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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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• •
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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, 0 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 ! 0 ' * ( ]*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 0 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 0 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 0 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 0
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*essive
force and freijoency of the \mi\H, and of reflex contraction of
the alHloiniual walls ami diaphra^nu, ^'eneraliy dye to j^culiar
U:'m[H"ranieiil or nervous excitaliility of the woiimn.
Symptoms, — The pains come on with little or no wa ruing,
and are heariujL'^ down in character from the beginning,
quickly snccreeding each other* atid rapidly progressing to very
great intensity. In a large pelvis* or when the child is very
small, lalior nuiy be terminated in a few minutes, without auy
n^'ct^^ari/i/ over-violent painy. Violent pains and a large pel-
vis may, however, coexist. The child may be Imru during
sleep* the woman drenminL^Blte bail eolic. Intensity of suffer-
intr, oii the other hjind, may jiroduce tninnient mania.
Treatment. — Treatment should Iw preventive in women
who have previously had prwipitate lahor» It in liable to
rt^cur^ — certainly so when the |>idvisist)ver-hir^e. The woman
should keep ber nmm durintr the Lost week of pregnancy and
go to beil on tlie first Indieation of labor pains, a competent
nurse havings l>een previou*3ly p^rovided.
During lalwr, anresthesia constitutes the readiest means of
lesstniing undue violence of the pains. Opium internally;
mnrphiii given hypidermically. or liy rectal suppositories,
when there is* time for them to act. Tepid enemata, to wash
out the IwweK and an ab<lominaI bandage have a soothing
influence to some extent. The woman must avoid bearing
down, tis far as possible, by crying out^ instead of holding in
ber breath during a jiairi ; and everything likely to increase
uterine contraction must \w avoided. Ppicidentia may re-
quire a T-bandage over the vtdva, an aperture being made in
it through w Inch the child may lie horn.
CHA PTER XXX.
DIFFICULT LAE0H-DYST(K:IA^FR<>M ABNORMALITIES
OF THE MATERNAL UKG.ANa
Deformities of tlie pchis have already I>een cousidered
(CliHfiter XX XL, page 442 ). The [ireseut rli»i>ter refers to
afjtioniiul eoiiditifins of tlie vo/f jtart^ produeiug njecrhutiical
obHtriielioii in the jmrtiirit^ut cauiih
111 (juite jtormaJ luljorf! there tire ahvaifj< t\\«j harriers liy
wliieh delivery of the ehihl w more or ic,%'< imjjeded ; thei*e are
the Oii nleri nmi the oh mfjina. The d»^gree to which thet*e
interfere with delivery largely defR'Tniw u}K>n the ease with
whieb the two o|>einugi« dilate. Ilenee a riifid o» and cer\*i^
uten\ and a rttjtd f/t^nnenmt which refuse to dihite before the
pressure ol the pre.^eiitiiiji part, may thus oh»tni<*t delivery.
Rigidity of Os Uteri. — I{i|^qdity of the os uteri is either
gpttfimodiv or ort^fauir. Sjiftf^modir rigidity »x^ciir8 in highly
nervous audetm*ti<>ual prirnif>ane most fre<|ueutly ; or may Ijo
due to premature rupture of the membranes ; or to pre-
maturity of the h\h}T, in which last the tissuei? of the os and
cervix have not yet undergone the usual S4jlh^uing hy which
their di fatal >ility is increased ; advanced age in primiparw
presents the ?<i\me conditiou ; the parts are leas 8up|>le and
dilate more ^h>wly than in younger women. Again, in con-
ditions where the presenting [wirt of the chihl eannot dejH^end
and iill uji the un nteri (a.* in narnjw^ pelvis or ( ros^ prest^ita-
tion ) dthitation will l>e slow. In m<tM aas^ of gfrtumodic
rigidity associated with an »/// ruptured bag of waters, lalwir
is delayed not so much on account of the rigidity itself, as
btH*anse of inefficient paius ; that is to say, if pains cowl in ue
gdnl and strt»ng» almost any ca^ of sjmsmodic rigidity w^ill
3nehl l>efore them,
Trtnftnrnf uj Spnmiodic Riffidihf, — When the mem brants
are intact, time and |>atience usually remedy the ditiiculty ;
BiGwrrr of the os uteri
653
I Hit in these cases, as in others where the memhranee ham
ryptnredt dilatation Ls greally f^xptMlited |jy full dose^i of
chloral hydrate, grs. xv, rt'[>eiited every twenty miuuie^ till
Fto,27t>.
Elon^tcd cervix with procltletnln daring lubnr. <Baiixe* >
two or thrciQ do«e*s have been taken ; or instea*! of this, a full
di)«e of niorjiliiit snlphiUe (gr. 1 to \\ may la* injeeted hypr*-
dermalieally ; or ji 10 per eent. sidtilioM of nK'uine niuv l»e
554
DIFFICULT LABOR.
applied to the cervix uteri on a pkniget of eottixi. Coajoiued
with the aiindviie^ a warm hiitb or hip Imth of fitteen or
twetdy miuutea' dunitiou, or a douche of warm (not hutj
wuter lliruwn atraiust tbe cervix for a few uiioutc^, ci>iitribute
to rtlax the rigidity. Artificial ililatatiou with the lingers,
itr with Buriies \vaterdmg^» h of iJervii'c in cui^eM where the
tiatural haj^^ of waters has beeu jirematiirely ruptured and
the cervix ii^ .stretclied tii^ditly ii round ihe head. In cases
where the mendiraues reiiiaiii (ndjrokeii artificial dilatatioti is
pn»babJy iiHelessf, or won^e.
Orffanif Tujidihj of the os and cervix uteri oi*<'urs from the
deveh)|iiiieiit in the piirt^ of librons conutHnive tissue, the
result of chronic intiarumation^ or the cervix is induralecl
from cicatricial, soH-^alled ^^-^car*' tij^^^ue folh>win*«: former
kiceration.s and this (still more rarely) is lialile U) be uccuni-
jMinieil with hifpeHnqihie eknnjitiuni of the cervix and pro-
hii*.^u,'«.
TnutmenL — Milder trrades of tmjanic rigidity may yield to
the remedies juwt cited for ^paMmodle ea,sea* Should these
fail, and the conditions uot admit of delay, the rim of the
external oei may be utctficd wilb blunt-jH>iiitcd sc-issors or a
prolnvpiinted bistoury, so as In nitike three or four notches,
abont a quarter of an inch deep, at ditferent |)oinls. Harnee
dilators may l>e used afftv the incision,^ as well aj*/;r/f*rf them*
Absoluie anti^ieptic cleaidiMe>'8 tutist^ of course, be ol)8erved.
In cai^e^ of by]jertrophic elongation of the cervix, with priH
lapsus or pnK'idetjtia (>ec Fig. 27t*)» incisions and mechanical
dilatation will Ik^ necesmry. Forcep may be used when tlie
|>art^ are sufficiently ojm'O, and <lebiy beiNmiei* inadvimhle from
imjwnding syai[ ►turns *A' exhaustion, etc. CtCKurean s<*iliou
lias been advised, and might he juslitbible under very urgent
circumstaric(*s. Wiieii gestation, coexisting with elongated
cervix, w nuide out aaou enough, amputatirai of tbe hyjXT-
trophied neck may be dV>ne at tlte third months It floes not
necf'iisari/if dii^lurb pregnancy.
Rigidity of the Perineum. — Tbe structures at the %^aginal
outlet, like ihost* of (he 08 uteri, must dilate to the extent of.
tbrce or tour iuclies in diameter betnre the bead cjin \m\s^
Tlie rei^istance of a rigid ])enneum h more eoiiinem in primijv
arie, e.«trei*ially in tfiost* no longer y<mng. Actual rigidity
(except in ca^s with organic cbauge^^ due to cicatricial ti^ue
I
I
niaWITY OF THE PERINEUM.
555
following tlie beaUiig of Ibmier lacerations) is, however, more
ap[)areot ihnn reiil. It i^ the fmw/'r, not the /mitsa*jr — th*?
pnitij*, Ljot the perineum — ^tliat are really at fault. It U an
f vervMlay exjK^rience lu seu tlie head fume *lown to the |>en-
neuni aiitl Htt^j) (hercT perhaps for ^^evenil hoiiiu The pains
fall off anil iiiTouu' weaker uikI le>ss frerpjeiit There rnay b*?
uo meehanical olistaele to ilelivery iK'feide resi6tam*e of the
&(>il ])art4? at the outlet. The u»ual reaMjii of this delay is
that the womb and woman have heen m far worn out hy the
prei'edin^' part>« of the lal>or that the little additional eHbrt
neee!s«ary to force the ehdd through ttie vaginal outlet 16
heyond their power. To usJe a figurative expression, the
resistance nf the f>erineuin is ** the Imt straw that hreaks tlie
camel's back.''
Treaimt hL — When the heiid h thuH arrested ai the inferior
strait, and there is no other n»eelianical ohhtaele to delivery
but reststanee of the jKM'ineuni, the Wt methixl of treatment
in the larger Dumber of eaues m delivery by foreeps. While
true that in a certain iiumlK^r of ca.*^es delivery wotihi in fiue
time, s}>onta neon sly oe<'ur after some liour^' further delay»
proviiled tiie uterine inertia and general exhaustion were not
excessive and there existed no abs<>lnte meehanieal olistacle
to delivery, ex|*enence has nevertheless, ainply proved that
the re(|uire<l a<Mitional delay is not to be *iepemled on, while
delivery hy lorce|^x*< may be safely and often ijuile ejisily jier-
tormecL The old maxim, **Metldlesome midwifery is liad,"
cannot be applied in tliese cases. Though delivery mitfht m
tiim^ spuntaiirnusly oecur, the ehuoces tif final and rapid re-
covery, after labor, are far It^ than when forceps are applied
%v If hunt delay.
In phnv of foree|x^ — as under circumstances where they
caiuiot l>e ol>tained — ilelivery may be ex)Mjdited Ivy mnuual
prfMure u[>pii the uterus (and thus njKui the breech of the
child) through the abdominal waib
Manual prt^**ure is simply a substitute for uterine contrac-
tion. It may he used to reinforce feeble |iains or refdaee
absent ones ; and must imitate them, esjjecially as regards
infermittenee, duration, and force, as nearly as |><»sslble, ( om-
])lete ex|>ulsiou of the rhild. l>y pressure projierly applied, has
even been accom[)tished when the pains were entirely absent.
It is applied thus : The patient lyi ug on her back, spread the
556
DIFFICULT LABOR.
palrri*^ of the hands out over the mdet* and fundus of the womb,
and when n ptiiii beirins make iirrii |>reasurt% while it lusts,
dowmvard and backwunf, in a line with the axis of the plane
of the t?ujverior strait Lessen, and tlien s^top [jre^sing ns the
pain goes off If there Ue no |»ains, imitate them a^ nearly as
p>ssilde, If the vvoniun lie ujKin her *iide, one hand only eao
be used (the leH, if she lie on her left !«i'le ; the right, if on
the right) to make pressure on the fun«i us, while the other
guards the progrei>s of the }>rei*enling [jart per w/inam.
Manual pressure lauM not be empfot/ed, of course, when the
uterus ia very tender on ()re^^ure» nor when It is spasmodically
eontraetcd round the chihi, nor when there is any mechanical
imfiediinent to ilelivery.
Sidphate of (jninin» gi>. xv, may he given to reinforce the
pains : food .and Htimuhints to relieve general exhaustion ; and
ergot to secure tirm retraetio[i of the uterus when lalx>r w
over.
Ortjank ritjidUy of tlie jjerineutn (eieatricial induratian
tolltjwing healing of former laceration:^) may require digital
dilation, ami, very rarely, incision of the resisting tissues
(episiotomy ) a.*J reeommetsded to prevent rupture^ (See page
2<JI). )
Be^iide resistanee of oa uferi and perineum^ which are quite
contmon, the t»ore rare forms of ohHtruction by the soft parts
may next be * ■on side red. These are:
Swelling and CEdema of tke Anterior Lip of the Womb. —
(Edema is canned by its getting |>inched betwc^Mi tlie head and
puhir symphysis. It must hepusherl up with the tinger-ends.
and held there for several successive pains» until the head jilip
by it. If miteh swollen and iip[»eriring nt the vulva, as mav
twcasionally occur, pushing it up is irnpracticuhle. IX^liver
the chihl by forcc[>s, *ir liy whatever meilujd may I je necessary,
without ilelay.
Imperforate Hymen. — An ahmlutelii imperforate hymca
would prevent ittipregnation ; an npf^dveidhj imjierforale one
njuy eontain a smalh undiscovereil opening, large enough to
admit en trance uf spTmatozoids, and may thus afterward
eonstjfute an obstruction to deb very. The organ may l»e per-
forated with a visible rtuind o[tening ( Innnrn anjtuJariA) or
witii several small apertures i htjmnt cnltnfonniH),
Diagnosis, — By imiH>t*8ibility of introdueiug finger, antl by
CYSTOCELE.
557
8uli«equeDt iuspection of jmrts. Previ(iU8 history of partial
retfutiun of iiieiisi's,
TnutinenL — lurihioii may very rarely l»e required.
Atresia of the Vulva.^ Atresia may be [Mirtial or eotujilete,
resulting fr*jiii iiitlaiiiiiiiitory aJhesiou ; heiiliug of ulcenUed
surfaces foil owing trautiiatic injury ; or ioiiauunatiou attt'iiding
exantlieiiKitaT former lalwtri*, etc. It may be eoLigeuitaL
/> Hi (f twx t%i. ~- By i tLs [ )v r i i r m .
TnaimviiL — Obstruetiuu u.^ualiy overf'onie by 8|joijt4iiiooufl
(libttatitai <!iiriiig labor. Artiiiriai dihitiitiou by teult», or
liariK'H (lilators, or earefyl iiieisiuo along the niediau line,
while labia are ritreiehed laterally, may l>e DtM.*t\*<sary.
CEdema of Viilva.^W hen excessive, it may require
iiumeruus !*ruall purietures for its relief, always preeeded
antl tcjl lowed by aiitiHeptir eleaiilinoas.
Atresia of Vaginal Canal. Atresia may ht^ cttnfjcnitai or
arq H i rrtf ; y as rt la l o r n t wj tlrte, N t m -eu i ige n i ta 1 cases a re i I lie
to iutlammatory atlbesious following injury of tbrmer de-
liverie^s |>e^arie^ ami 4ii1kt traumatic causes ; or lo iuflaiu-
nuitiou i>f exanthemata and nther n>nHritutional <!iseajiei*. Coti-
sidemble siurfaee^ may lH»come adherent, or couslrieting eica-
triiMul ban lis only exlnt,
JJiagnoMiff, — By cliirital examination, or ocular inf*poction
throngh sjH'CuluTn.
TicatmnU, — Artificial dilatation by elaMic water- bags,
tents ek\ Disjtection through nbMrncliiig Itswue with Hnger»
or finger-naih during hibnr jraiuM, gradually executed with
care not tci ftcnetratc vesici>- or recto-vaginal walls. Shallow
vcrtif^al irrcisions — hmgitndinul i5cariti<'rtti(mi*— for ciratricial
bands; and careful vertical nK*ision of central septum of ad-
herence in bilateral union maybe rei|uirtHh Finally, fnrce[i8
delivery, to ]»revent pndonged compression of part^ liy firtal
ht'ad.
Vaginismus ( Spasmodic Contraction of the Vaginal Orifice
or Canal \, — \ aginismvis is asgociatcd w ith >pasm of iht' levator
ani mnsrle very nirel y , it may inteHere with Inlxir and require
forct*|iti or other artificial aitl.
Cystocele (Prolapse of Vesico- vaginal Wall), — (y,«to<»ele
may Ih- due to, or a)N*<M*iated witb, retention of urine and
vesie*al disiention. ( 8ee Fig, 2><0, |mge 558). The pmlapeetl
wall presents a tenne, fluctuating tumor, more or less i>crluding
568
DIFFICULT LABOR,
the vagina ; it may be forwil duwu hy advauciug bead, or
even rii]>Uireil.
Symptoms and DiQ^jnosia, — Known existence of cystocele
befure «»r diirinji^ prejufniiuey. History of urhmry retention*
Uuriug lal>i>r : iiitetii*e i>rtiiJ ; ve5*it!al teoei^mui* and dysuria.
Fig. 280.
May be migtiiken for \nig iy( waters : diagnosticate by feeling
f>re$«euting part al»ove and l>ehind bladder tumor* and by re-
duction in size of tnnior hy catheterij^m. DiagnoeiM from
bydroee|>lialiL' beJi<l by snnie nieanst ntid by recx>gQitioQ rf
enlarged ;«uUires, fontanel lesi, el(\» of rranium.
OCVLUSION OF EXTEHNAL OS UTKRL
559
Trertimeni,— Catheterwm^ whirb iB difficult, and niaij be ini-
poaril>le» riHjtjiruig piiiieture or wspinilioLi ihruugh vesietv
vagbul .se|ittim. FiLsh hack ur lioM u|> tht* prola[>sed wall
diiriiij; j mi ins, till the fiead A\\t l>y il*
Bectocele (Prolapse of Recto- vaginal WaJl). — ^KtHrUM-ele
is produred much iu thesjime nmuiuT* hy disteutiou of rectum
\\y fk-al contetitii, and pushiyg down «>f projfcctiugrecti>vagiual
(wiuch hy Mdvauciiig fU'tus.
IHaglifmn. — By putty-like rouslstence of luiiior, and iuden-
tatioo of its coritcutii hy'digital prt'8»ure tbruugti rccto-vugiiial
wall, or exarainutioii per anum.
Tteatmeni, — lU'niovc^ feral accumulation hy emollient eue-
muta, or scoop out hard ruiL-ises with gpjon-haudle or Engcr.
Push liack proliii*!4td wall while head passes by it.
Impacted Feces. — Without rectocele, this may be suffineut
t4) «>bstruct delivery*
Treatment same iii? above described. Prophylaxis by laxa-
tives during pregnancy.
Vesical Calculus (Stone in the Bladder). — When of cod*
8ideral)le s^ize, calculi may very rarely obstruct labor, aud
lead t4» cyt<tt>cele or vesico- vaginal fistula from conj|ire9«ion
of vesico- vaginal wall between ealculu.-? and foetal head.
DiagtwsU from Exostom^% etc. — By moliility of calculus*
felt per vagiuam, between the pains, as a hard tumor l>ehiud
and stjmetimcs above the pubes, and by sounding bladiler.
TrealmenL — I/ift the stone above the [»elvic brim hy digital
palpation per vagiuam. If this be impracticable, crui^h it^ or
extract througli nifiidly dilated urethra. If tlu-se lie ttw*
tt»*li«ms^ perform vaginal lithotomy thrtJUgh neck of bladder.
Ve?*ical culculus recognized during pregnancy i»hoyld be re-
nioveii before labor, some time after the!*eventb month, i*othat
if labor be produced by the operation, the child may l>c
viable.
Ocdnsion of External Os Uteri. — ^The lip* of the os are
either completely closed from former adbesive inflammatioiu
or an ol>sserved or unol»6erve<l ofKniing may exis^t, of jhi small
a size aj< to (Nmstitute pritriiml (x*chision, !*o far as delivery is
concerned. The adhesions may have followed traumatism of
the parts from instruments used in pro«lucing abortion, or
eauterizatiout lace rati ouf«, ulcers, etc.
Stfmptoiwt and Diaguods, — Absence of the us on palpation
560
DIFFICULT LABOR
and even on inspection by speculum, A circular dimple may
Imj recognized where the ofveuiug ought to he. The cervix
and iaternul us ure widely di.-Jtt'iidcd, |>erha{^)S by the advuuc-
ing head, their tis«ue.s lieing s<i thiii iii? to iieeessitiite care nut
to inisliike ihem lor the tletal meriibntiieH ; the recognition
of their cuntujuity svith the vaginiil wall wouhJ prevent the
mistake. In uterine iatenil ubli<|uities timl exaggeratefl ante-
or retroversion, au existing o^ uteri may lie tilted out uf reach
ol* the linger in unlinary vaginal examinaliou, the os only
Ijeing diseovered by passing the wliole hand through the
vulva, and thoroughly es[)kiring every part of the vaginal roof*
When occlusion really exisLs there is danger of rupture of
the uterus, as well as of *' tedious'' labor, if relief lie not
afibrded.
Tnahmni. - IVL'ike an oj^niiig where the oi* ought to be.
Having tbund the circular dimple alx»ve stated, it naiy, if the
obstructing septum lie thin, l»e (»enetrated by prc*«ure of the
finger or hiiger-nad during the pains. Under other cireum-
stances? a snuill crucial iucij^iun must be nuide, preferably with
a guarded biKtoury^ over the same P[K»t or when no dimple
can be dis<.»overed, over the ni(»it depench'nt p*>iul of the dis-
tended cervix. Tents mirl flastie Imgs may lie necessary to
comjylete ililatatiou if it fuil to tsike place spoil tannnisly. In
a few cases, uht-re tifi tnu'e of the os eon hi be disco vere<i,
Ctesareaii 8t*t*lion has been snccessfnlly perfurmed*
Atresia of Uterine Cervix.— A tn^ia within the external os
refniire? either verticai shallnw iucisions or gradual mechanic
cal dilatatiou by himinaria tents nnd waterdiag dilators.
Cancer of tie Cervix Uteri* — When ordy involving the
lower portion of tlie eervica! canal, tlie disc*a,s<^d tissues will
often yield enough to ailmit delivery. When extending highej!'
lip, the cancen>us gnjwth, by it?* size and want of elasticity*
either prevent* passage of child or ruptures with severe hemor-
rhage.
FrognoniB, — Of coursct most grave.
Treatment — Incision of cervix with application of fierchlo-
ride of iron or ioilofurm gauze to stop bleed ing. rerfonilion
nuiy be afterward nef^essnry, if circymstancei^ demand imme^
diate delivery, A uother jilan, cerlain ly prefendile so far ii» the
child is eoMcerned, and, in 1>ad case*i, nnt adverr^e to (he
mother's interej*t, is to [>erform Cicsareau section a:? »oon aa
POLYPI OF THE UTERUS,
561
luhiir l>eging. Maj^seirof the (mueeroiis growth may goraetimos
he hrokeii away with tfie hand, mukiiig a sutliineut ofjeumg to
admit Vfrsiou or ibret'iis.
Fio. 281,
Polypus oliBtrticiin^ lubor*
Cystic, Fibrous, and Cancerous Growths Developed in Vagi-
nal Walls. — Tiiese izrowths may, very rarely, lead io Hut-
lieiei*t *ili^trurlioti irj require «>|ierative assi^tanee hefure deliv-
ery can lake pfaee. If j^nmll and reniovahle, the irrowth
should be removed. If imt, and I he tumor is hanl and uo-
yieldin^, tTauiotiHuy or C'usarenti seetion l>ee*ome hiKt resvjrts.
Polypi of the Uterus. — redieulated tihruus lumori? huuging
k
562
DIFFICULT LABOR.
in the parturient canal ni;\y be of sufficient size to ohstruct
lulMir. (See ¥\^. 2H1. ]m<re atJ:! )
JJiapwnis.^Bx their uiohiliiy — if nut impacted — insenei-
bilitVi [ledicululitm, et£\ Bmjill ones might, without care, be
niistJiken for t^w^llen scrotimi of hreech )ire*ientiition*
TreaimenL—V u^li the tuiiKir uj), out *if the wiiy, Jilx>ve
sujHrTior atniit, mid retain it there till iiend take prt-eedetn'e
in de,Si^enl* When the jn-diele ii* easily reached, remove the
growth hy tera-icur or seL^nrs. Borne break ofl' during hibor
am) eoine awiiy of thetnBidveii, S<:>me are sutficiently eom-
j>rei<sii>le as not to prevent tlt^lrvery.
