two tumors of different shajK^ and eonsisteney. In 
any case where the itiMloinen is enormously distended almost 
to its utmost capacity, a [positive dia^mo«fiis may be impossible 
witliHut an explorative afidorninal section, or rediietinii of the 
Huid by punelnre. 

Prognosis and Treatment* — Death of ihe fa-tm antl prema- 
ture labor art* ajtt to <K'cun One-f<mrth of the chihlren are 
MilllMirn. Interference with respiration and other tunctions 
of the mother may endauf^^er her life unles?^ rupture of the 
8110 occur »pontaueoui8ly, or tlie Huid be discharged l»y iirit- 



BYDnORElVEA. 



225 



ficially rupturin;,' it, wliicli is iilnnit all tliiil can l>e done hy 
way of troiitmi'iii, aiifl wliirb, of courts ends the ijregnancy. 
Attemjitfi inay Ik* mmie tt> make mdy n ^iiiaH jaitirture of ihe 
amiiiotie sac hifjtii up belweeu the iiieiiihraiR'S ami uterine 
wall, so as to allow the Mil id to run out ju^radyally, and thus 
avoitl premature hihor. Tap[)iii;^f of the uterus t!irou*rh the 
ahilominal vvalh for the same (nirposc, ha.s been repeatedly 
done, intentionally, in the interejit of the ehild, ami without 
any Hpeeud harm to the mother, l)ut the uneertaiiity of the 
ehihTs life tw'iireely justifies the nsk to her whicdi is insepa- 
rable fnjtu sueh an o|>era(ion. 

When the tluid is suihleuly evaruated, apply ahdominal 
bandn»,'e to prevent syneojw from rapid reduetiuu tA' intra- 
alnJominal pressure. DuriuL^ labor beware <jf uterine niertia 
and beuiorrhagej ma 1 present at ion, aud prolapse of funis. 

DEnCIENT LIQUOR AMNH (OLIGOHYBE AMNIOS). 

lit the al>senee of sutfieieiit liqitor amnii to distend the 
amnion and kee|) it away fnun tlie ftetus, adhesions may o<-eur 
between the f<JL*lal skin and amniotic; mem bra ne — they grow 
toj^elher. In ease* the dehriiiit Huid is restored later, these 
adhesiorjs may streteh into bands i^r eord.s produeini: *leform- 
iti(?s of the ffi^tns or amijutation of its limbs. Two lindis, in 
eunlael with eaeh other, may grow together when there in not 
eriouiih lirjuor amnii to sejiarate them and allow of their free 
motion. There is oo trvntmrnL 



HYDROREHCEA (HYPRORRHCEA aRAVIBARUM). 

During the later mouths of pre^ruaney (sometimes earlier) 
women observe a ilin^harjire of tluid from the vagina— either 
a perreptiblegush or aeotuinuous triekle or dropping— which 
they think ig flue to rupture of the bag of waters ; yet on ex- 
am iuat ion the hag is found *(idu*i>ken. The dim'harge may 
oeeur during rest, as after exereisi^ or violence. It is usually 
due to t'alarrhnf endomrtriiij^ — itdlannnation of the mucous 
lining of the uterus. The fluid rt^end»les liquor amnii both 
in txlor antl color, but is sometimes mueo-purulent or tinged 
with blood. It aeeumuhites between tlie chorion and deeidna 
reflexa, until rupture of the hitter nieralinuie allowa its escape, 
15 



226 



EXTRA-VTERIXE PREG NANCY, ETC. 



perhnpii in ijyantitk^s of a pint or less ; or It may be formed 
ehiefiy Ity the deeidua verii, iiiid esea(>e gnidimlly belwt/eii 
timt nieialjrant* and llit* detiduH: reflexa. Oh^^tnielinn to the 
outrtow at I he inU*riinl (»s uteri, or fnihesioiis hetvveen the de- 
eidya vera and retlexa, may a^aiiu cause aceumiilatkm itf the 
fluid and its liijrt'harjre in quantity later on. 

A few cases have beeo otji^erved lu which fluid aceumiilated 
l>etweeu tlie choriou and amnion, as shown io Fig* 80 from 
J. B. Niehols' pnldieatioo. 

Fio.ao. 




Afterbirth with double tac 1. Out^r iae— cberlon and de«ldUA. 2. Inner 
iuMj-aninitin. 3. Chonotiic c«viiy, 4, Amniotic cmvUy. 5. f'liiotftiUi. 



The diiRdiarpe is distinjruished from that foHowin^ rnpture 
of the amnion in that the latter only oi*i'urs oitcf, and is foi- 
iuwed by Ial>ar. Rare cmsei* are, however* recorded tA'atnuiotie 
hydvorrhma in which the amuiotU' fluid has jTradually ei«capeii 
at intervals, for weeks or mutiths liefore hdxir, tlmni^jjh an 
apt»rture in the amnion hi«rb u\i in the uterm*, far above the 
internal im. In one cnse the amnion had Imhmi punctured by 
an ill-fornu*d foetal boiu% 

In any cmi\ if the fbs«dinrge \w sudden and considerable in 
quantity, it may he fuUowetl by jmin and premature la!x>r» Ta 



HYDRORBHCEA. 



227 



prevent this we enjoin absolute red and an opiate, taking care 
to avoid the mistake of hastening labor, under the impression 
that the waters have broken, when, really, they have not By 
this treatment (there is no other) pregnancy may go on to full 
term. The catarrhal endometritis can, of course, only be 
treated after pregnancy is over. * 



CHAPTER XII, 



LABOR 



Labor is the aot of delivery or chilrlbirth— |mrturitioii* 
The i^eriofl jdhT iiupre^^niitiuu ut which it tiikci* place is ten 
liiiijir Jiiniiths (M "tfiereuhouts (2M0 days), Chihlren miiy be 
iRiru tiiJve earlier, as already exphiineih and excepli<j|ially, 
the |iregnaiicy may hist t^n linj^ iin eleven or even twelve 
iiioiiths. The /wH^i^fYiV^/ of these latter cases hef^jnie.^ ini|M)r- 
tHQt, eonaidered in a medioo-legal p>itil of view. Furprediel- 
iufr the date of delivery Jii a giveu ease tliere are several 
1 1 1 e t h od?4. T I le I lest i .s | h a t of N aej^e 1 e, to w i t : {1} A Hi*e rta i ii 
the day f>n uhieh the lai?t meiistruatioTi eeaKd ; (2) count hack 
three niimdnr months; (^4) mhl seven days. For example : 
Men.itrualion readied A tigiLst, 1st, count hack three monthy — - 
1* e., to J [ay 1st — add seven days, which brings nsto May 8th» 
the probable day of delivery. Jt is the same as, bnl easier 
than countiug forward nine calendar months and adding 
stn^en days. To be quiie exact, tiie nund>er of days to be 
added will sometimes vary, as shown m the dra|;nmi con- 
structed t^y Sehnlze. ( See Fijj. ^^1. ) Thus, if atU'reonnting 
back three months we reacli Marcb, ^fay, June, Jnly. August^ 
Octolier, or Ki*veinber, the number i>f days to be adderl 19 
jseven; if April c)r September, Mix; if December or January^ 
Jtve ; if February, /onr, Bhonld the (ircgnaney include Fel>- 
ruary of a leajvyear, the figures contained in brackets are to 
l»e added, except when the counting liack brings us into 
Decendier, January, or February. 

In cases where the date of the hist menstruation eanmrt be 
ascertained, or in which the woman l»e<ame pregnant while 
not menstruating, as may happen during lactation, etc., the 
|»eri*Kl of delivery can l»e only approximately detertnined by 
notittg the size f»f the uterus and the height to which the 
fundus has risen in the abdomen ; ibus estimating the present 



CAUSE OF LABOR AT FULL TERM. 



229 



duration of the pregnancy and the consequent number of addi- 
tional weeks before full term. (See page 134, Fig. 66.) It 
may also l)e remembered that quickening is first noticed by 
the woman, muaily about the middle of pregnancy (end of 
twentieth week) in primiparae, and one or two weeks later in 
multiparse ; but there are many exceptions to this usual rule. 



Flo. 81. 



^t^S 






*U<L3 



,/ 




m 280 i 



• '%!# * 





CAUSE OF LABOR AT FULL TERM. 

A number of factors combine to provoke uterine contrac- 
tion, chief among which may be mentioned gradual distention 
of the uterus near the end of pregnancy (not l>efore) from the 
organ having reached the physiological limit of its growth, 
while the bulk of its contents still continues to increase. 

Increased muscular irritability of the uterine walls and 
exaggerated reflex excitability of the spinal cord probably 
occur toward the end of pregnancy, so that the uterus is ex- 
cited to contract more readily ; while the stimuli to contraction, 
viz., distention, motions of the child, stretching of the uterine 
ligaments, j)re8sure of the womb on contiguous parts from it3 
own weight, and cx)mpression of it by surrounding peritoneal 
and muscular layers, are all exaggerated. 



230 



LA BOB. 



Wlieu the jiresenliijp: jmrt of the fo?tiL^ ilisteiuls anr! presjises 
U|^)ii the ueek (if the yturiis, coDtractions are excited (just m 
the bladder and rwtimi contnu^t when tht^ir contents press 
U|M)n and di^iteod their re8j>e<*five uw^-ks k but, in lahor^ (Ins 13 
after the l^efrinnin<_^ henee irritiUi<tii nf ilie sphincter (a*? uteri J 
cannot he eonsitlered ilw primnm mohiiaA' uterine rontraetion. 

Forces by wMch the CMd is Expelled- — Tlie niain iV»ree ia 
(bat tit' ulerine enniraetion, whidi dtTJves its (Kiwer ehietly 
by reflex tnotvtr intliienee i'roni the i^pinal (''^rd ; the secondary 
ur '*aree-^s<»ry '* force is contraction of the ahdominal nuiscles 
and diapbra^^UK Uterine contraelion is entirely involuntary, 
that of the aJxhuninal mu^*cle.^ may he assisted by voluntary 
eifnri in llie act of gtrainin;^^^ 

Labor Pains. ^ — A latmr pain is a cimtrartion of the uterus 
la^itiu;^ f(»r a little time, and then followerl by an niterval of 
rehixntion nr rvi^L In the heLnnninij^ of labor the paiui* are 
short in ihtrut ion {tlurly j^eeoniis *tr lesi* j ; feeble iu tlripre ; 
the intervals are loiuj (half an lionr or more), and there is no 
contraction of the abdominal muscles or Mniinin^ etflut. As 
hilwir j)ro^rre*s*\s in the mitural (»rder of thinpi, the jmius 
gradually incrtui^e in duration, streuirth. and tlie amount of 
Ft raining effort, and the intervals iK^twe^^n them bt*i'ome 
shorter. Uf) to the moment (»f delivery. The longest |>ains 
seldom exceed oiu^ hyndre<l tH^tanK 

The tarhj pains are called **cuttin;ir *' or "grinding** pains, 
from the acenrn[mnying sensations ex |>erienr"t'd liy the woman ; 
anil the later <Miei^ *' hearing-down '' pains, from the distress- 
ing tenesmus or straining by whieh they are attet^ded. 

Ill cases w here there is no nialprt)pirtion betweeti the size of 
the hea<l and pelvis, and other things are jK^rfecily normal, 
there arc still twf) great stphinelorial gateways whieh otfer a 
certain amoutjt of obstruct inn to the passage of the child, and 
the resistance of which mnat be overcome before del i very cim 



ITIm 




^ ' .*rorU»iM)tf- 


n^nl. may- 


fiiir ^ 




i the fait 


111 nut ions 


tM'Uv^ 




ifu-m to \» . 


rhQ Mymim- 


tJu'lir 


;. -I'-iii if 


. J, 1 i. itifi \iiiii nil.' iimtiir • « 


rsM * ir»wtl»>n "li 


ktuws u 


lit •*xl><t il 


lilt* mniiiiUx fiittf$nfffttn '* Ip 


I rii MlMM.k tif PhysJ- 


ofML'v :; 


h ilitionj 


^ 7<<l) "Hv* ■ " 'I'St* ^vtiot*' ]tr< t 





lurtluu upuu tile utvrii. 



irwii iiiiHir !>■ Jii'iu:i:iy rnrnirr hi 

MtwUtcb fiR'lUwiUMi f^iirtiirlUoii. 



THE STAGES OF LABOR. 



231 



take place : thejse are first, the mo ?f^ A af the tiierui ; second, 
the monfh of the vaijina. 

The '* Bag of Waters," — A oalurnl urraiigenient is pro 
vidtnl fur the ilihitatimj and upemner t't the rewistiDg o« uteris 
}jy the frrailuul forein^,^ iiUo and protriKsiun through k of the 
mo^t «!e|>endiTii^f j^irt uf the umnidtie i*ue, or ** ha^' of waters/' 
During |jthc>r-paiits tlir euutraetiiig' rinndar lavt*i-s of uterine 
imL^'le.-* fonipres:^ iht* '^bti)^*' ou al! sides, eireuiuferetitially, 
thiif^ tending to make it hiilge out at the ouly jwjint of e.s<'a|ie 
(the o* uteri) , while the loogitudiual ruuseuhir hiyers m the 
uterine well shorten the womb, and ihye tend to pull haek 
or retniet the ring of the m from off the bulging enrl of the 
protruding bag. The hag [*eiiig wft, !«mo«th, and ela^^tie, eau 
more comjjletely fit and more easily dilate the os uteri than 
any part of the foito:*, henre the im|X)rtanee of not !>reakjng 
it clnring the early [>art of the tabor* The iveighl of the eon- 
taitied lii|Uur amnii proliahly assists dilatation, the woman not 
being eontined to a reennd>ent (Kisture. 

Tlie hag of waters tdst» yiroterts the body of fa?tus» plaeenta, 
and umbili<^al eord from tlie direet prepare of the uterine 
wall ; and it allows the womb to maintain its symmetrieal 
t»liap, thus les.^ening interference with the uterine and pla- 
cental eircuIatifUL 



THE STAGES OF LABOE. 

I^hor is divided into three stages ; the first stage begins 
with the eonimeneenu'iit itf labor and ends when the os uteri 
is eompletely dilateil. 

The Aertmd stage immediately fcdlows the first, and ends 
when the rhild is born. 

The third ineludes the time oeeupied by the separation and 
ex(Hdsion of the |>lacenta ; it ends with safe contraction of the 
ntnv ern[)ty uterus. 

Premonitory Symptoms of Labor. — Sitiking of the uterus, 
which usually ocrnrs three or four weeks before term in prind- 
piara?', and a week or ten flays before in multijMine, with conse- 
quent relief to eough, ilyspiuea, palpitation, ete\, as previously 
explained (jMige^^ KU arnl 1*^4 ). Increased frwpieney of evacu- 
ations from Ijowels ant! Idadder from pressure on them of the 
now sunken uterus, C ommeneing and progres{>ive tjbliteration 




I'oimncuduK diUUiUiin of Itie m utorL Kxnitiliiiitluii with Indos attger uf 
• right Imitd, lAlWr Parvix;) 



Signs and Symptoms of Actual Labor. — The olmnicteristic 
fiijLmsare: L Liilior [Kiiiim, 2, C '<iriiineiM'in^' ^lilatatioii of ihe 
m uteri. -1. Fre?*eiKt% ttr iiirrrjiK* if |>revii»ui*ly exLstinj;, of 
iiniri»-?4iintriit»»**<»nf* iIL^^-hnri^i:— ihe **slHnv." 4. (*uitiint*ririii^ 
drwvijt int4» or prutrusiou tfiruu|rli the o? uteri of the \h\^ rjf 
waters. 5. Hujihire of ihe bug and dijjeharge of liquor nmuii; 




PHENOMENA OF THE FIRST STAGE. 



233 



6. Rt^Iaxatiou of exterual genitals. 7. The vocal outcry, ex- 
pression, eh\ 

Phenomena of the First Sta^e. — Feel)leue#»4* and iofre- 
cjueiu'v i>i tlic tii-st ****Littiii^''* paiim. StiWWing ilurinj^ them 
h referretl chietiy to the Imck. The womaii walks mImiui, if 
not prohilntt'd from clointr so ; is restlej*i?» desjmmlent, perha|is 
slightly irrititble frum iiii^njiiti'Ut at progress beiog slow* 

Fro. 83. 




Tliu o» liivri more dilated. Kxnmi tint ion by DiigerH of Kft hatnl. lAfLvr 

l*AltVlN.| 

As dilntation of ilie os uteri |>rogresses, the paiosi become 
**twaring-ilowa /* in character, nn»l the pain in l!ie haek 
increaj*ei* in ^'verify, Niinsca and voniilin)^ orcnr during 
further dilatation, and prolml»ly i\im»t it by prmlnring relax- 
ation. When dilatation is near eoniftletion slight *V8hndden<*' 
or even severe rigors oecnr, bnt without any fever. Full dila- 



2:14 



LABOR, 



hit ion nf tjif OS uteri i.H ijHuiiIly aiiiioiinf'ed by rupture of the 
bag of vvuters during n \mm uuil lui 'liudible gush of liquor 



no. 84. 




Complete dllntJitlorn of lb« ot titcH. B«ir *>f wttem will soon niptan' i AIT4?r 
amniiJ On vaginal examiimtitm we fiuil simply pmgrcsswive 

I hfsi^»tav ttuttion, nipttifii (if Uiv im$i ilcdtiun Uie eiift of Uic flr»t aUgv of 
l«.bor; it miiy, liowt3%er« |>ri^r«di* ctllnttition 



k 



PHENOMENA OF THE SECOND STAGE, 



235 



dilutiitioii of ihe m uteri ami protrumoii of tho hn^ of vvalers. 
The |»rfst^iiting pnrt of tlie child tiuiy he felt throuj^h tbe 
imhnikt'ii sac*. The duration of the Hrst stajj^e varies iinirh 
in ditl'ereyt cases ; it \ti uearly ahvayj^ murh loii)/er thau llie 
other two nta^tvs eombiue^l. h is, imieed, a eonmjor* ohserva- 
tioa thai a lonf^er time is rcHjiiired for the o.^ iittri U> dihiteas 
large a.s a jsilver dolhir thtui for all suhj^equent [nirts of the 
labor together. Tlie first stage is usually lunger ia ].>rimii»ar- 



/' l^t^-C 



WiS' 



Hcud Ml vulval ojx»nlMfr aj»t<»nding pc*rlneiim. (After I'ahvinj a. Caput sue- 
OMiAiU'um, h, iJisteuikMl perJQtiUfu. e. Anui. d. Coccyx, on lloe of clrcum- 
Jbrvncc t»f dlilvndfil i 



Otis women, and Htil! more m in prinnfiara" over thirty years 
of iijre. An ot* uteri rhjit !>* S4»tt, thick, and elastic dilate:* more 
readily than a lainl, thin, ri^iil one. Prematnre rapture of 
the l>a<r of wat^'i'H ;rr»'atty lni(MMh'j< dihitatinn. 

Phenomena of the Second Stage. — Tretnemlons increase in 
the fVec|uency, i*tren^'th» <lanitinn. and expiilnive or hearin^;- 
down character of the pniiiHt. Nevertheless they are more 




2:50 



LABOR 



ooiiti*nlc(lly lM>rne, i*mm (siuppwied) coost'toutiuess of pni^ress 
on the part of the womiiii. Tlie lieiul of the <'hilcl may now 
lie felt (lesceiidiiig itito iiud beghuiiu^^ to |)rohiiile tliroii^di 
the OS uleri. It eventually ^y^^ thrcjugh tht^ (js into the 
vagina, acconipsmied with it^ut^wnl tluu of srant^ reiniyuiiig 
lirjunr anuiii, TWre miiv he a rnonjHitary |];mse in the 8uf- 
fe^inl^^ and the woman may exehiinj. *'Sumellung bu?^ enniel" 
The head now preissing u|»oii seiiMtive nerves in the vagina 
elidls still more rellex motor pnver inmi the spinal eord, anti 
the paiQs are still lon^ier, iilronger. more frequent, and ex- 
pulsive. The corrugated st*alp of the eliild, swollen and 




UeAil iibout to yio** the vulval opentng- (After PAiiviN.) 

CDclematnu^ («*<*n?titutin^^ the rttpnf Hitceechtirttm), i^neee.si^ivelv" 
ftpprofi(du\s touchers and br^Ldns Ut dii«tend I be vulva and |H^ri- 
nenni, Theannn is dilated and everted, feeal njatter it* foreinj 
out» the jK'rtneum isstretehed more and more, ntilil iti^aut^rior 
border is almost a» thin an pafier, ntid al last, in a climax of 
siifTeriu^, the ecpmtor of the head s*li|»s throu«rh the 8ee<»nd 
8[>Innctonal j?att>way (the os vainme), nn«l tfie hear] \n iKirn. 
A minute of n^t mny f illnw, and then, with one or two more 
pains, the hody of the elnhl i.** exjM'lltHi, and the wn'nnd sta^e 
of labor is oven The duration of the i?econd 8tage largely 




VOCAL OUTCRY, EXPnESSION, ETC. 



237 



flepenfis \i\Hn\ tlie ililalability orilii^ perineunu In a natural 
cuKe, litlier thiiigjs l>t'iti;j^ equal, a H»ft, ihiek, elastic |>eririeum, 
witli aljuiulant inueourf diiirharj.fi% and in a yuung and nuil- 
ti|Mironj^ wi»nniu» will ililute sooner than when opjwjsite condi- 
tion ,s prevail. 

Phenomena of the Third Stage. — By the time the rhild is 
fnlly exj»t^lled ihe [daeenla i,s often se[)arated from the uleritie 
wail and lyini;^ loose in the now contracted uterine cavity. 
The wund) may lie felt as a hard, irregularly gloluilar hall 
ahf)ve the pu!>e». There may he an interval of one-quarter 
or onedialf of an hour's rest fnmr |:»ainK if the (*ase he left 
entirely ahaie. Then, sooner or later, gentle pains again 
come on, the placenta is doid)led vertically, the iietal sur- 
face of one half in a[>iK)sition with that of the other, and the 
organ protruded endwise into the vagina, from whence it ia, 
by other flight pa inn. finally ex}K:-lled, together with some 
Mood, remains of lirpior amnii, mcnd>ranes etc. The womb 
now^ 4*ontructs into a distinctly glohular hard mas,s no higger 
than a cricketdmlh thus eHectLially closing the uterine hlinnl- 
vciisels and preveuthig hemorrhage, which last is further 
stopj>tMl liy cimgulalion of bloiHl in the moutlis nf the ofjen 
hliMKl-eha nuids. Thus en<ls thti tliiri] siai^e of laixjr. 

The Vocal Outcry, Expression, etc.^ — ^^The^ vary with the 
different stages of htlmr, and with the tlifferent |>enods of 
each stiige, and even with tldferent pains of the tsjime period. 
At the very iH^gininng nf iht* lin^t stage, the woman, l>eing 
restive and ptTha[»s walking ahont the room, stops for a few 
inomeuts, fn^wns^ phices a hand upon the ahilomeii, or hack, 
holds her hrealh in silence I'ur a little time, and tlien. with a 
sigh of grief (the [lain heing over) g^oes on walking- and talk- 
ing as Uetore. A little later, when tlie suffering het^omes suf- 
ficient to caust^ an audible groan or outcry, it will be m^tice- 
able that the cry of the e^irlier pains, during commencing 
dilatation of the o8 uteri, is usually of a hufh-pitrhed, treble 
note — not uidike the plaintive whine of a setter-dog grieving 
for its absent master. So long as tins kind of outcr}^ *Ym- 
tinncH, there is generally slow progress only. With later 
and more effective pains, es|>ceially ti>ward the enrl of labtir, 
the note of the outcry is of a ti*f'pbaH.% or guttural character. 
The l>ej?t (>. c.» mmi effective) pnitis of all are those in which 
there i« actually 710 vocal myund of any kind ; the woman, with 



238 



LAfmn, 



closed eyes, com(iresfte*l li|i«i, uiid general ccmtmrtion of the 
facial musfOej;, gimply holds her hrwith ( milil nejirly '* blue 
in thefaee*M ftud i^tniuiM, with (}en\i^unn\\ l^rief jiu lilatinuiil 
rxjiiratory and inspiratory gasjw?, yntil tbi' pain is^ *^%^er, Tlien^ 
havia^^ n-irained Ikt voi<^% nhe di'claiin?? in InirrieiJ and V(»l- 
nlde terini* the intensity of tur a^rony, the deinatid tor hidp^ 
the hnitiility to Ifcur it any longer* and the helief ( j>erha|t*i| 
tluit i=he ninst die, fte. 

Durin"! tlie earlier pains the hands are eleuelied and the 
arms foreildy flexud. Later on« and eontioiion?»ly until the 
hirth, there \a a dispisilion to ^ras^paiid pnll any olijeet within 
reiieh, usually Ik tl-cdolhiuL^ or the hand of an attendant ; 
whih^ steady presi8nre downward \*< nuide l*y the tl^t u\t<m 
any firm ,«up|Mirt availalde tiirthai purpose. 

Tlu8 dis|Kiiiition to i^rasp junl pull with the hands while 
making prejvsure witfi tfie soles of the feet, is prolrahly the 
rudiaientary j^nrvival of haliit» aiijutred hy our i*ylvan auees- 
tors ages ago fntid still hi vo^nie with some uneivilized 
|H*oplej*). when wotnen were <lelivered in a mpiattiuL: jKisture, 
the hand;*, meanwhile, jj^i^Hsping" a s*;ipling of I he woo<h »»r a 
stake driven hi the ^^nmntl, to sready tbem during' the [inwx^sri. 

THE DURATION OP LABOR. 

The average ilu ration of hilK>r in natural eases is alwut ten 
hours. It may be over in one or twi> hours, or last Iwenty- 
four or longer witb*vut any bad conseqiienees* 



TBH MANAQEMEMT OF LABOR. 

Preparatory Treatment. — In anticii^wition of appraaehhig 
hibon t^*"^*'^"^^"'^^ aLrainst n^nt^tipation, by mild hixatives 
( esustor oil, manna, rhubarb k may be neeessan* to prevent 
feeal aeeumuhttion in lower boweb Mo<lerate exereise, as 
far as pmetieable in the often ain and eheerful wK'ial surround- 
ings to mitisrate de,'«|H»iideney. Phyj^ieal and mental excite*- 
menl mnst be avoided, Aseertain whether urine be voideil 
freely ; if not, use male elamlc eatheten 

Preparation for Labor and Its Emergencies. — Ou lieing 
ealled to a labor ease, the physician slaojld atb-nd tvithoiU 
dehiy^ and take with him aiwatfH the followiug articles: 



ASEPTIC MIDWIFERY AND ANTISEPTICS. 239 

1. Compressed antiseptic tablets of bichloride of mercury. * 

2. A pair of obstetric forceps. 

3. Fluid extract of ergot, f 5ij- 

4. Hypodermic syringe. 

5. Hypodermic tablets of morphia, strychnia, and nitro- 
glycerin. 

6. A stethoscope. 

7. Needles, needle-holder, and aseptic sutures. 

8. Male elastic catheter. 

9. A Davidson or fountain syringe. 

10. Iodoform gauze. 

11. Carbolic acid, gij. 

12. Bottle of carbolized vaseline or mollin (5 per cent). 

13. Creolin, ^ij. 

14. Rubber gloves. 

15. Sulphuric ether, Oss. This last, being bulky, may be 
omitted, if it can be obtained within easy distance of the patient. 

In addition to these things carried by the physician, the 
nurse or patient should be directed, before labor begins, to 
have ready also a bed-pan ; an abdominal binder ; a feeding 
cup ; a pint of whiskey or brandy ; two or three rolls of absorb- 
ent cotton ; large and small stifety-pins ; two pieces of rubber 
sheeting, each one yard by two in size (for which, as a matter 
of economy, ordinary table oil-cloth may be substituted) ; anti- 
septic pads for the lochia ; and larger bed-pads for labor ; and 
a pair of obstetrical leggings, together with plenty of clean 
towels and hot and cold water. 

The various " viatemity outfits " now on the market, con- 
taining most of the aseptic textural materials, are convenient 
and inexpensive. 

Many obstetricians recommend a much more elaborate and 
complicated array of materials, but if the practice of aseptic 
midwifery is ever to become universal, it is economy and sim- 
plicity that will make it so. 

Aseptic Midwifery and Antiseptics. — At the present time 
no argument is necessary to accentuate the importance of a 
rigid aseptic technique in the management of labor and in 
obstetrical operations and procedures of every kind. The 
aseptic method has almost completely blotted out puerperal- 

I The tablets I use are those of Dr. C. M. Wilson, containing hydrarg. bichlo- 
lid., grs. 7.7, animon. chlorid., grs. 7.3. Made by Wyeth & Bros. 



240 



LABOR. 



feviT fr<mi lying-in hoijpituli?, where* in furmer yeari?* many 
worneti <iie<l trivm that iliseu^. While in private |>nit'liee, 
with norniiii hyit^ienie i4urr^>lmditJ^^s, the niortulity fruni septic 
infection, without antiseptics, may by nceitlentiil giKnI luck he 
e<Hupiimtivcly ,snuill, it is exactly thi8 KUiall niuruiljly fnim 
which every woruiHJ ou^^ht to expect and demand protection 
at tlie hiioilH td" her uiedi< ill attendant. When [inijdiyhixis 
li-f [Mjs^ihlc, the liahility to dit^eiise and death eanuot legiti* 
mutely be left to chance and luck. 

The reiil reason why aseptic midwifery haB failed to receive 
in private pnietice the nniversal adoption which it deserves is 
not so much htck of belief in its ethcacy* ]>ut lark of kno\s led^^e 
m to the inetiiod of pnH'cfhire, ditfieully in the tseleetion of 
one method tVoni namy others, and patience in earryiug out 
details of whatever plan may have been rho.sen. Tt» facilitate 
and simplify tlie runt ten I lie following directions may be t»f 
service. 

Aniiitt'ptir Sahitions, — Three antii*epties, now in common n?e, 
are hicldoruh of mercury, vrmliu, and mrbnlic uckL The 
stronger bichloride jsidutioti ( 1 ; 1000 ) it* made by adiiinjtr about 
^ven and a half grains^ of bichloride of mercury to one |*i!it 
of iHiiied water; m«*st eonveuiently and more exactly done liy 
using the eompre^Hefl tablets now on the market, each contain- 
ing 7-7 grains of the liichlorifle, t.rarihj liufficient to nnike the 
1 : 1000 solution. < )f course, 1 : 2^*00 or 1 : :^000, and 1 : 4tKK) 
s<olution8 are made by adding the wirne amount of luehloride 
t(* 2, *i, or 4 pints of water re^j>eetively. 

The j^trong i^cjlntions of carbofic arid { 1 : 20, or '> |>er cent.) can 
1»e made, approximately, by adiJing f^^j (six gmall teas|ioou- 
fuls } of carbolic acid to one pint of water. This strong (solu- 
tion may l>e usi^d to sterili/e inj^truments, but a weaker pre]>a- 
ration — ^ij to the pint of water — wiJl be used for the vaginal 
or uterine «jouche. 

Vrealiii doe.s not disj*idve in, but c^asily nnxc^ with water to 
form a milky emnbion, the strength of which, for douehirtg, 
should l>e from 1 to 2 fier cent. — ubi^id f^j (or ii small tea- 
»|xHmful ) to one pint of water. 

Of these* three the bicblori^le i^ the best germicide, espe- 
cially for cleansing tlie external part*** C^reolin is .safer for 
the internal douching. Carbolic acid, in strong solution, ibr 
in»tniiuenti$. In making either prepnratioo, vms jirst a little 




ASEPTIC MIDWIFERY Aa\1) AyTISEPTICS. 241 

hot water whh [\w -Lrernik'i(k\ tht'ii ad*! the refjuired quantity 
later* 

The aseptk* nijinafjrenjent of iinriiial Jnbnr aim.s to prrvp.ni 
itifeelioiL The projihylaxis tNHij^ists iu thorough dij^intWtiou 
of the jfaiient, tht^ phymcian^ and the hiMmmcnts and apjdianee^ 
employed. The mniple^t method k us follows : The putieni, at 
the heginning i>f labor takes a tepid hath and is well jWLTuhheHi 
all over with Ruip and water. Then an enema of soap and 
water to emjity the fiowel ; aiU*r tlie action of which, the 
external genitals, thiglis l)ytt«jcks, and abdomen are carefully 
wai?hed with a 1 : 20U0 htchloride i*<>lutioii, special attention 
Ijehjg triven to overlook no fidd or ti.s.'^nre of the surface. The 
vaginal donche, of 2 per cent, creolio solution, or the weak 
solution of bichloride of mercury formerly used before labor, 
has bet^n abandoned, uule,'^s there be mme alrea<ly exis^ting in- 
feetion, when it may be us?eci. The normal vaginal mucus id 
it^ielf germicidal in ^^onie degree, as well a 8 a useful lubrtcant, 
ami shnnld therefore be allowed to remain umlisf urbet!. More- 
over, wai^hiiig out tht^ vagina expost\^ the wonuiii to .simie 
danger <jf iiifeetiori from an unclean syringe. The jthifsirlan, 
before making any exauiinatifni <ir 4!oiug any o|>eration. removes 
his coat, baren the arnij^ to above the el bow j^, wlien (he hand>! ami 
arms are thoroughly scrubbed with soap, water, and a 8tiif 
oail-bruHh. Scmpc the under .surface of the nail-ends and 
the fiiisurej^ surroun<ling the nails with Btjme pointed in.^tru- 
raeut^ not .4har[i enough to scratch, and having \va.^hed otf all 
soap ill some cleau water, imMierse the hauils and lave the 
arms in a 1 : 2000 bichloride solution, and continue this last 
washing for ten minutes. 

Some |mictitioners prefer to sterilize the hands by the |>otas- 
81 urn permanganate and oxalic acid method, winch ronststs, 
after s^Tiibbing with s^oap and water, in innnersing the hands 
ill a hot saturated solution of jyotassium permanganate and 
then in hot saturated solution of oxalic acid, the hist being 
removed by a final immersion in i^terilized water. Whatever 
solution Imi Ui^d for stcriliziDg the iiands, it will be still advl^^- 
able to put on rubber gloves, previously tnjiled, a« an addi- 
tional precaution, es|)ecially when the physician has been 
recently in contact with septic cuses. 

Forceps, and other metal umtniments, should he sterilized 
by immersion in a 5 per cent, solution of carlwHc acid ; or 
16 



Fm IStifk 



242 



LABOR, 



they may l>e wrMpi>e(l in towel** tnnl Uoileil for ten minutes ; 



tnal 



U) h 



:]i 



ijnb^, iisstir 



and the nozzles of *iynnges. All H»ft textiinil itiUrk-s^ — ^cotton, 
lint, etr. — to }je siterilize<l in the Ixichloride (1 : 2000) Hjhjtiou 
and wriinjj^ uyt, (n'ibre ei>mini^ io cootart with the ^eiiihils. 
Sjmtt(fr:\^ shoyh! I>e aljoiii^lH^d fnim the lyiii{^-iu room ; it is 
almoMt im|xAssilile to diHinfeet ihem. 

It is needless to add I but any fiidure.'* used (iuh in stnvln^ up 
a iKTineiim, ete. ) nui!?it, of course, he ttufptic^ as in any othi^r 
sur/jriual ofK^^ation ; and nurses must I>e snhjeeled to the same 
^ di^inieeiiou tis the physician. Kuhher cloths and oiled muslin 
or silk may he Hterilizt^d liy ruhhiii<i: them with the bichloride 
solution— l:*-iOi)(K 

The details of iiseptie tfchniqnt^^ during the several stages 
of labor, olistetrieal o| K-rations, and the pner])eriunr and its 
diseases, will be pven in their appnii>riati* [ihu-t^. 

Preparation of the Woman's Bed, — Let it he anythiut^ 
rather than a feather he<l — a firm oaitlress is I>e8l. I'laee it 
00 as to l)e ajiproaebahle on lM>th sides. Cover it with a rubl>er 
sheet, and over this un f>rdinary !ied-sbet»t Fasten tbt^se two 
to the mattresw with safety-pins ; they are n^t to be removed 
after laUir, hut over them are |>laeed a second rubber sheet 
and a s4H^>nd ordinary sheet, fasteneil in the siuiie manner, 
which fu'c to l»e removed after lalx^r, leaving the first set ele4in 
and dry* The ordinary sheet of the set*on<l s^'t should he 
tumefl down from alcove until the line of fohl is helow the 
woman*s shoulders (the rubber sheets nei^d only cover the 
lower two-thir<Ie of the tnattress), in order to facilitate iIa 
withdrawal from helow, when labor is over. Durin^r hihor, a 
[lad about three inches thicks and two or three feet square, is 
placed upon the second sht*et, lit'neath the woman's hip to 
receive {ill ilisi*har^e«s. It may l^e made of folded ^iheets, or a 
sofi blanket, or, stiU hettt-r, of oakum, jute, cotton, or some 
other ab^cirhent material, |wicke<l in a cheese-c*loth hag of 
proj)er size. All materials, blankets, and sheetinjr to lie fhor^ 
fiughly ittcriiized l)c*fore being use<l (see nlwve). When lalmr 
is over, the up(>er rulrber cloth (No, 2), with its soiled sheet 
and stsiden |wid, may [>e easily dragged off at the fo<>t of the 
l>e<i, leaving the patient resting U|ion the dry sheet (No, 1 ) 
firet placed over the rubl>er cloth ( N*i* 1 ; fastened to the mat- 
lueaa. 



KXAMLXATION OF THE PATIENT, 



243 



Insleinl uf tlit^ aWirbt'iit jrad, the caoutc*houc jmd, deviled 
by H. A. Ki'liy, luay \w UM^tl. It not only pniUK-ts the 
8heet><, l)iJt roud u(^t** di.'^churges over the side of the he<l into 
a vessel oil the lltMir. 

ArrangexneEt of the Klgbt-dress. — ^Its skirt should be 
rolled \i\% fjy the level of tfie armjiitj* or a little h>wer» scf as ta 
be out of the way of vugtnul disehar^e-*?. while a thin |K'tticM»at 
or light tlaiioel skirt 4'ovei'iH the partes in^ low the waist. When 
labor is over the soiled sikirt may he readily removed over I he 
feet, without lifting the patient^ and the dry inii!:hl-go\vn then 
|iulled dtiwu from aiiove. In place of the skirt a pair of id> 
stelrie lej^^^nugs may enrase the lower limbs as far uh the thighs 
and lie fastened to the iiigbt-^^own alrujve the waist. They can 
be readily removed from below when bibor i« over 

Ezajninatioii of the Patient. — 1. Veri>al examinatiou, iu 
as gentle and plejisaiit a manner a;^ jiossible-, into the child- 
bearing history of the patient, as to the number (if any) of 
previous labors j llieir character, duration, ami eomplieationa 
{es|>eeially as to floinling aft<T delivery). Did the cliildren 
survive ? Symptoms during pre^^eiit preipwnnjy if not already 
ascertained. Hati it reached full term? Present synqrtoms 
ofhtlKir? Pains, when did tbey begin? Their frtHjueney, 
severity, ehuraeter, ami dunitiori? Character of the tiow ? 
\hi^ the bu^ of waters broken? 

2, Abdominal examination, to asi-ertain, by palpafion and 
inspection, the i^ize and slia|>e of the^^nivi<l uterus, the |>resen- 
tation ancl position of the child, and the existence or otherwise 
of multiple pregmim*y, compliriitin^' tunmrs, hyflmmnios, eta 
Oti itn*p^x'tif) ft,, the praeti^nleye readily appreciates any marked 
departure from the Ui^ual synnnetrierd form and ordinary size 
of the normal gravid uterus: als*i deciiled malformatifms of 
the AVfmian'ii sluifie, indicjitiutj pelvic deformity. The greater 
width of the ahdomcn, in a tninsverse or oldicjue direction, 
vifiibly suggCMti? shoulder preBenlation, Suspicions a rou>*ed by 
inspertion to be confirmed, or otherwise, by palpation. 

The meihoth of p(dpatum here given relate only to tiormal 
easesi of head pre^ientation,* The woman liei? n|>oD her back, 
the lower bmhs straight t^tit, and the feet {^lightly separated 
or partially Hexed with the he^di* together; if com/>^'/c/i^ Hexed 

I PalfMUton tn riitier capes will U' coMflidfrtH) In rel&tion tothetflo^iid^of tli« 
8tiTeriu pre^teritHtloim a ad ahiMrmal couipllcationi. 



244 



LABOR, 



the thighs oome in contact with the enlarge*! nlwloioeii and 
ol>strui1 the examiiiatiou. The bladder ami rwtuni luiwt l>e 
eTn|>ty and the iil»donieii Uire, exeejit |>erhaps uoe layer of 
some thill fabric. The iniini[iulati<m^j to l>e [iractised nuiy m 
the absence of uterine cuutraetiou.^^ — between Llie (mins, 

FlO. 87. 




Fioxlon of the heAd. maktng the neciput drteetut AniS ihii /wthmd rUe. 



(Fron 



The educated hands or fingers will reecj^nize the fid lowing 
characteristies of the j^everal p*irt^ r»f the rhild : 

(a) The head: it feels har*l ami y/«//r//ar— there is nothing 
else like it — if not en^mjred in tlie |ielvi» it may 1k» made to 
8win>^ or move from ^ide to side between the hand» — u real 
ballottement. 



EXAMINATION OF THE PATIENT, 



245 



(b) The bvcrch: it feels soft and irrcf^idar — quite different 
frofti the cranium. 

ir) The back: it feels like a /rin, residinrf, plune surface^ or 
one side of a loug cylinder. 

(d) The abdomen : llie alxiominal asjiectof the child is cov- 
ered by the e:xtremities and lir^uor amiiii ; heae€ it feels mfit 

Fin. as. 




Pftlfifttltij? heatt in lower part of titeruH, but not yet iu pelvic ciivUy below brim. 

elastk, aud wnre^istio^, with irreijuiar projections (the ui>per 
and lower limbs), which nmy move actively or lie moved by 
the examintr — very flitfereiit fn^m the firm, resisting plane of 
the cfiild^^ buck. 

(e) The fnrfhrad and ocrlpat: the head being u^imWy jfexed^ 
the occiput will Im? tilted doten imvard the pelvis and it*» poate- 



246 



LABOR, 



riot projection reduced almost to a continuation of the plane 
surface of the back and nape of the neck ; hence the exam- 
iner's fingers reach it with difficulty or fail to touch it at all ; 
while the foreheady being tilted upward and forward toward the 
anterior plane of the child, becomes nwre prominent, and is 
easily recognized — it feels harder, larger, and higher above the 
brim than the occiput. (See Fig. 87, page 244.) 

Fig. 89. 




\ 



Palpating breech. (After Davis.) 



(/) The globe of the presenting head may 1h» ahoir the pel- 
vic hriin, or may have descended, more or less, into the pelvic 
cavity. In the former ease the examiiierV fiii^^ers dij) below 
the brim, and fin<l the |)elvie excavation eni|)ty ; in the hitter 
case, dewent of the head into the brim fills the sjiaee, and the 
fingers cannot enter the inlet of the excavation. If, before 



EXAMINATION OF THE PATIENT 



247 



lahoTj or during iU beginningy the presenting part descend into 
the excavation, it is a head presentation : no other presentation 
will do this. 

In palpating the abdomen experience has demonstrated the 
following series of successive manipulations to be advisable : 



Fig. 90. 




'^1 H/N^lK 




Palpating plane of back and movable small parts. (From Davis, after Lso- 

POLD.) 

First. — The examiner, being at the side of the patient and 
facing her, places the palms of Iwth hands aeross the abdomen 
above the umbilicus — the finger-tips of one hand touching 
those of the other — then glides the hands upward with gentle 
pressure until their cubital borders sink in above the fundus 
Uteri^ thus defining the height of the latter — its nearness U) 



248 



LABOR, 



the ensiform cartilage — and the probable duration of preg- 
nancy. The hands also recognize the head or breech (see Fig. 
89) occupying the fundus ; or their absence, indicating a trans- 
verse or oblique presentation. This examination may also be 
done with one hand. (See Fig. 91.) 



Fio. 91. 




rali»ating hard globular liead with one hand. (From Davis, uflcr Leoi'olij.) 

Seroftd. — Both hands, being used as in the last numipulation, 
now separate from each other, and the palms pass to the xidrs 
of the uterus, where one feels the sm(M)th rcsistin<r plane of 
the child's back, the other the irregular projections of the 
extremities over the child's abdomen. (See Fijr. ^M).) 

Third. — One hand only is used ; it is placed ncrotM the low- 
est part of the middle of the abdomen just above the pulws. 



EXAMiyATION OF THE PATIENT, 249 

its III mi r lionier being toward the mons veneris ; the thumb 
OD one Bide ancl finger'ti|)s on the other then attempt tt) graap 
bo<iily the [jrewentin^ heat I, its hard < oiisistemy ami iletinetl 
j^lobular fihape beini: easily diHtiiiguishetl from the illHlefiued 
outline and holluesii of a breech ease, (See Fig, 1)1, p- 248.) 



Fiafi2. 




Palpatioo with hea*f \n pelvic cuvity ; flnp;r8 towftrd the occiput enter deeper 
tliuu thofie towiird fori<acttd. ipAUYt?(J 

The hand may be plaeeil higher or lower, according as the 
head has at ha« not deweended into the pelvic excavation. 
In either case i\\^ forehrnd will be more prominent and more 
easily recog-niised tluiii the owlpui, as already explained. 

Fmtrlh, — hmtead of the third manipulation just previously 
described, the following metho<i may be used ; 



250 



LA BOB. 



The exfifiiiner* Btn rifling with hif* back tftwnrd the |mtienf s 
ih("i\ pliieej? his liaiidH on the abflrmien, almyt four im-has 
aimrt, j^o that the iiDger-tij)?^ touch the iLiii|ier iiuiri^iii of the 
[\nUiv nuui, while the thumbs point toward each other at 
al)oyt the levBl of the iimljtlieusi. Now let the fin^^er-enJj^ 
]>ush before them a i^hallow fold of the nbdomiual wull ilown 
between the |iresentin,ii: head and juisterior asjMH-t of tin- pi* hie 
bones near the ilithpeetineal eniineiiee. The fin^er-etid** thus 
aetually enter I be |H-lvie brim ht'/ow the heiiti, if the latter 
have Hid deHeended into the exeavatioti ; or, if the head hnn- 
so destreudetb the linger?* cannot enter, but reeotrnize tiie liead 
obstructi!];,' their jiaswige througli the brim, the more ]»nmii* 
UQUi Jroutnl region \mw^ retn>goizahle Hf^ offering morr »>kstrue- 
tioii to the hand on that side of the jHdvia than is otiered by 
the jwdeof the twriput on the other ^Ide, where the tinger-ends 
nm i>eiietrate a little dee|>er (see Fig. M7, p, 244, and Fig. ^2, 
p. 24ir). If tlie abrlomen sag forwanb it nniy with the palnmi»f 
the hand* lie lifted up a little out iif the way, ami thus facilitate 
the entranee <»f the finger:* below ; an<l if the abdonnnal wall 
Ih* tense, this may be partiidly relieved by the hnver lind»a 
l>eing slightly tlexetb with the kne<'sai«irt and heels together. 

The prtHiiittiitun of a head having been ileimm titrated by 
these manijmlatiiuis, the jmHttion of the occiput will be also 
known hy olM*ervir»g wlicre the l/nck is, ami wliether the pnnn- 
inent/row^f/ regl<in be directed nnitrioriif or fHti^tt*riorl}f. in the 
right or to the left. With the ab<lominal examinathm may be 
iricludeil extenuil |)elvimetry ( which st*e |. Every ])regnaot 
woman shtmld have her pelvis mea>-ured early in gestation. 
If previously omitted* it should lie ilone later, either bciure or 
during labor* 

3. Vaginal examination. To the young |>ractitioner, who 
may experience i**)me em Imrransment with hig first vaginal ex- 
atninationi tlie following sngge*iti«»ns may be of service : 

In laljor eases it la not neeeassiry to obtain verbat con«icnt of 
the patient before instituting the examination. Prot^eed (the 
woman iR-ing in bed » without hesitation, as if consent had 
already het^i obtaineii. Having l)ec?n sent for to attend her 
is a sufficient guarantee of this. If anything is to 1>e mi<{ on 
the suhjeet, t*ome such renairk as "Well, weTl see how you 
are getting on *' — suiting the action to the word — >^dll be 
amply sufficient ; or a simple inquiry m to the con^renieDce of 




INTRODUCTION OF THE FIXaEES. 



251 



eoap, water, ami towel may l«* enough to iritnMliice the s*ut»- 
ject autt iiidieute oue\s pur[)osie. The less said the hetter. Pro 
ceed, uithont h e»itatiotu ju^i ns in feelinj3: the pulse* Should 
the vvomati cry, cleuiur, uiid declare she euiuiot syhmit to llie 
exttnunaliim, jmn-ei^l just the g^ame, iiieajjvvhile addressing to 
her any kind word of etieouragernent that may serve to lessen 
fear or emharrajijimeiit. Nothing but phyttieal resistance on 
the part of the woman should induee the physician to give 
up the exaruination. Thia will seldom oecur ; when it doe*?, 
there ii^ nothing to tio but withdraw from the easi\ or the 
announcement of thisj intention will generally remedy the 
difReulty. 

Should the patient be drease^l and sitting up, she must 1^ 
requested to go to her room and lie down in order that the 
examinatinn nuiy Iki made. Instruct the nurse to plact* her 
tieiir the etlge f)f the right side of the In-d, thai the right hand 
may be conveniently nst^l. The lower lindis are covered vs ith 
6te ri 1 e c 1 ressi n gs sec u r e* i w it h sa fet y p i n s ( or wi t h I eg*^ i n gs i » 
BO that the vulva and [K?rineym are left eXjMised, Under the 
uatea and jierineum is placed a moist towel or pad freshly 
wrung out of a bichloride tsolution. It is assume<], of course, 
that the woman haj* alrea<ly been made asej>tir4illy clean, as 
explained on fiage 241. The |)hysician is to be notified when 
she is ready. 

Positioa af the Woman. — On the back, with the knees 
tiexetl, is the obstetric |K>siiiun most cmnmon in the United 
States. Some practitioners prefer the English jKjsition, the 
woman lying on the left side near the right edge of the bed, 
with her knees drawn up. 

Introduction of the FingerB, — After projier disinfection 
(see |i[K 241 and 242), am>int the right index finger willi 
earholized vaseline (or niolliD), 5 jier cent, or some other 
aseptic lubricant. 

Recently, to secure a more rigid aseptie technique, the 
vaginal examination is made under inspectiotL The ]mrts are 
completely exposed to view, tlie labia are separated by ex- 
tjernal j pressure with the thumli and fini^rer of one hand, while 
the examining tinger of the other hauil, guided by sight alone, 
is pnssed directly into I he vagina without so much as touch- 
ing the external surface of the vulva, on which germs are 
likely to exist. The woman^a lower limbs being flexed, 



252 



LABOR. 



the examininfT hand pas9e>s directly between them to the 
vulva — always lielow, never orer, the thi<^h. The finger is 
direeted rather toward the posterior than anterictr comrois- 
syre ; it will reach higher m the vasj^ina it' the remamiiig fin- 
gers are not doubled into the palm, but stretched out over 
the ^x-rineimi r) that the ptMerior eoniniii^ure fitj^ into the 
dee|>e.<t part of the ^paet:; between the index and middle fingers. 
The (Mrrinenin may thun be pnishKl in, or lifted 8<iniewhat 
iijiward and inward* when there is any difiienhy in reaching 
the 08 uteri. In ca^ the index finger will then not reaeh far 
enough, it and the middle finger may botli l>e introduced 
together. 

Care muBt be t^ikeii not to invert any hair, but to prevent 
thi^^ and for aseptic purpo*e>s all hair ii|ion the labia anil mons 
veneris *ahould have he*fn previously clipjied short. Shaving 
the external |>arts, as in hospital practiee, cannot always he 
curried out witli j private patients 

Purposes of Vaginal Exammation.-^By thi^ examiuatioQ 
we learn : 

1. The contlition 4if the vagina and vaginal orifice as 
regards their patency and free<h>m from ob^itnu'tion *<> the 
paasage of the child ; also th*'ir tenij>erature» sensibility (free- 
dom from teudernes** ), and moisture. 

2. CorrolH) ration of ilie exiHteiice of pregnaocy if not pre- 
viouBly aseertJiined by pityt'ical proof. 

3. Condition of the os uteri— its degree of diUiiaiion, thick- 
nefis, t^nsiatency, and ela.stieity, 

4. If lntK>r have actually k^gun. 

5. T<* what stage it has progressed. 

(I. Whether the bag of wate'rs has ruptured, 

7. What the presentation ii*. 

K The condition of the |»elvis, whether normal or deformed. 

IX The state of bladder and reitum as to distentinn with 
their res[)eetive content*i» 

When aceustometip by practice, to the exanunalion of nor- 
mal v^aginie, i^elvea, etc., the existence of any ahtiormitfiftf 
is readily appreciate*! by the linger without any particular 
attention being given to each of the details jnst enumerated. 
In commencing practice, much more care is necessary to 
avoid overlooking existing departures from the natural 
state. 




INTRODUCTION OF THE FINGERS, 



253 



In learning the degree to which the on uteri is dilate^l, it is 
the size of the circMlar rhn (or lips) of tlw exU'rual o» that we 
wish to fiij^rt^rtairi. Without <-*are tliu (infj^er may he jiassecl 
thn>u^h a f^tutU (>s uteri and swept nmnd a emisult^rable sur- 
face uf the prejsentiu;^ part or ainniotie sat', thus? conveyiug aa 
iuipres^itm that tht; o8 is tlilnte<i when it iiJ not, Fiudiug a 
gmall, hard, easily movable uterui*, per vaginairh at ooce neg- 
atives the existence of advanced |>regnancy, unless it should 
hap[ien to }ye an extm-uterine case. A pregnant woman naiy 
inuiirine herself in labor when she is not^ owing to the occur- 
rence of **faftie pauiK* These, on vaginal examination, are 
found to he inefficient im dilators, hence they produce ho dila- 
tation of the OS and cervix and no tension or prominence of 
the hag of watcn*. The (ircmonitory symptom.s of laljor are 
absent. There is no ''^how'* or Imt very little njueoua dis- 
charge. Thesutfering is almost entirely in the atidotaen ; not 
ill the hack, aa in (rue |mius. False jmins are irregular, and 
short, and do not incre4i9ein etrength, dunition, and fre(|uency, 
as real labor jmins do. In from twelve to twenty-four hours 
they stop altogether, without any detinahle cause. Furtlier- 
niore, false pains occur before full term, without any ajtpareut 
eause of uterine contractions. 

Some women pre-sent a remarkable monthly periodicity, 
others at intervals of six weeks, in the recurrence of false 
pains. They seem to he exaggerations of those " intennitUni 
contract iofii<'' of the uterus mnsidered as signs of pregnancy, 
or the insensible eiont ructions of the early months, hec<ime 
perceptible later on, at stated periods. Hence they have been 
ea 1 led * ' p regn an cy pa i ns. ' * Q u i in n e has been succcssfu I ly 
used as a test l)etween true and fidse pains. One or two five- 
grain doses, with an interval of two houre, will increiu^e and 
accelerate true labor pains, but have no effect on ftUe ones 
(Sehatz), False pains often fx*cur from intei?tinal sluggish- 
nees, and can be relieved by laxatives and opiatei*— morphine 
or codeine. 

Returning now^ to consider the uses of the vaginal examina* 
tion, the diagnosis of a hend presentation may l>e made out 
before the os isdibited. The hard, smooth glolje of the head 
may be recogni:£ed through the wall of the uti*nne cervix. 
There is nothing else like it. (tenerally the os will admit a 
finger, when the cranium, if not too high up, may be readily 



254 



LABOR. 



felt, covered by tlie iiiembraties. It is not always easy to 
artcerttiin whether the menibraiR>' have rii]>{ure(h Statenient^ 
of woriimi (»r niirst' iire not relinfjle. J f there l)e Ji layer of 
liquor ainiiii ht-tuefii the beiul and niemliraiu'f^, thf spaei- and 
fluid ruMy he readily rt^'o^^^iiiiterl by g^iHitle [in'ssure with hit^'er 
hetwfi'n the- pahw. Not Hi> when tht* menibniiies elof^ely em* 
brace the head. Thtn teelin^^ the < hild's hain and corrii|yja- 
tiou of the &ealp during a [»inu» show the liajr has broken. 
Tiu* membranes*, on the eontrary, heeonie snuiotli sunl teu^ 
during a |»ain, possildy wrinkled a little in ihe inlervab. 

Opinion aa to Time of Delivery. — After ojie examirmtion 
uidy, no opinion in^ to the duration t>f lulior can beeorjHdt^ntly 
formed : certainly none ^honld be expresi?eil. Having Itdt the 
bead, we nuiy ^ly ** everything is rights" and eneourage the 
woman not to desjiond. After a seeond exaininalion in twenty 
or thirty ininulej*, we mtiy Jhrnu but should not ex[»re8s, an 
approximate idt^a a^ to tirno of delivery, by degree ( if any) of 
progressive ililatatiou that may have taken plaee. Thetfie 
*ilalement8 refer UKiHtly to the first stage of hdior* especial ly in 
primiparie, Wlien the os nteri ban dilated to the size of a 
silver chdlnr, the labor may be said ( uj^nally ) to Ik? alKuit half 
over. When tlie beacl ha-* |wi>st^d tb rough the oh uteri into 
the vagina and is beginning to distend the jM^rineum, of eonrse 
an opinion a« to s|ieedy delivery is f//;ir'/v///r/ jm^titiable. 

Is It Necessaiy to Keep the Patient in Bed during the 
First Stage? — No. I^et her sit, walk, or ehange her |Mi*iition 
iw <^hedc*gire,s utitil the liag of waters is aliout to break, when 
ri'<;uml>eney i? desiralde (o prevent washing down of the uni- 
bilieal c^ird by the gush of lirjuor anniii, and for other reasons. 

Rupture of the Bag of Waters. — Just fnfore rupture the 
woman should be told what is going to hap[ien, to prevent 
alarm, espeeially if she be a (iriini[)ara, and arj extra eloth or 
pieee of hbmket may Ik? pbieed under her, to niak up tfie bidk 
of tlve flow. Just after rupture a vaginal examination j^liould 
lie made to aseerlain uiort* surely the presentation, and that no 
change has taken place in it, and the suture* and fontanellea 
may now Ik» fdt, and the ** |Hrsitiou " ' of the head made out. 
The extra cloth may l>e remove*! at once, 

1 '*l*t»#lUon." Ui otwHtotrlcs. mt<nn§ ihc {M«ltlf>t»iil rvlnUon pvlnttiiif betwtM^n 
II icfven itoUil oil thv )>rv*rtititi|j fiarl lotd evrtiiUi !\%ed fiofitf* on the riclvU. 
Then* ft ri* wtfVerul *' |M>8ltloii«*' lu ewch '' i>re*fnUiUori." at wtU be «rj>mtued 
li**n?ufler 



THE PESINEUM 



25S 



Number of Attendants.- 1 1 is not (le.**tral»le i\>r i\w j^hy- 
sieiau to rumaiit in llie lyiii^Mii room tliiriii;^ tlie firj^t 8tajreof 
Itihor. AfhT hnvitJi; >*wn ihal every prt'imnilirjti ha^s heeo 
nuuk% and havin|r expri'sst^*! n willin^neiss U* he failed at any 
time the woinaii may ile8ire, let bun retire loi^nme otlier apart- 
ment. Oneiiiirrte is uece.ssary* and an additional attendant or 
relative not object iunalde. bnt no othei*!;!. The lui^liaml rmiy 
be |>ri^ent or not, as tbe wife may |i refer. 

Precautions during Early Stage.- Jf tbe rectum be loaded, 
administer an enema of soap and water toen)pty it. Hee that 
the bladder empties itself. If not, use a catheter. Protect 
the woman from a jL^lare of lii^Mil* whether by day or niifht. 
Keep the teni|^»eratnre of the room at t>r>° or 70"^ R, if prac- 
ticable. Instrmi tlie jtatietit not to strain or bear «lowti dnr- 
iug first staL^e : it does n«> gooil, an<l tire^ her. 

Pinching of tlie Anterior lip of tlie Os Uteri.^As tlic head 
pas^^ out of the uterus into the vagina the hrwer margin of 
thi? OS uteri sli[Ks u\\ out of reach of tlie finger, but Hanetimes 
the uuterior lip of the osgets pinchtnl between the chihrn lieud 
and |mbic bones r> that it cat»not plip np. It nniy then 
become greatly swollen, eongetited, and cpdematous. 

TrtafnwnL — Push it up with the ends of two fingers, be- 
tween the (mint^, and hiAA it there till the next pain ibrtes the 
head below it. 

Cramp in the Thiglis, — Paitifiil cramps along the iimerside 
of the thighs may occur from pressure of llie head — probaldy 
up*ni the obturator nerve, or upon the sacral nerves — while 
passing through the pelvic canal. 

Tr*'iitmrtiL' — Knijjty (he bowel by an enenni ; wsq manual 
friction upim the painl'ul j>art ; and hasten ilelivery hy forceps, 
if necessary. 

The Perineum will usually require attention to prevent 
rupture. There is no fear of laeenition so long m the antc*- 
rior l>order of it maintains any considerable thickness ami is 
not fully t>n the stretch during the pains. Hence, no **8U|> 
|>ort ** ii* iiecegsary» and nothing is ref|uired but to watch (he 
progress of the head (now easily t<mclied inside the vnlvn ), 
and ascertain when the perineuni ilota bec<aae thin and ti^ditly 
drawn out over the ailvaneing head, and when there m clanger 
of laceration, esptHMally if the labor progress rapiditf. 

TreatmenL — Ask the woman to refrain imm be^iring dow*n, 



256 



LA Hon. 



from boliliiig her breath, jmliiiij; with her Imntls, puf^hiiig with 
her feet and kiiecs*, etc. If uniihle to contro) her Hlniiuing, 
aiiiestht'ti/x? lier. The mdhmh of nuiiiipiilatioti to |irevent 
laceration of the [u^niicum are almost too tiumeroiis and varied 
to inentiun» Init the principifn involved Mvhieh it is most iin- 
jiortanl to nnxlerslniitt ) are fen\ and always the «iine, viz.: L 
(iive the iierineiim time to streteh, by retarding expulsion of 
the head — e^peeially by retarding *' extenmrn.'^ 2, tiuidt? 
the head m that it may (M-eojiy a« little spaee as piK<silde, by 
keeping the [liane of its' sniallei^t eireumferetice parallel with 
the plane of the i>enoeal ring tlirongb whieh it must pass; 
or, what iH the sjime tbing* keep the lung diameter of the hend 
at right aoglej* to tlie [4ane of the jK^rineal girdle ; the central 
p^tint of the iMxiinit must lead go lin^t — and keep i[j the 
centre of the ring. 3, Itehix the })erineuni a,s much ai< |>ixh- 
sible by gathering in tether l'n>m hurrootiding lis?-ue8^**give 
it nn)e *■ from the onL<i<le, 

The luanipulation may be accomplished either with tlie 
woman upm her left mde, or in the dnrm! |x>8ition. provided 
tlie lower linilw he not furcibly Hexed ctr whiely se[Mirateth 
and for which there is tio neet^ssity, l'iirei»erved tirttiar in- 
Hpeiiion of the part^ ii^ aiisfdutely re^piired. Note e8|wH'ialIy 
that rupture uj*iiHlly m^urs <jI fhe uutmetti or tinring fhr J'rtr 
momenU of the foM oitr nr /im /min^, jii.«t aH the bead is being 
extruded. Normally the head is delivered by ''extension ^* 
(see Mefdianism tjf l^ihf»r» (lni[>. XJV,), the iK-eiput riHing 
over ibe mona veneris, while foreliead, taee, and chin j*u<X'eii- 
flively emerge at the perineal margin. Hence, to retard expul- 
sion (which nuiy Ite done liireHhj by pressure upon the central 
tXMnpm ), we atust retard fxtennioti by presj*ure transmitted 
through the ^lerioeum upm the frontal Iwaie (the forehead), 
w b ie I i i ml i net Itj ret a rdi« e x j m I s i o n ; the p 1 u ce on which t b IB 
forehead [iressure h made is* hviwern the aunt* mid coenjx* 
Extension mmt ix-cur eventually or the child could not well 
he imru ; our purpose is to drfaij, not prevent it. When the 
perineum has hud time to stretch, we jwrmit exteni?ion and 
consequent expulHion to take place. 

In the manipulation Ui e^irrv out these purpose's, both hands 
are simultaneously u?e<l (the woman !>eing either uiN>n her 
sifle or hack — preferably the former), as follows: The right 
hand is m placed that ili^ lingers rejsit u|)OU the posterior part 



THE PERINEUM. 



257 



of tlie kfl laliitim (>uden<ii» aud the tliunib upou the right 
liibiutii, the weh of skin lutweeii the thumb aud index (injrer 
bt*iu^' about in line with the ]>erintul niargiu. \ See FijLT. i^*'^.) 
At the aunic time the k'tl hiiiid, pas^sc'il down m frnut over ihe 
piibcs, inukes fUrrd pre;fMire iipon the centre oJ' the protnid- 
iijg oc^'ijuiL (Thi^ la not shown bi Fig, 93.) Dnrinj^^ the 
jmiivH the dingers oi' the left hand make direet pre^,^ure np<->ii 
the udvniieing uceiput in Hue with the hjrig iliaineter uf the 
head, to i4l<jp it Ironi eoniing oyt, while the tiogers atid thumb 
of the right hand gather in i)erineal tissues fruru the sitles, 

Fio. 93. 




Biodc of eflfccting rt*tiixatioTi of perineum, (After PLAVFArw). 



thus relaxing central tension, while at the name time they — 
aided liy the palm and ulnar border of the hand — transmit 
a deejier pressure throujih the perineum ujion the forehead, to 
retard eAtnimott ; meanwhile the manijadation unavoifhdily 
pushes the entire head np toward the pnbee* thus utilizing 
any ^pare ??paoe left IwHween the pubie iireh and bnek of the 
t'.hihrs neck. An almost ^imilnr method of i*egnhiting tiie 
birth of the head, aud the relative pot^itiou of tiie patient aud 
17 



258 



LABOR 



phyeiciaQ cluriii^^ ihe prweeding are well shown in Fig. 94, 
from JfweLt's work. During these proceefiiiigft the parts 

Fig. 94. 




Rcii;uliai 11 jf birth of htnd. (Jewett.) 

flhould be swabbed oceai*»onally with a hot solution of bichlo- 
ritle on a pledget of ju^ptic cotton* nnd the hand^ of ihe 
operator wa^^hei! in a similar fluid. It ta Wf 11 uIs<j to interpose 
a pledget of cx>ttou l>etween the fingers and the occiput when 



THE P£MiNEUM. 



259 



niakiDg pressure. When it is finally deemed advisable to allow 
tht! heiid to escL4f>p, let tJii*? octnir, if [>o8sil>Ie» hetween the pains. 
Iti Jellett'i< tiifthud, n^presented in F'v^, I^fi, **the heel uf 
the rifjjht hantl piishe^^ the head forward hy prfssure applied 
betweeij the anns and the coceyx, and the lingers of the left 
hand endeavor to drau} the head forward/' 




The iiidfrect metliod of preserving ilie pcriaeum. (Jellett.) 



Other methods of tiianipulatiou — the objects and principlefl 
of wliich will be the same ns- already destTil)etl — are the tol- 
hiwiti^^ : ( 1 ) riaee the thumb upon the advanein«: oeeipnt and 
two hngen? (of the same hand) in the rerium, by which the 
forehead i?' kept from extension and the |x?rioenm relaxed by 
liilitiLi^ it up toward pube?i duriiijjc the plains ((jioodell) ; (2) 
standing behind the wotiian (while she \\q» u|Kjn her left side) 
apply two fi niters of the ri^ht biuid to the oceiiJUt and pass the 
thumb into the reetnm, ami thus hold bat-k the head during 
pains i Fasbeiider >, To jret out the head hrhrfen the pains^ 
upward and forwartl pren^ure may be made with the thumb 
or tiuj^ers in the rectum, upon the face or cbiu ; or pressure 



LABOH 

upon ike onUride^ Itehlud Ihe atiU8» cli>se to the cotvyx, may be 
guiiiefl, and admitt*?d to pans at will, by the Uftiou of the 
iostrumeiiL 

The rei^tul niuiiipiilalioiis — at Wi^t iueonsistent with rigid 
atitise[>8is — require extreni*:* eleauliiie«8> 

In e4i*es where, Je.^pite tbese muni piilul ions, rupture ap|>ears 
in e V i til h le, I h e 1 1 j >e ra t ion *ii'cj its io to m y m ixy I le pe rfo r m v\ L The 
res^isliLig ring of ti.S'^in." being reeogiuzt^d by the tinker jn?*t 
inside the perineal margin, a probe-pointed curved lnsiutiry» 
or lenotomy kuife, is [las^ied in flatwiwe betweeu the head and 
vaginal wall, at a ]>oint uImuh one-third of the dii^tanee from 
the jjosterior eommiK^iure to the rlitorii^ ; then the edge of the 
knife is turned outward toward the %'agiiud wall, aud an 
inciision made about half to one inch long aud one-fourtli of 
an itieh deep. The skin may or may not lie cut l>y the incision. 

The di red ion of tlie cut ( when the parLs of eoyr^je, are Hiss;- 
tended) sliouhl l>e **up aud down'* — that is i>arallel with the 
long axii^ of (he wotiiairi« l>ody. It may be done on both 
sides. After kljor the wonmLs are stitched up with fine aaejj- 
tic catgut. It i« mit often restvrted to, ami it.s alleged extraor- 
dinary good rei^nlti^ are not always realizeil. 

Should the |K^rineuni esca|ie rupture during delivery of tlte 
head, it may yet be ti»rn during the pii^ige of fhr ghnaithrf*, 
Thif* may Im? prevented by lifting the head and neck up towurtl 
the mous veueri:^ so that one shouhier ^iw^*^ back behind the 
gyniphyi*ij? pubis while the other esca|K*8 at the ein-cyx. This 
enables one jihoulder to be Imrn at a time, aud protluees lejsss 
strain uj)on I he |)erineum than when Ix^th are pulletl out 
together, and with rude Imj^te, which must be avouleil 

Birth of the Head,^\Vhcn ti\e head h ex^ielled, fet*l with 
the tinirer if the umbilictil eord encircle tlie child's neck. 
If so, ilraw down the cord from whieliever rlirectiou it will 
najst freely come, and pass* the hwip of it thus formed over 
the head. See that nothing im|>edes the further free motion 
of the head. Keep one hami on the womb ami by gentle 
pressure follow down ity dtH-reasing j^ize, so a^* to aAnist it^ con- 
traction and prevent hemorrhage, Hupjxirt the head in the 
c»ther hand, and a*^ another piiiu or two expels the t^luaddera 
and iHMly, gently lift it in a direction contiuuuiis with the axis 
of the |K'lvie curve- f\ *\, ^Ihjhthj upward. No traction i« 
Decenary generally ; ami tliough the child's face begin to get 




MjInaoemest of the XI VEL sTmyo. 261 



bluish, there i^ no necessity for haste, no ft»ar of i^uflocatiuii, 
evvu thiui;fh ilehiyeil sevenil niioute^, which it nirt-ly will he^ 
lietbre complete expuL^ioii. After ivyyw/.Woj/ of thi' chihL dennse 
iti4 uostriLs and mouth frojii niueus, i^tr., lunl see that it 
hreiithej*. It* it do not, t*lup the InHtoek:? (not roughly), rub 
the spiue, dasli a little water in the face or on the chest, which 
will generally suffice iu an ordinary case. Wher\ respi ration 
is e?itablisheil, let the infant re^t ou the lied lit*tweeu the thighs 
of the mother, preferahly on its right side or haek, avoiding 
eontact with diHciiiirge.s while the mivel string is attended to. 
No liable is necessary m tying and enttiug I he cord* uides^s 
relaxation uf the uterus, tlooding, ar some other condition of 
the mother, ret pi ire immediate attention from the physician, 

III the absence of any such emergency, it is best tn wait 
until pylsation in the cord has ceased or become almost inifier- 
ceptible. By this little delay, while the chiUVs jjulmonary 
circulation is Iteing thoroughly establishe*! by chest expansion 
and the meehauical vibration of lung capillaries j^roihtced hy 
its erieii, the infant id>taina from the iatal srdeof tlie placenta, 
through the untied cctrd, several drams of blood that projierly 
belong to it, and of which it would be roblied if the cord 
were lied at once. 

Managenieiit of the Kavel String.— Ligatures — preferably 
of strong aseptic silk (but narrow ta|»e or any other suitable 
material, pro|M*rly sterilized, will answer) should have been 
previtmsly prejmred. When the child has cried — thus inflat- 
ing its kings with air, attd starting convplete pylmtmary cir- 
cnhition — the ♦juantity of blood thus dniwn from its general 
circulation Ix-iug renewed from the fa^tal half of the jdaceutn 
through the thus-far unoKstructe*! und>ilicns vein — the <'ord 
sh<iuld be cnt before Hgatitai about an mrh distant from the 
ahdameu, its root being pinched with a thunjb and finger closie 
to the umbilicus to prevent bleeding, while a finger and thumb 
of the other hand si:jueeze out of its distal extremity l>v a sort 
of milking process (** stripping ") any excess of Wharton's 
jelly. The stnntp of the conl i sometimes thick and vohimin- 
ous)tluis liecoUK's Harcid and ribbon-like, when the ligature is 
put ou near its distal eml, and lied tightly, but not so tight 
as to wound the Idi km 1 vessels. Should tlie end bleed, |>ut on a 
Bcinjud ligature just above the first one and tie it more strongly. 
A. C\ Kellogg of Wist^ousiu haa devised an instrument for 



9J{9. 



LABOR, 



passiug over the eml of the fuuis a streichetl rublk^r Hug (ave 
Fig* 96;, whk4i^ when the iu!*truuient l^ reirio%'ed, iijutrat'td 
down OD a cord, like a ligature, to (irevtmt hemorrhage. It U 
erteetive enough, hut not better tbau simple ligation, for which 
no in strum en I is neeejiHary, 

To prevent injuring lire child while cutting the eord with 
ordinary jwimmmfs — whieh might happen tVom tlie motions ui' its 
lower liraln* during the oj>eration — ^[ilace the haek oi' the left 
hand flat upcm the ahdonieu ami let tht- cord [>rojei*t hetwem 
the (mlinar surface of two fingers^ while the aciasors are applied 
t!at*wise with the right hand* 



* ) * 



(( 



Elmitle funis rins:^ iiTipliruinr 

There is no necessity for |»utiiTig u ligature upon tlje pla- 
cental end of the cord, unless twins Ik* »uj*(jeete<l when it 
E^hould Ih* done. 

Tlie eUHtoui of leaving the slutnp of the funis (me or two 
inehe« haig wui* nch»pU'd to [vreverit ignorant persons from 
ineluding the ( nnt uneommon ) protrufling gut of an umhilieal 
hernia in the ligature. When certain that nti sueh heniia 
exi^t^ the stump might jui*! as well he cut <"flr half an inch 
from the skin; sueh a pnictiee ha.s hi*on rec^'nlly rworumen<ird 
in the intereM of a^fi^is^ — it leaves less deati ti?<suei* to j»eparate. 
Still more recentiv, the cord has k-en cut close to the ahdomeo 




DKUVERY OF THE PLACENTA, 263 

am J iLm vessels ligated 8eparately aa m a surgical operation — a 
com I plicated |>ri>cej<« quite urii'alled for and Dot to be reeom- 
meitded. 

After simple ligation, a^* fir^^t above-tneotioDed, it is of prime 
importance ti> |>reveut infection of the jsUirnp, hy dres^in*^' it 
every day with a fre^h piei*e of dry aseptie (iHinite<l, or sali- 
cylntetl) cotton, the stiim|» iL<elt* a[id navel, having been first 
duiited over with boracic acid. 

The cord having been attended to, examine the child for 
deformities or msdformationii ; give it to the nun^, who holds 
a warm tiannel or lihiuket tor its rex'eplion ; and caution her 
4o let no i^trong light glare in it« face, and to get no soap in its 
eyes. Under rircnmsitanees and places in vv hieh the child is 
e3C|>osed to the infection of opbthaluiia neonatorum, (he eyelids 
ghould be carefully washed externally with clean warm water, 
and fr<mi the end of a glass rtxl one drop of a nitrate of silver 
solution (strength 1:50) should be dropi>ed on the cornea of 
each eye immetliately after birth. 

Delivery of tlie Placeata.^ — The child having been dis|)OBed 
of, place a !iand u\m\\ the fnndus uteri. If it be found sym- 
metrical in 8liajM\ hard, and as small in sisEe as a large cricket 
ball, the placenta is |>rol>aKly resting loose in the vagina. If 
it lie larger than this, ami not so j^ymmetrically globular in 
8ha|>e, the placenta is most likely still in the womb. In this 
hitter case rnanipnlale the fundus and make pressure upon it 
to excite contraction, meanwhile asking the woman to bear 
down when she feels the paiu Itegiu. Again, havinjf noted 
the ponifum of the uterus* it may be oliserved that when the 
wond) expels the phicenta the fundus will rise about two inches 
toward the unibilieus, as if the organ pushed itself up and 
away frfuu the discharged placenta. Should I he [tlaeeuta not 
he expelleil in fifteen or twenty miuutes sputa neon sly, the 
fundus uteri may be grasju'd firndy with the haml, ami the 
placenta litenilly s<:pieezed from the uterus intt> the vagina, 
after the method of Crcd^\ (See Fig* 97, piige 264,) 

To he successful iu this proceiJure, the uterus must be 
gras|>ed bodily by the thumb and fingers so that the fundus 
rests in the palm, and firm pressure made only ditritifj uterine 
(sonfrartlon — at the htujht of a hilior pain. Both hands may be 
used, the eight fingers going behind the uterus, the thumlts in 
front. Hold the womb coutinuously. but less firndy between 



264 



LABOR 



the [mint*, and rt'sumt* t^trong preKHure cus the pain returns, and 
St} oil tor six or seven |uiins if neeessiir)- — ^the direction of 
pressure being dov^iiwarcl tunl t)aekward in line with axis of 



Fta.97* 




Cre4«'i ez]»re«Blo& of tli« pUccfita. rBictCM, from « phDto«nii|tb hy H. F> J, 
After Jkwktt.) 

Uterus. If the pains are tnnly in their reeurrenee, press the 
finger-ends on the abdominal wall and make rotary frietion 




DELI V En Y OF THE PLACENTA. 



2()5 



over the uterus t<^ provoke coiilractiiJU. When the j>lrtceota 
has ptissei! entirely tlirou^h the os uteri into the vagina, it itj 
easily extracted by hookiug into it one or two fi tigers and 
making traetitin. WUeo it i?* uoly hall*uuy through the us 
the index and middle tiugers are piLssed nfito it, tollowitig the 
conl lor a guide, and the orgaw l»eiiig grasj^ed hehveen I he 
Huger-eoiK it is made to bulge eoninletety through tiie ot? hy 
directiug traction backward ti>\vard the sacrum, the other hand 



Fi«. m. 




Faulty method ol* removing- plAcenta by traction on the cord* {After 

rLAYFAIJt,) 



campre^ng the fundui^, and the woman heing told to hear 
dt)wii. Never, under any circurnstanc(^% make traction on the 
cord* It tends to pull the phicentu flatwise Hike a hutton in 
a htittondiole), thus obs^tructintr iti« egrea^ (sst^e Fig, 98), and 
might, if the placenta were still atlherentt invert the woadi. 
When uadi.'*turberl by traction on theconh tlie placenta will 
be folded vertically, in line with the lung axis of the wond), 
n» shown in Fig. Uy, page 266. 



266 



LABOR 



In normiileases It may Ik- |Hj«Hil*!e taflellver tlio Hceujjflines 
by C'xteniiil pressure alotie, aud witfioul ut^iu^ a (iijj.^er i[i the 
vagina, aud in the line of rigid autisepiji this b a(lviBtiljk\ 
It ifl iiutnereseary to htirry the deli%'ery of the pUieeuUi imiiie- 
(liuteiy after the iafaut'.-i Inrth ; au interval of iifteeu or 
twenty minutes ^ive^^ time for coa<:nhi to furtii \u the mouilis 
of the uterine bloodvessels, aud thua eontributes to prevent 



FiQ. ya. 




NomiAl doubling af |aa4>entA. (After DrurAJ*,) 



heniorrlia^e. The |*niftice of jrivinjr erfiat to expeflite expnl- 
Bion of the placenta ha,-^ been rtbandone<l. It may, however, 
l>e trivenj and with Hdvantiitfe, lo «»eeure firm uterine eontnic- 
tion, after the plaeenla w exjiellnl ; the dose Iieing ^ss to 5J of 
the i\md extract. 

As soon n» the organ lias |»as8eil the vulvar orifiee, hold it 
there, clo^^ up, and with luMh liands twif*t it r<nni<land rouml, 
alwavs in one direction, atnl the mendirane» will thuii l»e twisted 



THE BINDER. 



267 



into a sort of rope, which gradually gets longer aud uarnmer 
until tfrJuiiuiting iti a mere ntriug, which tinally slips from 
the vngimi, and tleli%*ery is complete. If thih twisting i levies 
be uitt luloincd. a |iart uf the membrane i^i likely \u remain, 
aod becommg entmiirled with eluti* of h!iMjd, cwnse afler-jnnns* 
and (^ome away fi4id, days aiterward, not without alarm to 
the patient. 

After delivery the |ilacentn shfudd Ite lns]M?cted to see that 
no part ha,s lieen torti oH* and left behind, un<l then dej)i>^ited 
in the veik*el hehl liy the nurse for it,s rei'eption» 

Firm mHimdiun and rdrnrtion ^ of the uterus having been 
8eeure<l, the tliinl sta^^e of labi>r h over. It renminbi to make 
the woman asejitirally clean and comfortable. The sniled 
sheets and pad;* are reinoviHl ; the nurse clt*ansei* the ^kin from 
blood-stains with a hichh>ride i^jlntion, dries it with a chum 
towel; puts under the hi|M< a clean, dry draw-t^heet, and the 
jwitient h now ready for the binder and vulvar dres,«^ing. 

A mild l)ichlorrde solution ( 1 : 4000 ) i^hoiild l>e useVI t4> w^ash 
out the vitfjifiu before tlie drydre^siugH are applied. It w not 
neeesi^ury or {k^iralile to wa-^h ont the id* r tot iti a normal caj^e. 

The Binder. — The biiiileris atjabdoudnal handa^'e dej^i^ned 
to supjKH't the stretrdiefl wallw of the abdomen and compress 
th« uterui4 so as to preveiit its relnxati*in ami conse<|Uent hem- 
nrrhage. It gives tlie woman comfort, an<l preveiits syncoj^ie. 
It scarcely improves her figure as was once supposed. 

Jt may be ma4le of Htroiiiy nnl»lea<'lied cotton or jean, and 
must lie wiMe enong-h to reach from below the prajt'ctimj tro- 
ehttntt'rs (otherwise it will slip up; nearly to the eusiform car- 
tilage, and lon^ enoytfh to go once around the hotly ami 
overlap enou^li for fasteniug with stron^j ** safetypin».** Ix-t 
there be no creases tnuler the back* Pin lu from above down- 
ward, where the ends uieet in front of the alidomen. as tiirlit 
as may he comfortable. Some prefer to [an it from below 
U|>ward. 

Another method of appl\iug the bimler is to pin it at lirst 
lo(Jsely with ordinary fans, pnl in transversely ha!f an inrh 
ajKirt alon^ the meilian line, and afterward ti^diten it around 
the narrower part of the waist by gathering in a fold on each 



ff'tfiii'tinn iw til 
lion, ttfier Ihr . 



■^utiOTt'* iixu\ " rc'f rnr/irtii " U -"vs font* vviR : Ton- 
itv 4if ihc Dnuiieite prtxliiccd by eontriu.*- 




2li8 



LABOR. 



siikMifthp Utf\\\ these foMs being retaineil in place l>v safcty- 
])iii8 longiUjiJiiiullv applit^d. (See Fitr* HHK) 

All iLseptie pad (]»ref'eralily niiitle of sterilized jute or al>- 
&orl)eiit etiLtoiK wnipped in elief^'e-i'lotii ), iHo im*hes thick, 
four iiiehew wide, aiui ten iiielies long, is applied to the lahiu 
to receive the lochinl di^?chrt^<;e♦ In the al»senee of siieb a 
pjid a perfectly elemi, aseptic luipkiji iiiuy be uscil. Tbey fire 
kept in place by beiu|( fh!?teiied tu the hinder til Hive and heli»vv. 
The jMids lire to be removed and Imrued m ofleu as may J>e 
uecessary from the amouttt of discharge. 

Fio, 100. 



A more [lerfei't at*eptie riielht»d — the sixnlled "occliis^ion 
drei^jing"— i.'s the ftd lowing : A piece of lint, 12x8 i[iehe>i in 
»im isscjakeil ill nnd wrnog iml of a I : 2000 bichloride solu- 
tion, li infolded in the middlt- lcn^»'thvvise, and then folded 
agaiiu wliich inuke*^ it three iuchej* \vi<le aitd four layers thick. 
This is applic<l tlirectty to the vulva. Over it in placed a 
piece of iLsc'|itically clean oiJed silk tjr ntuslin, four inches wide 
and nine inches! long. Again over this comes a large pad of 




DMESSIXa THE STUMP OF THE CORD, 



269 



cotton-batting, tlie whole being kept in place by a sc|utire 
half-yartl of mn.slin, tblded like a era vat, each end of which 
is thstt»ned tu tiie a b< In initial imuliT. The droKsing is ehaiigeri 
every six hours, and the external jj^euitais are laved with bi- 
chloride soUitirm bet*) re a new <me i?; [nit tm. 

Before any dreissing m applied, the |)enneiim shonkl be ex- 
amined, lit all cttn-it^s hij orular insptctintu tor laceration. If 
any he found it should at (au*e !>ere(iaired by sy tares of asep 
tie eatgut Catgnt snturea require no removal; they may lie 
left to diges^t in the tissues and come away of them^lve^s. 
The sutures may he passed l)efore t!ie plaeeuta is delivered, 
and ^'t<i after it.s delivery. The parts are lrs.s sensitive imme- 
diately after labor, and the auiesthesia produced during deliv- 
ery still remains. 

Attentions to Newborn CMld. — ^The nurse anoints it with 
olive oil, and then vvasht'fi it with mild t^oap and water, 
to remove the venux ca^rrmi — ^an acctimylation of whiti^^h, 
sebaceous matter — from the nkin, e3*jxHMally plentiful ahiut 
fohls and creases. It ia most abundant in over-long prepnaney, 

Dresoiiig the Stump of the Cord,— It is an old emUmi, 
still prevailing in s<nne runil distriol^, to draw the stump of 
the funis through a h«de made in the rentreof a i>it of grea^^ed 
rag, then fold the bordei*s fif the rag over, and at\er laying it 
upin the ab<I«anen with the end downwanl, phiee one or two 
t>elly-bands round the child to keep it iu place. It i.s an 
ahominahle practice. If there lie no defective development of 
the ahdomiual wallt*, the infant needs no artificial sn|)ix>rt by 
l>elly-bands (they are often a|iplie<l painfully tight), and (he 
cord itself only r€»fjyires to l)e dusted with some anlise]ttic 
powder (salicylic acid one part, starch ten parts) ami wrap|}ed 
in a bit of antiseptic cott<m to ahstirh its moisture ami prevent 
sticking t*> the clothing. The stump falls otf in alx)nt five <lays, 
more or lej<s. A light flannel tuindage may surround the al)- 
domeu loosely for the sake of warmth. 





CHAPTER XIII. 

MANAGEMENT UF MUTHER AND ( IIILD AFTER 
DELIVKKY. 

THE MANAGEMENT OF THE MOTHEE. 

The condition of heinju: in **t'hil*l-lM^tl," whether »hinng or 
shortly after parturition, m known as the ** |>uer(it'nil slate" 
(from **//«er/' a chilli und *'pnrlo'' to bring forth). The 
t^rm however, i.s prt-nerally ri\striete(l to a [leriud of tour or 
Jive weeLs immediately Julhnvhuj the eomideiioii of labor. 
Hence eertain di,^^ase,s following )ulx>r areenllcd ''puerperaV* 
fever, *^puerpenit' |teritonitis, ete. The woman \^ i«p)ken of 
as the **puerpera'^ and tfie condition or j>eriod as the ^^purr^ 
periHuiy** or *' puerperalifyJ* 

The more serious puerpera! affections — not of frnjuent 
oeeurrence — will lie reserved for a fulyre chapter. 

At present oidy the more trivial and iNimmoii accompani- 
ments cjf lying-in will l>e eonrJuiered. 

General Condition of Lying-iB Women, — A moflerate 
jimount of fatigne, exhanstitiii^ and nervi>i].H t^htK'k follows 
every lal>or, being more marked in long aird painful ones. In 
nornuil <*ases, re!*t and the mental stimulus of joy that a child 
m Inirn into the world, and that the trouble is over, atibnl an 
adetjuate antidote. 

The pnhe, atVer delivery, diminishes in frequency, dropping 
to 70, BO, oO, or even lower. A slow pulse is of favorable 
angury — not so a frecpient one. Tld^ is exjilained as follows: 
the heart, normally hy}»ertrophied to meet the extra circula- 
tory rtsjulremeuts (»f pregnancy (sec* jwge 146 ), <'annot, when 
pregnancy bus ended, continue its |M>werful beats as frefpiently 
as liefore without sending to the uterus and other organs more 
bbx)d than they require (with cmi sequent congest ion and 
danger of hemorrhage) ; nor can the hyj>ertropbied heart 
/iiir/f/r«/f/undergi>its8triietural involution back tothecondititm 
270 




INVOLUTION OF THE UTERUS^ VAGINA^ ETC. 271 

io which it svm l>efore preginiiicy l>egac (this requires time) ; 
tfic difficulty in lujwever yiiturftlly ovi^rt'ome hy the puwi*ri\il 
heart retludng the nvmb* f of lis \niUni\ou:i. Wlien this reihic- 
ium dofs not take place there is tlimt^^tT i*f hleediii^% and IkiKt^ 
theeuumiiiii olisSiTvatlmi tliiit ii juilj^e tmpieiicy of lOU or ninre 
|)er minute, is liahle io pmdiiee j>ost-j murium hemorrhji^e, 
under whieb cireunistiince« tlie physieiiiu BiumkI oot leave 
his patient, 

Owinj^ to a differeoce of temperature l>etween the bhH>d in 
the internal or^jfans anil that in tlio .skin, vvhirli oerurw jnst 
after the birtli of the child i ami hefure the pUieeiita in ex- 
pelled )» due to eva|M>ration id" nwent, exjxj^ure of the skin, 
and ee.'^sati»«i of nuijieuhir etfiirl, the wojjian may he ^eixed 
witli rigors (ehillintss, tremhliiijtr. ehaltering of the teetli, ete. ) 
— ^the so-called ** pofft-/)ftritnn chUL*' It finises <itl' in a few 
micutej5 without any ill etfects, imder the application of warm 
clothing and |K*rha|j>8 a glass of whie. 

Involution of Uterus, Vagina, etc. — By firm contraction 
and retract itiii of the uterus after delivery, ita? bloodvessels 
are compresried mid its blo«nl -supply greatly reduced* hence 
invohdion of the <>rgan immediately begins. This consii^ts in 
a pnM?ess of normal atrophy — a fatty degcneratifni of the 
enlarge<l muscle cells of the uterine widl, by which tlie size 
and weight of the uterus are ra])idly redueetl. The fat 
granules are absorbed and assiudlated as finn]. In volution 
becomes conjplete in about six weeks. During this time the 
recently delivered uterus, wiiieh weiglis about two |K>unds» is 
reduced to about two ouncejii — almost but not quite as email 
as the virgin uterus. Jy??t after labor the fundus* uteri may 
be felt by jjidpation io Ite about midway between the pulies 
and uml)ilicus. In one week after delivery the uterus loses 
about onedndf its weight by iiivolutictn* arid in about ten days 
the funilus sinks below the pelvic brim and (*an no longer be 
felt by abdominal [>alpation. 

While it IB fatty degeneration of the muticnlar wall that 
esf>ecially leads to reduction in size and weight, all other 
cells of the uterus participate in the fatty degeneration to a 
certain extent. In fact all the organs composing tlie repro- 
ductive apparatus, including vagina and vulva, hav<j under- 
gone some extra evolution during pregnane v» which is reduced 
by involution afterward. It is, however, with tlie uterus that 



272 MANAGEMENT OF MOTHER AND CIJfLD, 

we are ehietly concerDed, fur ehoiiM involution of this organ fail 
to iK^foinc^ ci>ni])lete, llie t'omlitKin kjitiwn im '* j<ii/nnvuhition " 
would reinnin, with iill tlie ><yniptoni>5 nuA iiiiserias jtroclui'wl 
by II Uir^je, lieiivy, rodixestedT ninl [HTlKips iliHphuxHl utfrvis. 

Tlie LocMa (Lochial Biacbarge).^ — It Is a diseliiirgL' froiii 
the uteriia folhnviiig Inhor, coijsiMtiiig tluriiiir the fin^t fimr or 
five days cliit'tly of blood which hai< ooxed from the pla- 
cetdiil sitt? or liecn s^jiieezeii from the phicentii iti^elf <luniif^' its 
expidi?ion from the uterus, Ihiring the sixth iiiTd f*cventl* 
flay;? the hhmd coh>r should clL^mppear and the iiis(*h{irge 
asBuruo a thinner jiiid inort- s^-rous L-hann'ttT, with t^fiirrely any 
color i^xcept i^t'rhaf)?^ a slightly ytdlowJsh (iiig<^; at thii* time 
it consists of a serous exudation from tiie walls of the uterus 
(ohietly ) and other parts of the genital camiL Fnun the 
eighth day on until it eeasi^^ — varying in dirt'erent eases from 
two to three or even four weeks — the discharge becomes still 
gradually smaller in ijuantity and of a whitish color^ this hist 
being due to leucocytes ami uftrmal pus cells connng from the 
granulating surfaces of healing wounds u|Kin the cervix or 
elsewhere. ( onformably with these three variatinns in color, 
the liichial dis<4iarge, tlurin:: the three successive periods, has 
been i'ldled loehiii ruhra^ hwhia nrroxft, anrl lochia ttfhtf. 

Examined micros<tipically, it is seen to contain ni tirst red 
and white bhwid-corjiuscles^ varunis kinds of ejntheliMi eel Is, 
decidual and placental deliris, etc. After a week [hjs cells and 
leuco<*ytes abound, with youtig e[iithelial cells, fat-grunules, 
conne<live-tiK!tue cells, and crystals of cholesterin ; also a 
variety of micn>organisms— tJie diphwocci ami streptoc<xiM, 
ro<l-bacteria, the Ti*i('homnrniH lYupttait^t S4>metimes gonm'CH'ci, 
ami the long bacilli of I Joderlein, which bmt are sahl to prevent 
sepsis by developing an aeid which destr<>ys |Kpisonous germs, 

Tref/fwetiL — Antise[itic dres^iiiigs are ap|die«l by the nur«e 
for its receptioUj as previously explained (page2*>H). The 
pads require to be changed, at first six or eight times daily. 
After three or four days, three or frnir daily changes may be 
enough ; all tlepends ujM>n the amount of discharge, which 
varii*s in difTerent cnses. It is usually greater in tbos^^ who 
menstruate freely, in tliose who do not nurse their children, 
and in multifianr. The average quantity during the first 
eight days is three and a quarter pninds; of this total, neiirly 
two and a quarter pounds are ilischarged during the first tour 



AFTER-PAINS. 



273 



days. The f|imiititY eaiuiut, ol' course, lie meai<ured ; it can 
on\y Ih5 juil^etl by the nuHiht-r of inipkius or pads used lo 
receive the flow. iSoiuctinies^ t!ie dischurj^e» after havin|i lin^t 
\U red cohir, will u|?ain fwome hloody. This is utinally due 
to getting u[» too m>on after <leiivery. In t*ucb ea:?et? put tfie 
piitient to bed again, and if this alone iJo not rcistraiti I he ilo\v» 
^\we ergot three tiniei* a diiy ; or linet fer, chlorid., gtl. xx» 
three times daily ; or a hot water ( llO*^ F, ) vaginal injection 
continued for titleen ndnutes. The moM imjxjrtant matter 
with regard to the lochia is the early rei.'ognitiim of any dis- 
agreeable. Really puiifi^renl mlar it may |Miiaset?i5. This calls 
for immediate investigation and tliorough cleanmng of the 
vagina and uterus liy untij^eptic irrigiition (see I'uerpenil t^{> 
ticiemia* Chapter XXXJ\'. ). The tiormaf odor of the lix-hia 
is, in a way, disagreeable, but it is not pntreseent. Dnrittg 
tile first few days tlie naturid odor has, not inujitly, lieen com- 
I HI red to that of raw mi eat, while later it bcconuv- of a peculiar 
character cliiHenlt to destnibe^ but withtint aiiv resemblance to 
janridity. It should lie Iforiie iti mind, however, that while a 
pntresrent odor indicates the [ireseuce of j.mtrid matters in the 
uteruiB from which mpramia may arise, there may also be very 
bad cases of septic infection without any odor of" putrescence or 
any decon^posing matter m ^liero. (8ee (Inciter XX XIV., 
on Pnerf)eral Si'jvtica'mia, ) 

AHer-pains.— These are painful contraetionfl of the uterus 
following delivery, for two or three — rarely four days. Often 
caused by retainetl blood-clots or meuiVinuics, owing to uterns 
having been iuif^erfectly eootracteij at\cr expulsion of pla- 
centa. Seldom occur in primipara\ Are worse in short, inac- 
tive labors, and in cases where the uterus has been overdis- 
ten<ied. The pains are intermittent, aceompanied with harden- 
ing of the uterus, and are not attended with rise of pulse or 
tern j^enit lire, liy which they are distinguished from pelvic pain 
due ti> intlammation. 

Trffitmtjit,—Ai\^T']mim may be prevented by securing 
eoin[jlete emptyitig ami firm contraction and retraction i>f the 
uterus during the third stage of labor. To relieve them, give 
two mcflicines, viz., t njot, t<» prrwluce firm contraction of the 
wonih and the expulsion of any hlood-ch>ts, etc., it may con- 
tain, and an anodijue to le^sc^n the pain of these contractions. 
Fid, extr. ergot, ^ss, with tr. opij camph., 3ij, may he given 
18 



274 ^fA^\i(JE^II:^T of mother and huuk 

every three hours, (ir erL^ut fiy the tmnith and a reetul sn|> 
pjsiti>ry of niorphki* I'hlonil, H*^niin>'; Dover's |M»vv<lt-r, 'i 
grains; pheuaetttiri, 5 g^rains, or any oUut arioilyiit*, Auo- 
dyue linimeuts and hoi poult it't^s of hops applied to the hypo- 
gtustriiini will sometimes utfonl relief. A laxative etiemti, the 
woman sitting np during itji iietion ( tliere being no eontra- 
indieation to ihis prm-eeding, from previoy^ lieinorrhage or 
\vt?akiiess ), will often eiiijity the uterus and i^eeure it.s Hrm eun- 
traetion, relieving after-pain.s. Digital rennnal of tdoti^ antl 
pieees of inenihrane lodged in the os nteri may [lossiljly l»e 
net^essary, but thi^ require.'^ ihe strictej^t aseptic tevhinqne : 
m JTiost cases ergot and opium will ht; HutticienL 

When the pains are due ta neuralgia of the uteruB, give 
quiuia sulphat., gr. v-%. 

They also oecnr from reflex irritation every time the child 
13 put to the breaj^t. Time and jiatienee will relieve this^. To 
lessen suffering give |wjtajS8. bromide, gr. xx ; also amxiyne 
liniments to brenst-s. 

The Bowels.— l>axatives during the fir^t two or three days 
after labor are not nefe>^urv, if the bowels were freely o[»en 
before delivery. If no aetion oi'eur 8jM>ntaneously l»y the end 
of the third day a saline laxative — either a Seidlitz powder or 
a dose of magnesia eitrate — may l>e given ; or an enema tini- 
taining one ouiiee of ejistor oil in a pint t»f ^\\\.\\ and waler, to 
w4iich» in eiise of ttfmpattitr% n teas|MM>nful of spirits of tnr- 
peniine may hi* achled. If pills are ]>referred» give tvvo or 
three of the pii. rliei comp., or in eai^e a more aelive jmrga- 
live he needed, tlie mueh-cominendt'rl *'im,4-/Kirtum pifT' of 
Fordyee Barker may be given, thus: II. ExL eoioeynlh. 
CO., 9j ; ext. hyikseyam., gr. xv ; pnlv. aloes ^oc., gr, x ; ext. 
Dua vom.. gr. v ; pwlophylliu, ipeeiie, aa, gr, j. M* Ft. pil. 
no,, xii. 8. Take two at once. 

The Urine, — The urine may be wholly or partially retained 
from swelling of the urelhra or want of eontraetion and h^ns 
of sen;*ihility in the bladder Relieve by the ♦*atheter three 
limes a day until tlie parls resume their iiornval fnnetion. 
Ergot internally stinndates eystie eontraetion. Hot ap|)Hea- 
tions to the pubes or laving the vulva with warm water may 
afford relief Tlie woman shtmld lie remir»ded by the nurse 
to paj^ urine within eight hours after i lei i very, otlK-rwise the 
bladder may l)eeome overdistendcHi without the [nitient per- 




SOME MPPLES, 



275 



CPiving it. Clmnge of posture from recumbency to sitting — 
there beiij^^ no ronlra-iiuiifution to it^ — nmy enable tho wuinau 
to [jass urint! wilhiHil a aitbeter, a.s may also tixiug ber atteu- 
tion u|M>ii tile 8i>uii«l nf water ilrililibiig iiitti a baj^iu. 

Wlun the cathtter is U8e<l it sbouJd bavo been previously 
sultmergeil in uii aiitise[»tie solution, ami tbe external geniluliu 
gboiibl have beea eleaawed auriH:'ptieally toftvoi<i thebjtrodue- 
tioii of vagitail discbiirge into tbe bladder. Tbe introiluction 
sliould l>e done under dire<"tioa of tbe eye, not l>y tbe toiteli. 
The bdiia baviug lieen separated by the fingers^ the njentus uf 
tbe urethra is srrn, ami the iiijilrunieiit put in. For restsona 
of delieaiy this may pret'eral>ly lie done by tiie nunie if ^be 
jK>sse*^.< tlie retjuisite skill 

The Diet. — The ** toiwt-and-ten *' starvatioii system after de- 
livery is injin-ioits and obsolete. The woman, however, re- 
quires hut litllf itmd during- tbe tirst two or three thiy*, for 
tlie reason that she li? absorbing nutrinjent from tissues of tbe 
iuvolntiiig uterus — from one to two ixmritls lost in weight l>y 
tbe uterus, being thus taken uj) into the blood, as so mueh 
iligesteil ftKKL iltuvover, most women store up fat during 
pregnaney, whieh eari l»t^ drawn ujhmi as food without the ex- 
jwnditnre of nervous ftu're re<|uired in the prm'es** of diges- 
tion. To lessen this ex|HMiditnre as far as |>os8ibk% a liquid 
diet — chiefly milk — aud soup is better for the first two days, 
or utnil the milk secretion has been established. The ilrain 
occasioned by the milk flow — atYer the third day generally — 
creat^^ a want for more f<M»d ; beuee si 41-Ik a le<l eggs, hsh, ]>ota- 
t<jei5, the breast of cbieken, oysters, and similar easily digestible 
Buijstauces uuiy be iillowed, at lirst in moderate quantity but 
gnidually increased as the [latient is aide to digest tbenu 

MEk Fever, — Milk fever is a transient, sliglit, febrile ex- 
citrinent, j>reeeded by chilliness, attentling the evStablishnient 
uf the milk st^eretion. It seareely requires treatment, and is 
far less frequent now than when women were iinprojierly ted 
and uu})rotecte<i from sejflic infeetiou. Reeent authorities 
attirm that "milk fever'* is a myth, and that it never *HX;urs. 
Thi? is for the most part true ; the disiea^e has l>een aholisheil 
by pro|ier feeding and antisepsis. I'uder op|»osite circum- 
stances it may, however, still e<mie on, as of old. 

Sore Nippies (" Chapped Nipples ";, — The a|»ex ami sides 
ot' the nipples are alfected with HssuretJ like a cluip|>ed li[x 



276 MANAGEMENT OF MOTHER AND CHILD, 



There are great pain aurl some bleeding during suckUng ; ptiin 
on touching HiiJ|ile ; tiiksiires vLsible ou iiJS[>ec'tioti ; in severe 
cases, ftfvt^r, Tlie iigony of sueklitjg and ruiirM^queirt unwill- 
ingiiesH to |>iii the child to the nii>]>!e riiiiy lead to aeconnila- 
tiou uf iJiilk. folluvsed by io flam mat ion ami ahiieesa of the 
breaiit. 

Tnittment — Preventive : Caution the woman against flatten- 
ing her nipples by prc^.sure of mrsetiii, etc. Keep them ftsep' 
iieaifif clean ^ for at IciM a week I ►e fore delivery, an well as 
after labor^ between the acts of suekHng, l>y fre<juent appli- 
cations of a mturate<l s^olution of iHinc aeith The rliihl must 
not sleep with the iii(iple in ili^ month* After each act yyi' 
nursing cleanse tlie nipple with warm water, dry it, and m>|ily 
a light coni[»re-'i8 wet with boric acid solution. 

( Uiraflve: While minting uj^e a nipple shield — one with hard 
Imse and rubber montb-[)itHT — previou?i|y rendered aseptic by 
imniersion in boric acid solution* Eiich fissure may be touclied 
twi(re daily with mj hit ion of argent, nitnw, gr. xx, to water, 
.^1 by means of a venjfiue earners hair |>eneiL Wet the tissurej? 
Qiihj, not the whole nipjde, with the silver s^dutron. This 
treatment by the silver solution, if conjoiiitHl with al*}<tlnntce 
from ttuckluifj for firehty-ff)ur hours, is most effective and will 
sometimes cure in a single diiy. 

Other ap])iications are: Tannin and glycerin, equal parts; 
nitrate of lead, grs, x or xx. to vaseline, ^ ; the tr. benzoin 
co.| applied with a brush, leaves a film over the ero«ion» 
Itaeens pahu ami promotes bealiug ; liisniuth subnitrate and 
CJttStor oil e<[ual [uirts applied frequently. 

Wright uses orthoform, H» per cent,, to lan*din, Of) [>er cent. 
It is antiseptic, tasteless, and also prodm-e.^* local ansestlie^ia 
lasting for several hours. Many other remedies have been 
employed. They must lie removed, uf course, Indore the 
ehild ntn^jes. For slighter an<l mine sy|>erlicial irritatioris of 
the nifjple without ulcers or fissures, cleanse and ilry them 
after each act of suckling, and dust with |iowdered oxide of 
zinc or gum arable. Another plan is to keep them moistened 
with a rag wet wltli Goulard's extract .^j, to water, C»j, i»are- 
fully washing it off Ivefore nursing the child. 

Sunken Nipples. — Tfie niftjde is U.o flat, short, or sunken 
for the mouth of the clii hi lo grasp. The infant a tteinpti* lo 
uur^, fails, and turns away erying* 



DEFICIENT MILK FLOW. 



277 



Treat7ne)iL—Hohl the child in reatlinesa while the nipple is 
firi<t dmwii out by the mouth t»r fingers of an lulult, or hrennt- 
pninj), ami theu a[>j»ly it protnptly. Another plan : Hold 
over the in[)ple the month of an eni]>ty i^ljiss Imtth^ wlio?^ 
contained air has l)ecn [ircviously ra relied by heat, till the 
air coeds, and the nipple is? drawn np into llie neck nf the 
bottle. Then remove it and apply tlie child ininiediaUdy. 
Still another device is to draw ont the nipple wilh the iingera 
and slip an elaslie rnbher riii^^ ronnd the base while thns 
drawn out. The ring niu.^tonly be worn a few niiruitcs, and 
must not 1h^ li;::ht enongh lo stran^^adak* the tiss^uei* ; or, a strinj^ 
havinjLi: been pa?<sed tbrongh the ring^ liefore it was ap|>Ue<l ro 
the nipplet may be ;=rently polled npon nntil the rin^i^ is lillecl 
away from the skin sufficiently to allow its being cut in two by 
a blunt |>air of scisson^ while tbe child is nursing. 

Excessive Flow of Milk. — The breasts overflow, or be- 
come tender, hard, and distended from accumulation of milk. 
Danger of inflammation and aljsoe.ss, if not relieved. 

TrenhneuL — Restrict the woman's diet to dry food, as fnr as 
possible abstinence from fluids. Laxalive^a. preferably salinesjo 
lirodnce vsatery stools and rt^iiuee tbe Hnids of the blood. Dia- 
phoretics ( liij. ammoiK acetat,, ^ss every two hours ) to ]>rodnee 
watery secretion from the skin, I^n-ally, R, Ext. beliadorimc, 
3[j, lininunit. camphor., .^. >[. Sig. Apply to breasts with gentle 
friction of the hand. Instead of the belladonna, which is dis- 
agreeable and liable in some patient-s to produce tlilatatioti of 
the pupil and other eoTistituiional effeet-s »»f the drug, rapid 
reabsorpfton of the milk may lie >it^cnred by painting the 
breasts (all but the nipples) with tinct. iodinti, and <'canpre^^^ 
ing them with cushions nf raw roit'iM and a liandage. 

Large doses <»f prtass. iodid. < gr. xx three times a day) with 
rigiil enforeement of dry, abstemious diet, and nuHlerate, cun- 
tinne«l conjpressiou of the breasts with adhe**ive plasters, will 
six»n enfirrhj .^op tlie secretion of milk» as may be nect^ary 
when the child dies or the mother is not able to nurse. 

Deficient Milk-flow. — Wlien due to anemia, debility, or 
hemnrrhagt% build np the (tatient with iron, rjyinia» bitter 
tonies, and nntntifius food, espeeially milk ; hat of all milk- 
producing foiuls the niost directly eihea<*ititis is rrahf*, whether 
r^nft or luinl-shelled. Oysters, elams^ Inbsters. and nearly all 
kind> uf shellfish are also ^<hm], eare being taken to avoid any 



278 MANAGEJfENT OF Mf>THKH AND CHILD. 



which, owing to iiliosyncrapy on the part of the wonian» dia- 
agree with hen A mode nit e uoiount of wine, or pre tern l>ly 
nnUt li<nior^ — lager Lwer — should 1h^ takdi with meals. The 
re[)Ute(l galactago^me projHTty of fomeiilatiouri to the hrea.'^ts 
of Jouves of the ea.*4tor-oil [>!iiMfc, im well as that i*f the fluid 
extraet takeu iuterually* luu^ heeu overratetL Theapplicatioti 
of elec'trieity has been recently employed with soiue i^uecessas 
a jiahietaprogiie. Oiu* of tlxe best vegetable fiKids is boiled 
fresh iH'et8» eaten without viueijar. 

Artificial Peeding; — If the mother cannot nurse her infant, 
it nnist be puiirisheil by a wet-uur^e, Wheu none can l>e 
obtained, pve row's milk tuie part (by measure ) to two 
paru of water and add milk sutrar. ^iv to eaeh pint of the 
mixture, the |iro|>orliou of milk to \w iuereu.^ed with age. 
When this fotnl disairrees, aial the ehild [nisses lujup^suf imdi- 
gei^ted eqrd, one-third of the water may be exehauired tor lime- 
watrr. The watt'r must Ik* steribxiHl by lK>ilin^, and the milk 
not by boilinj;, whieh impairs lu nutritive value, bul by Pan- 
trttrizatiott — /. *., by ke*'[iin;j: it c*<intiunously fbr thirty nduutei* 
at a temperature of }iu^ F, 

It is of the utmmi hnportanre that nipples, bottles, and ves- 
sels in which the food is jin'|«ired should be ki^jit aseptieidly 
cU^an. They must itot hr n^^tti /iiv>c without being thoroughly 
eleiini*e<l — the bottles iiud veftsels strahleil ami the nipples ira- 
mersetl in a soltJtion of l>oric aeid» The best rule as to how 
much of the milk-mixture should l>e given the child at one 
thm\ i^ to give it as much ai« it will trafUly Uikf ; if it reject 
any, pve it less next time. 

How LoBg Should the Mother Keep Her Bed after Labor 7 
— The ]>o[ndar, conventional rule is hiiic day^. It is a custom 
withiiut reason. Some strunL% vifforous wmncn with liealthy 
and well contracted uteri might g<'t up sooner; others recjnire 
a much hmger period. Everything iley»ends U|Kin the char- 
a<»ler ami ctmi plications of the ialwr, the strength of the 
woman, and the (vindition of tlie uterus, Tt)o early getting up, 
wliile the womb is large and heavy, and its natural sup|>ortB 
relaxeil from the stretching of pregnancy and In bor, endangers 
uterine displa<*ement.s cougeMimr, return of ld«HHly lochia, ami 
subinvolution. It is bcUer to err on thes4ife ^de by making 
the lying-in U^f Icvng, thnn to risk tocj early rising. Two 
wveks in betl i^ ii L'ood rule : durinL' the third week the woman 



THE MANAGEMKyr OF THE CHILD. 279 

(if all goes well) may mnvf about her rix>ni anil at the end of 
the fourth, leave it. 

Suckling the Child. — The iiitknt nmv he |>iit to tiie 
hreaj^t aa fioon as it is washed, dressed, and reuily i'<»r the 
naXluTt providerl Mhe Ih? not over-tirerl. If she he, lei her rest 
a ft'W liours. Tlie child muy uurse abujt every four hours 
during the first day t>r two, Ik tore the flow of ntilk Ije^dns, 
After then* more frt^[uently, every two hour^, exeept from 11 
p. M. to h A. M,, wht^u the mother fcihou hi heallowe*! e*mtinunus 
Bleep, Wheu the vhiUl is six months old, five or six tiuies* in 
twetily-four hours will he suffieleut. 

The hreiists sliouhi he suekled alternaudy — tir^t one, then 
the other — an<i the nipjjle.^ tenderly eleansed with a 4 per 
cent, sohitioii of h<nux and water In't^o'e aud alter each act of 
nursinji. 

Tlie tlow of milk is m^t ns^nally c.stahlLslietl until the j?eeond 
or third day after delivery. iHtriiitr these first tlays lljere 18, 
howeven a little iinperfeetly fonnefl yellowish milk, known as 
the * * ci> 1 1 jst r u ! ' * ( ]*ee [ m ge 6 h ) , w h ieh is eii o i »g 1 1 fo r the 
infant without the addition of any artilieial food» and aeU 
u|H>n it as a laxative to remove the " nietonium/' or native 
eonteuts of the intestinal eanal» eonsistiug of unaljsorbed bile, 
mucus, etc. 

THE MAKAQEMENT OF THE CHrLD. 

Laxatives for the Infant. — If the child's ijowels fail 
to tuove .«ipontaneousl3% which is rare, a little ** pinch'' of 
hrown su;:ar dissolved in a teaspioiiful of water nuiy he jLriveii ; 
or half a teas|wionfnl *if ntive nil, or a little enema of soap ami 
water, or a small reel a 1 snp|w>silory of glycerin* Before 
j^ivin^^ any laxative it most \w known that the child is not 
sufterinj: from imperforate anus. If the mother Im:* corrsti- 
pa ted, hixalives iriven to her will reap|*ar in (he milk, and 
o|>erate ou the child. 

The first evuruations from the child are black in color, 
slightly tin*jfed with tureen ; they heeonie yellow h^ a few days. 

The Infant's Urine. — If u jmju intjuiry the ehild is rcjHjrte<l 
not to hsive panned urine durinir the lirst day after delivery, 
examine the urethni and meatus for con LTenital deformity ; feel 
above the puhes, whether its bladder he distended, and a.Heer- 
taiu that the urine has not l»eeri voided in the hath unawarei». 



280 MANAGEMENT OF MOTHER AND CIHLlt. 



If the bladder hefiilU a Fpnokle of coKJ water uti the hyjK)- 
gastriumi or a warm Ijuth, niay answer. A very ijiimll ehi^tic 
catheter may, vertf rurely^ l>e re<]uired. 

Most castas of ap()areut retention of mine are really cine to 
iion-Heeret ion ; the infant takes but little f!M«l, and may excrete 
hnt little urine, 1x1 it alone. 

InfantOe Jaundice ( Icterus Neonatorum). — A common 
atiV'f'tion during the fir>t weuk of infant life. 

i^tjmptmnK — Vtdlow akin and eoujunetiva ; hjgh-colore<J 
urine ; light-colored stools. 

Cattnes, — ^Recenlly it ha.s been aserilwd to sej>tie inlection 
through the inivel, e8|)ecially \n lying4n hosi|utal8. The tight 
ajiplieatioo i>f 1 wily-hand:*, re>itrieting tlie resjiiratory motions 
of the abdominal walls ami diaphragnj. u|Kjn whieh the 
portJil 4'inndaUon <'hiet!y de|>ends, ia pnihahly a fat tor in the 
prodnrlion of the disease. It ocenrs more fie^punitly in |>re- 
nnitnre inlanLs ; in hoys than girls; in ihe eliildren of pri- 
mipane, ami in ea^^s of ma I presentation. 

Trm/mt^/i/,— Nothing further than the removal of belly- 
bamls may l^e necei^sary in wlight aises. It s4K*n goes away. 
In »evere oa?4t*« with eouMtipation, give ralomel one*sixth of a 
grain» with one grain i>f white .sugar, in |>ovvder, three tinien a 
day* for one or two days, followed hy a tea?^|M>onfiil of olive or 
castor oiL 

In scjme eases there is apparent hut no /^a/ jaundice. The 
skin i» colored, while other symptoms are ahsent. It passes 
off without treatment. 

Sore Kavel. — An ulcer, nanally with sprouting, flabby 
granulations, remains after falling off of stump of funis. 
Usually cau^etl by friction and pressure of Imndages ixm 
tightly ap|died ; may alwi be due to septic infection. 

7^rr<f///</7i/.— Remove all dressings and bandagej*. Cleanse 
tlioronghly wilh horir acid solution, Ttiuch the granulations 
with |>encil of argenl. nit. Then dust navel with antisi*ptie 
|H^wder of mlicylic acid and j*tareh (1 :10j and cover with 
aiiti^ptic cottfjn. In p>imie cases tlu' fungous granulation^ after 
eaut4*ri nation, faib to dimp|>ear ; it persists, hein»mes S4>lid, and 
perhaps j>edicnlated like a little jwdypus. The mass should 
he liLiatefi and cut offl 

Umbilical Hemia. — Iti the common form of umhilical 
hernia in inlaiits a soft protrusion, about the ^ize of a finger- 



OPHTHALMIA NEOyATOEUM, 



281 



end, projects at the navel. It Ij^comes more ieuso aud f imm- 
inent when the child erie,s. It is msily reduced hy digital 
j»re>ssure, and the liuij^^r can then ieel the sharp borders of the 
rinjt: through which it canic out. 

7'reittmctti. — A roood disk of wood* a coin, ur a hutton is 
wn»|:i|>cd in lint or some si»tV material, and kept in pos^ition 
over the uml>ilicus with a light elastic handage or with stri|3e 
of adhesive phi.ster, these appliance^ to l^e removed tor cleans- 
ing purposes and rejdaeed. lieeovcry mm n» with aiibsequent 
closure of the ring, 

A much more serious form of umbilical hernia rarehftmnir^ 
with imperfect development of the ahdiHoiutd wall, in wliich 
lanje protrusions of inte^stine and othtT abdominal organs take 
place. The^^ re^pjire a plastic sur;irical 0|>e ration. 

Secondary Hemorrliage from, the UmbiHcus. — A danjxeroua 
and ollen fatal hleediti^^ fnim the navel, coming' on days, or 
even weeks a tier delivery, and recurring (stmietimej^) ajj^aiii 
and again, in s])ite of fityptice. ligatiiresi, the actual cautery, 
and other menus that must be promptly tried for its relief, 
Tlie bc^t (jhin is to transfix the ba^e of the navel with two 
liarelip pios* and piyis a fi^^ure-of-8 ligature around (he ends 
of each pin, m jis to compress the bleeding vessels, llcmm e 
pins ill live days and leave ligatures to come away of them- 
si'lvcs with the ligaidl tissue, striit antisejis^is to be observed 
IkhIi iluring the triinsiixion and snbstHpient dressings. 

Inflamed Breasts. — In yon ag Infants of either sex^ one or 
btith of the brt-asts may become red, tentler, and swollen. 
On jtressiire a few drop of milky tlnid may be squeezed out, 
but this pressure should never he aiioited or praeli&ed. I>et 
the breasts entirely alone. The trouble wiJI disap|iear of 
itself in four or five days. If attertipts are foolishly made to 
press out the milk, [)us may furm, nnd m huicet be reijuired 
to o[x?n the little absee^ks always under antiseiitic precau- 
tions. 

Ophthalmia Neonatorum. — Ophthalmia neonatorum is an 
infections purulent conjunctivitis, due to the gomMM)ecns or 
some other pyc^genic germ, and produced by contact with the 
eye of vaginal secretion from the mother during labcir, or iiy 
infected fingers, instruments, cloths, etc. 8tatisti*'S sb»ov that 
bli miners in adults in about one-fourth of all cases is due to 
this disease. 



282 MAXAGEMEyr OF MOTHER AND CHILD. 



Sijmptoma. — Great Htvelltitg and Himetiiiiej* lileetFmg of the 
eyelids; the cH'uliir iiud puliiefiml coiijuiictivie are red from 
ititnue hyperopmifi^ and tbt- 8k in of the li*ia is <ifteiiof a dii^ky 
red or bluish t'oli>r ; profum puruleui dischanjf of ii^'nty* green^ 
or Vi'llow tint. The eonjniictiva swelh iirimnd the <\)nieH, a> 
I hat the hitler apj)ean* ^<lmk down in a eirridar dt^|iretii*ion. 
Bail cnH(^ <;o on to uh'eratiou mid Khniirhiti^ of the eornea, 
with perforatii»n into anterior eh am her, if tiot properly and 
promptly treated. 

Treatment,- — Kee|> the eyes elean and free from aeeumnlated 
pus by \vn.^hiu£^ them every half hour with a .sjiturated ndution 
of horie acid, lids to he separnti'd as widely as |K)?i^ihle, and 
the solutitui drojiped in ph^nlifuliy ; or the bnlhous tip of a 
glajBS eye-drop]>er is j»hjerd alternately in the inner an*l outer 
an^^leH of tlu^ lids< and the ^idnfioii ^^lowly inJH*ted wifhiii tliem. 
In phire of the Ixirif aeid sotue prefer a 1 : 5000 birhloride of 
mereyry f^olutiou used iu tlie same way. Beside this antisej> 
tic eleaiirtinf^, which must be faithfylly done, both day and 
nig^ht ( he nee hi*n our^en are rer]yired), drop into eaeh eye, 
every night and every moruiiijr, two dropn of a iwo |>er eent. 
solutiou of silver nitrate. Al\er inteh wni«hirifjr plaee over the 
eye a light wet eompres.s ke])t eold by eonlaet with iee. Aa 
the symj^louLS l>t*eome h'Rs actite^ n.'^e (he silver solution otice a 
day and rednee iti^ strenirth to 1 per eent.» the liorie aeid (or 
hiefdoriih) t^jjlytion to be eontinued utUil cure is complete, 
iDfbrrn rehitives lo iK'ware ftf eontagion. Isolate jmlient and 
burn all eloths, romprejiii^es, ete.» oiice useiL Id labor eases 
when inik'tion i^ fean^l, ut*e one drop of a 2 ytcr eent^ silver 
nitrate solutioii in eaeh eye as a prophylactic mea.^ure. 



CHAPTER XIV. 

MECHANISM OF LABOR IN HEAD PRESENTATIONS. 

By the niechauicmi of kibor we uiiderstmid tht' o|>eralioii of 
the nuM*haijiiMl forfrM^ ami the execution of tht* ioH4ianir!il 
mnvementa oect?s.sjiry to i^n^urt: the pa.^isii^e of the child through, 
ami its exit from the [)eh'io (or nit her [mrturieiit ) caiiaL 

In stiiilyin^ it there are &ix pre^enUitioftH to he considered, 

1. Heail pre.scntaltiHii*. 4. Kuee presentations, 

2. Face prescutatioos. 5, Feet [)re>*eritatioiiH. 

»H, Hreecli [jre^eittations. (>. Tniiwverse ])reseotations. 

Posture or " Attitude "^ of Child in Uterus. — The jMKsture 
of the eliiJd In Htem is very much that *»f tin adult when try- 
ing to keep warm in a et^ld bed before ^^oiug lo sleep, viz. \ 
the j?pine curved forward, the face l>owe<l toward the che^^^t, 
the thii^lw Hexed U|>t>n the al>ilnnicn, I he legs toward the 
thighs* and the ami* Hexed iumI fcddt*d acrns?* the hreant The 
child, in itdro, thus flex cm J and fohled, is more compact and 
«K»eupj(*s les?! sj>ace than it could in any other |wmtnrc ; itii 
whole fnime a|iproaelies the ovoht jhnn tif the ntcrine eavily 
in whicli it rcp>:«<ei<. 

Now* svhen either end of tins ia^tal ovoid |ireseulj«i, other 
tilings being norjnal, delivery is nieehanicalty pos.'^ible. When 
it pre^ient.^ croimwijte^ delivery m im|xtsHible» Hence, presenta- 
tions of the hcatl, face-, breech ^ knees, antl feet nniy bp consid- 
ered nHtnrai presentHtions ; while transverse presentations are 
pretentafuraL SinietiiiH-s head and face presentations are 
called "cephalic'' prcscntalions, because the cephalic (or 
brain ) f)*f7 of the ovoid presents; while breech, knee, and 
footling preHentatiouH are termed *' pelvic'' prejsentations, 



* The tecbnfciil terra " nttihtfU *' iherefore 



the reliitlcin whlt*h the dif- 



f<?rt»nt wirttt of the nbUft's »w»|y hour to fivh oihfr—i^ me-Atilux qnUo dilTerciii 
from the Ifrms ' p^fMnh}tUm" nn%\ " iMi'*tVon" a* wUI be seen imuUHlUtely, 
Vide Appeadi^t on CniTurrotty la Obeuaricftl Nomenclature, 

383 



284 LABOR IN HEAD PRESENTATIONS. 

Fig. 101. Fio. 102. 









Exceptional. Exceptional, 

Figs. 101-106 represent the six positioos of the occipat. 



TUE rosrrioys of head presentations. 285 



bet'ause the pelvic or caudal end of the ovoid comes first. 
The \oVi^ spinal column mnsi rome one end first — either heiul 
(jf tail, 

HEAD PRESENTATIONS. 

(_ ai^H in which the head preneDt*? at the o** uteri or j>el- 
vic hrim* 

The Four ** Positions " of Head Presentations.— By the 
term ^* po.-^itUnt,'' as applied in the uieelmiiijsni of lahor, we 
meau the positional rehithn exUihuj hefivven iitjin'n }Hjini on 
the premnting part ami cniuin oth*r giren points up(3fi (he 
pefvii. In head preHeutatiou the orciput i^ the ^nveu piiut on 
the preseinirig ]jart, and the given poinds rm llie pelvii* are the 
trim acefabuJa and the tivo Hacro-i/iac sijurhondroieifi* Thus the 
four posiiioitH oi' a resil prei*eutatiou are: 

1 . O ec i p u 1 1 o left aeeta I > u 1 u m ( 1 el\ <Kx'i pi to-au le rior ) * ( tx^ci [> 
itf>heva-anterior). 

2. Orripdt to right acetabulum (right oceipito-anlerior) 
{ occ i p i t < M ie X tr a-n u te rior ) . 

8, Oeciput to it'j'f fcjacrcHliac gj^ivehoudroeis (left oceipito- 

po«terior ( ueeipito-heva-iHu^terinr ). 

4, Oeeipot lu rf^;/i/ sjirro-iliaehynehondrosia (right o<x'i pi to- 

(w»?iterior ) (c>ceipitf>-dextra-|x>8terior k 

JVn/ rnreig the tw?eipnt |>otDtji directly in front, to the wyia- 

physii* puhifi, or ilireetly hehiod, to the i^icral promontory* thus 

njakin^ (wo more (>ositii*n8 (^i,r in iill |, Jiut these two may 

he left out. They usually litH^ome converted ititu one of the 

other four at the he^inning of lalM>r. 

The order of i^'^reale^t ftrfjite/icif of tlie four }x>sition8 is as 

iollowH : 

Fir^L t)eeipnt tu Itjy acetahnlum, L. O. A/' 

Seeonii, (h'eiput to right sacro-iliac i^ynchondrosis, R, 0* F, 

Third. Oeciput to right acetubrdum, R O. A. 

Fourth. Orei[mt to Ifft sacro-iliae synebondrosia, L. O. P- 

This order «:tf frequency iss worlli rememl>eriiig. but to eall 

the pjsitionf* hi-st, s^foiKh third, and fourth it* W(»rse than use- 

les;?, and hatl lietter be omitted.^ 



I So ralU^fl Ih'imium^ tl»e (W'ripnt (k folntfnc in t]iK' (rft nnd fnrrusttrH . 



plun of iKunt'Ui loturo t* 

* L. O. A.. U-n *ft'vi\AUt-AiiXtnfiT: L. n. 1 



Thi'fiaroe 



liito/Vi-iU'rior. 
t^ry MM} vvtty . uuiti!, 70 ari" L. O, A. poal- 

lions nW*i'Mi U. O, \\^ all others tteintir exlrenicly mfc ext'i'plioits. Prt>f Cum- 
eran'6 «gure» iin»' L- (K A, 67; H O. P„2i); R. O. A^ 10; titid L. O. P., 3 i»er 
cent. 



286 



LABOR IN HEAD PnESENTATIONS. 



If tlie ritudeiit be ii*it alreiuly runiilinr whh ihe terms and 
meaj^ureinenlii' given jij des^cnlHii^ ibe |>elvis* (Chapter L) and 
foetiil head (Chajiter JL)> lie should review them hellire 
attempting to Iwini the niefhaui?iin of Itihur, In the lul- 
lowing de>S(?riptit«ii k is designed to give only the main ptinei- 
plen of the irieehanisin, leaving exeeptional neeurrenees antl 
slight deviations and oliIii|uities, t»f ni> greiit ]>nietieal vulne, 
entirely out. A siinfile outline sketch htul helter he hnirnt'd 
first. The tiner shade^s of variation vnu he pnt in afterward* 
Mixture is conftisiion. 

Stages of Mechanisni in Head PreseEtatianfi. — These are t 
1, Flexion. 2. Des^eent. 3. Rotation. 4. Exteusiou. 5. Res- 
titntion nr external rotation. 

Mechanism in Left Occipito* anterior Position i Occiput to 
Left Acetabulum). — L Ffexion. It must be renietjd*ered that 
the fietal load is(rouLildy )egg-shajted, and measures, from the 
bi<j end of it to the /itffr t^nd (from the (H-eipnt to I In* eldn ), Tjj 
inehej*. While the oreipitid fwde of the head is at flie left aeetiih- 
ulum, the chin-pole must he s<>nie where toward the right 
saero-iliae syuehondrosis, and t\ line tlrawn between these two 
jjelvic iwints is one of the oldiijue dtnnieters of the hrinit and 
measnret? 4i inches*. Is a hcjid difjineter of oj inches, then, 
trying to imss* a ]>elvic diameter <if 4} ? No; the howed atti- 
tude of the elnhl'H head in ii/^rrj. already mentioned, kee|>s its 
chin-pole lilted i^Howard the uterine cavity, and the oci*i|(ital 
pole tilled down ti»ward the «J8 uteri and jm^Ivis, so that the 
forehead instead of the chin is really at the right saero-iliac 
synrhfmdnMis, and it is» therefore^ the occipito- frontal diameter 
of the liead (4i inchf*8 in length) that is ajiparcntly trying to 
go through the iddi»pie |n^lvic diameter of 4}. lint tbig 
would be too tight a Ik, The chin must be tilled yet more 
decidedly toward I lie sternum of the ehihU and the o^^cipnt be 
niade to dip more decidedly toward the entrame of the jjelvis, 
in order that the oval-sha]w^d hea<l may enter the brim more 
or less endwise. This i:^ /?^^i ori^ so called I>ecan8e the cldld^s 
ua^k is /?f\r/7/, and the chin pressed against the sternum. Fig. 
1*)7 shows diagraniiimtirally, the effect of flexion in [»eriuit* 
ting des<'ent. In the upper head, unflexed, it is sevu the 5J- 
inch oeeipito-mentnl diameter <'annot enter the 4Jdneh diam- 
eter of the brim { reprt^rnted by the ring at the lower part of 
the figure K The middle head is flexed sutticiently to descend. 



LEFT OCCIPITO'ANTERIOR POSITION. 



287 



The lower head shows an impossible degree of flexion — 
impossible when the head is attached to the neck — and unde- 
sirable, as it would permit the head almost to drop through 
the pelvis. The lines and numerals represent inches. 




Influence of flexion In permitting descent. 

What causes flexion ? The force of uterine contraction is 
transmitted through the body of the child to its head by means 
of the spinal column, but the cervical end of the spine, where 
it joins the cranium, is 7wt hi the centre of the base of the 
skull, midway between the two poles, but is nearer the occipi- 
tal pole ; this last, therefore, bears the brunt of uterine force 
and is made to dip down lower than the other pole. More- 



288 



LABOR JX HEAD PRESENTATIONS, 



over, the two fM)lc\s riieetiiiju^ eqiml re?5tstiin<'e from the inrcle uf 
the OS iiief] ami jjelvie i»riiji, tlie resisting force exerted innm 
I lie chin or front til pole will he more eftet-tive heeausc* it in 
artin^ on the etui of a longer lever than that a|*plieil to the 
ordpnt, lienee the chin and forehead are tilted y])ward. 

h must he adnntted, however, that Hexion of the heiul is its 
normal attitude dnrin;j^ jirejLrtKHicy befurL- lalHir IjeL'ins, and 
when therefore the CHtifif's of Ilex ion must he different from 
thoR^ just dej*cribed ; hut that the tlexiou, when int^utheu^nl. is 
increa^Htnl *lnnnL^ labor in the manner aUne mentioned I apjM/ars 
reajsonable. Whatever diU'ereuees of o])inion may lie held as 
to the manner iti which flexion is jmHhieed, one thing i^ cer- 
tain, vix.: the flexion mnd orettr or the head eanm*t descemh 
Henee, whether we regard it as taking phn*e dnring preg- 
naiicy oronly during labor, it is a iieeessary step, ami I lie tirst 
step in the mechanism by whirli the head is eiiabled to pasj^ 
through the |xdvie canal. An loiflexell head cannot pass; 
and in pro(>ortion ns the |)elvis is generally contracted the 
flexion rtH|uire8 ti» be increased. 

While the long (*K'cipito- frontal) diameter of the head is 
more or less purallel with onf' oblitjue diameter of the pelvic 
brim, the transverse or biimrietal diameter (Mj inches) oceu- 
j>ie*« the othf'r obi i<] lie ( 4} ). Hence there is ph'iity of rmmi for 
Umt to paas. The hi parietal diameter is also ftfmitt on a level 
with the plane of the superior strait, owing to (he fundus uteri 
being HJ tilted forward as to bring tlie uterine axis in a line 
with the axis of the plane of the brim* 

2. DeMcent — The head having l>een lilted eudwi^^ Ity flex- 
ion, it enters oi*eipyt first, tlie |>elvic brim, and dei^'entU into 
the pdvie cavity. It goes on down (the iKTiput t^till towanl 
the left acetabulum and forehead toward the right sacroiliac 
synehoiidrr)sis> until reaching the jielvie H<rtir (the bottom of 
lire basin ), 

While flexion and deawTnt are {\\im desi-ribed as sep 
arate [iroeesses, and while the former is neeessjiry to the 
latter, it runst uot be snpjwM^etl that flexion is complete before 
dew^ent begins ; on the contrary, they go on simultaneonsly, 
each increinent of flexion Innng accompanied by an iucre- 
meut of descent. In fact the whole pHw-esg of lalwir, from 
beginning to end, is a de.«cent or progrt^siou of the head and 
body of the chibl, from the inlet of the {wlvis above to its 



LEFT OCCIPITOASTKRIOR POSITION. 



289 



exit at till* tiutlel beluw, Desceut van *ti\\y lie [irofitably 
eLmi?i<Iere<l lis u separate prncess in thut it is one that niyst 
t*tke place, before the next ^tep, viz., rotation, can beiN.»me 

8. Iiokdion. — Tlie heml having de^ieemle*] tt> tlie pelvic floor, 
it* oecipito-frontul diutneler (4Ji now tK-rnpies die oblicjue 
diameter of the in/V-n'or «lruit, which, however* niea^nres only 
four ifirhe^*. It cannot go od. Hoinetbinij: must <M'cur to bring 
the h>ng dianieter of the head panillel with the itftfero-posferhr 
diuineter of the outlet, Hbich ue know measures 41 iuchej^ or 
even 5 when the euccyx is pushed back* This ih accomfdinhed 
by pitation. Near the end of its ** descent " the occiput strikes 




OftclpMi Hi irifcriof Ktrait after rnUtlon. 



the pelvic floor and t!ie slantinp surface of bone in front of 
the ischial spiur^thc .^M'alled left ftiihrior inrlintd phtne — 
and iilidin;^ downward, forward, and iJiward toward the median 
line, it reuchee the Hyniphy.His pubis, while the forehead, rotat- 
ing downwanl, barkimrii, and inward toward the me<Iian line 
( alon;^ the rij^hl pOHterior incljncil plane ), rearbc*^* the centre of 
the sacrum, Thtjs the «>void bead \mA e<mie to (X'cupy a |x^i- 
lion at^^rcein^' with the louL'e:^! f anien>-|Mit*tenor ) *iiameter of 
the ourirt and llie occipilul pole is almoMt ready to e^-ajie, end- 
wise, through the infcriur strait. (Fig. lOH.) 

The influence of the 'inclined [daues*' in causing rotatiiUi 
has latterly lieen doulited ; and oilier thei>relical explaiuitions 
have l»een giveti. But these lheorie« are of no very great 
niotnent. The practical fad remains, that in the normal 
nieebanif^m of labor the head does and must rotate in tlaa 
nut n tier described. 
W 



2m 



LABOR IN HEAD PRESENTATIONS, 



4. Extetunoti. — The bead now slreteheB the perineum and 
si>ft iMirt« into ti kind of ^^ntter, which constitutes the tieishy 
eunlininuiun of tlie prtrtiirierjt eauiil. The uedpnl des<*end8 
below the syni|iln>is jmhis and passes on liehveen the (inhic 
rand, yntil liie hiparietal tijuator uf the ht'aii Ul» mU* the 
puljic areh* Tlie liaek of tlie ehihl's iierk meanwhile htii 
ii<]iiarely against the jKMtenor >urfaee of lliu pidiic synlphyl^i»» 
and resting; tliere innnovaldy, the fort^e of nterine eontraetion 
is exj^iended n|>on the eliiii-jM.)le of I he head ; lieiiee» a*^ soh^ui as 
tlie resiHtanee of tlie soft parts permits the (K:cipiit to hegiu to 
eseape^ the eh in itf released from its eonilition of Hex ion, nnd 
extension is said to have hegnn. Finally the forehead slijiej 

FlQ. 109. 




UpwiiFd cxtcnsioa of tXHSipttt. 

by the projectinj^ cotTyx, the parietal etpiator of the head 
eniergei* fri>ni the vaginal orifiee* anil flu- immediate relraetiori 
of the ebi^Htie |H*rinenni oyer, seieerepisively. forehead, nose, 
mouth, and ebin, eanses the oerijnit to ri^e up iMiti^iide an<l in 
frf^nt t>f the pnU\« t*»ward fhe rnons veneris. Thus delivery 
takes |ilaee hy the head deserihirig a circular nioveinent nnind 
the fixed centre of the pulne areh — a movement exactly ihe 
reverse of Hexion, viss., e^enmon, (See Pig. lOli > Itemendier 
the iiirtriiun i>f extension in thiH L. O. A. [msition i« such a« 
to make the munpital p*de go ^ipunrd \\\u\ fnrwnrti t<iward the 
nK>ns veneris* In the R. O. P. and L. O. P. |j08ition8 we 
shall ^*e {\m sometimes reverscnL 




LEFT OCCIPITO-ASTKRIOU PUSITIOK 



291 



It i& worthy uf remark and illuintratesi nature's adnptiitioii 
uf meiitii* to eiidn — hi this rutie the julsiptiUiori of passenger to 
j>n;^8a*^e — that wfieii iiiilerior rolntioii of the oftijiut ijs com* 
plete and I he lieail ia aiMiut to escai)e liy extension^ the pro- 
jecting rorcifj' comet* exadhj in contact tvith the iiiitrrt/*r Jon* 
iimelle^ whose yielding surface i>flei's less re*>istauee than a hard 
bony one vvouhL (See Fig. 108, page 28^.) 

Fia. no. 




5. Reditniion (External Rotation), — The head, after being 
completely Iwrn by extens^ion, hangs tnit of the vagina , the 
chin <lropping iowiird the antis, the vaginal orifice encircles 
the neck. The head next (uist.«. or rotates, iu sncb H manner 
as Ui iiring the <MTipnt toward tlic m<ilhcrV left ihigh— tlie 
thigh eorres)wMiding to the n^'ctidndum at which it originally 
pre.^iiteiL Tlie purpose of this nmoanivre is to facilitate 
delivery of the i^houlder?. Their h ingest diameter ii<, of course, 
the hifv'icroiiiial — from ime acromion |vroee>t«* to the fvther. This 
diameter eotere<I the liriio and descendtMl into the cavity of 
the fielviH, parallel with ihe obliipie pelvic diameter extendirig 
from the niihi acetabulum tfj the left sacro-iliac nytichoiidnisi^. 
But hjiving reached the inferior strait, the bisacrinnial diann 
eter ninst rotate fri»m itn oblique direction in the jKdvii* to the 
anlcn>poHtcrior one. Hence the right t*houlder^the one 
nearer the puheis — rotatess to the pulies ; the left shoulder — 



292 



LABOR IN HEAD PJiESENTATfONS. 



the one nearer the siicnmi — rotates ti> the Bacruru. This rotii- 
tioii of the Bhiiulclen^ hmflc the jielvis fiuise.s rotnliwi uf the 
head otUnile of it. The shoiihler tit the \n}hv^ usual I y fixe^i 
itself there, while the other one at the |ieriueum swings round, 
ilesjcrihiugaeireiiliir niovemeut (as the oeei|mt did), mu] eoiuea 
out tirsU {See Fi;r. lUl) 

Wlieii the shouldci^ are ilelivered the rt*st of the hrxiy 
usually fillips out at oiict', witliuut any f?[)eeial mei-haninnL 

Mecliaiiisiii of E, 0, A. PositioE ( Occiput to Right Acet- 
abulum), — L Flf'xion, Uy which the I'hin tilL^ up and the 
oceiput dowUi so as to get the hni^ diami'ter of the head more 
or le88 endwise to the ]>elvie brim. 

2s Ih^cettl, hy whit'h the head dej*eend,s» oeeiput tirst, throinrb 
the brim, into the nivity, dowu to the inelined idaues t*f the 
|3e!%MC floor. 

S. Roiafitm, l>y whirh weiput frlides alon^ ritjht anterior 
inclined i>lutie, duwnwanl iorwiird, and inwanl U* MMnjihysis^ 
pubis ; and torehead ^Jidea along tfjt {losterior ineliuetl plane 
tti iniildle of saeruuL 

4. ExfenmoH, by whieh tK'(H[)ut eseaj^es under pidne arrh 
and rises up onlsidei toward moiia veneri^s while fcirehead, 
no4*e» mouth, and eh hi sureej^tfively eM*a|x? at (wTineom. 

5* Ut'Hfituthm (external rotaticm), by whirii cweiput tnrna 
toward mother's r'ujhi thigli (ibe thigh (•urre.><{K>nding to aeet* 
abulum at wbieli it originally pre^'utedj, in eonsotpn^oee of 
shouhiers rotatirjg U|K>n indined planes — left, slnudder to 
pub«*» right til eiK'oyx ; the hitter one generally eiHUii>es first. 
Delivery (jf the Ixnly. 

Thus we ha%'e de^scrilietl the two anterior positiuuH nf the 
c)eei[mt : L. O. A. and R. O. A, Next eome the two /w^mor 
on en. 

Mechanism of R. 0* P. Position fOccipnt to Right Sacro- 
iliac Synchondrosis ).^L Fiejrioru % i>^isw«/, tis in anterior 
po^itiuOH of tiie oceipuL 

3. Roiaiian, — In the large majority of eai^es (fHi per rent,) 
the <M*eipiit rotates all the way round to the symphysis? pnl)i»» 
In iloing i*o it pusse,«i the right aeetabulunn but it no sooner 
reaehea this fxtint thaii it befomen praetieally ami in reality 
a right anttrior pusiliou, and the rest of the metduinisra is 
preciiieiif the same aa already described lor the IL 0> A. j^osi- 
tiuD* 




MF.CHANISM OF R O, P. POSlTiON. 



293 



III tlio small minority of fn>if« (4 \y^r cent,) the occiput, 
iiisttuil u\' rotiitiiij4 lijfHiiril, rotateH (Htckivard to the sacrum, and 
the lurt'head cumi'S io Lht; pubes. 



Fig* UL 




Dla^mmmiitie view of mcchnnJvtn fn n k-fl-oci Ipito-anleriorpoff^fiOA of a hetd 

prr$irntiUian. {After Ll';is»lMAK.J * 

Thtni follows, 4, Ex(e}mon, which takt^B plaei", not upwani 
toward the mtins ven<iriss Imt the occiput ejjrajies over the 

iTn undenitaiKl Fljw HI, 113. nnrl Tii, tnm the liook iimund. so thnt the 
ilowiiMun]. 



294 



LABOR IS HEAD PRESENTATIONS. 



jK-rineiini, and is deprt'sscHl oiitsiile iif it downward atid Itack- 
ward toward i\w anu^, while furelifad, iio:^, mouth, tied dVm, 
suvvemvdj ettierge imdt^r the ^nihiv iirvh, (See Fijr, 112.) 
5. ReMUuttmi. — By iutenml rotatkiu of the ^hoiihlers?, as 
already explained, one ^?ik« to |Hil>es the othtr to f^aiTUtii, 
aud the <)cci|>ij| rolli< around to the ri^^ht ihigh ( the ihi^dieor- 
res|K»ndiiij^ tu the Biiert>iliai^ syuehoudrosis at which it orig- 
inally presented). 

Fio. 112, 




Delivery Alwut to oceur lij backward exietittl^n, tit dlrcftllou of nrrow, dowa 
over ihtf perineum. (Aller WiLUiJi«) 



Mechanism of L. 0* P, Position (Occiput to Left Seicto- 

iliac Syncbondrosis ).— 1. Vlrxlon, ^1. Ih^Mrntf, 3. Roiailon^ 
in the majority '>f eaaes all the way ronnd to the wymphvifig 
\m\m {when, on reaching left aeetabuluiii. it, of eourse, be- 
comi^ converted int4> a l^. O. A- jKKsition ) ; in the ntiriority of 
cai^c^ Imrkwanl rotation of oreiput to saerum. 

4. Ejtfriijitum of fM'i-lput dowjtwafd and hark ward over peri- 
nenni, while forehead^ nose, and chilly successively escape under 
pubic arch. 



EXPLANATION OF POSTERIOR MOTATION. iLDo 

5. HeMtUion, iutenmlly of .»thou!dem, right one topulies, 
ht\ to cofcyx ; extt^niully of ompiit to left thigh (thigh 
corresfpomliiig to the isauro-lliao syLicboudrosis a.t which it 
origiually presented). 




Dk^r&nitnutic view of mucbtLnisfn In R, O. P. posUlon* ttltor ^oiitcrior rolalkm 

of oictinO- 



Explanation of Posterior Rotation. ^ — In thtyiKy few ciises of 
ompi!fj-[KJst('n(»r positions whrro ihe mTiput rolatt^ to tlie 
jtacniui^ i\w rirrtirosljioce is ilue U* imprrffft Jhwian of the 
head, 60 tliat thu fortht^ad is t4>a low. In reidity it ii*, tliere- 



2B<* 



LABOR IN HEAD PRESEyTATIONS, 



fiir(% anterii*r rutatidii of the furelmiid whit-h eau*iesj piste rior 
roLalion of the occiput, in olieiHeiice to a ^^eiierul rule, that 
wliichever j^kjIc of the head is the lo\ve*>t in I be pelvis will 
rotate to the puhie fiyriiphy>iisi. <_>eeu?^ioiiuily. however, the 
forehead^ Iieiiig lowei<t, will t;tick near the acetabulum, aod 
then rise agaiu» [>eriiiitltug the iM-eiput tu dc-*4eeud ahm^ the 
opp:)site sacT<»-iliac syuchoudrosis, wheti anterior rotation of 
the otviput. ail the way round to tiie jnilies, will take place 
jui^L a^i the head is alioiit to ei?c^a|H^ fnnn the vulva. 

Still another variation may w-eur when tlie oeui[nit hit^ 
rotated fxititeriorly, viz., ins^teail of the *Mxipital |Kde et^enping 
over the margin of the |KTineum, the forehead, nose, and ehiu 
wiceeissively e»eape frd under the [in hie arcdi, when the e!no 
rises up toward the mons veneris^, and the occijmt etimes out 
/a/*/ at the perineum. In fact the case is nni verted intx* a fm^ 
presentation ju8t liefore the head iw Iwirn, This mmJitieatiou 
of the usual nie<'harii?!m in exc*e[itioiiah 

Diaffnosifi of tlie *' Position" in Head Presentations* — In 
the Ijw O. a. and L. <X I*. f>o>^itionsj, the ]>art of the liead 
firsst touched hy the exannjiing finger u the right parielal 
hone; in the It. (K A. ancl R, O. P. fxiriitions it is the left 
[mrietal Ikjuc, la either eai*e it i^ that ))«rietal hone vshich 
lies nearest the pula^. This is easily understood by remem- 
bering that the head enters the pelvig in a line with the 
long axis of the uieruH, which agrees with the axis of the 
plane of the superior Mrnit, while the linger enters the jwlvia 
ironi below, ancl more in a line with the axis of I lie inferior 
s«trait, so that it nefetvHarily tou<'heH the nldr of the |iresenting 
hea*h ihw parietal bone looks upward and hnrkw a rd, toward 
the stUTnl proinontorv, the other (hnvnward and forwnrd 
toward the jiubes. The latter one is touched iin^t. Then by 
pushing the finger a little higher up and further backward 
toward the Bsicrum. the wigittiil Future, running between the 
p;inetnl Inaics may be felt extending oblicpiely across the 
pelvis between the acetahulum and o|n>oiiite saero-iliae syn- 
chondrosi«. If it be a Ij. (>. A. [HK^ition, the finger, l»y fol- 
hh\ing the !*agittal HUtiire toward the left ai'etaluilnm, will 
there tind the small triangular fontaneUe at the pujetion of 
the sagittal and lanttMloidal sulure?». If it ln^ a IL (X A. pjsi- 
tion. tliis fontanelle will be discovered l»y toUowing the wnne 
suture toward the right acetalHilum. If it he a R. O. P. posi- 



PROGNOSIS AND TREATMENT, 



297 



lion, ft>!lo\vin^ the sagittal soture Lowanl the left acet4ihuluin 
will not Wmy: the finger to tbc^ litilt' fontimelle, but to the liirge 
nienihrauoas {uitt^rior one. 80 in a L. O- I\ |MK<itifm, the 
fiug-er will find the large fontanel le nt the rvjld iieetahulum, 
hy folhivving the wigittal suture in thai fliretlion. In the two 
|Mjsterinr [insition^s ( hust nieiitiatMHl ) the sirnall trkingnhir Ion- 
tanelle <*amiat he touchecl at all^ — it 19 entirely out of reaeh hy 
the usual tli^^ital examination. 

In Hiiori, having ielt the sagittal suture^ follow it toward 
the acetalmlyin to uhieh it jmint:* (it mH»f jM>int to one or the 
other), and there will lie found tlie jfitM^rnor Ibntanelle in ante- 
rior [Kwitions of the ocei}mt (right or left, «8 the eaf^eniay I)*;); 
or the ftfitrnttr fontanelle in poMcrior pot^ilionH of the ni-ciput 
(either right or left ). 

Later iu the labor, when rotation has taken place, the |k»»- 
terior triangular fontanelle, in aoteriitr )H>sition8^ will Imc' felt 
toward tlit pymphysiH (>ubLs, thej^agittal fiuture running baek- 
ward toward the sjieruin; while in those |>oi?ten<M' positiiins 
where anterior rotation of the <K'ei|>ul does not take jilaee, the 
liirgei niemtiraritius unmistakable niiterior fontanelle will l>e 
felt toward the pnbie ?yin|iliysis. 

The niode of naiking out the portion in head ))re,'ientati(*n8 
hy pal pa fit* ft, viz., by rcH'i>gnizihg the relative [►ixsithni of ihe 
child's hnvl% (orvhrath and oeriput, has btM:^n already explained. 
(See Cha[»t4^'r XI L) 

Prognosis and Treatment of Occipito- anterior Positions. — 
rr€»gnosis favt»rab!e ii* t<o far um the nsechanii^ni is ettneerned, 
and no assintanee re<iuired in i»r<hnary cases other than general 
tUtentions already mentioned under *' The Management of 
ljilM)r/' 

Prognosis and Treatment of Occipito -posterior Positionfl. — 
In the Oiajority of ctises the same as in aiiterinr |)ositions. In 
the minority of cases, where anterior rotatitui of I lie occiput 
imh h\ take |dact% a long and difficult labor m«y be »nlici- 
pated. owing to the difficulty the occiput encounters in cs^uintig 
nvt-r the perineuru, on account of the |M»sterior f sacral j wiill 
of the [lelvifi being m mueh ilee|H^r than the anterior (pubic) 
one. Force} w may be re<|uired to complete deli very* the 
short i«traight ones being preferre«L The perineum is enor- 
oiously distended and rci|uires adriitional care to prevent 
rupture. 




LABOR IN HEAD PRESENTATK^yS. 

Various e!t|M*dieiiLH have be*^ti devised ki promole atiterii>r 
nitalirm of the oruijmt whet* il does ii*it ot-cur tsprjiitiiQe^msly* 
ThoH, rtitice we know |j<)sterior rDtatiuu is generally the result 
of imperjvci fiexhm { (he forehead being ti>o low. tiie cHc-iput loo 
high), we may strive tu remedy tlie ditiieulty by makiug ilex- 
ion jierfeftt Thi?* niti he done by pret^ing two tingers of one 
hand U|>on llie fureheail during the pain^ m ai* to push it up, 
or \\{ leai^t keep il from c^>niing lower, while tlie foree of 
Uterine eontraetion is then exfKinded in deprejvviag theoeeipuL 
A veeti?^ may at the inanie time be jip|)Hed over the oeeipui to 
afwist in inilling it chwn. The objeet Is to get I he oeeipnt j*o 
low that it will pasrt />r^>i(? the i^pine i*f the isehinni to llie ante- 
rior inclined plane an<i rotate forward, while the fureheail i.H 
ke[)t high enoiiiih to pas-n ulmrr the op|M>site is<*liial ^nlw and 
rtj La te bar k vva rt L Rot at ion fo r war d ni uy i?o i net i ines \m aewj ni - 
plished with foreep whiie making trartion. (8ee **Foree|is'* 
page 364*; 

If the |K!lvis l>e hirge luid the ojieriitor's hiind nnalh the 
latter may be |>asseil in silonirHtdeof the head^ and the tH'ei]>nt 
drawn nblitpudy downward and forward to the pnlMs. A nollier 
|ilan : Etherize to full iuia^HthtAsia, I'uhs a hand irito vj*gina ; 
granp head, ancl .steadily and gently jmnh il up oni of the 
pelvin, ahovf* unperior dralL Then ilex it, iimi rotate iHripnt 
forward. Ilohl it ^o until the painw, aideil by prei*sure of 
otlier haml on abdomen^ push it down again into |>elvis» in its 
now (X'ei|iitiHanterii»r |H)sition. Forceps may l>e retpiired to 
complete I he deiivtvry. 

Another way to pnwlnee ant«'rior rotation of the or-eiput is 
that i>f Hi'rman, juid ron^irit^ in rolaling the ln^dij of the ehild 
by abdominal [)al(mtron. Il ran ordy lie done when the hea<l 
i^ above the brim ami the bag of waters is nnrufUnred, ihus 
the Hhuulfier of the ehild that is in front towanl one of the 
iteetabuia ih gently naudpiilatod laterally aeross the abdomen 
until it reach the oftfH)Hife aeetahuhnn. Thin brings the 
oi'eijiut from the sjiero-iliiie gynrhondros^is to the aeetabulnm 
of the J*t^m^^*ide, Here it may Ik? held over the brim until it 
be^Njme tixetl ; or it may be i*e4'nred by an abdoniinal binder; 
or the membranes may l»e rn];tnred, 

A tleviee, ?<oniewhal Himilar in [>rinriph\ is that of Tarnier. 
who |daeei» an index linger in the os uteri ht hind the air that 
is toward one of the aeelabula, keepa it there until a contrac- 



PBOGNOSIS AND TREATMENT. 299 

tion begins, and then during the pain, forces the ear across the 
anterior wall of the uterus in front, until it reach the opjwslte 
acetabulum. This rotates the occiput from the sacro-iliac 
synchondrosis to the corresponding acetabulum. It is best 
done at the end of the first stage of labor, and may be con- 
tinued during several pains, if not at first successful. This of 
course is an iM^er/m/ rotation, while Herman's method of press- 
ing round the shoulder and body is done by external manip- 
ulation. Both may be done conjointly by one or two o|)era- 
tors if necessary. 

Posterior rotation of the occiput is especially likely to occur 
when the head is unusually large. 

When, in occi pi to-posterior j)ositions, the occiput /iflw already 
performed posterior rotation — that is, when it has gone from 
the sacro-iliac synchondrosis to the hollow of the sacrum, no 
further attempt should be made to bring it forward ; it must 
be delivered with the occiput behind, the straight forceps 
being used, in order to allow backward extension of the occi- 
put down over the perineum. 

Recently symphyseotomy has been successfully resorted to 
in cases of impaction where the child has not already been 
seriously injured by attempts to deliver in other ways. 

Finally, it is especially in occi pi to-posterior cases that time 
and patienee are required to allow moulding of the head, and 
dilatation of the soft parts ; but assistance must be promptly 
rendered at the very beginning of symptoms indicating a|>- 
proaching exhaustion of either the woman or womb; by for- 
ceps when the head has descended below the superior strait ; 
by version when it has not — ^the other conditions suitable for 
these operations being present 



CHAPTER XV. 