Rbroid Tmnors of the Uterus, — llie^e tumors are not
f>ediculated, whether sulkserons, eubmueoUf', or interstitial^
and may or may not ohwtroet delivery, ae<'orfling to llieir sixo
and [Kjsitiom If high up above the su|»erior stniit, tbey pri>
duee no olvstnirtitm, hut nuiy renihn- patiL^ inetfieient fnun
Hsymtm^rieal nterine *'outrnetion, ami prt^dif^]io-e to ante*
and pojif'j}fifiifin hrtnorriunj^^^ as WiM as to nlinormal preseotn-
tiou and position ni' the <diild. Silnatt^d ladovs the brim, iu
the lower segment (jf the wondi, they neft^Hsarily obstruct
labor, and may \h.* large enough nearly to iill the jM-lvie cavity.
Diagmms.^By history of the tumor, l\s slow growth, and at^
tendimt symptoms before pregnancy, and by its firnniess, want
of rturtuatfon, rle.
Treatmevf, — In all 4-ase.s extra t'reeaution against oecur*
reuce of [>ost-|>artyin heniorrhsige. AppHcations of styptic
ir<m .solutions generally m'ci^siwiry to arre^^t it, Tumorw bffow
the brim, even in aj>j>arently very unpromising ease^, mav b©
puslit-d up fthore it l)y persistent presc^tire with the hand or
chmt*d fist, the luitient being amesthetized, Tfie knee-elbow
position may facilitate Hueeens. Surgical interference, etui cle-
at ion of the tumor, or its removal with m-o^r ro* when llie
l»a*e is not too large, may be advisable. The onlv other
remedies in bad eases are Ctesarean sci'lton and <'raniotuniy.
In a lesser degree of olkstruetion, forcejis or versiou may
suffice.
OTarian Tumors. — These tumors, whether solid or cystic,
occupying the pelvic cavity usually lietween vagina and reo-
turn, may obstruct delivery. (See Fig. 282*)
The degree of ol)struelion dejjends upon the size, hardneai^
and position of the tumor, and upon its mobility. Apart fipom .
OVARIAN TUMOnS, 563
olietruetion, there is danper that the tumor may hurst during
labor into the (►eritonenin and [>roduee fatal ]>eritouilb or the
pediele may get twiste<l and break oC Venj large ovtirian
tumors are less dangerous than medium-sized ones, beeause
they are usually discovered before labor, and further, because
they are toi> large to get l>elow the fielvie brim.
FtG. 282.
OYitrl«a tuiuof m pfilvic cAvUy oUtmcUng litbor.
DtQfjTioms. — By the |)osition of the tumor ; by its fluctua-
tion and coni*j»tency, Fibroifl tumor of the ovary may, how-
ever, l»e so hard ag to re^*ndile bony growths of the pelvis;
even eyatie oties may be so tense us to require puncture with
564
DIFFICULT LABOR,
troear or aspirutor before their oattne eiiri l>e positively ascer-
luiiiecl,
Tt'tatmenL — Attem])t to push tumor a hove tbe |>elvic brim
cmt of the way. Pa\iid* nt pressure, iiiokT iuu(.'^thei?ia, the
woman being in a kuee-ebeist jMJiiition, inny uuexpeetedly suc-
ceed. It Diuy, however, fail iie<*au?^e turiKir is ndberent* or
of large size, or held down Ity the pre?ientin^' part of the child.
Then puncture cyst throu^^i vaginal wall with troear and
canuhi, aod retain until Huid be evacuated, and if Huid be
too thick to How readily, make digital pren^ure UfKm the
tumor per vagimtm. When no trix^ar is obtaioable, make a
small incision in thf tuiimn and nfier eniptying it. stitch up
the woonil. Should [iiinctyrc fail t() remedy the diHicnlty,
from the tumor being s^iliiL the ehib) muf^t be delivered by
whatever o/j^/^inro/jcra^^Vjji the space will alhiw, or instead of
this, the tumor itself must he retiioved by a sttnjlcal operation
— ^vagiiml ovariotomy. Most cases are relieve<l by puncture
of the tyst.
The diagnosis of ovarian tumor having been iiuide during
prffjnanerj f i. f\, btjhrf hfmr hrtjlft^)^ it should he removed by
ablominal section, as in olher t;jises. The oj>eration tlcew not
interrupt the pregnancy, if care be lakeu to handle the uterus
as little as p<j?isible.
Hernia of Pregnant Uterus.— The varieties of hernia of
the /lofy-gravitl uterus* named in the order of frtHjucncyt are
nmbiiicafy rentntK frmoral^ higuinnl^ through the Joramtn
owh\ and thnaigh the ^rm\X atftcfo-sriatic for^imrn. All forms
are rare; and for the uterus while tlius tlit^hx-ated to become
prt'gnnut, stiil more rare. Pregnancy has never been observed
in uterine hernia through the forameri ovale or great sarro-
sciatic tbramen. Iftffuitinf, nmhilifaf, and fr moral uterine
hernias have been observed with pregnancy. The tiiginnal
and feifiora/ cjisca always entl in abortion or prf^nniture hd»or
— the sac of an nmbiUnif hernia may contain a uterus far
advanced in pregnaniy.
DiafjHOMA, — ^ By abs<nice of uterus from its normal situation,
by sfuijie and consistency of tumor, and evidences of its cnn-
tiiining a fo»tus. Iii inguinal and femoral cases the canal of
the vagina is <irawn on one side toward the hernia,
TrtdtmeitL — -Rejdace vvond> and a[iply truss. If growth of
pregnancy is already too great for this, induce alKirtion <u- dv-
HERNIA OF PREGNANT UTERUS. 565
livery. Growth may be so large as to require division of
hernial ring to permit delivery. If this fail, hysterotomy.
Ventral uterine hernia with pregnancy occurs more fre-
quently ; is due to separation of recti muscles, or of dilatation
of large cicatrix after laparotomy. Many of these are not
real hernia — the sac being contained within the fasciae — but
ordinary " pendulous belly." If the woman, while on her back,
attempt to raise the upper part of her body, the pregnant
womb will protrude as a globular tumor in the linea alba.
Treatment. — An abdominal bandage. These ventral cases
go to " term ; " delivery is not generally interfered with.
CHAPTER XXXI.
PROLAPSE OF FUNIS— SHORT OR COILED FUNia
PROLAPSE OF FUNIS.
A loop of the umbilical cord hangs dowu alongside of, or
l>clow the pregeutiijg part of the child, Befort; rupture of the
meiiibranes it is railed '' preHentattofi^^ of th'^ funis; after
rupture, when the loop falls down into the vagina, *' proiapse/*
(8<ae Fig, 2H*4. )
Causes.^Coiiditions in which the presenting part of the
child does not coniplelcly fill <>r block up the ring of the os
uteri un<l [Kdvic brim, viz., pelvic contraction or defonnity -
tnmiiverm?, foot ling* knee, breech, and lace presentations.
It may ocvur in ordinary hea*i jjrc^ntationsi, as well as
uuiier the circiinwtancei* just st-tited, fnun unusual leugth of
the cord ; inseriiun of pluceota near the os ulcri ; excess of
liquor amidi, and gUi^h of amniotic Hnid when membmnes
rupture at the height of a hilwr pain ; and in multiple preg-
nancy. Head ]>re-'*i^ntalion coinplicated wifh that of a band
or foot, or with both, «:^spH■ial]y favors prola]>He of curd. From
the far greater relative numlierof head prfj^enlations there are
more cjii^es of prolapsed funis? atwK'iated with fhrm than with
presentations of other parts But in a giveu ef/uri/ number of
each presentation, prolajise of the aird will \w found leiigt
fre<[uently with head cases, for the reai*on before totaled. Thus
BcaQZoni's figures are :
Funia presients once in 304 heail eaaea,
'* '* ** 32 face ca^ei*.
•* *' ** 21 i>elvic cases.
*' '* ** 1 2 transverse ciisea*
Diagnosis. — Diagnosij* may be alte tided with ^-vwi/' difficulty
before nieinhranes rupture, tie linger having to feel the cord
500
DIAONOSIS,
667
throuf^Hi them nr thmu^'b the tbiiiiiHl uterine wall. It feels a
Bott, ci>nipre«sil>Ie, unci niuvtible iKidy, in which pulsiitioiis, ^yti-
chrointus with the tU'tul lieart, niay he rec<>j;uizeil. rnx^nn: of
eiml during a jmhi may tem|M>rarilT interrupt puliiation?^. Pul-
sations in vaginal or uterine wall are sjyuchroiifas with mother h
Fio.
Pro1»p«e of th« csord by the tide of iha lioftd.
pii!j*e* Con f« Hind ing finjLj^ers or toes of child with funis \b
iiViAiled hy remernWrinp their harrier n)ni*ist**ncy, nundxT,
unci hy ahsenee of reeo^^nizalde pubatioriH in them. In cases
of uterine rupture a prohii^sed roil of small intestine ha^ ht*en
mistaken for fiiuia. The attached meseutervi and want of
668 PROLAPSE OF FUNIS— SHORT OR COILED FUNIS.
piiWtJon in the intastiiie, are gufficieutly diagnoi?tic witb or-
dinary ciirt\ When the membranes have rii|»lurtHi, or the
(iresuntiiiir erird has proliijj^ed inlu the vagina, there can
pcuirt'ely he- nny mj^tuke. riiibiliciil ptiKsatioti of course ghows
ehiUi to l)eali\n|[S»iit the pulsation may «'ea!?e gouie time before
the in taut die.s ; honre attsfultute for heart-t^ouJids before ile«ith
]s iLssuined t(» have <»c<*iirrf<U
ProgBOsis. — Not uufavondile to the mother, except in sk>
far a?i may result from eniutiouul disturbance aud subae<jueut
breast trouldes from ehdd being boru flead
Fig, 284,
Posturnl trefttmoivt of prolspsc of tbe cord.
As rt'irank the rbihl, it i^ a most serious etimpbeation,
Altout r>0 j)er cent, die, owinp to eonif)re4>sioTi of funLs during
* lei i very. The (hiuirers are lens in pn)jxirtion to the greater
length of time that tlie membranes are r/;iruptnred, and when
the pre.sentiitJort itnd titlier eoudit ions are favorable to nipid
delivery nfhr their rufiture. Hence lireeeh presentntionfl
wliieli a<lmit of j4|)eedy extraction are comjmrntively favor-
able. The bree<'h, inorefJver» is Hofter uiu\ Huialler than the
head ; hence there h less fear of fatal pressure on funia.
Trfinsverste viim^s do not nect^ssarily involve pre^^ure of the
cord, and are less dangerous than head presentations in ih%$
TREATMENT.
569
_ €ct. A large pelvis L^ favorable. CyifavoraUlecotiditifms
RPf* prlmiparitff (tiwing U> len^tli uf ialwr iVtim resistimee of
soft |mrU), eofttracted peln\ Ijhv placental ht gerf to n, nud early
rupture of }nmthrants.
Treatment. — Prei*ervethef!iertjhranes fnm^ rupture as long
as fNJs^sihle. The tt)rd is siifer from pressure, when hn^ uf
waters is intact, thaji it van hr unuli' Ny any o|H'rHlive treat-
nieut after mcmliraiies rii|ttiire. One i'Xre]>tion is nutetl below.
Fodund Trratmetd. — Before membranes rufiUire plai*e the
woman upon her »u\e — uf>on tbe side op{>ositetiiat ypim wbidi
the eord lit\s — and elevate tbe jx^lvii* upon pillowss while tbe
head and ebe^t re^t low. Tlie t-ord may tbut* jrravitate toward
fiinduH uteri during early part of hilKir. The knee-i*hest or
knee-elbow posili^ms are Oiore elieetive, but diflieult to main-
tain for any eunsiderable time. (Fig. 284.) They should be
re.sorted to at intervjibs durin^^ early sta*i:e, the woman after-
wartl re?<nmin^' her lateral jjositioti ns alnive stated. IjHter
oil, wiien tbe oi* i.^ sutiieieiitly dilnted for the head to pass, tbe
woman may l)e plaeed, teriifMjrarily, in a deeided knee^ll>ow
[Misture, whed, if tbe cord slip baek, the membranes are to be
ru[)turt'd, and manual pre?^<nre apj>lied externally to pnnluee
engagement of tbe head, which last tills ibe opening, and pre-
vents reprtda(if<e, tbe woman subsequently resuming and main-
tain ing her latero-prone |ioj^itIon.
Should |nwtnre alone not sufbre to cause the cord to slip
baek, let the memljraoes remain intact.
When iinally they rupture, ^rtifieial rrjxmtion of the eord
must be attem(ited» There are several methods of ojjeratiugt
al! of them being more likely to succee<i when tbe woman is
placed in tbe knee-chest |K»sition. Tbe /i«7f<hnay beearefnlly
passed into the wi^mb with the hmit of conl protec*ted in its
palm, until the loop is <'arned above the equator nf the head
to fhe Imck of tbe ebibrs neck, tbe fumlus uteri being mean-
whiie supported with the other hand, and the head gently
pushed ai^ide when the inner hand pai^s^es abaigside of it.
When this priweeding is inailvisabb% or imj>os8ible, from the
head having iies4:'ended t<w> low, two or three fingers may be
used to push up the btop. and bold it alu^ve tire effuator nf
the bcjjid mitil the latter is forced down by a sueeee<Iing pam,
when the fingers are withdrawn. Re|ieat during several sue-
ee^jve |ming, if necessary.
170 PROLAPSE OF FUNIS— SHOUT OH COILED FUNIS,
h) lieu of" the haml i>r tiii^fers, viiriuiis rrptmtor^ Imve heeu
<Ie%^is<wl, A tape iiiiiJ i^tyletted mule ekistie eiitheter iiiiswer
IIS well aw any of them, A fiiei'e of ta]:>e three or four feet
loD*; is ilouhled, end to eD*l> ami pa,ssed into the catheter so
tliat the Inpe Imyp eaii be dnivvn out an ineh or two throufrh
the eve of the inMninient. The sly let is alm> |Mi8.setl in, and
iti4 extremity made to prttject Irom the eye of the catheter.
Fig. '^85.
no. 2§6.
/^
Bcpoffitton of cord. (After
WlTKOWaKL)
Br»un'« reposition of oord. (After
The h«>p of tape is next |mssed roiinil the loi>p of eord,
and hooked over the (>rojee"ting end of the Htylet, whieh iast
is imsluul haek into the eye, aud i^hoved u|i iptite to thec'lo4*ed
end of the ratheter. The twi* ends of the ta}>e may now t>e
gently drawn tipin, nntil the Irjcip loosely hold-s the cord in
eoiiUiet with the in.«!rtiment. The prohiptsed fnni.s ig then
pusheil np into the uterus^ liy the uitheter ontil it is quite
TREATMENT.
571
iiUove (lie presentiiii? jmrt uf the fhild, when» by with^lrawitig
ibe s<tylet the cord is released. The ealheter iiiid Uqie may
be left in till labor is OYer. il mmpler method : The loop of
FIO.287.
Fio. 388.
Fii3.2a».
OtlicT melhodB of n^po«ition of rnrd.
tape, irisiead uf lieing paasied all throii<;b the catheter, is simply
[Missed iiitu the rye of it and over the end of the ^lylet> which
last ia pushed up to secure it ; the free ends of the ta|>e may now
12 PROLAPSE OF FUNIS—SHOUT OR COILED FUNIS.
Ir- luost'ly tied round the Ump of conl and the cmtheter iritn>-
dueed as before, luid stylet removed, (See Fig. 285, |>. 570* )
Or a^uin» a aitheter may be used with (wo etftit, op|iosite
ench other ; the loop nf tape or strings is jvassed trausversely
tbrou<j:h both eye^, then rouu4 the iiavehsfriug, then uver the
eii*i of the catheter (see Fig. 28B, [Kige 570) when theeudi^of
the tiipe, passing tdoug tlieslmtlof therutheter, are drawn tight
enough to hold fuiiij*, ete. Stylet to lie u.sed for iutroduciiig
itt aud withdrawn afterward, leaving catheter, etc., in utero.
Other iiiethiHb of Urging the eatheter, ttijie, and stylet are
sbowQ in Figs. 287, 288, and 289* which explain themscdvea.
Eeteiition of a rephiced funis has been seen red by attiiehiug
to the cord a collapsed elastic hag rjr pes.**ary, having a tube
bywbieb it maybe inflated, after introduction into the uterine
cavity — soH^alled ** balh>oning " the cord-
When re|K)sitioo fails, lus it is often wont to ilo, the next
element of treatment, generally speaking, is Hpeedtj defivert/ ;
or, when circumstaniTs render this impmcticable, it may lie
attempted to place the cord wl^ere it will receive a minimum
amoitnt of prfMurr. Thus, when the tKX'iput is placed at one
of the acetahuia, the loop of the con! should he put near the
sacrr)-iliac synchondrosis of the same si<ie. In breech presen-
tations put it near the sacri>-iliac synchondrosis which corre-
sponds to the autero-jM^sterior iliarneter of the breech.
Sj>eedy delivery may be secured hy for crpa when the os is
dilated and the head stiiticienlly low.
When forcep are not available, the next alternative ig
verttion by the fed, preferably by external or ctinibined ex-
ternal and internal manipulation, and substx^uent rapid ex*
traction. The dangers of versioti, especially when the condi-
tions for its easy anrl .s;ife |>erformancc arc not present* shouUl,
in tbe interests of the mother, be earnej^stly c*>nsidered before
the ofie ratio II is agreed U]>on. It shoidd he als^i ascertained
that pressure njwn the cord has not already so far irijured the
child as to render its chances of survival, af\er version^ irisuffi-
cient to justify any risk to the mother that may be incurred by
the op^rathm.
T!ie o|>eration oi' version, together with reposition of the
cord, may he facilitated by putting the woman in the Trcn-
d et en b u rg pt>st u re.
In face presentations, when operative interference is decided
TREATMENT. 573
ujMJti to stive the ehiUrs life, an early resort ta version 18 the
best, tliat !», when other iiiethods of relieviotr the t^ord from
presaiire huve failed,
F\Q, 390.
Hnud proUiptied by «ldc of bead. The prolapsed rord Is not T<»pre«ented.
Ill l»reerh vm^A the extrerajti**^ ^houM he brought iluwii,
and the chikl nipidly extnicteti liv tlie melhodn ul ready iJtnted,
(See ** Breech Pre-'^erilations/* paijes HI 5-337.) In Iwtling
cases the ^m%\i} ra[ml tx traction is nece.^'iiary.
In ea^es ui prohifiisied funics iisscK'iated with ^-untrarinl pelvis
or with transverse presentations, the treatment re4pnred for
674 PROLAPSE OF FUNIS— SHORT OR COILED FUNfS,
these complications, in the interest of the mother, must take
pre4*edeuce of that s^ilely relating to the interests of the
€hiM.
Wlieii proLifiseil fuuh is a8s<ioiuted in heaii presentations
with €oinci(lent prolapae of a ham! {im^ Fig- 290), the pro-
lapse*! extremity .^honld be replaces! witfi the funis, ami the
beacl maile to dt^-i'ml and iill u}> the i^jmee so as to prevent
reproliips^. Care nuii^t he taken not to dii^place the head and
thus prtjdiice transverse presentation ; it is best prevented by
abdominal |>res?s?ure rlnring^ the proceed in^j;.
When a foot presents with the cord ami bead, or when ffx>t,
hand, head, and cord all present at once, it uili usnally be
best to draw down the foot, while the head, cord, etc., are
pnt^hed np^ thns prcKlm'ini^ version by the teet. Such pi^esen-
tations are technically known as ^* mmplicated'^ or ** cmnptex'*
ones ; and are also so called when the ford does not prcdajise,
( St^c ** Fotjtlin«]f CaseH/* pa^^e 387* ) When the ]h'1 vis is I urge,
prolap&e of a hand tilongside of the head may still admit of
gpontaneous delivery, or forceps may be applied if the ex-
tremities cannot be replace*! and progress is much impeded
by the complication. When the child is thtu], prolapse* of
the c-ord requires no interference. In all <*as(\s where hope of
life remains, prepare ijcl(>rehand for resnt?citation by providiug
hot and cold water, brandy, electricity, etc
SHORT AND OOILED FUNIS.
Actual shortness of the (Kjrd (ca»e« have been seen na short
as two inches), or arfijidal shortenino^ by its lieing coiled
around the neck, bfdy, or other parts of the child, very rarely
oHers ronmde fable mechanical obstrnction U) *!elivery* and
more frequently a dight jjroJongation of the second stage of
lahtrr resultik Very long cords, of even six or eight feet in
length (such have been oliserved), may lie practically short
fnmi ct)iling. From stretching of a short or coiled conl dur-
ing Ia!>or there may result, though very mrely, inversion of
the uterus, premature sejianition of the jilacentii and hemor-
rhatre, rupture of the funis or interference with its circnlation,
and death of the infant. The strongest cords rupture under
a tension of 15 jMumds ; the weaker ones bear only about 5
{>oumls ; the average strength about 8 }x>umk.
I
SYMPTOMS.
576
Symptoms* — Before extrusioo of the child's head, ibe diag-
mmisy of a shortened funis i^ not always ea^y. Thy following
symptonia iiiiiy J>e i>ru»ent : A ]K^;nlriir pain or sorerifg*; ttdt
durin^T^ oterine coutraction, usmilly high n{> at the gn|>[>ose<l
plarcnlal isite, whkb is di\^^rilHHl liy iiiultiparaMis l>el[i|.nlitft^r-
ent from the sutTeriiig produced Uy ordinary hilior |»atns»
I>ater on there is partial arrust of labor pains, t^pecially of
bearing-down etlbrt^ ; and retardation in deHcent of prejaetiting
part, with elastic ret rati ion of it, between the jnung, to a
greater decree than vnn be accounted for by resifitiiijce of
maternal mil |>art^. Blw>d may be dischargeil liefore birth»
owing to partial scpanitiuo of placenta, and when there are
no co<existing bicerationH of cervix, etc, to explain it. D^-
prei^iou of placentid site, during pains, felt through ab-
dominal wall ( ?), An ynn«yally persistent desire on the part
of the wi^man to sit up, not occiisione<i by ftUne^s of bladder
or recttitn. A linger pai*sed high up into the vagina or
rectun) may feel an existing coiL
Treatment. — None iijs requireti in the large majority of cases
other tliaii relea.se of a coil round the neck alter the head is
boru» Tlie coil it^ h.>oaened by drawing it down to form a
loop, whieb is then passed over the occiput Harmlesss or at
lea>st remediable coil* of this fort t^ccnr once in alxmt every
five labon^. When ihe cord is too short to admit of releiise in
thii^ way, cut it after two b*gation.«, and ileliver at once, to
prote<*t the cbihi from hemorrhage an<l suffocation.
When labor is unduly retarded! from a short eord i^efareihe
head is born, let the woman assume a sitting or kneeling
posture ujmn the bed, and lean l^jrward iluring the pains*
The whole womh is thus pn?ihe<l dowr> and tensjrni uf tbe
cord relax ed» while the head, if its rotation hav** not previ-
ously taken place* will rotate, and sti \w prevented from re-
tracting betw€*en the pain8, thus? atfbrding the succeeding
uterine contnictiom* a better chance of completing delivery.
Bhould forceiii? be used in such easei?, owing to symptoms of
teiliouH labor, care must be taken not to invert the womb, A
cord that is i^ery short may re<juire tlivii^ion, in utem^ before
tbe head can be safely extracted. 8uch ca.se« are extrtmiely
rare. Knot a in the cord do not im|iede delivery^ but may
interrupt the circulation and thus destroy life of ftBtus when
tight ly <lrawii.
CHAPTER XXXTI.
ANJESTHETICS: CHLORuFORM, ETIIP:R,CHL0RAL, ERGOT,
Ql'lMNK
ANiV*<5TrrETics are used in ohMetrics to lessen suflTering pro-
du(v*d by labor pains; to le^seti the paiii attend in t^ ul^stetnc
ojjerations ; to relax the liter Ui^ when itjs rig-id contraction
ititerferes with versioti ; to promote dilatalitm of the t.ys uteri *
to re^luce excessive nervous excitement which may interfere
with progrei^s of" early stage of labor ; to relieve eelnmptic
cotivulBioui^ and iBauia ', to relax ihe abdominal wall and
lei?sen paio, while the uterus i^ being pushed down ; in cases
of abortion wheu the iiuger is lieing introduced to remove
retained secundioe*» ; in craniotomy to forestall unpleasant
recol lectio US* ; in vnses of uterine inversion to relax the nai-
fltricting cervix and m facilitate replacement ; in bijxilar
version to lessen pain of introducing the hand into vagina ;
io prmf)itate lalior to BusjM'n^l action of voluntary muscles
and retard deliver}'; to disi*ijMkte ** phantom tumors** while
makiug a differentift! diagnosis of pregmincy ; in all cutting
operations up<jo the aljdomen ; and -sometimes in sewnng up a
lacerated fieritieum when many sutures are refjuireii In this
last instance, and in all eaf?es\vhen an ana^thetic is tined afft*T
fhlivery, the greale.^t care is tiece^ary, for the retii^ons: (1 )
That the patient has usually lost some bhKid — -perhaiis a good
deal ; and (2) the reduction of abiiominul preisure after <le-
livery allows blootl to flow from the l^rain toward the abdo-
men, hence a liability to cerebral anaemia and syncope. AniE!i8»
thetics* after delivery should lie avnidt-ci if }x>ssible.
The pmctice of giving amesthetic^ in all ranes of lalion to
lessen pain, has been warmly advocated in certain cjuarters,
but is not» on the whole, advimble.
fornplete amesthe^sia irom chlomform or ether undoubt-
edly lemens the force of utenne contractioih *^od thus retards
676
CHLOROFORM.
lalior, as well as [>re<li>^|K>Hing to [w)st-|iartuiii liemorrha^'^f,
Hy«lrate of chlural, uii tlit* contrary, may liegiv^^ti id suffi-
cit^rit quantity ta pnxi^ure relief fri>ni sutfi?niig withtiut materi-
ally interfering with nterine roiitrartiuiu
Tfie ("huiee between etliur \\n\\ dilorotVirni- — I lie two anics-
tliHies ^^eoerally \i^v<\ — i^ unnL^ttlriJ ; some |>ret'er one, s<»nie
i\m other. Ether is imf|UtsTiiinul«ly safer; ami wliile the ad-
VoeatcHi of elilorform eUiini thiil hut very few deulljs are on
rentt'd from iln n.^^e when adniiiiisiereil with unremitting care
and hy the hands of an edueiited ami ex|)ertetieal phy8ieian»
yet them.* conditioni* euniiot always beeoni^iantly assure*!. All
men are human ; the irn rem it ting care will ^met lines remit;
nveraighta an<l diverted attention happen to alh luiil in iih-
*+tetric praetiee, with it;* inevitable fatigue, loss of ifteep, ami
anxiety* are more likely in ha[»pen ihun in other field* of pro*
fe&^ional work. Henee, as a matter of s:ifety, I prefer ether.
In ea^ses of aeiite amemia following prot'uf«e hemorrhage, all
agree that ehlorofonn i>§ autre dtinget'ous than ether. Ether
(24ul[>hiirie ether) may he siifely given dnrir»g the second j^lago
of ordinary labor at the lieginning of each jiain, and during
it^ eon I in nance ; and Mhottid be so given to les*si*n suflering
when the agony is severe and the patient parti<*iihirly H<*n»i-
tive; but eom[ih'te antesitht^sia anci in>*ensilnlity are not advi?*-
able, from fear of post-[uirturn hemorrhage, againj^t the ix-eur-
renee of whieh a double vigilance is always ne<»essury when
anie?»thetif*8 have been ui*ed. Kther is not m liahh? to retard
labor from lessening the foreeof nterine e^aitraeiiou ili* cldoro-
form. but it is not entirely free fnmi this liatiilily. It is i>lv
jeetionable flaring the early stage of bilior» and h dislinetly
m/irra-in<heated when there is kidney illseiiiit*. Ether 18 iti-
flamtinible, and henee care isre<]uired in using it at night* and
ehlorofonn in proximity lo the /itjht i»f a lani|», eandle, or gas
jet, will deeompisr into hydriK-hlorie aeid mul ehh^rine^ thiti*
|iri»dneing a vtipor thiit may irritate the air [»aKH;ige^ and lead
to pueinnouia.
CMoroform. — Chloroform, when ifiven to lesj^en the agonv
i»f labor [)ains, as it ftflen is in Euro|H\ I hough miieh lei^j* frtv
queutly in the Ignited States, u Ui^ually administere<l when
lalH>r h pretty well advamxii — wdien the tie uteri 18 well dilated,
the head ileseending, atid the |>ains are propidsive. A few
dro|>g jire phice<l mnm a handkerehief, and held near, not
37
578
A^^.ESTnETICS,
ckkse to the mouth, at the l>en;miimg of a pain, the inhnhttion
\}emg WMitiuyeil till I he jwun imt^ses it.s arrue, when it is at
oiiee sto{ij>e(L Pure n\r s^hcjulcl \k^ hrt^atheil cluriiitj the inier-
vals, ('om/j/^'^tiuseiibiihiJity is not tlet^irtid [ the woman should
rental n siiffieiently eciti^M-iouH to converse. I) n ring the atrftf
stiige of labor ell loroform j^houhl eertainly not he ^ueri mertily
to leHsJ^n pain. A mixture ot'oiie-thinl alwolute alecjhol with
two-thirdt* chloroform is less ohjeetionalyle than ehloroforni
ah me. All the uses to which chloroform may Ix? applie*J in
(jl>»itetric« may l)e attained hy ether, with t)ie exception that
clilorofi>rm is better than ether when there is renal comjilicii-
tion.
While it isj^enenilly admitted tiait chloroform is dangerous
in ca8ei^ of fatty hcjirt and iu cardiiic valvular lesions^, it has
nevertheless been given iu thoee caaes without aoy apparent
had efle<'ts.
During obstetrical oj^rations rw|uiring ana^thetics, anaes-
thesia should be complete; if* it be only |wirtiah the |>atient is
liable tu toss about withont any controU
Iu delivering' with ti>rf"e|)s, under una^thc^itu extra care is
necessary to avoid pinching the s<»ft. tissui'S »^f uterus and
vagina iu the grasp of the hiades, since the patient beiug
iusensible, ran not indicate by her cum phi in ts the tKX'urrenee
of so eh a mii^hap.
S^trong i'oni factions of the uterus» rendering rrrxioH ex-
trt*mely difficult and dangerous — or i>erha|*s imjM)ssihle— are
at once relaxed hy nmiplete nmesthesia. The chihl having
been turned, it shifodd iint he extnicted until the vvond* fia«,
at least in part, resiinu*d its contractile ctlorL^ so as to lessen
the danger of hem<>rrhagc.
Wlien ehlornfbrm is given fi>r puerfieral eclrtrajit^ia it shmild
lie rjdniinistered jnst before the beginning nf each relumiug
paroxysm in timt* to prevent the seizure,
CMoral (Hydrate of Chloral i. — Under itii influence the
woman mny s?leep during labor without any great suffering,
being only anmsed hy the recurrence of pains» the agony of
which is not then acute. It is especially valuable, as already
indicated, when the os uteri is thin, rigid, ami dilTieult to
dilate; in fact, during the early stage of lalK:»r, when ether
and chloroform iire inadmissible. Chloral does not dimin-
ish uterine contraction. It, iudeed, lessens the frcquenctf
4
ERGOT.
579
of the [*ains, but nt the sftme time renders them stronger
aud worr effimenty calms nervous exciteiuenti nnd promotes
tlilatutiou of tht* us*. Hfteeu gninis niay In* given in n little
>viiter ur syrup of iiniuge-peel every twenty minuter, until
two^ thn/e, «»r (|>i»s8ihly) four fli»{H:\s are takt-n, aeiortling to tlie
decree of 8<uniiolenee produce^l. More thaiii a <1niohiii during
the wliolu labor is seldom required. Serious and even fatal
synifvtoms have resuUed from ttHi large tlose^.
It ia distinctly coM^rti-iiulicated in organic ciirdiac legions,
aod it8 safety is very questionable even in functional disease
of tlie heart.
In ]>uer|^WL'nil eelamp^tia chloral is a roofit valuable remedy,
IxJth during ^nd tsfler labor. Large dos(*s of twenty or thirty
gruins may 1k^ taken ; or twiee tins quantity may be given
at onee by enema, and re()eated in a few hours if the spasms
recur.
As a sfee|>-|iroducer in puerjieral mania eliloral is better
than opium, iiyosiryamust or any other narcotic. It may be
e«mdMne<] to advantage with bromide of |yjtas»ium (xv-^xxx
gniins of earh ).
Bromide of EthyL — Bromide of ethyl has been employed
exjierimenlally as an amesthetie in midwifery. Its utility
has not yet lieen sutticiently deniun^tmted to warrant its rec-
ommendation. It requires thesanu' precautions as chloroform
ill its adoiiiiistration, and shares the dangei-s of this hitler
drug.
Cocame. — Spinal amcsthesia with cwaine has not yet been
dcmonstrale^l to i>e advisable it* olmtetric practice, but the
hyi>odermic injection of the drug into the cervix uteri apjienrs
more promising.
Ergot ( Secaie Gomutump Ergot of Eye, Spurred Eyei. —
Though by no means allied in its action with an:r-<thetiei*, ergot
may be here considered as one of the obstetrician's s|iecial
iiieiiiraments. Its efre<'t on the uterus is exactly opj»ogite to
that of ether and chloroform, with Hhicli» indeed, it is 8<»me-
times administered as a sort of antidote to their relaxing effect
upon the uterine mus<des.
When given in ordinary full doses { xx~xxx grains of the
powder, or xx-xxx minims of the fluid extract, or ^j of the
tincture or w ine) ergot jiroductis, in the c<mrse of ten or fifteen
luiQUtes, strong coutractious of the uterus, which, when the
580
AS.ESTHETIC&
drii^' u ref>eate«i bo &$ to obtain it^ full effect, become per-
9y<Uut an<l rxtnlinuoufi as well im^ jMucerjuL ThL« tonir and
unremittitig^ prr>^lMenjce of the cuntractions coii-^titutt^ one of
the chief draw hacks and daoirers of ergot If the child t»e
Htill unlw^rri, ci>iitiiiuous pre»^iire upon the tnird, oli^truLtioo
to the uten>-placenuil circulalioiu and consequent injury or
death of the fietuj* may result unless speedy delivery take
place. Injury to the uterine wall fn>m continuous pre^ure
or actual rupture of it may result wheu there exists any
mechanical resistance U) delivery. Hence the following
cutitra-indicatiunf* to tlie une of ergot may lie positively af-
tirnic^l : Pelvic dcff>rniity ; nialpro|jortio[i lK?tween the sixe of
the child and j)elvis ; transverse and otlier nia.l presentations
or p^Hitions of the fietus ; utidllated ut< uteri ; res*i.sting, rij^id
perineuria When powerful con tract if m-s are produced by ergot,
m nuiy hapjien from it8 injudicious^ adiniuisiration by nurses
and others and the lalxjr is not rajH^llj completed, forcepe
Mh<mhl he npplieil to relieve the child from dan^rer, a proi*ed*
nre all the more imperatively needed if unscultatiou reveal
irreirnlanty or feebleness of the fietal heart, Uti the whole,
it is a safe rule to alistain from trivin;^ erfroi at all Ixdbre the
chihl »K liorn, except in retention of tltt^ ntlern'oming head in
bree<'h prest^n tat ions, as already explaineil. Its admini^m-
tiorj in certain ca^^eK of placenta pra'via is generally reconi-
memled, as well as in accidental henicirrhage from seporation
of a nfjrmally placed placenta ; but if the child is to l»e saved
delivery must l>e exf>edited l»y every p»>^ible or practicable
means. Ergot was formerly used to irKbn^e prnnahire hhor,
btit hai? now been abandoned for bettir and le^ss dangerous
methods.
The chief use of ergot in midwifery is to ^cure persistent
uterine contractiorii afler lalnir. It thus prevents hemorrhage
and lessens tetnlency to after-pains.
Quinine (Quinia Sulphate). — Thimgh not yet generally
useii in lalior nisei* to reinforce feeble nterine contraction, it
hjL-* proved c>f sufficient efficacy in this resjiect to warrant the
hope that it may f jrm a safe substitute for ergot during (he
first ami second stages of lalior. Dose, x-xv grains everj'
three hiHirs. It^ etficiK*y in relieving aflter-pain^ has lieen
previously meutiontwL
CHAPTER XXXIII.
PUPIRPERAL ECLAMF'HIA DURING LAB^iR,
Puerperal eclam|»eaia, aasociate<l with pj^einaiurr delivery,
due to unemiii* from alljuminurifi aud rt'oal congestion or
inflammation during' preirnHm'v% have l»een already di^'Uds?e<l
in Sii fur as their etiolotry, .syniptonLs atid proplnj/artir treat-
ment are etinLvriied. ^ Their oftMetriv ireatnienl dtX'^ iiul *i(f*
fer niaterinlly from that of e<diinipia occurring during ial^or
at ternj, here t<» lie eonsidereih
Puerperal eonvnisioni< dnriiii.' lahor, beside arising from
unemia, may l>e due to other torms of hUMKl-|xnsoning, viz-i
eholscmia (retention of bile i ; im|)erfecl elimination of car-
Iconic acid by the lungs ; meflieinal poistms» as lead, narcotics
etc. ; ^jitic piui^ons^ aa thtiefc of ty[»hui* and other tevers, Tlie
op[xiHite cttiirlitions of congestion anrl aiuernia of tlie lirain
may produce e€laniy»«ia ; as may also *renerahyueniia, plethora,
hydrjemifi, and leukiemia, Convulsions otlen preciMle death
from hemorrhage during labor They may arisie from violent
emotional disturbance, or from rellex irritation due to indi-
gestilde food, fecail accumulationH, a ili.*teritied hlad*]er, etc.
The welhknown increased excitaliility fsoH-alled "convul-
sibility '') of the nervous system in pregnani and fmrturient
women predis| wises t<» eclampsia fnmi slight causes,
Ssrmptoms and Clinical History. — Previous otvMirrence of
<h^"ided renal symptoms, general dro[%sy, etc., during prt*gnaiicy,
es|H'ciaily signs of ini fiend iug uriemia.
Preceditig the acinal fM'currencc tjf n spasm there are irri-
t^ibility of temper, slight or severe hea<hi(d»e^ dizzifjejie, spits
before the eyes^ im|yairnjent cjr loss of sight, tinnitus aurinnh
halUicinations, tlcafncss, inlelleelual disturbance, unusual de.^i re
to sleep, with perhnps stertorous lirenthing, vomiting, etc
Sonje or all of these nuiy be pres<*nl.
The actual convulsion may resemble epilr^tsif or hjiiieria,
iSecChapk^r VIII, yi, 115.
681
PUERPERAL ECLAMPSIA prrJXa LABOFL
Text-lKioks give (hrrr varietifs ; opiloptic, liysterical, and
npcj[j|ectic. Hyi'ltrical attarkxS are ?!li|!;hter iu degree, not
acromjxinied l>y albuTuiuuria* aii<l foosciouHnefia is }tot ett-
tinttf loBl. Apoplrrtif ((ties are rare^ iiikJ are followetl hy
CO til pi etc €0111 a and luirfilysis, due to efiihsi«jD, or aefotof hlood
within the eraiiiimr, Tlie ttfpiea! puerperal oouviiL^ion is cpi-
if'ptic hi ehariK'ten It bej.nns with rolling' of the eyeball,
puekeriii^ of I he ri]**» dniv\in^^ of i\w lovvt-r jaw on one m]e,
bejidino: the heJid haek or toward one shoulder Then follow
twitching of tlie facial niustdes an<i of thoj?e »jf the extremi-
ties; protrusion of the tongue ; grinding ^jf the teeth ; violent
jerking of the arms ; in fact, elonic spa^m of the vohmtary
Diiiseles, aud mme of the i/ivoluurary ones', notaldy those of
respiration ; heue« bvidity of the lips atid face, disteiidc*<l
veins in the neek, and apparent inijieDdiug eyanosia. At tir&t,
however, the rejipiration in hurried and irregular hissing
throngb bhjody frolh In'tweeii the teeth, L rine and feee« are
Rimetimes involuntarily diHeharged. Duratitai of the eunvill-
siou from one to four ininyte^s. (*<im(ilete unt^^mseiousuess dur-
ing paroxysm, the patient having afterward no reeollectiun of
it. The fits nmy reeur at varyiiig intervals of mluuleii or
hours^ and in varying nuinl>er, iroiii two or three to twenty,
thirty, or more. They are aj>t to rei^ur with the reeurrenee
of a labor- pain. They sometimes eome oo (ifttr labor without
hiiving oecnirred before it. The uterus may partieipate iu the
spa.sm, and ex|>td the child rapidly, an unusual result, nnt
to he antieipated (tr waited tor.
Prognosis. — ^ Always j*erioiis ti* botli mother and ehild, iii-
er easing in gravity with the s€*verity of the symptoms and
existing impediments to speedy delivery. The eonvu Isions may
persist even lifter labor. Fortinnitely ihey do nut occur more
tliaii imce in f*uir or five hundred hd>ors.
Treatment of Convulsions during Labor. ^ — If jmssihle. ascer-
tain tlie cause. A history of uneniia atteutls ujost eases* tfie
treattnent for which ( purgatives, dia|dioreties, certain diuretics,
and nu'thods fd' reducing renal congestion ) has heeti already
eotisidered ((liapter \'JII. ). Should this treatment naf have
la^en [jrevirjusly employed, purgation may still hv of Iienefit
A droj) of erotim oil or a fi)nrili of a grain of ebiterin may
l>e placed on the Imek of the tongue if the woman be e<:)ma-
tose ; or if she can swallow, calomel and jalap nmy be given
TREATMKyr OF royvuLsioNs injniNa labor. 683
Hy the mouth, or a cnnrt'iit rated solution of E{i6om salt^ r^
peiitefi every 15 or *30 ririmitt\^.
The relid' of couvuImoiiH meun while chieHy clainKs our
atteiitioo- During tiie piroxysni, prevent the jwitient from
self-injury and place a piece of wood, or a s|x>on-hHiidlc
wriipi>ed iu tianuel, or a foldetl uapkio l>etween the teeth to
prevent the tongue from heiug- bitten.
During coma Jollowiiuj the c^mvulHiini, the tongue sometimes
falls hackwani, cloMing I he glottis iitid threatening i<uftbeatioti.
I'ull it forwnnl with a tenaculum or volj*eUa forceps, Wht-n
the fit is over the remedies are^ iu decidedly pUihuric wumeri,
bleeding from the arm. It re<hit'e.s cerebral <M)uge*4tion and
vascndar fulness — ciHjditious indicated by a strong, fuH» lK>und-
iDg pulse and lividily of the fiuse — and may prevent a fata!
ap>plexy.
After bleeding, or when it is not advisable, inject lar(jfe doeed
of morphia (| grain) hy|KulermuticalIy, and repeat a>4 often iw
the wnvulsions recur ; as mocb as 3 or 4 grain.^ may be given
in 24 hours.
In place of the mo rphift» chloral hydrate in large d^jee-s — 30
grairm — every three hoivr?*. may Ive given, or twice thi8f|uantity
by the rei'tum, if the pit lent cannot iSiwallow.
AuiEsthesia >vith rhforoform may \>e reeorted to on the ap-
pr<jach of returning jKiroxysma.
The tin id extract of veratrum viride in large doses flO-
20 minims), given hijpodeniuctdhj^ \\vla lieen 8uece«^fnl in con-
trolling thp ainvuissions : the sf^ML'^ms cease to recur when the
pulse h reiiuced to HO per minute. One large i\i)m (i\a aliove)
ia first given. This or a smaller dof»e may be re|x»ated in
thirty minutes, if retpiireiL When the pulse-rate hart In^en
reduced to 00, i^nudler doses of 5 minima may Ih* <H>ntiuned
at Itmger intervals, to keep it so. The veratrum viride and
morphia may be given UMjHhe^r hypMlermalically, often with
excellent results*. In various ho8pitjil?*convnlsion.H have bt^en
treated ex peri ?nenta I ly on nior|>hia nlone, on chloral tdtttte, and
on chlorof(>rm aloti^. The liest results were obtained trom the
morphia treat meat. The next lie^t wai* chloral
Ab a geneml rule* it is advisable Ut ikdiviT by force[i8 as
stK)n as dilatation of the <«* uteri will |)ermit ; but this* is not
by any meaiii^ always reipdred. Should ihe eonvnlMioui* have
been eufficienily cuntrolltHi by other rernefltes, labor may gv ou
5S4 PI' ER FERAL ECLAMPSIA IIURIXG LARfm.
iiud be K't't iM (Hnuplete iLself, any violpiit eflnrtJ^ with fnrrepB
ht^iiii^ liiihli; tu (imvukt? a reju'tiliuu ui tlieerlamptic jMroxy^m.
If the c^JDViilsicjiis coiitiuue iti spite of trejitnietit, delivery
offcrn the ottfjf port of Mifefy, Then, if the os he not sufficiently
(lihited fur for(»e|>s U\ be applietl, it may be dihited or he
inrised by one or other i>f the several methmls usually rcBortjed
to iu the c^o-ealled acrou(*hemeftt J<trci\ aow to be <ie^*ribed*
Fio. 39L
RAIiitt manufll cUlntiiticMi of m mu\ t^vrvix uteri by the TlArHs method.
AiTOHcftemtof ForrA- — ^liajiid or f<>reed delivery may be
aceoitiplisbed liy nieeliauii'al dtlatutiou of the its an<1 cervix,
either l>y the iiii^ert* **r liy ?*teel dibtton^, tir by the hydrostatic
bags of de Rilven i^r V*HirheeH.
The best nietho*l of iiiatuml drlatatiou is tbtit of Hnrria.
(See Fig, 291). First the index finger is iotroiluiXMl, and
TREATMENT OF CONVULSIONS DUmNG LABOR. 585
(hen withdriiwu fur eiiou^li to iitlmit thu tip of the thiiiuh (as
at 1 in the tigiiru K Ni'Xt push the tip of the h tiger toward
the root of the thunil*, and the tip of ilie thy tub toward the
root of the liiiger ( 2) j then ttro tiiif;er» are introduced with
the tbumbi and their ti[*?i dis|x)sed in a similar manner {l^ and
4), the same with the remainiug fingers (5 to 10), as shown
in the illustration.
Bintnimal ditaUtlnn of the parturient n.%. (Fpf»m Jkwktt, after Edoai;
Ethjarit iMethoiL — The o» uteri if? iirsi <iilateil willi s^teel
dilators UTitil large enough tf> adndl llie index fingers of WA
hands, as ^hown in Fig. 21*2, The nther tiugerg nre sneee*t<ively
introduced until dilatation becomes sufficiently complete and
686 PUERPERAL ECLAMPSIA DURING LABOR.
the cervix is eflTaceil, In Fig. 293 the os is almiit two-thirds
dilated,
Fi^. 294 (piige587) ghowsa photograph of the operation
as |>c'rformed at tfie ETnt^r;Lreti(y lldHpittil, New York.
Aui»lher tiiHhod is udt'ollowj*: TbejijUient h aiut\sthetisted,
phireil erosMwii^e on tlit^ eil^'e of iht* IhhI, her bladder emptied,
imd the purls made ajsL'pticaily cleaiu Theeutire haud is uuw
Fro. 29a
v% '
Binmnnnl dllntntfon of ihi* ruifturient os. (Prom Jewktt, after CiNfAft.) ]
IMii^Beil into the vagina, mid the first joint of the index finger
passed into the oh uteri. ^ During this and all snbstM|iu*nt
parts of the |>roreeding connter-pressiire must be imide iipni
tlie fundus uteri liy the otlter hand, or by the baud of HQ
assistant, to hold tlie uterus in plaee against the pre.^urc of
the diluting lingers. One finger iKiving !hh n hiN>ked over the
rim of (he OS, steady pressure is matle diwnwnrd until a second
finger can Ik' made to enter; tlfe two lieing held side hy aide
so as to occupy as much space as possible. Next, one of the
' Tf the ri* tM'tofifimiilHn nclTuft nin* fiiitriT end, «.'* mny h«t1'*'t» i'l pretnaturu
lubun imd Ja iinmffMirir, iL mA>' Anit be atietcbetj with siteul dUatora.