FACK PRESKNTATIUNS, 



In face pn^seiitatioiia the chil<rs hoad, instead of !>piii{; 
Ht^xvtl, h exXeiuhH], 8*3 that ther/M'» eud tif the iKvipitJi-iiHiital 
diutneter is tilleil dmvn towiinl the entrain'e of the pelvis while 
the txvipital cikI is prc,<se«l up Icmard the r'liilil*^ /^f/r^\ jti8t iis 
tlie diiii was pre«*e4 tmvartl the child's Bleruimi iu hejul pre* 
seiitalions. 

Causes. — Any |)roje<iuiii iK-lw^vti i^hin and stern uni irtter- 
terinji: intH^'haijically wilh dcxion of the cliiu, ^uob m^ congen- 
ital goitre or other tumors ; hyUroth«intx ; M'veral colli* of 
fyiii§ round the nfck, atf% ; any projerlion nierh^nicnlly arrest- 
ing di"3sccnt of the occi|int, and thns again nhstructinff HexifMi, 
»uch a.s ovarian^ tibroid, ornt her tumors of the mother's )mrt8; 
uarr*>w jielvia ; a very Lirge or ftnuf hetal lieail ; ^'.wtiimre hii- 
erni oblufutftj iyf the utcrtif*. TIiLs hi^t it* the nnis*t coiiinu^n 
CiinM\ It priMluees exteiigion* and eonsieqnently face presen- 
tation, iu the foHowinjir manner: Moc^t cases of face jirc^nta- 
tiou were at first head }>rej*entatirms, Now, if the m-cipiit 
were toward tfie left acetalailwm 111 an ordinary head iiren^-n* 
tatiou, aiui the fniulu« iiterl were tilted niwch toward the right 
side, the ilirectlori of force of uterine contractitm would he such 
a** to press the iKrcltiitai pole of the occlpito-mcnlal diameter 
n|M»n the let^ edge of the [>elvic hrlm, where it would remain 
H<didly fixcd> and the uterine fnrcew<uild then operate ution the 
other (chio } en<I, and fortT it down nito the pelvic cavity, and a 
face presentatHin would residt. Thus it is that |)Oslerior //o/rj- 
timiHui' tacii pre)ientatiou are more fretjuenl tlian anterior ones ; 
they w*ere ehange<] /*r*?f/ pre*;eiitatitaii«, ami ihepoj^ifitni m head 
ca8m is u**imlly o<*ctfal'>anterii»r ; irht:n changH, as just 
described, the chin is directed Indiind, 

Very rarely the face present?* original !y, and is jtnf a devi- 
ate«I hett(l ciiM^ ; these are !*up|>twed to txrur from the cluld 
having had eonvulsions hi idero (opisthotonos). 
300 • 



POSITIONS OF FACE PRESENTATION. 301 

Fig. 114. Fin. 115. 









Exceptional. Exceptional. 

Figs. 114-119.— Six positions of face prescutation. 



FACE PEESENTATfONS. 

Positions of Face PreseEtatioa, — The given |Miiiit on the 
presenting part from whi<*h the (Mimtiims at a face presentu- 
tiou are named b tiie chin i^ljatiii, '' mfntum'* ). 




TnuiBVi-rae imjaUIod of faw nt su|»er1or j^lmlt 

The uumher of pinithjiiH, like thme of the oceipiit, U four, 
as follows: 

1. Chin to !ef\ aeetalmluiii (left nK-nto-anterior). K M. A, 
( meutt>-hev»-anlerior ). 

2» Chin in ri^Hit ueetahnlnm (right men to-anterior), R. M. 
A. (mento-dextni-aiiterior). 




LEFT MENTOANTERIOR POSITION. 



303 



3. Cbiu to right sacro-iliac syuchoutlrasis (right mentopos- 
U'rior), U. M. P, (iiwiiloHlextni-iKisterior). 

4. Chin to left wirru-ilia^ syiirhutidriKsis (left men to-poste- 
rior j, JL M. P. ( mentoliC'vii-pfJi^tf riorj. 

The ^Hrwtly anteropostrriiir jHJiHitioxis of face pi"«8eutiitions, 
as st'cij ill Figs. 118 and 111*, are so extremely rare as to be 
aliiiust never met with in practice. They are, huwever^ pos- 
sible, ami when they occur, are spontaneously Cf»nvertecl into 
fine of the other four jwisititjiis ( rcj>rest'nte*l by Fig??. 114- 
117) dnriiig the progress i>f htbnn 

The relative frequency of the i^everal positioniii has not 
t}eeii jMisitively ascertained, but the nientn-posterior |K»sitioii9 
are niore frefjiient than the niento-anteriur one.'** While 
the four posUiofw of the ftice have lieen nanKnl according to 
the same phiri adopted for the fwciput^ it may l)e stated that 
the chin is ofVen not exact (if at either acetabulum or sacro-iliac 
gyuchondrohis, but at some pitint l»etween the two — i. ^., nearer 
the centre of the ilium, and hence the [^jsitions are called in 
mmui Iwjoks simply right and Ictl menia-Uiac, (See Fig. 120.) 
The ehiny however, will arrive at ihe acctal)ulyni or sacro- 
iliac synchondrosis during the labor, and the j)lan we have 
adopted we think h best. 

Freguency of Face Presentations, — Tliey occur once in 
about 2oO labors. 

Mechanism of Face Gases. — The wliole matter is easily 
nmlerstnod by remend>ering tlial the Mn is the mechanical 
e<pnvalent of the ocviput, and ftdlows the same mechanical 
movements as tlie occiput dctes in head pres<»n tat ions. The chin 
end of the egg-fthajied hca*i conies first. The several stages 
of I he me«-^hardsin are : 1. Extension. 2. Descent. ^1 Rota- 
tion. 4. Flexion, 'k ItK^lilntlon (exiernal rotation), 

Mectiamsm of Left Mento- anterior Position ( Chin to Left 
Acetabulum).— 1. Kxicmum, by which the occiput is tilted up 
ami the chin down, so as to get the long i'*] inches) (»cci]iito- 
mcntal diameter more or Icksi endwise to the plane of the [lel- 
vie l>rlm, (See Fig. 121, [lage '^fM ). The diameter of the 
child's face that agrees with the ohHf|ue diameter of the 
pelvis in which it engages, is fhc fron to- mental — L <'„ the chin 
is tovvnrd llie left afetahulum, the forehea*! toward the right 
sac roi 1 i ac sy n c 1 1 1 n i d rusi s. 

2. Dciif^nf ( sininbanc<mslv, ho we vert with extension \ bv 




InflueiiGc of extert&liin in pc^rmlt- 
itttg <!vftct*iii. 

the metliaii line, to the symphysis puhis ; ihe forehea*] meiiti- 
while glides ataii^ the rijrht |»i»stti?rior incUueti |ilane to the 
ceotre of the sacrum. rSee Vio;, 122,) 

4. Flexion^ by whirh tlie chiu e^cajie^ under the puhic areh« 
ami rises up outride towanl the niona veneria, whilt! the fonv 



4 



LEFT MENTO^POSTERtOR POSITION, 



306 



head, [mrletul protuberaiux's, nnd 4>cciput eucceasively emerge 
at the iM?riiieyiii (Fig. J 23). 

5. Reddni'mn, by wiiifU the I'iiiu turns tt>ward the nxother'a 
Ic^ft thi;i:h (tlui tliigli rorre,"^!*! Hiding to the iicetahnlum at which 
it origiimlly preseiiteil )» m conseiiueucx^ of fcihtndJors rotntiog 
upt»a the inclined plane* — left shoulder to ]>ulie8, right to 
ctK'oyx. 

Mechanism in Right Mento-anterior Position (Chin to the 
Right Acetahulum). — L lliUnsUm. 2. De^vruL 3, Roiaiioti 
of chin, ahuig right atiterior iudiiied plane to syniphysli puhig ; 
of foreliead ahmg left (Kii^teritir iueluied phme to siicrum. 4. 
Fh^xion of chin upusird, toward niona venerii?, while o<.H.'ipiit 
eHtmpejfi at |ierineum* T). Ri\^lilutioii, chin got^ to right thigh 
(thigh corresi>onding tn acetnlMjluni at uliic^h it originally pre- 
sented)^ l)y reason of shoulders rotating- — right shoulder to 
puhea, let\ to iiaerura» 

Mechanism in Mento -posterior Positions. — Before de.scrib- 
ing the.^ie, we may aittieipate the siinie dirtereitces with regard 
to rotation atid flexion aa we found in head pri^entationa with 
regard to rotation and extension ; that is" to say» in I he great 
majority of cases, when the eliin i« directed jKJsteriorly, it 
rotates all the way round tt» the symtihysiia pubis. In doing 
s<» it of conri^e passe^^ the aeetnhuluni, hut it no sooner fi'tivhcH 
the acetalmlyni than it i:^ in re^ility an tutterior [>o?*ition of the 
chin, aiid follows the same rnechauisin ej^utilt/ as just deftcriWd 
for mento-anterior |Hi4*ititins. And aguini with regard to 
flexion when the chin is being !>orn» it wouhh in mento- pos- 
terior positions, of cour(?e, be flexed thmnvmrd over the peri- 
neum, instead of upivard toward the mons veneris. 

It may here be anticipated, however, that such a mode 
of delivery in face prcsent^tioiLs is practi<idly a mechanical 
imjwssibility, as will l»e shown |jresently, and in which, 
therefore, tlie analogy l>etween head atul face presentations 
hitherto apparent, is wanting. 

Mechanism in Left Mento- posterior Position (Chin to Left 
Sacro- iliac Synchondrosis), — 1, ExttttKioti, 2, IhactnL 3. 
Rotaiwtu in the mf7./\j?wVr/ of ca.'4c\* all the way nnnid to the sym- 
physis pubis (when the lahi*r will be finished aj? in menti> 
anterior |x>sitioiis); in the 7/u* ii on' /y of ea^nes, rotation of the 
chin backward to the snerum, *vh*^n the merhnnlmi *<fops, (tnd 
eowpfetlon of deli very U mechaniralhj Imj/oisftif/lt', uule^ indeed, 
20 



306 



FA CE PHESEy TA TIONS. 



the head l>e umisimlly wnuiU aiKl the pt-lvi^ iiiiysually hirge, 
when delivery \vi>uhi take plfice hy l>ackward tiexioii of the 
chiu tlowo ovtT the perineunv. (See Fig. 126, [Wige 307.) 



Fia. 124. 




\ 



DUMrnuDDUiUc Tiew of mectifinliin] In a t\^h\ mfnto-poAterlor j>oii£ton of a Am« 

Mechankm in Right Mento-posterior Foaition (Chin to Eight 

Sacra* iliac Synchondrosis). — L Eximmotu 2. lh«c.ent 3. 
Rotation^ in lltr tiiujurity of vHB4f9 nil the way nnind li> the 
puhi'^ (tti»d ili^livLTy Jis for nieul^MiriRirior jxisitiou^ i ; iii the 



EXPLANATIOX OF ARREST, 



307 



minority of cases rotation of chin to saeruni, and consecjiieiit 
arrest of niecliauisiiu fmthT pr<Jirr<\^s 1)t'iii;^ HTr|>i>s8ilile. 

Explanation of Arrest, when Chin Eotates to Sacrum. — It 
IS iieecssiiry for tbe ehiii end of tbe otvi|iito-mcrU4il iliameter 
to esf^ape oi'tr ihr ethje of ihr perineum Iwfore it ran pusssil»ly 
execute the movenieut of down ward Hex ion oulMtir I lie fxMn- 
neum. Now, as we have sc^en, the depth of the puHtrrhr wall 
of the i>el%n8, from the sac-nil promontory t<j the tip of the 
eiM'cjyx* is four and a half int-heji, while the frngth of the 
anterior ^Hrfarr of the chtLPii neck, from (fie siernum to thu 



FiO, 1!J&, 



Fiii. 126, 





Arrcftt of mocha iifjim after 
po«tvrior rtUntiiiii uf eliin. 



Showing tlcxirmjf neck wei* 



ehiHt 19 only about one Inch and a half (only jni^t lon^ enough 
to span the de])th of the a^itrrlor jie! vie wall at the pnhie sym- 
physiii ) ; hence aft<.T (Histerior rotutitm of the ehin» the rhild*s 
sternum inipintrt^ up>n tlie pel vie hrini at the saeral promon- 
tory, or perhap;* lietrins ti» de^seeud a little Itelow it* and there 
stoj«, »o that tlie chin is thus arretted in tbe \k*\y\^ while it is 
yet a ^xmmI liisiance hitrher up thmi the |>oint of the etjciyx* 
and the chin-|K>le of the ocei[atn-inental diameter cannot rueapt* 
over the perineal lionler to f>erform flexion. (Sm* Fi^^ 12.\) 

If (he (irrk ui'i*- fnitr or five inehe>* h*nL', ilH sIloWU 10 Fig. 



308 



FACE PRESENTATIONS. 



1 26, the chin eoidd escape over tLe |>eriueuni and delivery 

take place hy flexiou downward jiiid Inirkward ovt*r Llie [ktI* 
tieuiii^ byt suc'ii a Jeiigth of tiet'k is an inijMjj^ible anatumiail 
riioiii^trobity. 

Diagnosis of Face Presentatioa. — Tlie nide of the fare (at 
the begiuiiiij^'' of lalwr ) is tlie jnirt lirst tuucliiMl liy tlje exaiiiin- 
iijg tiuger — that \i* to huv. in a L. M. A. poj^itiiiiL tbi^ left ujubir 
Ixjiie ; io a U, M. A. jxjsilion, the right malar bone; in a Ij. 
M. P* position, the k-ft inahir IwHie; and in a U. >l. R i)OHili<jn, 
the riglit nuihir bone. In j>aariiog the linger higher np, and 
iiiorL* bjickward, the noise nmy he tVlt, the openings of the nos* 
trils indirating the directitin of [hv month autl cliin ; while the 
orbit^s and forehead will W foiuul in an opjwj^ite direct ion. 

The face nmy Im^ inistuken for a breech, owiiiL' to the swollen 
features rt^nendjllng the genital organs, I hiigooj^tii'ate by feel- 
ing the month* which i» a lisstire bounded by the hard fjurns 
of the niaxiilary bont^. whiU* the anus f to l>e felt in breech 
cases) irt a soft eln^itic ring. No eo<.H*yx-|>niiit can be tell, m 
m bretH*b cases. 

Abdominal |)al[mtion fn cas*?s where vaginal examination is 
unsatisfactorv, owing to the presenting part lieiiig higli up antl 
ilifficult to reach, may be useful ami even necea^ary. The 
jM:il[jating finger recognizes the very round, large prnminntrf' 
of the ovi^ijittt on (hat ^/r/cof the pelvic brim ( higher nr lower 
acci»rding to clegree of dej*ciAut into excavation J ttfward which 
the ehifiFit hack 18 direi*te<J ; the hearl tumor app<mn? nimofit 
entireiy ahifrtit on the other Fide, In head pre^ientalion the 
fori'hf'itd^ direcled toward the ehihrH nhdovirn, wju^ the nu^i 
proniinent an<i {KH^essildc region ; cliHV'rence very aj>|ian'nt. 
The bretH'li is rccogniztMl by it» usual characterislies in the 
funtluH uteri, and while the palpating hand movc^ downward 
over the back toward the hca<b it f<htkf< into //<c drrp dcprrAAim 
or rnvitif between the back and roumlfMl pole of tlie cxtemlcsi 
(KTiput. The gma 11 irregu far projrHionJt of the eairemitirn oyer 
the anterior uspect of the child are niore eaj^ily re<xjgnixed than 
in head prej^^ntatiouft, owing lo the greater prominence t»f the 
a hi )o me a caused by the cluld'« Ixwiy l»«:^ir>g Wnt barkivrird, 
instead of l»eing Hexed forwiird as in head casen. 

In son»e eni§e« the hors**shoe shape of the lower maxillary 
Imujc and t^liin nmy he felt on that side of the brim opposite 
the prominent wTiput 



TREATMKNT OF FACE CASES, 



309 



Diagnosm of the pontions of a face presentation l>y |>al- 
patiou is maile by noting whether the iKiek anil cK'ciput 
are directed anteriorly or jx»tJtenurly» to liie right or to the 
lef>. 

Prognosis of Face Cases. — Swelling and di^coloriilicju of 
the e hi Id's face frequently occur (of whii'b notice should be 
given before Inrth;, liut tbey paaa away in a few days^ 

The child may die, if delivery l>e long delayed, from cere- 
lira 1 congestion due to pre.Hi*ore of its neck and jugular veins 
ag}iin;st the anterior jM/lvie wall ; yr risi funis may l>e fatally 
compreased, after rufUure of the hag of wateri*. between the 
antcnar projeaiiou of tlie childV ulHlona^n and lire ulerine wa!h 

Daugera to mother, such aw may iktuf from any tedious 
labor, esi>ecially when in meiito-j>o8terior positions anterior 
rotation of eliin fails to take place. 

Though »i>ontaneou^ delivery if* the rule, the mortality to 
lx>th mother and chib) is somewhat greater than in Jiead pre- 
seutatmns and iissistniu'e w more frequently refpiired. 

Treatment of Face Cases.— In uwuioHinterior |xj»itton9» 
genemlly r»one, further than careftdly watching the case for 
symptoniH of exhau^^tion from |*rolonge<l effort on the part of 
the mother, or of failure on the part of the child, when aHwsist- 
ance may be rendered by force p, provided the bead have 
descended iuto the |)e!vic cavity. Use of force |ie at the 
9 it peri or Mratt is not advisable in face cjiaes ; f)odalic version 
18 preferable. 

In uH cases av*nd rupturing membnuies duriog examina- 
tional in early stage, and beware of injuring the eyes with the 
finger. 

In ment(>-poMerior p<.)sition5=i, endeavor to secure anterior 
rotatfon of the chtn when it fails to take place 8|)ontaneou.^ly, 
Tl»e Rivend met huds of attempting this are: L Pres.* the fore- 
head backward and U[)ward during a pnin, s*> as to make 
exteuHion more complete, and thu.s cause the chin to dip lower 
down ami touch tb<Minterior inclined pbme utxai which it may 
glide forwanl. 2. Put a finger in the mouth, or on the outside 
of tlu' lowi^r jaw, anfl draw the chin iVirward during ii |>iiin. 

3, Apply the dlraiglit f^jrcep iind twist tlie chin to the puhes. 

4. Apply the vecti^, or one blade of the forcejjt*, nttder the 
most (Mti^terior cheek, ami over the anterior inclined |»hine, 
thus, as it were, thickening the latter, w m to make it reach 



310 



FACE PRESENTATIOXS. 



tbi^ malar bone and constityte a jmni (Tuppni which the chin 
can touch and :*o grlide forward, 

Shonld these atteiupu* to seuure anterior rotation fail, an 
effort may l)t* made witli the hand, vei'tjs, or filli*U to bring 
down the occiput and convtrl the face into a head presenla- 
titJH. 

In onler to8uccec<i in this nianieuvre the mem I >raDes should 
be unbroken, the m nteri dilated, the face not so deeply en* 
gageil that it cannot helifled to or above the pelvic brim, and 
an aiUTsthetie administered. 

Again, failing in this way to prwluce anterior rotation, the 
head, if it be nut t*H> det-jily engaged in the |»elviB, and have 
not [jassed through the o8 uteris nniy be pushed l>aek, aod the 
child he delivered by poduih version. 

Should aone t>l' these njethiwls he practicable and the head 
iK^ccjine impaeteil in the jKdviJ^with tlie ehio toward the ifaeruiii, 
the only res^jrt m cranifdnmy. Attempt.^ have been nuide in tlie^e 
oases to deliver by foree|v?' after lateral im*i.sion of the peri- 
neum Juit they can only succeed when either the child ist^mall 
or the |H'lvis over-large. Usually the chihTs life has been so 
far imt>erilled liy delay and it.s coiiHi'<|yences that craniotomy 
may he done without compunction. Possiidy gymphyseotomy 
may prove useful in ihc^se ciises in future. 

In a// caseji of face i>rej«<:*nta.tion special care is necessary to 
avoid rupture of the perineuiti. 

CorrectioE of Face Presentation by External Maaipula- 
tion. — Juirhj rectification of face presentati(m — its conversion 
into an occijiital one — by exterhn! matti/nthtthui, \m» been 
lately recommended. It is avuilable ordy when membranes 
are unbroken, abdominal walls rclaxeth and ojM-rator skilful. 
l^et one hand over the abdomen sei/<^ the interior shouhler 
and lift it, with the chest, upward and townrd the child's back, 
while the other ham! near the fundus presses the breech uj>- 
war*l and toward the child's abdomen. When the IkmIv is 
thus lifteil the m'eiput will descend, or may lie assisted so to do 
by the hand of an aseisiant jiressed upon it, low down, aOer 
which the hreetdi is pushed dir^rtiy doirnirard and Hexion 
rendered | perfect 

The aunextMl illustnitions, modified from I^usk^s reproduc- 
tion of S»hat«*s cliagrams (»ee Fig. 1*27), ex|dain the metliod 
more exactly. The arrows indicate the direction in whi*»h 



COERECTION OF FACE PltESENTATIOK 311 

pressures b applied to the several parts during nuccesisive stejis 
of I he opt^nitioii. To uiiderstarni this, note that in face pre* 
setitatioiis utjt only \< ttie htnd extrmhtij l>ut the >q}ine and 
hodtf of the ehihl are lient in sn<*h a way that the Mtnnim 
pmjedH m fronU while the Ijreeeh and oeeipnt in a measure 
approaeh e4ich other t»ehin<h ^^ sliown in the tirst of the three 
cuts* in Fig. Titl All tliih nuj^t Ik^ rorrecteil by [ujshhiri the 
projeeting sternum imek ancl the hea<l and hreeeh forward 
towanl each other uver the front of the ehihl, thus securing 
normal Hex ion of tlie hody as well as of the head. 

Thus let one hand pre^s externally njMin the projeetirig 
Fternnm and shoulder of the ehild, pushing it tuwurii the 
child's jipiue ami somewhat upward toward the fundus uteri. 

Fig. 127. 




SchaU's metbud of ntcttflmllun by eztenial nmnfpuUUoa. 

while the other hand presses the hreeeh fonvnr<l in the opf>a- 
site direction. One of the bauds may now he changed to 
press the oceiput downi arul forward toward the anterior sur- 
face of the child's boiiy, thus prfMlueing flexion and presenta- 
tion of the oeriput Agaiji, tlie?4e manipulations can be car- 
ried on by i)}if: oj>enit(jr fxh'vnalhj^ while tlie fingers or hand 
of n/iother assist in flexiug the hea*t by nmnipulatiug per mtji- 
nam, internally. 

Bome prefer th^ method of Bandelocque, by which the ^n- 



m 



312 



FACE PRESENTATIONS, 



gers of one ham! (in the vagina) press the lower j a vr and eh id 

upuartf^ while the other hand on the aWonien presuyes the 
occiput (ioivHf as shown in Fig, 128. A flexitm ]>rocee<ls, the 
iin^er^ inside press successively ujmju the upfic^r jsiw and finally 
upai the forehead, while the outside hum! cuuthiues to press 
down the ocripuL 

KIO. 128. 




IkMidelocqucH methfifl nf ehaiigitiga fdcv Int" n tio«»l prcM'titHtlon. Left hund 
in viMdua, Ihe rii^tit on the abdomen, filter JBt*t.rrr.) 



Final ly» let the young practitioner enjiecially remernher that 
the great nuijorUy of face ease« will he delivered with*nit 
awif^tance or iuterference, provided all other cooditions be 
nonnah 



BROW PUKSENTATWK 



ai3 



BEOW PRESENTATION. 

A rare presetitatioii of the *'brow" or forehead, hitermeili- 
ate between a hea*l and a face» oeeurriug oucu in about a 
thousand labors. It oc*curs iu this way : Face presetitatious 
are deviations iVoru head preseDtations ; that is, in face pre- 
gentadons the head orijfinally presented, but the occiput eateh- 
ing on the side of the brim, loil^cil there, while the ehiu was 
forced dowu, c<>nstitutiu^^ face prtfM?ntutiot» ; but in this proe- 
eiis of conversinn of a head into a face, arrest nuiy take pi are 
half-way ivetween the two, wJien, of course, I he tbreheail will 
be made to ajjfjear and stop at the centre of the sujM'rior 
strait ; this is a brow [jreseiitktion. Moat ea^i^es are traimeni ; 
they ehauge into a head or face. Those that d(> not change 
are ^^ pernMeni,'' and lead to a very diflieult tir ini|>os8ih!e 
delivery (the head aud pehns liein^f of usual size), for the 
reason that the long <xx"ipi to- mental dinnii'ttvr of ihe liead i i\\ 
in.), iaatead of beint^^ in line with tliefi.r/\M of the pelvic brim, 
is tthnoBt [>arallel with the plane of the lirim, and therefore 
cannot descend tiirouj^h the superior strait, the longest diam- 
eter of which is imly 4i or T* in. (see Fig. 10(>, page 287), 

Biagnosis.^ — The diagnosis may l)e made by vaginal touch 
revealing the large anterior fontanelle and its radiating 
sutures, the orbital ridges, eye«, and root of the nose. The 
mouth and eh in are out of reach. 

Treatment. — -Treatment consists in converting the brow 
into cither a head or face presentation by producing, re8|>ect- 
ively, txmiplete flexion or complete extension^ preferably the 
former, by pu^liing U[j the forehend and bringing down the 
occiput In many cases it takes phice Sfxmtaneously, 

Manijmlatious f)r this purpose may lie either external or 
internal or lioth crmjnintiy, as just stated, for face presenta- 
tions, Twi> Angers may be introtluced into the chihl s mouth 
ami traction made on the Hupf^nor maxilla to produce exteu- 
aion and convert the lirow into a face presentation. 

When the brow pn^entation has been changeii by manip- 
ulation into a beail or face, but reverts to its old jxisition, for- 
cejis may l>e employeti to prevent this reversion, as well as to 
hasten delivery by tniction. 

In mento-posteriorpo^f/foyM of a brow* presentation, the same 
difficulties may oc!Cur when the case is changed into a face, as 



314 



FACE PRESENTATIONS. 



in face presentation, hence every effort must be made to rotate 
the chin to the pubes. 

Should the foregoing attempts to convert the case into a 
head or face fail, the next best method is podalic version. 

When all other measures fail, craniotomy may become a 
last resort, and should certainly ire an early one when the 
child is deady for the mother's sake. *•« 

As in face cases, it is possible the future may demonstrate 
the utility of symphyseotomy in difficult brow presentations. 
Wallich has reported " seven operations with no maternal and 
only two foetal deaths" (Williams). 



CHAPTER XVI. 

BREECH, KNEE, AND FOOT PRESENTATIONS. 

BEEEOH PRESENTATIONS. 

These occur once in about fifty labors (2 per cent.). The 
pelvic end of the foetal ovoid presents, the lower limbs being 
flexed upon the abdomen, so that the buttocks first enter the 
the pelvic brim. Usually the legs are flexed upon the thighs, 
as shown in Figs. 129 to 134, exceptionally they are extended 
at full length, so that the feet approach the face or point 
over the shoulder. These last have been recently called frank 
breech presentations. (See Figs. 135 and 136, pp. 317 and 
318.) 

Positioiis of a Breech Presentatioii. — Of these there are 
four ; and the given point on the breech, from which they are 
named, is the child's sacrum. Exceptionally the child's 
sacrum may be directly in front or behind, really making six 
positions. Thus : 

1. Sacrum to left; acetabulum (left sacro-anterior), L. S. A. 
— sacro-lseva-anterior. 

2. Sacrum to right acetabulum (right sacro-anterior), R. S. 
A. — sacro-dextra-anterior. 

3. Sacrum to left sacro-iliac synchondrosis (left sacro-jws- 
terior), L. S. P. — sacro-lseva-posterior. 

4. Sacrum to right sacro-iliac synchondrosis (right sacro- 
posterior), R. S. P. — sacro-dextra-posterior. 

The two sacro-anterior positions are most frecjuent. 

Mechanism of Breech Oases. — In complete delivery of the 
child there are here three successive stages to be considered, 
viz. : 

1. Mechanism of the breech. 

2. Mechanism of the shoulders. 

3. Mechanism of the head. 

315 



316 BREECH, KSEE, AND FOOT PRESENTATIONS. 

Fio. 129. Fio. 180. 









Exceptional. ExrF.moNAL. 

Pigs. 129-134.— Six positions of breech presentation. 



LEFT SACEO-ANTEmOIi POSITION. 317 

Each of these may again l>e sulKlivided m follows : 



o. Muuhling, 

c. Rotatk>ii» and 

(L Delivery of the breech^ 

e. Descent, 

/. dotation, aod 



g. Delivery of the shoulders. 

L Flexion, 

i. De^'cnU 

j. Rotnti*»n, and 

L Delivery <f the hmd* 



Fio. las. 




Rr«'ech prost^-ntfttlon ; Tprs extended. 

Mechanism in Left Sacro*&nterior Position (Sacmm to 
Left Acetabulum), — Here the longejit tliiuueLer of tlie 
l^reech, viz,, fnmi «i!)e trofhnnter to I he otber* iirey|iie^ that 
ohli^jue diameter of the hriiti whirh extends from the riffhl 
aeotnhiiliim tci the ffft saercviliae synchundnisls. The sncTum 
of the child lieiiiL' directe*] towanl ihe left aeetuljulyrii, its 
back, and of course (lie Imck of itw heatl (mripijt I are directed 
toward the left auterior part of the uterui*. in a litie with the 
left acetabulum ; heD€e>» when the body \b delivered, the 



318 BREECH^ KNEE, AND FOOT PRESENTATIONS. 

ocripitt of the nfler-comintj head will also he directed to the 
left arttuhHliim. A« lafior j>ru|rreH8e^ there in-eur : 

1 . Mo u h li II tj f I \w l>r eech, I ly w li ie h i I si in pi y becoiii ei* grud- 
ually ('v)mprei4.^cl ( *' nujiiltled " ) ititn a eiR^ilar t^ba|H\ 8o that 
it riiuy pn?i,s ilirmi^b thf «j8 uteri and pt-lvic hriiiL 

2, Ih-m-rnt, — The breech jmssing down the {)clvic csivity U) 
tlie pelvic tlc)or. 

Fig. lac 




KolMton and dellTerjof hlpi. Ttiits fftpiru rvprcsouU the legs ealeiMled. whleh 

3. Rotation. — ^The left hip (the hip nearest the pubes ) j^Iides 
along the ri^ht nuteri<>r inclined plane to the pubic syniphysiH ; 
while the ri^bt hip (the hi[i neurrsl the saerutu ) i^lide?; ahmp 
the left p**stenor ijielined plane to the saenini. The long 
(bitrcH^hanteric ) dhiineter of the breech, which entered the 
brim in the oblique jjelvic dian^eter, has now, tlierefore lie- 
ecjine parallel with the lunge-sl (antern-posterior) iliameter of 
t hr i n le ri< >r st rai t ( See Fi jf* 1 8 6, ) 

4, IMivenj of the breech — the hip that i? toward the puliefl 
fixing itself agaiuj^t the arch, wjillc the other one jfweejis round 



LEFT SACROANTERIOR POSITION 



31 a 



the curve tjf tiio (inakTjiul; HiLcruiii atul comes uut tirf^t at 

It Bliouhi agaiu 1h^ observe<l lluit cleseent noccssarily occurs 
mmuHnneoHglff with uiul during all the other Bta^^^es. 80 
the sh«*uhlerj< uiul head have, Mrri>ur^% heeii simultaueouisly 
JeH<*endin^ with the hrwH-h. LKjsceiit if* ccmsiderucl as a »e\^ 
a rate stage only in so tar i\b it is a iiee<^s.siry (ireliiiiHiary of 
rotation — i, e,, the descending [inrt m^^s/ rv>y/i/' (Iftwu hivvenouifh 
t*j strike the iHe/f«€ff/;/fi/ttf^ and jjudvie tloor before rotntiini 
cau occur. 

Fio. 137. 




Uoifiiioti of 8honld(«rH ; their Inng 0>lsA<?roniUl) dJAmeter in liue with lone 
(anteni'posteHor) diAmeU^r of outlet. 



Kote further that when the hn^eh is extrnded the child*s 
borly has rieeeswirily Iweome ^>ent on iU .^uie <'(mfrirniin^ to 
the curve of tlie [)elvio canaL »Smietinie« thiK it* impmp'rly 
»et thrnri as a 'separate stage of mechanism, ealleil ** Jateral 
flexion.** 



320 BREECH, KNEE, AND FOOT PRESENTATION.-^. 

To rt'sume, the lireedi huvirig 1 Mini ilelivered, we have next 
to tU'ui wilh Ihf tilKiuhler.s ihu.s : 

5, DencenL- — Tliti lon^^f.st < bisarroiiiial J <liumeUT, t'liU^nug 
tlie briin iit tlie siime obli<[iiL- diaiiietur an the l>itri>t'haDteric 
diameter of tlie breech iVuh lietjeeiidn to the jxOamc floor. 

ti, HoUUiotK — The tihouhitr nearest the piihes ( J eft one) 
rotati*^ ttj the t>ijbe« ; the nhoulder nearest the Baerum (ri|i:ht 
i>ne) rotntt^s to the mtTUJn (see Fi|r* 1*^7 )♦ vvbieh briiij^s the 
bisarrumkil diameter aater«>poi5terior at the inflrior 2strait» 




Dwllvery of lower nhisuMiT fli>t, *t the (icHncfiitn, (In Ftg. 137 oe<?lpul i« W 
tbe Ifrt : rijMi ih*HildtT \* 111 eomc Ufsl «t lh<? poriiieum. Jri Fig. 138 ocdpul U U> 
the right, iind /<;(( ahouldiT comes out flri't at tlic perineum.) 

7- Delimnf of ike shouiderjt — t he one toward the |)ul>ef4 fixing 
it«»elf there, while the otfuT one sweeps romid the eurve of the 
aaeriiriK and i^>iueii out (irst at the perineum. (See P^ig* 13H. } 

The sh<mldera having been delivered, next comt^ the head, 
ihm: 

8. Fl^rumi hy which the chin-jiole of the occi pi to-mental 
diameter in nmde to dip down toward ihe ehibl*^ s?ten»um, 
wliile tl»e 4R*eipital ]¥Av is tilted up towanj (he fnn«h>s uteri, 
thuj* |)Iaeiiig the rHripit(>-riieiifal diiimeler more or les.H endwbe 
ami paralbd with the axis tjf the (hOvIh. The ix'eit>ut in 
t^pward llie lef^ aeetabulum and the foffiiead tovsanl (Ire right 
siKTo-iliiK* 4?ync}i«iiailro8ii4 ; henee the (H-eipito-frontJil diameter 
tx^cupies nn ol)lique diameter at the brhiL 




niGHT SAVMO'ANTJSniOR POSITIOK 321 

9. Descent of the heiid iuto the jkjIyic cavity, unlil oci-iput 
strikes left Jioterior incliuecl plaoe. 

U). IMatitm — i»f tM/€i|iut t«) jmhes — i>f forehead and face 
to hollow ui'wuTutrij thu^i hriiij^iiig loii^^est eiigugin^^ diameter 
of head untero-jiosttrior lU tlie t)Utkt, (See Fig. 13^.) 

IL Ihiiveri^ i/f htarl — ^the cKU'i|iut tixin^r itself /Wrm</ the 
puhic .^ymphysiif, the back of the child's? iieek imder the |iid)ic 
arch^ while the €bio e^ea[>e.s tirst at peri tie ii in, followed wye- 
eeasively by muutli^ none, ibreheaii biinirietiil etjufitor, ami last 
of all the occiput itself, which gweejis along the curve of 
sacrum. 

FlQ. 1^. 



^ 




Anterior rotation of occiput. 

Mechanism in Right Sacro-anterior Position ( Sacrum to 
Right Acetabulum ) . — Monkiinfh ih-'freNf, aiul rotation of the 
breech. The hip nc*arest the pubes rotating to the pube^j*, the 
one nearest tbef^acrum to the ?acTum. J^/iVm; of tlie breech 
- — the hip nearest the sacriini aiming <>nt first at the j»erineum. 

Denventtind rofafion of the ^liouhler^ — the shoulder nearest 
the pube^ rotating to the pnlies, the one nearei^t the sacrum to 
the sacrum. Thlinrij of the shoulders — the one at Ibe sacrum 
ooniing out iirst over the perineum. 



322 BREECH, KNEE, AND FOOT PRESENTATIONS. 

Fftwiiitt^ draernU Junl rtiUtthm of the liCiul^lhemTipyt Tnow 
at tht^ right atvtahitlym) rotating on i\w ri,i;lit Hnlerii»r in- 
clined pluiie to the [>uI»oji» the toreheiul to the jsiieriiiu. Ikfu'* 
erif of iht^ hfttfl — ehiii, iinHllli, tiu^e, ftireheiid, hi|«iriet:il e<jua- 
ttir, iiud Ijssliy oceipiitt auereKsively **J^ca(iiMir over |>cniieum. 

Mechanism in Left Sacro- posterior PositioE (Sacnun to 
Le^ Sacro-iliac Synchondrosis r.— Mould in j;, tlettcent, rotation, 
aiul ilelivery of the bret*eh ; ami rle^eeut, rotation, and deliv- 
ery of the shouiders exactly as already iie?*(^rilied for imkrior 
positiotis of the sacrum. 

Flexion and de^ncent of the head are also the same, except 
that the<xjciput enters tlie |M:'lvis directed townrd tlie left sacro- 
iliac synchondrosis instead of toward one of the acetuhula. 



Fig. 140. 




Poitcrior rotiitiuD of tteiiput and dclivc^ry by liuitioQ. 

Hence rotaiirm of the occiput tnk^ place, in the majority of 
cascjir all the way njund to the sympfiys^it* pnhis, when the re^ 
of the mechaninni is the same as jyst descrihed for anterior 
positions of the occi|>ut. In the mutority of ru!tf\i the twx"i[)yt 
HJtate^ jmsteriorly ioto the hollow of the sacrunu the forehead 
tu the pube«, 

Del'iverii of the head now takers place (nitJSt often ) by eon- 
tinued ficxton^ the chin-pole of the occipitu-ineutal diameter 
dipB toward the child's sternum {under the jmhic arch i. wldle 
the iKxnpul is tilted up posteriorly toward the sacral prom- 
ontory. The naj:»c of the chibrs neck resl.^ on the perinenm, 
while chin, mouth, nose, forehend, bipanelal e<|uator, and 
lastly aj'cipot, suecessively escape nudrr the pidiic arelu { kSee 
Fii^', 140. ) During delivery, the IkmIv iihould l>e heht down- 
ward toward the tloor ; if held up, il h phi in the riternum 
would lie brought against the chin and thus prevent delivery 



RIGHT SACROPOSTERIOR POSITION. 



323 



taking place. Delivery of the head may also take place (but 
very rarely) by continued extejudon. Thus, the chin-pole of 
the occi pi to-mental diameter, instead of being depressed under 
the pubic arch, points up above the pubic symphysis — in fact, 
toward the woman's bladder. The anterior surface of the 
child's neck is fixed against the posterior aspect of the sym- 
physis pubis, while the occipital pole of the occi pi to-mental 
diameter is forced down along the hollow of the sacrum to the 
coccyx, and escapes firet at the perineum, followed successively 
by biparietal equator, forehead, nose, mouth, and, last of all, 
the chin itself. (See Fig. 141.) The body is to be held up 
toward the pubes. 

Fio. HI. 




Posterior rotation of occiput and delivery by extension. 

Mechanism in Bight Sacro-posterior Position (Sacrum to 
Bight Sacro-iliac Synchondrosis). — The first parts of the labor 
are the same as just described for the left sacro-posterior posi- 
tion. When the breech and shoulders are delivered, the 
occiput is, of course, directed to the right sacro-iliac syn- 
chondrosis. In the majority of cases it rotates all the way 
round to the pubes, and so becomes an anterior ix)sition. In 
the minority of cases it rotates to the sacrum, and will then be 
delivered either by continued flexion, the chin escaping first 
under the pubic arch, or by continued extension^ the occiput 
escaping first at the perineum, as just described for the L. S. 
P. |x>sition. Cases in which posterior rotation of the after- 
coming head occurs comprise a very s:tnall minority ; such 
rotation is extremely rare, and will seldom be seen in ordi- 
nary practice. 



324 BREECH, KNEE, AXP FOOT PIIESENTATJONS. 



SometiTDes in ^ncTO-podcrior positions of the breei*h, the 
rotation which brin<^ the anterior liip to the pubt^i* fjocft on 
further, sc» iiiS to briiif,^ the child's ffUfk to liie ptibe?i, or the 
back etimej^ to the |mhe^ by conlinuutitm of the shoulder 
rotnlion. Iti this wny the oex^iput Is hruyglit in front to the 
acetabulum liefore its descent to the pelvic flfxjn It has he- 
co le oc c i [ n to-a I J ter i or. 

Causes. — Hydrocephahc enbirgenicnt of the cninium ; pel* 
vie oarrowiD*,^ ; placenta prtevia ; }x»lyhy(lninniio8 ; j^nuill Hze 
of the chikh or it"* being flea*! ; ninltiple pregnancy ; ]>reintiture 
delivery ; uterine tnniors interierinfjf with usual atlitmle of 
clijUI. Bree<*h present iition may <M:ciir repeatedly in thciianie 
woman, a.^ inight l^e ex]>ecte<l in vti^^s of peh'ic narrowing, or 
in tho^e with uteri defcnnied by ttJinon*. 

Diagnosis of the Breech. — The examining finger fird touches 
the ^kle of the anterior buttoek ( the one ilirected toward the 
pubes^, und feds the trmbanler covered l>y muscles^ etc., 
which makes it M>tler than the luird ^hdieof a hea<l presenta- 
tion. The fisi^nre between the nates, the genital organs, the 
tttius, the j*robable prc.*M?nee of meconinm (thick and nnfiiluted 
with liquor arnnii ), the tip of the coccyx, and spinous priK'cssof 
sacrum, are sutKciently obaracteristie. Scrotum in males sfitne- 
time?* i*wollen and aHienmton*^ resembling [lolypu** or tumor, 
but is less ?*<did. I>ithculty in early {*tage, owing to height 
of presenting jmrt. Bag of ^vatei-s may lie large or prr»trude 
as elongated >ac. Beware of ndstakbig fu-tal vulva for axilla^ 
and fat fold of elbow for tisi^ure of uate^. ^ KIbow has« three 
bony projections { olecranon and two humeral condyli^s), Diag- 
ntjtfjig from face (see Face C'lise**, p. HtfK ). Diagnosis of the 
**jMm(ion " of a breech '^preM>ntaf}on '* may l>e determintd by 
the direction of the fissure l>etween the nates and by the tip 
of the coixyx* which always [wjinL^ forward toward the pulies 
of the child. 

When the pr(^s4ciiting |mrt is tix> hi^h up U) he touched 
ftalittfactorily jht mfjinam — as will ot\en ha|)|ien early in 
latmr, or before its beginning; — iliagntisiB may be nnnle by 
abdominal ftafjmttoth Early in labor the breech will Im? at 
or alw>ve the (ielvic brim ; it never (ffHrends at thi» timt\ as the 
head sitmetimes d(X'« : heni^ palj>ating ffnger-ends, entering 

t OwtnfT to the nttittide of the chilrt, ntid tho undeveloped coiidttioii of iti 
f laiL'iil muBclvii, iherv Is rcttUy tittle or nojUtttr^ between the umUni, 




DIAONOS!S OF THE BREECH. 



325 



the Uriin behincl piiln*^ nuni, find f.rMmiion cmptij. Tumor 
of breech (nut often i^fiitml, hut usually more towarJ one or 
other iliuc fossa; fc^ela mjier, more irreffular, and more volnmi' 
nous tlmn ^\o\}e of head. Kesii^iin^ phioe of liark is cf/nthm- 
onn with hreecli from htlow, while ahovti* the Hnj^ers .-^ink into 
elastic depression between trunk utid head. Head discovered 

Fig. hi 




Dlft{;tiosii! of pelvic prtsctitalinn liy iiAltHitif)n (Afler PABvrN.) 

jndu8 uteri usually more on that side npp<isile to the 
iliac fog^a toward which the breecli Hes. Ih'a<l may be cou- 
cenled under liver or btOiind falne ribs» and hence difficult 
to palpnit^*, cMpet*ialIy in priniipane, in whom the child is apt 
to lie more vertically ( leK^ubliijue) than hi mnltipanc. Head 
may be made more palpahle by press^iug breech tuore toward 



326 liREECir, KNEE, AXD FOOT PnESEXTATIONS, 



the iliac fi>3?isa» wlueli briii;^ tlio heud imire within reach on 
the op|»osite j^ide of llio tuncJus. (8ee Fig, 142.) 

In following n^^istin-j: ]>luiu-of Imrk it will Ire f«mncl to r-urve 
over aboviUhe unihilitus tnw;inl I lie side where llie liuud lie^ 
The latter miiy sometiinej* lie iimde to move liy UifiuUcmenL 
III saero-y^rjW/'Wf>r [njsitioiis the hrtet^h iynn»r will firttrhfaiivatfB 
Uj n<eorrniaiiied by llie iiiuviible nmafl ptui,'*. In ^ucnt-anferior 
positions the iireeeh will ronhj lie ae<N>jniwiriied hy small 
parts. The small parts and intervening elaMie s|mee^ fillt-d 
with liqiKir aninii will usnally be found on the siile ni' the 
uterus o]>j)o.site the el li Id's haek. In rnvn^-poderurr |>i>8iti<ins 
the lateral a»|>eet of iheehild^s trunk will be more easily 
rt^'ognized than tbe liiiek iti?elf. (Si*e Fig'** 1-1*-1'>2 in 
whieb, however, the eliihrs body HhouhJ have Ih^'U jilaeed 
more ohlhpiehj — the breeeh m<ire over the iliac fos^sa, the 
bead further toward the ofip^ttite s^ide, ) 

ProgBoaia of Breech Cases, — ( ienerally favorable tu mother, 
though !a!>or may be long'; but dangerons to ebibb When 
body is delivered and bead retainerb ehild die^ from mffura- 
(Ion due to pre^^^^^ure i>n umUiliral eord or to partial .separaliou 
or eonjpression of plaeentn. JJangcr greater in footling than 
breeeh eane, because snml I feet do not dilate os uteri iiuflifiently 
to in'rniit ea.sy passage of afler-eoming bead* be nee tie I ay id 
longer after ex [luli^ion of body timu (K-eurs in bretHdi eaj^es. 
Liability to prolapse of t'unis» In easei? where leg** are ex* 
tended along Imiit of ebild. lalwvr may lie long and diftienlt. 
Tlie liniljs aet like splints, |»revenling that latrraf flext^m of 
the body by whieh tbe latter is eonformed to tbeenrve of the 
axis <if the jitdvie 4*anaL In dithenlt i*a.sts, ehild liable to 
injury fri*m manipnlations during ilelivery* henee fra<^tiire or 
dislo<*atitni of hmnerns ami femur ; injury to t^jiinal I'olurnn or 
spinal eord by traction or» trunk : temjMirary jim-aly^is from 
pres*3ure on bniehial plexus; hemorrhage into nins<h^ and 
eelbilnr ti«»ueof neck, esfjecially bieraiitoma of si erno- mastoid 

niUHrle, 

Treatment of Breech Oasea. — Do rjothin^ until tbe birth 

c)f the breeeh.^ Preserve meni!irane« from rupture, Kefrain 

fmru attempting to hai«ten matters by drawing down the feet. 

It prtMlueei* displaeenjent of tbe arms above the head, and 

* It l>ii* tHM'ti rfrt^fiUy r»'riunTni'n*l«^«l I** |H'rf**rtTi rrfA'i^tk' vt.«T>5loii by #'3(t*'niii4 
imirttptilutloii flirty, tK^fore rn}tturc of tnouibrmaest to Avert flUbscqiieTit datinrcr 
Ui child. 



I 



TREATMEST (*F nnEECH CASES. 



327 



also extension of the occiput. Delay rlunii^ early stufres of 
hif>or is tiot dantjerttHM, luit pre|uirt^ the piirts» by prulunged 
dilatation, for subsequent ea^iy pa,ssage of ftfternxmiiug head, 
Debiy of latter is fatal to chiltl. 

When the breeeh is boni» promote lateral flexion of body 
by pressure on perineum. When trunk is delivered, receive, 
supjKirt, and wnip it in warm ch»th, Gently \n\\\ down a 
lo(j[>of the Curd, iind ]»hire it t*iwaril that part (d* the j>elviB 
where it will tfe less lisjble lo pressure, viz., tnwanl that Siiero- 
iliac. synchonJ Typhis to whirl* the child's alMloinen is directrd ; 
but wa*ite no lime in doiu^r dn^. f'eel pulwitiuns in cord ; 
their feeblene^ proclaims danger to child, llohl tlie htxly in 
such a numner as not tt* imjiede rotation of i^houlders into 
antero-pvsterior diameter of outlet. When shoulders are 
born, direct liack of child to puhic symphysis, thus promoting^ 
anterior rotation of <H'ciput. l)uring birtb of head litl: l>udy 
toward nions veneris,^ 

In the rare cases where rapid SjHmtattrour'i delivery of the 
head follows extrusion of trunk, no further active interference 
is necessary. 

But ntpid Apontanf^ous delivery of afVer-cfmiinfr head is ex- 
ceptiouah Delay is fatal ; jurlieious ast^iatance harmless. If 
the shoulders l)e not readily extruded, first one (that at jieri- 
neum) and then the other must be drawn out by the finger 
hooked over the elbcnv or acromion process of the ehouUler, 
elmHiiiufi the breecii while withdraw ink' the posterior shoulder 
— d^prenAinff it t<i\vanl the perineum wliile getting imt the 
ptthirnne. For various methods in delivering: the arms in 
ditferent case?, see Chapter XIX., *m '* IVrx/on," 

The means fur nipid delivery of head wlien it hn» dencfmled 
to the inferior Htraif, and m'ciput has rotated lo the puhes, 
are : Ergot f hypoderiiiicalty if the ease be urgent); manual 
pressure of fundus uteri throutrh the ahilomen by a skilled 
assistant previously secured ; uririnju the woman to War down 
during the pains with sill the vid notary effort she can com- 
mand; and traction judiciously applie^l thus : Supfiort iKjdy 

' An iirm»ni«L gR^'aipR wnmHu nfthe wofid.<t,(ln(lini^ Ihi? l»nfiy of her child ex- 

tnif!e<!, vrni;!-* i ■•'» -T iriDJn a iTiint;l»'rT?!p1Ht r.f ritr*H'tlcit*Hnd Invwi- 

tigrftUoli. i' 'tfr ttwi* (ibitomt tt^UiW* {'imi^inv jm^Ajmmm the 

fundu* lit' ' in ii wnv tu j>rniiiote (Irllvtry <if tfif IwntL 

HcTH'f It i> i -i,.,t u • .r,,r,->\i* Ihtit ltu« tuclhoiis 4>f 8('k*n( r hiivi: utifon* 

scMiitinly foUowiMi Oiii iijH htim of Nutitrv'» school to tKcuntuU>r«<l sav 
sc'Al nf sanction not tu be disdutned. 



328 BREECIL KNEE, AND FOOT mESEKTATIONS, 



hi left iiaod, one or two finders of wJiiuli mtiy lie [liu^eti in 
aloQ^ [K)Htei"ior vuginal wall to fliibrH inoulh (or to upjier 
jaw-lKme, one fin^a^r hemg ou each .side of the nose ), and 
ita i'hm ik-presst^d ttnvurd iU t^hesU while two fiu^ei's of the 
n<,^ht iniiid are passed in ntider \nilm' urrh and preiised upon 
th<^ ix*ei[jnt so as to tdt it up and a.'iHiM jitxttju. (SSee Fi;^, 
143. Thn8, ilurin;^ tnietioJt, the chin-pole of oeeipito-niental 
diameter is made lo e.scape over perineum, and Jelivery fol* 
lows. The hiiger (or two of themj ol" left hand nniy also 
be passed into rectyiii an<l mafle to pre^ through the ret*to- 
vaginal wall ujx)n the forehead or malar lioues, thus again 
pro aio ting /exton. 

Fig. 113. 




Eirtractfon of bfiMl In bM*<H?b cascfi. 

Another }Ffit h otl —^i/jif the feel with the right hand, and 
hook the left Imod over the hack of the net-lc (Fig, 144). 
Tmelion on the lejr? h now nuide in a dir<><'tion ahncM at right 
anrfU'^ to tht pitben, «u» that the resistanee nf pnhic hones im- 
pinjj'ing^ a|^ainj«t rKriput pn^hes it np, while fhin ami face 
flex and desc^end along sacrum, escaping at |>eriueum. The 



THEATMENT OF BREECII CA^ES. 



329 



uikI iiIkj assists tlie ri|ilit hi iiinkiii^^ tmrtioii. The Imntl nf 
an as8istaut, pressing upon i"iiiiilu8 uteri, will expedite the pr<jc- 
e^, tii« in the first metlnMl dei^rribiMl. 

In ca**es of BHQTi>-piiHt*'rior positious where anterior rotation 
of ijociput has failed tt* oeeur, tle|»r£\si? the body toward |>eri- 
neiim, puss one or two tiugen? under pubes to ihat temple or 
Bide of the face directed anteriorly, and }>re:^s it round toward 
thesacrurn^ Face cannot I >e to reed round to saeruin l)y twid- 
ing body without danger to child's ueck. 

Fig, 141. 




Manual extmction of after-coming head. (From AtAEm.) 

Shouhi this prot*eedinp fail, and the wciput mUH remain 
ponienor^ rhc head must he delivered in i»ne of two ways, 
\h.i If I he head be/^/ycr/ with the chin befow the pubic 
arch, traciioti rnuHt he math^ clire<*tly (fwvnwunl ; that is to 
snyi the wi>uuin beiu^' u|>on her back* with her hijis over the 
edge of tlje l>ed, make traction on the body vertieitlly d^um 



330 EJit'KCIl h'M:t\ AXD FOOT PRESENTATIONS. 

townrd the flwtr ; nhl thi8 by supra pii hie external pressure, 
arid t>iie or hvo fin^^^erji may he passed iiilu rtrtiim, [)u^iun(; up 
the tKc'iphnI (wile, whiU? external luiiid pre&'*es doivn the lore- 
heiid, tlioi* iML^euriuj; romiflete //r-rfo//— the projier meehjiiibm 
for delivery. (See Fig. 140, page 322.) 

FIG. 115. 



:^=^?^^„ 



Arrest of b^d fil stipeiictr BimU -. methoa of deilvery. (Winckel.1 

The Cither way is by extemntm, Kow the chifi i» above In- 
8ten4 of beinw puhf^. Tniftion on IrhIv rnUBt }>e iin*de 
verticuily upward — toward the ceiling instead of the fl<M>r — 
while the hiind on iihdomen makes pressure downward and 
baekwtin) u\Hm the rhin. One or two finjijerH |wii^Ked far into 
the rectum iniiy a<sl«t exteuj^icni and extraetiuu by prt^^ing 
(kt\ put f n r w a rd t o %va n I \ni fies, ( See Fig', 141 . ) 

When manual delivery fuilj«, foreep nmy he applied to the 
aOer-eomini^ lieud, ( See ( 1ui (iter X V 1 11 . ) 

Extract ion when Ajlcr-romiftg Hmd m nt Snperi4>r Strait — 
Pressurt* ou the fundiiB uteri from tthove» and tmctton ou tlie 



TREATMENT OF BREECH CASES. 



331 



feet and shoulders in line with aocia of plane of superior atrait, 
may first be tried. When the woman is on her back and 
brought to the edge of the bed, the traction should be almost 
directly downward toward the coccyx ; and the manual 
pressure on the abdomen from above should be chiefly on the 



Fig. 146. 




Traction in aiter-coming head arrested high up. 

frontal pole of the head to secure flexion. When an assistant 
's j)reseiit to make abdominal pn'ssure, the obstetrician may 
draw on the shoulders with erne hand, while two fingers of 
the other are passed up into the child's mouth and traction 



332 RHKiCCil, KNEE, AM) FOOT Pi:ESEyTATIoyS. 

made on tlie jiiw. Tlius three expedient act simultiiiie<JU*?l}\ 
vijt. ; ahfituniifai prcssitre, shoulder tractioiu a-ud Jaw ttttdion, 
(See Fi^^ 145.) Hlitiuld these fniK forceps may he n^ei\ lo 
bring the liead into ilie ]>elvic eavity, Foreeps tiro also ail- 
vUiilile wfieii tile heiul i-< detiiiiied hy a resLsthiLT «>» or eervix 
uteri, 1)11 1 great care is uet'e.ssury to avoiti laceration of <;ervix- 
In ibese cases Barnes recom mentis backward tnictiau by the 

Fia: 147. 



Tftmf er*« fcirccpi applied to ihc thlgbn, {OLtmisn, Umi.y 



fet^t and n|Mni the na]>e i>f the neck by oneirclin^ the bitt 
with a fine iiafikin or silk haiidkerehi€*f, as shown in Fiju. 146, 
In any case where delivery of after-coming head i? tlelavH, 
and weakne*^^ of umbilical piil^ with spa^mtKlic contniclion 
of ebild\s respiratory mnsH'les indicates impen<rmg snffocation, 
we may enable thecbild to breaihe l>efore birth by parsing in 
two fingers between the face and vagiual wall, thus niakiiig 



TREATMENT OF BREECH CASF^. 



333 



a channel for air to the luoutb or nostrils, or a Jarge catheter 
may he pfisj^Ml into the moiitlL lu one ca.se life was saved 
hy tracheoiomjj lieliire delivery. 

In all case^ of breech prt^se illation e%'ery nieiins neeessary 
for the reistoration of Huspeutled animation in the infant should 
be provided beforebatid, 

Fio. 14a. 




Ttie fillet In dowo-nnterior poiiUlon. (LrsK.) 



In cai?es of HVHi*ual delay durinfr mrhj gta^res, arcomjTatiied 
htf fftpnjdonin of fixhuHi^t ion ^ ami tluv \o a lar;re breech, gniall 
pelvis *^r some otfier afpiirtrmily, a lin;jer, bttuU-ho<»k, c»r tillet 
nmy be pUH<*Hl i*vi'r tlie ^rroin and used for Inietion, ihe trac- 
tion lieinjL,' directed toward tlie child's sacrum rather than 
toward its thigh, ihus lessening danger of fracturing' the 
femur. 

Tf pjBsible to reach a foot, it may be pnlled ilr)wn, Forceiis 
and the vcetis have l>een employed ; tfieir use ig <juesth>nable. 



334 BEEECH, KNEE, ASD FOiiT PRESESTATIOSS, 

They may lie tried. howe%'er» ht-fi^re eridiryolaiiiy, wbirh may, 
very rarely, hecorrie a last res^tirt \u bud eiuse^ of iiiipii€lioQ. 

Occasiuually, owing to oblitjuity of the uterus* the breech, 
as it were, situ on the edge of the peine brim, instead of pre^ 
seating over its centre. Progress is innKttvsihle. Treatment : 
Relieve by mauunl pressure over abdonieii, or put a hand m 
the vagina and lift the bree^di ot\' the side into tbe middle of 
the brim. Combine bolb manipulations. 

Fig. wj. 




Method of bringing down tbe fooL (From rAJiviN, alter Farahositf ftn 

Treaimeiii when L^gg are Ej-tftideti, — Tbe^e are exceptiana! 
cHseA, ami often tR'caaion iliffieully and (hmger, iSbould the 
dia^nimis have l>t^n made early, before the breech has de- 
scended below briiu of jjelvis, and before the bag of waters 



TREATMENT OF BREECH CASES, 



335 



has been dii*c*htirged ami the womb contracted mund the child, 
cepUulic ve7'i<loJi, by ixiernaf manipubdimi^ is bei^t. This early 
diagnuyis is ditticuJt* and uj^ually iiut attempted stx^ii t^tioufrh. 
It can scarcely Ijc reached except by majipiog out the child 
by pal|-wttiou over the abdomen. Failing t« briug <iowii the 
head thus early, by external niauipulatioa, the next exptslient 

Fig. ifjo. 




Twic«on by fingeri hooked In gn^lo. (Jewitt, after A. R, 8t»ii>flOif.> 

is to pass the hand inside^ all the way ia fundia ti/m, and 
bring down the feet— a mode of procfedinfr at be^t difficult, 
and cn<hin*::erinfr niptnre <if utcrns, i^|>ec'ially after waters 
havi^ been evacuated, A lietter nu'tliod is to fwiK^ in two fin- 
gers nutil they reach tlie poplitenl j^paee oi' tlir thii:b (jirefer- 
ably the aoterior thigh), and then preHJ? the limb outward and 
backward, whicli at once Hexes the leg and briujjs the foot 




336 BREECH, KNEE, AND FOOT PRESENTATIONS. 




Bluttl-boolt applied Iti brtMscU prvscutallon, ^*am?1^<.> 



KNEE AND FOOTLINO CASES. 



337 



with In reach, when it eim be caught and drawn do wo. (See 
Fig* 14i).) 

When breech has de*M;*eijded iiitu pelvic cavity or beC45me 
impiicted, versiuii should he ii!>andoned. The expetlients now 
at our tli3[it>9al, nuiiifd in urdeT of preferent'e, are forceps, 
jiUet^ Uunf'hook, (^ephahttiitf. Exjwrience lia^ innply deniuii- 
straled that tVireeji^ (made tor the lu-ail ) may he aUu safely 
applied Icj the bretx^li wlieu it ha.s engaged in the [lelvic eavity, 
and the os uteri k dilate*!. When bii»3 have rotaled (one to 
sacrum and oue to pubesj one blade of foreei>s is ajiplied to 
safruni i>f ehild, the other to pmtenor surfaee of ehOd's ihighs* 
When \\\\yi^ have not rotated, hut remain tnuisversie, the blades 
are applied to the InfGmf mrfam of the ihujhn (st.T Fig. 147» 
page 332) not over the tniehaoterii, ihas avoiding )njuri<m3 
pres^snre U[)ou iliac cresti*, Traetiou only dyriiig pains, slciwly 
and without great force, assisted liy pressure of hauils of n^ist^ 
ant over fundun uteri through abdomen. Should foreejit* fail, 
or breech be too high up to admit of their ajiplieation, and ver- 
sion be impraeticable without using dangerous fbree» \^\^fiUei 
over groiu, in prcfereuce round the thigh direeted anteriorly, 
and unxke iraetion UL*e Tig. 14S, page -S'Ui ) until breeeh is low 
ernjygh for foree[)s, or for tinge rn to he hrK>ked in groin (i*ee 
Fig. 150); or the whole hauil may l»e pa^i^ed into the vagina 
and l»e made to gnu^p breeeh bodily, a thumli in one groin and 
fingers over ojjposite trochanter. The hhfni'hnok\ prti|>erly 
guarded, may be of aervi<*ei piis!!«e<l over groin for traction, 
(St*e Fig, 151.) It retpjirert ^k\\\ and caution to prevent 
injury to child as well a.s mother. In impaction cases, wliere 
all these inethojU prove to be nnavailing, Hjrmphifjieotnmjf 
should Ih' done if the cliihl he alive. When child is dead, or 
other mea,sure.^ have failed, use crphaiafrihr, a[»plying it tightly 
to breech, ami extract during [inius by judicious traction* 



KNEE AND FOOTLINO CASES. 

The«e do uot reijuirc separate study. The feet and knees 
are small enough to pass through the pelvis without any sjieciftl 
mcchanisuL The breecli and other parts following undergo 
the same movements ti.s iu tiriLdnal breech cases. 

Diagnosis of Knee. — Chiefly l>y exclusion. By its large 
size; by the tibial spine and patella. From a shoulder by 



338 ntlEECli, KSEE, AND FOOT PnESEyTATlONS, 

the iil^eiici* o( ribs and ihtrn-u^tiil HiMices, utc. From an 
elbow by ihe fiat |mu41ii — vtTV ♦liliereiit i'rmn tlie poutivd 
yle<'rancjn. 

Diagnosis of Foot. — Hy tbu prujeLiing IjecL From a baud 
hy the tinker!* beitig^ longer ibau the toes. Tbe great tt^ie if 
longer thtiu the others — the thumb i^borter tbnti the fingers. 
Tlie fingers ctiu be easily s<*[»ttratefl ; the t<x'f* CiinnoL The 
JiKit i?i pUiee<l at right angles to iht* leg ; tin* htin<l is in a line 
uitii the arm. Thefcjot is thicker and not so Ihit as the huD(U 
Ilh inner l)onler thieker than ka outer one — not i^) the hanrh 
When, before rupture of the membranes, the toot la touehed 
by tbe obstetrician's^ finger, it will UMiidly lie drawn up with a 
quick, jerking nujvement, while the hand, under like eircum- 
sljiucej*, will move away slowly, if at all, or if the mem bran ea 
Im* ruptort^d, grasj> ibu exaniinintr fitJgcr 

Treatment of Knee and Footling Gases, — Tlie management 
of these cases is |)rartiejilly tbe same as in hrt*ech ])resentation. 
So is the mechanism. Most cases* mrr lireech presentations 
originally, the presenting foot having la'cn displaeiHl dnwn- 
ward towarfi the os uteri, either by tbe active motiotm r>f \\iv 
ebild or by a gui^h of liquor anuiii when the waters broke^ or 
by some other (vrocess. Ha rely labor hetjiitu with the heel» 
placed agaiuM the butt<ieks, the lower extremities having the 
pame relation ti» tbe bc»dy as is observetl in a kueelirtg |>oslure, 
Fmitling cascjs are ofteu more tedious than when I be breeeh 
[iresents ; the sniiill ancl irregular-shaped feet (or knees) do 
not so well adapt tbeniselvej* to the shsi|>e cif the os uteri, 
betiee ilihitatirni of ihe latter is slow and hdnir jwunfnl. There 
is more danger to the child during delivery of ihe atler-conung 
head* frir the f«et, hifw>, and hoily come thnmgb tbe o^ uteri 
without [jrodueiog sufficient ililatatiori of tbe os to a<lmit the 
head afterward. 

Whether one or Imtb feet prt^netit, and whether at tbe os 
uteri <»r at the os vagiine, eitlier bciore or after rupture of the 
membranes, the hn^t ruir of irentment (in ihe ab*ience of any 
<'(urj|iljciilion ) is to leave theeaBe alone— taking s|i€*ciol care 
wd to rupture the bag (»f waters— until the hifisare delivered^ 
when aclive interference may be necessary, as de,««'rilied in 
the management of breech case**, to prevent ^lal delay with 
after-tHMiiing head. (See pp, 32H ami 327,) 

OeruLsionally, unusual and seriouti delay may occur when 



ik 



TREATMENT OF KNEE AND FOOTLING CASES. 339 

the presenting parts are at the superior strait, owing to a foot 
or a knee being caught over the edge of the pelvic brim, pre- 
venting descent The ol^structing limb should be placed 
right, or hooked down with the finger. Since in doing this 
there is a risk of rupturing the membranes (be they still un- 
broken), try frequent changes in the woman's posture; this 
alone will sometimes remedy the difficulty. 

Complex presentationsy of a foot alongside of the head or 
face ; or of a foot and hand ; or of a foot and a hand with 
the head or face, etc., may require interference. When the 
head or face presents, try to j)U8h back the accompanying hand 
or foot. Failing in this, the foot may be held down by a 
fillet while the head (or face) is pushed up and version j^er- 
formed, converting the case into a pelvic presentation. Should 
this l)e impassible, the head (or face) may be extracted by 
forceps, while the oflTending limb remains down. Should all 
fail, craniotomy may be necessary. 

When hand and foot present alone — i. ^., without the head 
or face — pull down the foot and push up the arm — really 
podalic version, as in arm presentation. 

The method of extracting the hips, body, and arms of the 
child in any case of breech or footling presentation, where 
some emergency renders such artificial extraction necessary, 
is described in Chapter XIX., on Version (page 377). 



CHAPTER XVII. 



TRANSVERSE PRESENTATIONS. 

^ Any presentation in which the child's body lies transversely 
''^9erons ihe pt^lvis. instead of efidwm\ is a ** trans vers*^ |>re;?en- 
tilt ion"; hence presentations rif the arpi» !!ihunhU^r» e!l»t)W, ^ide, 
hack, aiidonico* etc., are all included in this class, S<jnie- 
timers called '* trutik " and '' cross " prei^entatiuni*. They L>ccnr 
once in ahout two hundred and iiily labors. 

For practical piiriwji*es it is only necessary to study ttm 
transverse presentations, viz. ; 

L Ritjhl lateral presentation (mcluding right arm» shoulder, 
elbow* hand, etc.), 

2. Left lateral pre.sentation (including left arm, shoulder, 
etc. ). 

Each of these two preientatioju has two ** (wsitions,** viz. : 

1, Hi(jhf cephahKiliac (the head, or *' cephalic" end of the 
child, resting u|x>n the ritjht ilium), 

2. Ijeft cephah»-iliac (the ** cephalic" end of the child rest- 
inpr upon the leff ilium). 

Since in the r^fjht ce|>halc>iliac ** |josition '■ of a r*^/if lateral 
** presentation *' ( Fig. 15;^ ), and in the hft cephahi-iliac ** j>osi- 
tion '" of a /t/Hateral ** presentation " ( Fi^, loo) the Imck 
(dorsutn) of the cliild is directed t^iward the jioftfrrior wall of 
the jielvis, these two jwsitions have alsi) been c-alled *^(iftrso' 
po«/mor " one^ ; while the other two poBitioo!^, in which the 
dorsum of the child is directed tow an! the pubes (Figs, lo2 
and le^4 ). are callni dorAo-anUrwr. 

Presentations f»f the abdomen and hack are very rare, and 
80on become change^!, f^ponftmf'omfy, into hteral presentations, 
or they muM l>e so change<l artifiriafitj. 

In cn»88 |)resentations the child is seldom or never exartl^ 
tranisvertte, Imt ohlitpiely [daced ; the hrad is HJiU4iiltf lower 
than the l>reei:h, ns t^hown in the Hgures, hence they are some- 
times called ** oblique'' preseutatlonfi, 
MO 



MECHANISM OF TRANSVEUSE PRESEyTATIONS, 341 

Mechanism of Transverse Presentations.^ — There is no 
met' hail ism ; at h&H fur praclivai purp<men it muy he eon- 
si il ere*] 1 1 lilt iiatyral delivery iu crosa preseutii lions i** mcchani' 
cully impossible. 

Fig. 151 Fjq. 158. 





Left cephalo'lllac (or do reo-an tenor) Ei)eiitC(?pbalo-llla(;(orfIor»**-lHt5t«rior) 
p«>6l Hi) II o f rifjtit 8 h ou 1 dt' r. poe iti on af riff W a Uoulde r. 

Actually, however (>o womlerful are Nature^s resources), 
there are two pFocessea by which, in exceptional cases, delivery 

Fl6, IM. Fid. 156. 





Bight cephalo-tltac (or di>r»o-anteHor) Left cepbuio-illjic (or dono- posterior) 
pQfiitloti ol f</? shoulder. poaltlcm of Uft shoulder. 

may occur sfxmtaneou^Iy ; but they an* neither pufficiently 
safe Dor frequent to He relie«l upon or waiteil tV>r in |>raetica 
These are ** spontaiwom venton " aod *' spotUamous cvQlutioti^^^ 



342 THA \S VERSE PEESEy TA TIONS. 

Spontaneoua Version.— Tiuit eiul of the filial avoid 
iitarest i\w jielvk* liriiii (one eini geDfrnlly m so, for I he 
child's IkkIy lifs oh/ 1 finely urroas the [^elvi^i, t«elch*m exactly 
traii?!ver8e)^ under the iutliK'tict^ of meriiie cotitracticm, gets 
luwLT and lower, and the other end higher and higher, until 

Fig. 156. 




Cliiiirtt*6 rroti^n tecUon, rcprwenttng mreated sijw jutaiRuu* evoluUon, 

finally the lower end slipe over the edge of the hrim into the 
jK»lvie aivity, luitl the jiresentation hm* then lu'conie longi- 
tiidirial^ either a liead or lireeeh, Thi?* t)nH?ess is nnjet apt 
lo occur in multijMruus women, with feeblts titmue c>ontrao- 



SPONTANEOUS VERSION, 



343 



tion, and before riipUire of the niembraues ; it is sometimes 
called '* aponfanfouM trctiJieatitHi,^* thtise who use this terra re- 
serving the ex[irt\^i(m *• ffjmittatti^ouM version *' for eai^e* in which 
tliat piirt of the ehilii direr;te<l tnward the fuijiliis is turned 
dowiiwanl to the pelvir briiiL Tliij^ hiltiT |iroet'i'diii;i^ «R*eurs 
most fre<|Ui:'iitly after ru|>Ujre of the menihrniies in women with 
jKJwerfyl eoiitrnetioiis of the uierih^. In this the og uteri 18 
q>a«aiCKlically eoutracted, so that while do dowuward progrees 

Fig. 167. 




RfiontiineoiiB evolution (flrst BUige), 

f)f thai Hid i»f the fit'tal oyoiil nt^sin^^r the hrini can take [dace 
(it on the contrary Ldirlej* lateridly and upward), that cml of 
the c(iild nfarcd the fund m is forred nil the way down to the 
pelvic brim, and a head or hreech presentation re-sultii!. 

While spontaneous rectifinition and versiiou are usually 
a^sr^rihed to uterine contnirtion, it is prohaMe thai they are 
promoted hy antero-htteral prcs^mre i>f the woman't* thighs 
upon the aluhnnen, when ^he assumes a sitting, kneeling, or 
Ewjuattin*? fM>!sture. 



tu 



TEA NS VERSE PRESENTA TFONS. 



Spontaneous Evolutian, — Tlie cliiltri^ hody remmus erosst- 
v*hi' to die jK'lvii; hriin. The \wiui rotates iahore the brim ) 
toward the iieurest lUTUibuliim, the brtech luwar*! theop|RMjite 
sarToiliac sym'bimdrosis. The anii is exteruh-d from the 
vapiMi, the .shtmhk-r ilt'sreJKls into (he fielvie envity, the neck 
resLs lieliiii<l the symphysis [in bis. The hoily is tlieti dun bled 
hiteraily ou itself, breeeli and head aj>[inmeliiii«; etieh ntlier 
(just as one riiitrht [iress tu^^etber the twu encls nf a siusti^'e)* 
while tbe roundel 1, ei HI vex augle ordiipiieatiou is* fbreed down 




Spoot«n<*otw evohnion <sfcanc| sUMfe). 



tliroii;rb tbe pdvie envity to the inferior ^trnit. The side i)f 
theebild (I he sjcleof itSf'Ari/ ) is born firsts followed l>y hreerh» 
le^'s, and feet» whieh are «ue<'es.^ively foreed ilown along the 
mernni and eniert^^e at the |>erine«rii. UideKs tbe iwdvis I>e 
larire, the ehibi smidb and uterine eontra<'iion stnin^, fietal 
iriipaetion is aj»t to cK-^nrr, or the ehild is Imrn dead from the 
prolon^red and vitdent eorapressioti to wbieh It haa lieen 8Ub- 
jecteil. (Sx' Ki^, loii, \>n^e *S42» reprennitinff a ca^e ns exhih* 
itcnl by frozen ejection of eadaver, after Barnes.) 



CAUSES OF TRANSVERSE PRESENTATIOKS. 345 

When rhe pmcess is suwf^H^ful, ita several stages are those 
shtHvn iu Fi^s. 157, 15H, uud la9, 

Vrrtj mreiy a prot^es&s of spoutaneuns t^volutioj* (different 
in mi that juj'td evS(MM bed )<M*c'urs In whifh thei'irdd is (hlhrred 
witli flonbif'il htniy- — ^^ rvuhiih rortfhfpiinilftmvjmnv' Inj^^tead 
of reiiiaiiiiii;!^ tihove tlie Itrim, the Afvtv/ fnfrrM the pelna wifh 
the binhj, info which it is* deeply pres^d» m* that hen<l and 
nhflonien ranie loffether, followed suefei^ively hy hrecK'li and 
legs» The second arm lies hetweeu the head aud breech, Iu 

FKJ. 159, 




SpuDUiai:uLii!^4jvuluUi>ii (third stage). 



tbp c»lher more eonimtio mode of e\'oliiiit>n, the IkkIv wa*' 
i^idoubled clurinfrihdivery, bvHly riiminfj: first, heruj afterward; 
in tlie rare form, body and heiid reimtm tlonblrd and eume ti>- 
gether, {See Fi^. 1 i\i >, ) T \\m hi»i only o^tii r>< wit \\ prematu re 
or macerated iiifaoLs or almrtion ease^*. Delivery is hast- 
ened hy tmetioii on (he arm. 

Causes of Transverse Presentation,^ Prematurity of the 
labor. Plareiita privvia. Narrowness of pel vie brim, great 
lateral ohlitjuity of the uterui?, Muhiple preguancie^. Undue 



346 TRANSVERSE PRESENTATIONS. 

mobility of the child from excess of liquor amnii. Acd- 
dental pressure externally irom blows, falls, dress, etc Re- 
peated occurrence of cross-births in the same woman is prob- 
ably due to a narrow pelvic brim. 

Fio. 16a 




Birth of (lout»U'd child. Evohitio condupllcnto oorporc (Kleint^achter ) 

Diagnosis of Transverse Cases. — By external j>alj)ation 
and ins|H»ction llie womb is found to be unsyraraetrioal in 



JUIAUNOJSIii OF TKAS.S VERSE CASES, 



347 



shape, atid lotiger traniivei*i^'ly or obliquely thtin vertically. 
Siijoe ill i\w iartjr majotUt/ of ni*»ea tlie back of the child is in 
fnmi (dur8ci*uuteriur |>»>6ititjn ), auil the livad lower than the 
breefh (at least early in lafjor or iwfbre it begins J, one may 
inwardly r^ue^ (often eurreetly ) both presentation and [josi- 
tion l»y iftifpecUon alone, PaJpatifm in dorm-^nteriar pmitiou^ 




I>iftgiin«ls of sboutder presentAtton by patpAtton, (After Pauvin.) 

reveiilt* hard, nninii nirnhir tumor i>f liead on i»ne iliat* fos.^» 
aud 8ot\, irre<jular tynior of hrcerh in^rh up in op[)08ite fiank, 
purtly conceakHl behind false ribs or by the liver (see Fig. 
161 K UewiHlin^' plane of baek folIosvH curved line l>etw€*eri 
the^ two. AlK>ve the resisting plane, toward the bree<'h, are 
felt the s^miill pnrM in eh*>tir" spare oiM'ujiird by liipior aiiuiii. 
The exeavatioti ih usually enij)ty, or sujall pnijectioji of pn^ent- 



TRAXSVEBSE PEESENTATiONS. 



iii|£ shuiililer may l>e disiovereil Ijeliiinl luirizotital rann of 
\yn\ws Uvizhmiug to sink into brim. The Ilea*! an the iliac 
foirisa may be made to ballot. These are the conditions ohmerved 
earlfj In hilmr or before it htfjins. 

Later in \i\\mw, after uiembraije.H are ry|»turu(l and child's 
IkkIv Ijecome?* couipreH^ed l»y cootrai'ting uterus, the liue of 
resisting pbiue of back l>ecoiiie.s more vertical ; the bree^^b is 
fiUTvtl nmre over tu thf median line, mid plane of tmek 
np[K-an5 to join head lumur almost at ri^jrht antdes. 

In iXiiY^i^-imnhntir positions (extremely rare) palpation 
reveals hurd globe of heail lu one diae foswi, and large* miX^ 
irregnkr breeeh high up ou oj>|>o*fite side. Resi?Jtiiig ]daiie 
of btiek being l)ehind eamiot be felt, or only with ditfieulty ; 
wliile elastic .space of litpn^r amnii and sniiill parts (being in 
front) are/t/^ m^^ify. 

By vaginal exanniiation, early in lal>or, the presenting fuirt 
and OS uteri are found higb up and diBicnlt to reueh. The 
bag of water?* is elongatetl in sha|x\ sometime^n projecting 
through the m like a glove-finger* The globe of the head is 
missing. Vaginal examinations stbould lie made hdwven the 
pains to avoid ruprnre ipf mendjrant^. 

Diagnosis of Sttoulder Presentation. — By its ronnde<] 
promlnem'e ; the slutrp Inu-der of ils acromion proct-ii^ ; the 
chiviele ; the s[>ine of the scapula ; the liollow of tlie axilla ; 
and et«pedally by proximity of rihs <oo/ Dttfiro^ial f^parei^. 

Diagnosis of One Shoulder from the Other when the Hand 
and Arm are not Tangible, — I, Observe the opening of the 
axilla; it always pantji* toward the chihTs f>et. If the feet 
}>e, therefore toward the ritjhi eide of the |)elvifi, the head will 
l>e tosvarrl the irft t*ide. 

2. The scapula, its BpinouB prot^ess especially, will indicate 
whether the ehihrs baek be toward the pulx^ or toward the 
Faeral pn>montory, 

'\, A moment*8 refleetion will ^how tluit a eliild lying 
across the pelvis (let the reader imagine him^tif t<» be lying 
aero8s it h with its head in the ritjhi iliae fossa^ and its bfick 
to the piiben, vittut l>e presenting its Irft shoulder to the pi'lvic 
brim— the ** pisition " of the ** presentation *' lieing. ne<*i'«>- 
earily, right cepbtihMliae (dcirso-auterior). If the axillary 
opening show the bead to be in tlie frff iliac fossa, ai»d ihe 



positi 



ion of the scapula show the chibTs luiek to be toward the 



TREATMENT. 



349 



mothers sacrum, it will stil! be the left Hhoiilrkr preaenting, 
the position, however, heiii^ left t'^phulo-i line ( or dorso-poste- 
rior). 

The jiiime diitii iiod deduehoii may lie used for the right 
ehouider and its two *' jwMitioQS." 

Diagnosis of One Shoulder from the Other when the Arm 
is in the Vagfina. — (irusp the ehildV hand as in ordiittiry 
haiid-sfiiikiiifr. When the piilm of ih** Imnd of the praeti- 
tiouer and the palm of the child's hand are hrought Hat 
against eaeh other, if tlie thnmh of the (no haml^ rome 
together, the hand of the ehihi will be right or left according 
as the phymcian 13 using his right or left. 

Again, if the infant'!^ liand be at tlie vulva, and its palm 
he turned U|i Upward the syinpbysi?* pubii*, (he thnndi will 
pea lit toward tfie right thigh if it be the right hand, auti to 
the h^tl tfiigh if it he the lefl. 

Diagnosis of the '^Position'* of the ** Presentation " by 
the Presenting Hand. — Exfend the arm, and phiee the hand 
supine. The hand will then always point toward the head, 
and the fac*' of the palm will agree with the surface of the 
chihFs abdomen, 

Diagnoaia of the Elbow; — By its three l>ony project irms — 
the two condyles of the humerus and the ole^Tanon pn)ces8 
of the ulna. The end of the elbow, like the axillary open- 
ings points toward the child's feet. 

Prognosis of Transverse Cases,— Always serious. Oi\en 
fatal to the child, sometimea to the mother. Mnch de|Tend8 
upKUi the presentation being corrected early^ and ufmti the skill 
of the opt^rator. 

Treatment. — Early correction i*f the presen tilt ion — convert- 
ing it into a head, brc^eeh, or footling — liy the operation of 
version or turning. This may he done either by exierual 
manipuhition ; Udenml manifiulation : or by a c^imhined mwli- 
fication of both methods, known a^ bipolnr version. 

In cases of arrested s|>ontaneous evolution, with impart Ion 
of the chiKl, as i*hown in Fig. lo(>, version would be out of 
the qut^tion. The child is usual ly de^id from the ctmjpression 
to which it has been sulijcctcd ; the metlio<l of ilelivery is 
embryotomy ; usually decapitation ( q. r. ). 

Version, and the ^n*eral modes of j)erforming it, will be 
ctmsidered in Chapter XIX, 



CHAPTER XVIII. 
INSTRUMENTAL I>ETJ\1CRY, FimCEI^, KTC, 



There are fmir gresit (iivisions of o[«rative mitlwifery — 
ffuir grinit methtHls by vvliieb delivery may be at*complished 
wlieii the luityral jKiwers fail, Thes*e are : 

Fii\iL Delivery liy force [j8. 

Second. Delivery by version. 

ThiriL By cutting ojKTation.s upon the mother. 



Hh. liv 



ibi 



the ebihb 



operaliuns y 

Each c)f these itielutles a variety of (lifttTCLit jinxx^dures, and 
there are aiiinerou» other minor niaoifitdatioos j .Him le of which 
have been already dewrilted, aud others retnuia to he con- 
sidered)» which are, of cours«.% olistetrical ojioratiorLs in every 
seujie ; but it is when these minor methmls are inefficient that 
the ol^stetrieiau falls back ujmhi one or other of the four great 
methods of tklivery just nieutioned Delivery by forceps 
and hy vetf^ion are essentially o/>.'</r^nVa/ ojieratiMns ; cutting 
openitions u\Mn\ the mother are ibstiuetly nHrgiraJf aud muti- 
lating operations u|Mjn the child are awkwardly of a mixed 
ch a raet e r. Si>m e rect- ti t a n t hors h a v e i m • ! u d ed all ope rat i ona 
nmier the caption of "Obntvtric Sttnjerii.** 

It is imjMirtant to know that/rjrrc//» and wmow are far more 
freijiiently recpiired than the other two methods, and will be 
resorted to occasionally by almost every medical practitiotier ; 
while cutting operations U|kui the mother, l>eing so rare aa 
e*nircely to allow the obstetrician to acquire skill in tlieir jier- 
formauce by expt^rience, ought, in the interests of the jKitients, 
to Ire done by one possessing surgical skill, when such can 
i)e obtainefl without injurious delay. Under opfxiRite cir- 
cumstances every olistetrictoii should know how to do these 
o[HTations, anrl not hesitate in undertaking their performance 
himself Mutilating operations upju the child are seldom 
required, at least in this country, where f»<dvic deformities 
:i.>o 



FILLET, BLVNTIWOK, VECTIS, FOBCEPS. 351 

(their chief field) are comptirativtly iiifrecjuetit WJiile they 
demand carts rnuuual ilexttTity, luitl dt'liV>eratioii iu their per- 
f)>miauee to avoid woundiiii^^ ihe iiH»ther» they are doue with- 
out hemorrhage (at lea.«t from the living'), and are therefore 
exempt from that "fear of lihwKp' whieh ii* apt to unnerve 
and dii^tiirlj the .self- ]x>sse^sion of one miaecustt>med to j>erforni- 
iog snrjLn<*al operatiorm. In the lutere^-ts^ of living ehildren 
they are \mn^ hirgely supjvhinied l>y improved methods in 
doing cutting operations upon the mother. 

FILLET, BLUNT HOOK, VECTIS, F0E0EP8. 

A de8cri|ition of the tnrcepn may i»e htlintrly jnecetled by 
a brief account of the other iusirument.^ here named. The 
jiUei i$ a noose of cotton, silk, or leather tape, or an uncut 

Ym* 102. 




The blunt-hook. 

skein of worsted, u?ed for tract ion. The kH>[i having Ijeen 
passH^l arouml the part to which it is lo lie applied, the other 
end of the fillet is put throytjh the noose myd (h'awn to iorm a 
slij^-kuot. The vvhalehone fillet eonbiMs^ of a lonjj: s^lip of this 
nmterial, the ends of which are l>ent toward each other and 
joined iu a solid handle. A ;^nM>d fillet may l>e nuide by 
passing a strong piece of ta]>e throujtrh a piece of stout rubber 
tubing* the ta[ie being sewed to the tube at each euch where 
it projects a sufiicieut length to adnnt of a knot being made to 
facilitate in trot but ion, etc. The filled is fiehlom us^d except 
for Ihe fM'ca.*ional assistance it may render in certain arm and 
breech cast^t^ already nu/utioued. If the end of the fillet cau- 
not be passec! by the finger, n^e a large gym-ebistlc catheter 
with stylet, bent to j^uit the ca^i^, with a piece of tape fa.Htened 
to its extremity. When the catheter is iu |KJ^ition the fillet 
may be fixed lo the taj>e anil drawn through as ilejiired, 

Tlie h/itnt'hook Tsee Fig. 1(52) is a rylindrifal nwl of steel, 
one end of which is attachetl to a woollen handle, and the 



352 INSTRUMEyTAL DELIVERY. FORCEPS, ETr 



othor beiit to iV>r»ii i\ li*xik. in tlie encl of which i>: iin "eye" 
through whh h \i tilift may be threiulnL It h iis^'rl us u ^>rt 
of loiic^ ari'tficial fmger for passiii;^' tlie Kllet ami making tnie- 
liou ; it is Imt little employ eil for the <lclivery of iiviug chil- 
dren OD aceouLit of injury it is tt|>t to produce ; but becomes of 
great service in the extraction of dead ones iluriiig etuhryotorny 
o|>e rations. 



Fig, 1(»3 



Flo. IW. 




Vectis. 



l>eniniLii*s short Ibrcepai. 



The vepfiK h a flattened stei>l blade with a fene?^tra, shank, 
and handle reseaibJbig a single blade of the straight forcei»8, 
atui curved to fit the contour of rhe fret a 1 cranium* (See 
Fig. I6.*i/) It in sehlotn use*!, but may be uf 8ervi(*e aa 
a sort of artificial hftttfi, in promoting rtexion» rotation, ttnil 
extinusion, when neces^iry in the nieehaniMm of lalmr. As a 
tractor it haii Itecome obsolete since the invention of forceps* 



FILLET, IILUNT-nOOK VKCTIS, FOnCtPS. 353 



The forceps is a sort of pincei*is whose hladea, like a pair of 
ariijkial hamU, grasjj t!ie head and draw it ihroii^li the jjelvic 
caiml. 



FlO. 165. 



Fl6. IG6. 



e 



Hodge't long forceps, SlmpenrVs loriir fnrce|w. 

The instrynient is composed uf the hhtdra pn*p^r (vvhitrh 
grasp the head), the loek (where the two halves uf the iustni- 
ment ertms eaeh other nnd iire *' hw^ked " together )» the Hhunk 
(placed lietweeii the fork und Idndei* lo prive leii^h to theeon- 
trivauee), and the hundleH ( whieh are held liy the o|ierator). 
The two Imlves of the ii)striinienl are S4*|«iralely known Jia 
23 



354 ISSTRUMEyTAL DELIVERY, FORCEPS, ETC. 



the ** ri|jrl»t " and "left" hinder called also **u[>j>er" and 
•*lf)wer*' and **mHk'*' and "female*' Idade*. 

Fon*ej)i4 an* eitlier **8liort** or ** long/ ' T\w i^htfrl farct'^p^ 
called also **jitrai<rbt/^ liav«Miidy one curve — the cranial vu rye 
—which ndaplH diuiij to fit llie eraniurn. They are only need 
when the head is at the interior f^tniit or low down in the eavity 
of ' I he I )e 1 V iij, { S*.*e F i ^' . 164 . jiat: e I^ 5 2. ) 

The lung forvrp)*, beside the *'eninial " luive al^^o a **pelvie*' 
or '^.siierar' curve, by which they eonforai lo the axis of tlic 
|>elvic cariJiL (F'igfe, Itif) and KifJ, page 353.) They may lie 
a|>plie<I at almost any part of the jielvis. 

Action of Forceps.— They act ebieHy mtmciot$; slightly 
n^cnmpre<<!<nrM; H^-arcely nt t%\\ ai* Irirn*. They are aids to, or 
sidislitutes for, uterine eontractioru They oeenj»y hut little 
ftjMice, owin^ to projiH'tion of the parietal prolnberatices lb rough 
the fenestne of tbe blades which always occurs when the 
instrument is applied in its uhM favorable p<fsition, the long 
diameter of the head ajrreeing with the long direetiou of the 
bhules. 

Cases in wMcli Forceps Are to be Used, — (ienenilly speak- 
ing, itj all ea*^es wbere it is necessary to hasten ilelivery, ]>ro- 
vided their use for this purpose can be sjdely aiul succvK^fully 
employed. The eircumstances under which their «ppliealion 
is to be preferred to other mnde^ \y^ o|ienitiiig, and the vi\w^ 
to whieh tliey are esjH'cialiy adn]>ted, «re so varied atul numer- 
ous that I hey need not f>e reciiid here; they are considered 
elsew here iit connection with llie ihfferent kinds of labor aiid 
their eom plications. 

h may be added that utitisiial frei^ueney (almve 160) of 
the ftetal heart stmnds, violent f<etal movement^?, and dis- 
charge of nnvonium (in eai^e?* other than hreteh ] presentation) 
indicate speedy delivery for tlie chihrssake, for which fi>rt*ep8 
nniy be used in suitable case^. 

Tlie " High '" and '* Low Operation.'* — When the head (or 
faee) of the ehihl is at the infencjr strait, or low tlown in the 
[lelvia, it constitutes the *• low o|x«ration," and iweiimptira lively 
easy. When the head ig at or alKJVe the 8U[>enor strait or 
occupying the higher planei* of the yxdvic cavity* it \» tbe 
*" high operation/* This diHtinciion is inifKjrtant. Difficulty 
an* I dangen* of forcep ojnTations increase, catrria purilm^ 
from l>elow upward. 



APPLICATION AT THE INFERIOR STRAIT. 355 



Conditions Essential to Safety in Delivery by Forceps, — 

Tht» lAS uteri rim.st \w flihue«l ; tlie niomlrniups ruptured ; the 
reiiiun and hhuhler tiii|jty ; ihe pelvis nf sidtirtcnt sm to 
aiiiuit tlie chil4 ; and the upenilor must jwjSfH^as a requisite 
atinuiiit of kiiovvie<lge* streujL^tli, and Miuui|iulative dexterity. 
I'^*irre|>H, litnvever, iiiiiy lie applied before the o?« uteri is rom- 
pletely <lilate(i ( if it he paty]llu^^ uiui dihitalile) iujtl het'ore 
tlu-! heml has parsed ihrou^^lt it, jirovided the dangers of delay 
are Jinmife^tly jjreater than the riskiji incurred hy lutrtMlucing 
the hhides of the iuritniuieiit into the nteruj*. 

Antiseptic Preparation, ^Make the iiljiiornen, thighs, and 
vulvji aj<e|itieally eleiiii hy srrybbiiii^ witli soup and water and 
npjdyiug a 1 : 2000 liichloride solution- ( 'hniui^e the vagina 
thtiroughly with a liot 2 jier rent, ereolin ij^ilution. The han<i« 
of the o|)erator are |tre[*ared aseptically as nsuah (See 
** Labor,^' j^age 24 L) The fort-eji^* are rendered Merile hy 
boiling and pUu^d in a 5 per cent, cjirhoHc acid j^olution — 
preferably in a deep pitcher — ready for use. Before intro- 
dtieing each Idude, lubrictate it with earbolized vaseline or 
moll in, 5 jK^r fvut. A^eptie needles and sutures will have been 
previoui^ly [»r(*[)ared fur the [K-riiieum as a matter of <*oiirse. 

Mode of Application at the Inferior Strait when the Occi- 
put has Rotated to the Pnhic Symphysis.— This »s tlie siai- 
f)lest and most easy of all foreeps o(K*ratif»ns, Place the woman 
on her tiack. Aun^^thesia may or may not he necessary, 
according as the pain and difticulties to he antici|Mited are, 
respectively, great or little. Assistants, at leiu*t one even in 
the sidiplest cimes, will be reijiiired, hut an intelligent nurse 
will often be ^lurtieient* When ana'sthef^ia is usc^d, additional 
ajisistants become necessary i one to give ether and two others 
(one on each side) to snpjw^rt the hiwer lindi^. The '*IetV* 
(•*male/* *' lower 'Vl bhide is introibieed first. Which of the 
two blrtde^s this m nuiv be ascertained as f<dlows; Before they 
are taken apart look at the lock of the instruments while it 18 
held with the convex bonier of the sacral curve downwanJ 
a!id the handles toward yon, and ascertain wln^^h shank is 
u|)pcrmitst ; it is the one whorte handle is toward your right 
hajul (the **uf)|»er/* ** female,*' **riL'^ht*' blade). Lay it aside; 
the fptlicr hlaiie, held in the leO band, nntst he intrmlureil first, 
(trasp it just above the fork, mu(^h in I he same manner as you 
would a ^>en, so that the handle rests lietween the thnnd) and 



356 INSTRUMENTAL DELIVERY, FORCEPS, ETC, 



I h e i jide X -fi ii ge r, an d u po ii t It ei r j u u ft i o o . O ti e or t w o fi ngers 
of the riijhi liatid nre now JirM intrtHluced hetweeti the child's 
heiul and letl liitt^ral wall of the vji^dna aiifl reliiijii'd there, 
while the end of the bladc^ is |ilareil aputist thuir |iulniar »ur- 
facp, and hy gentle jire^i^ijre made to ^lide hi aud u\* lii4wet«n 
the head and fiojrers. ( iSee Fig, 1 07. ) At tiist the end of the 
futmUr isdirorted nither tcmard the li^^ht thi^di, litit is gradu- 
ally hrou^dit further down and toward tlie median line as the 
blade a^R'enda the vagina. A geutle, limiieti, up-imd*<lown 

Fio. 167. 




rie of fbracfw at outLst. lotroduoUon of flr^t Utntltt, {'Iw vAvxh. ) 

mrjvenient of the fdude, rocking it fin't up toward the pnl)e8, 
then down toward tlieet»eeyx. may fjuilitate it*^ entrance when 
the size of the heiid makes* it a tight fit. The fingers inside, 
having awertaineil that the blade \» entering pro|)erly, are 
gradually withdrawn ; and when the end of the instrument 
htts ahout parsed the e<jUalor of the head the letl hand ia 
plEOad alKJve and rjearer the end of the hanilh\ whieh is now 
depnaied toward the j)crinentn» where it in hehl steady by an 
while the other blade, held in the right hand and 



APPLICATION AT THE INFERIOR STRAIT 357 

preceded by two fingers of the left, is introduced along the 
right lateral wall of the vagina on the other side of the head, 
in a similar manner. (See Fig. 168.) When properly 
applied, the second blade crosses the first one near the lock. 
The next step is to lock them. 

The operator, taking a handle in each hand, by slight ad- 
justing movements gets both blades on a pro[)er level, the lock 
slips into position, and the instrument is ready for traction. 

FlQ. 168. 




Introduction of second blade. (Zweipel.) 

In forceps like Ho<lge's, having a screw lock, the screw must 
be tighteneil before performing traction. In applying the 
forceps, proceed only between the pains ; in using traction, 
only during the pains. In the absence of pains, imitate them 
by intermittent tractions and intervals of rest ; each continu- 
ous pull not to be longer than one minute. In drawing out 
the head by traction, avoid haste and violent pulling (unless 
imperatively required) ; draw by the strength of the hands 
and arms, not l>y hanging the weight of tlie l>ody on the in- 
strument ; direct traction in a line with the axis of the pelvis. 



imrnuMicNTAL dellvehy, FoncEi% etc, 

Whilt' iiiie Imtii] ^'ra^^ps tlie hjuidies let i\w oXIwt ^^rn.sp the 
ltK*k, unci r(^,st the lip of ibi iiidcx-tin^rer nguiiust the oi'ci|iUl tci 
guard at^aitist the head sli(n:iing out of the hlades ; iu restiug 
from tnietioii eHorls iK^tweeii {\w paiiKs» se*' thai the handles 
are nni held li^hfly together, so aw to make rontitHfotts eiMii* 
|>ressioi], hy the hhuk% u|k)Ii the head. Keep the handles 




Lllftiijl Imn^lli^ to follow e]ttvii»ioit. 



down so that tntetion is made ahoiit iu a horizcmtal line 
until the mTipilal end of the *)cei pi to- mental diameter is 
hegiin»i«)yr t*» e»ea()e under tlie puhie arefi^ then ^nulually lift 
them up, in a line with the axis* nf the outlet, toward the 
mong veneris, in order that "extension*' of the i»eoiput up 



jrrLICATI(K\ AT TUE tyFERiOR STRAIT, 359 
Ft*;. 170. 




;i60 INSTRUMENTAL DELIVERY, FOHVEPS, ETC. 

in front ai' the pulnv .sym]ih\>ls muy take jilace. ( Fi^. 1(>9, 
page ^J»5J^. ) Inexperienced optTuturs iwimthj contimie traction 
too long Injure lie»:iun!u;( exteus^ion. When twiripiit is well 
below jtuhieurch and l)ack of chiUrs* neck l»ehind pnbcjs pull- 
ing cloe*f no good ; extension, 1*y lifting handler toward pnltefc^, 
ninst now begin » Watch the perineum and gnard it from 
rupture as the biptirietal equati^r emerges. Readjust the in- 




* Forccpa la poititim. Tmctloii In &xl« of brim, downwurd aad b»ekw«nL 

strument from time to tirne without withdrawing it, if neees- 
sary* to keep the long direction of the hladt* parallel with 
the long diameter of the head (esjxH'ially during **extengion" K 
otherwise the terminal extremities of the blades will project 
and injure the fierineum or vagina. To av(»id ihiB risk more 
eompletely, mme ofierators take otf the iu^tniment just before 
the head emerges, and finish dcdivery, if further artificial aid 
l)e necej*Miry, by nninifuilatioii — ^a finger introduced into the 
rectum drawing ou the chin* 



OSCILLATORY OR ** PENDULUM MOVEMENT/* 361 

While tliui* fur we have relerre*! to tlit- ajiplicatioii of fureep§ 
with the womau lying up»JU her htick — the usiual |iosJtii>ii in the 
United iStiit4f» — tlie methiHl of usiug the ioiitrmueut with the 
worrinn in the Engiit^ih jmfsition, iijx>n her left side, nmy be at 
oiiee uudersttMxl from the j>reee(liijg illustrations taken from 
the work of Playfuir, of LtrnduQ. (See Figs. 170-173.; 

Ftu, 179. 




^lJ^^ stAgc of cxtrHt^lUm, Th<» hAiidtcss bcluif rni*1»Atly IiitthhI uji towunt Ihe 
mother*!! abdomen, lo deliver liy "exterwion/' 
Oscillatory or *^ Pendulum Movement/' — Dtirinj? traction it 
k not nei'i'mnry (as wiii^ fiiniterly sU|i]K»8ed ) to 8\vay the hftiidlee 
to and fro, laU'rnlly, with a view of levennj? the head out of 
the pelviJ* as a carjieiiter ** rocks** a nail in withdrawinir it 
from a kiard. Since there im no ratcht'tdike rouj^rhnen^ either 
to the jKd vie canal, forceps, or hea<l, tiothinju: can i>e gained by 
this movement, while the sweep it nei^esssarily gives to the ends 




M2 INSTHUMtNTAL DELIVERY, EORCEPS, ETC, 




(jf the Ultulei* nitty iujurc the w<jtl (wirt^. In rtTluin ca^cs where 
the [wild h fixed and Hniily inj|iactetl iu ihe jH^dvis, such a 
iiiutiou may l»o JLi:?titii«hle to di^ludge or loosen it, but a^r 
tins the latenil iiiovtMiKiit is uikdet^. 

Aiithoritie:!^ ilitJi^r on ihLs matter ; some eotiliniie to |»raetise 
the peiidiilum movemeiii, and explajy the theory of iU aetiou 

tistat'torily lu themselves ; other^s do not. 

Sinee the pinch in most ott4?n in the antrro-posterior (lii%tnHe^ 
of the pelvi.s ^he httrral nit»vemeijt.s uonhl iieern merely to 
tawing I he Iread from f^ide to ^ide nnmtl a eeniral pivot run- 
nittg from si;iorum tu puhe.s. TheoriHieally the t*>-and-fro 
movemeuU woidd apjHMir to he culled for in thr ather fliredUm 
— auten>-po!^terR»rly — ^in uT*\^r It* hwr the head down through 
the tvvri ends of the oh>lructing cnnjupite. 

Applications of Forceps at Inferior Strait when the Occlpnt 
Has Rotated to the Sacrum. — Forceps should not Ik* applied 
lit all in thet<e ea^es until a reason a hie time haj* l>een Hlh»wed 
and every pro[»er effort made (>ee |*a|fe 2H7 ) lo pnmiote 
anterior rotation, unless, indeed, aeeidenlal eireumstutices ren- 
der delay dangerous, Thea, however, the ofKTution k ns fol* 
lows: The liludes are put in exactly ji?^ deMfnhed for eai?es 
where I he occijnit hiiK rotated anteriorly. But siiu'e the occi- 
put ih u<iw toward Ihe sac rum? the rxiciwion tn//, nf course^ ht^ 
downwartl uml haektmnl over the pennennu instead of upward^ 
toward the puhes; hence the hamlles of the iustrunient, at first 
lifted K^imewhat npward townrd the puhes to draw the occiput 
U]> to the ed;:eof the p*'rineum» rnuM, when the head emer^^ea, 
Ih* directed flownivfini ami hnclcHfiffi, )n**rend of toward the 
moHn re Hens, A momcntV retiectitm will !<liow^ that the ?hort 
Mtntujhl fon*e|is fwilhoutany mrral enrvr ) should he u?cd in 
thej*e caries; for the saitf curve h only atlapted to follow the 
axis of the [jelvic caiuih hut duriuf^ Imckntird extenncm of ihe 
i}«*iM|nit over the pertneutn the he*i<l de)»artii from the axial 
line and poes in au almost ri[>|m8ite direction. If the citn^d 
fon*ep6 were uf*e<i, the eud^ of the blades would impini^e 
a^innst the pu hie arch while the handles were liein^' iieprt*ty*e«l 
iu follow iu^^ tlie movetricnt of hackwanl extcn.^iou, Airain, 
nwiu^ to the depth of the postcrinr fw'lvic Wall lieimr three 
time.'j a.s prt*at as* tliat *d' the anteriur one, ihiTe iM .*•» much the 
ujore ilitKculty iu getting tl»e occipital end of the tx'cipito- 
mental diameter to escape over the edge of the fieri neuin^ 



APPLICATIoy AT THE tSFERlOR STRAIT. 363 

hence greater clun^^er uf liic^eratinn. arnl Liece??*ity ior extni enre 
that the ucripkitl [^wjle naUij ^Imll ha%'e cleared the jieriiieuiu 
before eatleiisiou is attein[jted. 

In the cases of occi|iito-|)<jsterior rotation, in which the 
fu re heath faee» atul chin siicce^ively escape uinler (he puhea 
(whii^h sometimes goe^ on >Yhde I be forcejxs iire heiug uticd), 
the cane l»ecomiiiy a face preseutatiuo at the htj^t momeiil 
(see ** Mechanism ot' It. t). P, l\ii4ition," page 2i)i> k the handles 
are elevated toward the pubfs, t'ur, the chin liaving emerired, 
the mechanism is complettHl by \i^ fiexion up toward the mutiji 

Vr tif t'LH, 

Flo. 1T1> 




Porrc[i8 nyvpUed at infi^Horfstralt ; orriput to trjt ncrtf^ulum^ 

Application of Forceps at Inferior Strait when the Occiput 
is Toward One of the Acetahnla. — Here no rotation lias ocv 
ciirred. The hmg diameter of ll»e bead occupies the same 
oblH|Ue diameter by which it eLitered the siijjcrior strait 



3G4 iySTRUMENTAL DELIVERY, FORCEPS, ETC. 



As a generul rule, iipl>ly the hiades just ns if rolnthni had 
occurred, fur during tlit- sulii^etjueiit trnctioii nttittion i^iil takf 
pluee iiiMde the tn,4rametit. TIk' bhules eiuifonu t^i the siflcs 
of the pelvis^ hut gnii*|) ihe hrad ohli^iHfhjyime over the mle of 
the f<»rehead» the other over ihe x/f/eof the iHei(>iu. They du 
not s<i nearly a[iproaeh eueh other, henee I he haudlen ure wider 
a|yart, and rhe foreejj}^ are more ui)t U> sliii during traction — 
an areident to he uvoifled hy ad<litional eare. 

Anutber inudt- tif (i|)enuiii|:: i^ to (ihire the blade?* over the 
ififie^ of ibe un rotated hrtul^ uae blade being |>a»sed in along 
the sacro'iliac synrhondrui^is, the otlier near the 0[>j)osite 
acetiihulunj. When the instrnnierrl i^ thnw arljuHted, the 
handles will be directed deeidedly toward that tbigb eor re- 
sponding with the aeetabidoni at whieh the oeeijjut i?^ placed* 
(8ee Fig. 174.) Before or during the hn?t traetion etiurtij the 
occiput k made to rotate to tht* pul^e^^ by gently directing the 
hatnlle,*^ to the median line of the inter-femoniLspaee. This 
mode of o|)eratinir, while more jM'ientitie and dej^inible than 
the other, requires^, in mo?it teases, a special .skill, and from ilij 
ditfieiih exeention is not resurled to us often as the skimpier 
method fixvt above given. 

In doitig ilie o|>e ration the thiirha must be fortnbly flexeci 
to get them ont of the way of the handles of the instrument. 

When the rM'ei|nit is to /eff afetabnhiin a|>ply hwer blade 
fir^t ahmg left Hacro-iliae syiiehondrosis ; then sei'ond blade 
behind right aeetabnlnin. 

When nrriput is to f'itfht aeetabuhim it is l>est to apjdy the 
npfjtr bhide Hrst, alortg right saero-iliae syneliondro^i^i, and 
holding Its bantlle tip and on one side, out of the way, put in 
seeond Idude undi*riieatb il, behind h'ft arotjibnluriL 

Applicatioii of Forceps at Inferior Strait when tlie Occiput 
is Toward One of the Sacroiliac Synchondroses. — This is still 
more difheult than in unrotated a/i^e'nor jiot^ilions, but the two 
nifwie^ of opc*rating just mentioned — vix. : placing the blades 
either on the sides of the hcitti or on the sides of the prlvis — 
may be employed. 

Every effort should be made t(» rotate the t)ceipnt h> (he 
pnbe* ; failing in this, there is nothing left hnl ti> rotate it to the 
sacrum and ileliver it in atvord with tlie nn-ehaniftm of oceipitiK 
posterior jio^itions. (See page 2 'J 2, ) 

There ia, however, an entirely different way of using the 



APPLICATION AT THE INFERIOR STEAIT. 365 



forceps in these cases. Note that in all the inethmis of appli- 
f'ution thtis far clescnhn], the lihules ha%e iM'eu put on t<o that 
t\w ocvipititl pole of the heat I wild diret'te*! toward tbt' htt^k of 
the iiistruiiieiit. In tho nielhcxJ now to be *le^-Til>eil the 
Ijliitles are so \\\ii on that tlie fureht^ad is ilirfete<l tv»wanl tlie 
hek, Tlien the harKHt^ are ilirerteil bavkwanU 4*arryiog the 
forehead in a poderior direction, which of ue<'e^sitj carries the 
ureiput forward, a lid lla aiiteriur rotation is aecoriiplished. 
But when thi^s has Ui^n done the foreejis will iit^ npside rlovm ; 
the convexity of tht^ [leivic curve will be in front toward the 
]>Ld>ei!i, The blades must, therefore. Ih* taken out and re- 
ajijdied, as in an auti^rior jM>sitiou of the occiput winch iiaa 
been now produced, Ti> illustrate: Sup[>ose the ^Hvipul is 
toward the rifjfU sacro-ilitic synchondrtJ^is (by far tlie most 
cummon of the two occipitti-iMistenor |i<»sitions), the forehead 
wilK of eoUTi^e^ be at the %y a<'etabuUnn. Tht^ \ei\ (lower) 
blade, held in the left baud and guided by the rifi^ht hnnd» is 
|nus8e<i along the leil side of the vagina ti^ward the h4\ siidTO- 
ilitic synchondrosis until it gets over the chihFs ear. This 
blade is mnv held in [ihico l>y an aj^istant* while the second 
(iijjjXT) bhiile, held in the right hand and gnided by the left^ 
is passed ah>ng the riglil Hide tif the vagiua and manijai luted 
forward until it is at the right ttcetabuluui, over the chlhrs 
other ear. Then lock tlie bhnlt^s. Now the blades grasp the 
sides c>f the head, the forehfftd fjciug t<iward the lock of the 
ins^trument and the hamik^s |>ointing obli^joely upward toward 
the left acetiibuhnn. During traction etforts, just as s<M.ai as 
the head gets diiwn on the pelvic lliw>r, the handha art dtriTted 
(not forward toward the pubic syrupbysis as they Wutd<l he if 
the orrz/o/^ were toward the h>ck ) dnwriwanl and outward 
toward the sacrum, until |)ointing toward the left suern-iliac 
synchoudrosis, to which the forehead is thus rotated : and, of 
necessity, the otH*iput has l>een rotated to the right acetab- 
ulum ; it hns become an R, 0» A. position. The l<*rce|j8, 
by directing the handhi-s backward iustead of forward Jiave, 
t»f course, l>eeonie upside thiwu. They are easily taken off and 
rea[i[died intheuj^uid nianner alrejuly desiTibed for cases with 
'*the o4'ciput at one end of the acetabnla '* (page H63). 
This methmi is attributed to Scanzotn and is 8|]>oken of ag a 
"double** appliej^tion of forcej>s. J. Whitriflge Williniiig, 
whose wide exfierieuce entitles his opiuioii to great eonsiderti- 



366 ISSTRUMEyTAL DELIVERY, FORCEPS, ETC. 

tion, BtatexS tbiit delivery is so salely and readily aot*ouiplisbed 
hy I Ids nrt'lhod tlmt ln' nn limger drciids «XTi|»ittt- posterior 
l»rrs*^tituliniiH, Ilriiiv 1 Uiiw de-<<*rihod it with wHiie detail. 

Application of Porceps when the Head is in the Pelvic 
Cavity Between the Two Straits. — (Jeiicral melliod.n the same 

Fig, 175, 




Laik*t modification r»f Tifcniier's f^»rt«fpi. 



as alrt'ady ilescriUd. Thc^ inslnimetit rofpdrri* to Iw* pnsBed 
furtlitr up ( hrnce ltm*r. tnirvt'd 1nn'i*[w ar<? iiecesftary ), aad 
i\w traction niust bt* inadi- umre in a Imrkward directit»n, in 
ciinformity with axe** t»f lii^dnT )darifn nf pelvic canal, by 



THE ''HIGH operation:' 



367 



directitig tlie lifimlles more decnltHlly down ward t^iward the 
|>erineum while pulHng uilorts are h^wv^ niade. 

In these caj?e!^, u>* in all otliert* wlitTe I In? head nuiy not have 
|>as.seil entirely through the os uteri, tlu- tint^^ers that prei'tMle 
the iQlroductioD of the blades i^hould feel that tlie en<ls^ of 
the instrument certain hj \nim Iwtweeu the \wi\\\ and the lip 
of the OH, and not tmU^ide the hitter so ad U» piuch it Ix'tween 
the head ami blade. 



Fio, m. 




Slmpson^s nxts-trifcction forcepa. 

T!u» "High Operation " — at or Above the Superior Strait. 
•^It 19 very dirticuk. In many instances fxidalie versinn is 
^fmfer and easier if the cootiiiifait* favorable for it \\e j)res4^sjt. 
When the head Inis nr)t suffieiently desr*ended to fix it in the 
brim, but remains movalde alM»ve the siiprir>r strait, version 
is nsnally preferable. The foreejis is ititroduced in the nsnal 
manner, but, of course, hiirher up. so that even the loc^k may 
enter the vulva. The I^hidfs follow the ituh^s of the pdvi\ 
tio matter what ** posinon *' the head may m'cupy, heuce they 



368 INSTRUMEXTAL DEUVEHW FORCEPS, BTC. 



sp tbe latter oblirjtiely* autl there is great liability to 
flipping of the iiifilriiiHHJt^ and danger of the tiiM? of the 



Fn-, 177, 




Wiilchera i»ci&itJon. (FoTBltnoiLL.) 




DlAKrftTO to iihnw Incrpftirc In ronJupTate hi WalchcT'fi poiltlou. Th«' cltvtled 
JliH'h ^liim t>ulM>* ami conju^rrtte with tJit ItRii hani-tng *1own. Thr \Aixin Un»?t 
ihiiw ttit- Huitir » iu'Ti tlit.< Ipjgs arc HiipfKirtiMl. lu^tittkoh occurs about t Ik." (Ktlnt X. 



THE "HIGH operation:* 



369 



blades injuring the interior of the uterus. Traction must be 
made very slowly at first, and decidedly backward and down- 
ward in line with the axis of the plane of the superior strait, 
by keeping the handles as near the coccyx as possible. To 
facilitate this backward traction, Tarnier has constructed a 
special instrument (Fig. 175, page 366) with curved handles, 

Fig. 179. 




%J^ 



McFerran's forceps. 

perforated by a screw to hold the blades in contact with the 
child's head ; these handle.** steady the instrument and indi- 
cate the direction of traction ; the force of traction is applied 
to the lower handle, or cross-l)ar, attached to the traction rods 
fastened to the blade at b (Fig. 176). The direction in 
which axis-traction can be thus employed is well illustrated 

24 



370 INSTRITMENTAL DELIVERY, FORCEPS, ETC 

by the duUed Hue in Fig. 176, »howing 8iiniJ>8ou's nimlifi- 
catiou of TtiniierV iiistriiraciit. An ht»ur may be retiuirtd 
t*j liriiijij^ tlie ht'iitl dowu U} the j>elvic HtKir, and care mu«t l>e 
tiikt'ti to direct it in iiworduDce with the natural uuK'haniam 



Fig. \m. 



Fir.. IM, 




Stcphctii^n'e mrthwi of 
AxU trnotton. 



BreasU ajtls^trariton fiirrvps. 



of labor m far as prneticalile ; and also that the tnirtion 
€0118181 of alternate pulls wud jiau£«ed» lu iinrtatiou of uatural 
Inlmr paiti^. 



THE '' lUiUi operation:' 



371 



Recently Wnlch^rs ptmtlon (see Fig. 177) has beeu used 
in lhes?o diftifiilt eiwes to itirreui'i-^ tlit^ cuiyugute diiinieter of 
dio sujjt'riur strait. Tlic woitiuii is pluL-ed on her hack with 
her hi^»* not situply '//> hul ]>ruJLH.'titig otrr, tlie tnlgtMif thu heJ» 
her le^'s huD;xiu^^ tlovvii tuwanj tlic tloor without any au|j|M:»rt 
whatever. The bed — prefenil»ly a tahle — niyst \\e suiheiently 
hit^h to prevent the womnii*8 feet touching the Hnor* This 
sHj^htlj lengthens the distance between the siierid |>runiontory 
and gyniphyi^is pubis, as nhowii in F\g. 178, j)age litJB. 

FlO. l«2. 




Traction with &iini«ojf 5 lorccpa. 



When the head reaches the inferior strait the lower lirabs 
must he Bup|X)rted and tlexed as nsnah Wliile Waleliers 
posture IpHtjtlims the eonjiij^^ate of t!ie infeU it frsants that of 
the ontlA. 

Far securinf* axi§-traction various inodifications of the 



372 INSTRUMENTAL DEUVEHY, FORCEPS, ETC 

forcejjs hiive l^eell coutrived, notulily tfiat of IMcFerniu of 
Phihulel|)lnri (Fig 170), and Breus*s axis-tmctiou iu^trunient 
(Fiir. IHl). 

iStepliLiiH^jn, tj( Altenletni, u^^ea ii steel rod litxiked in front 
of the lock, lis siiowti in Fig. 180. 

ri«. 188. 




Tmcthm with *xb'tf*cUoii lbr(^epi. 



A Still better device iss tlie traction rods of R<^ynold« 
— two &e|mnite stw^l riAn hf^iked iiifa the fene^itne of the 
blades after tlieir iutnHliK'tiuii. tlie oilier cndhi being curved 
nnmd the perineum and fa^iteiietl In a wditi transver^ haiidle 
for axi^-tractiuii. 

Tbt; nietbrniH of making tniction with ordinary forceps md 



DANQEIIS OF FORCEPS OPERATION, 



373 



with axis-traction instrumtnit« iire well seen in Figs. 182| 183, 
1«4, ptge8 \M% 372, luni ^i73. 

If the hejifl be ulto^^elber ahove the i»upcnor strait, niid 
movahlv — *. f.. uot ycl tixed in its |Mj^itioii liy any luirtial 
eii^'agemeiU at the briai — versiuu should ceriaudy be prelerred 
to forceps. 




AxiS'iractlon with ordiiiAry fort'cf* Iteml iit «nT*erlar KtmU, 

Bangers of Forceps Operatlpn.— f 4iceration ami bniisiii|y 
of the uterus, vagiua, and f)erineum ; the vat^imil injurit^ 
sometime-s involving rectum. Jdadder, and urethra, thus lead- 
ing to ^ubs»e4]yent ulceration and fistula? ; ruiilure or injury to 
veins and subsequent pbiebitis ; pcissiblj fracture of p<dvie 
bn^nes and separation «»f jx'l vie joints when g^reat force is em- 
ployed, I>an*rcrs to the child are: abrasion, contusion, and 
laceration t>f the t*kin ; depression or fmcture of cranial hones ; 
laceration of bloudves^^cl^ and consei|uent sulicutaneous hema- 
toma : tempi*rary facial palsy from injury to farinl nerves. 



374 IXi^THUMENTAL DELIVERY, FORCEPS, ETC, 

Though no lesion may be iipparent externally, the rhiitFa 
braiti mixy have Ihm^u iiijureih and idiocy or Qtli<?r fbrrn of 
meuliil disease reaull in cunst^|yence. 

The protinosifi in fcjrrejis cusea hirgely dejmnds upon the 

eonditinns prtveditig and requinug their ii|>pliriiti(iu, and 

upon the cure and skill of the o[K*mtor. It in, oi' course* ruore 

fav<»rahle* other things equal, in pro|M)rtiun tis the head i» low 

in the i>elvi&. 

Via, Ibo, 




FoTct'pN In ruif pri'sentalion wt outlet. 

Forceps ill Face Presentations. — When tlie fare 18 at the 
inferior wlrait and the <'hin has* roLited tt» the ptd*es the o|K^r* 
ation is eany and almost identieal with that <leseTilK*Vl for head 
cases with the oceijjut to pnhie symphysis. The hinder are 
ap]»lied on eaeh si<!e, and^ af\er traction hna hroiiirht the tip 
of the cldn well out under the pnbte arch, tlie hanillet* are 
direeteil up over the moufi veneris, to proniiite delivery by 
flexi«»n. Care must lie taken to pnstg the hladi^ far hack so 
that their terminal en*ls fit round the m-cipital end of the head, 
instead of diffgintj into it, when the Imntlh's are e<nnprei<iiixi. 
(See Fi;,'. l^fM 

When the chin is toward one of the aeet^bida at the lower 
§trajt the same rules may be applied as for correspondintr un- 
rotatetJ anterior positions of the m*c'ipnt. In faee cai+es, how* 



FORCEPS TO THE AFTER COMING HEAD. 375 

ever* the chin h apt to he .Hmiievvhat behinti the acetahuluni, 
nearer ihe centre nl' the iHurii, the iiu*e and head uiyre directly 
transverse in the pelvis thun ocinirs in vertex presentation. 
In th&He the blades cannot well Iw applied to the sides of the 
pt'iri,^ hut iihouhl lie pas^scil, one aloiii^ the fiacro-iliac junction 
and the otht!T Jiear the opposite acelahidnm, i?o as to grasp the 
mdcA f>y tfir haift atid rotation mud ocenr, either s|»t>iitane- 
oiinly or by the aid impartetl by the hJades, before traciiQn can 
do uny (jooiL 

FlO, 186. 




Fof««pi applied to iiftcr-coming bead wben occiput h(i« mtau-a tu pnhea. 

When the chin has rotated to the mtcritm, delivery by 
force|»H IB int'chanically inipossihle (see ** ^Icchaidsni of Face 
Cai^s,'' [Kijiv 'AOri) if the ftetns and judvis «rc of noririal size. 
When the fa<*e is at the superior drati^ or hi^^h up in the pelvic 
cavity, ami ('irfuinstanceJ* rvqaire dtltvrnf to be haMmtdt ver- 
nioii must be preferred to tbrce^iB. And when verHion cannot 
be acin>rnplished. the only remaining resorts are craniotomy 
and (*;csiirean t<cction. 

Forceps to the After- comiBg Head in Breech Gaaes, — 
When the Hcveral manipuhitionts already describeil (8ee [lages 



376 INSTRUMENTAL DEUVKEY, FORCEPS, ETC, 



32B-329) for delivery in tbe^ causes fail, forceps mtiy lie 
tried. 

Ill the niore cominoti easew m which occiput has rotiited to 
pulx??; and forehead to siicruiii, the Inidy tif the child i** lifted 
up towsird the nmiis vent^ri:*, and the hhides? rtre applie*! one 
L»ri each sidv; uf the liead, as hefto't' dewTihc<t, the handles 
i>ciiig tinst dc]5re^8e<l toward the [>t:riiHHim» ef?|RH'jriIly wht?ii the 
bead iM bitj^h up, but iiuide to tnllow the body toward ibe luons 
venerii*, a^* the chiii^ fa<*c. iiud forehead buccesbively enierg© 
over the coccyx. (8ceFi^'. IHB.) 

Wben the occiput ha.^ rotated to the saeruiu. the direetion in 
which the child's body m hehi duriiig the ur* of the instrutneiit 
will de|)eiifl uptm wlietber the chin i.s cangfit afmiY or dipping 
befow tile pubic arch. In the former ( and rarer) cajic, the 
body is btiefl toward the |nrlH^, wiiiie tl»e forcejia arc paj^sed 
in to the iH'ci[itit, which in drawn nut fird alon^j the siicruni 
to the [K^riiieuni (**eontinued extens^ion '* ), the handles iK'ing 
lifted tovsnrd the child's back as the bead is l>oriK (8ee Fig, 
141» |>age :ri3.) 

In the latter ease ("continued flexion'') when the chin is 
beloit^ the pulies^ the IkmU' must lie depre^s^ed toward the peri- 
neum, while the blades, havitig beer* npidie<l to tlic M<k'^ of the 
heiuL the ha miles j ai* tlie chin, face, and forehead eoine out 
under the pubic arch) are depresse^l t^oward the child's abdo- 
men. (See Fi":. 140, luige •V22.) 

The application of forcejif when the after*coniin;r bead is 
arrested at the sxtpennr Htrattt is a diffinilt operation, and 
nninoai pres^sure frmn alK>ve, conjoinetl with every tither meaois 
sUiteil under tlie ** Treatment of Br«^'h ('ase,s'* ([lajje 32l>)» 
ghonhl lie taithfully tried lieforentlemptiny; their intnMlnetion, 
Their nse, however, is to take precedence of craniotomy in 
any ca4*e where thii? \» likely to Ijecome necessary, especially 
if the child Ije still alive. 



CHAPTER XIX. 

VERSION OR TURNING. 

Version is an operation by which some part of the child 
other than that originally presenting is brought to the superior 
strait When the head is brought down, it is ** cephalic" 
version; when the /ee^ "jMxlalic." 

When a face or brow presentation is changed by flexion 
into a head presentation, it is spoken of as ** version by the 
vertex." 

The cases in which version may l)e required are : transverse 
presentations; sometimes in head, face, and breech presenta- 
tions ; certain cases of moderately contracted j^elvis ; and in 
cases where accidental circunistances reiider rapid delivery 
necessary, such as placenta pnevia. rupture of the uterus, 
prolapsus of funis, convulsions, tedious lal>or, etc., provi<led 
delivery by forcej^s is not safe or practicable. 

The operation is contra-indicated in oases where the pelvis is 
too small to admit delivery without mutilation after it is 
done ; also when the presenting part (other than the arm, of 
course) has so far passe<l throuirh the os uteri that it cannot 
be returned ; an<l in cases with thinning and distention of the 
lower uterine segment, and rising of the retraction ring of 
Bandl two inches or more above the pubes, when version would 
almost certainly cause rupture of the uterus. 

Choice Between Cephalic and Podalic Version. — When 
correction of a malpresentation is all that is required, and cir- 
cumstances do 7wf. render subsecjuent immediate delivery 
necessary, perform cephalic version. When ni|)id delivery is 
necessary, jxKlalic — bring down feet, that traction may be made 
and delivery completed at once. 

Methods of Operating. — Each of th(» two operations (1) 
cephalic and (2) podalic version, may be i)erf()rmed in three 
ways : 1. By external abdominal manipulation. 2. By com- 

377 



378 



VERSION OR TURNING. 



hined external and internal nnirupulatioii. the fingers ontif 
going into the m uteri. 3. By hitenial iiiuDipulation, the 
u'lioh' lift fid pn,sj*ing into the uterine atvifif. 

AitfiMt'jdic Prf'imraiiottM, — liefore anjf verj^ion ojieratliHi the 
alxlHmt'n, ibiglis, an*l external ^'enitiil& tif tite wunnui, together 
with tht' han*Ls anU arin.^ of the ojjenitor, ninKt l>e made a>iepti- 
rally elejia (as alreafly t'X|ilainc'il, i'hiiptrr X 11,, page 2^0); 
ami wln-n th*^ tiiigi-rs or haml are to filter the titerug, the vaffhia 
and cerrix idcrl must he JirM thoroughly Siterilizrd with the 
*2 [jer eeut. ere^^lin mihitiou^ or the 1 :4()(l0 raemirie hirhloride 
.solution* When the ojieration ]:s done, and the third stage of 
hilnjr rompk'tt'd, the utcrtts ami vagina iniis«t Iw wa^^hed uut 
w i t h the e reo 1 i ii so 1 u tion. 



VEESION BY EXTERNAL MANIPULATION, 

Chiftly employed for eorrecting transvers^e pri\HL>ntati«in9, 
either hefore lahor hegids or lahor having hegiin» lielbre the 
waters have l>een di.s^diargefh or a*^ sit^hi thereafter aH ]H»js«iijle, 
while the t-hild is easily aiovahle and hat? not lieeonie Hxed hy 
engagement of the presientiug part in the pelvic Unuu It 
may i\\^y he done in hreeeh rase^s ; changing the lireeeli into 
a liead |>n'f*entatioti. Tlie nn^thod oY changing a face pre**eii- 
tation into one of the head hy external manipulation has 
already been dei^crilved under ** Face Pre8entations/* 

Operations in Transverse Presentations. — Haviog previ- 
out*ly rna<le out the exiu't [josition {}i the chikl (head in one 
iliac fo?<sa, breech in oppi^ite flank), phice the woman on her 
hnek, with the lower lindis s^lraight mit and. feet slightly ajiart ; 
uru'over the ahdonieti, and stand facing the woman — ivhile the 
hantls- — f>ne on the eiiild*:* head, the other on it8 hreeeh — make 
Hfrudy pre>«*ure with a slroking, gliding nioiiun» in a <hrectioti 
to lurn the head down ttiward the hrim ami hreeeh u|» toward 
liie fundus yteri. For examjile: In thedon-o-anterior /m^/fiVm 
of a right-shoulder /ir#*^/'«^f//o« (see Fig. 152» |>age 341), the 
right hand will grasp the head in tlic lef\ iliac fossa, and 
g^*ntly pres^ it down tnward the pulnvs while the left hand 
laid (hit u]>on the other ?*iih* *tf (lie alnlomen, with the finger- 
end;^ fM>inting toward the fundus uteri/ will push the l>retH'h 
ohliijut'ly iipHortl nm\ toward the nie/lian line. During a pain 
stop manipulating, hohiing the child just firndy enuugli t<) 



OPERATION IN HEAD PEESENTATIONS, 



379 



retain any degree of change in its position already gained. 
Pressure in the intervals. When the child A\\i^ round into 
its right position rupture the membranes ( if hibur have l>egun )» 
that the wotnb rnay contract x\i\d keep it there* If labor have 
md l^ie^uii, 1*1 ace two pad.< — otic ou the side of the uleruB high 
up again??t the hrreeh, the other on the opposite side lower 
«h*wn, against the head^ — and retain them with an abtlominal 
bandage \ or press down the lieaii and htild it in ihe |xdvic 
brim by abdominal manipulation until it liecome tixed l>y 
enjjagement at the 3U|>erior strait, and thus maintains its new 
and eorrei't i>osition. 

In thus bringing the head into the pelvis* cephalic version 
18 aceom pi is 1 » ed. S b o u K 1 t here lie any coe x i st i ng n evc^] ty fo r 
speedy delivery, podafir version should be done instead by 
pressing the heail uf) intu the fundus and the breech down 
into the jielvie brim. 

Operation im Breecli Presentations.^ — Tlie womar* having 
been [»laced in (josition a^ bifore de,^cribed, the ojK^rator stands 
on that side of her toward which the child's alMbjinen is 
directed] ; for example, the child's back being toward her right 
side, he stands on her left. His right hand ii^ placed on the 
fundus uteri and the head firesscd tatendly aud down towanl 
tlie left iliac foswsu, while the lefl hand» placi'd transversely 
alH>ve the pnbes ( linger-cnds (K)intinL' to her right), push the 
b reec h I a tc ra 1 1 y t o vs a rd t h e r i g h t iliac i\ wnsa , T he e h i h P s li o( 1 y 
having been thus made to bffjfti the de8ired change, the pre^ 
sure is continued, right hand pressing head down inh» the 
|)elvie inlet, lefl one pushing breech upward into fundus uteri, 
BhoubJ the beginninL^ of the change bedifheult to aecoai|dish, 
owing to the breech dipj>irig a little into the pelvic brin^ i>ne 
or two fiugers may be |tasse<l into tlit^ vagina, arid tlie breech 
lifted above the brim, while the other hand makes pressure on 
the bea<i externally. As a t{\U\ the pressure U|Hm tlie lireech 
V!\\\ be more ethcient than that npm the head. Tlieof>era- 
tion is caster in nndtiparie than in priinipane. After sm^eral 
successive failures to turn the child, the o}>eration shouhj be 
abandoued» 

Operation in Head Presentations.— Cimnging a head prea- 
entatiou into a brce^'h by external maiiipnlatiou, comprises 
the same nietbods (reversed } as thoi^e just described for chang- 
fing the breech into a head presentation. 



380 



VEESIOy OB TURNING. 



Version by Combined Majupulation. — When versioo by 
external in}uii[iylatioii i.s Tit'('f?v^urily im[>ossil»lL% or has failed 
after triuU the stHuinl ieiL^t <lunLri*r<ius ujeLlKHl, l»y combined 
pmuijHilutiotij siiunld he tritML I'hij^ ('nuyigi.s of Tiianipulating 
ouLside with oue band wliih^ I he other id passed into the 



Fw. M7. 




Bipolar venlon (UnlitcpK 



mt^na, two or three of ita fingers only ^joini: into the ntentg. 
Tile hand outside puslies do\Mi the part it i.^ de^ire<I to bring 
ta the superior strait, wfule the fingers ini^ide sifiiultaneoudj 
move the f>art at the on out of the way and upward along the 



OPERATION OF nWOLAfl VERSION. 381 

opposite side nf the pelvis. Thus, in ht'od pre»entai.ioiu^ v;hea 

it is dt*siro<l to brin^ down the I'eet, the o[)eratioii eompri^s 

tbree step^ : 

Operation of Bipolar Version in Head Presentations. — 1. 

The hu^er^i itJ8ide lift tiir head Uiward thai i Hue fuissii toward 

whicli the <xM.^iput ixnnt^, while the Jiaiid milside depresses the 

breeeh along the oppjsite siileof the wuiuh (Fig. 187). This 

having l>e€n done — 

Fig. 18a. 




Bipolar venton (sceoud step). 

2. The fingers inside can now touch the sbouUler, and they 
push or Hit It m the name direelion as the head, while the 
hand outside elill further de]>rei!k>e.H tlie breech (Fig. 188), 
The liead is now a little hi^dier above the briui than the 
breeeli, and ihe knee is within reach of the fingers, 

3. ltras|» the knee r tlie iriemViranes, if niiliroken* may be 
raptyre<l) and pull it down, while the hand outside chartifes 



X^ERSION OR TUBNING, 

Ua position 8o aa tti puj^h up (hr fw*tt! Umnrd the fuiulii5 (Fig- 
18^^). The foot may tiow l>e reach eil and the ca^ mjiiiage<l 

a hreech or fotitliij^ presc^nUition. 

In transr€rf<€ presentation i< the o|>enition (jiim|*nst'S I he second 
and third step alx>ve jriven for hend easels — that is, jiiis?h the 
shouliier after the head, then ^m^y the kuee, ete. Shnuld it 
he deiJirecl, however^ to eoinert the shoulder (traiinverse) pnv 
seutation into a head presentation instead of a lbi*tJing, the 

Fig, 189 




Bipolar renfon (tlilrd it«p). The eTtem&l h&tid. as shown In the flsrurc, hat 
not yet chuniretl Ilm itosillun. but \a n*a4y lo di> ao. 

finders iuside wilh uf course, push the shoiihleriti the direetiim 
of, and after the brtrcK while the hand onti?ide depresurA the 
head t oward t h e (>e 1 v ic h ri in . 

Bipolar Version in Face Presentations.— <>|icratiou i? essen- 
tially tlie same its tjreviouaiy dt8eril»ed fur liead presentation. 



ViCRStON BV INTERNAL MANIPULATION, 383 

The fingers iosiile iliiriu^' ihe Hrst f*tep pusli the face toward 
fhtttsi<Ie of the [K*lvis i>]>i>i)sile llie ibiti^^ e.» they lift it ou to 
that iliuc fossu towanl uliicli ihe fonthrad h ilirecletL 

Value of Bipolar VersioE.— ft skmhl \w |mrtieularly ol*- 
servetl that the main imrpmt of tliis t-nuiliiiR'ti or *'ljipolar" 
ijiethod istof^ii|>erst^<h' the more dmi^erouj* pn>cetHliiig ot' ifiiro- 
ducing the whole hand and [mrtof the tureanii iiitM thf uterus, 
\\hich is the only mode ot* ver^i«>n remaining when the exter- 
nal and l)i(Mdar methods have heen unsuecej^sful. The hipdar 
niethod can \^ «lone lielbre the 08 uteri U sufficiemly dilated 
f.to admit the wlnde liaud. 



VZBSION BY INTERNAL MANIPULATION. 

Like all the version operatiuiis» thin is emnparatively easy 
before the waters have es^t^aj^t^d and when tlie oteni^ is not 
tjrigidly contracted rtmntl the childp hut diflieidt when i>|ii>i>site 
rconditJonsprevuiL Additional eonditiotii*, however, are neces- 
sary l>efore tlve ojjeratjori slionld he attemptetl, viz,, the jxdvis 
must l>e of sufficient j^ize to admit the hand ; the u« uteri must 
he dilateil or ililatalile ; the head (if it present) ii>u8t not have 
pisise<l through the os titeri, and the presenting part { whatever 
it may be) nuij^t i»ot have descended so low or beeijme m% 
firrrdy injpieted in the jielvis that it can not be j) unshed back 
alw^ve the superior strait without rii*k of hi ee rating the utero 
vajriiial junction or olher sott parts. 

Internal Version in Head PresentatioiiB*— The operation 
comprises three steps : 

1. Introduce the hand and grasp the feet* 

2. Turn the chihL 

3. Extract the child. 

The first hrn stcjw* *i^** *^* ^^ proceeded with only Itehvren 
the pains, the third slep only (inrinfj the pain?. When a 
pain rimies ondtiring the first two [mrts of the o|jerHtion, hold 
the hand still, relaxed^ arni Hat, and thus avoid risk of ruptur- 
ing uterine walls with the knutkles. 

Op*'raikm,—*The wonnui is jilaced on her Iwick, the bifis 
brought to the etlge of the bed, the legs properly siipjH>rted ; 
the operator nU Ivetween them on a h»w seat. If the womb 
lie firmly euntractevl and waters dist^harged, mmplek fXXHSB- 
thesm is re(|uired. 



VERSION OR tuhnlsg. 



Bare ilje arm to aliuve the elbow, and nnoitit it with car* 
holizt-d viuseline on all parts except the pulni of tbt* haod. Use 
the bund whoj*e paloi coiTesj>onds to the uhdomen of tire 
ebild» viz., in the L. O. A. and L. U. l\ (lositioiis. the left 
huud ; ill tlie K, O. A. aud K. O. 1\ positkitii!, the ri^^^ht hand. 

Fio. 19a 




PodAlJc venlon : gniAplnf the f^et 

The fiDger-end? are hroiiirht to a rone over I he end of the 
thumb, an<l the bund intrwlnced into the vagina (with m 
alight rotary movement, if ntH"ejy*ary ) in the axij* of the 
pelvic outlet, it« back towanl the saeruni. The tinger-eniis 
and hand are then pres^d on into the 06 utert, the elltow 
being deprej^^ed toward the fterineum so as to bring the hand 
in line witli the axis of the bnni» while the other hand rests 



INTEHyAL VERSION IN READ PBESENTATWNS, 385 

outflifle, makiiij; support and cuuuter-pr insure ii|K>n the 
fundus. 

With the thumb Ij^twetai the heat! and pulics, und the four 
fint^ers betwet^ii the head and saerum, the liead is grasped aud 
lifted out of tlie way, '* on ihe shelf of that iliac fossa 
U)ward which the owiput poiul>?. The wri^^t restUig ugaiust 




PcmIjiIIc verelon ! turnlnE the ehlUI. 

the forehead keeps? it there, while the hand goes on up to grasp 
the fe€»t, the other hand continuously sup|x>rtiiig the fundua 
(eee Fig. 1^0). 

The feet (one, or both if possible) are then drawn down, 
while the other hand depressor the breech, which begins the 
25 



386 



VERSION OR TURNING, 



$€mnd step, or turfung the cliiltl (^e Fig. 191), As it gets 
partly rouinl, the liarnl uut^jile laay chuui^e its ]H>tiitioii to piLsh 
yji the iK^ad. The Uuttr baviug reached the t'yiidiis* tiiniiog 
is iR'roitipiished, and ( the /A/rf/ step) txtraHion {dnrnuj the 
piuufi ) Jiisiy Im^ completed^ tojlovving the me<diaiiisui and nnxle 
of deli very already descril>ed for breech eaaea. 



Fi.,. V,TL 




ght band frmsplng feet \\\ rtpht shotiklcr (nnn^ prefcntAtlon. <1oncv4ntciior 
pitfiltlou. (t*AVi>, ntter FARAHoErr ivixl V^itNiKK.) 

Rhould the menibraiuf^ he iirdiruken at the he^inniu^ of the 
operatinn they shrmld he rupture*! when I he Imiid |>a.s8es liy 
the head itilu I he uterus the wrif^t artinjjr ^^ a plu^-" iu the ds 
to prevent es^cttjie of waten* ; or the hand may he pai^i^ed up 
heitvteti iho uuhrokeii membranes and uterine walh the hag 



VERSION BV IXTEnNAL MAMPULATWK 387 

being ruptured when the feet are felt. The hitt/cr iiiethfKl m 
objtM'tiiiuahle frutii risk of looseuiii^^ pluceuta, unleiss the 
aperatur be i^kiliiil. 

Fir. 19:t. 




l^ioit hiind gmEpinf^ feet hi left shoulder mnn) presM^ntatlon, aorso-uDtenor 
poKition. (l)Avt£i| ultcr FAEABOEttF and VAJtMEii.) 



Version by Internal Manipulation in Transverse Presenta- 
tions* — This proceetliiig oom|»rises the t^aiiie three j?teps as 
jtmt rlefifriber] tbr hen (I ea^es* jiikI the snme general rules of 
0|>eratiiJ^% with nioflifinttions im»\v to he noted, lu selecting 
the lianfl (the woman lying upon her back )» use the right 
hand when the right side (shoulder, etc.) presentii, and the 
left for the lett side. 



388 VERSION OR TURNING. 

Where to Find the Feet.^ — In the right shouUier or arm 
*' pre^eiitatiou/' when the " jiosition " is dnT^'H-ftnleruir {fcj'i 
ceplialo-ilkc), it h evideul the feet will be fouDd toward the 

Fia, 194. 



Right hftnd gnksplns feet in rlgbt shoulder preg«ntJttion. dorso-poelerior 
pmtiiioa. (Davis, niter FAjtAaoEUF ftud Varj^ixk.) 

rifjfU and poderior part of the womh, above the rit^hi §acra- 

iliac ifyn/^kondrosif, hence efl«ily reached hy jmaeiu^ the right 
baud aJoiig the hollow of thtj aaeruui, to the right of its 



WHERE TO FIND THE FEET. 389 

promontory, and then higher, toward the posterior part of the 
right iliac fossa. (See Fig. 192.) 

In the left shoulder or arm presentation, when the position 
is dorso-aTi^erior (right cephalo-iliac), it is evident the feet 
will be toward and above the left sacro-iliac synchondrosis, 
hence easily reached by passing the left hand on the left side 
of sacral promontory, etc. (See Fig. 193.) 

These dorso-anterior positions are far more frequent than 
dono-poderior ones. 

In the dorm-posterior (right cephalo-iliac) ** position " of a 
right shoulder or arm "presentation," the feet will rest toward 
the left and anterior part of the uterus above the left acetabu- 
lum. The right hand, therefore, should be passed along the 
sacrum as before, but to the left side of its promontory, and 
then higher up toward the posterior part of the left iliac fossa 
(where it feels the back of the child's breech), and must then 
be pronated round the breech, over the thighs, toward the 
anterior part of the left iliac fossa, where the feet will be 
found. (Fig. 194.) 

In dono-posterior (left cephalo-iliac) position of a left 
shoulder presentation the feet will rest toward the right 
anterior part of the uterus above the right acetabulum, and 
will be reached by the left hand going behind and pronating 
round the breech as before described. 

There is another mode of reaching the feet in the two 
dorso-posterior positions, viz., by passing the hand directly up 
to the feet l)ehind the pubes and acetabulum, instead of going 
behind the child's breech and pronating round it. This 
method is made easier by placing the woman on her side (the 
side toward which the feet are directed), while the operator, 
standing behind her, passes the hand (right one for right lateral 
" presentation," and left one for left, as before stated), with its 
back toward the pubes and acetabulum, directly to the feet 
This is shown in Fig. 195, in which, however, the right hand 
is represented as being used instead of the left as above des- 
cribed. We therefore assume that in the figure the woman 
is lying upm her left side (upon the side toward which the 
child's head is directed) instead of upon that side toward 
which the feet are. In this {)osture the right hand is prefer- 
able ; if she lay on the other side it would \k the left hand, 
as stated in the text. 



390 vj-JHSioy on turninq. 

Which Foot to PhH Down, — From theiofretjueiRTof trana- 
vense premutations, only conijmratively fVw ojieratorg buve a 
siiliicient uuiiilier uf vasvi^ to form u lute ralci* biisetl uu their 
owti ex[MLTieii('t% luul tfi<(?^e uho havr-y do not a<;rree ; .^onio pre- 
fer oiiti im^l, Mime the oiIut* amJ liinl tlu-orelitai reji^uus; for 
their choice. !Nu fixed r»le8 eau lie .stated ; much de|ieuds 

Fio. 196, 




l>i I of rcfichlng feet in dorM>pf«iofloT ciacn. (Havui, liiter Tara* 

null Fun il VAKNtjn) 

on the coiiditionB present in each casH' — whether diilicult or 
e4L«y, whether early or hite, whether with *>r without sK>me 
preissiiig neeessity for hiiste — and a great deal de|;xn)df? ujx>n 
the aetjuired Hkill of the ojierator. 

It 1^ perha[>s hej^t to cet httth feet if thi;* ean readily be 
done ; if not fret one. and in iIiHicuh ejist*M with previous delay, 
discharge of the liqtif»r amnii, riiiid uterine eontraction, dangers 
from hemorrhage, iiiijieudiug rupture, or some other pre^^ing 



DIFFlCUI/nES OF VERSION, 



emerpfpiicy it im j^rftjqis belter tn *jft the firM ottf tjnn ran find^ 
aiJti ihus avoid rinkii of •j<.4ay luiJ jirulon^^eil nuiui])idiiti(ni in 
makin;^ u s^elertioiu In ea,^y, early ra.'^t's^ eitlier foot will tin; 
but a skilieil ojK»ratur wtnild prtdV^r to seize l lie oiiiMlijij^^otially 
opjKw^ite the pn'i<ontitig arm orshouldtT— 1\ e,, if tbf n^dil arm 
present* seize the left fintt, and vice verm: this nmkt^ turning 
easier 

Should there l»e no rliificulty in turninfjy there h a decided 
advantage diiriuL^ extraelion lu i?eitHlin|> the other fimt, *', *„ 
the anterior foot, the one l>eloiiging to the same *«icle as the 
presenting arm ; this dire^^ti* the eh i Id's IkhJv more in line 
with the axi.H of the [)elvis jind prevents the upp)8ite liip 
eatching on the |)elvie hrim in fn»nt- 

In tnin-sverse pre*»entatiotLs when the child ban hern //*r»(V?, 
the case may be li-ft to nature, unless eireumstum'e** render 
rapid ilelivery neeeAsary, when the third step of extrudiun 
may he performeil. If it \^ to be let\ alone, only ouf' foot 
.should be brottght down, ki^ that the buttoek of the other side 
mny add to the ?fixe of the l»reec'h and [o'oduce adeqniite ilila- 
tation of the oe, t*o as to |H'rmit ea-iy pa^ssage of the arter-<!onimg 
head. 

Ct'phafic version by infermif manipulation Ik not |>erformeri 
nowadays, owing to the cbrtieidty of grasping the globular 
bead and for oilier re;usons» though it was preferreil to ixwlalic 
version in former tiiiiea 

Prolapse of the Arm. ^ — A tajHMuay be put ufjon the arm 
by which an «i*sistaiit holds it extendetl in the vagina, while 
the operator's hand passes in to pt^rform iutenntl version ; 
but it must not 1k^ hehl liy the ta|»e so tightly as to interfere 
with its njiward recesjiion when t lie feet are lieing dnnvn il<nvn. 
Traction on the ta|w may also he used to deliver the arm and 
prevent its ascemling alongside of the head during extraction 
of thi-^ body. In performing hipoiar version the arm may 
sotnetimesj be m&l to advantage in puAhivfj the Ahoulder in 
the direction of the head, ns bet^ire explained. 

Difficulties of Version. — The external and combined 
inethoi Is of version, when they can l>e acc<»n»[ilishe<l at all, 
art^ done with coniptirattve ease, and only in the more favur- 
ilble cases, Tht\v would scnircely be attempted and seldom 
flueeeed in the more <btHctdt cases now to be considert^d, a ml 
in idiicb even internal version is anything but easy. 



:i\)2 



VEMSION on TUJiNiML 



The iiirj(Ft coniinon clitfirulty is fvaeuiUiuo of lln' wiU4*r8 and 
rifjifl eotiftactwn of the utentmiTouml thechilrL The inam|m- 
latioiis iricretu^e utf rine t^jwumn still more ; the operutor^ arm 
bewmiej^ (*rflni|MHl aod ii^aelesg imm pressure; tlie cliihl will 
iii^t tuni ; and there is great rii<k of uterine rupture if vink'iiee 
be eruphiyeiL 

Tnatmt ni: Compleie aiiJi?8thesia to rehix the womh, anri 
steady, gentle^ perseverh**^' efiort** on the part fif thk' o^x-rator. 
Should the openitors linud beeonie nundTed utid ii^+ehj^s it 
must be witlitirawii ior reeii|K'riUioii, utkI re-bu rod need alh.T- 
wanl, or in its jda<v, tlie hand uf a t<ki!led ai*.sistaDt may Ite 
reported to. 

Eveu when the foot liaw been drawn down to tlie o^ uteri, 
the fihoiibler (or head^ iia the nxse may be) will riot rei*e<le, 
and turning sec^nii^ iinfM.>ssibIe. 

Treafmtitf : Fas^trn tt tajH' to the foot of sufficient length to 
lie held out<«icle the vulva, *tu whieh traetion may be made l»y 
an a?ii*isitant^ while (he hand inside jnii^bei! the la-ad I nr 
shoulder) in the pro|Kr dirertiom Make tlie traction — not 
straight down — but diagonally toward tluM»ppo8ite thigh ; this 
lifta the child's breech otf the brim and into the cavity of the 
pelvis. 

In shoulder c!a^^e8 further a«8i*f|anee may be rendered by 
txif'f'ii*tl ufiward pressure of the head. The internal repres- 
sion must l»e made with rxtnine eimtion, to avoid laceraticju, 
ete. By j^raspiug the arm near the elbow, the sliatt of the 
humerus trniy la* n!*td to make upward preasu re in the glenoid 
cavity of the nhcmlder, WIumi the presenting part, whatever 
it naiy Ut\ will not reeetle ^utficient to admit the obstetrician's 
hand, plaeing the wonuui in a gntu-peetoral pofilun> will be 
w-rvh*ealde. Ko ease pbouhl be ef>ni*idered imp<is«ible until 
this pfj»Jture has iH^eu tried. Again, by plaeing the woman in 
appiatting f»osture (provided there be noeontni-in«lieiilion lo it, 
as might occur frmu trreat exhaustion, etc, ). the pressure of 
her own thighs uiMm tin' abdomen may lift both wond) and 
child, and thn.* t^'oure rhe desired rtH'ession of the pre*H»iiting 
part. Should all cfforti* faih embryotomy liefomes the oidy 
re!4ort ; ctr if the ebihl l>c alive and tlie mother in good cod- 
ditiou for the o|>enition, s^vnipbyi^eotomy may be thaie, 

Al\er turning, extrartimi may be difficult. T met ion on the 
lower extremities should Ik? made slowly when the soil parta 



DIFFICULTIES OF VERSION. 393 

are not yet dilated. It is unnecessary to attempt to aid rota- 
tion of the hips ; the leg that is down will spontaneously come 
to the pubes. When hips begin to emerge elevate leg or legs 
toward pubes, that the posterior hip may escape first at the 
perineum. In grasping the child's body after delivery of the 
breech, grasp its pelvis, not the soft structures above, which 
might injure the viscera of the abdomen. The hips and the 
abdomen having been delivered, the arms come next 

Extraction of the Arms. — Delay with the arms (as with the 
aft^r-coming head) is fatal to the child often within ten or 
fifteen minutes ; hence different methods of extracting arm 
should, if necessary, be tried in ra{)id 8ucce«*sion. 

Arms Flexed. — Normally, arms remain flexed on chest, the 
elbows pointing down toward the breech. Here delivery is 
usually easy, thus : rotate body of child to bring one shoulder 
to pubes, the other to sacrum ; pass in the hand whose palm 
corresponds to the child's abdomen up to the chest, seize the 
forearm, as near the wrist as possible, and pull it down, the 
delivered portion of the child's body being meanwhile lifted 
up and tow^ard its back, thus giving more space for the ojier- 
ator's hand over the abdomen. Posterior arm to be delivered 
first. 

Arms Exte7ided. — In version cases when traction is made 
on breech, arms get displaced ; they catch against sides of 
pelvis and become extended, and point straight up alongside of 
the head. Often very difficult to deliver. 

Treatment : With one hand lift the legs and body, as far as 
possible, upward over the pul)es, and to one side ; this will aid 
the posterior shoulder to descend and give room for the ivhole 
hand of the operator to pass into the vagina along the back or 
side of the child, until two fingers reach the posterior shoulder, 
and then slide along the arm to the elbotVy which is pushed 
across the child's face and brought down over its chest. If the 
fingers cannot reach the elhoxv, place one of them lengthwise, 
on each side of the arm (where they act as splints to prevent 
fracture) and push humerus across face and chest, as before. 
(Fig. 196, page 394.) 

If this effort to deliver with the hand i^ssing in along the 
hack or side of child fail, withdraw the luind without delay, 
lift the child's body toward the opjwsite side (but still upward 
over pubes) and pass hand in along abdomen of child, until 



394 



VERSION OR TURNING, 



two finsrcrs reaeli elhovv antl liuuk it funvurd over fiirc and 
clie,st, as Ix^fore statt^i, Jf tioic* allow any fhoioot the hnnd 
blunilil Ik' passed m l>etweeji the jjaiiis. 

Tbe posterior arm hiiviug been dtdivertHl, the other — 
(lirei'ted anieriorli/ tovviird the jmbvs — must lie extracted, 
tlma : la some cane.s depress child's* body, as far as fx>!?sible, 
toward perineum and to one side, while the o]H:rators hand 
pas'Jtxs in, either along iMifk or afMlomen (try lH»tli ifotie fad J 
until rearhiri|^ r'/frnWy \vhi*rh is tirawri by two lingers aeross 
fatue and chaat ami brougbt out under pubeSw (Fig, 1£*7.) 




Delivery of potiteHor urm when exten<ie<V fJEwrrr. ntlvr A. R, flTMi'W^M.) 

Another pUtn : Instead of trying to extract anterior arm 
umier pnl»t^s, or having failed alter frinL rotate nn^leHvenMl 
arm to wiiTum, wliere there ii* more rtwmi, and deliver ai^ if it 
had been originally |M»!Sitcrior This rotation i^ areoniplished 
by seizing rele^ii*c*<l arm and drawing »t up along one side of 
the pelvis, from the saerum to the pnbes; the shoulder inside 



UIFFMTLTIES OF VEmiON. 



395 



follows the mnvt-aient imd ^'oes to the .stUTimi* when it i?> 
delivereil in the winie way, hut more eimiy tharj I he first one. 
t^hauMcrH Tmnnvtr.<e, — Instead of rotating into anten> 
jHJSterior diameter, shoulders sometimes remain tmusverse. 



Fj.,, 19: 




Delivery of nEitcrJar arm wbon extcndQd. (Jkwett, after A R. SiHTftON.) 

Treaimfnf : Grasp thonix in kilh haudH niui rotate one 
«hrinhler to iront» orit^ lo reiir, Fuiliujr in this, if l>a<^k 1x5 
towanl |*uhe»s lift hoily u|>ward and piK^ Jiarul along abdomen 
lo seize pHkjw, and bring it down aiTos^s faee, etL\ If back 
of child lie toward »acntvu the arms, if fir. red, may be drawn 
uut under pubea ; if rxtended, this will be difheuU or imfKjesi- 



396 



VERSION OR TURNINO. 



ble. Try, then, to pass hand back of child and draw elbow 
backward and downward along and below side wall of pelvis, 
then push forearm over thorax and draw it down. 



FIO.198. 



Fig. 199. 




Dorsal displacement of the arm. 

DorfKil dhplaccineni of the aniXy as shown in Fi^8. 198 and 
199, may occasionally complicate extraction. This may occur 
in two ways: The arm having lieen extended alongside of 
head, the elbow l)ecomes l)ent, throwing forearm behind neck, 
l>el()w (K'cipiit, where it catches upon brim of |)elvis and arrests 
progress. It is <'aused by rotating the chiUrs binly, the arm 
failing to follow this rotation, and is treated by rotating the 
childV IxKly in the opjwsite direction to the rotation that pro- 
duced the displacement 



DIFFICULTIES OF VERSION, 



397 



It may also occur from the same cause when the arms re- 
main flexed across the chest, and is theti relieved by passing 
in the hand along the hack of the child and grasping the 
elbow, which is pulled downward and forward; or simply hook 
a finger in the bend of the ellww and push or sweep it later- 
ally and forward over the child's face. In the aise shown in 
Fig. 198 the finger would thus sweep the elbow and forearm 
toward and over the right ear and side of the head, until it 
got them in front, over the face and chest. When it occurs 
with the hrm flexed, the scapula will be found near the spinal 
column ; when occurring with exteimon, the scapula will l>e 
forced away from spine ; hence diagnosis of methods to l)e 
used. 

In version cases, after extraction of the shoulders, the after- 
coming head is to be delivered by the methods already de- 
scribed under "Breech Presentation" (pages 826-337). 



CHAPTER XX. 