I
i
TREATMENT OF COHVULSIOXS DUEING LABOR. 587
two fiogers is partly witlnlrawD (all but its tip), thus niiikiiip
room for the tip of the third- The three are t lieu py^heii lu ;
aod 44i> ihe fi>itrth, aud hiuilly the thiiiuk Then by expand-
ing the ^ve digits errciiiiifereutially, the wide!=t part of the
haud (over the knuckle«; pas^^es iu aud the os encircles the
Flo,294.
BlmAtiiinl dilatation of ttie parinrient os, (Jkwktt, alter Kooak.)
wri^L These are the ste|>s, and thus easily we read (hem;
hut the operation Ls often drftieult autl tefhous» ?onletinJeJ^ re-
(pjiriuiT Mil lioiir or more for completiou, Mort»over, it must
espt^eially be emphasized that in luaking pressure ajrainst the
eircular muscle^s of the resjistiug 0(s» the force used must l>e
1
^r
^^^m rrjsRPERAL eclampsia Buniso la boh. 1
intrrmiftnit, in this v>i^e : A certniii amount of force luiving
iR'L'ii itseii until tlie rin^ of tbe os is fell to offer <lij?tinct resist-
auce, tlie dilaling iiii^ren? are held quite atUi until the rmst- 1
auce is felt to rrlnx and dimppeur^ pliowin^ that tlie finders '
have exhausttMJ the resLstiuir niy.seuhir ring hy s^iniple fntigiie ;
then the tiui^a^rs pj in further until agjiiii resistance is
etieountered, and are so held until I/im resistance yields by
Fig. 295. 1
-
Bosiri dJlJitor closed. (From Davis.)
Fib. 296. J
i
1
^^^^^^^^^H r2^l|£fl
i
fnltgue» atifl m tm r<te|> by s^tep, until I he proeess be eotnplete.
In difticult antl (erlioUM ease?* the hantl rnay he<^oiiie rrani|ied
and ns«4iess and uiust he taken ont for re^t before the clihitiitioD
ean In* resumrd ; i»r it may lie omlinned l>y an n^^gistaot.
In all metlpMls of manual dilatation it must he remeiidH*n*d
that if only the ring of the €Jri*'nml oh is to heeidarged, it j
may he eah^ily dune f>erha|)6 within 10 or 15 minute^ hut if a 1
^ J
1
theatment of convulsions during labor. 589
eenficat canal k to lie efliKXMl, it is dittieult^ aod may recjuire
out* or two h»*yr^
lufitrtimt'ttfaf DHatalioit wifh Site! DihtoTS, — The nK>8t ai>-
proved ik-vice of tliis ^irt i^i Bossi'r? dilator (P'igs, t^S>''> and 'i06),
Frommer liiii^ iiUMlititHi Boi^i's dilator ; his iiisJtrmiieiit, aou-
gisting of eifjflit Idado^ instead of four» with an indicator
attached showing the degrw to wbieh dilatation has [irogre^ed.
And there are several others. Their mode of action is ap
parent ; they are introiluced closed, and Uy a sctcw device in
the handle are slowly opened, s<j as to gradually stretch and
dilute the cervix.
The methods of using the hydrostatic bags of Barnes, Voor-
hees, and ('hampetier de RibtiS have already been descriljed
(pp. 484 mid 485).
[fichlouof the Cervix. — The multiple incisions of Diihrssen
(usually four), one io the naedian line in front, one hehiud*
and two lateral, extend iofj from the external os to the utero-
vaginal junction* are (nade as follows: The cervix i» held by
two pairs of vol sella force [>h, one on each side of the site of
iijci.Hiou, by an assistiint, then the o|M>rator passes the letl index
finger into the cervix and the middle finger between the
cervix and vaginal wall. Along (he^se fingers the blunt-
t)ointed scissorn (held in the right hand) are |ms8ed in, and
the cervix is cut by one or two elij>s of the instrument. More
than four incisions are sometimes necessary. After delivery
the incisions are sutured. An a^septlc technique is imperative.
Instead of several small incisions, one long one (>:»metime8
two) may be made in the median line and extend through the
lower uterine segment, almost to flmt never into) the peri-
toneum, and t he child delivered rayndly hy foree|38 or version ;
BOH *a lied ''vaginal Ctrmrmn fteciiou*^ (q. r., page 420),
Still again, delivery by the ordinary ufxhmhiul Camretin
sect Ion constitutes another method of aeeoitfhfinent Jore^,
Returning now to the treatment of etd am |>siu when the t*on-
vulsions continue in spite of medicinal remHliefi, and the un-
dilated os and cervix will not admit delivery by force|*s or
version, the olistetrician must cUride a.s to what method of
forced delivery will he best, rememhering that speedy delivery
in mme way is the only hfi[K-fid resort Much of course will
dejnnjd on the cajiacity of the attendant — his surgical skiJl^ —
and u|>on hospital facilities, assistiints, instruments, etc.
590 PUERPERAL ECLAMPSIA UURING LABOR,
The methods of digital dilatation will be beit when the at
only require?* dihxtution. When there is a cervical canal to
dilate, a steel dilator iiiny tirst l>€ used, ami when sutHcieDt
space is obtained, u Voorhees or de Rllws Img put tn, for fur-
ther expansion of the cervix. Forcejis, or perhaps %*er$ion for
delivery when the •' passage** is eufMeiently oi)eu to admit the
•' paissenger/'
The next lea^t harmful, and most generally available
methwl will be the multiple incisions of Diihrssen ; or in place
of any or all of these, the circumstances may he suitable to
justify a skillful and opjwrtiine Cttsiirean section, either vagi-
nal or ahdoniiual ; liut tlie^<e last will rarely !>e admii*ible.
It is souietinieH advitiitageous to rupture the membranes
early, even before dilatation of the oi<, |he (lains ai^erward be-
coming more etHcient and the tendency to convulsions
diminished^ owiug perhai>8 to consequent reduction in the size
and weight of the uterus and in its pressure ojK»n bhxxivesaela.
This of course siiould never he done iu cases in which a
version h auticifiated.
The hot wet pack and vajwr bath can be used to advan-
tage even duriuL' Inlior, and without interfering with its prog-
ress, retained urinary excreta being thus eliminated with the
profuse perspiration that ensues, or an entire hot bath may be
employed, as recommended in Chapter VII L (page 164),
Elimination of toxins, Imth before and after delivery, niay be
further santred by (he subcutaneous injection of normal salt
solution, one or two quarts in 24 hours* ; or an enema of the
same solution high U]> in the rectum or colon. Pilocarpine
should not be given ; it produces tpdema of the bings.
When the child is born it is well not to ha^ften the third ?ta^e
of lul>or. A moderate loss of blood is beneficial, and withiE
proper limits should be enccni raged. In fact, when cimvulsions
continue after delivery and the patient has not Irjet much btood,
venesection should be done without hesitation, the proper
repletion of the vascular system being renewed by the saline
injections.
In all cases absolute quiet in a dnrk room is desirable; no
noisy talking or walking, no slamming of doors or windows.
Mechanical jarring of the bed will sometiicnes evoke a
[laroxytm.
CHAPTER XXXIV.
PUERPERAL SEPTICEMIA.
PrERPERAL septitwniia (ohhr f^ynonyms : childbed fever;
iyintf^ifi fever; puerperal fever ; etc. ; modern synonyms:
pnerpt nil Hvp.nf^ ; puerperal infection, *^tc. } is a fever begin-
ning^' within a week ailer lahur— usuully i'mm tlie third lu tlje
liftli day, inclui^ive ; iittended with acute infitimmafion of the
reprtwlyrtive organs (one tir more) an<! with aeptic infection
of the blood and ^'•eneral system. The local acute inflamma-
tions are simply hx^al infections of the inflamed parts— their
invasion by [mlhf>^enic micrtjbei*. The blood infiH'tiou ig
prmiuced either iw the sjime piithoireni<* microlH:*^ invading' the
blood and raQlti|^ilyini: in I he rirculalion, or the bhwid Is
[M>i8oned by absorption of ptomaines prod need Ijy tlie colonies
of niicr<x>r^anisms existing in the inflamed orf;:ana These
two phenomena, viz. : (1) Local infeetioDs, and (2) tn/stemic
or ffcnerul infections (90-called ** blood j)oisoning** j, muat
be constantly borrie in mind, Jo somejCiises the lacal phe-
nomena predominate ; in others the ffeneral processes are the
more pronounced ; usually both are present in varying de-
grees.
Itecaiise the condition ia attended with the symptoms of
fever, and occurs during the puerperal p* nod, it was called
*^ jtucrperul fever, ^^ Later, when it was found that the chief
cause of death was septic p(w>n in the bloiNi, it became known
UB ** pnfnrperal aepticctmia,** Neither term is sufticiently exact
or comprehensive to include all the ol>served phenomena.
And the terui ** neptic infection*' used by recent writers
simply represent'* t he /iroc/'^x by which thcol}serve<l phenomena
are prcKhieed, or hrought to begin ; really the cnu^e of the
trouble. But the want of a suitable mime is of secondary
imix>rtancc, if the catij^i\ prevention, and cure of the patholog-
ical changes are suflieicntly known. This knowledge has been
591
692
PUERPERAL SEPTICEMIA.
greatly extende*! by recent research^ i^o that today c^erlain
well-esuiblij+hetl tViris linve !)eeii dejiionstrated, m% which u gys-
teni of prophylaxis iiml chit fans heeii ilrvised, greatly rediic-
iiijx the freqiU'iify aud mortal ily of th«.^ dist^a^e. The^^e facts
will iKJW he presented in as easily intelligible u manner as may
compiirt with the brevity of this work.
There are two sets of phenonrcniu to study, viz. : FlmU the
genetfil infectmns leiKling- to systemic ]>insonin)y; ; scmoml^ the
iornl infections leudinir to hH^iilizcd iiittaniniatious.
The g^ntnif infections comprise three j)roce:^seii, viz.,
sop ram m , >iep t ictrnt i<u pjfftm /a.
The fofut/ infections comprise vulvitis, vaf^initis, endometritis,
metritis, sidjiiniritis, ovaritis, jmrametritis, and peritonitis; that
is to say, intbimmadtm of the reproductive organs and their
aduexa, the i^eritoiieum arid cellular tissue. Other orgaus,
distant tVoni the repruilyclive structures, w a j/ become involved
secondarily by the floating' otT and lodgement of infected
thrombi, as will be ex|dainwl farther oil
Ketnrnin<r to the three iUvnuMyf general infretiony we find:
1. Sripraviia, caused i*v the absorption of toxins from the
uterus or va^i^imi, iiroduce*! by the ]>ut refaction of blood*
clots, renuiants of placenta, niemliranes, etc.» left in the uterine
cavity. The putrefaction of these lifeh^ss remnants e<iuld
tiever take place in the tatenis (any more than orjranic mat-
tei"s would putrefy in the external world) without miembes;
and the microbes eoneerned in these eases are the scMudled
saprophytic Infetrrin, The derom|x)sition they pnxluce leads
to a foul-sn^ellin^, frothy dis(*hartre from the nlerus, contaiii-
intr bubbles of otfcnsive ^jas, much res4^mhlin£,' tmlinary putrt*-
faction as known elsewhere. ('onse(|uent UjHm this process,
toxins (ptomaines) are ev<4ved whirvh, beiu}^ al>s«>rbed into
the bloodi |Hnson the patient either mildly or fatally. aceor<l*
iug to the cpuintities absorl>ed^s<nnetimes called ** putrid in-
toxication.'* The condition is easily amenable to treatment
by t'arfij removal of putrescent matters and antiseptic cleans-
ing of uterus. The putrefactive p^nns themselves do )wt
really invade the tlviufi tissues of the uterus, nor ilt» they
enter the blood, but remain in the nidus of lifeless miiterials
in the uterine cavity ; hence this tbrm i»f infection is not gen-
rr«% attended with ioc^al inflatnmation of any serious dejrree,
and iis therefore easy of cure and seldom fatal, thus contrast-
py.^MTA .
593
ing in a marko<l maimer nith the two other forms of general
iulectiou mnv to Ire t-otisiiKTed.
2, Srpticiemia* — Thin iti a geueral iiife<*tioii jiroduee^l Uy the
absorption of toxitia from liviiii^ tiis8Ufi* timt have litH-ome iu-
vadeti Uy putho^eoic niicrohe?. thutj prmlu^iug iuttanimation,
gij I t[ni ration, and necrusin nf the organs affec-tt*d. This gen-
eral se[ai('ienjir infoction niay he eoineitknitly accentunted by
tht' rnicrobris fhimxtitr.'i getting intt» tlie hkxjiL nuiltiplying
rajiidly, and generating rmne toxins themn. In thc^e case**
the iiitecting nnrrrjhes arc% most i'rLH[Uvi\th\»(ref)t4)co€ci ; some-
times the colon baciH*t,-*oT the Mtajthyhicorru^ ; oecai^ionally, the
Kle!ts-l^ieifler had tins of diphtheria^ (»r the iyphuid hnciUun.
Mihl infections otH-nr from the yonocof^us. Rarely still other
fomis of microl)ej^ are t lie infeeting agents. Tiie ebief offender,
however, is the etreptcMHM'eus. The mierobes (of whatever
kiml ) invade the Jiving tin^^nes of the vulva, vagina, ami
uterus u|Km their mueons suriaees and f^enetrate fle<^[>er
til rough tlie lyni|>hatio eliannels, thn.s iiegiuning in the lining
membrane of the uteru?4 (prcuhn^ing endometritis ; {lenetrate
to the mnt*cuhir walls (thus metritis) ; then through to the
peri uterine connective tishue (parametritis) ; an<l finally reiieh
the peritouenm with a resulting |»entouitiB. Of course such
a eonirnencing entlometritis easily extends by continuity to the
Fallo|>ian tuln-s and ovnries, hence salpingitis and ovaritis.
Thus *weur all these forms r>f acutf; infhimmiition, and frtJin
one and all toxijn^ nrrW whieh, being abstirbcd, lead to the
svpttCiTmie form of general inffffinn we are imw ennsidering.
8inee in passing from without inward, the microbes go by
way of the hjmfihntks, this form of se|iticiemia is sometimes
deJ^ignaltMl **/ijmpha{ic »eptie(nniaJ^
*\ I)/*(nufh — Here we have a general infection of an en-
tirely cliffereiit tirigiu*
The infecting microbes may be the same, but they produce
a f/enentl infection by a dittercnt nu^'iiarjism.
The streptiXNX'ci first deveh^ji ami ninltiply in the thromhi
of the placental sUr : really, tlierefore^ already irt^iiir the
rfwoiw chiuuifh in whieli the throml>i have been tbrmed.
Thus oc4'urs rnilammatiou of the veins rpldelutis) usually
first of the nirrine 'veins thcmsielves^ but later other veins,
those of the pelvis and sometimes of the lo>yer limbs l>eeome
infiamed, in this last case leading to crural phlebitis aud phlcfj-
594
PUERPERAL SEPTICMMIA.
masia uUtti doletis. Worse Mill, the iuf'ected thromhij wherever
aituuted, tire liable to breuk up and Hout awiiy hi small fmg-
nieiit« to dis^taot organs \vliere» lieeomin^ arrested in ve8.^lstoo
Brtuill tu allow their pa.sm^'-e, they »et up new fix'i of iiifeelion
aD(l L'oiiHe<|uerit iotlaniiiiationj going nn to the format ion of pus
and so-ealled nietxieitiitic ah?K*et*^e^, j>erbaph in the lnng.s» liver,
gpleen, nod joint**, bul no organ is surely exempt from the Im-
bility tothej^ poj^ lormaiion^i i'nmi the Imlgement of fragments
of mteeled ihrondji. Thus from a primitive local infection
of thrombi in the uterys nnse» the getteral iufeetiou known as
These three varieties of general infection {sapnrmia^ septi-
ciemi*!^ and pyaitiiit )^ two or all may of course coexist in the
same patient.
Next to r/fw era/ infect ioni* we mujit siwly the usually coin-
ctilent loeal infections by whieh nctdr local iufiamutation of
the organs is proilured.
Thus, beginning with the vtdva and nKjina, we find vulrtttB
and raf^ijiiiis, in which thei^e organs premie nt the ut^ual redue.ss,
hcnt, tenderness, and swelling, with mucous or mueo-purulent
discharge common to inflfimmation? of mucous surfaces.
Ulcers niiiy ocfur, frequently begimiing on tetirs marie during
hdM>r Tliese ulrvratcil surfiice^ may jjresent a diphtheritic
apjtearanee, l>eing covered by a p«^udodiphtheriti</ membrane.
Fsoally this lesion rtJ^emhlts true diphtheriji without l>eiug
rfftllij so, but iM*casionally the Klebs-Locrtier bacillus may lie
dcmonstrnted, thus shiiwing a true diphtheritic infeelioii.
Kmhimelrith and Metritis — The cavity" of the uterus is the
most frwp lent seat of puerperal infection and intlanumitioD ;
and as these usually begin on the surface of the mucous lining
of the organ, f^/j«^^/ometritis is the most common form of pner*
fiend inllammatiiui. Fnun tlie mucous n^emhraue infe<"ti<m
II nd in Ham mat ion may extend to the muscnbir walh imiducing
tnfirft(>^. In puerpeml tnffomt'frittM the infecting mierol>es
peiietrate into, breed in, feed on. imd thus destri>y the mucous
Uinrig, which thus breaks up into a necrotic mas8 of ulcerated
and sloughing tlehrh, which, when dis<*harged per mginoni^
may be foul in odor if the inflammation was prmlucetl hv in-
fecrion with colon bacilli or wnth saprophytic baeteria, Imt which
may have little or no inlor if the agents of infection were
strepttxjocci ur staphylococci.
PARAMETRITIS,
595
In osseB in which tlie "miectinii: microbes and consequent in-
fl4aramnti(m exteinl thnmgh the liriinj^' metnhnioe U> the iiiusru*
hir vvtill, meJritin f!Jlu\vi^ in vvhit*h hir||er iiiul deeper ^lonLfhin^
proces.<es take phtee, con.-iiderahle luii^st^ii of nee^use^J muscular
tissue hein*( sometimes thrown niYi ti^i-oalled dis.iefiing metntU);
or infected throndn lotigiijtr ]u the nterine blot>dves«eIj3 hnnl
to pus collections nn<i local <!e?ft ruction of tissue with necrovsis.
As if de:?«i^nedly to prevent thin deej>er jjeiietration of
micro J)es from the mucous meinlmitie into tlie nmi«eular waU,
Nature rnterpo^Heja between the su|jerficial infet*ted and rleep»T
«»itifected tissues a zone of resisting leucocytes — t^ocalled
**i^ranuiar layer*' of small -c^ 11 intilimtnm, through which the
nntTu< ir<ranisms as a rule cannot pjiAs In Bonie C4i.sea they
nevertheless tret throu^^h and inftvt the muscular coat This
}n\ii been ascribed lo tlie extreme viralfure of the microbes (a
term ditheult to detine ), hut is probably just as explictilde by
their la^reater uumberH when first introduced, or by the cf»nstiUi-
ents of the pabulum in which they grow, leatling to their ex-
treme 1 y rap id m ult i plica t ion.
The difference* in the degree of tissue-oecrcwis largely de-
pends u \ion t h e ^' 1 n r / of i n foi 1 i ng o rgitn i snis^ In saprien \ x v cases
due to siiprop!iytic bacilli the intiamniatory lesions are usually
slight; in streptoem*eie infection they are more prononnce+l,
and in mixed infections still more disastrous. GonoetK'cic
intection. while not decitledly destructive, leads to chronic
trouhles, whieh i»ften bring the {mtieiit after recovery into the
hands of the pynieeohrj^ical surgeon.
Salpingitis and OvarifiA. — Here the infwtinfj microbes usu-
ally extendi tlireetly from the uterus into the Fallopian tuU'S
and ovaries liy simple contimiity , mort^ rarely they reach
these orjjans by way of the lymphatic vessels.
Then folhiw the usual |>henumena of inrtammatioii in the
tubes and ovaries, often p)ing on ti> abscess of the ovary autl
to collections of pus in the inflamal an<i obstructed tuhes>.
Here there is always danger thnt the ovarian abseessand pua-
distended tul>e nuiy bnnit* discharging their contained pua
into the [>eritoneal cavity, with <tjnsequent f>eritonitis,
ParametntiK — This is int1sHuniati«m of the connective tumte
surrounding the outside of tlu' uU-rus l»elween the ntust*ular
wall ami the |H*ntoneum, snmefimes called reUuliti^ cellular
and connetaive tissue l>eing identical Infection having
PUERPERAL SEPTICEMIA,
wMmTted ID the uterioe cavity or in laceratioos upon the
cervix uteri, tlie aiicn»l>etji riiuke their way by the lymphatic
vessels through the uiueous and uiu^cular coats to the peri-
uteriue cuunective tissue beotnith the [jeritoueum. ludamiiui-
tory exudations take phire wliirh may disappear by rt^^olulioQ
or go OM to the formaliim *jf puis and iihs*'esi?e^ beneath the
l>erituoeum covering the uterus ; or the infeetioti may i*pread
in many directioo.s tol lowing the various hiyers of connective
tissue that accumpaDV the jK'ritoneum fobls throughout the
abdomen and pelvis, with correMfjouditig pus formations which
may discharge external iy in the vicinity of I *ou partes ligament,
or internaily into tlie bhvdden vagina^ or re*Munu or unlortu-
nately, into the cavity of the jM^^ritoneiim.
Periio}iitU. — InHiimmation of the |)eritoneum resijlt.s usually
from hifecting microlies having made their way from the
interior of the uterus through all the uterine coat^ into the
peritoneum* usually through lymphatic ehanneU. Sometimes
the peritoneum liecomes infected froiti the bur&tiug of abscesses
of the ovary, tubes, and peri-uterine connective ti.^sue^ the
inftrting jms rapidly devebipiuEf a fatal septic jjeritotutis.
These canes are usually due to ttrcpffjeorclc infection, and the
(K'rilonitic compli(^ati<m is the worst and most mortal of all
puerjierul iutlfiminations.
To recapitulate, we now understand timt tlie process of
septic infection in puerperal women Icjuls to two sets of phe-
nomena, viz.: (1) Bystemic septic [xusoniug, either sapnemie,
seplicicmic, or pya'mic' atui (2) local inflammatitjns, suppura-
tion, and necnmis of the re|inMlyetive organs iunl ^if their
adnexa* ppntonemn, and eellular or connective tis.sye.
Etiology and Prophylaxis. — These two are almtist ueces-
sarily iiiHe[>arabIe, ami may l»cst l^e considered together.
Why is it that one woainn, or a u umber of women, have no
iinpleai^ant symjitoms after delivery and make a good ** getting
up,'* while another suffers and perha|)« dies frooi one or
more of the various troubles we have just described?
The answer is : The woman who e^cafied unpleasant symp-
toms did so simply because no pathogenic micndies gained
a*''-ess to her vulva, vagina, or uterus ; or at h^ast in insuffi-
cieut number to ppMhice recogTiizable unpleasant eHU^ts^
This being the rauHf\ {hv prophtflaxig is self-^^viilent, viz.»
juotectioa of the woman from microlies by aseptic and anti-
ETIOLOGY AND PnOPHYLAXlS.
59T
Btptlc management during pr«?gaaiicy, labor, and the puerperal
period.
The recent history of olistetrics throughout the world dera-
oii^tnitt'8 beyond a tloybt that by theeurefyl employment of a
ri^id useptic teclmit[ue piH^qieml fever can lie preveute<L
This^ bius Ijeeii e.s[>eL'inlly evident in maternity hospitals where
tlie diseane, formerly fre<|uetit and fatub ha;? U'eu almost
nbolished ; and the i*ame could \ye said of private practice* if
the rigid aseptic tecbnii|ue were curried out with the 8arue cure
aud fidelity as it is in well-regulated lying-iu establisiimenta,
Kvery labor ca.-^' should be amsidercd as a surgical ease —
a ease of woumls — for there are always r ran matic lemons, no
mutter how minute, njxai the jierineum, vulva, or cervix uteri,
«nd always a birger traunuLt it- surface from wiiich the placerita
was sej)anited. Jt is the jnirpose of aseptic midwifery to
protect the*se wounded surfaces from contact with microlfcs,
wbieh is to be acconifilifihed by eteriliziug the han*l8, instru-
ments, fabrics^, and appliances brought in contact with the
p«itieut. a^ previously descri be*] under l^ilwrr (Chapter XIL).