CUTTINC; OPERATIONS ON THE MOTFIER. 

The cutting: operntions on the mother are : Symjihyseotomy ; 
Csigarear) Se<:*tioii ; IWro's OfH-nitioii ; the Porro-Miiller Oper- 
ation ; Ci V 1 i otoii 1 y ; ^ Vii^W o-e I y t rii I o ruy . ^ 



SYMPHYSEOTOMY (SiaAULTIAN OFEEATION). 

Au oi>erutiou invented hy Sigaull for entargin^j^ thr pelvis 
by dividing the f^yinphysis pubis aud separating the pubic 
Ivones from earh other. It wa^ tiri?t firut'tis^^d on the living 
woman Uy Si«i^aull in 1777.- Siiiee that time the ojjeratioa 
has been rei^arded at different |ieric»dw with akeriialiug favor 
and o[)|Ki?<ition in European eounirie^ but was never i^erfonned 
in the rriite<l States nntil IK^2. In Septend^er of that year 
attention vvaf^ en I led anew to the good reitnllH obtiuned by im- 
ppived methcwls of <h>injr the ojwration under antisepsis by 
Koliert r, Harris of I'hihnlelphia, amlsuljsecjnently the utility 
of I he prw^eeding has been pra«*tieiilly demonstrated in this 
and other eounlries, ami ih now jrenerally reeof^^nizetl 

Wlien tlie ??ymphysiH is divided dnring hdM>r the pubic 
Imnei* i^pontaneonsly st*[mrate from eaeh oiher lo the extent 
of an ineh or more; they r»peu like a jiair of fohlinL'" ih>ori*, of 
which the wiero-ibae sy n eh ond roses rt^prestnit the hin^res ; by 
separating the woman's h>wer limbs the gap may be inereasetl 
to twa» two and a half, or even three inchen, but so wide a 
Beparntion as three inehen is not usually advii^able or neoes- 
8ary. Should either of the ^icroiliae joints (hinges) lie 
anehyhwied, and eonsecpiently immrivable, the o[)eration can- 
not Ik» done 8UCTes.sfully, ar»d is t^mtra-indieuted. Tlie ehiUi 

* Tlic lerm Copnotomyifrom KMUn, thcAtxIotiienk hnc been iKtcty i^iibxtlmi^d 

fiirT.npnr<t!nTtty ifhau iM^tani^Ww tlniik «>r htUIuwnf the* Wiil»in Common UMiiicv 

•till i nimlliir ttitMinlnir to lM>?b lormM. i'ti'lliHcuny \% ihi* mf*r«* rorrccl. 

' «*iifvee, » French phy*lrUii, uperntvii oo a rtfod womnti to Mve 



CASES SUITABLE FOR THE OFEBATION, 399 



is deliverefl^ usually by forceps or version, imraedintely after 
division of the pubit' joint. Less frequently the natunil |x)wer8 
are Piiffident t<» ucroniplish del i very. 

After division <jf the symphysis the puliie boues im\ only 
separate hiierally^ but the i\\i> liiilves of the now divided 
pelvis (more exaetly the \\s\\ itiuoriiinute booe^ )» owio^ to the 
peculiar strueture of the siu'roiliae sy neb ond roses, have ill so 
m\ anierwr dip ; they ^^o down a little in front, toward the 
jieririeuni, thus moving the anterior wall of Uie pelvi.s tarlher 
from the sacral promontory ; the line of the etjnjngate diam* 
eter of the brim beeoines more slanting, more like the *'diafro- 
imV' conjugiUe, and is thereby lengthened. This de.s<'ent in 
the anterit)r part of the iinnHuinate bones is farther inerea^d 
by pre.ssure of the head during labor. 

Cases Suitable for the Operation. — \ 1 ) ContmcftHl pelves, in 
vhii'h the true eonjugate diameter measures between two and 
Uiree-<]uarters and three and one-c|uarter inches (7 to 8.2 cm. ) 
— the pregnaney having, of course, reached full term. Hy 
sefMiration of pubic lR»ne4< the conjugate is lengthened a^a«^ 
half an inch, while a farther gain of ahuid one-fourth of an 
inch 18 retjuired by the prei^entiug y)art jn'otruding into the 
gafi l>etween the diviiled bones. In ''piUent'iV |>eUes, in 
which tlie transverse diameter is relatively wide, the lower 
figure (two and threeH|ynrtcr inchej^ i may, after symphyse- 
otomy, admit a living chi hi to pa.sa In '' fjeneralhj cimirficteiV* 
jiel vest the higher figure (lliree and one-*|uarter inches) will 
be more necessary. In both kinds of txdves .<vm|ihyseotoniy 
pn)duce5> also enlargement of the tran^verne and oblique diam- 
eters. In fact-, these two cliamt'lei**' are lengthened more than 
the conjugate ; thus, when the pnbie Iw^nes se[iarate two and 
three-quarter inehe;^, the conjugate will he inerease<l half an 
inch, the obltijue <me and one-third imhes, and the transverse 
one and one-fifth inrhes or thereabouts. 

r2) Cases in whieh the ehild is vnuHualbj large, or iti which 
it has become tmpavied from faulty meehanism, as in arrenicd 
vienh'podn'ior |H)sitions of face eai*es, and occipito-pontrrior 
positions of head presentations. A lm> arrested eases of breech 
or shoulder pre^ientations when usual methods of delivery faib 

(3) It 18 evident that eonditions mentioned under headinga 
(1 ) and (2) may coexistt and still be suitable ft»r the operation, 
but with les8 prosjHiet of suceess in some instances. 



40ri CL'TTiSO OPERATIOSS OS THE MOTHER. 

In oftXtfT x\i3a tin; openukio ^hall niooeed, certain other ooo- 
Ahhftui kIiouH lie preHeDt in every case, viz. : 

("a; Tfie 'jt( uteri muict lie mijfUnenlly diiaUd to alloir impid 
<lelivery aAer Kyuifih\Vu« i^ divided; or sufieienily dUaiabie to 
allow ra|iid dilatatiou artificially. 

(h) The eliild must lie not merely a/ityr, but so &r MRiDJured 
by delay, or by previous attemfiis to deliver, a^ to give it 
evf'ry cliance to Hurvive after birth. 

(c) The nufi/ter nhould be in good condition ; neither ex- 
hauNUfil by delay and exertion, nor injured loctally by fruitless 
atteni|iti< t/> deliver by other raethodg. She must be free from 
nejitic infwftion. Hhould the uterus be already, infected a 
(JifiMantan mtcrtion with hysterectomy, that is, a Porro oper- 
ation, would lie the proper pnK'eediug, not symphyseotomy. 

The ojMjration is rontrorindlealed when there is anchylosis of 
either Hucro-iliac joint Thence in the oblique pelvic deformity 
of NiUigele, and Itolierts' pelvis) ; in all cases when the con- 
jugate is IdHH than two and three-quarter inches — presuming 
the (rhild to be full-sized ; in cases of bony, cancerous, fibroid, 
or other tumors occupying the pelvic canal, etc. Anchylosis 
of the [lubie joint itself does md necessarily contra-indicate the 
ojM^ratioii — a chain-saw being in readiness to cope with this 
difliculty. 

Dangers of the Operation. — Hemorrhage from the wound ; 
huu^ration or other traumatism of bladder, urethra, and 
vagina, and HubscMpient fistuhc ; impaired locomotion from 
faulty union of pubic boiu^s and injury to sacm-iliac synchon- 
droMiw ; He|)tic infection of wound. All of these have oc- 
curred ; but impn)ved metlnMls of ojx»rating are gradually 
HMlueing the frt»<|uency of their iKrurrence. While the ma- 
ternal mortality during the last few years has l>een alwut 12 
|H»r eiMit., niort^ nn^ent rt»sults, owing to impnived technique 
and making the o))eration an **elei*tive" one instead of a last 
resort, show a diminished mortality and indicate that in future 
the death-rate may be re<lucvd to uothitnj under favorable 
eireuuislanet's. The infant moHality is not increased by, 
but largely de|H»nds u|k)U the conditions preceding the 
o|H'ration. 

Instruments, Assistants, etc. — One assistant to give the 
ana^sthetie; one \o hold a catheter in the un^thra, and other- 
wise* aid the ojH»rator ; a nurst> to take charge of the child; 



OPERATlnX. 



401 



another assistiitit iiiiiy bo jidviwihlt* Id secure uterine eoutrao- 
lion and retraetion» anil ik*livL*ry of placenta. 

The iuMrnmenU netre^ary arc a iiealj:>el ; a pryhe-|H)inte(l 
hbtoury (the Inder in plai\i of Giill)iiUi'.sor Monsaui's knife ) ; 
A tli&KH-'tin^ turcejjs ; half a dozen artery forceps; neeille- 
holder and curved needles ; a njetnl female catheter ; a ebam- 
saw ; sutureri of t^ilk or silkvvonii-junit ; iodoform gauze; litja- 
tures; 8tri|>8 of adhesive piaster two or three inelieii wiile, 
kmg enough to ^ro round the jwlvis; a strong binder or a l>* 
dominal liandage of inela^titr material ; together with iodo- 
form and the usual materials for antiseptic dreeing, and a 
jmir of otjstetric Ibrceps. 

Operation. — The metlmd of f>peratJng is still undergoing 
revision, necessary moditieations and iniprovetrtents in ils 
iechnhpit> have heen achled during the past lew years. The 
piilK'S, labia, ami iierineum are shaved, and togetiier with 
the ahdonien, thortojgbly disinfected with soa[> and water^ 
hichloride srohition, ether, etc., i\^ in auy abilominal section. 
The vagina also is tborouglily sterilized with a hirbhjride 
solution 1 : 2t)0(>. The uoman is amesthelized ami placecl on 
her back near the edge of the l^'d. Some i>|terators stand hy 
her si fie j others prefer to he in front between her lower limbs. 

The bowels must, of coursi\ have lieen j^reviously emptied 
fliid flie hhnlder eatheterizcd imnuMliately hetore ciminiencing 
the o]>eration, when it wilt also be advisable, hy a final aus- 
cultation, to ascertain fumfinty thai the child is still alive. 

There arc tw^t tvaya (4'doing the o[icratitin, j}t'M, the ** cltmeiV* 
or ^*it\dt<Jutanfo{tA'' method, with a iihorf incision : j^crotid, the 
^*npen'' method with a fottfj incision. Each has its advan- 
tages and disadvantages ; some oiH?ratiu*s |*refer <me, soujc the 
other. The cloHefl method i^ith ^had incision is generally 
preterred, as wilt presently Ive seen ; it entails less danger of 
tie|>tic infecttr)!! of the wound from the lr>chia» and less risk of 
hemorrhage. 

SuheutaiirouH Mfthwt^ with Short IncmofK^— In the median 
line ti( the ahdoincn, an ineisitai is matle one and one-half 
inches long (some make it ofip, others tn*o inches) the htver 
end of which is half an inch ahorr the np[ier end of the 
puhic sym[diysis. Cut through skin and ta-kna, down to the 
recti muscles. The attachments of these muscles art^ se|)a- 
rated from the posterior surface of the symphysis and pubic 
26 



Kb 




402 CUTTING OPERATIONS ON THE MOTHER. 

rami with the Buger, which is passed dawD behind the joint 
UDtil it can be hooked under the pubic arcK The a^i^tant 
now passes a metal catheter into the bladder and holdis the 
urethra backward towanl the right side, to keep it out of the 
way while the joint i8 \}v\n^ dividwK 

The siekle-ehaj^ed knife of Galbiati (Fig, 200). or what is 
just as good (or l>etter in s?ome ojL*e^ ) a jjrol>e-jH>inteti. slighlly 
curved bi!!*tour>% ii* passed down, guided by the finger liehiudfl 
the articulation, ami hi>oked under the subpubic Ugameutt ™ 
when the cartilaginous and ligamentous tissues of the joint 
are cut from liehind forward and from below upwani, until 
the bones se|>arate — sometimes with an audible crack. The 
joint is not obliged to be severed in this particular manner. 
The pinnl of the bistoury luay be guide<l by a Uay*& director 
(previously introduced) instead of the finger; or, again, th< 



Fto^an. 




1 



Galblatl's knlfif forsymphywotnmy* 

bistoury alone^ \t» piiiit kept closely in contact with Uiol 
articulation, may lie pa^-^seil down» guideil by a finger of th€ 
other hand in the vagina. Again, the joint vtaij he Beveredl 
fn>ni al>ove downward and imm Wfon* liackward, a lead 
plate, or lara|*on of iodoform gauze having l^een tirnt plac 
behind the joint, to prevent injury of the retm-pubic tissues. 

Note that the ^tthpuhic lt(jam€nt^ ii^ well as the interarticulari 
cartilage^ rauM Im? divided, or the Ixmes will not si'imrate 
fiatisfactorily. There iVa plan, however (devised by Hurris, 
of Chicago> in which the subpubic ligament h intentionally. 
left w/i-cut ; ini^tead of cutting it in the mithlle he ^pamte 
its centnd and lateral attachment.^ to the pubic arch (l^^gethe 
with those of the {perineal fascia ) with a blunt-[jointe<l bistouryJ 
closely '* hugging" the Ixine, under guidance of the fingerj 
Numerous advantages are claimed for this method. 



OPERATION. 



403 



The joint having been diviih'tl, i\\e wouml i.s packed with 
iodoforrn piuze and cyvereil with ii t'i>ni|irt«s wet with bichlo- 
ride solution, while the child is delivered, either by labor 
pains alone, f^hould lliey \w strong euougii ; ur by forcepe, if 
the Iveiid huve uiready engaged in the pelvic brim ; or by 
ven^iun, if it be yet above the brim. The child having been 
delivered h handed tu an m^sistant or tniiiie*! nurse, who 
.^hoiiM have previously prejmred bowlsnrhiH and eotd water, 
ele., tu eeeure it.s re8iisc'Jtftti<jn. p^hnnl*! thin be require*!. The 
placenta h delivered by expression in the nsnal manner. 
During delivery of the child* pressure on the trixhanters 
must be made by assistants to prevent too wide separation of 
pubic boncj?. 

Open Method of Operating, with Long Incision. — An in- 
c\mm is made iit the nieilian line tJiree or four inches lonjr, 
heg^inning half an inch or an inch alwive the up|H^r eml of the 
sympfrysiis, and ending at the root of the clitoris, or a little on 
one sh]e ui' \L 

These tis.syesare cut down ti> the joint, and the incision then 
continued through the curtihige of the joint itself, the *?ym- 
physis being thus severed from before backward and from 
above dow^tiward. The precautions to prevent accidental 
injury of the urethra, bladder, etc, are the same as when 
0|>erating by the sulKHiUineon-* method, by short incii^ion. 

Delivery of child and placenta accomplished, the iodoform 
gauze tampon and Hublimale compress are removed. The 
wound is cleansed with l>iehloriile solution, hemorrhage 
arrested, and tlie incision closed by sutures. It is not neces- 
sary to suture the liones or cartibigt^. A catheter \» iiseil, as 
before, to keep the bladiler, un-ihra, or vagina frt)m being 
nipjved and pinched between the two pubic bones while 
the hitter are being contiiuiou:^ly \wU\ in iipjxjsition by iL«^ist- 
auts making pressure upm the trtudiauters while sutures are 
lieing pussed. The sulun^s ((»f silk <»r si Ik worm -gut) may 
advantageously pass thnnigh the librous tissues on the anterior 
aspect (jf the pnbic joint. In very fat wcmien a separate 
rutin ing catgut suture may be used to unite the recti musckis, 
hefr»re the superficial ont*s are put in. Antiseptic dressing is 
apfdied to the wound and kept in place by adhesive stripe ; 
while over this if* placed a strip of strong rubber adhesive 
plaster, three or four inches wide, going over the trochanters 



d 



404 rUTTING OPERATIONS ON THE MOTHER 



mul rt.mi[iletvly roumlthe |H.4vis, to keep the Iwnes immovably 

ill a[>|n»!3itioiL Ijiltral |>rev^*^ure hylbt^ aj^^iHtatit!^ nniA be im- 
reiiHltiDjjjly ctjutimuMl until inimnbiiity uf the iMme^s is isoeurc'4 
by the tYUUpletiuti <>f the dressingt^ jii^^l ilcKTiiied. The riililMT 
a<lhc'sjve phuster inay l>e reintorreil l>y thhlitiunul s^iijUM^rt M' 
SLU Di'diiuiry i mi si in humhige. All mr\& of dv\m^ — ean%'Uii 
In'llji with i*lr:if>s iitul linekleis lu^niareh bsiiidu^es of ssolid 
rubber, a wire euira.^% padde<l plates<, sfiecial l>ed?<, s«aiKl-bji^, 
eta — ^hiivebeen used to seizure immobility of the bmiei^, lint the 
strip of ruli]»er |ihi.*<ler is iihviiys avaibilde, anil it.s eilieieney 
has I^'eu liernoMstriited ]\y nyiuerouH ojjerators. 

An auti^eptie nlis<»rbent pad, or aronipk'te ^'' occ! Hmxm dT€B9^ 
iiuf^' (stK? ]>agt^ 2(«H) stitmhl h<' apjilied to i\w vulva, and as 
a further ftecurity against .sejisii*, the vagiim may receive a 
tam|Mjn iif iodofVirm gauze. 

The winuau must remain on her baek for two weeks, her 
lower limlj« l>ein^ stretched mit straight and tht^ knees 
lightly tied together. During the third week she may luni 
ou her !?ide» ami al the end of a niotith sit up. Tive pelvic 
bandage ^houhl l>e worn i-Cix weeks «»r more. The il reining 
n|*«in the winnid (which must of course be kept -^parate from 
the Lisnal vulvar [(ad.H) may remain mitcniehed for live (hiys^ 
there heing tio indiealion of suiipnraliou and noeuntaminatiun 
from the loeliia. 

F>|jeeial eare should l>e taken to keep the external geuilftls 
and adjoining parts aseptieally dean liy washing them tw<i or 
three times daily with a mUd bieldcjnde solution wbiie a \wd' 
pin is j4aeed under the nates. Thr lower limbs (still ticnl 
together) may be lifted straight up, thus exjx^sing the geiii- 
tids for these ablutions withntit sepanitiug the feet* 

Aifcrif Opt ration, — A thud metb<Ml of ofKTaling, deviseil 
l»y Edward A. Ayers^ of New York, has btH:'n reeenlly 
praelised with sueeess, and |>r(mnses welL In cHnitrn-dis- 
linclion to the **8iibcutanetKis" iiielbod, it might be called 
"snbrnucous/* for no wound is made in the fikin. It is 
as follows: The vulva, vagina, etc.^ having been nuule 
a»eptieally clear** the patient, on her baek» is brought to 
the i^i\^^ of the bed and the thighs flexed. The bladder 
and urethra are drawn to I he left by a urethral sound, wliile 
clitoris and laViia mirjora are drawn upward an4l Im the left. 
The i>pnUor s left index tiuger uow^ eotei^ vagina and pawsea up 



OPKHATIOy. 



405 



alon^ posterior ^niove <)f syiin>hvsi5( until reuchiiiif the (op uf 
tlie joiiiL A Hnjiill inrLsion, b^ginnitii: Iialf an Inch l»elu\vlbe 
eliUiri^ unly iotig enuu^^h to mhint oiu^ily tlie hliule *•!" ii 
bisloiiry, is made over and ilusvii to the urtieyluliun. A blunt- 
piiuted bis=lt»ury is then pyished up along the anterior face of 
the symphysLs nadtr the vessels of the elitoriM, until the 
|ioint of the instrument tmn l>e felt uver the top iif the joint 
[iy the tip of the finger in the vagina. (Umrded by this 
tiiiger, the blade of the lii^toury is now worked tlown thnmgh 
the artieulation, cutting from top to liottom. To sever the 
subpubic ligament the direction of the bi>«toury may l>e 
changed, so as to cut from below upward. The Hnger in the 
vagina easily determines when the Iwnes iJejMirate ami (he 
distance between them. Deliven\ etc., as in the other 
methods. 

The little wound h packed lightly with itxloform gauze (to 
l>e removed in thirty-i^ix hours ) ; covered with a gauze dress- 
ing (no suturing reipiired) ; while vagina and vulva are kept 
ele4in by liichloride irrigation. ( Jitheterisni (the wound being 
alH>ve the meatus* urjnariu.s) may be dune, if necessary, with- 
out infection, 

Difficuitiei* during Opemtwn.^-lltmoTrhA^e from the wound 
may be controncd liy ligature if [Mjjisilile, es|yecially if arterial ; 
venous tM>7.ing by a tampon of iiwloform gauze stutfeil in the 
woimd» with eon n re r-p reinsure by the fingers in the vagina. 

There imiy be<iifficulty in fimltng the joint ; it i»nol always 
centrally placed, nor always straight. By moving one h>wer 
bndi of tlie woman while the o^HTator's finger in in [M>iHition» the 
mt>tion of one side will thus reveal the sitnalion of tlie sym- 
physis : or bihalhiw cxpb>nitory punctures over the joint may 
be made with the jM*int of a knife, until it strike the yielding 
cartilage between the bone^ 

In ca^ the joint l>e anchylosed, a chain-saw may be passed 
down l^hind ami up in front of the articulation, and the junc- 
tion sawed in twain. 

Accidental incision or laeeration of the urethra or blmlder 
should Ih* sutured with fine silk. If thew»iunds fad to unite, 
ase<*onthiry opera tioi* may lie needcHl after the piierpeml pVioil 
is over. 

The presenting head of the child maybe jammed so closely 
against the pubic liones as to interfere with the operation. 



40G CUTTiyO OPEEATIOSS ON THE MOTHER, 

Tlie pre^st'iitiug [»ad should l>e pu^^kMl yp out of the wiiy, and, 
if space ("Uiiiiot tlieu l)e obtained for the bistoury to cut fmm 
the back of the 8ymi>hysi8 forward, the inoisiou must he luiide 
from before backward. 

It msiy \Ki observed, when the pyhic joint is severed, that 
the two umomiiiutc l)oues at the site of sejmrntiou are not on 
the ?iiime level ; one is lower uud farther iVoui the mediua line 
than the other. This should be etirre* led by ^^entle pre^ure 
or traetiort upon the hii^her half of the divided «tructure8 ; 
otiierwise the pubie separation may take plaee at the exjteusc 
of one saero-iliae joint mure than the other, and eau^^e uKire 
iajury to the suero-iliae structures thau if lioth were move J 
ei^nally. 

Finally, be it remembered that whatever the method of 
operatint;:, symphyseotomy is done for the nioj^t part in the 
interest of the child^ an<l is desi^ue*! ehietly to sup|ihint 
erauiotomy and other methods of foreilile delivery by which 
the life of the infant is jeo[)ardized and ^ouietiruei* lost. 

The utility of eombnj if ij^ syTuphyi?eotomy with the iiuiuetion 
of preniaturo labor in eases uf eontrneted j>elvis lias not yet 
been poj^itively demonstrated. 

In certain eases wheo the ehiid in dnid, sympliyseotoray 
combineii with endtryotomy may be resorted to, iu the iiitereni 
of the mother. In practice these cases have r»ot yet ^>een 
detiaitely settled. Theoretically, when the jielviii is so much 
contracted that the danj^er to the mother of a diffienlt cnmiot- 
omy alone m so far reduced by symphyseot^jmy thut the redue- 
tiou is g^reater than the additional ri^k ineurred by the latter 
operation ; or, a^^ain. shtmld it l>e [x^ssible to obviate the 
greater danger of a bdoudnal se<!tion by combining emhryot* 
omy with symphyseotomy, the latter operation would seem to 
be indie^ited. The^» are matters for future decision • 



CESAREAN SECTION (FORMERLY GASTRO-HYSTER- 
OTOMY; LATER LAPARO - HYSTEROTOMY ; MORE 
RECENTLY CCEUO- HYSTEROTOMY j . 

Au cijxTation wliicli consists '\u rutting tlirou^d» the walla of 
the alxlomen and uterus and <k*Hvering the child and fdaceuta 
through the incistiivu, after which tfie uterine and abdominnl 
incisions are closeti by sutures, bince no pan of tlie uterus 



THE CONSERVAT/VE C^mAEEAN OPERATION. 407 



or any other omtiTiial oTL^tiii i.s reiiioveil diirin^r the f»|>erntinn, 
the proeetnliti^r i^i kimwii us ci^uiictvfftivt ('ifMireati w^ctiuru iu 
coDtradbttnclioij Ui iirn>t[i*-r tnjerutiud kiicmn im the radical 
Cit^Sll^t^au sect ion, in uhit-h, iiW^r extrat*tiug the child as above 
de«cnl)e(i. tlie uterua itself is taken out ; either aiiniutated 
throuf^h the cervix or tukea out entirely, cervix anil all. 
The radical operation devis*_^<l liy Porru is known iis the 
** Porro oti€*nition '' or *' Porro-Cii'sareaii se^'tion." Again, 
since the okler, coitJ^frvatire openitii)n waa' nuicli iin[rrove<l by 
a si>eci[il method of ^uturiJig the uterine incision devised by 
♦Sanger, It is now H^nneliniei* called the '*Sanger-t'iet4areau 
section." So, once more*, the Pi>rr<» ojicration was modified 
by Miiller, henc-e the " P<»rro-M idler opemtion/* These 
names (and olliern miglit be added ) are chiefly of hutoric 
interest ; they represent stages in the progressive improve- 
ment of the o|>eranon from \vi\at it was to what it m at the 
present time, Havini^'' understtMxl their meanings the student 
may dismi&ts iht- ni ; bnt let fiiin reniendjer that out of the 
confusion of the |jast there have been evolved two dUiiuH 
oprratioiu^j Vihwh survive us the recognized best methods of 
oixTailng at the present time. These* are first, the eoui^erva- 
*tivf! CfE^tarean section, ancl second, the radirai Cesarean 
sectiofit both of whieh wiil now be considered with eom© 
detail. 

Tlie Conservative Caesarean Operation, — LidieaHonfi. — The 
cjL*M^*s in vvljicii it is [XTt'ormed are : ( 1 ) Ejctrt^ne deformity of the 
pelvis, in which dt-liverv by forceps and version is cx«*!oded, 
and in which cranioti^niy is citlier irn[«K<'*ilde or would l»e 
more dangerous to the niother than euttiog into the abdnmen 
and uterus ; and in which tfiere is not nwim for a succt-ssful 
sym|ihyseotomy* Such cast^ [jresent the ** positive *' indicatii>n 
ibr (*a:!SJirean sc^ctirjn ; there is nothing else to be done. Flat 
IK' Ives having a inmjuguta vera of 21 inches or le«3 (5.5 cm.), 
auil jii?st*>-minor |>tdves with a conjugate vera of 2i inches or 
le^ (iyM cm/) present this^ [jositive indication ; (2) iiises of 
more moderate j>el\i€ contraction in which cnmiotomy is 
possible, but C'^saretm se<*tion is agreed np)n to t^are tht^ life 
ofthechiUl; r3) mechanical obstruction in the |.>elvis fntm 
tibroi<l, canconuis, Iwny, or other tumors which cannot he 
pushed up out of the way or he safely removed ; ( 4) irretluc- 
ible ira|>action of a living child in transverse presentations ; 



40H CUTTING OPERATIOyS ON THE MOTHER, 



{*}} iu women tlying near tlie end of prt^gnant-'V the ciiild, if 
alive, is rapiilly deliverril hy posl-motinn C'asarean setliou ; 
(t5) various othtT ol)«tructi(His fn»in intlarimmlurv udhesiotis^ 
iitrfs^iaj const rictioiii*, itc, of [he vagirin, ami uterine displace- 
lueiitSt rnay rarely require the operatioii ; (7) recently tbe 
operiftioii ha:^ l>een floue in eolamjisin eases, where lutjre con- 
Ht^rvative method;* of rapid delivery were irn practicable ; and 
(H) in [jlaeenta [jricvia, ehietly with a view lo les^nen the infant 
mortality attentlin^^ tlie usiial treiitment of this eornplicatiuo. 

Contra-indications, — When the portfire in<iii alion exi?t^ (i\s 
in tbe eaaes of extnme deformity, fii^t alntve rnenlioned ) all 
euntra-iiidicationrtofconrjse vanish ; the oj>eraticni must be done 
hi spite of every tbinJ,^ When the mdieathm h '* rt'iatit'f\' 
viz*, when aomethinjt^^ ei^e ( us^ually eraniotomy ) ran be dune, 
tbe Oesfirean seetion is contra-im^ieatcd ( 1 ) when tbe child is 
dead or dangerously near it; (2) when tht' mother is m far 
exhausted that the ojieratiou would \\g likely to kill her; 
(3 J when the mother Is already infected, or ha^ been sub- 
jected to nnc!can (utLsterile) exaTuinutions whieh render it 
almost im|Mjssihle that she shoultl esrape infection ; ( 4| when 
the surroundinirs of tlie patient are surh as to make the teoh- 
niijue of an aseptie o| aeration impossible. Under these cir* 
cumstaiiecj* cranioifmiy sliould l>e done ; unlca^ the woman and 
ber relatives prefer to run all risks for tbe sake of the living 
ehibl. Furtiier^ if they so decide in any ca«e of iufedioih 
the raflicaf of>t^rnlion f takinjr out the infected ulerns) should 
be done instead of tbe conifer votive t'iesarenn taction. 

Prognosis and Danger.— Death may result ( li from hnnor- 
rhitif*: during'' or alter the operati<>n ; ( 2 ) fr*>m nhork, es|»eciaHy 
in wimien greatly exhausted : (3) fuym jieritttttUis And niHritU; 
( 4 ) from Atptif'irmia, The j>crcentage of maternal recoveries, 
Its dei bleed from statisti'^'s, is notably unreliable. Tbe tigures 
usually include all eai^e.s, alike thos*e who die ajt*r the o|>era- 
tion and those who die oh actsiunt of it The result dejiends 
more on the rooditions preredinp. attenrling* and following 
tbe o|»*ration, limn ujion iht- ojwTation itself Not \on^ ago 
tbe resirltij of siM*aHed '' rnttfr'-httrn (\rMirraii Hrction ** (cases 
in wbieh jtreirnant women were torn «n»en by the horna of 
infuriated animals) were more favorable than cas<*8 oj>enited 
u[nm by surgeons, for ibe rejis^ai that tbe cattle were goring 
healthy women, while the surgeon waa o|>eratiog on women 



PROGNOSIS AND DANGER, 



409 



exhausted by long lalwr iiinl with tissues injured by uusuc- 
ressfid attt^m[)t^ to tkdiver liy lbrct^[)s, version, eU\ While 
the njortulity tn^^fl to l^e 50 j*er cfiit. or more, it bus of late 
lieen m tar re* I y fed by imprined nirthoils and kno\vled^% 
that by '"a recent aniilysis <d' llie literature i)f llie v^•orld, 
contlneted witli the idea of det^'rnjiidng the prtrLrntiisis of this 
ojierjitiou nnder favorable cuuditions, it was diseoveretl that 
up ttJ Augu-*t, 18H.H, thirty-nine Cassarean sections had lieeu 
performed by thiny o|x^nitor:?/' with the re.snlt that uU the 
ni ot 1 1 ers r e< o v e re* i a n d t h i rt y -e i g h t e h i I d ren we re aa v ed ; ' an d 
thlsi even thouLch most of tlie oj>erators were doing the opera- 
tion tor the ill's t time. 

From biter statistics p%'en by Reynolds and Newell, in 
their 1IIU2 work, we fiod that in 100 famrnble easei* of 
siaiple Cii'sarean seeti^m there were only 2 ileaths, anrl the.^ 
two oeeurred years aj^^n |>resnmahly from def^^t m theast-fitic 
techrutine, which irt»proved miMlern methtaLs could well pre- 
vent Of the 100 favorable canes, the authors give 20 of 
their owii, m which there was tto ileath, Jn N^davorablecase^ 
(from delay, infeelioii, exhaustion, etc., before the operation ), 
however, the in* i r ta I i ty reac I le* I T) in 21 cases — 24 pe r ee n L 
These authors therefore eonrkale that the oirt'ration |M'rfonncd 
on favorable case.s has only a very insigniticant mortality, but 
that in /o/fiivorableones the mortality is so great as to render 
the (Ji>eration alrm^sl unjustifiable. - 

A table co in p i 1 ei 1 I jy W i 1 1 i a ni s ( q n t it ed by We bet er * ) gi ves 
162 oases by H i>peraiors, with 5 deaths; a mortality of 3.08 
[WT cent. 

The hed result.^ are obtained by makintr the o|>eration a 
so-called ** elrefive^* one — that is to say, the oljstetrician (hav- 
ing previously ascertained (he advisability of the o[>eration ) 
rif'rU a favorable time, place, etc., ibr its performanre, instead 
of doing it by cianpnlsion umler adverse circumstances, when 
other methods of delivery have failed ; which simply means, 
do it near theenrl of pregnanty, hefore iahor bfffin^ : eleel the 
time ami phice ; secure assistants, nnrses, instrunienls, dress- 
ings, and prepare the patient hy previons trealrnent etc. 
These things raniud be s<^ well <lone during the sudden emer- 
gency of labor* esj>eeially at night 

• Blwanl H<'v iiohls I'mrticFil Midwifi^ry. |rti^e VXi First EdUlon, 1892. 
*ReynnlUis an*! N<wcll t'rnt ticul (aistctriei, page '2m {VJfti). 
' Wcbstcr*fl Otjstetrltij, page 711 {lim). 



I 



410 CUTTLXG OPEEATIOyS ON THE MOTH EH 

Siijco surrouiKlhii^' circLiTiistanc**!^ iiml existing couditious 
s<.> tkr vary tlial ii<) twtj ^X^ i(f ua^^es are exjictly alike, isUtti»^- 
ticul result'* n\UHt vary also, ami fi^aireseao therefore give only 
approxiiimte imlieatiims fur future ^uidaiiee, 

Ut!ni%'t^nilile eonditimis, i^ueli im the atiiHit^jiherie impurities 
iif linfipituls ; |>reviijus exhaustion ( Iwith of woiimii aud woiiih; 
iVoni protracted hibur, or eoexistiu;Lr diseai^e ; previous injury 
from uiisuet-es^ful atteiuj^ts to deliver by version, fortvjie, etc. ; 
buufjling from lark of skill diiriii!^ tlie o|)erati()n ; nej^lecl of 
fiAcplle prec4iutk*n> ; and injuiJieion^H aiter-treatinent^ have 
largely increased tbe<lcath*rate. To l>e sueeessfnl, the o[)e ra- 
tion should rn>t be [)ut oti'asa Inst re^^ort, but performed early, 
the condiliims re^utriiit: it having l»een made out, if pnietica- 
|phs at or before the begiiiniu;^ of labor. 

Preparation for Operation. — If praetieahle» lei the patient 
UYoid solid fiHid for twenty-tVnjr hf»urs betbre the o|>eratioiK 
Emi»ty lioweis and bladder, 8bave the hypotjasiri** reirion, 
pubes, etc. Scrub the abdomen with soap* water* and lirusb ; 
then wash it with ethi-r^ and then with a mild birhlorirle solu- 
tion (1 : 30(H) j, iiiicl doui'he the vaj^nua \\ith the hist-mirned 
sobition* Sliould there be time the abdomen may be (*ov- 
eret! during the tvveuty-four hours |>rerediug the operation 
with a sterile towel wrunj^ out of n 1 : lOUO bichloride ndu- 
tion, over which goes a tliirk layer of sterile eotton and a 
liiader. 

I>urin(]j the oiieration all jjarts i»f the limlis and l«xly 
exce[»t the field of operation must be ]jroleeted iVorn eohl by 
gterile towels or some otlier li;jbt covering. 

Instruments, etc. — The t«)liovviui; iui^truments are ret{uir©d 
( I tpl*>tc direetly from Williauis' Ohaicirha, page 4lM ), vi/^ ; 
*MJiie scHljM.'k one long blunt-jioiuted scissorj*, two ili?iseeting 
forceps, twelve short anil six long artery cbirn|is» an alMlom- 
itail retractor, a neeilledudder* and appropriate needles, a.-^ well 
as the usual sicrile dressings, suture materials, and ^lus^^ 
gjMinges/' 

Besides the other numerous refjuiremeutfi u^ual for a surgi- 
enl op+*ration, there 8houl4 be in readiness a separate table 
with af)|mrtemirjecs for ref^nscitating the ebihL 

Assistants,— ritvi, the tdiief as^istiitit to help the o|)erator ; 
»e<*ond. one for the anaesthesia ; third, one to take care tU'tlie 
child ; fourth, one to hand instrument*!; and a fifth ready for 




OPERA TIOX 



411 



anjdiiug the oi)eratur may desire. The assistants should 
receive sjiecitic ioatructioua before tlie operation, as to what 
tliey are in do. 

Owini^ to the f/reat danger of prolofifjcd delay in obtaining 
instruments aA<istaoti^, unti?ie|itie!?, etc. (as may mx^iir in t-oun- 
Itry praetit-e), it nniy v^eli \m i|Uestioned whether it wonld not 
be better to do (heu|ieration with a knife, netnlleri, and sntnres, 
using boiled water lor ai*ej>tie cleanliness, nml having **one 
phy»'*ieiaD and a few women " for assist ants rather than waste 
very much time waitii*g for lietter ajjfdianees. 

Operation*^ — The operator j^taiids on the right side of the 
pali(."iit, who shoohl rest on a liigh, firm table, with her slioul- 
ders slightly elevated and the lower limbs moderately flexf^. 
The ehief assistant, standing oii llie lefl an<l faring the [)atieiit*8 
feet, steadies the uterns in the nuilian line and |)ro<iuees mod* 
enite tension of the alidomiiial wall over it by pressing the 
ulnar l)order of eaeh hand down on the sides of the n terns 
while his thmnbs rest on tlie fundus. The incision is then 
inudeiti the metlian line. The /f/if/Z/i of this ineisiou depends 
npm the method of o|r^ rating selertetL There are really two 
metlimls : one wit!r a >thort abdnminal incision of four or five 
inehe^i, during whieh theo|x^rat<M' will take out the child wlnle 
the wondi rfmain^ iti the ahiiomnmi caridj ; and nNiflher with 
a lon^ abdominal incision of seven or eight inche,s» iu which 
the uncut uterus is bronght ouUidc of the abduminal wail 
before it ia incised and the child extracted. 

Most oix^rators iiowatlays ]>refer the hnig incision of about 
i<evai inches, through which I he uterns may or may not l>e de- 
live re* i I K" f i I re I >c i 1 1 g cu t. S h i n j 1 d t h e re h e reason 1 1» s o s | lect t he 
utenoe cotjtents are infcctc^l, the organ i<htnifd In? delivered 
l!irough the incisioti betbre it is o|M:^nedJn order that it may W 
securely pac Iced around with sterile gauze, and thus the better 
prevent infected matters from the nterus getting into the 
j)eritoneum. Should there be no infection of the uterine con- 
tents, the wonrb may remain in the abdomen, sterile gauze pads 
l>eing nevertheless ]Mickcd in Iwtween the uterus and abdom- 
inal widh the latter meanwhile bt*ing pres,^'d against the uterus 
by the hands id" an assistant, so as still to prevent li<jUor amnii, 
etc., t'etting into the perilotienm when the uterus is incis^nL 

The incision is made in I lie median line of the abdomen, 
not between the umbilicus aud pubes aa waa formerly done, 



412 cvTTisa oPEnATioys on the mother. 



hut hii^her up, one half of the cut hehig above, the other haT 
ht'low tlie unihiliru.s this lu^t l)eiog, thcrelore, itst'eLiinil point. 
Hleeilini^ vef^eln in tlie abdominal iudtsioo are secure*! by 
chimiw. 

The uteriLs is uovv visil>Ie ; it i^ inci^seii in it« metUan line, 
eitlier withio or outside the ab<lomen, a.s stateii in the preced- 
ing paragraph. If it is to Ik- iielivered thron^:h the abdorainaJ 
incision before beinL,^ cut, this delivery ( m>i always easy ) may 
be facilitate' t by rotaling^ the uterus so a?* to iirin*^ the side 
(orcorjuni) of the orL*:aii toward the aluhjudinil o|H'njng. If 
it is to bt! cut while reTnainiij*^' u\ ihe, alidonrnial cavity, care 
shfUild be taken to rnaui|»ubite tlic uterns (if it lie obliquely) 
in audi a tuanner vl^ to brintr {{^ median line in the centre of 
the abdominal opening. Tlie uterine incision h liegun with 
a m'alpel at the lower eml of the abdominal Incisiou, atid 
finished with s<.nssors to the requisite lenfrth uf six or seven 
itjchen, cutting^ up toward the fundus. The memliranes* (if 
intact) are now rui^turcJ, and the ehild seized ti.siudly by a 
font and extracteU The mrd is clanqied in two placee, 
between which it is cul, and the child taken by an assistant 

There will usually be some hemtjrrba^^e from the nterine 
incision, but not mm:h, if the uterus c<»ntract promptly, and 
the o|>erator be sufficiently expert to complete the part uf the 
operation thus far described within two minutes, which eaii 
often be done. Encircling the lower pirt of the uterus with 
a rubber tul)e to const riet it*s ve.'^sels and |>revent hemorrhaire 
(which ust*d h) be done) is unnecessary and inexpedient. 
Should there be too rnueh bleeding, the vessels may Ik* lein- 
porarily c<»mpre*sed by tlie hafids of an as^iistiint over the 
losver self merit of the uterus. If the placenta ha[t|>en to l»e in 
front, ;jo on and rut tiirouirb it without delay, or separate and 
push aside that part of it which overlafis the incision, and 
extract the ehild qiiiekly. Now com proas the uterus ami 
aeeure iLs contraction, and if it were inciseil within the 
abflom^n, it is now (easily) broutrht outside, surrounded by 
warm wet sterile gauze or sterile towels which also ef>ver the 
abdominal incision — this last to be tem|Kiranly held together 
by artery elanqiH at it.s up^K-r en*!, alw^ve the uterus. Next 
the phK'enta is delivered by manual expre?wion through the 
incision, or if thi.-* tail, the baml is passtMl inside lo sefmrate 
and extract the [>lacenta and membranes Befon? tlie band 



OPERA TIOX, 



413 



jg finally withtlrawri horn the lUeriut* t^avity, a finger should 
he pjiHsMi'd lo th<_* <'er\ ix U> iisrertiuti tluU noihiii;^^ ohi^truet its 
ctivity. Sonii^ i>[K*niinr.s rarry a strip of iixlotorio j.'auze into 
the uterus, nml push one erul ut'it throuj^h the eervix into the 
vatriua» wheuee il may l)e drawn out tlie next day. Others 
eouBider this uuiieee^sar}'. Bu mine dimufeet the uterine 
cavity by irrigatiou with an antiseptic solution ; others* do not 

The next step is i^ftttiriittj the uterine iiieisiim. This requires 
speeial eare. It was (lie Siinger niethotl of elosing the uterine 
woinid that so greatly (liminishetl the nmrtality uf tlie o|>er- 
ation. There are niauy nioilifirations of hid original jilan, 
but the purjKjse of them all h the sanu% vix.» to secure s<j firm 
and perfect a e<ia|itatJon of the uterine in*^isioo as to prevent 
hieediug, and also to preveul. the eut ranee of hichial matters 
from the uterine cavity into and through the incision into ihe 
[leritouenuL^ 

The modern methixl of suturing is as folkws: First, a set 
uf drcp inlerrupteil ^Hk sutures which enter one fourth of an 
inch i'i cm.) from tlie edge of the woutul, f»enetrate pen- 
toueum aiid nuiscuhir eojit.s down Itt, l)ut not into theiiuicosa^ 
then enter the opposite side jnst cdenr of tlie nnicosa and 
emerge one fourth of au inch from I he edge of the wound nn 
the |H?ritoueal swrface. Tho^e dc'cp sutures are placed a!>out 
h{df an inch apart. It is well not to tie the first one until 
three linve Iweu put in. Then put in (he fourth and tic tlie 
second, and so on all along. This enables tlie operattir to 
easily explore the <Hit surfaces and see exactly where hig 
ntHnlle is going, which he ctuild not so well do if the suturt*s 
first put in were inunediately tied. 

Hirst leaves nil tbcj^e interrupted sutures tutiKn] until 
he has passed two tierx of a running catgut suture through 
the muscidar coat afone : the interrupted silk sutures are 
tied, thus eoniph'tcdy concealing the miming catgut suture in 
the muscular wmIK The method is exrt lleut, but it requires 
lime and skill, and is not generally adopted. 

The (hrp sutures having Wen tied* another set of .-<i/^ifr/icia/ 
catgut (one between eacli two of the deep ones) are [lut in, 
passing only through the peritoneum, or embracing a few fihrei 

I It now secm^ inmnUhk', but fs neverthelcsj< (rue, that within the luftl fifty 
yi'firs. If ihr uti'ni> tviiitnu'leU w<'U, it wft?i Tn«l dt'tmotJ f(t"t'*'>!snry lo put anv 
witnrr'w ^n <h^' ulrriiM' wtmrul. Xo wonder that Tn«iiy died from tvntcjige <tt 
itifrt ti d l^ieliitt iiitu the peritoneum and aeplic ptTltonili*, 




i 



41 J CUTTfNG OPERATlOyS ON THE MOTHER. 

of the nius^.*aliir coat Siiuger origiiirtlly pare<l off a little 
gtrii* froin the outer eiJgc tjf the mu^^'ular coiU aucl turned in 
the borders of ihu i^teritooc^iiru, as shywii m Figs. 201 and 

Fig. 201. 




Shr»wlnff ponltloM of i(uturi>« In relaUoa to strtjctnrv^ in uterine w»tK a, 
IVrltoiU'uin* h, riorfnc niu»cle. c. JJ«c1<1ua. d. Hu|>ertlciftl auture. e. l>ceii 



Fin. 301 




Phowliif the AUttire* when tied : pcrftrvneAl nurrnct's being bmiight Into con- 
tM't by the Rupcrndal sutnrcN a Pcrltoncmm^ ft. I'terloe muiclc. t, DectduA. 
d l^itperficlal suturva, t. Deep suliiro. <Afti'f Galabiw,) 



202. Thi!^» however, talieg too murli tinie, atnl is iinner^««niT ; 
the jierituueul suriace« muy be brouglit together jn^i m well 




THE PORRO OPERATION, 



415 



by iifiing the Leaibert stitch, which is now g-ciierally 
preferred. 

The sc<x»ud set of sutures having been placed (ari tle^ribetl), 
any iidditioiml imes may he put iu, irregularly, tbruugli any 
bleeiling <»r gaping \mut ahmg the line of iucii^iou, where 
pressure with the tiuger or a hot compress fail to stop ooziDg 
of l»hM*d, 

It only rerriaius to cleause the peritoneal r4ivity with steril- 
ized gauze of blood clots or other nialters, replace the uterus, 
dniw ilown the omentum into ita natural jM>Htio[j, an<l close 
the abdonnoal wound by sutures in the usual way, the peri- 
toueutn, muscular wall, fascia, and skin being brought together 
in 8e[jarate layers. 

The wound is covered with a dry antiseptic dressing, kept 
in place by adhesive strips and a bintler. 

8ti much lor the *^ consfrvaiive^' i>f>e ratio o ; we have next 
to study the *' radicaV^ Cicsareau eection. 



THE POEEO OPEEATION {CCEUO- HYSTERECTOMY), 
RADICAL CESAREAN SECTION. 

This 0]>eralion, as now |>t*rforrned, may be hrieliy defined 
m a Csesarean section, in whieli, after the child has been taken 
out through tlie uterine inei:^ion» the uterus iti*elf ii? removed- 
It is either amputated above the vaginti, lea%'ini: a cervical 
stump, or taken out eutirely, ct^rvix and alL Sometime;*^ not 
nlwavH, the ovarie^f and tubes are renioveil also. Keai*on» for 
this will be stated further on. 

Indications. — Broadly ii[)eaking, the indications for the oper- 
ation, with regard to pelvic measurements, etc., are the same 
AS stated for the conservative o|>eration \ see page 407 ). But 
the question now is, in what cases of Ciuj^arean iiection sliould 
the oj>erator go further aud remove the uterua. The eases are 
these: 1. Uterine tumors: fibroma, myoma, cancer, etc. In 
cancer cases, of course^ the whole uterus should be remtjved, 
cervix and all. 2. Cases of complete inertia of the uterus^, the 
organ failing to contract, thus endangering death from hemor- 
rhage. 3. When the uterus is infected. 4. In bad cases of 
Uterine rupture with jagged and irregular tears that cannot 
be perfectly brought together by autures, 5. In cicatricial 
narrowing of the parturient canal which would obstruct the 



CUTTING OPERATIONS ON THE MOTHER 

IfK^hlal tli^'harge. H, In cases af odeomalacifu apart from 
the pelvir dt'f^>rmity resulting from this iliseasc, wliiuh may 
require alxjominal section, removal of the uterus and (waries 
arres^ta the dis^ease of the l>one8, whirh the conservative (\csa- 
rean st*ction wouhJ in»t. 7. In aoy case of pelvic deformity 
when it is desired to uiisex the woman and thus prevent a 
future j^refjnancij. 

OperatioE. — The original operation, a^ done Ky Porro, which 
consisted in tim[ujtiuinf5 the uterui* thmuirli the up|>er [wirtof 
the cervix and suturing the cervical slump into the lower end 
of the abdominal wound, is so seldmn done at jiresttd that it 
will here receive only brief attention. Okserve that the pur' 
pom of the operation wtis to keep the raw surface fif the cer- 
vical stump exphsed out.<idc the Hkin. su that uo hemorrhage 
or inftH^tiiig discharge from it could enter the peritoneal cav- 
ity ; it was thus spoki^n i»f an the '^^-rZ/vi-jn'ritontaP' manage- 
ment of tlie stump. The |»nK?eetrtrig was i\a followj* : It l>egftn 
and proceeded until the child was fxtraeted just like an ordi- 
nary t ** const^rvntive " ) Ca>*jirean section, Tlu-n, without dis- 
turbing the plac^entti, an ehistic ligature of rublier tul>e or a 
wire loop was passed over the fundus, down behind, and 
drawn tightly ronnil the upper jmrt of the eervix, si>as to cut 
otl* its circulation, taking eiire not to inrludc any |»art of the 
bladder or rectum. About an iucli above this constricting 
ligature the uterus was ampiitatc<l. Then two st^iut needles, 
several inches long (like onlinary knitting netHlles i were 
pas^ied crosswise through the rtnmp to kin^p it iVom drawing 
Imck into the abdominal cavity. These needles, re*^ting upon 
tlie gkin outside, acteil n^ a s«irt of crucial hufton to keep the 
atunip outside the huiUm-htyh' of the abdominal incision, which 
was further secured by suturing thecirrumference of the stump 
all around into the h^wer end of the abdimiiual wound. The 
remainder of the abdominal incision was then clostsi in the 
ordinary way. In ten or twelve days everything outside of 
the coDStrieting ligature sloughs otf an<l comes away^ leaving 
a small depre^ied wound t<» heal by granulation. The ojjer- 
ation can V>e done quickly, even in less time than it takes to 
do the suturing of an ordinary Oesiirean section, and is com- 
paratively easy for inex|>erieuced oj>erators, but there is always 
some danger of infection through the sloughing stump, and of 
subeequent hernia. The convalescence is als<J protracte<l. 



tup: modern porro opk ration. 417 

For these and other reamms the o|)eration \ii\s been practically 
abamiciDt'^t *^r it might rather \w. siiith Jins given place lu the 
iiKxlerri niethn^l \*' tM/m-jKTitooeal '* n vet bod ; of treating the 
eturnp, nttvv to be ilt^scribttL 

The Modem Porro Operation ( OcBlio-hysterectomy ) Intra- 
peritoneal Management of the Stmnp. — Having extnictcti the 
child through the uterine incision, tas in an ordiimrv (Usiirean 
section, and leaving the phiccnta undit<turbed, the renin ining 
successive steps of the i^pcration are an folio vvj? : K Ligate^ the 
the infundibnio-pelvic liganienU ( through wliieli run the 
ovarian arteries) in two jihtre^, and cut between, or instead 
of the second ligature near tlic iilerns, a claiiip may lie u^ed. 
2, Ligate the round iiganients and their coiilaine<l arteries 
ID the Slime niaiintr, X The broad liganierns are chmifK-d 
and severed with ^nssor^i, <m each jside, 4. Make a transverse 
incision tfirough the |ieritoneum in front, jn^t aliove the junc- 
tion of the blathlcr and uterus; and a similar incis^ion through 
the perit^menni of the pogttrior uterine walL at the minie level. 
Then with the finger or wmie blunt instrument, 8tripd<mn the 
peritimeuni to form anterior an<l posterior f^aps, near the lateral 
junctions of which the uterine arteries must now be found, 
isolated, ligated, and severed, taking special care to avoid tlie 
ureters. ^. The uterus has thus been severed from all iti^sur- 
rountiing connections* except its jnrulion with the cervix, uhich 
is now amputated^ anil the body of the uterus is removed. In 
doing thi(4 amputation some operators cut straight through 
transversely ; others try to leave a cone-shaped hollow in the 
cervical stump; and others make a V*j^ha|H^<l incision, leaving 
a transverse trough dike excavation with anterior and jK^sterior 
edges. Again some operators burn out the muctais lining of 
the cervical stum]! with a cautery ; others <lo not, (>. The 
etlgesof the slump are brought together by sutures, and after 
the anterior and p>sterior p^-ritraieal tlajis are stitched together 
over it, it 13 dropped into the pelvic cavity. The ojieninga 
in the broad ligaments are then closed by runoiug catgut 
sutures. The pelvic cavity is cleansed by sterile sponging or 
by flushing with sterile water, and the abdominal wound closed 
without drainage. 

27 



418 CUTTINU OPERATlom ON THE MOTH EH 



TOTAL HYSTEEECTOMY. 

When it is desired tcj tsikt- out the wlmle utcnis, cervix 
and all, the operation is the siinie us jii^^L dc8t'nhe<l tor s'upru* 
vaginal araputalion, except tlujt when the nterine arteries 
have heen tied, instead of amputating the cervix, the vajLrinal 
vault is incised all ari*nnd it^ and the entire uterus removed. 
After this tlie opening in liie vagina is ehx<ed \\y eutirnt snlnre.s 
ami the hroad ligament openings and ulKhmjnial ineisiun are 
sntnred, just as in the sn[iravaginal nmpntation c^iises. 

In the three hystereetomv ^iieralion^s aiiove deserihed, the 
o%"ariei5 and tubes are usually removed with I he uterus; but 
one or both ovaries [ provitled they Ik' n<it diseased j may be 
allowed to remain when it is desired to shield the woman (she 
being young) from the emotional decadence tif a premature 
menopause. In thisca^ the ovarian artery should be Jigated 
between the uterus ami o%'ary. not outitide the 4^nary through 
the infumlibnlo-|K;dvic ligament, as in onr (lestTi[»tiou of the 
openition previf>iislv given. 

Removal of the uterus of course prevents any future preg- 
nancy, but when it is desired to do this in a case of ctwMr^'tt- 
the Caisarean section, the bt'st plan is to excise a p>rtion of 
each Fallopian tul>e (where it passes thnmgh the <x>rnua of 
the uterus) hy a wiHige-shaped incision, and close I he wouud 
by sutures, the remainder of the tubes and the ovaries being 
left in. 

After- treatment. — The patient Bhould remaiu on her back 
two or three days, the alnldminal wall being well 8n|if»orled 
with a bimler, and the vtdva dressed antiseptically as in ordi- 
nary hihor case^ Tci avnid ^'om^^^llr7 ( whirh is sometimes a 
trcjuhlc*s*mie symptom) no Jood should be taken for twelv^e 
hours or even twenty-four, and tbeu at first only li<|uids, ndlk, 
beef-tea, etc., in teas|K>onfnl or t«bl«^[Rionful f|uantities a^ the 
stomach will tolerate, ami rejH*aled at intervals of an htmr. 
Small piecei^ of ice may be swallowed, which contribute also 
to relieve thirst. If voiniting |)ersisl, suj»(M>rt the patient 
with nutrient enemata and stoji all month-feeding. The 
bowels having been well emj^tied before the ojM'ration» niay 
remain undisturbed forty-eiLdn hours, when, if not acting 
spontaneously, a soap auil water enema may be given, or a 



FRITSCH'S TRANSVERSE FUNDAL lyCISION. 419 

glycerine suppository. Should tympanites occur, a teaspoon- 
ful of turpentine may l>e acided to the enema. The bladder 
must be emptied by sterilized catheter every eight hours, if 
required. If the uterus were imoked with gauze during the 
operation, the tampon must Ikj removed after twenty-four 
hours, and a second one put in, if desirable, on account of 
bleeding. The sutures in the abdominal wound should remain 
ten days. The child should be put to the breast and the 
woman have the same treatment as after an ordinary lal)or. 
Owing to shock or exhaustion, the ap})earance of the milk 
may be delayed several days, when the child should l)e arti- 
ficially fed ; it may still take the breast every six hours, and 
thus, even after a week, the secretion of milk may b<KX)me 
established. 

If all go well the patient may sit up in bed after two weeks, 
and sit up in a chair after three. 

Fritsch's Transverse Fundal Incision. — In this method 
of doing a Csesarean se<>tion, instead of making a longitudinal 
incision in the median line of the anterior wall of the uterus, 
the incision goes transversely across the top of the fundus, 
from one Fallopian tul)e to the other, or from one round liga- 
ment to the other. The advantages claimed for this pnx*eed- 
ing are: 1. In consequence of the abdominal wound \ye\ng 
higher, there is leas danger of sul)sequent hernia through the 
line of the abdominal incision. 2. Diminished hemorrhage 
from the uterine incision and a more firm and rapid shrinking 
of the uterine wound. *]. After retraction of the emptied 
uterus, the uterine wall at the fundus is thicker than it is 
lower down, and therefore admits of more Jinn closure by 
sutures ; and, after suturinj:, massage of the uterus — sliould 
this be required to promote coutnirtion — can l>e more fearlessly 
employed than when the incision has In^en made in the anterior 
wall. 

A modification of Fritsch's nietluxl has l)een recently prac- 
tised by making the fundal incision longitudinal instead of 
transverse. The incision, six or seven inches in length from 
beginning to end, commences on the [)osterior aspect of the 
fundus and extends along the median line over the top and a 
little way down the anterior surface. 

All these methods, under favorable circumstances have given 
good results. Experience has not yet demonstrated which is 



420 CUTTING OPERATIONS ON THE MOTHER, 

the hest. Of uiie things however, we may he sure, viz., in no 
instance shonld the nterint* iiiciiiiuii W m low as to cut into 
tht^ thinned segment i*f tht- \vi*inlj lirlnw the n-tmrtmii ring of 
Bundl. (8eo Clmpter XX VII.) This tliinned ^^gnient cun- 
irnt l>e ?<ft iiritily f^t^nircU hy 8iilure*s as the ihuker purls of the 
uterine witll Ingher np. Wilh refriinl to hennjrrhii|re, lliere is 
no more dnnger from tlie lori^ilmliniil incision, pn>vided it \ye 
riinde t\rmthf in the sagittal line, than there is from the central 
transverse cut. 



VAOIFAL OiESARILAJr SECTION. 

This operation wth^ tleviRd m>t lor pfiric deformities, Imt 
to remove olistrnetion ut the osand eervix uteri in eases where 
inuncdiate delivery wiiii mor*^ or le*^** imfienttive. It i;* really 
mpid enhirgemeut of the nlerine orifice by extensive ineisioua 
insteatl (if liy the eoinmon slower jjriHVSs of artifieial (iilatntion* 
Henee it hiLs Iteen done in some cases of eclan)|)sia and ante- 
j)artuni hemorrhage ; also when the woman wa« in articulo 
modi.^ or dangeroussly near it from org^anie disease of the 
heart, hniij^s, or other or^^ans, and in eancer of the cervix or 
eervieal steno^^is from «»lhcr causes. 

The Operation. — liy means of a pro|ier8peeulum and vol- 
sellom foreepis, the lervix is hrought ii*lo view. Transverse 
iueisioiis are then made through the anterior and [posterior 
fornieeB of the vagina itito the cervix. The bladder is stripped 
off at iLh junction with the uterus and pushed up out cd' the 
way. Vertical incisions are then made througli the median 
line of the anterior and j>i>sterir»r eervieal walls, extending up 
into the lower uterine segment immediately ahove the cervix, 
taking care not to wound the jK^rltotieal coat of the uterus. 
Through the o|M'riing tluis rapidly made, the clnhl is delivered 
by version or by forceps; and at\er delivery of the secundines 
the incisions are rh)8ed liy sutures. In cancer eases the o[)€r- 
ator gfjes on to remove the whole uterus by vaginal hysterec- 
toniy aecording to the metbiMl of gyna'e<dogists. 

The ojjeration has a snuill field, re<|U ires special skill, and 
its merits have not yet been definitely settled. 



C(ELIO-EL YTROTOMY, 



421 



OCEUO-ELTTBOTOMT (LAPAB0-EL7TB0T0M7, 
GASTEO-ELYTROTOMY) . 

This operation is only of historic interest. It is never done 
now. Its object was to deliver the child through an abdominal 
incision without cutting either the peritoneum or the uterus. 
At first sight this seems impossible, but it is not so. An 
incision was made just above and in line with Poupart's liga- 
ment, down to the peritoneum ; then with the finger-ends the 
peritoneum was carefully peeled off from its connections with 
the transversal is and iliac fascia?, until the top of the vagina 
was reached, and opened on the side. The fundus uteri was 
then pushed over to the opposite side so as to bring the os 
uteri into the vaginal opening thus made, and through this 
last the child was delivered by forceps or version. The un- 
wounded peritoneum was then laid back in place, the abdom- 
inal incision closed by sutures, and the vaginal wound left to 
take care of itself. Details are unnecessary ; the proceeding 
is now quite obsolete. 



CHAPTER XXL 



MUTILATING OPERATIONS ITON THE CTflLiX EMBRY- 
L'LCIA, CRANIOTOMY ; EMBRYOTOMY, ETC. 

The object of these operations is to re^luce the size of the 
child or to divide it in pieces, ^o that delivery — otherwiseiin- 
practical lie — may l»e accoiiijjIUlietl Openitiiig upm the /trad 
is called **craijiotoniy '* ; ujkih the /lor/i/ " eml)rvotouiy,'* 
Since the lerm ** embryotomy *' literally means euttintr the 
embryo, a more correct terminology, 8Ug;^ci«tcd by Webster in 
his receut work» \v*mld seem to be craniaf cndiryotomy : oper- 
ating ufHm the cratnam; uiid mtporeal embryotomy: oper- 
Htini? U[ioii the hodtj. 

Indications. — tVmdiiions requiring niutihition are chiefly 
malpro|>ortiori between the size of the chihl and pdvis^ or 
other niechiLnieal olistaele^ t<T delivery such as impacted shoul- 
der presentation (arrested **gj>ontaiieoiis evohrtion " ) ; arreet 
of mechanism after [Mtsfcrior ro{ati<m of chin io face cases; 
very rarely, arrewt of mechanism after posterior rotation of 
oct*iput in hea*l canes ; h>cke<l tsvitis, etc. 

With modern improvement 8 in the Ciisarean section and 
conse^jnent reduction of danijer and mortality attendinir this 
ojieration, nnitilatinj; pnjcedures \\\Mm the <*hild are happily 
brconnn^* le?^ fre<|iient than f<»riiier]y. It is now i^fneraUy 
admitted by most oltstetriciaiis that no craniotomy should be 
done in a tiattened j^elvis the civnjn;:ate diameter of which is 
less than 2 inches (assuming! of course the child to be of usual 
gize at full term), ancl if beside beintr contracted in theanteri> 
piisterior dire<'tion, there should also be reilucti<in rn the tmns- 
verse diameter or *' general contraction/' then the true con- 
jujjate should l>e 2| or 2A inches in order to justify craniot- 
omy- If smaller than these measurements the dangers /« the 
mttthrr vvcjuhl be greater than a well-timed Ca^ireau section. 

When the child is dead and delay in delivery endangers 

422 



CRA NIOTOM }\ CRA MA L E3IBII YOTOM \\ 423 

i\m inother*s life, cniQiot<»»iy may be done, when the con- 
jn^-^ate meiisures as naifh as 3i or even Hi inches, 

WJieu Hie rhiltl is iiUvt\ unci parrifirlug it is nef'essary to 
savt^ the tiR^llier'i^ life* the ehoice lietweeii craniotoniy and 
alKloniiiml section becoiiies a serious and ditBeult resjMinsi- 
bility. As a rule, most ulistetrieirios lurord sn}>crior value to 
the inolher*s life. In some eases the ne<'essity of u mutilating 
operation ufjoii the child, as \vt;ll as ahduoiiiial n^eetiun U|kju 
the mother, may be obviated by synipiiyseotomy, as already 
exphuned. Miuvh will depend npon the confitfion of motlier 
and ebild, ami the ehaio'et* of their survival afuT an abdom- 
inal operation, which will aiiain depen<l npon the surgical skill 
of the operahir and his assistants, and the favurable r)r un- 
favorable surroniidiu^s*«f the patient* A^ain, while the child 
may not be ar tuiilly rlead, it nmy be moribuiid, or so nearly 
this as to leave little tir no bupe of itw survival after birth. 
To wail for tiueb a child to die m utera before doing a crani- 
otomy, when the mother is in no condition to bear a Coesareau 
section, and when, too, the delay may greatly reduce the 
chances of her owr* survival, woidd gcem to 1m* unfair to the 
wonuin. After the chancers and comlitjons have Iweu fully 
explained to the patient or her relatives, it would seem but 
just that they should have a voice in deciding what course to 
purine. 

When, however, the conditir>ns are ffeeufedfy favorable for 
an abd<iminal section, Init this is jxisitively refused by the 
patient and her friends, the obstetrician must decide, by the 
dictates of Ids own conscience, whether to withdraw from the 
case or do no ill-advised craniotomy. Ever}- man must be 
governed by his own code of ethics in such emergencies. 



CRANIOTOMY. CRANIAL EMBRYOTOMY. 

Operation, — ^The several ste|i« of the operation are : 1, Per- 
foration. 2. Excerebratitm. 3. ( ephalotripsy. 4. Extrac- 
tion (delivery ) of the head, by several different methods. 

The i>atient is placed U|my her back on a table of con- 
venient height or crosswise on the bed with her hips near 
the edge of it. Every aseptic precaution is to be rigidly 
followed. Anaesthesia while not al>s(>hitcly necessary to 
frt-cveut |uiiii, is desirable to shield the woman from the horror 



424 MUTILATING OPERATIONS UFoy THK CHILD. 



of the pr^x'eediii^r^ TIk' fi rf^t fite(> ia perforation of the akulL 
For tlii« |)iirfK)j<e jH^riijmttjrs ( *' pierce-i^rsuK-H" ) hnve t>eeu 
ik'vi?ie<t, miwt of thrm iiiodiiiciitioii8 of Sinellie*?? scissors. 
(S<-e Figs. 20;i li(l4, 2*^:^) 

The iTijitnnneut fonsi:?tj^, in lirief, of n w*issorw with long 
Imadles siinl sliort hhidcs, the terminal inch of the Itrtler torm- 
ina ti triatifi:le whow tijwx h the jKntit^ and at the Imse of 
whieh is an elevated margin, or projecting shouhler-stope, to 



Fro. 2oa. 



Fro. 2CW, 



Fig, 2(15. 




Vi.riouB forms of perftjrntora 

prevent a too (h^ep ] penetration. Uolike ordinary scissors, th© 
onlftidf l>order tmly of the bhide i.^ i«harp, Carefnlly jijuardeil 
and ^Miided iiy the tiiiLrirjs while entering; the vairina (see Fig, 
2f)B), the [M>int of tlo' hliide \^ made to penetrate the sknll, as 
iirurly a* pns.'iifdc »t rijiht an^'^h-i* to \\s :^urface, to pre%Xiit 
frlatic»n;i^ofr, until further |ienet ration \^ arreste<l by the Khonl- 
der-«toji8, The handler* are then manrpnhited so astoti[ien the 
hlade^ the outer edcres of the latter ihnt* niakimr an incision 
in the cranium. After withdrawing'' fhe reehi?HMl hhide-p*urtt« 
from the .nkull — not from the vagina — the in^^l rinuent is twistt^d 
one-fourth of a circle and agaiu a}»plied as l>eforei so as to 




CRAMOTOMr. CRASJAL EMBRrOTOMK 425 

nmkv a erufial irieLsifiii. Il h llieu |>uslit'd mi>re *leeply iiit<* 
the rniuiiil mvity nut I iiirneii a I tout in all dirtx-tiuns to break 
U[i the Unuw nnd it.s rut-mhrmu:-?;, vtire ]wnv^ tiiken, it'lJuM'liild 
be alive* tu kill it at *intv. l»y breaking ii[> the niedulhi uh- 
loogata. The puiiaU lo Iw preferred for peuetratiou are, in 




Pcrfrywiiion of the skull. 



henfl pre^entntitms, tlie |MirietH! hone : in face ca^^eja. the frontal 
booi^ orliit-s *>r nwd' of the iiiouth ; atitl in relaint*il heml fid- 
Icminir hreech presi-nlatioiis, the liase of the mTipul, J>ehind 
the ear, f*r, if the ehin car» be pulled down, tlie roof of the 
mouth, as* in face cawes. 



420 MUTILATiya OPERATIONS UPON THE CHILD, 



\Vljt*u jwrforating a head that is )mtvahle at the hriiii, it 
shcjuld i>e hehl stea^ly l:»v tht* bandit of iiti ast^istaul niakiu|j^ 
extc^rnal prt't^^un^ over the alidnnrtn ; or the head may be held 
in jjhice hy ^^raj^pmg the seulp near the point to he punetured 
with u volselUim hiree^ia ; or, if practicahle. the ehild may be 
t (timed and perfomtiou done on the after-eoming head. The 
operation is easier wlien the os and eervix uteri are fully 
dilated, hut may he done when dHataiion is* incomplete, thb 
prmx»i>8 heiiig afterward exjjedited hy artiticia! meaiie. 

Jieside the seitLsort*, perforator?^ have heen eoni?trncted on the 
])rinei])le of the tre|)hine. {See Figs. 20" and 20H. ) A round 
hide 18 cut in the oranium, through which tlie brain may come 
out. i>nt the t^cissors ore best when it is de8ired to break up the 
bone8 afterward ; or the more mtnlcni |>erforaU>r of Tarnier 
may he used, esjiecially when tht* head In nui%*ahle al>ove the 
pelvic l>rim, ami the seisHjry are liable to slip off from it. 
(See Fig. 209.) 

Contraction of the uterus, together with resistance of the 
pfdvic walk, after perforation, may cause the brain to ooze 
out and j»utliciently re<lncc the Hze of the Iiead to admit of its 
piij^siige through the |>tdvis ; geoeraily, however, further arti- 
licial aid li^ nercssary. 

Excerebration (Decerehration),— This is the next i?tep after 
|>erforatioiL It iiu juis rtTnuval of the brain. This is done hy 
a sco<Tp or sjwxm pju^sed in through ihe rjpening, or a Htrong 
str*^am of sterilized water, or. preferaldy, a warm 1 to 5000 
hieldoride solution nuiy be injected with an ordinary David- 
son's syringe, and the cerebral mti«? washed out 

When colhip*^' of the head after these measures in atill tiot 
Rirticient fi*r delivery, we prmeed to extract it artitiriiilly. 
The .Hcvt^rid in^^trnments used for this pnrjxK^e are ordinary' 
obstetric fort*ej>s, the craoioelai^t, the ce|dialotrihe, live ba.^io- 
Irilie, the crotchet, the hlunt-hook» and, when the comminuted 
head refjuires to be extracted hit by bit, eeveral fornts uf 
enmiotomy forceps. 

The ohatHnc foret'pB may be used after perforation when 
there is? only moderate resistance to be overcome. In bud 
(lines it 18 apt to ^V\\\ ijor thien it exert i^ufticient corn preflgioD to 
flatten the skull, and heoce i^ selthjm atlvisable. 

The crnnktchd ( Fii^J^ 210 an<l 211 ) is unquestionably the 
beat instrumeut for extracting the skull after pc*rfonition. It 



CRAmOTOMW CRANIAL EMBRYOTOMY. 427 
FIG, :^7. 



MurUn'i trephirit\ 
Fiu. *2m. 




PerlbrftClon with Murtln's (rcpliliM. 



428 JilUTiLATiya OPERATfONS UPON THE CfULD. 

consists of u stron;^ solid puir u^ forre|)4s with small iluckliiU- 
shajjed bladei^ i?errattHluii lbt'iriiii[»ui^iii;j:8urfiicei». Duf blade 
goes inside tbe skull, tbt' otlier miiside. They nre introduced 
separately, and lock like for<c|*8. Wbeu applied, the iu.side 
blade which is siuuller I ban Ibf other and hai^ no lenct^tra, 
apjKises its coitvex serrated surface a^aiust the ctjucavity of 
the enmiuni, while the outBiile one — larger and having a 
fenestra against which the olher may pre^^g- — rests its concave 
se rrat ei 1 s y r face u | >ct n t h e con vex ex terior of t h e sk ij 1 1 . \V \\ c u 
the handles are brought together aHer locking, the blades 
gra^p the skull firmly, never ^lip, and m^cupy hardly any 
sjMice. ,-^incc one i:^ inside the emptied cranium antl the other 
imlH'ddcd in the m^ tissuci* of the scalp. Ijaceration of the 
mati^rnal i^i^ft |*arts is avoided, i\m\ sh(*iild the piece of nkull 
gras(>ed by the instrument break off, it is easy to take a fresh 
hold by ohauging the position of the blades. To prevent this 



Tarnicr's perforator 



breaking off, the inside blade may be pa,«scd in far enough to 
touch the base of the skull, while the outer one is applied over 
the face or hiwer part of the occijjut, thus a firm hold igmade 
on the solid part of the skull near the Imse, which last is also 
eomprei^^d by turning the wrcw in the ham! lea of the instru- 
merd, ami the jMrfi»ratcd skull in its entirety is extracted. 

Ceplialotripsy. — ^( Vf»halolnpsy consists in crushing the skull 
with the fephalotribe, an instrument e<mij»ost*d of two thick, 
narrow, s<did blades, which are applied singly (like forceps), 
anil afWr being ItRked are made to appn>ach each r»ther liy 
means of a screw rimning transversely through tlie handles, 
9o that |^)owerful tMmij>rc*ssiot] is made npm the skull anti ita 
bones crushed ; or, witlu>ut ernshing, the instrument may 
siniplv be used for compression and traction after perforation. 
(!<ee Fig. 212, page 4:U>.) 

The field for the use of this instrument as an extnictor is 
limited. As a rule, it cannot be employed without inllicting 



CEPHALOTRIPSY. 



42d 



serious injury to the nmther vvJieu the coDJugate diameter 
measures les8 than 2| ittcbea. 



fm. 211. 



Fio 210, 





Cmuiocla&t. 



Brmun's cruiitoclitAL 



It raay be used to compress the skull J)^fore it becomes 
fixed rtt tlse brim, arjd 11*5 the intitrunient here seizes the Jiead 
obliquely^ \\ie euiiȣ*(|iient buljriug uf rhe eraniuni \n theo|>i)0- 
site direetiun tnkts [ilare in the other oblique diameter, where 
there is usually more ftpac*. 



430 MUTILATING OPERATIONS UPON THE CHILD, 

If eraployefl below the brim, the instrument is afijilied to 
the truiisvt'rso diiiriietfr, ninl here compression causers liulging 
of the hemt in ihc !uitero-|j<psterior tlireilion — just where there 
is iii*ually U^SvS room thun nnywhere else, Heuee, after com- 
pressiou, the bead shfmhi be rotated into aa oblique diameter 
before tractiuu is attempted. 




Ci»phalotTlbe, 



The eephalotnI>e h mmeimwa n.«efyl in exlnictmg the after- 
coming head where pelvic tTuitraction ia not greaL 



PIECEMEAL CIlANIorOMW 



4:U 



Piecemeal Craniotomy. — Witli the pniper selection i>f cases 
and [xjss^es^ioii uf jm>j>er infjLnniieiilii, the iield for this repul- 
sive operation hiw lnn'(ir»i<' »ti linuU'il that mme ol'nur nnxlem 
text-l}o«)ks onut any ile,s^ri])tion of iL Sinre, iiowever, laider 
opptmfr eircumdancea the o[KTatl<iu will doubtleik? become ttti 
yuweletmte neeessUy, the method i>f doing it may now be 
de^erilM'd, 

When the pelvis is too miall to adnnl the extraetion of the 
periocited sknll iu iU entirety, the eriinioehist or the *Tuni- 
otoniy f'orce[jB (Fi^^i^. 213 tu 216 ) may i>e uj^ed to break off 
pieces of Imne and deliver in frajL'^inents. When the whole 
vault of the cnuiinm ban l)eeu l>royght away, bit by bit» the 
larger feneist rated blade of the iTanioelast may be placed id 
the mouth or under the chin, and the smaller lilade in??ide the 
baAe of the frootiil hemes ; the interveuiiv^^ tii?i«ues? are theu 
comprei^sed by turninir the screw in the handles of the instru- 
ment, and the renniins of the heiid turned round so as to bring 
the flattened base of the skull into the transverse diameter of 
the pelvis. The thickness of tissut^ betw*^u the chin and 
orbital plates thus irraspcil is about two iu^dies, and can there- 
fore be drawn throu^rh a flattened [>elvts the a titer*> posterior 
diameter of which slightly exceeds that measurement 

Attain, when the cranial vault has* l>een removeiJ by the 
crauiocliu^t^ etc., extraction of the remaining bjiseof the skull, 
which is tock sfdid to Iw broken U]\ may l>e facilitatc<l by in- 
serting a blunt hook in the orbit, or getting a Jirm bold on 
the l^>rehead with craniotomy fnrcejKiJ, and tlien, Uy making 
downward and backward traction, brintjhuj tJoivu the face. 
The syni)>hysis of the lower jaw is next divided, an<l the two 
halves of the bone pushed aside or remtived, when the re- 
maining pijrtioii of the face, from the alveolor hoarder of the 
upper jaw to the root of the nose — only measuring Ij inches 
— njay be made to enter the pelvis, and the base of the skull 
extraetefl. 

In taking away the skull piecemeal, smaller iostruments of 
various shapes and sizes — the craniotomy forcep8 (Figs* 213 
to 216) — may be employed. 

These differ from the cranioclast in l>eing smaller, and in 
having their blades yK^rmariently joined at the lock» like ordi- 
nary tooth forceps. The inner surfaces of the blades are 
serrated ; some are straight, others bent at right angles 



432 MUTILATING OPKnATIONS UPON THE CHILD. 

(Figs, 215 aud 216). They are uaed to grasp, twist off; and 
extra€t jnetn^B of lxmt% (lie piiijt of ofte hiade going i)ito the 
skull, that of the other mtiMule of it, but nndtr thf scalp, this 
lih^t haviijg beeD previously loosened from its aitiichmt-nt to 
the bones. 

Fig. 214. 



Flo. 2151. 





Craniotomy Ibrecpt. 

lo all theee operations the greatest care is neceesaiy to 
avoid lacerating the soft parts while wlthdrHwing sharp Ixxny 
fraijmentja. The vaginal wall must be pushed aside by the 
fingers or, better, a large nlitHlrical or a 8inis* speculum 
used, and theofneration rondueted under the guidance of sight 
instead of touch. 

The croUhet ( Figa. 217 and 218) is a steel rt)d, the end of 
which, flattened int(» a sharp* triangular |wint» is bent round, 
at an acute angle, tu form a hooL It is passed into the 



^ 



PIECEMEAL CRANIOTOMY. 



433 



cranium through the foramen magnum or through a perfora- 
tion made in some solid part of the base of the skull, and its 
point made to penetrate the bone from within outward, so as 




straight craniotomy forceps. 



to get a hold by which traction can be made. A finger-end 
is placed outside, opposite the point of the hook, to prevent 



Fig. 216. 




Curved craniotomy forceps. 

laceration in cjise the instrument slip or tear out. The " guard- 
crotchet" has a second solid blade (attached to the other by a 




Crotchet. 



"lock"), the end of which takes the place of the finger in 
fitting over the hook to prevent injury. How ever constructed, 



Fig. 218. 



Crotchet. 



the crotchet is a formidable contrivance, and since fearful 
laceration will often occur, despite all "guards" and care, is 
now seldom used. 



28 



434 MUTILATING OPERATIONS UPON THE CHILD, 

Basic trips J. The Basiotribe and BasOyst. — While the 
biLse ut'thf t^knU b U»t solid tn he hrukcu up wilh the iuMni- 
ments thus fur meulioiuHl, othery hiive heeii tlevmnl imperially 
for thin purpii^e, noUhly the ** biisilyst'' of Sinj[it?uri and 
Taroier*H ** haijiolrilK?," Tbe ojK*raiiou is called ** hjusici- 
tripy." 

Simpsou*8 ingtriirnent (.'^ee Fitf, 219) cimsists uf a r(*d \vhi»?*e 
distal eDd terminates in ii eonicnl s<Tew ; iMitli the rod and 

Fio. 21». 




Sim|»on'a basil 78t. 

the Bcrew are split lonjritndinnlly, ami m urruuired that the 
two Intlve^ nnxy tm ti)reihly ^e)iarated l>y a device at the 
liaiidle. The smtcvv is (>a.ssed intn tbe !<kull — throu^'h (lie 
ot>t'i»in^ previuu^y niude hy [>ertiiratii*n — niitil it eonie iit e«>n- 
taet with the base, which, hy n htrrinir motion, it ij* made to 
peuetrate uotil tbe iustrymeut m well tixed, when, by pressing 



Fig. 220. 



^^ 




srmtison'e busltynt. when applied. 



the two purta of tbe ban<He toother, tbe two halves of tbe 

screw i»e|nirate (see Fig. 22<V) and break nf) the lK>ne, 

More recently Simpson has improved hin original device hy 
adding a third bhiile which is ititroduced over tbe outside of 
tbefaee or occiput, and when prcip-rly adjitstcHl thus eonverL<i 
the instrument into a craniocdnsit^ a^ shown in Figs. 221 aad 
222, 

Tamier'p basiotrdie fFijr. 228) h eompo^^d of three pieces, 
vh, : two stronji blades and a central shaft. The eentral 
shaft, at its dii^tid end, terminates in a hollow etme of four 
bare, the a()ex iif which w a screw. In n>iin^ the inj^trumml, 
the oentral bar, by itself, ia U>red into the dome uf the skull 



BASiorniPsr. 435 

(perfaratioii), then piisbt^<l on lhroy;i;h the hratii, until the 
fecTew cume iu L-uiUact with the base nut I jH.*uelratt' it The 
twQ hladei} (oue loii^ an*! ime sliort) are theu introtlueeil, one 
cm each side of the head, ji>i sliowii in Fig. 224, and erui^h- 
ing of the skull |irodueed by turning the uompresgiuo st-rew 

Fig. 221. 




SimpBon's improved liasllyiit. dlsartipuluied. (Frum Willi amsi) 

paaeing through the handles. Tbe instrument h really a 
cephalntnlve, with i\m athlttiun uf a third blaile or siaift for 
breaking up the ba&e of the tskulL The i^hnft is pruvideil 

FlO, 2J2. 




Simpson** ImproTc^ bwilyBt. ftrtleulntcd, (From WitUAMS,) 

with a Imtton pivot, by which if i^ liM'ked serurely to the other 
blmle when applied. After nsiuf? the deviee snccessfulfy the 
BkuU will be rruslied and red need in size, as shown in Fig. 
225 (page 437), the outline ^jketch representing tbe shape of 
the compresst^d eraniuni. 



436 MUTILATING OPERA TfOSS UPON THE CHILD. 

GeneraUij Hpeakirig* a pelvis sufficitntJy large to allow ex- 
tradion of the head hy craniotomy will permit the Ixnly to 
pasa without miitilatioii. It iiviiy he ueces^ry, however, to 




Ttmier's biAlotribe. 



pull on the neck until a l>1unt-hcx)k t^an be poaaed into the 

axilla, hy which the shoulders — first ouc, then the other — 
may be drawn out. 



CORPOREAL EMBRYOTOMY. 



437 



ExfepiwaaUy it niiiy lie iiecesMiiry to o|x*rate on the body ot 
the child ; corporeal embryotomif. 




Fio.22a 




Appitcatlon of Tttniler*8 basiiA ri ix;. BftsfotHpey nccoajpUjiUisd, 

OORPOEEAL EMBRYOTOlffT. 

This emhraces seveml y]>erntioris, viJt. : Decapitation, evi»- 
cerntioii, s|>tinrlylotomv, and cletHotoniy. 

Decapitation. — S('|Kinitin^ thu head from the ImkIv is re- 
quired in imparted shoulrit^r j>ri\sentationFi (arrested **8|)onta- 
neoua evolytiou") when tlie child ia jammed tightly in th© 



438 MUTILATING OPERATIONS UPON THE CHILD. 



fielvis and cannot be moved up or down ; or again, in cases, 
williout iniiiaction, IkH whore the lower segment of the uterus 
is St) tliin }»elow the rin|^ of Btuidl thut verssion would lie .sure 
to produce uterine rupture. It niuyals^o i>edoiieo[i iheafter- 
eouiin^ lieii*! of u child whose delivery is prevented by *' locked 
twins'* (q, ik ). 



Fig. 226. 



P». 227. 



1 





Carl Bmun'B decApiutlon hook. 



Decopltatlon by Br«un*< htiok. 



Oftrraiioru — Get down an arm for tmetion. |ia99 a hlunt- 
ho<»k around the ntM-k, arid while it is^ held as low tlown as 
poHMible, niblite throujijh the verte)»ra? ami soil parts w^ith A 
blunt-p>iuted |»air of scissors. Cut everything* so that the 



DECAPITATION. 



4aU 



biM>k or fiiig'er niny be |>hssch1 tliroug^h theitiei^iioTi to aecertaiu 
that tJie lieiul ami iMwly are t-omplvkly sej>a rated. 

The ba«t <levice for det'njjitatioQ is Bniun's hluiit-h*Kik 
(Fig. 22 1) ) made for the special }jurposc of disartieulntiiig 
the vertehrse. 



Via, zib. 




niAnrticnlatton of cerviciil vertulira^ by the dwApUatlon hook. The Arrow* 
Indicittti tlitt tcvtindl frcj movement of the hook tnnde \*y the mtary moilon of 
the haniUc, thrciugh l^K) dt-grces tir thereabouts. 

The bladder and rectum bcini^, of course, empty, tlic book 
is guided over the neck by the iudex*finger, which alg»o 



4ii} MCTfLATrxa OPfCnATiOXS UPON Tilt: CHILD. 



gminh the [xjiut of the iiistrunleut from injuring the mother; 
theu with fc^Lroiig lj*aclii>ii oij the handle ami a brisk tiMtnd- 
fro, rotut'if mofion the ctTviral vertehrte are diwutieuhitt-d, |)er- 
hups with u p^rcepdldr snap. By re|M^ating tlie niovi-ments 
the reinaiiiifig tissues of tlie uevk may hei'onjpk'tely s^everLnh 
or thib .sevt*ra!jce raay l«e hiustcnt'd hy blunt sciissors while the 
hook is niakinir bteady tnulion. Wlien the arm is dovvn^ the 
»:i|>i^ratiou nniy he tVirilitntetl by .stroii*^ traction upon it made 
hy a liliet in the liands uf an a8?*L'*lant> 

Other contrlvaiifei? consist of chidui^, wires, aiid si rings 
passed annind the neek and throngh a Jong, doulile caniihu 
to j>rotect the vagi nOj while, hy a sawing to-and-fro movement, 
the neik is severt^il. 

After deca|>italion, the head Is pushed up out of the way 
and the lM>dy ileliven-d lirst, by iraetion on the arm, evisi^era- 
tiou, etc. The rerniuning head is theu extraeUxl hy fon'e|T8 
or, if re<}uired, hy eraniotomy. In atteitipling the latter o|>era* 
tion upon a decapitated head, extra care is ueeessary to pre* 
vent gJippiug of the jwrforator. An assistant i*teadies the 
uterus hy firm abdominal [ire^^sure to keep the head from re- 
volving whih/ tlie in^trnment is lieing ns**d ; or lie may sleafly 
it from hehiw hy long vulselhim forceps hooked iritrj the st^alp 

Evisceration ( Exvisceration, Exenteration), — Evisceration 
jjieans o|M'!n;nL' the thoracic and ahdominal cavities (one or 
Iwth) and lakijig out their viscenu 

It may, though very rarely* l»e necessiiry in extracting the 
hody after eraniotomy, or when there is H>mc ahiiormal en- 
largement, or monsin>sity, on the pai1 of the child. It is re- 
sorted to more frequently in iiii|(artrd transver^ic jirescnlaiion, 
arrested **sjM»ntaneons evolution/' etc, 

Oprmfiou, — The thorax in |jenetrated near the axilla hy 
curved scissors or the |>ierce-crane, and the thoracic organs 
hroken ufi aiid removed^ either hy instrumeiUs or, if [^raclir'a- 
hie, hy the fingers, Throngh the same o|wiiing the diaphragm 
may he perforated and the abdominal viscem removetU The 
same care is nei'essary as in eraniotomy to avoid lacerating 
the vagina with s|dinters of lw>ne. 

When evi.«ceration U performe»l t?ul>se<|Uent |i> cranjoton»y, 
the Ixxly may heaOerward tlrawa out hy a hluut-haak in the 
arilla^ as above directed. 



CLEIDOTOMY, 441 

lu impacted transverse presentations the eviscerated Ixxly 
may be delivered in one of three ways, viz. : (1 ) By traction on 
the arm and shoulder ; (2) by passing a blunt-hook to the groin 
and pulling down the breech ; (3) by grasping the feet and 
delivering by podalic version. Which mode is to be selected 
must be left to the judgment of the obstetrician, much depend- 
ing upon the position of the child, its size, and the shape and 
dimensions of the pelvis. 

Spondylotomy (Division of the Spinal Column). — This may 
be necessary in those rare transverse cases where the back 
presents and delivery by more benign methods is excluded. 
While an assistant holds the child firmly against the i)elvic 
brim by ab<lominal pressure, the spine is divided by strong 
scissors, or by bone force|)s, per vaginam. The lower seg- 
ment of the spinal column is then drawn down by strong for- 
ceps, or by a cranioclast^ and scissors are again used to com- 
pletely divide the child's Ixxly transversely, the two halves 
being then delivered separately (lower half first) by traction 
with the cranioclast or some other suitable forceps. 

Oleidotomy (Division of the Clavicles). — This has recently 
been done in impaction of the shoulders from their excessive 
width, or from a contracted pelvis, in both head and breech 
presentations. Normally the bisacromial circumference meas- 
ures about 13i inches (34 cm,), which may l)e reduced one 
or two inches by division of l)oth clavicles, the ends of the 
severed bones over-riding each other, as in fractures. 

A long pair of scissors, guided by the fingers, is introduced 
closed, along the anterior surface of the child, j)er raginam, 
until the ridge of the clavicle is reached, when the instrument 
is opened just wide enough to grasj) and divide the bone. It 
may be done on one or both sides. The divided l)ones at once 
over-ride each other. 

If done on a liring child (which lias been suggested) the 
division should be made near the scapular end of the i)oue, or 
between that end and the middle, to avoid the subclavian 
vessels, which lie toward the sternal end. 



CHAPTER XXIL 



PELVIC DERmMITIEH. 

A < GENERAL study of i»elvic Jetoruiity i** necej^sary, in order 
(hat we iiiuy learn tu ascertuir* — ni leust approximately — the 
degtre mid kind of rnalfiirnuitiini exis^tiiig in u given ease. A 
kn(»wleilgc of the d^'grre oi' detbrniity iodieatee whether de- 
livery by the natural [iaa<age8 l)o or l>e not pnicticnble, and 
deternnnef? the niotie uf aasij^tanee by o|ierative measures, A 
kucnvle«lire uf the kind of maltbnnation, derived ehieily from 
examination of speeinieiia in muHeums, indieales what diam- 
eters are most likely lu be alti-red in lenirth, and what parts of 
the pelvi>?— brim, cavity, or uullet— are ehietiy affected, thug 
determininij necessary mod ifirat ions in the meehauii?m of lalx)r, 
and indteatintr the methods of treatment. 

Numerous attedipts have been rnaile to elassify the various 
kimis of deformity, grouping them aeeording to their etiology 
and jtfithology ; their mcnles of origin, ete., and while thi.s is 
endnently desirable ftir scieiitifi** pnrpo.^es, it helonp* to the 
pathologist rather than to the obf^tetneiaru The eharnetew 
of the different tyfR\s uf deformity — of their varietiesi and >\\\y- 
varietie^s- — may be m mixed in a given ease, that no one can 
say to whieh grou|> it pro]>erly hehrngs. The raelntic jiclvis 
may be Ciunbiiied with the deforndtyof osteomalfu-ia* the so- 
called pt^endo-ojiteomalaeic raehitie pelvl«. Again kyphosij* and 
raehitis may eoexint protlm'iug the kyphthrarhitir jieivis ; and 
to thi» may sometimes* be added seolioi«is |*rodueing the kf/pho- 
^eoliQ-rtjrhitic ;/t7r<\ There are many "iubvurieties tif this 
sort, but if one ask what is the ol>stetrical management of 
labur in the^e different varictie-s of jielvie contraetum, the 
same answer appli*^s to all viz. : it depends U(K>n the length 
of'the ptdvie diameters and the i^ize of therlnhrs head, in each 
given case. 

It may lessen the embarrassment of the Ftudcnt and young 
obstetrical practitioner, and give them some encouragement 
442 



THE FLATTENED PELVIS, 443 

in considering this somewhat difficult subject, to reflect that 
many of the varieties of pelvic deformity described in the 
books are very rare, and will seldom be met with in practice. 
Let it be noted also that at least two forms of pelvic contrac- 
tion are of comparatively common occurrence, so common 
that they constitute the principal basis from which rules for 
obstetric practice have been formulated. These two forms 
are: (1) The '' flattened pelvis '' and (2) the '' generally coiir 
traded pelvis^ And to these may be added a less common 
third variety, viz., (3) a combination of the two, that is to 
say, a "flat" pelvis mith "general contraction." 

Now let it be understood that by a ** flattened " pelvis we 
mean one with antero-jmsterior flattening ; the sacrum and 
pubes are too near together, the conjugate diameter is short 

The "generally contracted pelvis" explains itself; all its 
diameters are short, its shape may be normal, but its size is 
too small. 

Finally, such a small pelvis may also be ^'flattened " antero- 
posteriorly, producing the combination (3) above stated. 

The great majority of cases met with in practice come 
under one or other of these three kinds of pelvic contraction. 
It is from experience with these cases that rules for practice 
have been agreed uix)n. In the rarer forms of pelvic narrow- 
ing, no definite rules can be stated. Every case must be 
treated by itself, on general principles. 

The Flattened Pelvis: Rachitic and Non-Rachitic. — The 
typical rachitic pelvis is the most common and most impor- 
tant of all deformitias. The pelvic brim is shortened antero- 
posteriorly, the sacrum sinking doxni between the ilia, and 
having its promontory tilted forward toward the j)ubes, thus 
producing the ^'flattened pelvis,'' — i. e,, it i.s flattened antcro- 
posteriorly, the posterior and anterior pelvic walls approach 
each other too closely. 

With the forward tilting of the sacral promontory (as if 
the whole sacrum had rotated a little on a transverse axis) 
there necessarily occurs backward projection of those segments 
of the sacrum immediately below the promontory ; in fact, 
this part of the bone projects so far backward as to become 
almost horizontal. (See Fig. 229.) At or about the junc- 
tion of the fourth and fifth sacral vertebrrc, this backward pro- 
jection abruptly ends with a sharp bend forward (also seen in 



444 



PEL VIC DEFORMITIES. 



Fig» 229). This beading forward of the lower end of the 
sticTum fund ciXTyx) ij^ |inrtlv due to its bc'iug held Imck by 
the 8aeii>sK'iatk' UgajJieiitB urni Dtbt-r lUtnchrneiUN and partly 
to the sitting or senii-rwuniheiiL p)fiture»> fre(juejitly af<8iime<l 
by rachitie ehildreo wlio are too feel tie to walk. The eon- 
<'a%'ity of tite siR'rum h lewseued from side lo i^ide, and niay 
even liec-dint^ fhit or convex from forward prujectiim <if ibe 
bodiesi of the U|>[»er ^icral vertebiie. 

M(»st of all must it be uoti'd ihat the nornud relation bi^ 
tween the length of the interspiooui^ ami interere^tal external 
nieiLsureovenUs iVl and liH iiicheis re^jyeetively ) is Imt, i. r,» 
ioHtead of the inter^piiiout* beiu^ an inch shorter than the inter- 
erestal, the two are uearly or rjuite alike, or the iiiters-plnous 



Fig. 229, 




Rachitic pelTta with bacVTrard depnp*»lr>Ti of symphyiis puUrs- 

even mea.Hurei< more than I he interert*stal. This is due to the 
win^'9 and ereM;* of the ilia, wfiielu instead of maintaining 
their normal degree f*f vertieal elevation, bei^orne 8prea<l out 
laterally, henee the anteriur .*ii|)eriur s|iii)oui4 prorej*ses In-eonje 
farther apart. The rand of the puben l>eronje tbiftened, the 
puliie areh wideneiL an<l the iscbin diverge from eaeh oiber» 
The total result is a ehallott pehm with contt'aeied brim aud 
expituied outUi. 

There is fiflen a relative lenptheniujEj of the Iransver^t* 
diameter of the brim, which fni^hi be compensative, were it 
not ff>r the fact that the |>elve8 of riekety ?;ybj(»et8 are uBually 
under?ii7AHlfTA initio, hetjce the letjtrthened transverse diameter 
seldom exceeiU the uonunl measurement. 



THE FLATTRSED PELVIS. 445 





Wom«n with fliH iwlvis, (Prom Womnn with tmnnftl iw^lvK bneunB<»cif 

l)AVis, iiQcrSTKAT*.) MJrJnii'lis w«ll furmiMl, <Fr..Mi hivis jifirf 

STItATJ!.t 




Ou irii^j>eotion, ii racliitie wotimn, i^tarniitig erect, fe«hows jx>9- 
teriorly, a tnnuHverse «lepre8sior» (almost tlie iK'ginniiij? of a 
fiflwiire) arrom the hack, prtHhiced hy the baekwan^ or hori- 
xnnt4il projectioo of the snrriirii, while fmni (he same muse, 
the nonnai vertical iiiteniiitul fosure is ^t tar ohl iterated as 
to rentier the anus visihte. 

Surh are tlie ityitai, iiiid most pronDuriet*il e ha ract eristics of 
the typical rachUir fiatfefH'd jK^lvi?. More rarely all eorte of 
variutiotis utrur ; thii^ eonjoiiitly with the foregoing altera- 
tioo8 there may he iatcrul curvalure of the P|>ine, hence the 





1 



THE ''GENERALLY CONTRACTED'^ PELVIS. 447 

aeoli(hrachUic pelvis in which one iit'etabuluin is pressed iu, 
productiij^^ irregular and ohlujue dt^brmity* fiwiog to the 
curvetl hpint' cun^iug the patient to walk with thi' weight of 
the body more on one ucetabwluTn tlniti the othiT, A gain > if 
the rickety ehihl, with its softened pelvic biMiet?, be able to 
run about, the weight of its IxmIv falling ef|ually ujxin bofk 
acehilaihi, then both titles nf the jwlvis will l>e [iressed in* 
produeing a deformily resrienibiing that of i>9tt'onialacia, hence 
ca 1 1 ed * * psf mh-ma laco4 eo n ' ' o r * [i^emlo-m a htei a. ' * Sr \ | kjs- 
sibly, we may have a riekety infantile pelvis, or a rachitic 
*^ tjeneraiiij cmitrurtfd ^' pelvis, and nniny other c*implicatioi)8. 
But these are ^nuisual ; the eornnion rsiclutie [iclvis, with eon- 
jugate flattening, as first abovt^ desiTibed. is the ooe from 
which we get nupst trouble in obstctrir prailiee. The degree 
of obstruetion has no linut ; in slight eases it is moderate ; in 
bad ones so great as to make C'a^sarean seelion a neeessity. 

Beside the raehitie flattened [telvis there oeeurs qnite fre- 
quently, a Hat |Kdvi* viihotit rickets ; the lifm-nwhitic fiai 
pehm. III some countries of Eiirri|>e it is said to be more 
common than the rachitic variety, Fortuiialely it seldom or 
never produi^-s very ijrttd obstruction, the conjugate diameter 
m s< areely ever less ihan three in<dies and in most cases it is 
three and a half or three and threes |uarters. (Ht^e Fig. 232.) 

The obstruetion is [>rijduetMl, as lu riekets, by mnkiug ilowu 
of the saerum between the ilia* but, rod ike ricketi^, the saeral 
prouKintory does mtl projo4*t ff^rward by rolation of the sacrum 
on its transverse axis, hence there is no tdting backward of 
the sacrum hehiw the ]>romontory. Nor is there any exfrnn- 
sion at the outlet. The sacrum ( whieh is usually snuiller 
than usual ) sini|>ly sinks doiPttyard, hence w bat little degree 
of obstruetion <j<'eiirs, exists in all parts of the |>elvis ; 
sijfierior and inferior straits as well as in the cavity. The 
lateral walls of the [lelvis do mtf flare apart laterally, hence 
the iioniia/ rt fat ion between the inlerspim>us and intercrestal 
external measurements is preserved ; i, e,, the intercrestal re- 
mains longer titan the jntcrspinous. 

The **(}6neraUy Contracted " Pelvis. ^T he most common 
ihrm of ** tjf'rtrr*il/f/ eiintt'aHf'd'' jMdvis is the so<*alled *' prfvis 
tupiftbiiiirr JuHt.o^mitiar,^' in which the nhitpe of the i^dvis is 
normal, byl the mze is sujall ; hence the measurements of rtlf 
of its diameteni aTepropurtionukij/ shorteneih It was observed 




448 



PEL no Diet OHM ITtES. 



m '17 |>i»r ceui, of tlie t*oiitnuTte<l |ielvcti repirteii by Muller, 
autl in 28 |>er eeut nf (JiiiinerV casi^. Winiunm, uf Baltiuion?, 
found it in oiicsthinl of the (oiitrnctfil i>t'lvo^<w'c'uiTiug in white 
women, autj iu two-tliirtk uf those in black woujeu* Observe 





X Jnflo>mi^)or pelvis, B. Normal iut<*r-CTCflLiil dtAmetcr. V Jotto-mtnorjkoWli. 



that in this juslti-minor j^lvig, the oonlraction i» mifmmdrioal ; 
it 18 a congenital variatiim. exii^linj;' ah I nit in, and is not ao- 
ncmipanieil by any disease or Kjftening of the banes; in flirt, 
the [>elvis is quite nortual, except in mie. While it w mure 



THE '* GENERALLY COKTRACTED'' PELVIS. 449 

likely to tRtiir in tiiiiii!! women, il is al.^o found in lar^^^r and 
appurtintly wt'll-niarle individuals. 

Besiilt^ the jnytfi-mhtor \nA\\s, *' grntntl ctt/dracttou *' nniy 
alsKJ oix'tjr with tlif^ Jfal pelvis of mr/u7/>. That ii* to 8ay, 
whik^ the i^hcirti^nijiir '»t' iht* iTim t-^mju^'ntt'. com n ion to the 
nu'hitir lhitt<*ned judvis^* h very prououu<v<l, thi-re is aUo ^om^ 
nmtraction ty^ all ihv other diauieterji. hul n^^t a prfyjmrfionate 






The jiiYMiilc (Infuuttle) pt'lvin, (From .I»rwKTT, after Ajilfeld^ 

€*ontracti<ni a« in jusio-iniru)r riisK*is. The p<4vis is #/mrW/y 
flat, while the other diameters are fmly mor/rra/r/i/ contracte<l. 
Very mrthf n ** <rene rally contracted " pelvis is met with, 
due to raehitii?, in whieh there m a more or lesi^ proporfionate 
contractinn of «// diameterj^. Tliere is certainly nolhiuL^ im- 
pj.^ihle in such an unusual conduuation. Willianis, who has 
met wilh some cashes in the oe^rro race^ designates thetu aa 
**gen€raiiy viptalhj ctmtradtAl rachitic pelves,*^ 



450 



PELVIC DEFORMITIES. 



Tlie Synunetrically Enlarged Pelirls (Pelvis £qual)01ter 

Jiisto- major ) . — Exactly uf>jK>>iio to the ]\\m>muioi' jH'lvi?* is 
til e j 1 1 Hto major on e. 1 1 i ■* u < u i i^e d i tn 1 et i n ( 1 i 1 1 o 1 1 . T I u* 8 1 m| « 
is ijtitural ; size in nil (lire<"tion:« inerea^setl. It is «J)piorve*l, 
not only iu iitiantessei*, but ulst» in women of usual tiize, l4ilM>r 
is iipt to lie unniitu rally rapid, with fousfquent liability to 
uterine inertia, |xint-partum hemorrhage, perineal laeeraliou.s 
au*l all the other retsulla of ** Preeipilale Labor*' (see pages 
550 and 551). 

A reprei?entati*m of the justo-inajor and just^viinnor jwlvee, 
as compared with the uurmal 8ize, is ciboun in Fig, 233, 

Flg. '235, 



1 




Masculine, or fkinnel-Bb*i»«?«l |»elviJ. (From JEvrm, afV«r WnscxiL,) 



The Juvenile Pelvis, — ^8hape resembles the pelvis of infancy 
and chiklbood, (See Fij?. 234/) It is an arre:*t of develop- 
ment, TranHven^ ineasurenienti? rcbuively shorter than the 
conjugate, owinjir to mirruwnt^s^ of ftnerunh Side«* of pelvis 
unnaturally ntraiglit, pubir ar<'h narrow, and isehia too near 
tocjether Ijilwr dillitnilt or iin|Ki*i*iible, pro re nnia. In 
]irt*i'uoiouH ni<>ther>J titne may remedy the drformitp. 

The Masculine Pelvis. — S^^metimescnlled ** funuel-shajjed/' 
It is deep and narrow, resembling' that of a male, the nar- 
rowneK** inereasinp: from alwive downward : henee ol>»lructiou 
lo labor most marked toward ihe onth't. The jielvi*' bnne.« are 
thick and boKkI a condition thought to lie produced by laboritni* 
museular work only suituble for tneo. (See Fig. 235.) 



THE MALAVOSTEON PELVIS, 



451 



The Malac osteon Pelvis (see Figs. 236 and 237). — Results 
itom osteomiiluda, a uniform sotteuiiig of the Wiies occur ring 



Fi.;, IJiiC, 




OsWooaal&cie }k4vI», wlLh lM!ak-Uke slmpo Of pub^a. 
Flo. 2S7. 




0!iU.'oiualuck Jivivis. 



i^Kab 



452 



PELVIC DEFORMITIES. 



in adult litk It inuy c<mie on m women who have previously 
horue rhildrc^o without »lit!ifulty, lis? jirouregs tifinii jL^rmJual^ 
tlie jintient ii* iil)le to uy;/^- jihout, beure prej^>iure of thiirb hones 
in iiiTUtliuhi [iiishes in the ^tihs of the jh'Ivis, Hliorleuirig tlie 
tratiMt'eriir diurneter. Aiileriur border of jielvie lirhu hns a 
js|MjUt-shinH:'d uT Uenked apjieiiranco. Kxiejaiomilly, uud in 
very liad vtoies, tlie uhliqUf tunl emijugiile iliumtters may lie 
altfo coutraeteth Ofcuteonialaeia is atjout four hundred times 
leKS freffuent than rieket.s, ("rauiiMorny or t V'sarean sectiim 
may l>e refjuirwi for delivery. Sinuetinies tlie softeued Ij^^uea 

FlQ. 238. 




ObUque dt'foniiity of XiK-Rvk* ; liiM-nsc uu ifjt side, (B41tKtt.) 

yield at»d admit the pasjsa^re of the eliih! by other methmlsL In 
doing at) alHlomioal i^et'tion m the>»e pm^es the oixintm should 
always l>e removed, CuBlratitJii arrest*! the tliswise of the 
pelvic hones. The uterus may or may not lieremoveil. (See 
[ni^vn 416, 4lM, ) 

Tlie Oblique Deformity of Naegele (see Fi^ 2*18). — The 
saer<>-iliac svuehondnifljs of fo*r «ide is auehyluHetU the i^irre* 
»pHiniling win^ of the .suerum alro|*liied, or imjiertVetly «!♦ vd. 



THE SPONDYLOLISTHETW PELVIH. 453 




The Roberto iwlvis. 
F»o. 240. 




SpomlylolliUieyc iwlvls. 4. Fourth lumbar vcrt«brE. 5, Fifth i uio bur verUfbim. 



luk 



454 



PEL VW DEFORMITIES. 



opeiI» so that the aeetiil)uhim of thtH sido approaches the 
heitltby sacroiliac gyiit'hoiit I rosis of the other* sliortenir»g the 
oblique iliumeter l»etweeii ihese two |ioints. The other ohli(|ue 
diameter, starting' from l!ie d'txeuHed j^acro-Utuc synchoiulroj^is. 
18 leiijitheiu"<l, owiri": lo the jiyniphyyis puliis and acetahukiiii 
of tlie healthy j^ide being torced out <jf place toward thei?4>uiid 
gide of the mediau line. This variety of deformity is com- 
paratively rare. 

Flu. 241» 




The kyphotic pflvJs. 



The "Roberts Pelvis" (see Fi^'. 289).— A double oblique 
deformity. Both Hi'icroilinc sytichoad roses ant'hyhn*ed, and 
/►/i/A wiagsi of the ftacrnrn absent of noilevt'lojKMl, The hrira 
is obhmj^ : jK'lvi*' sich^a iiic»re or le.-<«< parallel w ith earh t»ther : 
isehia pren^eil tx)warc| each otlier» and side?* uf the pid>ie ureb 
nearly parallel. Transverse diameter univcrmUy shortt*ned 



THE KYPHOTIC PELVIS. 



455 



at lifimt cavitVt Siud oiitk^t. Olmt ruction very great, re<|\iiring 
Ciesareau sectioiL It is really the olilicjue deforniity of 
Tsaegtle «.H?cyrriy«j: on l>uili slides, and ia extremely rare. 

The Spondylolisthetic Pelvis (see Fig. 240),^ — Due to for- 
ward Mini duwnwanl disKwiitiou of the lumbar end of the spinal 
culiimu, t'rorn its |*ro[)er j>la('e ot'supjn>rt uii the luise of the 
satTuni. It jinHliiees innrkeil runtraetirm of eoojugate <liam- 
eter of I he hriiii, nn<L *ivviug lo sacrul promootory heiiig 
forced .snjiewlmt l>a<'k\vard, the M|>ex of sacrtJiii taay l)e tilted 
f<jrwanl, thus lessening conjugate diameter of outlet. Degree 
of obstru€tiou very greats ^yuiuetimes requiriug last resorts is 
o|ieratiug. 

Fig. 212. 




^M Tlie Kyphotic Pelvis (Fig. 241).^ — Kyphnfus^. — Anten>- 

™ pjsterior curvature of the spine, with the 'vhiirii|r* projecting 
bnckmird (especially when hehiw the ihirsal region) cauHes 
the weiglit of the hofly iilinv*' the hend to he tmnsniitted U^ 
(he sncrnrn in bxiv\\ an ahnorrusil direction hs lo force the hase 
atid ]>roniontory of the Ix^nc huckvv:ird and dtjwnward, and dii^ 
place itd apex (and coccyx) forward, Tlie s;icrum is also 



Kyphotic pelvis showtnii contraotctl outlet, 
wjiciiTiea.) 



(From Jewstt, alter Klein- 



45G 



PELVIC UEFOBMITIES. 



leagtheDed vertically, and narrowed from side to side. Hence 
the hinotiiituite IroiiesJ ap|iroucli eacli oilier lielow ; the ischiai 
t*piiies and iscliial tulieru?iitie^ are brought nearer together, 
and all the diameters of the pelvic helow the brim are short, 
e8[H*eia Uy the transverse oiiti*. The result m a eontracleil 
pelvic cavity, especially eniphaifiiztHl at the outlet (see Fig* 
242). 



Fl6.3l3v 




The kjrpkiospoliO' rachitic r^lvls, rFrom Jicwrrr. ^Iter AiiLFELt>.) 



Hince the contraction incTeasee. from alwve downward the 
p*dvis becomes more or leas rurnitl-shnpc<b The coujufrate 
diameter of the hrim is lenp'theiietl, owioj^ to recession of the 
sacral pnmiontory. Iti about 30 j)er cent, of kyphotic pelves 
there is ali*o some *^ fjrueral canfrnrfinn" Tlicre arc^ many 
"' huinjibacked '* women who escape pelvic clefnrmity, Ac- 
eordintr to Kleiiu kyjdiolic |H'lvis oeenrs once in BJUO biliors. 
A >till rarer tbrin of kyftfiotie pflvis is the stM'alled prh^U 
obUvUi, in which that part of tlie spine projecting forward 
ahoiw tire hutnp eiicroaehcs n[Kin the i^dvie brim. 



THE SCOLIOTIC PELVIS. 



457 



TTie Scoliotic Pelvis. — iS!fWiWiA — Ijtitenil curvature uf the 
S(>iiif, uhfii low (l(ivvu» limy priHhji^i" ii slij^ht (Init not serimii^) 
uh/ifjue our I tract ion of I he |h*1vIs The innoniiiiale ho tie 
toward whieh tlie detlertcil lumhar spine is heiit, rernjivea 
more thau it^ share of the body-weight> heDc© pressure hy 



Fia. 2U. 



FIG. 2^ 




Side and back rlows of wntnun wjtb lcyphn«roUi>rachitlc pelTla. (From 

the lipjid of the femur on this side foreef* this half of the f»el- 
via ypwitn!, iiiwardt atul haekwiird, puj^liintj: th»' arctahuhiiii 
toward the sacral promontory and the pu hie .symphysis toward 
the opposite side. Ib gimple seoliosis lalK>r may not be much 



riCLVW DEi'-ORMlTlES, 



oYmtrnvU^X ; hut, uiifurtutiately, mtml cn^es of siH>liotic pelves 
KTi' fNirit billed with ntohitk and iC£ lifi'onuluai, yfXww the 
oliKtruetiim may \n* extreme. Again, ^t»)iufil8 and nichitis 
may be combined with kypbogis^ producing the '' kyphu^c^lio- 
rmhiiie jH'lnn *' ( Fig. 243, page 456 >. 

Lordosia* — Ivord*j«*i^ is autero-ji<Jsterior spinal curvaturt* 
witli t\w roil vex ity in franit d*»e» niil interfere with lulxir It 
irti-xtrefriely rare as a primary condition, but occurs 8f»me what 
mori! fr<Hpiently im a com[»cns<Jili\e s€*<[uence of kyphossis. 
Hinit ( Tfj-t-hfjok nf OhMtlricn, ]>afre 41*9) de|jicts a primary 
caau which he uscriWl to iiaru lysis of the spinal museiek 




OtiUrtucly cnntrarU*«1 ju'lvls from cnxnlfrlA; eoxitla on right side. <lefonnUy on 
left (Miiltt'f >Ju'*euiT», tVilkgf* of I'bynk'lttiiii* I'liilaUvlptiia;) 

Deformity from Hip Diseaae (see Figr, 246). — Coxitie f in- 

HninnmOoh < it* I be bi]>joint ), <M*riimu^ in early life, causes 
\\w pulieirl !«♦ re^t the wi'iirht of the Inxly on the healtl\}' hipi 
wliih* llie lame one in not u»ed* Consequently tbe beuUhy side 
of tbe pt^viH is grudmilly pu>«hed over toward tbe diseased 
(iitle, pr*Miucing an oblifpn' deformity resembling Uic ob!i<|ue 



DEtORMlTY FROM EXOSTOSIS, ETC. 469 

pelvis *if Nai'gele. The earlier In life the disease begins, the 
greater the deformity. In Fig. 24t> the right side is the dis* 
eased «j|ie ; the icjt half of the |»elvi.s, huving supj»<»rtcd the 
weight uf the biMly ujx>u the left aeetalniluni, \a punhed over 
toward the right jside, 'YUm^ that i^ide of the jxdvis hnvirig 
the tiyrmal hi|>joiot in delbrmed ; the other uiie not so, Tlie 
defonuity is uot UHnalhj sutHcieut lu seriotmly obstruct labor, 
but maij be i5o exeeptioualJy. 

A similar oblitiue eontraetioD may be produced by congen- 
ital disloeiitioii **f «me femur, fry tlie hjjvs of one leg in early 
life, or l>y any eoudilioii uhifh leads to a |ierbisteut overui^ of 
one lower limb. 

Fig. '247. 





The split pelvis. (After KtltlMWACllTKlt ) 

The Split Pelvis ( Fig. 247X — A very rare eonditiou of 
faulty dtnelopn^enl^ in whk-h the piiliit- bone?* are wiilely ^\> 
a rated. It prodiire?=' ** Preripifntr Jjdhnn^ 

Deformity from Exostosis, etc. f,«*ee Fig. 248). — Bony and 
oBteosarriMMiitoUHi tuinor« growing from jielvio bones — im>st 
nften from fnnit of saernm— |irc)jeet into judvie ravity and 
prLwUiee obstnielion. Bony projeetions nlf«oiK*c'ur from callus 
resulting from fnietnre of the bouei*. The it^ehial s|iines are 
sonietiiues t-oo long» and encroach upon the pelvic canaL 



460 



PELVIC l>Kl'<nU[lTIES, 



Ordinary Symptoms of Pelvic Defonnity without Refer- 
ence to Any Special Case. — rreviou?^ lnst*iry uf clitBrult 
lalK>r?i, :iii«l of the (liseuses or awiiliutw liy Hliieh i)elvie de- 
fonnhy *« jirinl urt^i I ; shortness of stutiire* i^|)ituil ciirvalure, 
|KviiJtiliiii.s iK'Uy, Inriieiies^a, iricrejii^od olili^juity, nvn\ nuibility 
of I lie uterua, J/iWr^ni^^ pt'lvic t!ujitnirtiou ean ow*iir without 
tlii'>«e »ymptoma Kiuci^e a <*uritractetl brim will not admit the 
hesul, the latter is movable iilwve the brim, when it out^ht to 
have b€M'urne fixed by de.seent. On vaginal i-xamination I he 
sacTttl promontory is more easily reached ; the linger can pasd 




B'tTiy ttinior of fncniiTi. 



more easily between the rin^^ of the o?i nteri Jind \m\^ i>f waters ; 
the latler |>rotrudei< duriiii^ a pain, |xtIi!1|»i in a finger-jrlove 
form. The present in jlt part is high np when brim iji eontracted. 
Intense paiiis prodtiee no pro|H>rtioriate deseenl of pregenlin^ 
part» the latler heeoines ^^ arrtntfuV^ when tiiere h partial 
deseent ; or later on ''impacted'' ( wheti it eannot lie moved 
up or flown), I'nj^ually large eapul suei-edaneum ; its grad- 
ual swelling may be mif*iaken for progre*?.s in descent Ua- 
bility to malprest*iitaUonHaud to pre»entatioug of fuiiid* 



ADDITIONAL SYMPTOMS AV ;SPECIAL CASt\% 461 



Additional Symptoms in Special Cases. ^ — ^In rickrts: ** bow- 
legs/' €urve<l spine, and uther iMmnnUi-^i^ of tbc skelelou, with 
history of rachitic in early life. 



Fig. 219. 




llAudelocque's ealipew, ThJj figtire nlta sh(t»ws Cduiouly > p^l^to^**^'' uppUcd. 

In osieomafacm (malacosteon) : prol>able history of previous 
labor wUboul difficulty, ibe disease liejiriiminp mtm after a 
delivery, SyiiiptuuiM i>f ^i^ta^mahu'iu are paint* in Unies of 
|)elvis HI id liiwer liiubs : bones tender on pr&ssun% espeeially 
over i^ynijihyais piibiai. Tbey ure aIs«o pliable, yieltling to 



462 PELVIC DEFORMITIES. 

manual pressure during labor. "A history of rheumatoid 
pains and difficult locomotion, requiring rest in bed during 
pregnancy, associated with a decrease in height, is almost path- 
ognomonic of osteomalacia" (Williams). 

Old-standing cases of hip disease present previous history 
of coxalgia. The diagnosis in the above ca^es must be con- 
firmed, and in the other varieties made out almost entirely by 
measuring the pelvis (pelvimetry). 



Fig. 250. 




Collyer'B pelvimeter. 

Pelvimetry. — Pelvimetry may be accomplished both by in- 
ternal and external measurements. The he&i pehimeter (pelvis 
measurer) is the hand. 

To measure conjugate diameter of the brim, pass index 
finjrer under pubic arch and rest its point against sacral prom- 
ontory.' (See F'\\*. 251, page 463.) (It is not easy to tonch 
the promontory in a normal |)elvis.) With a finger-nail of the 

1 Take cnro not to mistake the (sometimes prominent) junction of first and 
second sacral vertebra* fi)r the real promontory. 



PELVIMETRY. 



463 



other hand make a mark on the examining finger where it 
touches the pubic arch. Withdraw the finger and measure 
(with a rule) from the mark to its tip. From this measure- 
ment deduct half an inch, and the remaining length gives the 
conjugate diameter of the brim. The half-inch is subtracted 



FlO. 251. 




Pelvimetry with the finger. 

because the length as measured from the promontory to the 
under surface of the pubic symphysis (the diagonal conjugate, 
see Fig. 4, page 29) is half an inch longer than from the prom- 
ontory to the upper surface of the pubic joint, the latter being 
the brhn measurement it is desired to ascertain. During this 



464 



PELVIC DEFORM ITiES. 



examiuatinu the woman should lie ou her back with the hips 

elevate*!. 

Thi« iiieii^uremetit may l>e iacilitated l>y using two fingers 
ujsteail ot" ouf. The tiji uf the luiihlle tiuger touches the proni- 
imtorVi while the iiitlex finger re^ti* against the puhtf fsyni* 
phy}*is. A finger-nail uf the other hand outrks the jKiiut on 
the index where it toyehei* the puljic joJut, and afterward a 
rule measures the distune* acrotjis the two Hugera ais shown hy 
the ilutte<l line in Fig. 252. 

Fio. 252. 




MeaaurlDg the dlngoQal conjugate with Iwo fln^rv, {JrwsttO 



Another metlidd : Patient He43 on her left side, near the 
edge (if the lied. Ktherize, if ne<Ti^iry, to i>revent |iain. In- 
Innlure entire Inmd into vagina and dit*|M»se it Hiitwij^e with 
the little finger towanl symphysis puhis and the index-iinger 
against s^aeral pnnnontory. Ij^arn how many fingers ran thus 
tie mmnlt(t^teonj*/ij introdueeti lietween the two jiointj*. The 
breadth of four fin;rers, in a hand of average size, is aUnit 
two and three-*pjiinert< inches. The fingerw iutroduct^d may 
l»e aft e rw a n I m* 'a?* u r*H 1 hy u r u 1 e» ( See F i g. 2 5,'i , page 4 fio . ) 

Many jwlvimeters have been mtniv tor internal use, notably 
tbufleof (Jreeuhaigh (F\y:. 2.'>4)» l^umley Earle (Fig. 255 j, and 



EXTERNAL PELVIMETRY. 



465 



the more modern devices of Hirst, Faraboeuf, and others. It 
is hard to say which is the best Few obstetricians possess these 
instruments ; most are content with the results obtained by the 
hand for internal pelvimetry, and a good pair of calipers for 
external use. 

External Pelvimetry. — Some modification of Baudelocque's 
instrument is generally used. It consists of a pair of circular 
calipers (Fig. 249, page 461), a scale near the hinge indi- 
cating the space between the open ends when applied. An 
inexpensive calipers is that of Collyer, Fig. 250, page 462. 

FlO. 2&8. 




Moa.suring conjugate diameter with whole band. (After Davis.) 

In using the calipers let the thumb and index finger of each 
hand grasp the little knob on each arm of the instrument, so 
that the terminal ends of finger, thumb, and knob, all touch 
the akin together; then with a number of little lateral to-and- 
fro motions, the finger and thumb readily feel the points upon 
which it is desired to place the knobs for measurement 
Having done this, hold the knobs in position, while inspecting 
the scale near the hinge of the calipers, to ascertain the dis- 
tance between them. To measure conjugate diameter of brim, 

30 



466 



PELVIC DEFORMITIES, 



the ^v<JlIlat] lying on her siile, jjlace one [xunt of I ho iii&tru- 
nient up<jn the upper edge of pubic symphysis, aud the other 



Fl«. 254* 




Greonhalgh'ft pelvimeter. 
Fia. a&5. 




opposite sacral promontory, u e,, over the depre*i*«ioTi just h<>low 
spinous process of last lumbar vertebra, (See Fig, 249» page 



DIAGNOSIS OF THE OliUQUE DEFORMITY, 467 



461.) Nurmally this fthould measure 7 J inches*, DtHJucting 
3i tor tiiicktie?** *»f honei* uiid isofl parts, leaves 4 iiieht*:* — the 
iioriufil kaigth of the i>rinvs< euiijiigate diaiueter. The «le^re4? 
uf rediietioii iti this meusuretuftit, uMovviu^ for iDflividua! 
variutiou fr<nn (»l>t^ity, etc., will |2:ivti tTppt'oxhntttrhj, tlie 
armmut tjf pelvic cunt ruction, but a liniiled reliauce utily can 
be placed uj«ni this metboil withuiit uther corrolMiralivc cvi- 
tU'iii^e mI' ilctoriiiity. 

Two other external iiieiLsurements are inijxirtant, viz. : (1) 
Between the two anterior syjieriar i»|nnous proce»He« of the ilia 
(normally 9i ioilics); and (2j between the most biterally pro 
jeetitiji; tx>ii>ts on the two credj^ of the ilia (nurmally lOJ 
hiclies). Wiu-n butli mea^urenients are red need it indicates u 
uniformly contractetl pelvis. When the inter-<'re.stiil njca^ure- 
ment is nornmh or only a Utile diminished, while the inter- 
spin o us one ii5 increa-^cd, it indicates a jxdvii^ with conjnp:ate 
con fraction of the brim* but other wis*" normal. When both 
measurements are decidedhj diminished, while the interspinous 
one exceeds the inter<TeataL other diameters are contracted 
br iti fir the conju^ntc. 

The Lozenge of Michaelis. — ^fust betow^ the spinoun prtx-ess 
of the hii^t bunbar vertebra a barely visilde depression may 
l>e ol«*t*rved (on this «le|)resped jxiint the |>osterior arrn of the 
tmlitters is applied in nieai«urinir the conjugate diameter J, A 
litt!e lower thiwn, on enrh m\e, two very distinct ilimples 
may be j^een, wddch in<lieate the jKisition of the |KJ«?terior 
sn|)erior !>ipim>n8 }»roee8J4e« of the ilia. Lines <lrawu from the 
de[ pressed jwunt tirst mentioned, to the latenil iHrnples, and 
then from thej^e dimples to the n|if*er eml of the internntfd 
fitk^ure, will eiu'Iot^* a fonr-side<l ?pace, the lo^ertj^a^ of 
Slichaelis*, (See Fijr. *JU1, |»age 44').) Xonnafhj, the fnur 
sides an<l an;rh'S of tliis h|whv are *tfmtd etpnil : the tnins- 
verste dmn»eter, 8 J incht^ ( 9.K em. ) ssli^rhtly exceeding the 
vertical one. Any |>ronouuce<l variation indicates an ir^mornuii 
pelvis 

Diagnosis of the Obliaue Befonnity of Naegele. — I^ime- 
ne.ss, fr<im inequality tn the height of the hip?*. If two (dnndi 
linei* l>e suspended, one from the centre of the gaenim. the 
other from the ^lymphvi^is |tubis (the patient i^tanding erect), 
the ptd:>ic one will deviate toward the healthy :?ide. Measur- 
ing from the .spinous jirocets of the last lumbar vertebra to 



PELVIC DEFORM ITIES, 

the anterior aoil posterior spinous processes of the ilia, will 
show a red yet ion of half an inrh or more on the diseased 8ide» 
ADiitoniii^al iWuure.* of xlw *leforrnitv, already described, to 
be turtber made out hy vaginal examination. 



Flo. 256. 





Froul aDd buck viiw <»1 wGoiaii with spcrndflQliBtbctJc fn-lvis. 
after Wince el.) 



(From Jkwett, 



Diagnosis of tlie Kypliotic Pelvis.^ — Meosurnticni reveals 
marked narrouiiitrof &paee betweeti tubert>eiitie» i»f the ii^ehia, 
lietween i*!thial spiuoui* prfK^eswt^s, and l>etween slides of puhie 
arch, Sfmee between anteri<»r superior iiplrious prix-es^e^ of 
ilin, dH'idedly iiit readied. Aliseiice of >iaeral promontory 
and other aiuitondcal churnrters revealed by vaginal toueb. 
Ilunipback vi^^ible by inapeclion. 



MODIFWATIOSS IN MECHANISM OF LA BOH. 469 

Dia^osia of SpoadyloUathetic Pelvis. — FijLTure peculiar; 
(see Fig. 2ot3j, Jburux uunual ; alHiuinen short and sun kt^n 
between cresti? of ilitt» the luttt-r widely K*|»araled. Aoriie 
pulsiitivHis (I'lt tLii*t^ugb jwjaterior vaginal wall. History of 
violeni \mns lu sacruru at puberty (?). Vfiginal t'xamina* 
tiou rt^vt^ui.-i dit^liK^'atiou at snon* liiruhar articyhui<fU. 

Diagnosis of * ' Roberts ' Pel vis . ' ' — * Hv i u t; u > 1 1 u rro w u es« nf 
sacrum, tlit' ^tpaces between the two iliac ere.^ts, In^tweeu the 
two iliac apiucs, between the two tnjehariters. and between the 
two ischial tuberosities are ail retiuced. The two posterior- 
»U[)erior iliac spiuous processes, e8[»eeiaily, appi-^iach each 
other. 

Diagnosis of Masculine Pelvis, — ^Meui*urali<ui demoui^trates 
diiiiioirtlied width between [nduc rami anil between bchiiil 
tuUen>;3itiej4, etc. No obj*truetiou of lalxir at suiK'rior strait ; 
head nrrestetl in jjelvic cavity. 

Dan gers of Pel vi c Deformity , — Tei lions I a 1 lor ; t^ 1 1 ock ; ex- 
haustion, and inertia of utcrut^ from prolonged coutraettle 
efforts. Inthnnmation, ulceration, and siloughing of maternal 
soft parts from contusion and ]>ndonged [iressure. Child's 
lite jeopardized by proIapse<l funis ; by coulinued and exagger- 
ated coTupressiou of <'ruidnm, esipecially against sacral proro- 
ontory. Operative measure!* for delivery may necessitate de- 
Btructiou of infant. 

Modifications in Mechanism of Labor when Coi^jugate 
Diameter of Brim Only is Contracted, — Flexion is imperfecL 
Theoccipito-frontal diafneter of head ♦nxupies transverse diani* 
eler of pelvic brim. The biparietal diameter is tilted m that 
one end is lower than the otherj hence the antmor parietal 
boss [» resents near the pull's, while the pftHtf'nor one is tilted 
backwar<] and npivard tc^ward posterior shnuhler, which 
carries the sagittal suture toward the sacral fvromimtory. 
i 8t*e Fig. 257.) Thus anterior end of biparietal diameter 
is f»ermitte(l to descend before |Misterior one ; there is not 
space for htith to enter t^imultanfOHahj, The S4)mewhat wedge- 
ehaped Bides of head impjtrgmg against protnontory and 
pnftc^ now cause <x*ciput to t^Iip, laterally, toward that ilinni 
t*j which it points, llius bringing the narrower bitemporal 



1 TMsliltor 
Nntijrtr' ; It I 

deformity oi ii 



times Apolcpti of ii» th<? ''otilimiUy nf 
i^ authiug to do with, the obUquo 




PELVIC defohmities. 



diameter (3J inthea) to occupy the contracted conjugate in 
plat'e of ihe wider hiparietal one^ As desceDt ihu^ proceeds, 
ihe forehead and larger foittauelle are lower thau occiput and 
small one ; hut, later, flexion cK'eurs, wbich brings ii<viput 
down on one side of pelvia, while forehead ri-sei? uji on the 
other. In this way the hrim h parsed, when, the rhief tlifti* 
culty 1>ejng oven occiput rotat€*s to the pul>e.s and labor is 
oonipleted in the usual manner. 




Hcftd possirtfc throusti (nJ«t Id flat p«lri«. (After Pahvik.) 



ModificatioQE in Mechamism of Labor when Pelvis is Uni- 
formly Contracted. — Tlie head may enter in any j^elvic «liam- 
eter. though iisunlly in the otdicjue. Flexiu;i ijj unu»uully 
coniplele, so that orcijiital ]mle of ompitonienlal ilinmeter 
IKiint.s filniost %^ertieiilly down at ri:rht angles tc* plain* of 
8Uj>erinr strait. (8ee Fig. 2rtH, ) The *♦ ul»lii|uity nf Nui^mrH,.** 
u very slight or absent. Both parietal boHi-ej* enter at the 
same time. Small ftjntanelle found near eentre of iwlviR, 
Bhould transverse narrowing continue toward outlet, the 
fxfreme Jfexion f^ontiinies with liability to injfiuc'tion and 
arreist: Imt if the pelvis widen below the bnrn. the exagger- 
atjed flexion lesi*eii8» and tlie occijatal |wle of the head leavea 
its central (xvition, and rotateii** in the more favoralile cashes, 
toward the pulses, when delivery follow 8 in the usual way* 



DEFECTS RiCQVIRlNG nECTIflCATtOK 471 

Modifications in Mechanism of Labor when Pelvis is 
*' Generally Contracted " with. Antero-posterior Flattening.^ 
Ill thia ciise we bnve the ** Naegele oMif.|ui(y" of lisittencMJ 
pelvis, joint'd vvitli the exaggenittftl Hexioii of justo-miiior 
cases*. The < »cc i pi U ►-frontal cliaiueter of the head usually 
occii[ue?i the transverse diameter of tfie jx-lvis. If delivery 
be pt»!^ihlt\ Htnx*;; tlt^xion cau!^*^ the o<*cipul to det4<'eiMl firyt. 

Defects in Methods Eequiring Rectification. — J tj pelves 
with very narrow eon jugate and high pronitnitor}', e^|>ecnally, 
hut sometime.*! in others that are le*« so, the **ohlii|uity of 
Naegele ** is over-done. The (lonterior |>tirietal Innie is 
directed toi) strongly ttiward pw^ierior sbnilder* so tliat t^agit- 
tal suture may lie even abov*' saeral proinoutory, and the ear 

Fig. *^. 




Miirkod fleiioii of ticttd eatcrinf m gcncinlly coniracied pclTls. (Aitcr Pavviit.) 



he fek just l>ehindpuhic symphysis. In tlatteued pelves with 
trantiverse shorteinn^t the oh!i<|uity may Im* the other way ; 
the pofiteriin' [inrietnl hone presentint^, thejiagittaL^uture Ix^iug 
t4iward or even aliove I he [)tdK\s while an ear i?i felt near 
promontory. Again, the pri)j>er deficiency of flexion in the 
early stage «tf lahor in ilattened j>t*lves may be overdone, thus 
leading to l)row or fare presentation, and iu which anterior 
rotation (respectively) of forehead or chin will l>e im]K)ss!ble 
later on. 

During breeeh deliveries, in couiraeted pelves, the arm 
may l^e displaced to the side^i of the head, and thin last may 
be unfortunately extended by die ehlii calehing against the 



472 



PELVIC DEFORMITIES. 



pelvic brim* In marked traosverse shortening, extension of 
the diin in breech cascis makea delivery iiujiossible without 
perfc*ratioiL 

Methods of Assisting Delivery in Pelvic Deformity. — 
Exelurlin^% fur the present, the kHiyetiun i>f hihor l^'ftire full 
term (to he t'onsidereii in the next chapter) the resourees of 
the olistetrician are forceps, version, syuiphys»eolouiy» Ciesa- 
reaii section* and cniniotoniy. 

In dec id in rr the met hods* uf o[3e rating in ditfereiit sizetl 
pelves, it is evident the size and eoriipressiliility leapaeity tVrr 
miinldiny-) of the ehtbrj* head ghnyld he delenniiKHl Un* 
fortunately this can oidy be done upproximalely. Instru- 
ments for measuring the u id torn head are un.<ati?ifactory ; the 
best we can do is to gra>ip the lirow and w^ciput td' the heatl 
with tlie hands (under an:estbe.^ia| by alulominal pal|mtion, 
and by steady pressure downward and backward, in line with 
axis of superior strait, ascertain i^ith what readings ur diffi- 
culty, if at alb the head may he nuide to enter the pelvic brim. 

Durii\g labor, with a fully diluted o.s the entire a^^[ilie 
hand may enter the vaj^ina, and thus e.*5timate tfie siw of the 
head in relation to the pelvis. In mtiltipane. the hardness 
and size of the head in |Krevious pregnancies! may afford some 
information ; rememtwringt however, the liability to increased 
size with sueceasive lalwrs. 

Beside the dimensions of the head» a third factor, to be 
considered in any given case, is the drenglh of fhe lahor jminn, 
Strong jjains may aceompli-^h delivery where weak ones would 
necefsftitate artiKeial aid. 

RemerrdK'riiii*' then that in every ease of ditficylt labor 
from eontructerl pelvii*, the three fact<rr^ of potrrr, jmmaijt\ 
and paj*4ef^eT (i. e„ pains, |K'lvis, and child ) must be duly 
considered, let us now return to the methtjds of of)erating iu 
different degrees of pelvic mirrowing, 

ihving to improvements and diminished mortality iu the 
Cgesarean section, m*Mleru obstetrics ha^ largely increase*! the 
field for this operation and lessened the raises f(»r craniotomy. 
The determination of ojn^rati ve methods according to jxdvic 
measurements is now in a transitional sta^e ; authorities differ. 
Hard and fast rules are impracticable, but there are some 
im|iortant points upon which all agree, to be now emphasized* 
viz.: 



ASSISTING DELIVEnr IN PELVIC JfEFuRMITr. 473 



Fir«L — Tu at 1 1 ill t n g^ i v fii u j m ru t i on " ^fc n e m f(ff eo n t m He* t * * 
pelves refjuire u coiijiigale diiiiiietir of oiu'-fuurtb «»f an inch 
longer (some m\y oiie-lialf) thim would be uei*e5«un' for llie 
same opt-nitiun in a Bitnply '*j(ftUt'nvti** jielviK That ia to 
siiVi if a **Jiat^* pelvis with ti conjugate of 3 itirhes would 
iidiuit the passiige of a given head» u **tjenerallt^ contniottM^^ 
|>elvis, to admit the name sized head, would recjuire a con- 
jugate of ol (stime suy *^V> ) inches, no matter by what altera- 
tion the delivery were accomplished. 

St'cofifL — When the cf>njugate* i^ 2 incht^ f 5 em.) or less, 
Ca*sareau gectiou ii* the only resort, be I he child alive or dead. 
Craniotomy would \h* more dangerous to tlie mother than 
abdominal section. The tendency is ti* rcistrict the limit for 
craniotomy still further. Souie coui^ider 2^ or 2| inches, or 
21 in '*riat**and 2} in **gcncnilly ci>utracted ** pelves, ob the 
limit l)elow which craniotomy j^hould Ik? exelycied. Elimt- 
naling the-«e small fractioui* and remtvnil»eringthi^ irn^ioasiliilily 
of at*curateJy meiU'^uring the head, let us fix on an even 2 
inches as the conjugate measurement excludiug cmniotomy 
and reijuiring abdominal R'ction. 

Third, — When the conjugate i» l>etween 2 and 2| inches (5 to 
7 cm,) in flat |>elves Kir one-fourth incii longer injusto-nduor 
ca»ep^ ) the trt^atment will 1k5 craniotomy if thechihl Ite dead, and 
Cics^iirean R^'don if ii lie alive. Symphyseotomy is excluded 
Indow 2 "J. In stdecting the Ciesjircan ojH'ration regard nnist 
be hu(i tn the rtmriltion <if the woman (whether exhauHied or 
iidtH.'ted ) and the condition of the child, as to its being un- 
injured and likely tn survive the projxisetl ojH'ration. Hut mi 
iar a^ the jxdvic measurements are coucenied, the operation 
must l>e one or the other, either craniotomy or Caesareau eeo- 
tion, at^:^>rdin!? to existing ct)mlitions. 

Fourth. — When ihe rnnjugate is between 2} and 3 inches, in 
**flat'* cases for one-fourth inch hmger in *'getjerally con- 
tracted** pelves) the choice of ojieration is extremely dirticult, 
Forcejift, version, symphyseotomy, C*ie?arean section, and crani- 
otomy may each be pro[x*rly resorted to under d liferent condi- 
tionin to lie now stated.* Forcf-ps delivery will be extremely 
difficult ; it may or may not succeed. The instrument is tJieref*ire 

I By tbo *' conjiiiratft " m» here repeatedly use*l, we memi af course Uie " ftm^ 
jumffi tvra** cjftlie brim. 

*lv thu (ll«rtis8fou we refer Alwtys to fUll term children of ivefKipo •iie, M 
a niaUcr of course. 



474 



PELVIC liEFOnMniES. 



usetl tentatively aud with care not to itijiire or infect the patient, 
the *fj^V^riic//o« ii>rce{ks tmhj beiii^ i]j*e<U in conjundiou with 
the Walcher [Hisitimi ( ^^et- Kig. 177, patre M6H ) unci only at'trr 
several lionrs <jf strem^'' \mi\u^ have ba<] ii ehtinre to rt-ihire tiie hi- 
purietal tliameter l>y moafdimj of the heml. Sbirt? this^ ilianit*ler 
normally niwL*inrt*' .">} inches it in cnideut that j^onie nionhling 
rnusf ovcur to allow its transit through a conjnpiteuf less than 
3 inehes. But m\ce heads difler in size and eompres>ibiHty, 
a Icntiitive use of tbree(i8 may be advii^alde. 

Version. — P«»dalic ven*ion will enable the narrow base of 
the nkull to enter a eonlraeted brim, wbieh the larjtrer dome 
of a vertex presentation would not do. (Fig* 25!) j More- 



Fia, 259. 



Fro. '2m. 





Fia. 'JTiil.— Scctiun o( fti^tal Bkull bhowlu^ baW n&rFowur tht& dome. AA. 
Bi]ja.rielaJ itlAmeCer^ BB. Bft^tuporal dfanicler. 

Fio. 26().— Further nftirowlng of cranium by pressure iifWr luming. AA. 
Outline of ikuU bffart voraion, B 1 2, Outline e^er turning. 

over, after turning, the o|x^nitor may expedite delivery by 
traetion on the ImhIv belc»w, and prfx*;yre on the head from 
alwne, while the rehistancv of the jn-lvic walls ^hirjn;^^ traetion 
prodnee** further narrow in;^ of tlie rniniuni as shown in Fig, 
260, This is the the^iry, and it is true; but unfortunately, 
displacement of the arms, delay with the after-cominjf head, 
aud c{mii)ression of the cord, pnnluee so grc»at an infant 
mortality (about tMy |>er cenL ) that the o|ieration is decltning 
in fwpnhirity ihonjz^h it has tH*me a*lvantiig:e« so far as the 
mother is concerned. 

Symphyseotomy, — The measurements of fhe conjn;.rate we 
are now con^^idering are exactly those suitable for this ujwr- 



CRANIOTOyfT. 



475 



alioij, perhajjs in conjynctioii with foreeps or veraioo, aa 
alremly stateiL (8ee **Synnihyse<Moriiy/' Clittpter XX.)* 
But tlie whole subject of syiii(ihy8ei>lurny is ^\\\[ sub juiUce* 
Us |K)|*ulariLy in *'ou llie wane/ ' It' it it^ lu hoUi any rank of 
utility m ixiutnu-ted |M*lves» these are tlie meusuretueuta ia 
which it is jy^tiiiahle in })roj>erly seh'cleil t'ustfs. 

Caesarean Section. — ^To avoitl the ilaugers and difficulties 
of forrep;^ arid the iidant riKtrtality t>f versi«>u in tlit^e t-ases 
(conjugate l>etweeu 3 aud 2J j. the Cie«?4irean o|>eratiou, under 
faoorabte clrcunidancea wouhl certainly Jw? preferalile. Thise 
circuinstances are a healthy woman, uniiifecleti and ^vjthout 
exhaustion ; au uninjured ehild ; a coiupetent ojK»rati>r ; 
tngetlier With an a»iistaul:^ instruments^ materials, and sur- 
roundings necessary for the |irovision of a rigid aseptic 
tecluiique. These einnmistatices ttnttf he perfectly attain* 
aide by o|>erating early in a profjer h^ispitaL In private 
practree they r»iuy he only partially ( or donlitfully ) altiiinalde ; 
here the obstetrician must vi)^' his judgment aa to ihe dujrct 
fd' risk involve*l by the ti]>eration. 

Tn o I crating on an inftjctetl case the Ctesarean operation 
ahonld be followed by total hystere<^^)my. 

Craniotomy. — This ofieratiou may lie done to hasten a 
required sjwcdy delivery^ when the child ija dead; and in 
castas where tlie clnhl is ilying, or has lieeti iujured by fbrce{»fts 
and the mother is infected, craniotomy i(^ still jn^tiHable, unless 
the woman da^nire to run the risk of abdominal section for the 
sake of her infant. 

Fiji fh— When the c<>njngate is 84 to 4 inches! in "flat** for 
one-ion rtb in civ longer in ** generally contnieted*' palves) the 
mode of delivery will usually he by forceps — the axis-traction 
instrument being used, either with or without the Walclier 
|)ositiun. If the head be not ovirhirge, and the jniins are 
nurmully strong, with time for moulding, many of these cases 
will l»c delivered H|wjutafieously. In «_*ase of exhaustion (of 
woman or wimib > assistance with for<*eps is the rule. When 
tfie head biLi [)nssed tljc brim, the Walcbcr |Hisition must l>e 
disT'ontinued, since it les&ens the capacity of the outlet. 

Reducing these statements to tabular form it may be said 
that n« a general rule (not to be ri^itUy followed, however) 
the methiKis of ojierating in the ditferent degrees of pdvic 
contraction in ''ftaiiened'' pelves (from one-fourth to one-half 



47(J 



PELVIC DEFOMMITIES. 



an iocli being added to the fi^iirei^ to allow the same prcjoeed- 
iug ID a '' tjaieraily contriicted,'* or justo-iuiut»r case), will be 
a^ tbllows: 



Wlwti eonjugtite diameter of brtm 
mcasurcii : 

Between 4 atid 3 J im-hei* 

Between 2J and 2 inuhes . . 
At 2 iDcliei* or less . . . . , 



The mode of delivery at term 1i ; 

By Forecjw. 
I By ForreiM*, Versiion, 

j < tt«sare<in seciiou, or 

[ I'niniotiiuMy, pru re huUl 

j ♦n.t<iiie;iii HCH^ti<>ii, if (Lliijtl alive. 

\ Vmimtioniy, if vhild dfi'^d. 

ICu'sarean section alwuys. 
CranioloTiiv exeluded, 
wIh'IUlt tliild Ueud or alive. 



As before stated, and m a matter of course, selection of 
the raetbod of delivery irnj:«t not depend wh'ltj upon the length 
of tlie cunjugnti? diameter. Since we cannot during lah«»r 
nietL^urc the {)c*lvijs cxadhj, ami i^till It^aa? the child's hcMtl, tlie 
ini|K>ssil*ility of nialhenmtieal rulcj* for pructi<'e it* painfully 
evident. 

Furthermore^ no two sets of cases are exactly alike, and 
the exi>eriencc of no two iintftitioners exactly similar ; hence 
hardly any two anlhrjrttie-^ exactly agree with regard to the 
pelvic meaAurenjentj* determining the kirul of uf»enitMin to lie 
employed. In easels with the hrfjer figure^ nlxjve mentione<l, 
the ()(>eralioD called for will he compjiratively easy; with the 
smtj/ifr rHCji-surcmciit-s more ditficnlt. 

Among the host of other i"<jnsideralions upon which our 
selection must, in jmrt, depend, may he mentioned : 1. The 
kind uf r^ntracticiri ; whether fa i simple aitlerc»'pK«terior Hat- 
tening, or ( //) getterul tHmtrm-tion, or (r) hnth of thei*e com- 
l>iued. 2. The site of etm tract ion ; whetlier at hritn, cavity* 
or outlet. 3. The esti mated »\w of the head and its degree 
of o*istification. 4. Whether or not it k* ** arrested/' f>r ** im- 
pact e* I " (and at what [Munt in the |>elvij* j, or have piistiitMl 
through tiie oh uteri, o. The amount of dilata.tion of the oh, 
ami the ^tate of the membrane!?* C. Hclraction of uterua 

' Thexi* are ii1«o thf< mpAsiiri'metils Un the iDdiicUun of pnunntuns tabor, to 
l* considered In the next eh«*pter. 




CRANIOTOMY. 



477 



1- 



2_ 



5_ 



6_ 



above the head with consequent fio. 261. 

vertical tension of vaginal wall. CENTIMETRES. 
7. Is the child dead or alive, 
and if the latter, will its 
life be jeopardized or lost by 
the pro{X)sed ojieration? 8. 
History of former labors (if 
any) and results of methods 
then employed. 9. The number 
of previous deliveries, as indi- 
cating present labor-power. 10. 
Imminent danger or actual 
occurrence of uterine rupture. 

11. General condition of wom- 
an as regards her ability to 
survive the proposed o|)eration. 

12. The "presentation" and 
"position" of the child. 13. 
The existence of complications, 
such as hemorrhage, eclamp- 
sia, placenta prievia, prolai)sed 
funis, etc. 14. The estimated 
knowledge, acquired skill, and 
native dexterity of the opera- 
tor, together with (what is not 
often sufficiently considered) 
the kind of hand he hapi)en to 
possess, whether small, soft, and 
pliable, or the reverse. 

An approximate estimate of 
the size and com^intency (hanl 
or soft ) of tiie child's head may 
be obtained by external palpa- 
tion over the lower abdomen. 
In this way also may we 
ascertain whether the wi<lest 
(biparietal) diameter have or 
have not entered the brim, and 
whether it be |M)S8ible to force 
the head into the brim by man- 
ual pressure from above. 



.INCHES 



.3 



8- 



9_ - 



10. 



11_ 



12 _ 



13_J 



Relative scale of inches and 
centiineires. 



478 



PEL VIC DEFORMITIES. 



As much myst deftend upon whether the child be alive, we 
may here tiole llie si^rtis of Its deuth. 

Sigih9 nf Ffttnl Ihath ut Ukro. — St»me of these have already 
been lueiitioiHMi \\% ttie i liMfiter on ^'AlKirtiou" (page 1J*3}. 
Ad^iiiioiiul ttne.s ree<»Lniiziihle during lalior are t*e4!ieyitHm of 
fieUil lieart-PiHindsiitier they have lieen jirevioiL-^ly reci^giii/ed ; 
ceskjation of qakkeiiirig', e.speeiully when iiniiiediately preeeded 
by irrejj:ylur and lumuUous ftettil motions. The dii^ehar^e of 
meetHiiunij when the ejxse i.s not a breech j)re^nluli(>nt is of 
pome sig^nifieanee. In head pre**entiition the sealji is ijcjH aud 
flabby ; the cranial Iwmes are loose and movable, and may be 
felt to grate against ur overlap each other more than nsnaL 
No eapnt SHCcrdannim Ls formed during lalvor since tliere is 
no cirenlation in the ik-alp to prmltice it In hirer h ra?!es the 
anal sjihincter is relaxed and d»>es n*>t contract <in the finj^'cr* 
In Jftrf cast^f* the li[>s and the toiigne arc tlabby ami motion- 
less. In arm prei*enlatif*n the hnnfj limb is warm, |»erhapd 
&tmic\vhat livid or swoileufrotii pressure alwve, and il may l>e 
made lo move; uot m the dead arm. In JurtiM |>resentatioti 
the living cord ia warm» firm, turgid, and pulsiitory ; the dead 
one cohl. tlaccid, em]>ty. and pidHtdess. i^mw of the above 
sign^, it will be evident* can only occur when the <bild baa 
been deatl *ome time before lalior — the condition of the w-alp 
and rranitd bones, for example. 

In any ilonbtful ca^e where the baud enters the uteriift» it 
may feel whether the cord ptdsiile, and how Mrtjngly; or ft^l 
the precordial region of the child and thus re<'ognize itJi heart* 
beata. 



CHAPTER XXIII. 

THE INDUCTION OF PREMATURE LABOR 

By the end of the twenty-eighth week of pregnancy the 
child is sufficiently developed to be capable of extra-uterine 
life. Delivery between the twenty-eighth week and full term 
is called " premature labor " ; before the twenty-eighth week, 
"al)ortion." 

Cases in whicli It is Proper to Induce Prematoie Labor. — 
1. In pelvic deformity where there is sufficient space for a 
seven months' child to be delivered without injury. The 
object is twofold : (a) To save the child's life by obviating the 
necessity for craniotomy ; (6) to spare the mother the dangers 
of craniotomy, Caesarean section, symphyseotomy, or other 
operations that might be required if the pregnancy went to 
full term. 2. In cases where, in previous labors, the head of 
the child at full term has been prematurely ossified, or unusu- 
ally large, so that labor has been difficult and dangerous, even 
though the pelvis were normal. The period of delivery need 
only be two or three weeks before " term " in these cases. 
8. In cases where the children of previous pregnancies have 
died in utero during the later weeks of gestation fn)ni disease 
(fatty, calcareous, or amyloid degeneration, etc.) of the pla- 
centa. 4. In conditions where the continuance of pregnancy 
seriouslv endangers the mother's life, such as excessive vom- 
iting ; albuminuria ; unemic convulsions, or paralysis ; chorea ; 
mania ; organic disease of the heart, lungs, liver, bloodvessels, 
etc., threatening fatal disturbance of the respiration, circula- 
tion, and other vital functions ; irreducible displacements of 
uterus ; placenta pnevia with hemorrhage ; and in dangerous 
pressure upon neighlwring organs from over-distent ion of 
uterus, due to dropsy of amnion, tumors, multiple pregnancy, 
etc. 

479 



480 THE LXDUCTIOX OF PREMATURE LABOR. 



Induction of Premature Labor in Pelvic Deformity. — ^In 

jhtt jx^lves (the itiort cuminoii ruiiiitic deformity) the degree 
of roujiigate contract Jon in which it is |>nipt?r to induce pre- 
mature delivery, when it h dt^m^ntid to save the ehiUFs life, 
iH prat'tically limited to l)etvveeri 2-4 and Hj iueiie^. 

A child atthe end of the i?^(*venth lunar mouth (28th week) 
may be delivered alive throujrh a corjjupitc diameter oi 21 
iiiehc:^. 

t )ne at the end t»f the ei^rlilh lunar oiouth {Z2f\ week) 
through 3 itiehes — ^jH»jj><ihly lliroii;rh 2 J* 

(hie at the end of the tuulh lunar mouth (3t>th week) 
throu)j:h 3 J iuche?*. 

When the mea^^urenient is over 3 J ioche*? I he labor may be 
left till full term (40th week ). 

In ffnieraUff fontrarttff pelvic wheu a// diameters are nbort- 
ened, the eonjuj^fate uuist measure at \enst ofi€'(iufirler of an 
ifif'h fougrr thau the figurei^ given ah^ive, in order to allow the 
same rules of o[Krating to be tblluwed. 

Owing lo the difficulty of determhiing ejtact size of the head 
and jielvis. the more precipe rules given in textdiooks are 
practieally useless. Furthermore, it is not always easy to 
ai^certuiu with prechion the ilu rat ion of pregnancy. The seleo- 
tiari of any week intermediate oi* the period.^ alxtve noted must 
l»e left to the judgnjenl of the obstetrician, and decided by the 
circumstMncesof each case. The most u.'^ual time for bringing 
on labor, all thing** considered, is between the thirty*secoud and 
thirty-fotirtii week. The date for inducing labor may be 
decided by Muller^m method: Near the end of tl»e si^venlh 
month, weekly examinations are begun. Two lingers in the 
vagina are made to touch the head l>elow, while a hand over 
tiie abdomen gras[is it from above. Over thin hand, l^ie two 
baufls of an assintant are sui>erimjx»sed. So long as prudent 
pres^uri' by ihe three bands can ptjsh the eipnitor ai' the head 
down through the brim, labor may be deferred, but when at 
any i*ubM^t]uent (weekly ) examination the head has grown too 
large to be thus forced down, labor must he induce^l at tmcts. 
Labor pains, with Tnouldiug, will still cause descent, though 
the hands fail to do so. 

In any case with a conjugate of 2i inches, chances of saving 
the child's life are exceiMbngly t^mall ; but a.* craniotomy, 
gymphyseotomy, and abdominal section are the only other 



INDUCING LABOR IS EARLY PREGNANCY, 481 



ineftiis avaihil>!e% the attempt ought t^be made, ilelivery being 
aided, if iieees^^ary, by vt^rsioii, or by s^mall farreps — n dimin* 
utlve instriirueiit huvint,^ bt^u eoustriicteti for tiii^ purpose. 

Wheu the roujugate diameter nieai^urei* fern thau 2 J inches, 
abortion should l>e iudui-ed as ^oou as jwii^ible after the diag- 
nosis of pre<^naiK*y is eertain. When the cuiyugate diameter 
mtnisure^s 1| inrhes, iiKlurtioii of alRirtiou must not he post- 
polled later than the l)egiiiuiug of the tweuty-tirst week ; when 
1}, not later tliau tbebeginuiug of the seventeenth week ; and 
when only one inch, not later than fourteen wet^ki*. If, how* 
ever, the woman i being childless, or for other rtiawou^ i prefer 
to risk thedan^j^ern of a cutting aljdomiual ojK^ration, and there 
are n o s jx*c i a 1 e i re u i ns ta n c 'e,H r eo de r i ng s lie li a co ii rse j »ee u 1 i a r 1 y 
inadvisable, the L'ase may be allowed to go to term, and 
the child tlien extracted promptly by t^eetion through the 
abdomen, 

Metbods of Inducing Labor In Early Pre^ancy befoiB 
the CMld is Viable. — Two nietboda of inducing alxjrtion in 
eonnnon useduriug thee^rly mouths are: 1, IHlatation of the 
oi^ and rervi.r uteri, 2. Puncture of the amniotic mr, 

1. Dilatation of rVmx. — ^The vagina an*i vulva, the handa 
and iustrument.'* of tbeopemlor having l>een rendered aseptic, 
a tu|>eIo or larninaria tent ( previously sterilized ) ^ is j>iLsse<i well 
uj) into the cervix with a \k\\t of dressing forcefis until its 
upj>er eml [lenetrate through the iuternai os ; it is kept in 
pbu'e liy a tam|KHi of imloforni gauze place<l below the exter- 
nal m in the vagina, and there aUowetl to remain. In a few 
honri* tlie tent atisorl>s moisture, Mu*r/L% and thns dilat<*« the 
cervix sufficiently to invoke uterine cdutractions (pains). 