This is the pith ancl substance of cause and prevention. In
aildition it may be sai<i tliat there is a |xjssibility that the
woman may luive been infected — as by coition or self-exami-
nution, etc. — lR4bre lal>or tK^gan. Not only prei'xisting gouor-
rhceal infection can be thus understcMid, but also streptoixxt'ic,
diphtheritic, staphyl<>coccic, and other iufectirms. Pathogenic
microlie,^ oAen exist on the external genitals in mmierate num-
bers in i:|uite healthy individuals before hik)r, without any
symptomatic evidence of their presejice. But when wounds
are ad^U'd (a^<luring lalior), and when !'urther, the pnxH^sses
of involution of the reproductive organs ( as after labor ) furnish
a lowly viialhefl pithtilifm in which microbes may grow atal
rapidly multiply, the small nundier of jifitbi»genic organ ismg
thjit were hurmless on the outside, now gel inside r/<( tfie
wounds, and multiply in iunnl>era that are no longer harnde^
and latent, hut sutHciently numerous to develop all the phe-
nomena of septic in fell ion.
It should l»e ntjted that the dideuse may be conveyed from
an infected woman to a healthy one. Patients with erysipeltis,
di[ditheria, carbuncle, nod su|»pnrating wounds are known to
produce the pjithogenic germs that in lying-io women leatl to
puerperal fever. Hence no i>b8tetrician or nun*e should go
598
PUERPERAL SEPTIC JSMIA.
frtJiii these eases to attend a labor oise. Physicians have
theiuaelvt^ bwti kiiowy to infect women, liy lia%'iQj^ at the
time of their attendance, in their own hiHlie:^, a miico-pnrylent
ef>ryza, a suppurative atlenitis, and the remain,^ ofu disseeting
wound. Phy,'^iciiin8 who disseet or make nuti>pjsie«i are liable
to earry infection, at least from septic bodies, to their puerperal
patienti?.
The air is sometimes the ajurce of infection. It may \ye
contamitiated with mit^robes frotu other puerpeml fever pa-
tienLs ; atrept(K!occi have been found in Hoatirig air diii*!. Air
may ije rendered] infertive by f^ewer ^as, by Iniri^ted wa^te-
pipes. by the ** contiguity of church-yards, dungdiills, privies*
stabler*, shiu^hter-hou!*es, oes8|K:iols,"* and many other places
where the decum|x>sition of organic matter is going ou. A
dead animal, even a rat or a mouse in the wainscot, may
cause a dwelling to swarm with infecting germs.
Symptoms and Diagnosis. ^In every ca^the constitutional
8ym|itoms in« heating >(tj4^mie infection begin with malaise,
chillines"^, or a ilistinct chill, tljllowed by rise of tenijierature
and the ctimmon jdunitHncna of Jeret\ viz., headache, thirntp
anorexia, hot f<kin, furred tongue, frei|uent puLsi^ and the
like. The degree to which these j^yuiptonis are exhibite<i
vary in the three kinds of systemic m feet ion.
In mpnFmia they are mi hi in degree, with no serious
fretjueucy of pulse or elevation of tem|)crature. In nearly
every ejise there is an abundant foul-smelling, frotliy vagiual
discharge.
In Heptirxemic cases the chill is more decided, coming on
early, about the third or ioiirtb djiv, and the temjic-ratnre
higher, 10;r, 104^, or lOr^^ I^, and" remmns elevated, with
C4>rres'>onding frequency of pulse, and general depre^ion. In
pure septiciemic — pure strepti^coccic^ — infection, even in the
worst cases, there may be little or no foid odor to the dis-
charge, thus contrasting decidedly with the milder .^nprrennc
cas€^.
In pifitmk infection the constitutional symptoms again vary ;
they come on later than the third or fourth day, and prej*ent
the chai'acteristics of hectic fvtrr, that is, alternating chills,
fever, and sweat, with remissions. The tenijHTature is not
eotitmH<*w*/y elevatcfl, as in septiciemic ca.ses.
In mixed infections these constitutional symptoms will not.
SYMPTOMS ANJy MAONOSIS,
599
of tHHirse, present ihe typifiil cliaraeteristit*a uf eitber uf I he
three st'pnrate hifertious rnetitiuoeii
The ahsulutf dia^uixsis of the kind uf microbea present can
only be poi<itiidii demonstrated hy n had or it* logical exaiuina-
tion, as staleil fitrlhtr (on pa<fes 001 and VA)2).
SifrnpttjniJ^aitd Dititptositi of the Sei'erni Loral Injiammatton^,
— VuivtiU and Fttynn'/M.— The vulva and vajj:iim present
diffuse retliiess uud -^wening with heat, tenderness, and some
ptun when urine pussies over the hitlamed j^ur faces. Ulcers
may ap|)ear suj^>erficially ; or in very severe causes deeper
ulceration and sIouLdiin^ may occur. The ulcers may or may
nut present a <liphtheritic apj^earance, which may or may not
l>e really diphtheritic iufection. There is a mucous or muco-
puruieut discbar^'e,
KudomelrdiA. — The yterua its hirger, softer, and more tender
on prejssure than it should he. The lixfiial dis^-^hllr4fe may \m
increased or *iiniiruj^hed, and in case^^ with very high lem])ern-
ture 8lop entirely. In sapnvmic (putrid i eai^i^s it will have a
foul odor and frothy consistency^ a« already exphiined ; in
sc^pticiemic (septic ) casei? there may be no odor and no gas-
liulihles. In severe cases shreds of necrotic memhnme and
decidual drhri% with blood and pus, come away in the hx'hia
a nd i n 1 J Mirt t o i t a d i rty o r y el 1 o wis h -*: ri^e n a p| wx\ ra n ce. U 1 cer-
atioius or hiceration>i visible on the cervix may present, as in
the vatrina, a diphtheritic character,
Mrfritiji. — Xo well-marked h>cal symproms indicate exten-
sion of inflammation from iheemlometrinm to theniu?euhirwall
of the nterus. The same symptoms exist as in endometritis^
l>ut the case does not progress so readily to a favomble
termination, and i^ more likely to go on to inflammation of
other strnctnrei*, leading to parametritis or peritonitis,
Stiljiinffifi,'^ and Otardis. — Pain and hn-nlized ti-ndemess on
pressure over the intlamed ovary and lube- On bnnanual
examination the va^'inal finger may cletect, on uue or other
side, a dixiinci circuinseribed wwiw — the swollen and tender
ovary or tul)e,
Paramdrifis ( Pe/vic Crlluliti^). — Here the l(K*al j^ympUmis
are usually late in appearing; and resendde those of eudome-
tritis which may have partially disapjveared, when renewed
ebilliuess and fever again recur with increase of jxdvic [Miin
on one or both sides of the uterus.
600
PUERPERAL SEPTICMMIA,
The diagnt^is is made I>y digital examinatiou, revealiDf? a
iinii, hard niaiia (of iiiHammatory exiHlatc- ) on one or all
part^ of tlie vaginal rctof, surnrundin^'^ the rervix uteri, and
rendu ring the uterus more or Jes^s itMni(»vablL'. The niai*?^ is
tender (HI pressure. It may he ak^orbed or gu uii to su[>j»urar-
tioti ami iil>w'e?y, when the finger will re<.'4>gnize softening and
Hurt nation iti the rrtasnes of iutlnmniatory exudate.
Penimiitu, — The hjeal syinjitonis vury very niych according
as the intianiniation atfect^ only the fokU of peritoneum in the
jjelviceavity (ptlvif pcritonltU), or extends to the [leritoneiim
lining theahdoininal cavity iuhdomuinl or tjrtwrti/ pt^rttonith).
The i^yatptoins of peivif peritonitis nrv much the same as
thoi^e of p^ vie eclluliti.'^ (jnst deH'rihcd ). Then? are the
sanic liM^al tenderness and jnun, low down in tlieal>donien; the
same areas of inclnration, guing on lu the same termination of
suppuration and atiMees^s with aliout tlie !=»ame final results.
The two inflammations often coexist The treatment of both
is sitnilar.
Aluhminai FaitonUu. — ^ThiB is the much dreaded general
peritonitis r puerperal peritonitis) hy which the livc^ of so
many women are lui^t. The symjitoitts Ixgin hy the iintial
chill ancl fever being severe, venj severe, with continued high
tem[ierature (1 04'"- 100^ F.J. Then ftdhnv ioteiiscpiiin over
the entire abdomen, with extreme tenderness on pressure ;
even the weight of the bedclothes or slight vibrations frnin
jarring the bed may be painful- Hespiration8areac*'elerated
(25 to 50 j>er minute )i short, and chiefly thoracic, owing to
pain produced hy movements of the diaphragm. Tym|MUiitic
distention of the intestine makes the abch>men tense ami en-
larged. The pulse is very frecfuent, and soon gels weak nntl
thread-like. The woman lies on her hack with the knees
drawn uj*. Persistent Vf»miting and scnnetimes diurrhaui
ocenn and later on nervous sympt<»m3» delirium, together
with a coated, dry, and red or brown tongue, and all the signs
tif extreme exhaustion.
Phlebiiis. — The ItK'al symptoms of inflammation of the
veins? from sej^^is due to infected thrombi will depeu<l upon
the hK'ation of the affe<*ted ve>*sels. Wlu'ii the veins of the
pelvis and lower extremities (usually one, sometimes Ijoth)
are infected and intlsimcd, the leg swells, beromes ftKlemntoua
with tenderness and enlurgemeut of the femoral or other
pHLEJurrs.
601
veins, aa detfcrilwd in the cba[»U'r on Milk Leg (**Periphenil
Vmous Tlir(jmho4?b/' Ohn[itt^r XXXV. ).
Ill other ra8t',s the /o//i/x ( wrists ollitiwis ankles, etc) liecorae
iniliuiied, as in<lit*ated ]yy n^dnef^s tendi^rtie.ss, heat, jwtin, nud
swellins't tincl HtM)n tluetiuitioii oct-ur.s t'ruui Ibnuatioo of pus
in the iifieiled jt)inti4.
Infected thrond>i lodghig iti the lung lead to broncho-
pneumonia, a not uuiLsiial tertuination in futnl c:tbiea of pya?mic
infection. I^CK'nlized pn'm in the elujst may Iw due to area^
of j>leuriti« inflammation |>rmlue^d by Jodgement of throml>otic
fragtneuU*
Thu^ briefly^ have we de^sc'ribed the gentral symptoras pro-
diitH'd by Hy.*fimlv infect ion, and the heal «^ympttmj8 resultinj^
fntni the various iutlammatiorm.
With regard tn liiagnosis, it still rcniiiins to lie ^t\\d that
fever — rise of lemj>erature — may (xrur after lalH>r frurn oihrr
cau8e.<i, a3 from menial emotion or exf'itcmrni, whieb» however,
is easily rei^oguized by the previous hisUiry of events by which
it was produced, and by its l>eiog only ianparanj — jmi<«injj
away in a few hour?.
Again, trouhleH alioutthe bremU may cause fever* Exami-
nation by |>alpation and in8[ieetion will here render a diagnosis
easy.
It if? commonly lielieved that lying-in women wIkj have Ik'CU
supposed to have u sort of /ntmt mafaria beflire lalxtr exhibit
symptoms of malarial fever (chill, ri»e of temperature, etc.)
after lalM>r is over. This is pure hy|>othesis. Such eases* are
genera/fij fyrdhmry puerperal infection. In malarial regiouH,
however, true ague mfuf otxnir. Diagruisis in donhtfiil e«j?<.'is
can be nnule only by bloiwl examination revealing the pre^ionee
or absence of the malarial |MirH!^it4'.
iSf>, again, lingering case^i nf mciderate puerperal infection
are sometimes c<pnfontided with» or mistaken for h/phoif! fever.
Diagnosis ean be matle only by demonstrating the Widal re^
action by bloo<l examination.
8ometimt*« a rine of temperature occurs from ac<»umubititm
of Uixic matters in the bow^els, the result of ci>nstipati<>n.
Diagnosis is demonstrated by the immediate relief afforded by
purgatives.
In any anil all cnse^ of doubtful puerperal infection a
positive diagnosis eau always he made, not only of the iufeo-
60*2
PUERPERAL SEPTICEMIA,
iitm itself but also of the kind of mk'rnhea (whether simply
^i[^rojihylic badt^ria, streptociM_*t'i, or S!ta|ih\iiH-ocd, etr^)* by
mitkiii^^ a bat^te n o big icjil fximjiiiiitioii of the bwhiiil discbarge
and clenvuiistrutiag the pre.HeiK*e nr ab?*eiR»e of jjathogenic
riiicrobt^ and tbeir kind. To jLscTrUiiii jKisitively whether the
interior of the u^rr/M be infected^ it is iie<*essary tJ> obtniii a
!-|Mieiiiieii (llrecfhj from the ulerhit^ cavity. Toaeeoniplish ibisi
DiMlerlt^iji htm coimtrotted a device by which a small glaf^si
HLcrile tube, attached to a small syringe, is pa-s-fi^'d into the
uterus (the cervix having betn previously drawn down to the
vulva with a voLselluiu fort!e[*s and slerilizt^d ) without touch-
in ^r the vulva or vairina. Suction by the piston of the syringe
drawn a little of the uterine contoiiti? into the gla^^s tube, which
i.s then lakeji out, detached from the syringe, closed at Inith
ends whh ^iea!inl;-wax. ]>laced in a sterile test* tube (dn.sed by a
fotlou plug, and t-aken to the labonitory. The lube is now
broken near the middle and iie eontent^s used for cultures and
tnicro^*0[iic examination.
Fig, 2Jt7 (page (503) tihovvs the small sterilo tulfre contained
in an ordinary (but sterile) tf'^st-tu lie, with cotton at lx)th ends,
for con^'enience of portage. In Fig, 21^H ihe tul>e is attached
to the syringe ready for use, F:g. 299 yhowi? the lube with
uterine rontent.s sealed at the ends, aud later, broken in the
middle, an described.
Prognosis. — This depends upai the kind and degree of
infection and ujjon the site, extent, and number of loeal inflam-
mations.
In some cases the systemic fMiiisoning liy alx^rtied toxins is
Fxi rajiid and virulent that death may ix'cur within Iwenty-four
or frtrty-«*ight hours, before time ha^* been allowed fbr any
local le&sions to ileveh>[i. Such cases are now very unronmion,
but were not unusual in former tinier?, daring endemicj*, when
women died as fjuickly as from pbigue <>r cholera,
**IMcmia/' with its attendant metastatic abscesses, ia ex-
tremely fatal. **Sapnenua " — putnd ioferlion from ptomaines,
due to de€om]>osing aniteriaLs in the uterus^is sometimes at
once relieved ami proceeds to immediate recnivery after the
putrescent matters are removed from the utern.s. Comliina-
lioris Iff **seiitica'mia/' ** [lyicmia/' and '*s4ipra^mia/* of course,
increase I he danger. The degree of danger from bhxKi-
infection iu individual cases may perha|)8 bej^t )kj indicuted
BODEntEiN's srmyGE and tubk 603
FlO. 29T. Fio. 296. Pio. 290.
\
or
IKklerl&ln'B lyringo tnd lube*
G04
PUERPERAL SEPTICEMIA.
by the pronounced frequency and Jeeblatem of pulse and the
uanjrrence of deiirhun, dupor, coma, or other ncn'ous symp-
tonu.
Of Until inflammations, the most rapidly fatal is general
pej'itonitis, Pt^iina jferittmitia is less imme<l lately datigeroua
lo life ; reeovery is the rule, hut exception ally jms may fitid
its way into the general cavity of the pri tone urn and lead to
fatal abdominal peritonitis, Celluhtis has about the Hanie
risks as peh^ic peritonitis. Ovaritis and salpingitis usually
end in reeovery or at least partial reeovery (for sueh eases
commonly become chronic ones, reijuiring removal of the dis-
eased organs hiter on)» l>ut exceptiutuilly pus from a dise^ise*!
tube may find its way inio the |x^ritoneiim and ^et up general
piTitonitis. Tlie degree of danger ni mflnttA varie.^ with the
extent of ti.^ue involved — the prognosis must l>e always doubt*
fuL In ibphtheritie cases, in those accompanied with uterine
phlt-hitis and consequent lialnlity to embolic complications
and pyaemia, the danger h great. The disease is liable to
extend from uterus to peritoneum. Vulvitis and vaginitis,
when existing alone, with proper treat mi'iit usually end in
rec<»very. There is, however, always danger of other organs
becoming involved, which increases danger In diphtheritic
ca'^es the prognosis is more grave.
EvenjmHe at' \meriwTiil infection ami inflammation must W
regardcil with apprehrtmon. ILnvever mild in the beginning,
no one can safely say how it will end.
Taking together all kinds of cases, mild and severe^ the
mortality with modeni treatment is only about 4 fier wnt.
Treatment, — The preventive treatment e<msisJ»ts in a rigid
observance of ase|>lie precautions in all labor leases, and
e8|>ecially in eases requiring of>erative procee<lings. The lying-
iu rm>m, the air, the clothing and utensils, all inytruments
and appliances, the phys^icians and nurses, must be uueontani*
inated with germs, or rendered thoroughly aseptic by the
met boils already described under ^* aseptic midwifery " (Chap-
ter XIL, page*2:3fr).
The earative treatment will differ very materially in the
dilferent local inflaminaiions and their progressive stage-S, but
iu the great maj*irity of cases there are principles and methods
of management that ap|:ily to nearly every ease, whatever may
be the site, extent, or degree of local inflammation, or what-
TREA TMENT.
605
ever the kind and degree of blfMid-piigoiiing. Two tliingH at
Ifitst are *)f the uluioHt value/ aiul in their eurative intluenoe
prohahir tar tmtueigh tluit of all other remedies combjuetl,
The^ two tiiiiJgs are : First» ihorotujh UHtptic and a)itifteptic
dmnfeclioiL of the partitrient canal, from vulva to Fallopian
tube.^ : and setxmd, fjeucrni sujtport of the patient bij food and
iftimnlaidji. This staleinejit by no means detracts iroiu the
imdovilited utility of siirh remedies aii may lie addressed to the
reduction of temperature, the nlief of paiu, tlie eeucuation of
piu^ or the ablation of diseased ortjarui by snrgieal proeedures
and other measures; imt loeaf ant isepms and tjtneral itudetiaiice
apply to more eases ami m the long run aeeoraplish more
giMMJ than can be credited to any o(jm hi nation of other eirra-
tive agent,'*. Anfifieptic diifhifeftion ib aeeomplisbed chii^fly hf
irrigating the vulva, vagina, and uieru^ witU antiseptic ffnitis^
hy removal of septic masses of debris* from the uterine cavity
hy tfie iLseptie tinger or curette and hy the introduetion into
the utcrui4 of antisseptic gauze, for the double purpoi*e of di»-
infeetiori and drainage.
With the results of recent exf>enence in large hf^pitals,
where many more cases are available for clinical ex|>t^rimeiit
than in the private pnietice of individual «dtslelncjans, it haa
been pretty well dtMuniist rated that a toi> stn nntiusly aetive
method of treuhnent, sueh as has prevailed during the last
one nr twf> (h'cades, is both unnecessary and barmfuh Es|kv
eially is this true with regard to tlie use of the curette. The
finger is the best iuslrument for intrauterine use, both for ile-
teeting the presence of »eptie masses and for their remomL
When no such masses ciin !a' tiiseovered, the uterine cavity
should not he scrajK^d either with the fiuger or curette; ft
rough or even gentle ue*eof the latter iniHtrument leaves freshly
Wf»tmded suHaces tli rough whieli more germs may enter, and
disturbs the proteelive layer of leucix*ytes. In napr<rmie
cases, however, with decom|>osing clots, membranes, or pla-
cental dthrtJi, the removal of these by the fiuger is imperative^
and the curette may sometimt^ be required lo separate ad-
herent massi*H.
So the routine practice of intrauterine douches of a ?i/w;>^t*c
fliiiils has tveen of late much tjuestioned. douche* of sterile
water or of sail solution, it is clitirae<l, are all-fiuifieient and
prelerable.
PUERPERAL SEPTICEML'U
Again some, [x^rhnps a gooiJ iiiiniber of mmhrate septic id-
fertioii cases get well without auy Iixral treatrueuL But Dobudy
knows how soon a nioderatt^ eus*^, without treatment, may bt>-
come a severe one.
Therefore, notwitht^tunding diflVrenees of opinion which at
present cannot he settled, there seems to be no good reiyH»n
wliy either the douehe, hnj^^er, or enrette should lie abandoned*
In Hni table eases e^ieh will Hnd a pri>iier use. It ig their
indiscriminate and ronline nse, without j>roj»er regard to
eirennistaiicf.s wliich modern uhatetrir:^ is striving" to correct.
In irrigating the parturient canal the vnlni and iHigtria
f^hould be first washed out. before the antis4^ptic solution is
[ia.«^etl into the uternn, for the reason? that the vulva and
vagina may be infected while the uterus is /rer from in feet ion ;
hence by puii.**ing the nozzle of a syringe through an itifeeted
vagina intcj the uteroH we shcujhl carry infection to the latter
organ from the vagina. The K)lntii>nH eonimonly used are
the 2 jier cent. creoHn sohition, tlie 2 pvr cent, carbolic acid
8oUitkio» and the 1 to 'A(H)i\ bichloride of mercury solution.