This method R^cure?* jvreservatinn af the bag of water, w hich 
aids subwetjiient greater dilatation of the as and cervix uieri, 
and fav«»rs dis4*harge of entire ovum — ^fretus, (ilacenta, and 
membranes — all at one lime ; and also tends to minimize the 
amonnt of hemorrhage, 

2, Puncture of the Amniotic *S<ie.— The sac is ruptured by 
introducing a uterine sound, or some other similar instrument, 
into the cavity of the woml^ and turning it aliout therein until 
the liquor amnii escafje. The methtMi is more often used crim- 
inal ly than for beneficent purjKJses, It is perhaps the worst 

1 fhHmm tents are no longer u#ed ; tt U imposfttblc to «t«riUze tb^m thnr* 

31 



482 THE INDUCTION OF PREMATURE LABOR. 



of all metlimLs, and must certainly uever V>e employed lati? in 
pregnancy vvlieti it ii^ ileaigued u> save the cliilir&i life, fcjr dis- 
charge of the ** waters" subjects the soft and i immature toetuis 
to fatal tx>mpres3ion liy contraction of the uterine walls? during 
delivery. 

Sitrfjifal Mefhod. — -It ha;^ lieeii recently recommended to 
treat the ovum a.s it' it were a murl»iil growth, and remove the 
contents of tlic uterus l>y a surgical o|>eraliou. 

At\er lhnroi{<jh dinufedhm of tlie alMiomcn, vagina, and 
external geiiilaiia, iu* well an of the linnds and int^trumeuti* of 
the oj>eratyr, the patient is auieslbetized ; or iiL^tead of <reQ- 
eral aoie*thet)ia | should this Ite cuiitniindicuted ) A of a grain 
of i^oc*nine may he injected ^vith a hypodermic needle into 
both m\\}i< of the cervix, A 3i>e<*ulum i:^ introdueed, ihe 
anterior lip of the uteruj^ .steadied i*y a volHclUmi force[)6, 
wliile with a steel hraiiehed dilator r(MKMhdr.s) the os and 
cervix are i^lowly rlilateil in the extent *»f erne or even two 
inches*. The wliole hand is then pa.*vse<l into the varjuin^ while 
the index finger slowly uoes into the tdtrm until reaching 
the fundus, which la>it is pui^hcd by nhdominal pre^^sure deeply 
down inio the pelvic cavity. The entire ovum, riiemhranes 
and everything, is then |>eekd or scTapi-d fn»m the uterine 
wall with tlirfinifcr antl oxtrnete^l. In v\im^ the womli cannot 
he sufheiently depressinl fur tfie finger to reach the fund as 
a long curette may l»e used to nepnnttn I he ovnin, and its 
extraction accinn|»l itched hy the finger or ovum-foree[«? after- 
ward. Ergot ami riim|u*ession nmy h** nei'e-^ary to fM>utrol 
hemorrhage. Finally, the emt>lied womb \^ th<»ronghly washed 
out with a 1 : 5000 sidntion «if bichloride of mercury nr with 
a 3 per cent, Bolntion of creolin, after which a drain of steril- 
iz<hI gauze is parsed to the fundus*, and the prcx-ecding is fin- 
ishe<l iu short order. The gauze is lo Ik* removed in sixty 

Wlun the cervix is rigid and refuses to yield to the linger 
or frteel branched rlilator, the cervical canal (having l>een 
dilated as far as* [>racticalile hy the.^^ method*?) is stuHed with 
sterilized gauze, which after !«ix or eight Imnrei so far softens 
the tijisuesof the cervix as to allow of comph^ting lbere<[uire*l 
dilatation with the finger or instrument, when the o|>erntion 
if? proceedtnl with as l>efore deftcrihed. While this nielh<^i 
comjxtrts with the reigning surgical bias of the age, there are 



INDUCING PREMATURE LABOR. 483 

lit) |>r<><»fs as yet that it is tx4tt>r than other aseptic modes 
of tnanagiog aUirtiuu ca^es. After tlie fourth month ahodifm 
may Iw "ujilured hy the same methods employeil for thti induc- 
tii>u of pr'ttnaturr iahor, now to lie dest'riheil. 

Best Method of Inducing Premature Labor when It is 
Designed to Save the Child's Life.^ — After thorouprh anejwiiB 
of vuiritia, vtilva, iiistnimeiiLs el< ., I»as8 into the uterus he- 
l^veen iti* wall and the tbtal inend>nuie8, with ^nvnt rare anti 
geiitleiie**, to avoid rupture of sac and dif^tiirhame of pla- 
eeula, an ehustk* urethral hoygie (more easily remlered ase|itic 
than a hollow catheter i to a l(*ngthof Tor H inehes witliin ihe 
us. Let it remain there (kept in place hy a vajjinal laniiw>n 
of to(h>form jranze ) an a foreign body to invoke uterine con- 
traelion. Some of the lyauze may he jjacked in the cervix 
uteri ahaisji-side of \\w l>oug>e. 

To asi-ertain lla- jKiHitinu of the placenta, with a view to 
avoid disturhiuL' it with the hou^^ie, it has lieeti lately recom- 
mends I to map out tile Fallopian tuhe?! and mund ligaments ; 
if they eonverfje uftteriorhj, the phii'cnta it? on the 'po^terinr 
uterine wall ; if they are jmralkl to the longritudinal axis 
t>f the uteruB the placenta is »m the anterior wall of the 
nteruH,^ 

In introducins? tlte iMjUtrie the woman should be placed on 
licr left stifle in the laterr»-prone iMJsition, wntli hi|x« near the 
edL-'c of the l>eil, A H\nm i^pi*tnihjm \^ useA : the cervix 
steadied by a tenaculum or vtil'^ellum forceps* in the anterior 
lifj* vvliile the l>ou^ne ii* pnj*se<^l up and guided inlo the os uteri ; 
then let one finger follow it up to the luterrml o8 and deilect 
the i>oint to one f^ide, so as to avoid injunrigthe hag of waters. 
Thuj! guided liy tlie finger of one hand it it? punhed up with 
the other. With the oh uteri iif a primi|>ara it may 1m* ne<*es' 
nary to ililate it with the steel hranrhed dilator before insert- 
ing the Uujgie. In*!tead of using a spe<'ubmi iir the Sims 
jKi-'^ition, the wonnin may remain *»n her ha*'k, and the bougie 
be paHs<'d up, gni.»«|>ed in a hmg |mir of uterine dres8ing or 
|M*lypu.s for**e]^, and gnidetl in by the finger? as ju!«t de* 
Hcriheil, If. in tweiity-frair hours, no effect lie imMfuced, 
(which rarely hapfjen?*), lake it out, and again intrtKluce it in 
a somewhat different direction, and leave it m liefore. Uterine 

t t^opr>1i! iiiu\v» ttuit the corrvctneaa of this view hM bc«a vcriaed by numer- 



484 THK INDVCTION OF PREMATURE LABOR. 



coDtnictions eventually oecyr, when the instrunit^ni is rc^movcnl, 
ixm\ if the jiains iucreiuse in strength, the case may be lell to 
nature. 

If llie Cdntrnetions lie only ieehle and do not inrrease in 
strength and treijueney, accelerate both them and dilatntiun 




BiirDi'fl* bag. 



of the OS by introdiicing elastic dilators (Barnes' water- 
bags), hrst a Hiiinll one, afterward larger sizes, into the 
eervix. No other ineiusures will gvtttrnlhj l>e re<jiiire<i. One 
of Bjirnea* water-bags, with ii» attached tube, is shown in 




IMtfttor and foreepv of ChAmpctier dc Ribei. 

Fig* 262. The bag is^ intrrHhiced (the woinnn having be^u 
plaeeil on her back, her lower !ind*si flexed, aiul hifis nc»nredge 
of l)ed ) by means of a uterine sound, the end of which is in- 
serted into the little jiocket fixed to the liag near \X» upper end. 
or it may be fob led and grasped by u pair of djeseing-foreeps^ 



THE VAGINAL DOUCHE. 



485 



paased jiiat into the c^ervix, and |lU8he^l up further with the 
lingers. It is next lille<l with sterile watt*r i nut with air) hy 
a Daviilsijn j^yringe, the ea purity uf the luig having been 
previously learned, sso that it will not cli^tencl Ui hursting. A 
string tied tightly around the tube retains the water, or a 
sto|H!(K*k niiiy lie uttaehed^ as shown in the figure. 

A I n«>di lied dilator, invented hy Cham | metier »le Riliess, differs 
from that of Barn e,^ in heintr hirtrer (*M inehcM in diameter at 
the Imsej, of eonteal phajie, and made of Mjelai*tic water-pnmf 
silk. It is introiiueed with a s|M_*eiai euived foree^iss as shown 
in Fig. 2H3. 

It remains in fdla until expelled hy the pains, when dilata* 
tion will be suttieiently eomplete tt> allow of delivery. In 
cases of pelvic narrowing this dilator nui!*t not l>e ilistended 
to its full eajiaeity, Init only so far as will allow it to pasa 
easily through the coutraete*] canal. 

Voi^rhees, of New York, has devised an inexpensive con- 
ical liasr, in sets of four sizes, to he usi'd hke that of de Rihes. 
The dihiting piwer of the^^ hags may lie increased, after 
their introduction, by fastening to them a weight of one i»r 
two pjmids which hangs hy a string over thefiKitUmrd of the 
l>ed ; thus steady traction antl pressure against the rf*sisling 
OS uteri are maintnineih If, when the os is t/>7^ dUaUd with 
the larger bagj^ uterine amtrai'tion lie still delayed, the ?iiem- 
hnines may he ruptured, 1>ut ih* it delivery must l>e hidenrd^ 
usually hy getting down one fcHii by the Braxton^Hicks methtni 
of version, in order ti^ save the chihfs life. 

Otker Methods: The Vaginal Douche. — l^la(>e the woman 
u|K»n the bed, her hips near the edge of it and resting on a 
ruldier cloth, in which is arningeil a gutter to guide the re- 
turning fluid into a vessel on the tloor. By means of a 
fotintain-syriage, Davidson's syriuge, or a rulduT tulx^ con- 
nrcted with an elevated vessel, dirn^t a stream of warm water 
atjainH the cervix uteri» continuously, for fifleen minutes^ 
tl^ree times a day, at inter\*als of six hours. The nozxle of 
the syringe must go tvjaui4 the ncf^k^ never iido the mouth 
of the womb. Temperntiire of tiie water about 100° F» 
From four to twelve or more injections nmy \ye ne<*es8ary. 
The woman need not keep her lied liefore labt)r liegins, A 
modification of the vaginal injection is known m Cohen's 
method. 



486 THE INDUCTION OF PREMATUHE LABOR. 

Cohen's Method. — This cousists in parsing an elastic cath- 
eter ln'twetiii Iht" memhraiH'8 uiul iiteriDe \vall^\ and injectrng 
wiirni water shjwly, iii <juantity nf seven or ei^ht ounces, into 
the nterii^, i^relerahly iKiir iht; fun Jus, until the paUetil feel 
some disteoliou^ Ljiljnr conies on mueh more certainly and 
ni})ifily than allcr the vaginal douche, but both these methods, 
for good reaiJons, have been alumdoned, and are no longer 
used. 

Uterine Iiyectiona of Sterilized Glycerine. — A reeent raetliod 
of indueini^ litbor cuiisists of itijt*elniLr between the uterine wall 
and bat^of uati^rsfroni one to three ounce-s ofsfterifUefi ^jiifctrint. 
It acts by urodueing a nii*id exosmosis of fluid from the 
amniotic sac or from the uterine wwU, with coneecjnetit separ- 
ation of the membranes and jiroduction of labor |mins. The 
glyeerine k sterilized by boiling. After a sitffieient trial it ha^ 
been found lioth unocceAsary andilangerous; it is no longer used. 

The iLse of ert!:ot and other oxytr>eii's ; the injection of ear- 
iHMiic acid gas into tlie vagina ; the induction of uterine con- 
traction by electricity, galvanisn, abdominal frictions, irrita- 
tion of the mammary triands, have in turn all been rei^i>rted 
to for bringing on preniuture lalwir, but cannot now be reconi- 
nunded. 

Whatever method is used, the main |nirj>ose! of tire opt^ra- 
tion, vi'/., that of saving the chihj's life, mnet l>e kej)t eoij- 
stantly in view, an<l sini*t* dehiy after ru|>ture of the membranes» 
if prolonged, is likely to destriiy the child, it should be deliv- 
ered either by fon/eps or veivion, a>* soon as dilatation of the 
08 uteri arul other existing eondilions render such a proceeding 
sfifely practicable. 



TREATMENT OF PBEMATUEE mPANTS AFTER 
BIETH. 

The two great demlcrafa are warmth and ffxid, to which a 
third might Ijc addetb visu, rest. Lay (he child ujkjm a mass 
ot anil cover it with, ei)lton wchiI. Keep it near the iire, 
protect e<i from changes of 1f»m|>erature, Ilaodle it carefully 
in wa^nhing, the water used Iteiug a^ warm as 100^ F. The 
mother's milk- — given with a 8|M>on if the chil<l be too feeble 
to suck, or drop^ietl in the luouth from a pij^ette — muKt be 
adroinistered at fie<pieut intervals, every hour, and without 



TREATMENT OF PHE. MATURE INFANTS, 



487 



a loDg fast during the iii^'ht, Should the mother unt huve 
Bufliciont milk ilurinj^: iirA *lay or twu, it tmit^t bt* obtaiuetl frum 
a wet iiurse, or artiticial ttxwl be .ivilistituted. 




A simple Inru^wiuir M. Hot-water CAtia- K. MoIj«t RfHmjf©, P. (hilil's \)*:t\, 
the (ifTuw* ihow nirrt^nl* of air iFroin 1>*vim, nftor AI'tahu,) 

Th(* diUd's .*ikin ii» extremely delit!fli«? ; hrnrn* it shnuJcl have 
a daily bath (100° F. ) nut exceeding three or four minuted ia 



mm 



488 THE IXDUCTION OF PIlEMATmE LABOR 

duration, aud its napkins nni^t \\e ehiui^tMl promptly, as soun 
as soiled hy di.si*harj^a's fr<nn the liladdtr or l>owi'L 

To maintain preuititort" cfiilflreo tit a uiiifonn and elevated 
temperature, '*incubntoi>i" have lieeo empltiytHl These t'on- 
sist of t*band>era wirh sufficient breathing ji«paee, in which the 
child He8, aud the air of whieh ii* kept at thtMlesired temj>era' 

Pro, 266, 




Tubctnd funnel fbrfCBva^v, 

lure f 90** to 08** F. ) by artifieud heat, f^upplied by another 
chamlier having hollow double walls coiitainiog hot water 
surroinidhig t!ie interior eoniiiartinent ctaitaining I he infant. 
The lid is of glass through whteh the fhihl may l>e swn, and 
the apparatus eontiiinn oonlrivaneti^ for reguhiting tenv(K»ra- 
ture and ventihition at will. ^'Taruiers iiteubator '' and the 



TREATMENT OF PREMATURE INFASK, 489 

"apparatus of Cred^" are now used in many maternity hos- 
pitals. Tamier's incubator has been much 8im))]ifiiMl by 
Auvard, whose apparatus is shown in Fig. 264, page 487. 

An incubator may l)e improvised by phicing lK)ttles of hot 
water or hot bricks or flat irons l)eneati) and around the cot- 
ton-wool contained in the l)ox or basket in which thechihl \h^ 
the hot bottles, etc., being changecl frecjuently. The Huccew 
of this incubation-process re(juire« the constant attention of a 
nurse, and largely depends ui)on the weight and prematurity 
of the child. Children weighing less than thriM) )N>undH 
seldom survive ; of those weighing four or five |N)uudri many 
survive. 

The process of "i/amz/c " — artificial intnwluction of foo<l into 
the stomach — has also l>een em|>loye<l in infantM too young 
and feeble to nurse with a))parent advantage. A sofi-rubl)er 
catheter with a small glass funnel at one en<i (see Fig. 2ii^)) 
is moistened, and the free end )>assed U) the back of the tongue, 
which provokes a reflex act of swul lowing, when the tul)e is 
quickly pushed <m down into the Hti)mai'h ; now two, three, or 
more teasp(x>nfuls (aaiording U) age) of the mother's milk, 
previously made ready, are )K>ured into the funnel, and as 
so(in as it disa))|)earH by gravitation the tul)e is oui<'kly with- 
drawn — there must \h* no waiting, or the child will vomit. 
With pnictice and expertness the whole pnicee<iing may l>e 
done in flfleen secou«ls. The <'hild rest« on the nurse's lap 
with its beaii slightly raised during the ofjeratiou. 



CHAPTER XXTV. 

PLACENTA PR-EVIA— lIEMnKKHVGE BEFORE AND 
DUR1N<5 LAIK^U. 

PLACENTA PEiEVIA. 



Placenta j)nevia wiisist« in implauliitiuii of the placenta 
abnormally iietir to, or mure or Ifsst^vtr, tlie internal m uttrri. 
There are three varietiei? : ( 1 } The Imrfler of the pluceLiUil 
diak may l>e near the mari^iti of the os without ijverlappiug 
it, hence called " marfjinar'; (2) the placenta may lie par- 
tially or (3) completely over the os internum, hence, resjiec- 
tively. **parti(tf*^ or '*compfde'^ cases. 

Causes . — N ot cert n i n I y k no w n . Pro ha h I e e x pi a n jU i o ti s a re : 
Displacement of ovum from il;^ normal |K>8ition ami ItKijjjinent 
lower down, as after arrest of threatened fjimrtion ; alinormnny 
low ^>o^ition of orifices of Fallopian tnbes ; larjjre relaxed nteri 
of nmkiparous women, in whii^h folds of decidua vera <lo not 
retain ovule near fundus when it lirst cutci's* tlie womh ; hence 
the undoulited ^rcatpr frefpienev of piacenta pnevia in multi- 
pane. 1 1 Is also mo re iVeq iien tin m u I tlple prey'nancy, ( *h ron k* 
cn^lometritis is a [iredi.'iposinir rause, and ihe same may Ik' 8aid 
of my<miata, carcinomata, and other dis*ea<ej^ of the ntenm. 

Consequences of Placenta Praevia.— L Liahiiity to prema- 
ture lahor: cmly about one-third of the (%"ise.« reach full term* 
2, Tendency to maljirei^entation. '^. Fearful hemorrha^, 
generally cominii^ on durini^ the last twelve weeks of preg- 
nancy, or when labor be^in.** ; the bleeding l^ein^^ earlier and 
gre4iter according' t<i tlie greater d^^i^^ree of placental en<*roach- 
niont over the os ; in the marginal cai<e.M ^tmietimes not until 
**terra'*; in complete ones, exceptionally, before the Inst 
twelve weeks, 4. Death of the child, due to agphyxia, pre- 
mature delivery, hemorrhage, compression of cord duriug 
4fN) 



CONSEQUENCES OF PLACh\yTA PE^EVIA. 491 



version, or to prolapse «jf cord iitid ii» insertion near mar- 
gin i«f placcuia, 5. Liability to post-partnm hemorrhage; 
6, Diitigfr of septic intertioiL 7. Morbid atlhe^ioii of pla- 
centa ; in prenuiture niHK'^ tht* ti8sne<*hanj4:<?s in the utero- 
placyntal junction, uoriiuiOy preparing for i^t'paration at fnil 
term, \mvv unt yet taken pla<.*e, hen€e i40H*aIle^l mor/^ir/mlhesmn 
is aflmitteil bf exist in 40 ]>er rent, of all eatje^. t5<nne say in 
a majority of the cases. 

Sijmptfjnui and DiagnoaU, — Before labor sets in» phu^euta 
pran'ia is generally nnsnspei'ted until the sndilen occurreju'e 
of hemorrhage, which begins trithont uny htonm cause, some- 
times even at night ilnring wleep, or while urinating in a 
chamber ves%?^el. It m;iy stop and re<'ur again. The rjimiitily 
varies? with the amount of phicental Hrfturotioft ( whii-h always 
precedi^ the bk^ef ling). Firnt attacks usually nuMlerate ; ex- 
ceptiomdly, rjuart.^ of blood are h*st, mu\ death follows one or 
two rtK^urreuces ; such cases are usually ^^'t'omphit'' ones. 
The ijiiantity k apt to increase with each recurrence. 

During labor the bleeding begins early with tHimmeneing 
<libitation of the m. It may, in marginal cases, he arrested 
by rupture of membranes and rmiti^Hiuent **(tmpres«*iou of 
bleeding surface i«y the presenting head. Lalior pjiins usually 
feehle, and dihitation slow. To these symptoms must be j»<idi'il 
those due to blood-loss ; svueope, restlessness^ feehle pulse, cold 
extremities, vertigo, heaijache, etc. In fatal cases c*onvulsions 
often I vrecer 1 e deal h . 

The tlia0iiosl,^^A^nT\y sns|>ef^tecl from history and symp- 
toms — 18 confirmed by vaginal exandnation* the irregularly 
granular spongy texture of the placenta being easily recog- 
nhed by the finger passed into the os. In some pnmipara^ 
passing the finger tu or thnnigfi the internal os may be <litti- 
cult itv im]>i>ssible ; then, however* one side of the lower seg- 
ment of tlie uterus may W felt, through the vagina» to Im? 
boffrpj, m)ff, und enlarfjvd where the [»lacenta is attached ; and 
the pulsjition of arteries may be felt in it, A stethoeux»pe 
applied to cervix may reveal hi ml placental murmur. The 
sign balloitement is ol^scured, Diagnosis <*ann«t be pontivt 
until the placenta is actually touched and reco^rnized hy the 
examining finger. During the firsl ha!f of pregnancy a cer- 
tain <liagnosis is /j/i]>os>*iblc. By skilful hands the s|x>ngy 
cushiuu of the placenta may l>e recognixeil (chiefly in head 



492 



PLACENTA PR. E VI A. 



preseutatious ) by abdomiiiai palpation, A region pf the hard 
glDl>f of the heiul TumAh «ibN'iired liy tlie plu<"enta1 niiiss, whiie 
the piirf not covered hy the phu-eiitji retiiiiiH ib* iii^ual hard- 
De«s. Thi^ eiiu ooly i>ccur when the placenta i« not situated 
posieritjrhj. 

Prognosis* — Prior to the hust twenty-five yeai-s, the maternal 
niortulity hi them eiiseii used to he tVom ^^0 to 40 jkt cent. 
Since thcn^ with the advent of aseptie midwifery and im- 
proved methods of treatment, it has l»een reduced to 4 jK-r 
cent., and in sotiie well-conilnrte<l hospitai^i. even to le^ than 
2 per cent. Placenta prievia occurs t.ince in aliout 12tU> 
lalxirs. The iidant mortality s^tiU ccinthme^ high — fiO to GO 
per cent. A gootl many iiifant>^ Iwjrn alive snccnmh goon 
after birth. 

Treatment, — Whet her the hetnorrha;Lre o^i-cnr at full term, 
or 8<-'veral monthi^ heiore then, ami the woman U In tnffoi\ 
there can Iw no f]uewth>n that *hlhcnj, Uy whatever methmj it 
may he jiidlcioui^ly aceompli.«lied sjx^edily, is the pro[ier prin- 
cijile of treatment, f^ince it ntoji^ and [irevtiiLs the recurrence 
of Idcedinjr. 

When the woman i^ not in Udtor, and the preptianey has 
not reached the aire of ird'nnt viahility (twenly-eighlh week)» 
scmie advise palliative mea.sures tn control hemorrhage until 
that time arrive. But tins is unsafe for the woman, and the 
child will seldom he saved by tem|Kmzing. Tlie l>est rule is 
to delh'er as iMnyn oh pracfirahie after the ftrnt orettrrence of 
hmiiirrho(ft\ whether the chlhl be rtnhle or not. If lalnir have 
not he^nn, indiice it. An excejviit>n may l>e made to this 
rule in hi>spitnl practice, a i^hy^icinn lieing a/mttfj^ present to 
attend at i>nce in cane of bcmorrbage retiurring aA^er Us teui- 
jxjrjiry <*e5J.siiiiim, 

The best meihod of ttrrestin^ hemorrhage and of inducing 
ialtor, when the os uteri is not sufficiently dilated to allow any 
method of immediate delivery, is to jwick the vagina (and 
f^erinx utrri as far as practicable ) with ioih>forni gauze, or any 
other sterilizeil gauze, and in ca^e of emergency* strijis c>f 
sheeting iir of n towel, ?terilixed by ten minutes* billing, may 
be tise<l instead of gauzc\ 

This tanip-m, firmly applied, and kept in place by an 
"occhisitm dressing*' (see jmge *Jt>8 ), will certainly <'he<'k 
heiuorrhage^ c«mtrihute to soften and dilate ihe cervix* and 



DELIVERY BY THE BHAXTONHICKS METHOD, 493 



will usually evoke uterine contract irmi<> and 80 liriiig on labor* 
This kind of treatment will he niosit often called for in prinii- 
pnne antl In preiiiiiture eiises, when the m uteri 'u too sianll 
for operative *leliverv. But the same thing may oceur more 
rarely at full term* \\i\d \n multiparfie. 

If aseptienlly ap]>He<i the tampon may remain from four to 
ten hours, or even longer, unlei^ Mrong pains oeeuri or hlixHi 
hegin 1o appear thnnij^h the (K-elu^ion dressing, when it should 
he removed. If the cervix still remain too small for <»[M-rn- 
tive delivery, the lam|K>n may l)e replaced, after a vafj:inal 
antiseptic douche. When the os uteri will admit two tioi^ens, 
it is large enough for bJ|Kdar version* which is the method 
of delivery most usually adopted, for reasons to he now 
stated. 

Delivery by the Braxton-HickB Metliod of Version i Bipolar 
Version).— Wlii II the os uteri h a.s larp' »^^ a silver A<r//- 
ilollar* [)a.Hii the whole hand into the vagina, insert one or two 
fingei"s inside I he cervix, and get down one ft>ot by Braxttm- 
Hicks hijMjlar version ( described in Chapter XIX., p[K 3M0and 
381), As the leg, thigh, and breech are successively drawn 
down, while the dilating cervix yiekK they prca^ vptm the 
piaretUa, like a tampon, and ^top hemorrfiatfe, Observt* that 
tins is the chief object and virtue of the nR-thod. Note, too, 
that a leg could not l>e brought down Uy fxiei^iKil wrvhm, and 
that the os uteri in not ?iutfjciently dilated for ijttrnmf Vi't^um ; 
hence the hi|)olar method is the only avaihilile one. Hemor- 
rhage having bec»u thus controlled, there should be no haMc 
in extnicting the child. One hour, or sevend hours, nmy lie 
required ; tniction on the leg should be ju.«t i^lrong enough to 
maintain suflScient pressure of the child against the placenta 
to prevent bleeiiing, hence it must be in projjortion to the readi- 
ness* with which the dilalmg cervix yiehU. It would he quite 
possible to extract the body ♦piickly, but the temptation lo do 
thi« must be resii*ted. It is this hasty extraftion that kills so 
many infants; the Ixnly is drawn thnaigh before the os is 
sufficiently dilated to readily admit the af\rrcoming head, 
and, as in ordinary breech pre.«mtationa, a few minutes* delny 
at this time is fatal from pressure on the cord. Moreover, 
extensive and dangerous lacerations of the cervix may occur 
f r o m i m \ i r u d ent h ast e, I n so m e cases i h e t iss ues of I h e cer v i x 
are especially fragile. Wright compares the comlition to 



^1)4 



PLACEXTA rn.EVLl 



tluiL of **wet blotting-pai>t'r/' but it is seldom as had as 
this. 

Ill doiDg bijKilfir vc'i^iun in rentral cwses of placentA pnevia, 
it may be necessary tt) (VUnige the finger rigbt ihrmrgh the 
pifieetila and linug tU»vvn ihe leg ihruugli tlie u|KMjirig tbut* 
tiiude* III other eai^ei^, thti finger may jjenetmte tlie niem- 
l#rant*s^ or enter tbriHigh the 8paee where the jtla<*eiita hjjs 
iilready geparsited from the uterus. From tlie great liabiMty 
to seplit* in feet ion, the aseptie tef^niirjue must lie most rigidly 
enforced in all </ast/i*. 

Treatment by Rupture of the Membranes, Supra- pubic 
Pressure, Ergot, and Forceps. — While hijiular verriion. sinee 
it can be cbme before the eervix is mueb dilated, ami sinee it 
Hto^KS hemorrhage and exj^etlites delivery, is pnilmbly tlie 
method of treatment mud uften pnictised, it must he un<ler- 
stoftd that there are other eaitt^i* in which this method wmi Id 
l>e rpjite otit of the ipiestion. For example, when the iks nieri 
is fully, tir pretty well dilated ami dilatable, at or near full 
term, with strong pains, a good [*e]vis, and normal prei*enta- 
tion, and pjirtieiilarly in '*nmrginar* or ** ijartial*' case.^ of 
placenta jinevia, simple rupinre of ihr membraur^^ with dis- 
charge *»f the li4]m>r amnii, nniy lie all that is neceskSEiry to 
eheck hemorrhage. Under the eireiimstances inentxaietl, the 
haul of (he rliiltf if* forcrd ihtwti upon the bleeding placenta, 
and acU UH a plufj to stop lieinorrhagt*, just as ihe leg and 
Wly of the child did in the version easei*. Should thiB 
pressure from labor pains ah>ne he insoftieieut to control 
Ideeding, an abdominal binder and numual iirc^ssiire Ujiou the 
fundus, tirgctlier with small tlosies (11) drt)|irt every lionr ) of 
flfl ext, of ergot niny l>e u^^d to reinforce them, and the 
delivery may, if necessary, Iw completed by forceps, Ru(>' 
tare of the mend)ranes shoidd, of course, never lie done when 
the child presc^nts transversely, or in any other cBse& where 
version is likely to he called for. 

Treatment by the de Ribes Bag. — By thu^e who have 
beeonn? sntbeiently dextrous in the application nf this deviee 
(see Fig. 2<>*i, page 4H4) its u^k^ in certain hospitals ha^i given 
such good residts, especially in lt^s?terdng the intani nmrlalhy, 
that it deservcH neparate consideration. It is ijserl, when the 
child is alive and viable, instentl of the bi[M»lar vei^ion 
inethcxl, atid in the same ca^^ That is to say, when tlie os 



METUODS FORMERLY USED, 



495 



will admit two fingers, the hag \» pushed in througli the rm> 
tureil nit'mhniiif.s ur through the phiceiitiiitHeU' (in 'unnitnil '* 
cases), inid dis^teiHltMl with water. Tiieii l*v tmctioii u\wm 
the bag — ^ai'cotn|tliHhed by a weitrht uttachtHl U* it by a t'ord 
going over a pulley at the foot of the l>ed^ — the harj ihilf arh 
(lA a pfidj Uy i^U}[y hemorrhage and dilute the tj*s just as the 
ehi!d'fi leg did in the version method* By the tijne the hag 
eonies away it will have dilated the os uteri sntheiently to 
admit of ^[jeedy delivery by fureejm or vej"><iori» should either 
af the^e be refjuired. The distemleMl bag is liable to displaee 
a htijid pre^entiitioiv and change it into a traiu<iver*ie (me» but 
this can be eorret!ted by manipulation. In place of I lie de 
Ribes bug, the largest nhe of ViM>rliees' Img may 1k^ nssed. 

The ebief value of (his method is to altiiirj sueh a (h'gree 
of eervieal dilatation as will reailily ndniil the atler-eoming 
head when version is done, thus It'hiMening I be iufnul mortalily* 

Treatment byCsBsarean Section. — While this operation bus 
been done (again with the view of le4?i*euing the infant mor- 
tulitj), in certain eases where tlie eld Id is viable ami the 
mother in gootl eondition, it h not like!y to supplant the 
methods* of treatment already de3<eril)ed. In welbrtp[K*inted 
bcjspitals*, with skilled c)i)erators, it \^ quite admissilile that in a 
few vuiK's of very rigirl eervix in uniideete<l }jnmip»rte. with a 
ehild alive and near full term, the o[>eratiou might be right 
and justifiable ; otherwise not. 

After tlie ehifd is delivered, the phieenta may follow 8|>an- 
taueously, but in many irjstaTjees, owing to udbesions» the 
intmdnetion of a rubl>er-gloved awiilie band may be recjuired 
to separate ai»d renmve the afterbirth. A hot aulitii^|»lie 
dcntebe ami a uterine tampon of iodoform gauze shoubl then 
be used if hemorrhage ecuitiuue. Hemorrhage from laeera- 
tiou of the *X'rvix will rerjoire sutiires. 

Other Methods of Treatment Formerly Used. — Earm-H 
int'tlioft consisted in passing the hafitf into the vagina, aitd 
one or two finiftrH ax far i%^ they will reaeh, into the uttnifi. The 
fingers, then insinuated ln'twet^n tiit* plaeetila and I he uterine 
wall, are swept aroimd in a eirele si» as to compHr the se|mra- 
tion tif that jfftrt of the plaeenta attached near the eerv^ix, and 
whose iV/e<unplete tletaebnmtit kee|is I he bleeding vef^ds open. 
It is ufifu followed by retrnetion of the eervix and rej^sntion 
of the hemorrhage, and is esjieeially servieeable when the 



496 



PLACENTA PRjEVIA. 



placetita is |iliit*ed entirthj over the 03. l\Jipi(! ^xpnnsion of 
the cervix with Barnes' dilators uiul tlelivery l>y vergiou may 
follow, if desireti ; or, tliere bt^.itig no ijeceivsity for uctive inter- 
ference {ie., no more hleedini,^), tliecnae may complete itself 
witliont further flssistiiure. 

Neiirly allit*d to Bsinics' method h I hat of Cofunnntl Davu, 
yh, : Pass one or two tiii^ei-s in between the |diieeiita and 
uterine wall on that Hide where the reparation hay liegnn, or 
where the attMcliment is lea^t extensive ; et>mplele the ge|>ara- 
tion on this side, and then let the fingeri* hook down the 
border of this loosened flap of placenta and |>aek it cki**ely 
against the other side of the cervix. Then rupture niera- 
branej«» irive ergot, and hapten tlelivery* Should |>ains l>e strong 
with tlie head pre.st'nting, the latter may engage wit hint he os^ 
and, l)y its pressure against thnt ^ide from whieh the plaeental 
flap wa;^ removcih [4ug the veKs;-ls and stuj* bleeding. Should 
the pains not be {*trong enough to force down the head in this 
manner, a foot may be brfvnght down by ver*iion, ami thus 
iU't a» a plug to sto[> bleeding, a,s in the Brax ton-Hicks pro- 
ceeding first above «te*cribed. 

SimpAons method of treating placenta pnevia consistenl in 
completely sefmratingaml extracting the phicenta, trusting to 
p>werful uterine eonlraetion for sub^iHpient rapid delivery of 
the child — a trust so seldom realizcfl in prrtctit^e that Simp- 
son's plan scarci^ly allows a chance for thechild*s life^ (Vun- 
plete separatii»n of the placentii, howeven will often arrest the 
hemorrhage, and may, tht^rofore, be of ui*H when the child is 
dead, or not viable, or [iretty sure to die from prematurity of 
the lalwr ; or when great exhaustion on the part of the woman, 
aud the state of her pidvis and mflt |>artis contra-indicate 
fie livery by version. 

Aniemin, syri(»c)|>e, or c<dhi])se from lotiis of blood will recjiiire 
stirnidants, etc., as more jiarticularly descrilx'd umler post- 
partum hemorrhage, in the next ehapten 

Tlie use of ergot in placenta pncvia early in labor is not 
oliji^'tionable, as in ordinary hiliors, because in most cases the 
child is KMui//, being premature. Before using it, however, it 
should always be a^^certained that there exists no otht:r mecfiau- 
ical olnstruction, such as trausverse presentation^ ^lelvic nar- 
rnwing, tumors, etc. Shoo hi the pregnancy W at term and 
the ehihl/w// .^h^d^ the use of ergot is not m) safe, yet the risk 



HEMORRHAGE BEFORE DELH^RY. 



497 



of usin^ it eveu here may be le.«e tban the daagers of delay 
fmin iiit*fficu»nt jMiins, 

After (k^Iivrry er^rot muHt hi- giveu, an*! for several days, to 
prevent pM-piirtuni beiiiurrhMge ; and a 2 \^*v cent. sM*lutiun 
of ereolirj should l>t^ injected into the vagina twice a day to 
[>rr vent septic infeelion. 



HIMOERHAGE BEPORE DELIVEEY, BtJT WITHOUT 
PLACENTA PKffiVlA. 

Partial se^Miration of the placenta, with hemorrhage, may 
occur dnriiig the hitter montlis of pregnancy or after hiiwjr 
has heguni when the organ is normalhj »ituaied. It may 
re«*nit from blowi*, Iklls, or other mechanical violence : pat ho 
logical degenemtion of t!ie placenta or utero-phicental junction ; 
profound antetnin, alluiniinuria, and multi[i*)rity with fr«3<iueut 
child-lH^aring are proluihle pre<Iitij)osing causes* It t^onieliineH 
results from nephritis during i»rcgnancy, as well us fmni <itlo^r 
acute diseases, viz,, variola, s<'arhitina» typhoid fever, and 
acute yellow atrophy of the liver Sehhim occurs in prini- 
iparre. 

Traction by a short cord may t»***><liit'e it ; as may also 
miirke<l diminution i>f the utero- placenta I area following the 
birth of a first twin child, or the sudden discharge of liquor 
anmii in exteiL**iv^e [x>lyhy<lrarijnioi5. 

Symptoms, — Blood trom the [lartinlly separate^l placenta 
may H'nv from the vagina {esieriHtl hemorrhage )» or it may 
accnmnlate in arohbiitend the uterus (roticraltti hemorrhage). 
Tlie severity (if thesymptomi* varices directly as the amonnt of 
bleeding, whether inside or out, they may tilm he sudden or 
gradual, and ixtnir either l>ef€^re (usually) or during lalx>r. 

In exirrwil cases there ie hltHMJ-fiow, shtX'K symptoms of 
bhKHbloss, (K^rhajis mmr diMenlion of and juiin in the nt«*rus, 
and on vaginal exaniination no placenta prievia can lie tound. 
Unlike pla<'enla ])rievia, there may be a history of prevtoug 
injury ; blows, falls, jai-s^ etc. 

In ** nmcealed *' chm-s, svni[>tonis of blooddoss, distention of 
ih** uteni.»j (from aceumnhiting l»l»>od ), niid teanng pain in the 
nbdomen, really in the Ktreiehrd ut<Tiiie wall, which nmy be so 
si*vere as lo produce profound nervous shot*k. The [lain is 
more moderate in slow distention of the uterug» with small nnd 



498 



PLACENTA PR.'KVLL 



gnifhuil aecuTimlrttitjn uf IiKkkL The roJlapi^ and paiu 
occurring during liihtir nmy be mrsstakeu lor rupture of tlie 
tiU'rus. The latter, however, will be aceonipiiuied by 
receii^iou or Tuobility of tbe present iug part, and e?;4.'a[K^ of the 
chihl, wluilly or imrtially, into the abdominal eavitj* Ruj>* 



tu 



ilH 



ded \y 



•if € fit ute 



onti 



di- 



l^eeeu^ 

Prognosis, — Ext rem e 1 y grsi ve, e.s j leet n 1 1 y i n cxHiceti 1 e< I ciu?es, 
where the diagn«i8i?^ may be utteertaiii and eflieient treatment 
fKJHt|>oned. The muli^rnid ni<jrlality used to he oU jn-r cent,; 
it is uow much less. Tbe infant mortality is from 50 to Hi) 
per eent. 

Treatment. ^ — Exeejtt in very mild nn<l moderate ease*i» no 
expettiiucy is admi^jsihle. I)eli very otters the only port of 
salety. 

8uec^ss in the treatment of any ease (whether **extemar* 
or ** coucejtied ^^ ) largely de]>en<k upm llie presence of efficient 
uterine cmitraviions. If, in q given ea*je, one could antiei|iate 
diflienlty atid ilclay in seeiirhtg g<K»d etmtraetious, a prompt 
and elean Porroo|>t ration would give tbe best ehanee for lK>th 
mother and ebihh Thi:^ has l»een done sueees^fuHy even 
under less favorable cireumstance^, and is a reeognized melboii 
of treatment. 

In a concealed cascv before lalmr begins, when the large 
pregnant uterus is still further distended with effiistHl bhwHl, 
the eonditions for efficient uterine eontniction are at tbeir 
worst, the w(»mb i** weakened by overdistention, the woman 
liy hemorrhage and shock due t<> siiHiTing, a vaginal tarniMm 
would do no good, except in w fur as it might excite uterine 
<'outniction. Ku])ture of tbe mcmliranes \n letting out eon* 
eealed bhw^! wctuld only lessen inlra uterine pressure, and 
thus promote further internal bleeding. These are the easea 
that die. If a prompt Porr<i ojM^ration be not done, the only 
other ho|>e is to exeite uteri tie contraction by ergot, masi^ge 
of the uterus, an alMlominal binder, and vaginal tampon. 

Uterine contractions hsiving been setnired^ the whole aspect 
of the case is changed for the better. The membranes should 
now be ruptured, for them/i^rnr^j/ir/ uterus will leave nos|mee 
tor further bkwMl iiJCf*umnlation, Krgot, nia^^ge, binder, and 
tam|K)n mav still he continued* to maintain and increase the 
contractions, until the os uteri become sufficiently dilated for 
delivery by vergioa or forceps. To hasten dilatation, all 



TREATMENT, 



499 



methods have been, and may be used, viz., the de Ribes bag, 
Bossi's instrumental steel dilators, Harris method by digital 
manipulation, and incision of the cervix, as the operator may 
prefer. 

After delivery the placenta should be removed, and the 
uterus packed with iodoform gauze to prevent post-partum 
hemorrhage, which is not unlikely to occur in a womb that 
has been overdistended and a woman enfeebled by hemorrhage 
and shock. 



CHAFTKR XXV. 

POST'PART['M UEM< IRRHAGE— " FLOODING." 

HiiMOKRiiAiiE after ^ieliveryof ther/nVf/, ami either l>4*fore 
or aiU'T (lelivrry i)f tlu' plact'iiia^^ is a iiujhI (laniren>Uf* nmjpli- 
eutic)[i, somelirne*^ eausitig <]eath hi a few riiituiles, ejfpei'ially 
wheu uo]>rejH*retJ fur and irresolutely maiiajLCed. Heoce, 
necessity of tixed priiiri|»lei* and de<*iiled reTmHlk'8, useil with- 
out hesitation, hi the hour of need. Gooch well mul: **No 
pliysieiau should iiave the a&4uraue4? or luirdihoo<l to eroBS the 
thre^hohJ of a lyiug-io eliarnher whci is uot thoroughly eou- 
veTwmt with tlie remedies ti»r !l<KMliu>r/' It eousij^t^ of bleed* 
iujZ from the open moullis of »iteriue IiIimmI ehaunels from 
whieh the ]>laeeiita lias, wbtdly or in part, been separated. 

Causes. — Correetly apprtH-ialiuLT tlie eauhes of fl(KKlin|!j |>t*r- 
mits prt'renlioft^ whieh is belter than cure. Ex<*iudiiiir, for 
the present, the rarer eases in whieh blee<Iiii|> oeeurs from 
laeeratiou of the uterus, va^riua, and vulva, the one eoudition, 
ahtn^e all others, that leads to ilmMlintr is defirieui utpruif* con- 
traction — ^sometimes a tohtf want of it — inrtila «/^ri ; hence 
the term **<r/o/i/r" hemorrha;^e. Why shonhl the womb 
reiuaiu inert after the ehild is born? Its musi-ular walls nuiy 
lie worti iHit by n foitfj fabor ; or jiartially panilyzed, like an 
overfull bladder, from previ*>us ovcrtiintention due t<» amniotic 
dro}>sy or pUirjil jireL'^naney, etc. T<x> rftpni hibor, as by 
injudicioui^ hante in artificial delivery, or from abrjormally 
enlarged j)elvis, es|K*cially when preceded by overdistentiou 
of the womb, produces it. The uterine muscular wall may he 
cuji^eni tally defirifat tii fh'vrlopmenl (as in precocious nmt her ), 
or itutffmmrtl, itr IxHind down on the outside by penlotiml 
adhtnloHtt, nrtcxfurnffi^ degmerttted from previous in rtammation, 

Iti'i •ow'ML'i* ill wliit h the* jf/'if*o»/*r 

of yet over; hffn-r It I* nut cv •' 

thi- 11 There Is no rent Ufli? in I / ; , ui 

be (kiiiic^l ii>^ iL^er chUd-b^rth (and il tiAeti Uj \Mhi will imludc it^u i'«m^« wiUi 
retnlfied placcntA. 

soo 



SYMPTOMS. 



601 



or numeroHH and iiutckly mece^mre lahorn, m \n t»ltlerly womeu. 
Weak uterine innarles muy txTur fronj (jfneral wraknc^s of 
the womitiu 'lue to coriHtiiiitioiiid distUK*, severt* previous 
illiieKS exliiiustiiig (liiR;hnrgt*», heul ul' climate* ete. 

DiAtrntion of bladder or rertum f'nus<*4* m/ntptithetic uX^nne 
inertJH, lu* may aho vioUnt viental amotion, 

Rtienfion of place u (a — vv Let her tVoiii inorliu] mlhe^ion, lar^e 
gixe of ihei»rpui, or irregultir ( ** liour-glaise '* ) ttnitniftioii of 
the wonih — meehnniculhj prevents 01081* contractile tipproxitnii- 
tion of (he uterine walls. lu the vnse of raorhii] plnceutnl 
aclhe8ioti» the ittniially ne^mrateti bh)ofl-chanuelti are kejit oi»eu 
and cannot retract to jtrevent hleetliug, us they normally should 
do. It m liahle to occur, aj* aln-ady stated, in placenta j)nevia, 
A short or coiled \nim nuiy hmd to Meparatlon of lire piacenta 
before hirtli «if the child. The [ilaceuta follows the delivery 
of the chihl almost af once, and with it cumcs Hinietinie.'*, a prt> 
fuse henion ha^'c — IdiMMl that had accuouihited in the uterus 
tjetweeu the lime of phicental f^^fiaration aud delivery. Occa- 
sionally fibroid timjor of the uterus, when situatei) near pla- 
cental Bite, will priMlucc hemurrhaj^e. 

Those who liave rtnoded iti previous labors are apt to flood 
a^ain. Thin i.s olkst^rved in plethoric women, Puhje«H to pnifu«<e 
inen^iruatiou, and it* further explicable by exti«tence of eondi- 
tious, as trj pelvii?, wond*, etc., previously mentioiieil, which ai^ 
pernmneut and irrenjovable. 

Further causes are e<mflitiot»i» which interfere with forma- 
tiou of, or which tend to move and displace co«|tjula in the 
nioutha of the Ideedhi^ vefi?*eU The blootl changes of pro- 
found alliiiminnria aud wastiujj? diseases, pissibly the so-called 
''hemorrhatric diathesis/' may retard fonnalion of coa^^ula ; 
aud fiirmed or half-furincd clots may be displaced by stn»nj^ 
arti-rial lent^iou and pulsation, or by the [wtient suddenly 
risiu)^, **sneezin^%cou<:hnifr. laughinj?* vouiitlup/* etc. { Lusk). 

On the whok% the one main cause is dejieieitt uterine c^m* 
traction. When a contracted womb contiuuee to bleed there 
isi probnldy laceration. 

Symptoms. — O ushinff of blofwl from the vagina, either imme- 
diately or some time after birth of the child, or still later* after 
delivery of placenta, tjuantity variable : moderate or fatal 
— a trickle or u flood. Ab^nce, |>artial or complete, of hani 
Uteriue globe on liyiK>ga>tric palpation. The womb may be 



mi 



POSTPARTUM HEMORnBAQE. 



soft aud grently enlarged from accumulation of bl(x»d in itd 
cavity, with little or no external tlow ("concealed !tenior- 
rhage'*). In either ca^e there are syni| ilo ins of hloo(14i>s.i : 
deathly pallor ; cultl extremitieii ; feeble, frcijuent* tlireiidy, or 
irnpen*e|itilde puUe ; ^aping^ rej?tlessues.s dy.<piue!i, and huiii^cr 
for air; thirst, and even hunger for ftHid, In the uortit cases 
syueojie, loa» of vis^ion, convnl.^iot>, death. 

Treatment — Preventive and Preparatory Measures* — The 
neee^^ity of gnanlini,' aj^^jun^t relaxation of the ntcrus and 
prcjiiKiting uterine einitnictifjn during the third, and near I he 
end of the sei-ond Hta^^^e of hihor, by nuniual presi^nre has 
already been insisteil n)jon Jis a prtH'uution in every ease* 
K very obstetrician shonhl [n^eparo f<u' ilooduiir during second 
stage of labor, whether it In* likely lo occur or nnt, by pro- 
viding beforehand a good*wi»rkiog David^rtn syringe, ice m 
p!e<jes the !*ize of an egg, brandy, :*!iil[ihuric ether, carlM»lic 
acid, ergot, a solution (jf morphia, a can of iodofonii gauze, a 
hypKlermie syringe tilletl with tiiiid extract oi* ergot, or two 
grain;* of ergotin in solution, together with pitebers^ of hot and 
cold water, an empty basin, a fountiiin f?yringe, and a !M.^d- 
pan, all plaoetl within easy reach of the Ifeds^ide ; a prep- 
aration neither tc<hour? nor tmubleaomc, but which may «ive 
a life. 

When the hcniorrliage occurs, grasp the ntern?^, tvitkont a 
moment* A defnif, through the alulofninnl wjill, an<I knead it with 
the finger-end?* to secure eontractiim, while an assistant injecta 
hy[iodcrmieally, a dra*dim of fluid extract of ergot, or two 
grains of ergotin in a drachm of water into the outside of the 
thigh. Iji^i the nurse give a dojje of ergot by the mouth, and 
also put the child to the breiLHt. With projH r previous prcjia- 
ration and stdf-pc^sseasion, all this can have bi^*n done within 
thirt)^ Hccomij^. 

Should the womb not yet contract and the flooding c<mt in ue, 
let one hand continue to gnisp the fnnrlus* uteri on thetnitside, 
while the other (again without he:«iiation) is passed tjuiekly* 
but gently, into the vagina and uterus. (The hands mnst^ of 
eourse, be rendered mepitcfdhj eimn.) Now the uterine wall 
is l)etween the two hands, and may be pres^^ed lietween them, 
while the outsiile niie njiplics friction to the fundus ; or, again, 
the hand itiside may l>e gently hviiittd ar*>ntn( so a.s to irritate 
the woml* and produce eoutractiou. Jf the placenta be un- 





TREA TMENT. 



503 



delivered,, it must be removetl at once, either by gra^pititj: and 
sc|ueeziug tbe fvjntlus timily \\y the outside hiirid, or the hiincl 
iiis^ide ^m*ipa the pbict^utu iKHlily, bavintr previously separated 
nny remaining a<lbesi<uus nrul gently witiidntws it, the hand 
outside ineaiiwliile ei*mpre8siiitT tlie uterus with eurtieifut firru- 
tie.S8 to Htjueeze its anterior and |M»j<terior wiills t<»L.'ether, //' 
fhe pfnefiifa he deilverrtf. before tfie fi<Kxlin«z"» m^id hirtre bhuwl- 
eh>ta oeeijpy tlie euvity, tlii'si* niUfJt Ik- fearle^^^ly reinove<l, aiid 
the obistetrieian's hand tuke tlieir phice, A E«|x^'ial mode i^t" 
grasjtiu^ the uterus ( liinumual niatu|»uhitiou ) may be tne<l as 
fiillowis: IVess the finu:or-end8 of the out^^ide hand dfc*ep in be- 
tween the umhilieus and uterus so that the latter, re^stiug in the 




BImAniia) mmpressinit pnMlinlnjf mUollexinn, etc, 

pidrn* may 1h» pnsfied flown and forward a^inet the pnbes, 
while the other hani) (or tw(» finp*rs of it), |wig»ed high up 
alouj^r the |HJBteri«)r vaginal wall, pre?^eH the lower jJt'irnieJit of 
the wondi— in faet, its eervix — forward toward thei^yniphvsigi 
pubis ; thim by a mri of tem^iornry anteHexion the canal of the 
Deck is elos*»tl and rni bhwKl ean came out, while the pref«ure 
above prevents enlargement of eavity and aeeumulation 
within. It also stimulant* eontnulion* (See Fig. ^fHi.) 



.504 



POST PA n n ^V HKMOnRUA GE. 



A perfetlly eleaii tij^eptk' !?|ioii;.'e, ijr» prt*fenibly» a i^iniiliirly 
elemi lj!l uf rag tjr Kniull piM'kt^t-hmnikt^rrhu^r, suturateiJ with 
spirit of ttir|)futitits or vvlji>4k«^y, pib^stMl iiUo I ho wfimh aiui 
&<lUt'czcii so that tiif sjiirit rouK'Si itt ruutiit:! with thi* uti'rint' 
walls, ure effitvifnt stimuli to uteriuf routrurtion. A t'h>th 
cotitaitiiur,' pure eliloroforni, pn^vsed into tlic uterus and iiHowed 
to rem a ill there for a time, has uko been u^ed feutTt>si!*iiilI\% 
The old hot well-tested renuniies, of a rollt rl. gnsht'd lemon 
and i\ H[M>nL'e tilled with viiieL^ar» being intrndnred and Rpuezitl 
while in the uterine eavity, have of late been i»bjeeted to as 
iR^ing'aseptieaily nnelean* Tluy ftrt% howevtr, |>i>vverful ex- 
citants of uterine eontraetion. The viivegar eati be i^lerilized 
by boiling, and in eaties of einer^reuey it h us^ually olitiiinal»le 
in every hou.^elmhh A leiimu ean be rendered aR'ptie on its 
exterior by immersion in a hiehloride wlution, and that scptie 
germs inhaint m interitir ^^tnieture it* at lea><t improbable aud 
eertainly not demon.^nited. 

One of the hest in I em a I method** for a r reciting this heiiior* 
rhagc is irrigation of the uterine eavity with hot sterilized 
water (ILi** to 12(r F. } by njeans of a Day idRni or fountain 
eyringe^ eiire being tuki^n lliut the rio/zle of the iiMrument is 
free from germs an*l its tid>e rompielely eiiijitied of air iieihre 
Ueing ut*ed ; a lied-pati rt^eeivet* the returning water 

The external parts ghould be Mueared with ear holi zed oil or 
va^eliius to prevent |Mdn eau&€*d l»y eontaet of ^ueh hot water 
with the skin, 

Iji every ea.^e the ebihb whether watched or not, may be put 
to the lireuist by an aK^intanl^ in llie ho|>e that i<lictici0 of the 
nipplejs will produee rellex uterine ronlraetion. 

(Vmtnn-tion may scnnetinu>8 be »ndue<d hy rf»lliijg a piet^o* 
of iee on the abdomen over the fundus at hilervals, or jrtjuring 
ct)ld water from a height ttfKin it, or tiA|i|iing it with a wet 
t4>w*eL 

Of liite years a safe and effieient method of arresting hem- 
orrhage has been foumi in the uterine tan^ion of ioflofnrm 
gnuxei or of gauze soake«J in a H per eent. cre4*lin Uiixture, 
Remember, it is a tam|»on in the utrru^, not iu the vagina* 
The gau7x' is s^mked in a "20 |>er eent, iodoform Kjlulion and 
sprinkled with iodoform fiowder. Three 8triji8 of gauze, each 
2 inehei? wide and 3 yard** long* are prepared. After disin- 
fecting the vagina with a 2 per eeiU, ertsoHn sc^hitiori, or with 



TREATMENT. 



605 



II 1 to^OOO solution of corn>sivewulilimat4% the patieiil l^ iilaccd 
crosswise on the eti^i^e of ttie be<l, and tiit' tatiijMju ininMluctHl 
by seizing the cervix uteri with tht* hooks of a volsella fon^eps 
ami [lulHug it dovvu to the vulva while one einl of the gauze 
8tri}j lA grasjHMl l>y a |»air i>f lonjr uterine force j>i and enrricd 
io the fundtiH ; then the force |)« are vvithdrawji and neve ml 
folds of the strip intRMluced uutil the wouil* l»e filled — <xnu- 
ptctely and fit'inhj tilled — from fundus to external os. When 
the gen i till paK<a;re and vaj^ina are lar^^e, su that there 
is plenty of riH»m, the uond* may Ik? fUK^hed down l)v prc?i«iure 
of the left hand over the fundu.-* unlil the os beeurue vit*ible at 
the vulva» when two lingers of the ri^jht hand pn^h up the 
ganxe into the nterine cavity until it be full. The rout|:h ^auze 
is thought to firoduce irritatiou of the nteriue muscles, and 
hence eotitraotion. The tam|)on may reuniin twenty-four 
hours, when it is easily removed liy tractiou on one end of the 
8tri[j. This method is so sure, safe, and simpkv that ins^tead 
of making it a last restirt, it riiay lie used at oiiee^ if ergot 
and uumual ccriuprej^'^ion fail to arrest the blecdinir. After 
the uterUiS is well jntcked, the vagina also may be tnm(x>ned ; 
it acts as an additional excitor of uterine coruractjon. But a 
iw/t'/m/ tam[K)ii must nev*^ he used alonf ; \n these cjises it 
would cause the uncoutracted empty womb to fill np with 
l>h>od» thus converting an external hemorrhaL'e into an ijiternal 
"concealed" one, an<l enlarging instead of «liminishiug the 
literiue cavity. 

The a[)[iliauion of perchloride of iron to the interior of the 
uterus lias, for gocul reasons, btn^n abandouerK It endangers 
both infc<*tion and embolism. 

Ci»m]>ressiou of the abdominal afirta has been employed 
with giM>d residts as a temi»orary measure in urgent ciist^. It 
cuts otf the ldood**!up[)ly to the Hootiiug uterus, stimulates 
uterine coiiiraction, auil h'sscns risk i»f fatal j^yneofje by k*^f> 
ing 1 lie K)d in the brain that wtnjbi oiherwisi* How^ downward. 

It has been recently recommended, particularly in eases 
** where the bleeding results from large arterial vess^ds that 
have undergone atheromatous fb^'generation/* lo ofx'n the al> 
dornen aud rrmove the utfruf* by snpra- vaginal amputation, a 
method that few obstetricians in private practice would will- 
ingly undertake^ and that still fewer women, exhau8te<] by 
previous hemorrhage, would Lk* able to survive. 



sou rosrrARTUM hemouhhaqe. 

Anotlier receot suggest iuii is to invert tlie uterys completely 
tb rough ibe vagina, t^nrircle it neiir tlif neck with a rubber 
tul>e ur l»antlage of" iocioform gauze, ami thus arrest bleed- 
ing. After six hours the tul*€! (or banilage) m removed, and, 
there l>eiug no recurrence uf hemorrhage, the inverted uterus 
is replaced. Praetiee has tiot yet demoustnited the uliiity of 
thi;* o|:»eration. 

To epitcmiizve the moet UHeful urul must available remedies, 
and the order of their syccessioii, we may t^ay, jirH : External 
and iuti^rnal maiiipnlaiiou, ergot, and putting ehihl to bi-i-tisl ; 
Mmml, irrigation <tf uterine cavity with hot \ 120^ ¥.) s*tehiized 
water ; ihinU firm tdrrine taoiiHiu of iodoform gauze. 

In every eiLse when the bleiMling hiu? been arrestee! aud good 
Coiitrti**tion of the uterus produced, tbc organ must \\q sufi- 
(Kirteil on tbe outi*Hle by tirni and erpiablc comprt*s.siou over 
the alMhimen, in order to maintain it.< retraction ami |ireveDt 
recurrt^nee of bemorrliage* A well-adjusted alwh>minal Inmler, 
with conijjrc^scs over the to|i and sides of the uterus, slionld 
Ur earetylly a|*plied, Liisk sug^'ests a sack partially !ille<l with 
itjoisteueil sand or oonunon Halt as a rclialile etunpress and one 
easy to obtain. A small b^isin pjidded inside mth uupkina, 
[>hiced over the fundus^ is another similar device. 

Fnt,<ch has devisefl a mode of ctimpression which not only 
prevents tbe rernrrrnve of bemorrbage, but which { be claims) 
will !ilso.^/f/;> it, even without a tamjRm, or any other internal 
mftnipuhition — the latter being extremely desiral>Ie to prevent 
infcciioiL Tbe womb is graspe<t by ]>»ssing tbe band well 
hehiiiii the fundus and then HjlM as high ns [Missible nnd 
tbrcibly anteHexed against tbe ii////^r aud a// ^rr tor surfaces of 
tbe pnbic Imnes, any aintained clots l>eing of course expressed 
by this pro<*ee<ling. A large pad ( folfled towels, or simie- 
thing similar) \^ ntjw forced (bnvn behind the womb almost to 
the |>elvie brim, aijrl kept tirmly in place by i\\\ abdimiinal 
roller bandage; thus the uterus is acUuilly compressed against 
tbe an^vior abdr>minal wall and pubes — its anterior surface 
being, as it were, turntHi down over the mon» veneris. 

In all cases itsbtmld be asc-ertained ihat itierlia of the womb 
is not kept up by a full blatlder or re<num. 

To restore the eirculation after hemorrhage has ceaaerb or 
to prevent im|iH?iiding fatal syuco|>e during its continuance, 
etimulants, luitrientj?, and opiates are requireib A drachm of 



TREATMEXT. 



507 



brandy, whiskey, or sulphuric etljcr may he given hyinider- 
jiiiaiUy, mid rej^eattMl at re<|uire<l itilervfils ; (ir stryt'htiia, 
gr, 7^^^* ornitrojrlyeiTiDet gr. jj^, ; m<»r|*hia hyixitii^rmiealiy to 
)>riiuu»tenr'ri'hnil coii^fostioti, aiul tiiirturi^ nf o[»iuru urul lirautly 
iuteriHilly iu full <lost»8, t<)jr*'ther with stn»n;jr iu'et' rw^rz/rr, milk, 
etc., at short ititorvalB, Jji fWding the pitit'iit, the t*jmilleHt 
tpmniilp (unly a tea.Hpoouful every one or two riiinuiet*) may 
\w all iht' stomach will hear without vomiting; this to he in- 
creai*eii as larger portions are tolerated. U\ in spite of care, 
vunutiog owur, opiates, simiilatiug and nutrient eiiematji, or 
hyiMulermic lojeciions may Ik' ukhJ, to the tem|mrar>- txelu* 
81 on of niouth-feediug, Aihiiit j)lenty of fre.sh air from opei» 
windows. Remove all jjiIIostjs, to keep the head lt»w, and 
eh'vate the fiM>t of the bed, thu.^ promoting gravitation of 
hkHiil to the l>ratn and medulla. The headmvis^t not lie raised 
from its dependent [Kts^itiou, to give food or mtHlieine. nor for 
any other |»nrJ>^i4^^ for feur of syncope and fatal fieartrclaif 
until reaction have taken plaee, 

ronipre»sion of die brachial and femoral arteries, or bind* 
ing the four extremities with R«>marrh't< bandageji, like aortic 
compression, may keep enough bh^od in the lira in, temiH>- 
rarily, to prevent death, while stimnlanti^ get time to act. 

When ilcath is so near at hand thai respiration seemt*alHnit 
ttt eeag€% flick the face, neck, and brca.^t with a wet» ctihl 
napkin ; it invokes additional inspiration!*^ and is usually 
gratcfnl to the patient. 

When stimnlanls and the nilier measures mentionefl fail to 
produce reaction, tninsfusion may j^ave the patient. The 
transfusion nf hloml, or of fresh cow's nnlk, formerly ns**d» 
hsive of late iR'en superseded by the more easily available 
proceeding of infusing inio flu- ctrculatifai a saline s«ilution. 
A8 mnch a^^^ a quart of the following mixture may tit? slowly 
introduced hi to a vein : 



B. 



Socbi chloridi, 
BtMJii bicarb., 
Aq. destillat, 



Oij.— M. 



Lusk use.s a simple aolntion of eommou aalt. five grains 

only, to a pint of water. The fluid may lie pass^nl into a vein 
of the arm (usually the median cephalic) liy means of au 



POSTPARTUM inmORRIJAOE. 

elevated fumiel, or ffjyiitniii syriii^^e, from ulikh ilept*0(ls ii 
tulm sunijfiiuited at it^i lower end hy a sum 11 fiiiiiila for j>ene- 
trjitiiig the opened vein, or itito the temorul artery, after the 
method of Daw f>jiriu But thei<e o|>eratioos rexjuire surgical 
skill atid art^ not devoid of dao^^ r. 

The slmph\4 and bed method of repleiHshin^ tlio depleted 
Ijloodveasels arjd re^itoriiig tlie cirrulutiou (tar wiferthnn tran$- 
fosiou mto au artery or vein )» in to iiije<'t larf^e cjuatitities of 
the saline solution hypodefniieally into the eelhdar tissue, 
either iix front of the rhest, or Ijehitid, between tlie s<-*a]>LiIie or 
iato the nates. Two or three piuta of ^* normal suit solution " 
(i, e., three grains of conimau salt to the ounce of water — 
approximately 100 grains, or a snnill teaspionful to water, 
one quart ) i?5 prepared (the water hjuiiig heeti previously gteril* 
ized hy lM>ilinj^M jnid jilaeed in a fountain syrin^^e, the tui»eof 
whieh ii^ nurmounted with a large hy[MKlermie or exploring 
needle whieh h plun^^ed beaeath the skin, and tlie solution 
allowed to How into the cellular tissue by gravitation. What- 
ever method is used, the i*olution must ahvavH he hot — ^alMuit 
lt)0*^ F. Half an hmir tjr more nuiy lie re* pi i red to allow 
the gradual intriMluction of a sufficient quantity of the fluid. 

The slow injection of a pint or more of normal salt solution, 
high up into the rwtum, through a suitable tube, may be 
usinl with» or instead fjf the hyp»»lernun metluMl, and answers 
almost as well. An ounce f»r two of whiskey may be added 
to the enema. 

After reliction has Imen tistablished, the woman will suffer, 
perl laps for several days, with neuralgia, headache, and }iho- 
tojihobia, due to cerebral anaemia; hence iron» quinine, and 
nutritious diet will be required, and opium to relieve the jmin. 



SEOONDABY POST-PAETUM HEMOEBHAQE. 

Secondary |>06t-|Mirtum henrorrhage ( puerjierah or remote 
hemorrhage) may m'cur wif hin three or four days, or even 
as niiiny weeks, after labtjn Its atti><en are retained hltxid- 
cloLs, membranes, or pieces of placenta, or ( [lerhaps unsus- 
pected) a f>lacenta succ^enturiata, in the uterus. It may 
also arise frtmi violent mental emotion, or physical exer- 
tion, or u«e of alcoholic stimulants s(Kjn afler lalwr. Fecal 
accumulation, retroflexion of the womb, lacemtion of the 



MORBID RETENTION OF THE PLACENTA. 5(39 

cervix, inversion, thmmbus of cervix or vulva, tiliroid and 
|)oly|wjic] tiimorH, and CA^rtain bkx»d-ehange6, such as thot^e 
of profouiTd autemia^ uraiiuia, or ^ iiiiai*matic iKjiBoniug, are 
additiniral fa uses. One ease iKirurriujj^ eight day** ailer lahor^ 
ffil lowed the inhalation *d' chloroform ami aconite for inaoomia. 

Symptoms* — Blccslin^^ may <'<>nie on suddenly (quantity 
vnrJahic 1* ^Ui]\ ami recur at intervals. It may »>r may not 
be a*'com|>a!iie<l by fetid discharges and sejvticicmic .-jymploiiis. 

Trt'iitmvnt Ai^yn^mh ujMjn cause, which mus^t 1k» thoroughly 
invesrigated* Ju ca,se ot' retained clot^ or secundiues, remove 
them with an a,septie, rublK*r-glove<l hand or tingers (better 
than the curette) irrigate the uterus with a hot anti^e^jtic 
wvlution, and if ne^'cssary, i»ack it with iodoform gauze. 

If the OH uteri will nut admit the hand, uh may lnip[>eii nmm 
week.H after delivery, it muist be dilated with the finger:^, or 
Hegars dilators. Ergot may be given to insure firm uterine 
contraction. Other eticilogicnl factor;^ — uterine displacement, 
laceration, inverfiion, fecal accumulation, etc.* — mustof wurse 
receive appropriate treatment. 

Hemorrbiige i*oming mi very late, that is some months after 
labor, mail be due to decidunma ma lignum, ihii* malignant 
growth nircly deveiopiug at^er labor, jusat as it d<»es after 
hy«hitirliform mole. (See Chap, XI, p, 221.) 

In any cai^e absolute rc'^t and menta! <|uie1nde, with tonics 
(e8|»trially tinct. ferri chloridi ) and nutritious liquid diet 
will be rw[uired. 



MOEBID RETENTION OF THE PLACENTA. 

Morbifl retention of the placenta^ from causiea other than 
inertia uteri, ha>« l»een referred to as an additional factor in 
the ]>nMlnction of ]*(>i*t-partnni hemorrhage. It ij* eommotdy 
ilue to morbid mUuHtun of the placenta to the uterine wall, in 
consequence of [dacentitis, or intlwnmiutiou of the utero- 
plarentiil junctinn, having taken phire during pregnancy J or 
there may have been chronic inflammation of the lining 
of ttie wond> (endometritis), with hy|x^rpla3?ia of eounectivc 
tissue. l>efofe impregmition. Abnormal placental adhesion is 
often aa«<M'iated with, and is* indeed a cause of Irretjuhr 
** honr^fjfa^^* couiraeilon of the ntcrna (t*ee Fig. 2H7 ), which 
consists in a ftpaBmodic contraction of some of the circular niua- 



)10 



POST PA RTUM HEMOMRHA GE, 



cuhir fibres of the womb near it^ middle, the pliieeota Wm^ 
retaiiR'tl tilmve the cuLMriflioii, thnm;^4i wiiirh last the umitili- 
eal eortl miiy l>e I r nee* I u|> IVom the «>s extermmi, 

Spamioiile contruH'wn of the ott ig another eon<litioii by 
whk'h (lebvery of the [ilaeenta in ay be <lehiyefl. 

Treatment, — Spiu^iu *ti' the i>s, and .^pasni of t!ie eiR*ular 
fibrt^ higher U]i» njay both be overeonre Ity i^fadi/tronfinomn^ 
jtreHHure with the hand, the tiDger-emis being a{j|iroximateil 
into a c*>ne or one finger put in at a time nutii all have 
entered* when the hand may tie gradnally foreed throogh the 
ooiii^^triction, eoyiiter-i>re.<snrt' IxVing always made by the other 

Flo. 2ft7. 





Hmtr-glii^ contraeticm of uu*rus. with cneyvtmeQC of the plACenla. 



luiiid n|Min the fuiulLis. The iihieenta is* tlien, \f not tidhr rent, 
simply grasped by the trand and gently wilhdrasvn (Ittrhnj a 
rofttriwtton of the u tern if, aid Ijeiiig aff<»nled by [iret^iHure on 
the fundus and by erguU If the organ bt ndberenl, ihe 
morliid adhesion rniifit be broken up and the phietnita com- 
pletely separated In^fore withdrawal \» atteniptetl. A fiuger 
— one or twr>^ — nTUt^t be insiniiatnl betwi^Mt the uteruH aTid 
phiernla at MtUH* \Hiuii already partially i*ejmrated» nr if no 
jmrtiaJ separalion exist, at a point where the f^laeental iMirder 
is thiek» and tlien [Misled to aii<l fro transversely, through the 
utero- placental jiiuctioui acting like a sort of blunt ** paper 



TREATMENT. 



511 



kuife/' yiitil seijanitiou l>e complete. Another moiU* h to 
fiini or nuike a nuii'L'Hi *»t' !*e|niration a.s bi'fore, uikI tLen 
|)eel up the |*laceiitri with the fin^er-emis>» rolliuir the feejmnitetl 
pcirtion towtird the pahii of the huml ujxhi the^surtuee ot* llie f^till 
n^lhereiit part, aa one might lilt up the edge of a huek wheat 
eake ami r<dl it u|)oii itHelf until it Mere tyriie^l completely 
over ami se[)anite<l from ttie })hite ♦>» wliieh it lay. Stroutij 
tihrous and tilir<M*jirtilutrnioihs narely even partially ojSi^iHed} 
hamii* may reijuire to be pim-heil in two between the thnnd>- 
Dail fta<l intlexdin^en (ireat rare is necessary to avoid 
peelinif up an olUiijue layer «jf uterine niUHrular fibre, which 
might split deejK?r and dee|ier until leading the fingor-emls 
through the uterine wall into the peritoneal cavity. Should 
fluch a splitiitig begin, leave it alone and recommetjce tlie 
aepnratiou at s<»me other pitint nn the jtlacental margin. It 
18 sHoraetiiMcy only pcjssible to get the |»hict'nla away in |Mfee*«» 
Tbci^e should be afterward put togt'iher nnd examined to imli- 
aite what remnants are h'ft Indiind. It may he ijuite im]>rae- 
ticable to get ont every hit, hut ?*maU remaants or thin layers 
too firmly adherent for removal do not distend the womb 
enough to create hemorrhage from their bulk, anil the suh- 
8e<|uent dauger of septiciemia tVom their de(*ompo{^ithnt mny 
he obviaterl by iKJeelinL' warm < 2 per cent. » cre<diti water into 
the uterus twice <hiily, until everything have Cfmie away. 

In ca-ses where the plaeentii h retained from ha nnu>*uafly 
lartjc H{zt\ hook down one ttiVs^" of it with the fingers to insure 
its presenting endwii*** instead of Bat like a button buttoned 
iti a huttoudiole, and then make tlowriward and fmclunrd 
traction — aided by nhdamutnl prt'Si^nn: — to drtiw it through the 
c*8 uteri. To make the backward traction referreti to, dig one 
or two finger-eutls ijito the substauce of the placeuta, if it 
ennnot he grasfjed firmly euongh by the finger-ends, and 
manipuhite as if iittenij)ttng to pu^h if Unvard thf mitrutru A 
part of the organ having thus been made to bulge out of the 
oa, release the lingers ami hook them into the [dacenta again, 
higher up, and m on until it have entirely piUiwcHi int^i ihe 
vagina. 

In any case wliere tlie hand is pnni^ed into thf nternn to extract 
a phicentft, themosi rigid aseptic technique mu>*t Ix* olwjerveih 
The danger of in fetation is ai^Tntuated by the hand fneeeft- 
sarilyj Ijeing outside the amniotic i«ac, hetween it and the 



512 



POSTPARTUM HEMORRHAGE. 



uterine wall, in immediate contact with the open mouths of 
bloodvessels at the placental site. In extracting a child (as 
in version) the hand is viside the sac, the membranes being 
between the hand and uterine wall ; hence the increased danger 
in placental eases is evident. 

Introducing the hand into the vagina for extraction of the 
placenta is sometimes sufficiently painful to cause objection 
and resistance on the part of the woman, the vulvar orifice 
being tender, or jierhaps more or less lacerated. A little firm- 
ness of purpose, sometimes lacking in the young practitioner, 
coupled with moral encouragement of the woman, and gentle- 
ness of manipulation, will remedy the difficulty. 



CHAPTER XXVI. 

INVERSION OF THE UTERUR 

The womb may be inverted in various degrees, from a 
simple indentation of the fundus to its being turned com- 
pletely " wrong side outward," and hanging upside down in 
the vagina. It usually begins by " depression " of the fundus, 
the top of the uterus being indented like the bottom of an 
old-fashioned black bottle ; this may go on until the fundus 
reach and begin to protrude through the os into the vagina 
C' fxirtial inversion'^ )y or the protruding part may come 
through more and more, until the whole organ be turned in- 
side out {*' complete inversion''), (See Fig. 268.) 

Ocaisionally inversion begins at the neck, the fundus being 
then inverted last. (See Fig. 268, page 514.) 

Causes. — Under any circumstances inversion of the uterus 
is rare, but it is usually the result of mismanagement — trac- 
tion on the cord, or upon an unseparated adherent placenta, 
during the third stage of labor, especially when the womb is 
not well contracted. Other causes are an actually short 
umbilical cord, or one that is practically short from coiling 
round the child ; sudden delivery, particularly while standing, 
and when the uterus is overdistended and relaxed ; violent 
straining or coughing efforts after delivery ; forcible and 
injudicious pressure upon the fundus trom above, whether by 
the hand or heavy compresses. In short, a relaxed womb 
may be inverted, either by pressure from above or by traction 
from below ; inversion of a weW-contracfed uterus is well-nigh 
inijx)8sil)le. 

A very few cases have occurred after abortion and in un- 
impregnated uteri with polypi whose pedicles were attached 
near the fundus, hut these Inst belong to gynaecology. 

S3rmptoms. — Hemorrhage, faintness, shock, pain, vesical 
and rectal tenesmus. Abdominal palpation reveals "depres- 
sion" of fundus, and bimanual examination, in "partial" 
3:3 613 



514 



L\ VERSION OF THE UTEIIUS, 



auil **coiiJiilete** inversion, demou&tr rites re^jjet^tively partial 
i>r complete fibseuru of uterus from iti? tioniial jxtsitiou in the 
pelviH. Diagnosis nmy be olLscumd by a full l)ludiler ( pro- 



Vin, 'Jti*^ 




Three degrwt's uf Inversion, a. Tk-prcsslon nf fiitiduB. ft, T^tcrine onrity. 
c, VH^aiu d to d. Norniiil line of fuiidus before InTersiun. 




Inversion li*ginnlng at the cerrlx^ ( A flcr Ui^ncas ) 

duced by the inversion ), but using n eatheter will relieve this 
(ItfficuUy, Vajnnal exinn inn lion iJi.<4(*overs uterine tumor iK!* 
cupyitiji the vaginii, tnireiher with the placenta, if this last 
have not been previously delivered* 



THEATMENT, 



515 



A fibrous jKjlypus (the only thing liable to be eonfoumlod 
with iiri invt^rted wtmih) muy \y^ dia^nostk'iitetl Ircuii the uterus 
l)y its mmpUtr iHf<* n^duiUy^ it« (tdaf tnittt ftjcontractioti ulurn 
hantlit'dj lUul hy Joliowiny ii'^ ptdich' throiftjh the os uU'ri up 
ittto the unincertid ttterute cai'tlif^ wh'wh hist uiay, in any t*iise 
nfduyht, l>e demoueitratiHl with thf utrrhu mttnd, ^Veling 
tiie wijiub ill its pmpi^r [Kn?itioJU Uiruogh the ahdomimd wull, 
shonj* the organ i.s ut>t inverte^J. Uterine inversion is hardly 
likely Uj be niiiitakt^u for polypus?, exeept when the organ 
reniuiuB inverted lor niotiths (sonjeliures*for yeari* ) idler la lior, 
J>e(!<uuing re<lufed in t^izt* hy involution ; sueb eiii^es are called 
**elironie inversion/' and pnii>erly belouji to gynieeology. 

Tha progiuMis nf oterine inversion during lalior i>< always 
Berious, The gre^it iniiiudinte danger is profuse hemorrhage, 
the more profuse when Jiissoeiated with inertia uteri, ami |>er- 
haiii* Horne spiism id' the os?. Murh dejienda u|>on the early 
rediH'tion of the inversion. Every minute a<ltls to iHjih 
danger and dilKcnlty, Exeeptionally» the plaeeuta may lie 
suffieiently a<l herein ti» preveiit great hemorrhage, 

Treatmeat, — *'De|)re88ion '* of the fundu*? and ** partial** 
inversion may he readily redueed by pajising the hand into 
tlie womb and jaiBbiiig out tlie imleiited portion* while the 
organ h then stimulated to eontniet. 