Beveral pints of either solution should be prepared and iulro-
duced from either a fountain syringe or a Davidson's syringe,
the nozzle being ( preferably > a bent glass tul>e, with several
o[)enings on its siiies, \mi none on the end, appendtnl to the
ruhlier tiling A bed-pan, or j^referably a caout<fione Kelly
jmd, receives the retnrning tluid, or a simple rubber cloth may
Ik- arnmgefl under the woinnirs hi|*s when she is bn>ught to
the edge of t\w bed, liy whieh the ^nid is nmducted into a
vessel on tht* tli>or. Irrigating the vulva and vagina is harm-
less and easy, but it requires to l>e done //(oro«r; A /t^ by passing
the syringe to e%^ery part of the vaginal canaL Irrigating
the utentif carify requires much nn>re caution, and is not
altogether free from danger— certainly not in wj/skilfui hands,
Care must Ix' taken that no air \w fmssed into the uterus by
letting the fluid run through the tnl>e in a full stream so m
lo ex[>el any air it may contain before the nozzle is introduced
into the varolii b. Care must also be taken that there is ample
room for the fluiil to escape through the os alongside of the
tui>e, as fast as it goes in ; otherwise the fluid may lie forced
iiito the Fallopian tubes and [KTitoneal cavity, or the womb
will lie distende<l» |>nMlncing ** uterine colic.'* In septic cases
the OS and cervix uteri are commonly sufficiently o]x?n to
TREATMEST,
GOT
easily ndrnit the ^laas nozzle, and this last iwm l>e rearlily
giiirlecl l)etweeQ twrt tinkers of the let) hatid into the oa iirKl
pushed with the other hand up into the Ciivity of the uterus
witii">iit the iiid of u a|>eeuliim. The eurreot— easily retru 1ft t eel
hy comjjreHsing iht^ ruhber Uibo — shouhl tirst he s*hnv, wheu,
if it l>eseen to ri'tiirn frtx'ly, it miiy be aUovve*i to ruu ut full
strength while the clis^tnl eri<l ^A* the tuln? ii* tJirected j<ueee,ss-
ively to all regions of th%i utenue cavity. (The gliistj tuljei*
niacle for this purpose have a little protubeniMce on one i<ide
of their ei reunite reiitte near the end, to which the rubber tnl^»e
is firtaehe*], to iuiiieate the direction of the eurve at the distal
end of the tube when it is out of sight in the uterine cavity. )
During the irrigation^ if the current should eease to return
freely, the ghiss tube may be pushed gently from side to side
or (lid led forward toward the pube^s w> tis to stretch open the
OS u little or dislodge tVtiin it some jneee of clot or inenjhrane
by which the returning j^treiim is being obstructe<L Irriga-
tion of the womb should be done by the physician and not
intrusted to the nurse, unlf^As, indee<l^ she be known to have
Me(|uired the necessary knowledge and skill, Reeeotly it ha^*
been stated by Williams and others that irrigation of the
uterus with sterile T boiled} water or normal salt mdution ij<
as effeetive as hiehloride and carl>olie sol u lions, and ilo not
endanger pfjisoning of the patient by alisorption of these
drugs. In sapnntuc ai^e^ espet'ial!y» after putrest^ent autterials
have been renroved by the iioger or curette, it is claiuuNJ
simple cleansing with sterile water is all-sufficient. In support
of this view the ex[)erifnenl8 of Bumm are brought forwani,
in which he submerged infected pieeea of liver io bichloride
stdution for thirty minutes and found that the disinfe<'tion
scarcely extended lielow the surface. These piecet^ of liver,
however, were (ft'ttd tissue, while the uterus is livtnfi and
absorbs scjiiie of the antise[rtic solution into its lymphatic vessels
(just as septic toxiiis are absorbe<l) following in the (>ath of
the microbes. Were this not scj, general biehlondeor <'arbolie
poisoning could not take place, and it would not be nci^essary
— as we find it atVer irrigating the uterus and vagina — to
avoid leaving \y^H)U of the antiseptic solutions in tbeir cavities
to prevent this poisoning,
Ui*e of fhf Fiitgt^ror Vnrtiit\ — When the uterus is sus|KH!te<l
or known to contain tangible masses of putrescent or ncerotic
tJOR
P UERPERA L SEPTiaEMIA ,
mKterbd that ciinuot lie Urougbt out by irrigation, mivh as hits
of piiiceuta» iiienibnine^, tir auylhiag else, thes^ must be
tiem|>ed out by the finger or curette. The woman shoulii l)e
auiesthetizetl, place*! on her back, my} brought to the edge of
the be<L Tlie whole hand^ previously disinfecteti and hd>ri-
cated with carbulized vaseline or molliu, is pasiied into the
vagina aud one or two fiugers (nirely the eutire hand) loto
the tit trift e m i n ty, co u u ter-pr ess u re I )e i n g m a c 1 e o ve r t li e f u « d ua
hy tbe other bund u]nm the abduujeu, wheu the fingers and
fiuger-uaifs inside senij>e tiU* all adherent masse-s fi'oni llie
uterine wail and extnitl them. In case the uterui* will not
adriiit the tlngen< or hand, or when these for any reasiin are
ineftieient, th«> long, dull curette (a sort of artificial finger;
may lie introduced ami the uterine cavity carefully gcrat»ed
with caution to avoid rough nninijnilation and consequent
perforation of the ulerine wall ; and also luavoiij leaviug any
reres-s notably the angles of the uterui* near the ofieniuga of
the Fallopian tubes, iniscraptHL In using the curette, the
anterior lip of the cervix shouI/1 be seizefl anrl the uterus drawn
down to the vulva with temtculum or volsellum force|jj*, as in
gynaecological cai^es. Should any remnanti^ of adherent tissue
lie detected hy the finger, the curette nmy lie reintro<hice<l and
the mass scraped ofl^. After all offending materials have been
thu^ removed, the uterine cavity is irrigated with H>me anti-
se|itic ^solution (creolin or bichltjride ) and packer! lightly with
iodoform gauze, or instead of the gauze, a 8 n ppc^sltory ( so-
called bacilhm) of iodoform may be passed up with a pair of
long dressing fonM^|»?* and left in the cavity of the womb.
Tbe supjiositories are pre|iared as follows :
H. Iodoform
Gum arable
Glycerine
Starch Tpure)
Ft Buppos, Ko. iij.
5v fgn). XT);
aa 388 (gm. ij),— M.
Thei^e siuppoHitoriei* are about two inches long, Thev are
paired into the cervix with forceps aud then pushed up be-
yond the internal m with the finger.
In place of iodoform, Welister, of f 'bicago, uses a gnuze
tampon soaked in a solutiou of formalin (formalin, njjxxx;
TBEATMEST,
(i09
glycerine* ^iv ; sterile wfiten OjJ. which he considers i>refer-
al>le to antisej»tic <lourhi.\% uiid hIsmj a more peuetratiog gerrn-
iride. The ^^auze is left in the aterus twelve hours, then
withdrawu and a fresh piece ins€*rted aftt^r the use of a i*terile
douche, Wheu the va^na otily is iofeotetl a vaginal tampion
of fomialin is used in the same way.
This Mutiyeptic rleant^ing of the uterine cavity, if done
thorough Iy» nmy not rcr|yire to be repeated. In nmtiy iti-
staocew itj* salutary intlueiiee is ho well nrnrke<t that [►niu,
fever, and elevati^d teni[KTature are at once relieved. 8Iiouhi
these syinptoms continue or return, the uterine irrigation niay
be repeated and another supj)ository i>f iodoform introduced*
and so on for several days if neces.'iary. Antiseptic douching
of the vfighm should lie re|M.ated twice or thrice daily in all
caseft, or even more frequently. The temperature of the anti-
septic ft*}lution (whether used for uterns or vagitui ) should he
pleasantly warm (almut 100° F.J io nicjst cas+*s ; when, how'*
ever, there is bleeding from the uterus, the fluid should he
h^i (100° to Wy"^ F). Hot sidutions, unless necessary for
their • hieniostalic effect are inadvisable on account of the
snuirtin^ they prodiu-e.
General Sttppori of the Patiertt by Food and Siimttiants, — In
all cases of blood-|K)isoning there is, aj* we have said in de-
scribing stfmptomii, great general depreaswn^ iudicated chiefly
hy frefjHciicif and ftrblnie»8 of ^mlse — a feeble pnl^e means a
feeble heart The heart-action must be kept up teMijmrarily
and direvtly by eanliac stimulanlB (by whiskey, strychnia,
digitalis, sirophanthus, etc/)» |iermanently and indirectly by
nutritious and €*asily assimilable li*|ui<l fcKxl (by milk, licei-
te4i, Ifeef-ex tract, and other meat broths and animal juices ^
Of the alcoholic stimulants— whiskey, brandy, ett*. — it is
impossible to say how much will be re<|uired. In some casea
iist* I n i s h i II g q u a n t i ti es m ay be g i ve n w i 1 1 1 o n t i n t ox i ca t ion , One
or tw<* talile^pjonfnls may be taken cither with water or ndlk
or in the form of egg-nog. an<l re|ieated every three or four
hoiirs» to begin with, and the quantity and frequency of ad-
min ist nil ion increased or diminished according to the effect
produced and the requirements of the case. I^^Kjuacity and
undue exhilaration indicate that too much has been given,
lieturuing strength and redncetl frequency of pulse indicate,
without any signs of intoxication, the desired result of a
610
PUERPERAL SEPTICMMIA,
proper quantity. In place of, but preferably conjointly
with alcoholic stimulants, strychnia (gn .^^), or digitalis
(fltl. ext, gtL i-ij ). or tinct. strophaiitlmis (gtt. iij-v ) tuay be
taken every four hours. The sulphate of quiriia in five-grain
|iiik every four hour^ is also useful both as a uerve tonic
a Oil to reiluce temperature.
The biiuid (nwU — ^milk suid beef e.<?cnce, etc. — must be
given at frequent intervals, one or two hours, iu small
(tahlesi^oonful) dosed or more, as the j*tonuic*h will liear. Tfie
more the lietten If the patieol ha%*e no desire for these
things they must nevertheUsss be taken, and at regular inter-
vals, like medicines.
In addition io aiitit»eptic disinfection, food and stimulants,
a laxative, given early, when bcnvels are not sufficiently 0|>en,
is advisable. Calomel, gr. v-x, with rloublo the quantity of
stiilii bicark, or c;astor oil, may be given onee. Sluggishness
of the liowels having l>een relieve^l, the laxative must not be
repeated*
For the reduetton of t^mprratnret the he.st and miist agree-
able method is sponging thesurHice with water or »ome evapo-
ratiug lotion at a tenifierature pleasant to the patient, and
« I r i n k i u g co< > 1 wa ter free I y. T h e u se of ni ed i c i 1 1 a I a n t i py reties,
including (|uinine, has of latf been given up eutirely.
To relieve pain morphine may 1m? given. If it dt^press tlie
heart, j}^^ of a grain of atropine may be given with each
dose.
The treatraeut required for spi*cial eases — for the various
local inflammations — will now l>e considere<h
Treatm*Mit of Vtiliniin and VnginifiA.—The vulva and the
vagina, by the use of a 8j)efuluin, nuiy he ins|x*('te«l and
clean.sed almost ns. easily as lesions of the skin. Infected
perineal wounds require removal of sutures that they may 1k»
rciqiened and iils^j made aj5k?|»tically clean. In acldition to
irrigation by dourhe.-! already described (seepage (iOti }, ulcer-
sited surfaces u[)on the vulva, vaginal wall, or cervix uteri must
be tou<*he<l with a strong silver nitrate s*>lution (5JI0 water,
.^ )» or with pure carbolic acid or tincture of iodine. There
is no [positive evidence that one of these is better than the
others. Should the ulcenitions be diphtheritie, the same lo**!!!
applications may be used,
Treatnieut of Endonwtntis. — It i* with regard to iuHammar
TBEATMENT,
611
tioti of the mucous lining of the uterus that there is at pres-
ent s<> much ditfi rence of opiuioo as to the methtKl of lotral
trentruerjt utmI disifd\M*tiou.
Observe that the ledoutu are still iu a measure with hi our
rtach; that is to fiiiy, the eii%'ity of the uieru;* enu he ex-
plorer! and loeal remediei? direelly n|>ijlied. But note a;j;aiu,
that this is as far as we eau go ; we eaunot exphjre the Falh>
piau tube*! and <^varie4* id this way, nor yet the musf^uhir eoat
or j^K^ritoueal eoat of the uterus^ nor the cellular tissue be^
tweeo them, without a cutting operatiun of some t*ort.
It is importaiit to reniendx^r, with f-mpha^is, that endome-
tritis is one of the most eimimoii Icv^ioius of puerperal iufee-
fiun ; hetifv it.< local treatment Iuls ooramanded special atten*
tion and intereist.
The ilitfereiit methods of cleansing the uterine cavity by
sterile water or normal wilt solution, by antiseptic fluids, or
by the finder or curette, et^c,, have l>een previously fh^scribed.
But the f|Lie8tiao 212^ to wheti anil how they are to be used in
ditierent enneii remains unsettled,
No one dis[>utes that in sa|)nemk' castas — pnlrhi ertdome>-
tritis — the detxmi|>05iin|; matters in the uterus (whatever they
may be ) must be ri'moved either by the fiuj^er, curette, douche^
etc., as already descri hed.
But in endtmietritift due to infection with streptococci (as
demonstrated by a barteriological examinurion) agreement as
to trejitment 19 still far away.
perhaps in lio instjince is this disagreement more pninounced
than in the difference '*f opinion between two of our most dis-
tingyished Anierinio antboritie4* on obstetrics, whiiHe text-
iKioks, to<i, are much u^m] by students ; viz,. Hirst, of Phila-
deljihin, and Wil limns, of Balliinore.
Mirst atfirms that " Loc-ally» 11 thorough dipiufec'tion of the
whole genital canal is called for in every vn^ of puer|K'ral
infection, '' and adds that ** it should invariably precede all
other treatment*' 1 In using the curette he observes, "the
uterine walls are gone over thoroughly, bur litrhtly, in alliliree-
tions six to twelve times, until nothing is bnmL'hl away hut
hriL^ht blood ; " adding in a f(M>t-nrite that the uterine wall*
riniHt lie scraped lightly s<> as '*not to jMnietrate the layer of
granulation cells under the endometrium/' After curettage
1 Text-book on OUttJlrlta. EdlUou liKW, jip. Til and T£L
612
PUERPERAL SEPTICEMIA,
he tad vises irrigation of tlie iilenis with i^uhlimate Ritutiou,
ami if the uteros is large aD<l flabby* with a tendcocy to
tiexioii, a taiiJiM>ii of sterile gaoze wiiluu its cavity.
WUiimm MfdhmL — \^MietJ ut-eriin^ infect iou is sus|:>ecled, the
uteriue cavity is eX[dorwl with a sterilizt d index Hnger. " If
the uterioe aivity is perfectly stiiooth, a douche of several
litres of boiled water or normal salt solulion should be
giveti» but curettage should uot be thought of, Ou the other
haodi if it^ interior is rough and jagged, and coniains more
or less deifHs, it should lie thoroughly eleaned out with tlie
{inger, atTter which an ahuudant .sniioe douche should he em*
ployed. Curettage as a rnutiiio nieamjre iu all eiise^ of puer-
peral endometritis is by no means to l>e recommended/' ' Iu
maoy enscs he says there is nothing to reoiove, and the
uurette hre^iks down the protective granular leueocytic walk
When the uterus thvs exmtain firbrw its removal is more
readily effet-ted with the finger than hv the euretle {ib'td)^
Williams again discards antiseptic solutions (bichloride, ear-
holic acid, etc, ) and usi*a a douche of boiled water or sterile
salt sidutioii instead.
In recaijitulating the treatment of puer|ieral endometritis,
he says: "If the hartcriological examination shows the pres-
ence of strept*>C(xx'i, all local treatment should at once lie
omitted. If, on the other hand, one ha.^ ti> deal with a putrid
endometritis, and t!ie symptoms do not yield to the first injee*
tion, additional douches may be given. When the infectitm
has extended beyond the uterus, local treatment should
not he persisted m, as it will do more barm than gotxl "
(p. 788).
It seems almost inevitable that the gentler metho4i of Wil-
liami; will supplant the more strenuous surgical methods of
Hirst in general |>ractice, especially witli regard to the curette.
While curettage of the uterus is ijrofierly relegated to the d«>
tuain of '' nnnor surgery,'* there are many obstetricians of
snjnll surgical ex fierience who would hesitate to undertake even
so simple an o|>eration. The pjpulation of the world does not
atlbrd surtieient surgical work f(»r all to Ivcrome expert o|ier*
ators : these last must always remain in the minority. To the
unskilled majority it may be gratitying to know Umt Wil-
liatnfl' mortality in 52 cases of streptoeoccic endometritis w«»
« Tc'X^tMKik ou QbBt«trica, Edition ltK>l, p. 78S.
TREATMENT.
613
only 4 per certt^ there bemg hut 2 death?, and in then*? the
f<tri*f>h>L'oocic infection was a,8so<?iiiU'd with the colon bacillui^
nmliinjLij a more «liinfrerous comhiiieil inftMHion.
In elisor of endometritis with hirge titiM>y uteris ergot
shniihl lye given Lo eontniet ihe uterus iimi thus oeelude lym-
phatic rhnnoela of infection in the uterine wall.
Treaimeni of Mt'tritin, — In ca^^ of endometritis, where the
infection and intlamnmhou have extende<i frtmi the endo-
metrium iiito tlie inuscuhir wall of tlie uterus, with |»ns* foci
( iihisce44ses ) or |>ijrnlent inlillratiou in various parts of tiie
organ, the only hoj>i> a|i|>cars to l>e the earlij i^rtbrmance of
hyutertiriomy — extirpation of the diw.^nj^^d nteruj*.
It is unfortunate (hat the neeeAsity for r> serious an o|x?r-
ation in difficult Uy make out— at \^m»i in m(Ji?t c^i^e** — l>efore
it is too hite to prevent a fatal termination.
Treatment of Feline CeflaliiU (Parametntia) and Pelvic
FentoniiU.^Thesi^ two intlamniation?^ so freijuently m^^o-
dated and >uv difficult to ilia^mi^sticate from each other, re-
quire aJHiut the jsiime treatment, Urdike lesions of the vulvo-
va*rioo-uterine canal, jn?^t tueviously considered, thei«i.^ in-
flammatious cannot he directly a|tproached with l<K'al reme-
dies ; they are heyond reach. The he^^t we can do ts t«) apply
cold compressp!* (t^>wels wrunj? out of cnld water jhhI ciivered
with oileii silk or some other waterpnjof material ) (o the lower
alMlomen, to he chan^'eil every four hunrtj. Ice ha^s may he
Ufled in?*tead of the com[>re?ise^- In ceases of jj^real depression,
or again when there is diarrhipa or enteritis, hot fomentations
(or [wultices ) may be applieil instead of cold, and hot vntrinal
dtuiches of sterile water (110° to llf)"^ F. ) <'ontitiuonsly for
fifteen or twenty minute.s thrice daily. Thei^e remedies are
?up|M)Scd to eonlrol intlammation ami promote res<ilution and
the absorption of intlannnati>ry exndjUes ; wldch hi.'^t nuiy f»e
assisted by painthig the lower part of the alMhvmen and tlie
va^jiniiil fornices with tincture of iodine. Ointments of iodine,
ichthyol, and mercury are appli€*d to the alwlonien for the njime
pyr|M)se,
In erne mqypuration occur, the ahsce^ss must he open ^tl (the
presence of pus bavin*; been ilemonstrated by an exploring.'
needle) either exterimlly (usually near ron[>art'!» ligament)
or through the vaL'ina, either lM*hhid the cervix or in one of
the lateral vaginal furnicc^'^. Cavity of the abM<css to l»e
h
614
PUERPERAL SEPTiaEMIA.
It m>!utioi} and (inUDtNl hj strip
daily doucheil willi sterile i
of sterile i^uuKe.
Ill opening a ijv<*v?s<i tbruiigb the vagina, fe<?l for pulsation of
uterine arteries and avoid theiin Thtj ureters may be avoided
by euttiiig podertor to an imaginary line drawn trani^versely
dirongb tlie cervical cainib
Most cases eonvalesee, but there in^ always danger of pus
tinding iLs way into the peritoneal cavity^ thus leading to
general peritonilia
Tretttmenf of Dlffuae Abdominal Pertttmitis. — Most ca^ea
die m i^pite of aijy trealnH-iit. A few may be saved by ahdnni*
iual ?5e<"tion, irrigation of the |x^riti»neal cavity, and drainage.
An incision is made in the njedian line of I he al>iloriien
through wbicb an irrigating tube <'ondnci:4 an abundance of
hot sterile salt Holutioii^ wbicb is conveyed to every |iart of the
cavity and luatie to return easily by kee|iing o|>eu the incii^iou
with the lingers and irrigating tube. The wound is then
closed, except at it.s lower end, where a glass drainage tul>e
or gauze strip remain in the wound and extend into the j»uch
of Douglas* Sane o per atoi^s prefer to add a wide o|M»ning
fhroitfjh the Douglas pouch iiiltj the vagina; ihejielviH being
then }Micked with sterile gauze, a ]*art of which extends into
the vaginal canab wbenccit may be draw n out in three or four
days and a fresh one intnKlueed from below. Through the in-
cison in Douglas' ptmch, irrigation of the peritoneal cjivity with
hot j^terile water ur saline sol ution may be done twice a day ; jier-
ha|»s for several days if the patient live so long. Should im-
provement occur, the gauze is finally withdrawn, the opening
through Donghis' sac lieing letl to take rare of itself.
Should the aliove surgif^ul mellmd of treatment not lie
ado]>ted, we may attempt to cnnd»at the inHamnnitory process
by thesanu' to[)ical ajiplieations lo the ahilomen (cither hot
or cold ) as already stated for pelvic pc^rittmitis. The bowels
must be ke]*t free by small doses of calome! ( \ grain every
hoi I r ) or by Ef nscnn sa 1 1 ; w4n 1 e a hu n d a n ce of 1 i ( p j i d foe kIs ami
alfoholic lii]u<irs are administered, the latter just short of
commencing intoxication, to counteract the cardiac depression
always produced by septic toxins.
Recent anthoi^ scarcely mention the opium treatment of
genenii [icritonitis nowadays, tbontjh (xarrigues^ of New York,
not very nmny year?? ago chdnu'd to have wived ou€*-half of
I
TEE ATM EXT,
615
his cases by the "opium pljui/' ft eonsist^ m ^ving large
iltjses (2 or 3 grains of opium, or an enuiviilent uf morphia)
every two hours until the patient is su Tar nartittizftl lluit the
rt'HjnrationH are rtMlured to 12 f>er DiiniJtt\ at wlii(*h point the
hreathing may hf kept by regu luting the <lo;*<^r^amHmjiieQcy
of admiuiatration.^ As a forloni Ijope in the absence of sur-
gical treatnient it is worthy of trial, c'ombine<l of course with
whiskey, t<Knl, etc., ami with euenjan uf caBtor oil, glyeerioe^
iiijfl uil of LurfH^iJtini' to obviate const ifia(lon»
Tir.atmettt of Std/^uitfitU ttud OntrifU, — Here again the
iuflamc<l organs jire lieyond reach of direct local a p pi i cations.
The be^t we (an ilo i^ to f»pply hoi tnmenialions to the lower
aVKh>men and give hot water irrigations per rafjinam aa
already chdiucd for pelvic cellulitis, etc.
Wlieu Bupimmtian occurs, either in the tube or ovary, the
ttl>^'eAs if a^/AfTt*;^/ and easily acce^sibh:" from the vagina, may
be opened through the vaginal wall (usually I h rough Douglas*
poui'h), washed out, and packed with sterile gauze. If not so
easily accessible from below, and movable, the mtdiility show-
ing that lolhcsions have not Xnkvn place, the di^ased ovary
and tube shouhl be rem^vi^d by codiotimTy,
Trffiimtnit of Vlfrine PhlrhHu. — ^ Absolute rest, li<pnd
tnitrieiUs, and ahitndaueeof alcoholic si imidanls. The vagina
may la- cleatised by sterile water or sail solulion, but the uter-
ine cavity, uidess it contain pntresceut matters winch muM be
removcnh should not l>e disturbed either by the finger, curette,
or s}Tinge. AtWr rnnning a <"ourse of ]>erha[>8 weeks or
months, most cases recover under rest and nutrients. All
inanipulntions in the uterine cavity are liable to displace in-
fected throadii from inthimed veins, start oti' (kmting iVagments
to lodge in distant organs, and produce metastatic absi-esses
and pyieinia, which is the great danger.
Abscesses in the viscera (lungs, liver, kidneys, ete.) are
usually heyoncl reme^ly. Those in the joints reijuire incision,
sterile doncldng, and drainage^ accord ing to surgical rule.
In phlebilic cases where arrested thrombi have caused
al)scess<\H in the uterine wall, fierhaps projeeting externally
toward the (jeritoneum, into which they are liable to bui^t and
1 AlMii«^» rhirk -.v'
W.!»<'.UOnim or Mu
In Ht'ven *1«y^: On
"M -nMns of oiihim in four ilny* . Ford yec Tin rkcr,
A\\m in rli'vnt r1uy» ; KiiJsk, nriO gratnei ofoptttm
TrMln-"! ofmorphUi tI296 of i)pium} iu Iwviiy Ihnju
-nP-^.
6it;
PUERPERAL SEPTICAEMIA,
discharge, bysterectomy is clearly indiczUed, but the difficulty
liejs iti making a diagu<jsiri of tbe^^e eouditioiis before the
woiiiUTi lias beajrae too weak to survive so serious an o|jera-
tion. (For the treatmeut of ** Crural FhJebitis,*' see Chapter
XXXV., page 624).
Treatment of Oihtr Puerperal lufammafions. — Fleuritifi,
pericarditis, pueuruoiiitis, hepatitis, spletiitJs, aud eurJcx^arditis
may be treated as in iion-puerpend case^*^ with the addition
of antivseptie cleansiifg of the parturient cauab together with
alc(»holic stimulants and focxJ to combat the septic jxiison.