When inversion is *' eon^plete,'* reduction may still he eagy 
if altempled at onee^ but not eo after dehiy. If the plaeentii 
be Htill wholly or in great fuirt adherent, it should be at- 
tempted to push it baek witlj the uterus, the eloeed ii^t Iwing 
pressed againnt the clependent fundus, on which the placenta 
firms a cushion, wldle eotinter-prt^i^ifre Is mmle with the other 
hand over ihe nhdnmen. When the bulk of the placenta inter- 
feres with reduction, and when it is aln^ady in great [mrt 
dctaehe<l from the wondi, its i*cparation nu\y lie completed 
befi^re pushing back the fundus. When constriction of the 
OS ami otlier rauses have proiluced swelling and congestion 
of the inverted uterine body, the latter must be comprt^^d 
between the two hands steaclily for a few moments to lessen 
its bulk before reduction is atteinptetl : or this may be done 
more eftectually by bandaging the inverted organ with a strip 
of iofhiform gauze. 

Slumbl spasmodic ecmstrietion of the os render reduction 
im|Kjssible even by dcadtj. Jinn pressure, anis^stbesia may be 



51 G 



ISVERSrON OF THE UTERUS, 



resorted to to reltix the sptism, but the main principle of suc- 
cess in these cases is to mamtaiD continufd prcftHure, without 
any iutertnission, for five, ten, or iifteeu oiitiote^, and with 
likt^ eontiiuieti enuttltr-prt*!^nre. 

After re*kiclitiD, the hau*! iiiuHt H<>t he withdrawn from the 
utoriue wivity until the orgiiii have heen ninde lu rnntntcl^ 
and the plnceiitHj if pushed hack with the wond), must then l)e 
M^parated nrid withdrawn, as in other eases. 

To furtlier prevent a return of the inversion, the uterine 
eiivity shouhl l)e irrigated with hot water — 11;>*'-120°F. — a 
quart or nn^re may be retjuirefi : it seeures contraction and 
arrei^t^ bleeding. 

When the <lei>endent inverted fundus refuses to yield readily 
to manual pre^ssure, one or hnih of the angles of the womh, 
where the Failo|ijnn tnbevS enter, nmy he first indented in the 
oj>eration of redurtion. Inertia and hemorrhage resulting 
fnun, or conipliciiting inversion, require the remedies* for jx^st- 
|>artum hemorrhage, f Bee Clmjiter XXV,) 

The SitrirteFt nntiwptic technique must, of course, be oli- 
served in all these manipulations, and atYer tlie inverted 
womb is filial ly replaced, its cavity must be washed out witi 
the creoliu solution. 



CHAPTER XXVII, 

RUPTLTKE or THE UTERUS, VAGINA, ETC. 



EUPTUBE OF THE UTEBUB* 

UlTPTURE of tlie iHertis may occur in any fiirecfton, iran.^* 
ver?!ely, longitydiiiallyt or iMith ; in any pomfioUf huuhis, iMxiy, 
or neck, rn*jst fre4|ueudy toward the lut^l ; and iu varioiLs 
degt'*'es~ilmt is, throuti^fi the muscular wall without rnpture 
iif the |K^ritoneuni — '* inrompfete rupturti '''■ — *>r thruugh h^uh 
{>erttoneal and Tnu^^cidur *x>at^ — '' romjtleh' ruptnre," 

Causes. — Strong uterine eontractum iM/ttpft'd with mechanical 
impediment to ptusage of child — conditions existin*^ in tran»- 
veT%B presentatioQi?, jjelvic defornnty, or contraction* and witfi 
Inrge siae of fo^tu.s esfKHHally in the tlelal head» ag in hyiJn> 
cephalu.s obstrnctitm from tiliroid or (»ther tuaiori*, etc.; the 
danL^^er in all of these tnem is increaseiJ ivy ergitt, which is 
8<j!iietinie8 nnfortunately giveo. Occasional ly rupture oecnrs 
withotd ol>8triiclion to pasj^a^^e of child ; it Ia then exphiineil 
by tisane degeneraiiim — -fatty, Hhrons, or tu})ercular — of the 
uterine wall ; or the texir may (H;cur at the site of a previous 
rupture, or through the old scar of a former Cjcsjirt^an mk'I ion. 
It nniy also result from traumatic injury following Mows, 
falls, sf^ueezing, etc. The uterine wall is, rarely* nip]w:'d ami 
pinched l>etween the prt^mting part of the child' and abnor- 
mal sharp edge.s of Iwne pnyecting into the pelvic canal, by 
which a solution of continuity — the beginning of rupture — is 
produced. Multi|mrity, and the tlntniing of the uterine walls 
due to frc^quent childbeanng, are predisjHising causes. Ante- 
flexion, anteversion, cervic4il obstruction, and lateral obliquity 
of the uterus constitute other instances of me<dianical bin- 
dmnce to labor liable to l^e attendeil with rupture. The 
womb may be ruplurett by violent and unskillful manipula- 
tions during versi«)n and forceps ojx^ rations. Intlammatory 

617 



518 RUPTVllE OF THE VTFJIVS, VAlUNA, ETC 

ehanj^es hi tbu uU-riue tissues, due to prolonged pressure 
lietwiTti lilt' i{viui< iitul the ju'lvk* walls, coinhice to rupture^ 
evi^ti yircmtidii \md ^'suigiviie may (KX'or, 

Symptoms.^AUhoiiuh rupture gt-iuTuIly <x'eurs snddeiily 
and without wiirniug, the existruce of couditioiis niriitioiRnl 
under the head of **ciiiweij ^' ought to be suifieieut to ijidieate 




luteni&i OB 



cxtemAl 01 



internat 06 
external ot 



Arm prroentAtlon wtth threatened mixture ortliinncd lower segment ofiitertiii 
(After SCBit^'ii>£R.) 



darijorer of the aet^itlent. In the more uj^ual cases of niechani- 
nil f^l»stnjHioo there (xx'un*. mme tinte before rufiture, a 
reuiurkahlf* thinning aud atretehinp of the lower j^piient of 
the utt^nis, while the up|)er and nriddlt* ?(»gniruts of ilu- v\o»oh 
are tliiekenerl, the Hue of divisinn between the thin and ihiek 



SYMPTOMS. 519 

|K>rtioas constituting ii |>erreptil»le ri<lg*3 or furrow, comniouly 
known as tht^ " runj of Bamlt^'^ or more tiimiliHrly of late 
ii^ tJie ** fon tract ion riug." Thw ctiiulitiou in ^howu iu Fig, 
270 < page -ilH), ilhMratiiiir the result <»f proluritft^d IsilM^r in 
an arm presentation. On one side fnJly half of the uterus, 

FiO. 27L 




Thlnnitig of lowernegniiMii of uterus ht rfK^rurtiou from hydruceithAlni. 
(Aaer Bakdl.) 

extending from the shoulder of (he ehild to the top of its head, 
is thinned na deserilK'd. The ssiriie condition app<>iirH in Fig* 
271, showing olistruetion from n large hydnx-ephalie head ; 
the thin, stretrhed part of ehe uterus extending from tht* oa 
Uteri, on a level with the jielvie hrini, up to the elnhl's arm. 



520 RUPTURE OF THE UTERUS, VAGrNA. ETC, 



It is {\\m tlnii portion tliiit in es[>frudly Vm\M lo rujiture. 
Tl»e incrwised thicknt\sw «»t' llie ujijkt «^)j:ment i^ fX|ilaiiie<l \\y 
inusfuliir retratlifiru ami by wliiU \\\m heeu ternitnl *' mUjt'ntioH ** 
uf the miL'ic-ultir layers — lliey ?t'pHmle fruiu L-at-h cjtlier ; sotue 
alip up l*y ciMitrai'tion aud leave tlie wall l»eluw thiiiHen hut 
thicken the part ahove. { Si-e Fv^. 270 and 271. pa^^e*? "?18 
and 511].) Pret'cdhiii rii[)ture» theret'orc, tlit? ring of Bai)ill» 
running ^»hli[plely or tran^ver?jdy across the uterui*, may l»e 
discovered liy alMiomiiial pal[>ation, and a8 the jmint* — usu- 
ally rapid and violent — pn>;rrei^ the ring get» hitrhrr up 
toward the fundus ; ^ the rotitid lifjamentft juay ali?t> he i'elt i\s 
tense cords through the abdominal wall. The vatjlnal wall 
may also Ite teniae and s^tretched. Such conditions indicate 
dnufjer of impeNiiin*j rnplnrt\ They arc otVen couplctl with 
symptoms of general exhaustion from pntlongt^l etibrl, viz., 
small, i\\x\vk pulse ; hurried breathing ; anxious expression ; 
pron I m need inenlal ile?»p<aidt'ni*y or iles|»air, etc. 

W h '.^ n r u J rt u re : i cl mill y < m -c n rs t b e t y pi ca I ny n i pt o r n,-* a re a 
sudden .shar[) jMiin in the womb (cau.«.ed by its tearing ), s^nne- 
time» accompanied by an audible nois4^ ; jiudden and siniulla- 
neousi ceRmtion of labor pains ; a seDsation a*i if warm tluid 
(really Idood ) were lieing ditfuj^ed into the abilornen : violent 
shock atid colla]X'^\ inrlicated by pallor, feelile and Impient 
pulse, cold extremities, faintinij, hurried respiration, %'oinking, 
et<j. (usually due to heinorrhuge into the j>entonca! cavity). 
On mfjitial examinatinn the prej«.*nting |wirt of the child in 
found to have receded from its former situation, owing to 
partial or complete escape of the fetus tli rough the rent into 
the abdominal cavity, where, by abdomhml pnljmlion it may 
b© felt as an irreguhir-shaped, rijovable tunmr, more or le8a 
diHtinct from another tuinor formed by the partially con* 
tract e<i uternn. Blood may or may not e*Jca[K/ from the 
vagina. A hK>p of inte.'^tinf* may prolapse through the rent 
anr! be fouocl by vaLnnal examination. 

The foregoing array of gympioms wouhl leave no room for 
doul»t in diagnosis. But when rn|»ture takes place more 
gradually, or is '* inromplelr'*' — ^t. e., when the muscular e<>at 
only is ruptured, the peritcjuetitn remaining intact* the syrafj- 

' Before labor lK'(rtfl^, th«* rctrii<*llon rine in riluntotl About 3 Inchffi ftlK»v* 
tho «M (nfrmum : In lm|ML'?»rllnK ruplure U may Iw f*!tl Um)ugli the ubdutiiiuiil 



TREATMENT. 



521 



toiiis arv less deouieil Tliu child will 7iot have ewmped^ — ^at 
least i'onipietely — into tlje alMlonieu, lint will be ctJuUiiutMl in 
a stretched puueh of t>eritoiieuiii, »** tense that the diiflTeiit 
piirti^ of the child eaujiot he recognized in it by ul)dorninal 
jnd[mtinii, wbcriius in *' cttmplete'' rupture the fiutal |uirLs arc 
eaMiltf reco^iii/Anl and can bi^ t^a^ily Dtovtrl aboiit^ resilitj^ l<xii*t»iy, 
a^ they do, iranietbatt^ly heiit^ath the al)doriuual wall. The 
presenting part may or may uut have reeeded. In a j^n*adii- 
ally progressive rapture, labor [laias may eontinue and force 
the chihl gradually throngli the enlarging rent, lu i«ome 
cases the presenting part la^comei^ impiU'h'd m the |ielvis, so 
that it cavntd recede. 

Prognosis. — It nuL^t l)e undei'sttKwl that rupture ( lacera- 
tion j (»!' the lufjitiaf porlion of the ctTvix uteri nnu% and fre- 
quently dm'.s occur during hiUir without any necessiiry imme- 
diate danger to life; hut in the?* liie tearing does uut involve 
the [Kvritoneunn and e5cn|>e of IjIooi^, etc., into the alxlotuiiial 
cavity. 

Rupture involving any jxtrtion of the womb a/wnf the 
vaginal part of the cervix iaadiJTerent affair. Theprognosia 
is here most grave. Death may ensue rapidly, eillier from 
profound fc^hock or hemorrhage into the |»eritoneum, or, sur- 
viving these darjgers, fatal j>eritoniti& and septicemia may 
shortly follow. The maternal mortality much cle|»end!5i uptm 
the fjeverily of the cas*% the extent of ru|4ure, and the treat- 
ment adopted. Formerly it was stated only one out of i^ix 
caHes Murvived, turf by the timely i>erformanre of laparotomy 
the retindts have bec*>me m nuivh more favorable that over 
half the women are saved. The ftetal mortality is? s^till 
greater, survival of the child lanng a rjire ext^ption. 

Treatment, — Before the oceyrrence of rupture, but when 
existing condhions indicate an evident liability to the acci- 
dent, every means of preirfttion must be ndopied. If }>ossi- 
l)le, the mechanical ohstrnetion to deJivery must Ik' rcntoved, 
and the pains le,<seued by ana*i4thesta ; therj the uterus must 
l>e enijitied without delay l»y /orrr;j,% if this Ix' practicable; by 
eraniofomif, deeapiMion, or emliryotomy in suitable case«(the 
child will usually have died from pndonged pres^urt* ), or by 
whatever metlKj<i the ** passage " an<l ** pn44.^^oger " will allow. 
As to r(^.*inn in any case of imptntUfuj rupture, it should tiot 
l)e attempted ; it would be ahnoi^t certain to produce rupture. 



r*22 nUPTURE OF TUK UTE/H'S, ['AaL\A, ETC 

Aflvr rufilure lias ^KTurnMl, f^jwH-ially ii' h he '*c*(nnjtlfte" 
iiml e:Jtttii.-<ive, iiinl rlit^ I'hiltl t^litnild have et<('n|K^fl, wlitdlv or 
ill *rriat [jurt, thrtni«^li tlu> rent h\U> tlit* ulnlojiiiiial mvity, 
laparotomy Hhoijl<i he done nt once, flilltl, pluceiitu, l>ioocl- 
L'lot^ etc, Imni*; removed thraugh tlie alnlumiruil int'imon ; the 
j>eritotieal ruvity rletioserl with hot saline solution ; tlierentin 
the titeruis repaired hy suture ; or iii aiM'ofan itiikned uterus, 
or one tlisit will not eotitract, *iT m whieh the rnplure eaonut 
he well semrt'd, (he entire uterus should Im* renio%^ed. 

In ea.^'s eoaipliesite^l wilh laeeriUion of \\iv hhid«ler, or hy 
prohii>se of an inlestirial loop thjit cannot lie rephued per 
vaffiKam, lapnrotonay is ti«:u!Ji ii ni'eessijy, tlie prola}>^ied giil 
being drawn up and the hhidder sutured from alwive. 

In tmses of tncooiplele ru pturei when the rent is snmlh 
and the uterine fHvntents have not invaded the peritoneal 
cavity, delivery sht»uhl he dtaie hy forceps or endiryotomy 
per ragififim^ Jiere again rrrxion wimhl l>e almost <'ertain in 
complete the rn]>tyre. After delivery of * liihl and [dacenta 
in these eases* the rerit sliould he plugired with iodoform 
gauze, and erj^ot driven to erintrol heiiiorrhntre and eorruj^rate 
the rnplnred wound ; the uterine cavity having Ijeeu pre- 
viously eleaose*! with a hot sterile salt solution ; the gauze 
to renmin tsventy-four or forty-eight houm 

III eases where the ohstetrieian is }i(d a snrgeoo, and FUr- 
gieuJ ftkill eaunot be readily obtained, is there anything 
beside eceliotomy that can l)e done in the had, "complete'* 
case^, firi*! Iiefore nu ntioned ? Something must be done 
quickly ; about one-hsdf the fatal cases die witiiin tweiHyfouT 
hours from shock, hemorrhage, or sepsis, I'nless delivery 
l>e accrimplished in some way sj>eedily, all will die. Under 
8ueh eircumstaneesi, the hand mat/ be passetl in to grasp the 
feet (even pai-sed through the rent into the abdoannal cavity), 
and the child and placenta delivered through the vagina. 
Then the cavities of the uterus and abdomen should lie 
cleansed In' irrigati*>n through the rupture and finally a long 
strip of iodoform gauze passed through the rent into the 
peritonaii cttritji, enough to form a large pad (or splint) on 
the tmimdr of the uterus, over the site of ruptur€\ a con tin ua- 
iioi \ ( vf \ h e ga u xe st r i [> (all in one j ji ece ) oceu py i n g a Im i the 
initkh of the ulems as a tampon, A binder over the abdomen 
compresses the abdominal pad against the uterine wound. 




TliEA TMEyr, 



523 



Day by day, littli^ Uy little, the strip of gauze is drawn out 
per vafjinaTih tiutil iu the course of a week ( niore nr lussj it 
b till reinnvtjcL 

The rf*siilti* nf this in^utriJinit liiivo Ikh-u s<» far surct^'ul 
Willi iirii|H^r nkill niul iii54.*[Ksir* thiit wlieu llie lietter plnu of 
surginil ititertWeiici' is uiuiviiilaf4e, it iiOoflL^ u itleasintf r<**iort 
for the lOf.skilled ohstetrit! .Hurge<»n m the t^uiergeiifiei* luey- 
tioiieil III fnot .Home of the rep<irt'«4 have nhowii fiivoralile 
results nliiuist equal to thi>se of c«eliutomy, Bulstatii^tie-^ are 
unreliable ; no two sets of ca^es are alike. 

The daup^rs and conditions of eoinplete uterine ru[rtunj 
are much the same as thiieie of a ru))tured tukil |jregnaucy. 
The hrst irumedinte (lan*i:t*r is fiemorrhui^e ; the ei>utrol of 
whirh is one of the msiiu (^hjectj^ rif prrrymethod of tre^itinent. 
By eielititouiy, the s<»ur«*e itf Ijleetlirjjj: is ma<le i*[>enly visible 
aihl can be .seeure<l 8oruehnu\s, when the rupture is in the 
lower uterine t^**meut, it may l>e possible to chimp, or Hijate 
the bleeiiin|ir vesseU throngli the vagiuu, usiog a suitable 
speculum. 

When the child has been delivereil without eoeliolomy, the 
phir-enta may have [>asscd through the ru|>ture into the alulom- 
inal cavity* To ^^et it back, use traction on the cord vnth 
the hand in the uterus, fme or two tiugers hooking into the 
placeutu through the rent, when it has thus been drawn within 
reach. 

After delivery, stimulants and opiates will be retpdred Ui 
counteract shock and colhq>se from hemorrhage, with absolute 
rest fas alrejidy describeii under [•ost-|iiirtuni hemorrhage), 
and every precaution taken against septic infection. 

FroRi the dreadful mc^rtality following rupture of the uteniB 
the im|)ortance of prevention in the ditferent ca<es, when it is 
likely to *iceur, nmnot be too ardently accenti»fited. Thus, 
in Hupendi ng rupture with cross presiM nation, deca pi talc ; with 
hydn>cephabLs p'rforate ; in brwi-lj presentations, deliver 
with b!unl-h<K>k ; in cases uf f>cdvic narrowing, the rei^uired 
ojK^rative methods must be done without dday. As a tjf'urral 
rule, when the lower segment of the womb ia greathj thinned^ 
Yereion is contra-iudlaited. 



24 RUPTURE OF THE UTERUS, VAGINA, ETC. 



RUFTUEE iLACEEATION) OF THE VAGINAL 
POETION or THE CEEVIX UTERI. 

Slight HU|H^rtidul laceratimis are very cammou, and often 
uurec!ogtiiied. Even rousideralile ones pass unnoticed by the 
oltatetri^ian more irecjuetitly than tiiey would if pro|)erly 
souglit for^ iis they should l»e atier hibor \s over» Uf^^as'ion- 
ally they extend up to the uterovaginal janetiou» or into the 
vaginal wall, Sometiniej^ tnmsver^e in direction ( thongb 
generally luiigiiudiiial ) ; pie^'e^ of the ojj may bang down- 
ward in the vagina* and rarely au entire ring of the vaginal 
cervix nmy lie >H'[)a rated. 

Causes. — Distention hy the presenting |mrt of the child 
during labor ; rtjugb maiiipahilions during version, tbreeiB, 
and other o|K'ralioni* ; ineareeration uf the anterior lip of the 
08 betwetui tbe head and i^K'h'i^'*, Tisisue-eliaiige.s preventing 
dilatation of the o!?, and primiinirity, e.-Jijeeially in elderly 
women, are prt^di^^ [mining causes, 

Bymptoms.^ — Hemorrhage, more nr les^s profuse, accorditig 
to the extent of iaeeration, the latter to lie diagnostitrnted hy 
digital examination, or, if neecesary, by ocular inti|>ection with 
the s*f>eculuni. 

Treatment* — Sliglit lacerations^ get well rapidly without 
treatrnciU. In more severe inie> hemorrhage may Ite c**ntrone<l 
by vaginal injections* of hot illiO'^ F.), sterile water, or hy a 
tampon of icidoform or alum gauze. Ex tenst%'eeer viral laeer- 
atiorus should he united at onre hy s^nturci* of riUgul, Kilk, or 
eilk worm-gut ; thi.n prevents the subsequent m^cnrreuce of c«*n- 
gestion, inflammation, and hyj>ertrophy» etc., of the cervix* 
which may require re.stunition of tbe hieeration Uy 3uture«s 
etc., months or years afterward. The suturing may lie done 
with the aid of a Sims speeulum : or the womb may be 
pnsheil ilown by abdomimil pressure from above until the 
cervix become visible at tbe vulva, or pulle<i dowti by voL^lia 
forcepe. 

Carl)olized injections into the vagina ihr a few days after 
labor, when lacenition exists, should always he employed to 
prevent ahsurptiou of septic matter by tbe raw surfaoea. 



TUEOMBUS OF TUB VULVA, 



625 



LACERATION OF THE VAGINA. 

LaceratiotKs of the vagiim it^eli* or of tlie va^^aniil orifice, 
are recormizfcl by digital exiiiiiiiuitioii <jr ins|^H^t-tiot4* Karely, 
BU|>erlicitil tjr iiitKlfrateiy deep laceratioiii* *XTur itear the 
aHterit^r commissure, involving the nynjphii^ vestibule, urethra 
auci its mt?atU8, stmietiinei* with considerable blee<ling. They 
refjuire a^^ptic eieanbness ducting with todoforra — aoth if 
dee|i enough to cause hemorrhjige» j^utnres of iitie silk, which 
may be removed in four or five days, 

RUPTURE OF THE TISSUES OF THE VULVA. 

Rupture of the tuner tissues and bloodvesselsi — without any 
nece^sfiary laceration of skin <>r mueoiis niendjrane — may otvur 
either du^iI^g or after hil*or* Blood h iinmetliately extrav- 
asated, cunning the labium to swell rnpjdly, and eonstitutiug 
a hiumatoma or throtidjus, to be now cWsenl>e«L 

THROMBUS OF THE VULVA. 

A tumor, bluish iti etdor. elai?itic or fluctuating, aci»om- 
panied by sharp pain, usually on one side, forms rapitUy ; 
Bi)iiietime« of sufficient size to jirevent (delivery mechanieallv. 
It may burst and lead to profuse or even fatal external 
hemorrhage. Extravasation may extend upward outside the 
vaginal wal! to the uterus, or even to the cellular tissue of the 
iliac fossa, or behind the peritoneum to the kidtteys. 

The proffHoi^iH is variable, anntrding to the extent of the 
injury antl extravasation. Death may result from hemor- 
rliage, or froui ileeomftosliion of retained clots and .^pticjcmia. 
In many cases of tnoflerate extent, absorption of the effused 
Idood ami rec^overy take place. 

Treatment. — During !alM>r» delivery whoubl be hnstene<l — 
jireferably Ijy forcejis, and this ^rir//^— beftire the ihrondajs 
has hail time to grow very large. 1^ its size prevent ilelivery 
the tumor must be inrige<i« the clot^ turnefl out, subsecpimi 
hemorrhage controlled by compression or ple<lgets of nsejitic 
eotton or gauze, an* I ihdivfry by forceps rapidly 'completed. 
Attcr labor, when the tbrondtus lias been oj}ened, nrtiilcinlly 
or otherwise, styptics and etunpression nuiy still lie ret] ui red 
to prevent further bleeding. If ileliverj' have lieen eotupleted 



h 



526 RUPTURE OF THE UTERUS, VAGINA, ETa 

without afieiiJTig lire tumor, it must he left iilone for ahsorptirm 
lo take plae^. Should supporatiou rx'ieur, as* sometiuiei* ha[> 
|>ciit4 in a few dayi*, the |>art luui^t he jmnM'd to gi\*e exit t»j pus 
and t"li>U, ami aiilisejitie treutnuMjl ot'tlie wmnid atlopted in |ire- 
veut »eptie iriJeetion. In all case^ ahwilute rest m the rwum- 
Iveut jKistiire and the avoidance of stniiniug- effcirts of every 
kind are iudis|M'nsiilile» to prevent re^'urrenee of hemorrluige. 
The hleedirii^ I r>r exiravasatioii) may aLso he eontrolled i»y 
vaginal liyilro^tatie prt-Sfinre^ au ehistie rnhl»er hat^ or Barnes 
dilator tilled with iee-water being intrtjducH'd into the va^nnal 
canal for a few hours 8ul>g(er|nent to delivery ; earbolized 
washes lo be used after its rernovah 

RUPTURE OF THE PERINEUM. 

Causes and mode of prevention of tins ac<'ident during 
labor have already heen considered (S<^e Chapter XII. ) 

Every vvornnn ought to be carefully exaniineil after delivery 
by inspection of the parts, to ascx^rtain if perineal laceration 
exist. 

Slig:ht fissures of the posterior commissure, or of ihi* fonr- 
ebette in priniipane, usually heal of theiiiselveH wit hMiit treat- 
r nei 1 1. K x t ij 1 1 ise |>l ie e lea n I in e:§8 is, ho we v e r, ad v isa hie. Even 
tears of appareruly eonsiderable r^ize shrink almost to tiothing 
when the tissues have recoverefl from the distention of par- 
furition, as they di* m a whort time. The extent of rupture 
may he either seen or made out by passing a finji^er into the 
rectum and thumb into the vagina, so as to hold the remain- 
ing rwto-vaginal septum between the two. Extensive laeera- 
tion.s often involve the sphiueier ani, |K>sterior vagitial wall, 
and rectum. For eimvenitTiee of des<Tiption, lacerations of 
the perineum have b(*t*n dividrtl, a^TordjiiL' h* llieir extent* a^ 
follows: Those extending from (he |KWtenor commissure half- 
waif to the urnis are calletl hieeratinns of the fimt detjvee ; 
those extending to the anus but not involving its sphincter, 
the second tlajrre \ and those* extending through the sphincter 
ani info the rectnm are lacerations of the third detjree or 
''com/ drtc '•* r u \ it n res, Kii re I y » a * * ce n t m / " | )e r fo ra tii>u ( w i I h - 
out any tearing of the posterior eoinmis'^ure id* the vulva) 
takes (ihicc between the twn oiM-ning-n of the vagina and 
nH!tuin, ihrou^di which the child may pass. 



RUPTURE OF THE PERINEUM, 



527 



While the ilia/fnoHts of hiceratiou and its depr^ee is made 
hy iu^ptTtion and tljtritiil innin|iylaticiri, the i^tpnptom^ of pnin 
and mreneiHf at the seiit of injury, and nu_*n^. or leH.s bleediiij^ 
from ihf vvitnnd vvUl, of e(int*si\ lie prt^stnit. 

Treatment.- — I'ldess th<^ la(vration he quite inFiguifieant, 
tht^ Ireatnient eoiLsists iti lirin^ing the frtshly hi«»erated 8iir- 
tiices t()gether hy 8ilk or eatjrut suluren immedintcltf after labor, 
Thii* is to ive done whether the j^(>hin<*ter ani he torn or not. 
In fact, the more extem^ive the laeeration, the jnore the iiece*^- 
sity and greater advisaliility of stiteliintr n[) the rent. In 
I mil ea.^<-s re<|yiriu|r fxtra ^iirtriejil .skill — D(»t immediately 
availahle — a tlelay within tweniy-four honr« may he jn.<tfia' 
hh- in olitain it, antl wrmhl uut nmke very material diiferenee, 
apart from distuihing tlie womau wheu she ought to lie 
at rest 

In hicenuion^^ of t!ie tii'st and .second degrees (/if>i involving 
the sphincter ani and reiluni ) the o}>eration is not difficult. 
The woman is laid acn»ss the bed, her hi[i6 hronght to tlie 
edge i»f it, her lower \m\\)8 held hy as^iiatanlH ami tlexe<l in tlie 
lithohmiy y)oBition. AnsKsthesiii hy ether, or local aniestlu^ia 
liy injecting a 4 |)er cent, sterilized solution of coi*aUK\ nnty 
he ns^ed, if necessary, to keep the patient fc^till. The parts are 
cleansed and a pledget of sterile cotton or ganze pns^hed up the 
vagina to stop any flow from the n terns ohscmring the wound. 
The sutures fpreferahly of aseptic s^dk) are passed with a miid- 
erately curved needle alwut two inches long, a^ follows : Begin- 
ning at the fMisteriorend of the laceration (that neiirertheauusl, 
the needle entei*s Hic skin near the edge of the w«mnd and 
follows a circnhir course until its [loiiit appears at the very 
hottom of the laceration (a finger of the other liajid in the 
rectum guarding against its fn^net rating that canal ) ; it then 
enters the o|)(H)site side t>f the laceration at the hottom itf the 
wound and I'ljmes out of the skin opjM>site its|K)int of entrnm^, 
having foihuved a sinnlar circular course to tluit pursued on 
the other side where it first went in. The entls are hnsrfij tied 
or sei^ured liy calch-foreeju^ until the reipnsite numher r»f 
sutures are passed in a similar manner (half an inch apart), 
when the wound is again rleans«'d, the vaginal plug removed* 
•*nd the sutures tied tightly eniKigh to coaf»t the parts without 
injurimis constriction, the order of succe«si«»n in tying Ijeing 
that in which the jjiutures were |>as9eiJ, 



tP8 RUPTURE OF THE UTERUS, VAOmA, ElU 

In **c<Jiii|jlete" lawnitiims — those of the third decree — 
tliroiigh the ?*|>hiiiiter atii to the rertmi)» the o[M?ratit>n ig more 
ilitfirult. 'Hie rectal (ear i^ tinit tjtltcbt^l witli vahjnf sutures 
(a fiiort, tnirvfii needle l)eiLig used) aurl jL'oiiig l!irMU»i:h the 
reetnl wall only. The sutures are tied on the iiii^ide, so that 
the knots are on the luoeoti^^ nieinbrane oi' the iMiwel, They 
he;::iii tVojn above and eoiue dt>\vn lo the j^phineter atii, the eut 
ends of whieh are drawn out with a ternienlunj while the 
suture-? penetrate them. Tht^e cutgitt sutnres need nfit he re- 
moves! ; they will di^reMt m the tissues and dii*appear of ihem- 
^Ivei*, The piw^terior wall of the va^nna is next >«ytnre<l with 
line silk, from above dtnvnward toward the hymen* Fimilly, 
skin sytnrefti throneh the periiieym in^elf, inelndin^ mys^'lei? of 
the i)elvie tloor (as jyst de^^ribed for laeeralion!< of the tirst 
auti >yCH*oml detrrees ) complete the operation. Tiie j^ilk sutures 
may \m reuiove<l in alunit a week. Antise[itie dre8*iinp* are 
ap[ilied a8 after an ordimiry la bur, extni eare being taken to 
kwp the wound aseptical ly cleau by daily irrigation with the 
creolin sfiUition. 



LOOSENmO OF THE PELVIC AETICULATIONS. 

l>wi?»ening of the pelvic articulations of the pubie Bymphysi^ 
an*l sacro-iliac synehontln)ses oec-asionally oeeurs. either from 
fwithologieal chanL''e?^ in the jc»iot.s, or fnnu great violence dur- 
ing forceps^ and other modes of artifieial delivery, or I with con- 
ditions exist together, Tlie itijinjdom^i are, at tlie time, pain 
and increased mobility of art iculationt<» demonfitrate<l hy grasfK 
ing the two iliac Iwmt^s near tlie anterior extremities of their 
erei?t, one in each hand, and moving them slightly to and iro, 
transversely, in oppit^ite directions. After getting up, pain may 
lie absent, Iml the jiatieut is unalile to walk, except with diffi- 
culty. If tw^> lingers be passed into the vagina and placed 
In^hinrl the pubic pyniphysiis and the thumb in front of it, 
while the patient, standing, rests her weight first on one leg 
and then on the other, or sways her body from gicle to side, 
moveTuent of the pubic l>onea againat each other may bo 
reeognized. 

Treatment. — Rent in lied ii(>on the back, and support of the 
pelvi<* walls by a ein*nlar ha mkige of strong canvaw or strip 
of rubber adhesive pla^^ter alnvut three inches wide, passing 



LOOSENING OF THE PELVIC ARTICULATIONS. 529 



round the body between the anterior superior spinous proc- 
esses of the ilia and trochanters ; it must go just below the 
spinous processes so as not to press upon them. It should be 
worn for weeks or months after getting up. It may be made 
continuous with or attached to a pair of short breeches or 
tights fitted on the upper part of the thighs to prevent slip- 
ping up. Recovery usually results. 

34 



CHAPTER XXVIIL 



MULTIPLE PHK(;NANCY, HYDROCEPHALUS, AND OTHEK 

enlak(;emknts or the child, 

MULTIPLE PEEGNANCY. 

The simullaneoue existeuce of two or more f'oBtuses m the 
womb is ter0ie<l *' multiple*' or *' plunil '' pregtmrK-y* The 
Dumber oi* ova mny lie two, tliree, touFj or five, uameil, re- 
8|>ectivt;ly» twius, triplets, ijuadnipliHi!, unci 4|iiintuplets. Kc*- 
[jorteti ease.H of more tlmji j^ix are not well utilbetitieateil. 
Twins oceur diiiee iu about ^eveiily-iive eiiines ; triplets once in 
alxjut five thoysand ; qyadnipleta and quintuplets are ex- 
tremeiy rare. 

Fio. 272. 




A rase of scxlcts, (Frotn Kehb himI Cookmaw.) 

In tlie ense shown (Plate III) four of the fiTtUf^es were 
femalf??^, one male. 

A few :?extuplets are on reeord ( Fijr. 272). Jellett figures 
sueh a ciu^e in his '*' Maitua! of Miilwifery,*' (p. M09). 

Plural preirnaneiei* are produred by two or mtire ovules 
enlerinjj the uterus and be***>ruinjr inipregoakMl about the same 
time. One ovide may eunje from eaeh ovary, or two frorn I lie 
sanie ovary. In the latter case both ovulei* may come from 
one Oniafian folliele, or each from a w|iarate one. Apiin, 
one ovule may contain tw(» irerm.*, like a ilcaihle-yolked e^g 
from the fowl. These stevenil modes of origin explain the 

530 



PLATE III 




Case of Quintuplets. 



I'ubHabed bf Dr, Q« C. Kijhoff in tho **JottnuI of Obctclfie* And 
Gsmteology of th« British Empiiv." July, 11MH, 



MULTIPLE PREGNANCr. 531 

observerl vfiriation hi the arraiigeiiieiits of the placeiitxc and 
fcjetal niemhraiies iti (iitftreul: cases. Generally eadi ovum 
(in twin eai*es) has its own kjic of amnion and ehorion, which 
comt».s in euutmrt with that of the other as growth advances; 
l>iit the twu saca do not amalgamate ; they remain sejiarate 
till birtk In theiy? tliere are two phu'entas usiiallj separate 
from each other, thoiij^'h they may l^e near together, ur jiar- 
tially united. In otiuT ca^ea e^ich ovum has lU^ own amnion, 
hut lioth are eontainefi in one chorion* In tliese tlie two 
platvnUe are fused together, ur the two unilnlieal cords may 
lie united before reacliing the phicenta. Rarely both Itctuses 
are contained in one amnion, ns well a** in one chorion. Here, 
again, the placentie are unit^tl in one mass* Two ova con- 
tained in one chorion are of the same sex* 

The tiict that the vesa^Is of the two placenta* and of the 
two eords niay inosculate with each other (lint wliich ciinntit 
he made out hefi*re delivery), leads to an impirtanl moditica- 
tion of the mana4!:enient of labor m twin cases, lo be men- 
tioned presently. 

The growth i>f the embryos in twin eases is aeldom exactly 
ei|iiab and sometimes the difference is very great* one chi Id 
ajijjearing fully develo|K»d while I he other remains very email. 
One ftietus may die and be thrown off prematurely* while the 
other remains till full term ; or the little *lead one may still 
remain iu ttft^m, ami come away at full term with the live one. 
These variations are due lo conditions favoring the nutrition 
and circulation of otie ftetns at the expense of the other* such as 
folds or compression of the cord and compression of the pi a- 
centa. When the two tteial circiilat ions inosculate in the cord 
fjr placenta, one fcetus having a stronger heart than the other, 
favors lis better nutrition and development. In this way 
acfinliize monsters are pro<luced. 

Oecasiomilly one child remains for days or even weeks after 
the birth of the first one before it is delivered, and thus eom- 
pletei^ its development. Such cases are beet explained by the 
existence of a double uterus. 

Plural births generally occur a little before fall term, the 
degree of prematurity increasing with the number oi' foetuses. 
In twins only a few weeks nmy he wanting of the usual f^eriocl, 
quint uplpts are always abortions : the others are intermediate. 

Diagnosis.^ — The certain diagnosis of twins before one child 



MULTIPLE PREGNANCY. 



IS burn is sometimes tlirticiilt> l)Ut the fonuvviii<,Minta wil! oftea 
l)esutfident to rt^mier a dia^nioisis pruhuhle, ami in Hjme eases, 
when they are all avaihible, a fiositive dia^iii>eis may l>e 
reat^hed On hupevinyn^ the ab< lumen uj»pearH lurg^e in msie 
and irret^ulur in Hhape ; tbe h>wt*r region ut' tlie abdumiual 
walls jnst abuve the jnibes is ut'ten swollen from localized 
ojtlenm. An S-sha|KHl sul^ns indieating line of division be- 
tween the two ftvtal j^^ch may sometimes |je BeeD on the abdo- 
men. (See Fig. 273. J 

Fic. 278, 




Twlm; one hea4« f>fio brc«ch. Tlie c ri>tu$e.ii K and B indicate poinU of gretleil 
IntttQxity of lieiirt •sounds. 

On palpation, the ii^killed hand dis<*overs perjgid*^ut trfmon 
of the nterine v^all — /. e., in an ordinary isinjile) jiref^naney 
the womb becomes of a tvooden hardiWKS during eontraetions 
of the organ, but mff and pUnhlr between tlie r'*m tract ions, 
while in a womb overdi^ttended with twins the organ btn-omt* 



PROGNOSIS. 



633 



hard during contraction, l>ul diies jwt get soft and pliable 
4lu ring relaxation ; an htirrmf^dittit' decree of permanent. Um^ifm 
rnnatti^ betwe<?n tht? ciuolnirlioni:?, which Is neither wooden 
hfirdness* nor pliiihle solVnfs^* 

In twiiu^ tliere are four fa^tai |Mdes — viz.» two heads and 
two brtH'chei*. Pal|Ktlion reveals one jmle at or below the 
brink another in an iliac ti>ssa. and one (t»r two) winjewhere 
toward the fnndus; or they may Itt? situated ditferfntly. The 
reMi^^tin«^ [vhincs of ttro harkft nmy be made onl ; and the mov- 
able j^mall parts ( liiubs > may be felt at t*nch divert and widely 
distant parts of the uterus m to make tt inconceivable that 
lln^y all lielting In ottf* chiifL Fn rt her Hijjjni? : Exaggeration 
of tbosse conditions of pregnancy dne to j)ressiirc of the gravid 
ntern«;the iiniMjssihility of iHMMf me iti ; thi* recognition of 
twof<etal heart-^^>nnd!s, not t^ynchronouB with each otiier* heard 
loiident at twti diliercnt jioinl.s on the alMiorainal ^uriace, aud 
becoming feeble or inandible lietween them? [H)ints. 

After i>ne cliild is liorn, the existence of another is readily 
made ont l)y the Fliil hirge size of the \vond> ; by feeling the 
child thffingh its svall oyer the abdnmeri ; and by a viigimil 
exjunination, recognizing the bag of waters and firesenting 
pari i>f tlie seconii intant. 

Women who have borne twins omvare likely Ut d^i -^o again* 
The tendency to plnral births is alsn hereditary in s«jme crises, 
ar»d may be ctmveyed hy thi^ Jhihrr : hence a previous history 
of plunil hirlhs in the family nmy he of mme value as a 
means tA^ diagntisis. 

Prognosis. — Delivery of the first chikl nsually te<lioiis from 
im*4eqnate labor panis, doe to overdistention of the nt'^niiis 
and from force of uterine contniction being necessarily <litf used 
(hroygh Iwubes of both children, instead of being ^ii>nc*n- 
tratecl ufjon the pres^enting one^ Delay is greater when the 
first child pr<»sent*i by I he hreech, e.s|»e(?iany so in delivery of 
the after-coming head, Prolougjition of lalior, large area of 
placental surface, and overdistetition of the womb, pretlispose 
to inertia nieri and jKist-partnm hemorrluigc-. Maliiresenta* 
tioiis are nttire freijuent than in sit^gle births. In Jibout half 
the cases hoth children fvresent by the head ; in one-third of 
the ciiJ«e« one liy heail and one by breech ; in one-ninlh, lM>th 
by the brecrh ; nud in one-tenth, either one or (rarely) lK>th 
chilli n ' 1 1 I > rest • 1 1 1 1 ra ns v e r»ely . 




MULTIPLE PEEGNANCY, 



Excluding tbe complications of mal presentation, the oo 
current*eof twins, with |>r<ii>er manaL'tmfnt^ need not preclude 
a iuvunible pn»gno.si« in tlit* great majority of cns*^. 

Treatment* — Tie the placental end of the conl when one 
child ifiiHjrn, lu prevent jM^ssiljle heiin>rrhi4^e from the second 
child, owing to inoftculation of ves^ely between the two cords 
or phicentxe. Let tfie placenta alone until after delivery of 
pecond chihl, unleBi^ it be Bpoiitaneon^sly expelled hefore then, 
when it may he carefully removed. Should M/i placentie be 
exjielled lietlire the l»irth of the KH^oml child (wiiich nirely 
hti])pen8 ), ppeedy delivery k nece*i*mry lo save the yet unborn 
foetus from suiiwatinn and t\* 8top beniorrliaire fron] the 
placental site, which h liable to occur. 

Tbe alleged clanger of mental sboek from telling the woman 
she is to have a SiH!ontl child, m seldoui serious, especially 
wben she is t<dd its delivery will Iw short ami easy. 

After one child is l>orn there ut^ually Rueced« an interval 
of rest from labor pains for fifteen Titinntes^ sometimes for 
half an hour or an hour, wben <Mjntractiouhi again come oii» 
and the >»ec*o!al child is eiwily expcllcii, the parts having been 
thf>rotighly dilated, and the seeon<l ehihl being n?^nally srtmlJer 
than the first. During the interval, when resi is adviftable 
for recuperation of the ( per bajja exhausted ) uterus, examina- 
tion must lie made to ascert-ain the presentation, and correct 
it if transverse. 

After an hour, or bc^fore then if the uterus be not exhausted 
by previ<ms prolonged effort, the mendiranes, if intact, may 
be ruptured, and the womb maiiijtulate<i through the abdo- 
nu'U to produce contractions. 

In ease of hemorrhage, convulsions^ feebleness of the foetal 
heart, t^r any condition rendering immediate ilelivery neces- 
sary, toreeps may be applied if the bead have des<'ended into 
the pelvis, and version if it have not. In either m^Q, extract 
the child slowly, so ns not to leave an empty relaxeil womb, 
every means being taken to secure siinultaneom* uterine con- 
traction. 

When tKJth children are delivered, extra care is uet^essary 
to overc*mie inertia and prevent |^^H>st-j»artum hemorrhage^ 

When tbe ^rut child presents transversely, it must, ofeounM?, 
be changetl by version ; but should a necessity tV»r f^|M^cdy de- 
livery arise in any other presentation, the iirst child should 



TREATMENT. 



535 



not be delivered by version (which would be liable to en- 
tangle the two cords, as well as occasion locked heads), but 
by forceps. 

Treatment of Locked Twiiis. — When both children are con- 
tained in one amniotic sac, or when, there being two sacs, 
both have ruptured early in labor, both children may present 
and enter the pelvis together, and thus get locked and pre- 
vent delivery. 

Fio.274. 




Locked twins, both heads presenting. 



When both heads present at the brim, one may be pushed 
up out of the way by combined internal and external manip- 
ulation, and forcops then applied to the other to bring it 
down into the pelvic cavity. 

When both heads have passed the brimy push back the sec- 
ond one and apply forceps to the first (the lower) one. 
Should this l>e impracticable from the heads having descended 
too far, the lower head, and then the other, may be successively 



'536 



MULTIPLE PREaNANCr. 



ihWvereA by forrep.*?. If tliis metho<l fuil tTanii»t<inij trjay he 
required, prelt^raljly <in the fir.st (lower) head» tiif st^CDud iK^iog 
more likely to survive. Tlu; siinie nKxle of treutineiit may be 
ne€e&*iiry wbeti one head» liaviujuf pasi^ed the lirini, h urre?fted 
by jamiiuTi^ of the thonix a;iaiii8i the second head, either at 
or uliove the hriuL ( Kt^e Fig. 274.) 

Wlieu [jus^hiug Imrk the hx^ked prc^eDtiog ymrts api)ears 
imp^fssible, it may s^lill lie made eiit^y» in s^ime easels, by [ihu-ing 
tlie woniau in a knee-cht^t |K»»ition, whieh i^houhl always 
be tried before any serious o|>eratiou ; the [mrta go back by 

Flo. 27^ 




Liicktfd twins* one breeeh, one beftd. 



gravitation. When the first child presents by the bree<*h and 
ig ilelivered m far as the head, the latter may remain above 
the brim, owing to the bead of the se<'ond cliihl imvlng dc?- 
8eended into tlie fjelvie ravity, the head of eaeh ehilil rest- 
ing again j*t the neck of the other, t*o as to hx*k or lap the 
ehins together and prevent further pnjgress. (S<*e Fig, 275.) 
Oiagno^ii* «jf the exact arrangement of the fHmiplieation 
having been made by the hand in the vagina, several different 
methodn of <lelivery are available, selection of either being a 
matter of judgment determined by the |)eculiarities of each 



TREA TMEST. 



537 



As a rule» the life of the child H'hose breeoh ia delivered 

wUl I^ enfeebled or lost by C(>ni|»re^ion of its fuuis, or it 
may be already extiQct. lleoce in selection of o|»erative 
njeasures !syi)erior value Hhouhl be nllottt-d llie s<h'oihI I'hild. 
The head of the «e<MJnd ebild nmy jiossildy be posbeii up out 
of tile way for the other tcj jiUHft, The ht-eniid he-iid nutii (/) 
be deliveri'd liy foree[)S while llie tirst renuiint<, but not with- 
out fliiticulty aud preat dauger to both children. The head 
of the tirst ehlld niuy be puuctureil, or even deeapitated, so 




lAbor Irapcdcd bj hydfocephalu*. 

m in allow extrartiou by force|)« of the se4*oiid one, the IxmIv 
of the first (when dceapitatiou lias bet*u |KTfoniied ) bein^, of 
couriie, previously remove*! ; it.^ head <*ondug after the tJther 
child is lK>rn. This \nM method pndinhly alfc^rds the best 
chanee for ihe second child. Moi^t tm_|uently Ixith are lost. 
When tf»e lives of kith are extinrt befnn* deliver^' there i*iill 
remains another re??tirt, viz,, tliat of puncturing ihe weond 
head and dtdiverinjr it by forcep or cephalotribe jmst the 
body of the lower child. 



538 



MULTIPLE PREGNANCY. 



The operation of sjn]|>hyseotomy would seem to he a feasi- 
l>le nielhod of relief iu Imkt^tl hvm>*, but rases have uoi yet 
l>et'n rejKirteii 

lu easels oi* conjointd fivinH — doubh 7no7iJiiers — when the 
natural jxiwers are insuffirient for delivery, version l>v the 
feet » and jxif^ibly ^uiiseijueut nuitilatioiT^ ntfbrd thelient means 
of relief. Most such cusei* are, however, delivered Bpoiitane- 
ouBly- 

HYDROCEPHALUS. 

Tlydrueephalus i^^ distention uf the nkull from n^'eunmUi- 
hou nf effused serum, aod eotislitntesa dan^feroui* ini|H'dioieut 
to delivery, leading to rui>tiire «d' the uterus or dan^'eroua 
inflaminntioQ and sloug:hm;^ of the mother's soft (larls from 
their prolnn<reil <t<uu|iression iluring a tedious labor. When 
slight in iJegrre, lalwir may, however* terminnte s^|MjotimeouBly 
without danger. In extreme cases the ehild's he^id is na 
hirge a^ that of an adult. (Bee Fig. 276» also Fig. 271, 
page bUK) 

Diagnosis. — IHHicult early in hilM>r Strong pains eon- 
joined with a (knimii) normal |)elvis» luit without ex jHH?ted 
deseeut of I lie bead, should exeite snspieiou ami induce a 
eareful examinati«iii. Owiug to unusually large size of iiptal 
ht-ad, the ehihrs body is higher up, henee s<nmds of fletal 
iieart heard level with cir even above the umljiliens, Wlien 
head ii< arre.steil almve 8Uf)t*nor strait, |>as8 the whole hand 
into vagina (lunler ether^ if netressiiry from jjain ) and feel 
the he^d. Its lar^e sixe, wide, ami jxThaf^ thu'tuating fon- 
tanel le^* au<l sntyrt*« are <iuffieieutiy eharacterblie. The head 
is le88 eonvex, and feeh^ neire like a tlat lid over tiie pidvie 
hrin» than a globular mass. The sutures an<! fontaueiles 
lieeome tensi* during a |min. The eranial iHmes are Je.KS re- 
gistiUit tti the finger. An eularged/jri^//'r/rir fontaneile i.s very 
mgnitieaut. The prominent forehead ami sti(>en'diarv rid^€« 
eontrajit with the eomparatively small face of theehibh The 
previous birth of a liydrot*e[)halie infant, and eompanitively 
feehle f(etal movements, art* corndiomlive eireiirni?mnt*eiiv 

In hreeeh pn^^entations ( they cK'cur one out of five in 
by<lroeef)halie eajk*s ) the diagnosis is more rlouhtfuh Ni»th* 
ing wrong is ?u8peete(h usually, until the l>cKly ig Imrn ; then 
there is delav, an unusual reslstauctj — a sort of ehidllc, 



EKCEPHA lOCELR 



&39 



reellieut resistauee — on making tractiaQ upon ihe body. 
Tlie IkwIv mny be well nourii-hefl, but frequeDtly is small 
awl emutiuttHi. The utiTiiie tumor is of larger j^ixe thau 
U8ual iibove the piibe^s, uwiug U) its? txmtaiQJng the distended 
cnioiura. 

Pro^osis. — T!ie chief dangers to the mother are uterine 
rupture; exhtaMion ; hiceration, contusion etc., of sot! ptirlSt 
with subsequent ult^Tutiuns and tistula? ; all jjreventable, in 
great measure, by timely assistance of the obstctrieinu. TJie 
child general ly dies, either befure, during, or shortly al^er de- 
J i ve ry - K\< 'e j ►ti o n w j k )ssi b le. 

Treatment. — In bead [>reseD tat ions, aspirate, or tap skull 
with tTocar and cannla to lej?isen its size, when this is abstv 
lutely requireiL Cases of nnHlerate enlnrgenjcnt jnay he 
delivered sjiontuneously, but it is better ntit to risk life of 
mother by delay ior the isake of a ebihl whctse survival at 
l^est is extremely dubious. After puncture and reduction of 
gize of head, it may \ye pomb/c to extract liy ii>rce]is, l>ut 
they are nearly sure to slip off during tniction if the bead be 
very large. Then either the cephalotribe or eraniocla.<t may 
be Ui^^(\ ; or the child may Ihl' turned and delivered by the 
feet, ef^jtecial care and gentleness being Decessary to avoid ru|> 
ture of tlie wondn 

In breech jjresen tat ions, puncture of tfie after-coming head 
may lie made bcdiind the ear, f>r throuirh the iMTijiut, or 
thnnigh the orbit, or nmf of the mouth ; or the spinal ei»ni 
nniy be tJt>ened and a wire or a metal catheter passed through 
it to the brain and the fluiil thus drawn off*. 



ENCEPHALOCELE. 

Associated with, though at other times independent of con- 
genital hyclnM*epbidus, may be an accumnlaiion of ceplialic 
Huid outside tlie eraoium underneath the scalp, fornnng a 
tumor, insignificant in size, or as large as a ftetal head, 
whose cavity may or may not communicate with that of 
the cranium. It is attached to the head by a pedicle, 
and constitutes a st>-called cnrephaltK'ele. (See Fig, 277.) 
Fortnnntt'ly, ^juch tunroiv* are more otVen attached either 
tr> the froulal «*r <K*cipital |x»le of the tVetal head, and 
hence are lees liable to interfere mechanically with delivery 



540 MULTIPLE PREGNANCY. 

thau when placed elsewhere. The bones of the cranium are 
also usually softer aud more yielding. Puncture of the sac 
and evacuation of its fluid will remedy any mechanical inter- 
ference with delivery that may arise. 

ANEKGEPHALUS. 

A not uncommon monstrosity in which the brain is deficient 
or rudimentary ; the upper part of the cranium is al)sent, 
leaving the base of the skull without bony covering ; some- 

Fig. 277. 




Encephalocele. (From Hergott.) 

times arrest of development in spinal column and spinal 
cord. Often associated with |)olyliydramuios. Shoulders 
may ])e very broad and ()l)struct delivery. Diagnosis some- 
times made by finger touching the srl/a iurcicuy covered by 
sofl tissues in base of skull, which may present a( centre of 
pelvis. Child either !)()rn dead or dies .^oon after birth. In 
case o|)erative assisUuice Ik* necessary, |)erform embryotomy. 



LARGE SIZE OF THE CHILD. 



541 



ASCITES, TYBCPAHITES, DISTENTION OP UEINAEY 
BLADDER. ETC. 

A»cit€ft, tympanites, clisteatiuii of the uriuary hladiler, 
hvdrcithorax, liydRHieplirc^ais and viinous ythi^r putholoj^qi'iil 
eiibr|;enieiiti« on tbe piirt of I he fluid, mny ixx^ii^iiomiUy Imd 
to ilifhoult laJM>r and rt'<(nire ui>emtive iiiterferenee. (8ee 
Fi|^. 275.) They are extremely dilticult lu diaguotstiaile 




^litcntlnn of uHuitry 1>Ut1ili*r of ttplum, 

before delivery- The dia^nogis chii-Oy reikis u}nm the exclu- 
sion of more common cmnses of mecbanicid oKst ruction, and 
(in the onm of giiaeous or liquid distenticni of eavities, vie.) 
OD the sprimjy, TCHilicnt rrntiMnfice r^^y^x\m\h\v when tmction 
is made on the presentinji!: or extrudtHJ fteial parti*. Li«iuid 
or gaseous accumulations are to he relievnl hy careful punc- 
ture, preferably by a^^pi ration, if the chihl l»e livinjfr. Kon'e|iH, 
version, aod excepticjnaUy emiiryotomy, may afterward he 
recjuired, 

LARGE SIZE OF THE CHILD. 

Fremattire Ossificatiozi of the Cramal Bones. Tn over-lon^^ 
I»rei!:nanciej^t ( tlioM** of 104, 11, or 12 lunar monlhs i the cliild 
iij apt to l>e far aln^ve the usual sisse and weight. Instead of 
wmghing seven or eight piunda (the average )» it may reach 



542 



MULTIPLE FEEGNANCr. 



twelve, iifleeii, or eveu more, and tbuugli tlie iucreaae is dis- 
tributed over the whole hmly, the degree oi* ernuml enlarge- 
ment e.sjjeebilly iiniy eouHidenddy imptMle (Irliverv, aud a 
eertiiiii amouat uf ditHeiilty may eveu ulterid rxtraetioo of 
the nlioulders mid hody\ In eiirdully tneaatiriog theeraniurti 
of aeliild weigliitJg thirteen und a Imlf piuud^, imraediately 
utWr birth, I tbuiid all of lis irmineter^ nearly an inch aboye 
the avenige length. Such iiiiauls are ni^ually males. In 
well-formed and goml-sized i>elve»» delivt-ry nniy be accum- 
plishtHl by forceps, version, or symphyseotomy. In very 
extrenje casei« eniniotomy, or, if the child be a!ive, Cieaiirean 
seetion may l>ecomt^ a |K)twible neeessity. In delivery of the 
body, traeiion and manual aid in furthering the nunual 
nKchanitim of Inlnyr will nsnally snffiet'. 

Premature Ossifieatdon of tlie GraniuiiL — ^Thls insufficient to 
interfere with moulding of the head, thus pro<lneing dystocia 
((lifficult bdior). It li* very nire. 

DUignmh by complete cloiaure of the tontjinellcj* aud sutures, 
and unyielding refiintaneeof the b»ineslo pressure of exandning 
tinger. 

Treatment — Forcejie, if required ; |K)ssibly j>erforalion of 
the skull, or alidominal section. lo some cases symphyseatomy 



may 



be advisable. 



CHAPTER XXIX, 

TEDIOITS L,4B<IU (DYSTIK lAt, POWERLE8S LABOR, AND 
PKECiriTATE LAKUK. 



TEBIOUS LABOR. 

TEniot's labor is also i-alfecl '' lunjcring'' ** tanltf" '* pro- 
travted,*^ and "'prolongt'd^^ labor. These terms refer lo timff but 
tlie durutiou of luJ>i)r varies so widely within the limits of 
nunnality, that it alime i.s not sufficient tu indieate the tet-hnieal 
and prai'ti<'al lueauinfr of '*tedicHLs" deliveries. Certain tither 
plienuiiiena^ meotioued below under the liead of *\Sifmj>(oinH^** 
are r*ei*ej?sary, before any ease ean beset dowti in thiseategory. 
Ret»eot authors have ala^ost abandoned the term *' t^'dio us 
lai>fjf\'* and irielnde su<di rsn^'ji under the eaption of *' Dtfdocia,'* 
meaning difficuit or obt'trueted labor. 

Causes,— The very nnmertnis eondition» liable to produce 
tetliouiH lalnvr mity be broadly eoniprised in two lists : 1. 
Conditions impairin}:: the tiatunil JotreK of lalior. 2. M^chan- 
iral impediment to (delivery. Both kinds of conditiatiH may, 
an*l neei^sarily often rlo <Hjexist, 

The meehnnical imfK*dinieiit« refer either to the mother or 
to the chi/tl. Followin^^ the classification of Simpson, we 
have» therefore, altogether : ( 1 ) AbnormaJ power ; (2) tibnor- 
inal paitmtje I (3) abnormal p*Mtttnger, 

Abuormaliiirn of Power. — The main force by whj<'h the 
child is ex|>ened is that of utrriut* (nmtmHion, This may be 
impaired in various ways. In some cai^es the pains are veak 
and inrffieiefd from (he be*jinnin<j^-ii eotHiitiou uf thin p:8 quite 
ditterent from weak pains fidlowinrj long-rejx'ated stroittj oiitf^ 
and |tr<>dured by uterine exhaustion. Or. a^ain» the |i«inB 
may liave been iiUHlerately sln>ij|: or uornial at first, mui then 
la[)se into weakne^'* later, but again wtihoui uterine exhaus- 
tion from prolonged effort. The caum^^ of this prirnanj ineHi- 
cieney of uterine cootractiong are overdistention of the womb 



544 LABOR: TEDIOUS, POWEIILESS, PRECIPITATE. 



from plural pregnaucy or polyhvilramiiios ; disteutioti of the 
bhidtler or retliim ; oliliquitie^ and displacemeuU of K\m 
uterurf I ihrtiuing of the uterine walls re.^ultirjg fruiii freijut^m 
aiMl c|uiekly rt^|)eatefl laimrs, or from dcgenenilion of the 
uterine tissiie.s ; precocious or advance*! aire ; general ilehilily 
or feeblene^ss of the woman from previous disease's ener%vating 
hahit.s heat of eliinate or of tn^asou, or the air of a super- 
heated r^Kjm ; exhaustH>n of the \v(jman from hemt^rrhage or 
from Jack of sleep or tbtKl Uterine action is sometimes ineifi* 
cient from unemia^ and when there is raorhid adhenion 
between the ftetal membranes and uterine wall Mental 
emotions; fean ^rief 8or]>rise, anxiety, 4lisupjK»intiueul» at»d 
the preseiiee of otlens^tve jiersotia or thinj^ wiil j produce iL 
The«e last may depend upon idii>synerasy or nnaceouiiiable 
pers<mai anttpatliie:^. 1 1 sliouhl ije espetnally noted that tiie 
lingering' eases now ile.s<Tilied are characterized by ineffij*ieni 
jMiiti.<f ftrtm the begimiing of tahor ; hence sometimes called 
primartj tnrrtia. 

Auoilier ami different class of cases is liiat in w^bich 
lal>«ir pains have been normally strong, or even stronger than 
nonnal, and after frard become feidde and lej^ frecjuenl, or 
cease altogether. In these the womb becomes more or lea* 
passive from muscular exlmuHtion on account of overwork ; 
it is serondanj inertia. The organ ^^imply nee<ls rest. There 
may or may not l>e mecbiinical obstructioTi t<i delivery. This 
[Missive womi) ia mft and pliahie ; the different parts of the 
chibl may be ta4/tf feii by abdominal fwilpatiou. 

A third set of cjises is that »n whiefi the norraal inter- 
mittent latwjr ptins Inive grown feeble or ceajw^l ahogetber. 
while the wnrnl)| inst«'ad of Ixnng .soft and rebixed, it* in a 
couditinti ni' i'otdinuoitJi ritjidity : its, muscular walbs ri'^a'im 
hard, and closely end>race the chihl with a pfrainteut spa^ 
modic grasp. This condition is s|iioken t*fas '* tonic confra<y 
iiofi*' and ** utirine letanm.^' The womb feels like a WiV/ 
tumor; the different part^ of the child ran not be recognizee! 
by pal|mlion tlinmgh its rigid walls. It is usually canard by 
some mfehaitit^al ohdrut^iion and eonseipieut iderme txhaiiidion 
after prolonged and unAucccAAful strontj ixpiihive pains^ Ergot 
may produce it. In sojne (but not in all ) of these cme» the 
thinning of the lower uterine segment atid thickening of the 
upper region, seiMirated by the **rttractiou ring of JJandt** (as 



TEDIOUS LA BOM, 



645 



frevlously described iu the clmpltr im ** liujiture of the 
Jterus" ), may l>e dij^tnivered by (wilpiitioii* 

Tlje RML'allt'd eawcs of '^ tetanoid falciform conMriciion of the 
vlen(.%' .supjMisinl to Ik* nu irreguhir, [itirtial, or .«pfjj?iiio(lic 
eijjitrmliou uf tvrUiiu murt' or le^^s ct'iUml iircular bandK of 
iiiusoLikir tihrej^, and rej*eml)biiji^ the ^* konr'ijia,vi fontracUon** 
tdis^rved during the third stage of labor, is probiibly nothing 
more tiuiu tetaiiit* constriction of Baudrs ritig. It is so ex- 
et'editi^ly nire that its of'rurrenre luis l>een denied by some, 
whilt* others attirni thi y hnvo elinifuliy demonstrated its ex- 
isteoce by feeling ttie ttmstrk-tion band like a *'vieiaUic ring*'' 
or ^*cii'clf' o/ tVo/i/' with tlie hand la the ntorus. 

Stiil another abtiorauibty of pou't:r eoasisti* in the pains 
being txccsjflvt/tf jxtinftil paitis^ usually due to exahe<l nerv- 
otL'< fttn^iOiliitf or unusual gusef'ptihliifjj to suffering, Home men 
bear pain tietter than tithers ; so with women in lal>ar — mme 
tolerate the suffering without much complaint, others are ex- 
cessively sensitive. 

lij st>me the extreme puin has been aj»cril>ed to rheumatiam 
uf the literiiie walk or to parenrhyiiiatouH metritis following a 
b!ow or some other tmutnatie injury beti>re labor. 

Again, either with nr without any abnormnlily of the utt*rhie 
eontractious. hilior may he im^ieded by some abnurmality in 
X\\v mtUraetmhi^ uf the ahdomirtal irafU aitddinphratjm — ^iti the 
etrjuning or ** bearing-down '* efforts, eoustituting the Aecmid- 
ary forces of parturition. This may occur iu any e?u«?e where 
the woman is unable to take in u long breath antl hold it hjug 
enough t'o aemmplish the act of straining, iia in rliseases of 
the lungs, pleuni, heart, or abth>men. or any other condition 
producing dyspmea, Bronchoeele, obesity, ascites, deformities 
of ehe,**t and sf)ine scmietimes^ net in thij* way. Feeble ab- 
dominal contractions also arise from the woman herself l»eing 
enfeebles! }>y previous disease, or exhauste*! from previous 
prolonged straining efforts ; or again, exce*«8ive suffering may 
cause the wuman (o vnluntarily refrain from Itearvug down. 

Ahnonnaliiit'^ of the Pamafje. — The mi^^hantral inipefiimenta 
tt> delivery referable to faults iu the parturient tanal from 
which tedious lalior may result are uumertnis, embrafir*g, of 
courses every kind and degree of obstruction, »uch as snmllneiis, 
deformity, nnd abnormal growths of the pelvis ; and resistanee, 
rigidilyi deformity, and abnormal growths of the soft part^, etc 



546 LABOR: TEDIOUS, POWERLESS, PRECIPITATE. 



Ahiiormaliiieg of the Passt-nger, — The inetthanical iiji|tedi- 
metita on the part of the child tire its over-hirge size, nisilpre- 
sentntKJD, dliaturlvetl mechauism, patbulogiciil growlhsi, UK'ked 
twins, etc 

FroynosiA and Danger of Tedious Labor. — The fii^t stage of 
labor, before rupture of the nu'inbraiieii, may be greatly pro 
touged, even for several days, witliotit any nccfHStirU^ serious 
OQUsecjueoees to either mother i>r ehiltl. Exceptions, however, 
m^eun The continuance of anxiety, suffering, and physiail 
effort, witb ct*nsei|ueut loss of sleep and inability to digest 
and atisiiuilatefoiMi, if long protracted, a/M'at/,f entails a iiaifHity 
to nervous exhaustion that cannot lie regarded witbout ap 
prehens^iou io any mse. Be lore rnpture the waters act as a 
cushion between wonil* and child, thus protecting hoth fnun 
injurious pres^sure. Frt^^ure ujhju the funis and tjhst ruction 
to the placental circulation, such as ovay occnr when the wnnib 
is long contracted round, and in cluiie contact with the child, 
are also obviated. 

During the second stage, when the womb does contract 
powerfully, and in close contact with the infant : when the 
phicental circulation, therefore, is, or may be, partially inter- 
fered with; and when the s^dl parts of the mother, both the 
uterus and otber jiarts helow, are neee<«sarily subjected to great 
pressure, the results ol' ]>rolungation of the bibor l)ecome far 
more serious. 8welling, tedema, inflammation, with subse- 
quent sloughing and tistulie, may cx'cur ; the cbihl may die 
frimi contHuied Cfmipression of its sknlh cordt or placenta; 
and general symptoms of exhaustion and collajiee Uxke plaice, 
from wiiich the woman, if not proni|>lly delivered, may die 
on the s|>ot, or smM-iindi nfterward fmm post-partum hemor- 
rhage, pner|)eral inflammation, st'pticiemia, etc. 

Every ciise, therefore, of actual or impending tedious latiar 
gliould excite apprehension for the womairs sidety, increasing 
in degree acx^ording to the extent to which the symptoms have 
progreeged, and the estimated difficulty of prompt delivery. 
With timely assistance, s^ifety may often be assured, while 
delay may render recovery impossible. 

Symptoms. — These, l>e it noted once for all, usually \yeg'm 
m<Hlerately, but increase io varying degrees of rapidity with 
delay. 

In cases of primary uterine inerim the pains (as we have 



SVMPTOMS. 



547 



Sftid before) are usimlly ineffident from the beginninff. These 
CSMeSf unless very nnieb jimltmired, are not at'eom|mnie<l with 
itfrioi*^ general 8yni|>tonis. An u ntii\ lliere ii5 no great fre- 
fjueney and feelileiie^H of |iijlse, uu nipid rt^spinitiou, uo hwit 
of iikin, uu fever* uti geiienil exhtiustiun ; in fact, there has 
been uo violent physiail etfbrt — no strong \yiunA — ^tn produce 
fatigue aud expenditure of nervous forc^-, I^oas of »\ee\\ 
lack of food, and anxietVi etc., may, however, eventually pro- 
duce it in very protracted cases. 

lu e^iscii of sefottdary uieriue inertia the pains have coni- 
iiionly begun normidly, and n<»rmally increajsed in strength, 
fre<[ueney, aiul dnrutioUt or tiiey may have exceeded t!re 
norma! limit in die?ie resjiectis. Both wondi and wotnun bave 
usually lalxired liard and (more or less) hmgy but I he pains, 
though strong, have still been rvlatirely inethcieiit — (. e., I hey 
have been insutfieient to overcome the existing rt^istance and 
accom]»lish delivery. There nou apt)eiir ^yrajitoms indicating 
exhandlon of ike uuijiib, viz., the pain.^ IxH^orne irregular m 
their recur rence, .^hortrr in dnrati«>n, more ferl)h\ i\ud Ita^ fre- 
ffuent, Eventnally they may stup altogether. The ulerU8 is 
worn out by prnhmged effort. \\» rehixatiini t>eeomes so com- 
plete that the ditferent parti! of the cliihl naiy W felt hy al>- 
doniinal |m!inition through tbe now inert uteriue wall. 

A second set of symptoms indic^ites ejrkauMion of the 
wamati, viz., lucrense^l feebh»ne*»8 and frequency of pulse; 
coaietl tongue, l>ecoming later dry and discolored ; rapid 
t^reathitig ; vomiting ; dejected countenain*e ; re.<itles8ness. <le- 
8[ioudency, irritable tempter, |jeevishness, wilfubicss, drifting 
on later (if not relieved) into <lelirium and despair. 

A third set of symptoms usually mo^t prontmufed wlieu 
Inlwir has advanced to the s^K'oiid stnge, and due to eummru* 
einy hiflammntiott in the mft partn from prolonged pre^ure 
against them i>f the child, oc*cur8, viz.: nwelliny^ tentlrmiem, 
jKtin^ heat, lack of moiJtture in the vagina, uterus, vulva, etc.» 
and demonstrate*! by digital examination, together with red- 
ne^% firidiiy^ or other abnormal <liscoloration denionstrated 
hy inspection. 

It shouhl be especially Udtetl I hat these three sets of symp- 
toms may exist in erenj shade of degree : they may lie only 
glight or verv pronounced. No ca^'^e ^tiould l»e allowed to 
progress from the slighter and earlier syujptomis of exbaud- 



548 LABOR: TKDIOUS, POWEHLESS, PRECIPITATE. 



tioo to the liitt!r Miid more grave ones without prompt mea^ 
ure.s <>f as.sistmif'e uikI relief. 

' In the H^i^rA cimeH, iiiHteucl of the wonih reiiiainiug soft and 
iourtj iiDd while ititeniiitleiit |miii» may iiiivt' tniirehj Cia»ed^ 
the uterus is hard aod i^iijisnutdierilly contnu'ted round the 
cfi i Id^ and re ma I ns so cofU I a uo nabj ( j?o-Cii 1 1 eil * ' li t eri ue 
tetanus ^*). Here the BytnfJtomi^ indicating t'xhandion of the 
ivonmn are much more jiroiiouured than when the uterus is 
in a state of rcdaxation ami inertia. Furlliermore, hi the 
ri^ul eontraeting eomlition the womiU h Irudrr to the touch ; 
in the inertia fu^tej? it is not usually so. Snne meelumie^il ol>- 
8trii('tion» either Itetal or muternal, h eonnmady prfi^nt, n» 
indicated by lark of jirogress in de^scent^ imniofnlity and 
swelling i>f the presenting part, or hy actual demonstration 
of existing'' impediment. 

Diagiiosis* — The combination of symptoms just stated, even 
in their early and sli^^htcr nianifesUitiotiii* especially when 
coupled witli ftrolontred dnration and hick of progre^ss in the 
lahor, and evident causes of merhanieal hindrance to de- 
livery, can leave no fiossible numi fur doubt. (It her condi* 
titajs leading to eessatioti of labor ]>ain8, fre<jyent and feelile 
pulse, C(>lla]ise» snrh as, e. f/>, rupture of the wund> and hemor- 
rhage, liave a different history, and the symptoujs are i*uddeu 
histead of gradual in their ap[>roaeh. 

Treatment*- — The main element of treatment i« to treat the 
caiie earhf, before the symptofus have progresses! lieyoiid re- 
covery. The indieations are, in the begininng, to eorrei't or 
remove existing causei^i of uterine inertia an<i existing me- 
chanical impediments to delivery. When manoai or instru- 
njental delivery is required, the operation should be l>eguu» if 
practicable, l>efore, «>r at least as soon as the symptoms of 
tedious hilnir fiefpti. 

When the |Miiiis have been inefficient and feeble from the 
la-ginning (primary uterine inertia j, the causes that leaul to il 
must l)e removed. 

In every wise ai*certain that the Id adder and rectum are 
empty. If they are not, a catheter and purgative enenmta 
must be used, 

Excemve distention of the womh from dropsy of the amnion 
retpiires evacuation of thr tlniil hy rupture <if the ntcmhnince j 
distention from twins, delivery by foreeps or version^ 



TREATMENT. 



£49 



The effect of viulent menttil eniotimi can scarcely be ameli- 
orate] else than by riKirul [►er-s^iMU'^iiiii, quiet rest, and perbai>8 
a CM>m|x>i*iri|T:tii*se of valrnuH (t^lix. vtilfriivat. ammou., gtt. xx), 
or one cb^aehni of the H<1. extr. of valerian. Any uffeosive 
j>er8oii or tbiiitr j^hoyM hv reniuveil. 

Uteriue ftebleiieKs from sleeplessness due to a [irolonged 
first stage of lal)or reijuires a full thm*. of mcirphia (jrn -}}, or 
of chloral bydrute (gr. xx). The i?anie reiuedie>* may be ut-ed 
with good rf8uhs in ense^ where the jmius l>eeome feeble fp>m 
the woniiui having endurecl exeei^i^ive t^iiMeririg — the pains 
having Iwen extreinely ''puiujul j*ains." The caui^t; of the 
extreme pain shoul<l be founfl and, if jxissihle, removed, be- 
fore the aiii>ily»e in taken. The jsiiffering nuiy be mitigated 
by a little etlier inhaled junl ilh the Inlror paine iiegin. 

Lateral obiiipiitiit!: of the uterus nuiy be eorreetetl by a 
finger booked iyto the os, while prei«ure is made in the right 
flireetion njK)n the fund uft. The wonum i^houkl lie on (he »*ide 
o]»po!^ite that to which the fundus is direeteil, »o that the 
hitter falls stniight l»y it>^ own weight. 

Unusual resistanee of "tough membrane**/' or adhe^^ion of 
the iiecidua to the uterine wall must Ite remedied, rei^|>ee* 
lively, by rupture of I he wie, or by l»reaking up the adhegiong 
with a finger. 

A feeble, debilitated woman must have fcM>d (milk \» best )» 
and a moderate i|nantity of wine or alcohol ie!?iti mil hint, given 
eautioiiwly m small cj nan titles at j^hort interval. 

When the cauHfa have been removed, the lazy actions of 
the uterus may lie stimulatefl into more vigorous eontractiona 
by a warm vaginal douche, inlroducing a lH>ugie into the 
uterus^ dilating the ct^rvix with Barnes water-bugs, and 
by the internal atlminiHtration of sulphate of cpunine in ch»s4-s 
of It} or In grains. The u.s*' of ergot it* extremely *piestion- 
alile. It mhould never be given to primipine, nor in cases of 
mechanical oltat ruction. If given at all, it should only Iw in 
email doses of 5 or 10 drope of the fluid extract every half 
hour, and i*lo(>jH'd a.*^ soon m^ uterine contractions have been 
reird'orced* In ca^e,s where tlie inefficient pain** have con- 
tinued long enough to |)roducc exhaustion of the woman, or 
ttimmfficiuij exhaut<tion, delivery shouhl be a>sii?isited by fon'cps 
or by whatever o[K^rative measures the stiige of labor and 
n a t u re i>f I h e ca.se vs i II ad m i t. 



550 LABOR: TEDIOUS, POWERLESS, PRECIPITATE. 

In eaeea of nemndarij uterine inertia, in which tbe womb 
and woman are exhiuisted from fruitle&'< [^rnlon^ed effort, the 
hoiit Ireatment in l(j restore the Hugging jiovviTs Ijv Hound aleep 
(iroilycerl by Juli doses of ojtunu^ inorpliui, ur eiUoraL By 
sleei> the nervous energies^ are reatoreil^ the pahis are re- 
newed, nuil noiv delivery shonhi be tiui^teued hy foreejM or 
other o[)erative meiusures the existing ohstrurfion may call for. 
If delivery by an ojK'riition should be ae^'LimjiliBhed^ while the 
uterus nmained mjX piiaiiff\ixnd inert, fK>st-partiirn hemorrhage 
would \k* almost 8ure to folhm. 

In eas<_^ of '"'^ tonic routrudioft,'' in whieh ihe womb retracts 
down ujKjn lu wuitentii with eontinued jjer^iBtent rigidity, and 
the vvoiimn \f^ greatly exhausted, th'iivn'tf at tmce^ without any 
delay, isi the only pro(>er course to pursue, the method of pro 
cee<Ung de[*ending, of eour&e, upon the kind and degree of 
ex isti ng o hst r u ction . 

POWERLESS LABOR. 

Powerless labor praetieully nu/au?^ nothing more or lesa 
than the hij^t stage of tedioiit* liihor, ]>revionsly deserihed- The 
jKvwenH of the woTuau and of her uterus are completely ex- 
hausted. Such f*ni?e^ sfiould never he |iermitte<i to cxTur ; 
and scarcely ever would if '' te<lioui!!** ^•ases were prom[jtly 
delivered l>efore they he<*ome ten) far advanced, as above rec- 
ommended. (See •* Tedious Ljiljor,'' pages 547 and 548.) 

PRECIPITATE LABOR, 

Precipitate labor \a one in which the child is delivered with 
unusual rapidity. It isfif eoui|iaratively infre(|nent iMi^rnrrence. 
The infant may [>e ex|iidled unexfiectedly, while the woman is 
8txinding or walking, and m sometimes unpleasantly happens, 
in public phu^e!i: or while she is at Ptm>L The child may he 
injured by falling from the mother^ — such case^i sometimes 
leading to undeserved suspicions of infanticide. The umbili- 
cal cord may lie ruptured in its ei^ntinuity, or torn out at ita 
junctitm with I he navel, but the IdtKulvessels usually contract 
ancl prevent hemorrliage. The child may \w \mrt\ in itg un- 
broken membranes, and fln>wned in tlie litpjor amnii. Numer- 
ous alleged daugera to the mother may result Irom precipitate 



i 



PRECIPITATE LABOR. 



551 



labor ; but their occurrence i^ an the whole, excepdonah 
The«e are inertia and jwst-partum hemorrhage froru jsiuhlen 
emptying of the womb ; invfreion of the uterus ; sym*o|)c from 
aliruj)t reduetitm of ab(k»minal distention ; ru[jlure of the 
uterus, hieerulion of its cervix, and of the perineum or vagina ; 
proeitientia of the womb. 

Causes. — Unusually large size of the pelvis f pelvis axjua- 
bilter justo-major). Unusual laxity and diminished resist- 
ance of the soft parts, as in cases of uncured extensive lacera- 
tion of cervix uteri, ihe result of a jtrevious labor. Ext*