Ci/stUi», usually [iniduced by inlectixju from a septic eaibeter,
requires the hhulder to be wai<hed out with mi hi, warm solu-
tions of creolin (1 |>er cent.) or of hojric acid (20 |)er cent),
twice or thrice daily, Frefjuent niicturitiou is to be relieved
by suppositories of inorjihia. Extensiim of the diseai*e to
u re te rs a ml kid ney b r eq u i res d i ^i n fecti on by Ix >r i c acid Bol u t ion
thrtiugh ureteral ciitheters ; ao«l sometime.s when infectioti has
invaiied the sulistance of the kidney notbint,' but incision of
the renal [>eivis and drainage, or if taie itnly l»e iufecte^l, ex-
tirpation fif the disease" i organ will be of service. As in the
renal troubles of preLnianey, »ti in puer[>eral cai^es a miik diet
and a free action of the bowels and skin will help to cure.
AV«f i^cwc^/t''%*.— Recently three uew remedies have been
used in the treatment t>f puerperal septicaima, viz* :
1. Nuclei II,
2. Hy|>odermoclyeis of normal salt solution,
3. Antistreptococcic serum.
1. Nuclein (nucleinic acid) is supposed to increase the
nund>er of leycocyles in the bh3o<l Tlu\<e leuf^K-ytes feed
upon and destroy l»acteria anJ other pathogenic micrt>l>es
with which the bloiKl may lie infected. It is given hypo<ler-
matically, a 5 to 10 per cent, solution of the drug l^ing used.
The skin surface to be punctured is rendered aseptically cleuo
by a 1 to 1000 solution of bichloride of mercury or a 5 per
cent Bolution of carlxdic acid. The syringe is boiled for five
minutes before being used. The puncture is made lietweeo
the scapulic, ou the outer surface of the thigh, or into the
gluteal region. Dose of the solution just named, 10 minims,
gradually increased 5 minims for each successive dose, until
60 or HO minims are given daily. It is also given in sinnlar
quantities by the mouth. Tablets of proto-nuclein, each con-
y£W REMEDIES,
GIT
taiulog 2 grains* have also been prepared, of ^hich one may
bti taken every two hours.
liesjile proniotiiig phagocytosis by iucreasiug the white
curpiin^chiii^dh^ hlood» oucltim is also believed to iticrefti»e the
uiititoxio and germicidal [jru|Hirties of the blo<j<i »t^rum.
It hurt been used in ra^^e:* of puerperal septic iDfeetion with
a[tparent benefit, but always in conjumtion with othtr reme-
dif% tit> that ili3 indiridHai mine as a curative agent eannot be
<ietinitely stateil It its, however, harrukss, and there is suffi-
cient evidence of m gwd effects* to warrant its employment us
aboVe stated,
2» Ilfjpodermtfciysitt of Xorjuul Salt Solution, — The saluie
sobition * is itijeeted jinbcntaneously (with strict iLseptic pre*
eaubmis as to inatrument^ and t*kin surtace to lie punctiire<i)
in tjuanlitieQ of from one to six pintii. A lar^^e aspirating or
exfikiring neeiJle is plunged under the 8kin, usually in the
sulrt'lavicular region, under the mammary glands, or in the
gltiteal region. The needle i^ joinwl by a rubljc^r tiil>e to a
glass vensel or rubiver bag (xnitaiiiing the pollution of jialt, thus
llie rtuid is slowly transferred into the eelhdar tissue. The
temperature of the sahition shoidd be lOt*^ F.
It i.^ HUp|KK4ifd tci act, like luu'k-in, by ii^Teasiug the white
cells of the blood, and by it;^ rapid absorption, and subse-
quent excrt*tion by the kidneys* is lielieved to promote the
elimination of toxins fnmi the bl«:KKL It is also it* mmie sense
a imtrient and siip]Xirt t«> the heart and general syntem. It
has only been used tr/ZA other rr?/irf/iVji, sothal its actual cum-
tive power remains to be determined- It may, however, be
regarded as an eligible addition to our former ree4*ginsM*d
luetliods of treatment.
*{. AfdUirepfococcie Strum (Streptococcic Antitoxin), — This
preparation consists of the blood serum of animals ( horm's and
assses) that have been rendered immune against strep|t»c<H*eic
poiisoning by repeate*! artificial infe^'tion with cultures of the
istrept/>ccx"cic microbes. It is made about on the same plan as
that by which the antitoxin of dijihtheria is pro<luced.
It is given, always hyfioiiernjatically, always with rigid
aseptic precautions, usually in thit^'S of o to 10 culiic cen-
timeters (approximately HI minims to f'^yiies ). once, twice* or
thrice daily, but much larger doses — 20, i^O, and 35 e<v —
' For ItA prvf>ariitioi], see t», 16&.
G18
PUERPERAL SEPTICAEMIA.
have beeu ^iveti at ouee lu some cases^ ami in others the
smiiller doses of 5 or 10 ec. hnve been re|H:^iite<l every two ur
three hourt?. The -jize of the duse will dej)end» /r.< upm the
sireufjth of the pre|mr!itioii (for whit*h we ha%^e tt) rely entirely
upon tht^ stateriterit uf the iimiiufiieturer) ; ^ aecoml, upoTi the
severity of the ejuse, Jar^^er or snmller doj?c*.s heitig Ui^eil ac-
cording? as the syniptorius iDtliejUe ref'i>ectively a very viru-
lent (jr mill! de^'-ree of iiifectioii to be uvereome. Again, vv hen
8yni|}touis abate, the struru may lie omitted or used in smaller
dii94^H ; when gym j>tomrt return the larger doses mn^t be re-
sunied.
Ill some easts the serum ha?4 apjjareully bad a nio§t marvel-
hius and mtisbietory eunitive pmer, Wbt^n tem|>eratare has
been very high, with freqiienl anrl feeUie pulse, i^nppre^sion
of milk and loehia, delirinnu dry, brown tonjrue, s^ordes on
the teeth* nrt*e!istve breatli, and every indiention i>f a fatal
terndoation, after ottr injtrlion of the iserunii the bad symp-
toms have allabidtd within lirtnbf'Joiir fwur^ and the case
gone on touninterrnpted convaleseenee and complete reci3veTy.
Hueh a good result is not always (ditained, hy any means*
The remedy must be itJ^fil ear/if^ before the various inHamma-
tory lesions, esjjeetaliy pus formntions, have had lime to
pr(x*eed tveyoud recovery.
In other e*ise.^ goud results liave not lieen obtained, even
though the serum was ns^ed early. In nane this is aeeoiinti^l
for by the eomplieation i>f a niixt*d infeetion — ysome other in-
feetion Iveside lliat with the streptoemx'us, such as, for ex-
ample, the 8taphylc)eo**eua, I he BucUfii^ roli communi\ the
gonoeoeeus, or the hnrillus of di|ditheria. In puer|>eral
eases due to dijduhoritie iidVetion, however, the suheulanetms
injeetinn i)f diphtlieriti** antitoxin has sonietinit^s been fob
knveil by the same benefieent eorallve ctfeet observed lo fid-
low (he use cif slre|iioecKTic antitoxin in stre^itm'oeeie infec-
tioiL In short, ihe antistreptocMjceie serum will only be of
serviee in streptoeoeeie iutection, and tlie diphtheria anti-
I
1 r 11 the cases tluis fur repnrte^t, Miiniinivk^ s.-r
MAfmnrck of Vieiiiwi, mi4 llnH |tremrtd at \hv " i \ ♦>
llihoDimtry hy Piirk*?. Ituvil^ ACo., of rktron, <. nl
nunw otlitT m^iiUjftirHin'rji. Ttie prnco^ if a fiti i
hor!«e 15 siflid t" rt'iOMn- f r»'ji( nn'iri for ?«f vcral tii' : . :^ -
lM'f»>r«* lt> hi iiitJit)U' for T»s<.:. Tilt cak*M> iif t+tiy i*r» !>•
Aration iiiDHt ,. m4>ihrKl uf productluti, liK well ii»u|M»ri
Ihe agv and pr. , . luct tta<?rward.
NEW REMEDIES.
(JU)
toxiij ouly in fliphthentii^ infectittiK For Cflj^s of mixed io-
feet ion, a mixed ^eruiii» in»l Vfi dt'vised^ would seem lo b©
retjuircMj.
Until we huve leariit'd to ditstinguish the various kinds of
iidectiuJi l>y clinical .^^ifmjfttjms — a (•oti^urnnmlion nut yet at-
tained^— we rimst aiHertaiu the kind of infection l»y a iw>
called '* bncivritilogioal tiififjiwsi.%'* Thi» is a neeeH^ihj in onler
t*^i use lire serum udvistHily. But it re<iuireg time. A cover-
slip preparatiou niuy l>e made Uy nti fxpcrt in fifteen minuU^;
a eulture-tybe pre[iaration requirt^ at ieai*t twenty-four
Lours, bul both methods rwpiire special ^kiU and afjpuratus.
At [ire^^ent St is not known whether the antistreptococcic
erum acts aa a ^rerndcide by killing the Htrrptoci>eci thera-
bIvcs Its an antidote to tho toxin prtMbiced liy them, or in
both of thei*e ways. Yet if it cure the patient, that is the
main jHjint. whatever may be its juodm opfnindi.
It i?' not jniStifiable at prestmt to U86 ttu^ serum ahme. to the
exclui*ion of other remedies. Antiseptic douching of tfie
genitnl canab alcohol anrl otfier cardiac stimulantsi, with snf>-
f)*>rt of the patient by nntrienti?, have been and should Ite wW
in conjunction with the scTuni therapy. So, too, the admin-
istration of nuclein and *^nbclltane^^oB injectitin of tl»e s^idt
solution have been and should be used ixtnjointly with the
serum.
Under these circumstances tbe individual valne of the
serum treatment, taken ahne, remains to Ih> determined. In
some caseii where it ba.s been used, tw benefit has resulted ;
some have grown wor^e, in others decidedly uuplea*iant
symptoms* notably h hematuria and caniiac depreseiion, have
been producetb while in a few ca.'*e^ death, apparently from
nipid colla)ise, bus been direetly ascril>ed to the sernm*trcal-
ment. It fshciuld not be used when there is renal disease, and
in cases of simjJe snpr.emia or putrid intoxicatioD it would
do harm rather than gotni.
Fiuidly» it should l)e remembered that tbe mortality of
puerperal infection under the treatment by autii»eptici», fcxwl,
and stimulants is only about 4 or 5 f)er cent,, hence further
exjKTience is needed to demonstrate the superiurittf of the
sernm treatment.
Be^^idc tbe^e three remedies, several others have beea
tried, but cannot at present be rec4>mm ended « viz. :
620
PUERPERAL SEPTICEMIA,
Crede'8 OinimenU — An ointment contaiuing 15 per cent, of
colliirgol (a soluble form of jfilver) uf wht^h 2 to H gm, (15
to 45 ^r. ) are rulihed into the skin uo the inner surfaces
of the iinus or thi*^^hs for 20 minutes, once a day, the surfaces
bci iig t \\^. 11 CO ve re 1 1 \\ i 1 h ru b ber t iss u e. fcki 1 u l i ona of col I argol
have alsu been injeiMed loto the veins. The idea is to correct
general septic infection,
Fochiers Method — ^Id pyiEtriic caflee Fochier pnjOuceU what
he called abticea de p^utlon \\y the subcutaneous injection of
tur|»entine. If pus formed at the sites of injection and the
abficesi^es were allowed to increase without opening, the result
was thought tt> l)e beneiiciah Thesje al>seasses were supjiosed
to take the place of, and ])robably lessen the teudeuejr to
internal metastatic abscet^es.
KezmaXitku followed by MfHmiannt attempte<l to correct
sepsis by the intravenous injt^^tiou of minute doses (I to 5
mg. ) f}f rfjrro»ive jtiihiijnafe ; and Barrows, nf New York,
made tlie same effort vsith minute quantities of formalin ami
formaldehyde, which he used in the siime way.
Concludiiig Remarks. — The numerous and dreadful lesions
cau.<ed by septic iufection, ami tbeir fatal fonsefpieueeA cx>u-
stitute the strongest sort of aj^peal for intelligent and paiuB-
iakmg prop hy lax h wliich, wliile it may retjuire time and care,
will be as certainly effectual as anything w ithiu the range of
medical science and will ariijily reward the conscientious ob-
stetrician for any time and trouble he may ex|K»nd in the at-
tern 1 4 to attain a rigid aseptic technique in the practice of
midwifery.
CHAPTER XXXV-
CENTRAL VENOrs TIlKoMJinslS, 1M:RIMIEKAL VENOUS
TIlliOMHoSlS. ABTKKIAL TIlUOiMBOSia
CENTEAL VENOUS THEOMBOSIS (HEAET-CLOT).
Blood in the rit^^ht ventricle of the heart t-oagulatt*, iorm-
iiig clot which phi^s ami jyerhajw exteuds into the pulmonary
artery, thus usual ly |>nKlucing sot I den death by ai?j>!iyxia in
eouuequenee uf ol»8tnictiou to entrant'e of hh>od t urrent into
lung». In s<iiue cjiset* the coagulation hetjhn< in the heart pri-
nmrily* in others an end>olus« from a thrornhnn in some dif^lanl
vein fmhjrs in th^ htart, and this becomes the nucleus around
which further coaguhilioii takes place.
Causes. — ^Condition** by which ten<iency to lyhMxl coagulation
is increased, viz. : 1. Hemorrhatje either liefure, during* or
after labor. Blood-loss i^ always followed by increaj*e of
fibrin in the blood retained. Increa.^ of fibrin favors coagula-
tion, 2. Siownfifs or Jrrhlenem of blood cur rim t ; hence i^yncojw
(in which the heart is alnK>st at rest), whether from hemor-
rha.ge, from exhaustion following a hmg ialior* frtjm suddeu
reduction of intru-alMlominal pressure after rajiitl delivery, or
from previi>u8 deinlity, favor*? coagulation. Great ft^ebleueas
uf the circulatitHi, %vifhfntt j*ynco|H% may produce it, 3. Stfjp-
tie i?ij\'ction of the bb>od and accnniuhition in it of effete
matters resulting from involntiou of uterua, etc. 4. Ktrenn
of Jilfrin, t*onum*n to bliMMl of pregnant women. 5. Thromhi
in other irlnn may give off fragments (cndudi) which hnlgt*
in vent rick* or pulmonary artery, and constitute nuclei for
growth of larger clots by accretion. Several of the above
Cfinrlitions may Iw combined in lying-in won»en.
Post-mortem Appearances. — Firm, leather}, laminated, and
decidorizt'd clots in right ventricle and pulmonary artery and
its larger branches. Coexistence of thrombi sometimes in
Other veins.
622
THnOMBOSlS,
Sjrmptoms. — SudJeti occur reuee tjf juteasie dyspnoea and car-
diac jmin, prei'edKl or hot liy sym'ojie. Extreme pallijr or
lividity of faee. Violent triJi^]»iiig iitid re<[)initory riiotions,
wlurh are ssliort arid liurried. Pul.se tli ready » leelile» tl utter-
ing* or uearly tuiperceptiljle. Skin cool or eold. luteliisreuc'e
nuiy be uuiiu paired. Death may occur in a few luinutes, or
if olistruction in pulmouary artery lie uot eomplete ihesymjv
toms may ameliorate, but return repeatedly when patient
attempts the slightest movement. .Suue live houn^ mme
tlaijM ; a vertj few recover. Cardiac murmur may sometimes
be hesird uver ^ite of pulmonary artery.
Diagnosis. — fhsjuuea ami asphyxia, with sudden death,
may be produced by entrance of air into uterine vessels
at placental site, the air having reached the vagina and
uterus by use of imjierfeet syringes ; during manual and hi-
jitru mental deliveries, from |)lacing tlie \v<jman in the genu-
pectoral or latero-jirone |Kisition ; or sudden removal of abdom-
inal prejs«iure after violent pain si that have expelled lifjuor
anmii may if. vulva ga|»e, protluce aspiration < if air inlo vagi-
nal canal. (tases may lie prorlueed in utero from decompo-
sition. Symptoms are nearly the sjime as in heart clot ; so is
treatment.
Sudden deaths frum hemorrhage, slio«:'k, uterine rupture,
and concealed bleeding from separation of a normally placed
placenta have already been mentioued.
Treatment of Heart Clot. — Prrtrni the accident when, as
at\er severe hemorrhage, etc., it may be anticipated, by keep-
ing the head low and eajoining Qlm»lnit' repose in recumbent
poMure, not |>ermitting the woman to elevate her head /or any
purpose white ver. Treat the accident, when it ha.s occurred,
by bold administration of Aiimuinntg — whiskey, brantly, am-
monia, eie. Whiskey {^ )^ sulphuric ether (."^j )» iiitro-
glycerin fgr, 7^ )» or strychnia (gr. 3'^), may be re|ieate4lly
injected hypxlermatieally. Fresh air, Inhahition of oxy-
gen. Milk and beef essence. Alisolute and [lerfeci rest
The slightest movement nmy be fatal. Apply warmth to the
surtace. Prolongeil rest after subsidence of violent symp-
toms, until blood be restored by iron, quinine, and food.
■
PERIPHERAL VENOUS THROMBOSIS,
623
PEEIPHERAL VENOUS THROMBOSIS.
Clotfli of bioo<l fonninu' in the y»enpherai veins occur for
the Di08t purt m the veins of the lower extremity or [m^Ivis
(ootably in the crural, tihial, or ]>eroneaI ), aud thus leading
to olistrtiction* [jrtxiuce swelling uf thelimh ; hence jieripheral
venouj* ihronjljotfis is the new name for old-fnahioneil **nnlk-
leg/' (8yDonynis: *' White leg/' *' phlegnoaiiia alba dolens,'*
*'Le«len\a laeteuni/' *UTnral phlebitis/' etc)
Causes and Patliology.— Conditions favoring blood ccja^nila*
tioii (jyst mentioned as prodoetive of central ihrombosit*) act
as predisposin*^ causes. The disease is apt to uceur aft<*r
placenta pnevia or after inanual extraction of placenta,
i'oagula from phuvntai nite nmy Hoat into hyiM.>iraj*tric veins
and obstruct hluuii-tb»vv through crural veins. Multifmrity ;
feebleness ami debility; dithcult and implicated lalwrs ; ID-
flamnuitions ahtiiit the pelvis following obstetrical operations;
hemorrhageii ; septic infectiou ; cancerous and other pelvic
tumors ; occurrence of erysipelas and of puerjieral and other
fevers during chibll>ed may be set down m causes.
The disease may occur after alwirlion ( es|>ecially when some
part of the placenta has been retaine*! ), and si>metimes it be-
gins independently of Ijoih abortion and lalx»n
Formation of blood clots i thrombi ) in the aifected venous
trunk is at [)resent roost generally admitted iw the starting
point of the lacal phenomena, though various other theories
severally reganl the venous obstruction as l>eTng sec<mdarv to
phlebitis, cellulitis, lymphangitis, etc., and finally the*»e local
inrtamnnitious have l>een traced back to .^f'piic infrrtion^ which
liy nii*st modern autb*>rities is now regarded as the real cause
and origin of the disease.
Symptoms. — Usually begin within nne» two, ar three weeks
after hibor. Premonit^irv malaise, depressed spirits, weakneas,
and irritability of temper. Paiyi in the lindx [perhaps first
referred to the hip-joint or inguinal rc^trion and then extending
U) thigh and leg, or may liegin in the ankle or calf of the le^r
and extend upward. It is a dull, dragging pain, incrcasal by
motion. Chill followed by fever. Arrest of milk and lochial
secretions. Pulse may reach 120: temperature 101*^ or 102**
F*, with evening exacerbation. Tongue coate^L BoweU con-
624
THROMBOSIS,
stipated* Restlessness, sleeplessness, thirst Chill, fever, etc.,
may be absent in mild coses,
WiihiLi tweDty-Rjur hours limb begins to fnvell ; swelling
increaseii until sskiu is tense, white, and shining from a^dem-
atijus aci'umulatiou of effused serum in the cellular tissue,
Ctjoiplete ioM of pouer iu the leg, the patient bein*;: unable to
turn it over iu bed, Srmie loas of sensation in it, a '* wotxien *'
feeling. Its temperature increased. Affected vein or veins
may l>e felt as thick hard cords, roliirtg under iiugen reil and
t*;uder. Od the inside of the thigh the femoral t^lyeath feels
a^ large as a walking-stick ; a red flush and tenderness on
prt'ssurc mark its course, (i lands* of groin may be swollen,
intlamed, and hard. Vulva also o?dematous.
In a week or two Vwjth Incal and general symptoms abate.
Swelling diminishes by alisfirption of effused serum, ending in
reeo v ery , Ot her cases ter m i n a te i n s n jip u ra t ioi i a n d a I >s<?e8ses
in the limb, pelvis, or lymphatic glands of groin. Rarely
gangrene octnirs. Floating Ihigmeuts of tbrond)us may lodge
in distant parts, producing metastatic abscesses in lungs^ li\*er,
joints, etc., with pyaemia, septic infection, and death.
In easels of recovery, some swelling, im|>!iirnient of motion^
and liability to rehi|)sc njay continue f()r weeks or monlhi^
Prognosis.— A fatal termination is* exceptional. It is to be
fearrd in pyteniic cases and in those atteinled with suppuration
of the limb. ComplHe recovery as rt^gards the limb itself
may he long delayed, owing to partial or complete fX'clusion
of venous trunk and it^ conversion into a fibrous cord.
Treatment. — Ahmlute rest on the back, perha|is lor two or
three weeks, the patient not l>eing allowed to rise lor any [lur-
IMme ; hence the use of a l^ed-pan is indispensable. Tlic limb
to he slightly ekvated and wrap|x*d in dry ct>ttnn batting or
absorbent cotton and protected by a suitable scret'U from the
weight of the bed-clothes. Anodynes to relieve pain, eitl»er
internally or by liniments of hiudaoum, aconite^ etc., apjilitnl
withmif frictioo. The old *' lead and opium wash " may he
used. Williams obtains excellent results by painting the limb
with a solution of ichthyol (15 to 20 pt?r cent,). Rest and
elevation of the liml) are usually sudicient
The *' gentle frictions*' formerly used to promote alisorption
had l>etter lie (miitted entirely, Afi frictions are liable to
dislodge a thrombus and cause it to float away to 8on»e more
AETEPJAL THROMBOSIS AND EMBOLISyr 625
diingemus locality- The limb may be pamtetl with tincture
of imline, or oimrneiit of iodiue may be applied to prrmiote
abi*or|>tion, but witliotit any frii^tiou whatever.
Formatioos of [lus (sometimes deeply jjituated in the cellu-
lar ti.ssue of the lirab) retfuirefree iucigiou uoder aj^eptie pro*
eautions anti-'»eplit: cleansing, and drainage aceordiiig to sur-
gical nde.
During convalescence an elastic stocking or elastic band*
a^e is extremely useful to prevent swelling of the lind> when
the patient begins to walk»
The general treatment is the same as for other manifestii-
tions of septic inftH*ti(m» vis^, alcvhofic dimulanh and liquid
foods; and in casc^ occurring 3<h>u after labor, andfiepHc
flouches to the genital canal must l>e used. In later caj^es —
Conihig on three or four wtH'ks after delivery — the douching
may be utineeessury unless there be stmie indications for its
employ menu sucii as an offeusiive tliscbarge.
Laxatives to relieve consti[>ation, aud anodynes (either
Dover's powder or morphia), to relieve pain during early
stage ; and later, bitter tonic-s, tinct. ferri clduridi» f|uiniue,
and strychnia, will he necessary.
Alkalies given with a view to diss^dve thrombi are un-
certain and questionable, though recently fivr-(^ru'm d*»se-s of
the [lotassic nitrate evrnj hour during acute stage have l>een
extravagantly extolled as producing ct>nvalescence in two or
three days < ? ), The [intient shoulrl on no a<'('<>unt leave her
bed until the thrond>us has entirely disapfieared and the vein
beeomc rei^toretL Should she do so, it would endanger suflden
death from the thrombus jjlugging pulmonary artery afler
dia placement.
The almost hofieless pyannic cases will re<[nire the same
treat men t as already described under Uterine Phlebitis (see
page 601),
ARTEEIAL THEOMBOSIS AND EMBOLISM.
Very rarely clots (thrombi) form in the arteritjs of puer-
peral women, instead of, or as well as in the veins. They
may also result from the lireaking up of a venous ihrondms,
the fragments ivf which pass through the heart and go on in
the arterial system until arrested by some artery too small to
40
626
THROA\fBOSIS,
let them pass. Such arreted Hoatiiig fragtiients of a thrombus
are nilleil " emboli.'^ Arre^sted tletiiclied tra»^imnili? of ** vege-
tatiniLs " frurn eiirdia€ valvest ful lowing rheumatk' tuiluoarditis,
so rin^t i n 1 1^ wcur.
Symptoms. — Symptoms de|>etid chiefly upm the defect or
arrefst *>f function ami niitrilirm of thejmrticiilar urgan or part
wbijst- artery lias been ub^triicte*] by the clot. Paralysis and
aphasia relink from [ilngging of cerebral urterie.s and bliniiutjss
friHii obstryctioD in the «ipbthalniic. When the b^ichial or
femoral arteries are the seat of thrombi, the re^jijiective limb?
heliiw the t)bstrnctnin suffer a reduction of temperature, h>sssof
mot ion and senrntion, or inj«tead i>f this hii<t, tjevere ueumlgic
pain. Pnlsjition in ihe artery is lost hriow the olistruclion
and strengthened almvr it. Gangrene may occur when the
collateral circulation is inadetpnite to sustain nutrition of the
Ihnk
Treatment. — Rest and good diet with perlia^is stimulants,
ancl anodynes to relieve piin. In time tlje obetructing liody
will disintegrate or unrlergo alietirption, but no treatment of
wliich we are aware can hasten these proeesaes. Gaugroue
belongs to surgery*
CHAPTER XXXVI.
INSANITY l)rKIN(i G1^>>TATI( jN, LAi TATION, AND TUB
riiKHPKUAL HTATK, PCEUPKHAL TCTAMS, ETC.
The o14 term puerperal mtntia, iiiiyiniuch t\^ it im[»lie»
situple majiift, ami <mly liuriiiir the piitTperul pterin*!, in Invurn*
injr i)lKs<>lete. Viewed muriMximprebcnsively, riK^ritul tlerajtjfo
iwemH iiJ the female having a eausal rtvlatiou witlj ri'produc-
tion may be classified elinmologiciilly as follows :
1. Iiisiiiiity of pre*riianry.
2. Insuiiity of tiie pijer|>eral state,
'S, Irusjuiity of lattatioiL
TUese, it IS evident, may overlap each oilier or (xmr suc-
cessively ill the same patieut
The insanity, at w birliever period it ix^eun*, presents one of
two s|K.H'ial and to some extent opjKJsite phases, viz., mania
and melancholia. Both are sometimes eorabiiied.
MMiiia is charaeterized l>y paroxysnml violenee, metita! fury,
raving» etc. Mtlanrhtdtit means continued desjN>ndency,
steady ploonit quiet depression, suspicion, miHtrusl, etc. The
mental alruospliere in riwhitichnUa is steadily dark from iitipend-
iiijjr clouds; ill man in it is violently agitated, na from a cata-
elysmif storrn.
Causes. — The three varieties uf insanity have certain causes
in comnion^ xh., lieredjtary preiU^jx>sition ; pnnn|»arity after
thirty years of age ; pre-existeiiee of insanity, epilepey, hy«^
teria, dif)6omania, and other neunrsea are predisjMi»ing cauiie*.
During prtgnancy, eonslijiation, indigestiori, mental worry
from aeeiileutal circumstances adding to the depression and
desfxKidency common to pregnant women, as t, 7,, aediKliott,
desertion, etc., tx>ntribute to prrnluce the disejise. Spfcial
causes of infinity chiring the purrpf^ral jH-riiMi are difficult,
painful, pndonged, antlconipliaited hihors ; j>osi-parttim hem-
orrhage ; e<*himp(ic convulsions; exhaustion and debility, a«
from over-frtMjuent child liearing, fn>m lactation during prt^-
627
628 INSANITY DURING GESTATION, LACTATION, ETC.
Dancy» or from previous diaease. Violent mental emotion as
fright, fthiime. sorrow, etc. Septic iiifeetioti and alhuniinuria
with unvmicL'outimiinationof the blood are ail<IilionaI causes.
Borne cfij^es occur from toxius alis«>rhe(l iunu the iiitestiue,
owiurr to ilceorupositiou taking phire in the contents of the
larger bowel from eonsti|)atit)n and defective dij^estiou. The
insanity of lactntion ig essential ly a dis^ease of debility and
aniemia, theae conditionij arisiti^^ from prolon^^ed laetulion, fre-
ijuent cliildbearinLTt |wist-partiim hcmorrha^'e, or other causes
of exhaiiMion. An ill-nourished hniin cannot jierforni its
normal functions.
Symptoms, — The iosanity of preptaney commonly begins
about the third or t«>urtb mouth* or from then to the seventh,
rarely later. Sympt'imis follow the melancholic type and are
sometimes exagiiferatious of previous^ly existing mental, moral
and emotional (listiirbancea, usually noticed as sujns of ges-
tation. There are headache, insomtda, gloominess, or irrita*
bility of temf)er» prsonal <lislikes, etc., with tendency to
suicide. Cure before delivery is exceptit»nal, and there is
liability to mania during or after lalwr.
The insanity of the puerperal period is most frecjuently, hut
not always of the maniaetd ty|>e. In very painful laliora,
when the be^Vil is just passing the os uteri or fierineurn, a trm'
p^jranj frenzy or *' delirium of agony/* is stunetimea sudilenly
develope<l, but soon pitMes awatj. This is not the kind of mauifl
now under consideration, Piier|>eral mania projiker licgins
usually within two weeks after delivery. It may l»e a week
or two later. Sometimes it ctmies on within a few hours*
rarely in a few minuter* at\er labor. Jt may or may not lie
j>receded by premonitory syniptomSp such as restlessnef?i8, head*
ache, insomnia* or sleej* dif^turlK^l by [«nnful dreams, mani-
festations of su&]iiciou and dislike toward relatives ami atten-
dants, etc. ; soon followed by incoherent talking, prol>ably
«j>on amatory, obscene, ur religious topics Patient steadily
refuses to take f(jod, and as excitement increases, refusee to
stay in lied, tears off her clothing, screams, prays, attempts
self-mutilation or suicide, or to inflict injury uimuj others. In
time the paroxysm of metital excitement S4>bers down to mel-
anclioly, but fresh outbreaks are liable to orcurotii^light prov-
ociition. During excitement the pulse is accelerated and
small. The digestive system is usually at fault, as shown hj
TREATMENT,
629
furred and coated tongue and constipated bowels. The urine
is liigh-t'olL»re<i| and often pnsiie^ involuntarily ; there may also
be involuutary stooln.
When man'ta is absent, the melancholia ^yiwi^imm^ are |ier-
sistent refussal to taki- foud ; iiijioinnifl ; iiiteii;*e deprea^^iou ;
religious or other del unions? ; weeping ; praying ; ijh>on*y
fiiJeD<!e ; tendency to suicide, infanticide, etc. Signs of diges-
tive derangement.
Tije insanity of ladatlou h generally of the Diehmeholic
type, but limy l>e asstK^iated with tninsient mania. It m uiueh
more common than insanity of pregnancy ; le^ so tlmn I hut of
the pi^cTperal j^riod. It is uaually attendeil with symptoms
of anamia, May tlegenerate into dementia and bo|)eleiSS
iii.sjinity.
ProgBOSiB.— As to life, the puerperal form» usually favorable,
but not always. Kxtreme irerpjeoey of pulse, elevation of
tern j>e rat ore, and eorxi4?teneo of |i€?lvie or other intlammationrt
are of grave s-signiJieiinee, Mania is more daugerous lo life
than mehiuehoiia. The prognossis m to re6*toratiou of reaiiuii
is less favorable in nielaneholia. In this rej^ix-et also, pre-
vious exifc^tenee of insanity, or its coming on during hicln-
tion, or during latter half of pregnancy, are unfavorable,
though not invariably ^k InsaDity cximing on early in preg*
nancy anci constituting t«imply exaggeration of usual mental
eccentricity of ge.*«tation is less serious.
Soraetimes weeks or months pass before a cure is elfe<*ted.
There are rio special j>«)st-niortem ap]>earaDces other than
those of aua?mia or coexisting inflammations.
Treatment,— The transient frenzy of acute auffenng during
delivery is relic ve<l by anfestbei»ia.
True insanity, at whichever of the three [periods it occurs,
and whether of the maniacal or melancholic tyj>e, recjuirc«
remedies aildressed to general conditimi of {mtient rather than
to mental symptoms. No depletion is called for ; but on the
contrary* /or>^, rest, sleep, Jinrl strengthrnin^ rnedif-lneji.
At the outlet give a laxatit^, mild or stronger, aoc^jrding to
strength of patient and previous constipation, but alwayt
with caution as to re«luction of strength by eatct^ve purging.
After its o|>eration, secure sleep by liromide of ptitassium (^^
every eight hours) ; (»r if this lie incHicienl give with each
dose hydrate of chloral, gr. xx- Thirty grains of ddoral
630 INSANITY DURING GESTATION, LACTATION, ETC
with sixty of the briHiiide may l>e given by etieiim if [mtient
refuse to swallow. 0[iium aud nior|>hla are, ot» the whole,
objt^ftiniirtble— et^rtuinly wu iu uuiuiH «/il^os ; the latter riiuy lie
given hypKleriiiically iu inelnuehulia. In niaoin cjises, par-
ahleliy<h' lu dnses of oue or two ilui<l clnu'lim,s Inrgely dilulni
iiud hyoMTauiiue iu doses of gr. y]j,j to ^*^ have been given
with udvuuttige to produce sleep,
Ffed the patieui with solid nieat^, if she will take tJiem.
Jf not, give lieef-tea aud as wuich iiiUk ns possilile. The
latter will sometiniLi* I>e atxepted a* a driuk when liie patient
decline?* to raf, e8})e<'inlly when brought iu ati earthen iusjitead
of a glaiw vesi^el, aud iu a darkeiu'd rf«tDt, Cold to the head,
waruj j»ediluvi;i, a hiith uf 90^ F., or the hot, wet pack for
refraetory patieuts, as.si?t in promoting sleep.
In eaiies with iute,'*iiual ludigei^tion indieated by offensive
ami thituleut di^ebarges, a purge of ealomel aiid ,soda f*d-
lowed l)y uaphthuliu iu tlones of 5 to 15 grains three times a
day» and wiiBhiiig out the bowel with atilist^ptic solutions of
hi>nix, nirbolic acid, or sodiuiii hyiKwddorite will not only
correct the iutei^timil troiilde, but al^o indirectly produce sleep.
(jfmti nuraimj is of gre^it importance. Every [>atient
should be constutitlv watcheil^ to prevent self-injury, but
without her being aware of it, if jK^ssible. Strangers are
more acceptable to most patients than husband, relatives, and
friendf*. The bladder and rectum reijuire special care to
secure their being regularly evacuateti at proj>er iutervulik
Beware f)f betisores. Great tact is nece^*ary by tirm yet
gentle [>ersuasiou to iuihice the woman to take food, It«
artificial administration by force is seldom advisable, though
fkimctimes nece^isarv. The room .should be rjuiet and dark.
The woman must not nun^e lu^r child.
Insauity coming on during hictation ahvnifi^ requires imme-
diate weaning of the child, and in addition to food, sleep*
etc. iron and quinine are necessary to restore the IdocnL*
The propriety of sentling patient to asylum dei>ends much
on facilities for good nursing at home. When the latter are
wanting, an asylum is demanded* Mania being of shorter
duration tlian melancholia, and k^s likely to l»e followed by
confirmed dement ia, may be managed at home in most in-
st4iuxx's. In chroni(* melancholia, trending the patient to an
a«yltim sbiiuhl not lye unduly postponeii.
I
PUERPERAL TETANUS.
631
Duriug convalescence, avoid all sources of mental exdte-
rneiit. Ointiime careful feeding?, ^-^leeping ine^Ucines at ni^ht,
hixatives, an4 tunics^ until stren|i:tb i^' fully restortHl, when
chauge of scene and cheerful surroundings com|>l€te the cure.
PUEEPERAL TETAinJS.
Res^^nibles ordinary surgictal tetiiuus. Very rare in tem-
perate cli mates, lei^a m in tropical ones. It tx-cuns after full-
lerm labor. Init more frequently after abortion.
Can^rs and pathology probably the same as in surgical
tetanus. The greater number of recorded caaes has followed
utMrumenfnl iibortiou or opernilve ineasuref* to empty the
uterus in abi*rti<>ii ra.^e^. It is probably due to infwtion
from introduction of a .specific microbe at the site of some
traumatic lesion, vvhetiier the latter be from operative pnv
ceediugs — snrgical or obstetrical — or laeenitions incident to
labor* Expoj^ure to cold and damp or to draughts of cold
air is an esptM*iul exciting cause.
Symptoms. ^ — IVnu and stitfnes?*^ in muscles of m*ck and jaw ;
n*Tvousness and ngitiition ; rise of tem[)eratnre. The muscular
stiJfticss incrcjises, soon leading to hM*kjaH\ and later to geneml
attacks of painful spiisiii, opislhotimus, etc. The general
spasms arc eaj^ily provoki^d by slight shocks, noises, or jars
about the rtjom and l>ed, or by nttemja.^ to tiike ftx>d. Swal-
lowing soon becomes im|>o8sible ; hence nutrition fails, and in
a few days, varying from one to three or four, the patient
d ies fro i n ex ha u st i* u i an < 1 i n te rfe rence with res pi rati on . iSome
die in a few hours ; about 10 per rent, recover*
Treatment. ^ — Antise|<tic irrigation of uterus aiid vagina.
Internally: chloral, o[)iunu the bromidei*, (/nhibar bean,
cannabis indica, and curani, as in ordinary surgical tetanus.
I Aniesthe.sia afiVu'ds i>idy tempjrary relief from spjism and
I Buffering, Nntriertl enemata and inunction of the skin can
be tried losupjMirt the patient when deglutition b impoaaible.
Tetanus antitoxin is deserving of trial
632 INSsiNirr DURING QESTsiTION, LACTATION, ETC,
TETANY ( TETANOID CONTRACTION).
This m a deningenwnt tx^'urrmg m nursing women, or
(luring prejL,^tian€V% iti wliicli there is psiiiiful cramp or s\)ii&-
mudic coiitraetion in one or more JiinjcfH or loes^ hegiiuiiiig
ht^re niid uclviincing u[j the Tmihs, in severe cn^es to the
nrek imd trunk. The <^M>iitrn<*liotvs are iiiteruiittent, and
tlifier from tetami!? in bejjinijing in the extremities ius^tead of
in the neek and j awn. The fontnietious are ^iinetiniej* jmin*
ftiL at otherH they U-giu with tingling ^ensaliouB, and iigaiD
there may \>g amesthesia of the at!eete«l parts. It is rare.
Sometime** they may tie j^imply hynt erica 1. Among the earner
are blood h>ss, prohaiged lactation, diarrlia\% this last sug*
getting that the cramps are identical with tliose (if cholera or
choleraic diarrha^a. Most etiseji? recover* It is trrattd by
antisjiai^UKMlics, opinm, chUn^al, valerian, bromideiS, etL\» and
by arresting the tliurrlnea, overhntation, or whatever cou-
ditioij may exist ns a cause of exhaui^tiou.
CHAPTER XXXVII.
INFLAMMATli>N AND AK8CESS OF THE BREACT—
I.VrTATIoN AND \VKANIN<;.
INFLAMMATION OF THE BREASTS (BIAMMITIS;
MASTITIS).
Inflammation may attiick the ttnbittanee of the mammftnj
gland itself Cglflinhilar niJMUtii*" ), or the layer of cdluiar
connective tisLsiie \ym^ iinileriR'tuh the glariH, between it uml
the |>eeturalia Tuaji>r uiusclr ( "tiuh^^lunduhtr nia^tili^/* *>r»
more* pro|>erly, subuianiniiiry t'elliiliti!?), A more eircum*
serlluMl form of iiithuiimati^iti mriins in tlie Hiiln^utaneous
tissue immedialt'ly beneath the arenhi of the nipple (iiiilx'U-
taneouH imustitis).
Either variety of inflammation inaij terminate in rei^olution
without ^uppn ration taking pi are ; hut in every cane an oppo-
site termimition Ls to lie feared, viz., the fonnation of pU8»
ami eonsHpient "mammary alwes^" (**^athere«l breast**).
In '' ijlatultdar mantUis'' the inflammation and suppuration
(when the latter oeeurs ) are nsnally eonfined to one l(jl>e, or
to tWk\i eonti^Mjous lobei* of the ^dinid. hut when the abs<*e88
has disehartred iti* eontentw, the iuflammalory and suppurative
proe<'.ssej< may po on to the next adjoining lolie, and so on to
another and another, until a greater |>art of the gland i^
clestroyed by the suecession of abst^esses, the woman l>e<x>ming
meanwhile senously or even dangemnsly debilitated by eon-
tin ifed sufferin^r and exhausting jmrulent dis<diargei«.
In ifultmnmmary reUulitifi intiannnation is more ditluse, not
fonfiopil to the vicinity of any partieuhir lobe of the gland ;
and when pus forms, it is apt to in lilt rate it^df lietvveen the
gland and chest-walh separating the one from the other, or
kutding to long, sinuous tracts which eventually form fistuh)U8
opeaingiS through which matter is discharge*!. In neglected
caBes the fistulous orittces may enlarge by sloughing of their
633
634 INFLAMMATION siND ABSCESS OF THE BREAST.
borders into ulcerated surfaces of ei>nsiderahle size. In owe
auc'h r^ise I vvaa able, l>y lifting the gland awuy tWnn tbe cliest-
wall, to look in ut one fetuluus ulcer and .see dajbgljt adnjitted
thr<ingb others on the opjKisite side.
This form of iuiiatiunatiou may be^in de iioifOf as a cell u-
litis, or the latter may he aj^x'iat*?d with or j>roduC'ed by
iuthimmiitioii of the gland itself, the gbmdnlur aliH^'ei^s* when
dee [I 'Sell ted. dij«ehurti^ing its pus pitsteriorly into the cellular
tissue lying beueaLb the gland. It i« not of frequent occur-
rence.
The *'snf}cMant'OHd'' form of ma.stitis iLsually termniate^ in
auppii ration, fornnn^ snuiU alTy^ce^se^ or boils m the vicinity
of tbe areola, their o[iening stmietime^ forming fistulous com*
mnnication with the niilk-clneU.
Causes of Mammary Inflammation. — The most common
cause is Hcpitc inffditm of the brea.-^ts (through erosions antl
fisLHures of the nip|de» or through the external oriticos of milk-
duets), ami rapid propagalion of niicrolK's la acntmniatcd en-
gorg^'mfnts of sfngiitittt mtft within the ihnl.s and acini of the
glands. MieriK'ocei of variuii!* kinds? (the Sfttphtflocomt» p]fo(j-
ene^^ anrcH!*, Staph y if tt'omt^ j^tfagrnt^ft tj/ftuif, the diploccK'cus,
the strcptoctK'Cus, ami various formsi of bacteria) have ln-cii
found in the milk and the pus of intlamed breasta. If the
nipples were always kept absolutely aseptic, aial no 9tn»i» of
ac^cumnlated milk was ever allowerl to take place (a thing
much mt>re easily said than done in private practice), inflam-
malion and ali^^e^s of the breimt won hi probably never <xrcur,
except in rare cases cd' trunmaiir hijary,
Wiiiaen who hiive oni^e suffertnl from mainmary nbscess are
liidile to ch) soaguiii at Huceceiling lactations, |>rolmbly because
cicatricial adfiesioni* and contractions have prodnctHi tihwlruc-
tion in some of the lactiferous dtict^ Those who do not at-
tempt to nurse at all are |)cculiMrly exempt from nuuumary
inflammation ; while in thost^ who l>egiu to nurse and then
stop, the alfcction ts most apt to 04*(Hir.
Symptoms. — Inflammation of the breast, of either varietVt
may or may not be prcccderl by excoriation or fissures of the
nip]»le. So, too, a lump may fi>rm in siune part of the ghoid from
aecrumubition of milk, and be attended with some slight tender-
uem on pressure, but yet be dissipated umler proper treat-
ment withont inflammation taking place. Such an indurate*!
SY^fPTo^fK
635
nodule, however, is never safe from sLi|)eradded inrtammatioii
ujxHi very silit^ht provoeiitioiL WLen the iutiariimatory
procvi^ really jiegiiis* the i^ynijitonis are chill, lever, rise of
tenipe rat lire, hoi ??kin, fre<jueiit pulse, headache, thirst, ano-
rfxiu, etc.
Locally, hiuciu utility paia in the lircast iiKTc^used by j>res-
KUre, iticreiised hurduess, lieiit, awelliug, arul at Hrst very i^light
redtie^s,
Should the ease termiimte in resolution, the symptoms
gradunlly disappear in a few days. When it goe^ on to snfv
pnralinn the syruptonis increa?<e in severity. There are eon-
tilaiil throbbing pam, increased tenderneiisj* iinil swu)ling»
deluded redne>vs with hli^^ht lividity «ud hriit of skin over the
iuHiinied part, whirls als?o apiK^art* ght/ed, shining, and teilem-
atous. The hard Inmp has uow become .^oO and duetutiting ;
tlic latter, however, by no means di^^thicl at tir.Kt or when the
abw^resa h 8umll or dee[K^^ated. The fever is eontinuous, but
liable to exacerbations following slight rigors, wcurring
sevend tinier* a day. If left alone» the pun eventually nuikes
it** way l(j the Hurfiice, the alMScess l»ur?iliA and h> discharged,
greatly relieving the j>ain and tension, and either recovery
f«io[j follows or sul>siietiiient renewed attacks develop later^ as
betbre described,
rnflannnalion without abscess* ocenrF most often within the
first week after delivery. InHamniation with ah%*^s8 is mure
fre4|iiently a later occnrreuce, e^miing on in three or four weeks
after labor, or apiin, the acute symptom!? of in liam mat i<tn nniy
apparently disajipean leaving only a feeling nf weight with
some pain ami tendernesfj, and yet suppuration may occur,
even afVer .several months.
The symptinns now dej*cril>ecl mx'ur. varying in degree with
the extent of intlnmnnition in each variety of mammitit*.
When, however^ the snbglandular cellular liKnue is inrtaniedt
a few^ of tlie symptoms are consideraltly niotlitie^l ; tlms the
whole breast \^ jiwollen and tender insteacl of there Innng one
Bjiecial jxiint (»f tenderne.*5s, and every motion of the arm pro-
duw^ pain, t)wing to the movement of tlie chest muscles under-
neath the ;r!and. The pus is slow in coming to the surface ;
may accumulate in large quantities before doing so, an<l leati
to severe constitutional disturbance and uumeroua fiistula* and
sloughing uleenitions.
636 L\FLA}fMATION AM* ABSCESS OF THE BREAST.
Ill protracted case* of either lorrri t>t" iutiammation, acconi-
paiiie<i with profiint' Jiiid |m»liiy^efl jiiiruleDt «lii*t'harge, t*ynip-
tt>ms of ]>rulo(i^^tnl exhuuHtioD and debility tuny eusue^
MamiiJMiy alx^^fes.s usually afTecti* unv hruiKst only, tiuiij^li
scmietiiiiei!? hot li. Tbt* seiTetm^' fy tietion uf thi- diseiised ^laud,
thou^li not sit lirsl iiet'etisarily arrested \ for llie beiiltby b)liule»
continue tbeir 8ecretioii ), is eventually b>ftt from the nece^ity
of witbholdinif the cljibl from siicklinp^ the inflained breusL
Wheu, however, the inflammation hfn^ been t>nly sli^dit and
the abs<*esti sinall^ lactation may often beresomeil after con va*
leseence.
Treatment.— Frnp/iv^ar^rr treatment eoneistsiD keeping the
nipples aseptically eb^an by ap|>lying l>orit! add Kihaion (f^ee
*' Cbappe<l Nippleji** p, 276' 'ind in preventing engorgement
of the breasts by aeeumnlated milk,
Cunitire Treatment' — In the very beginning try to get rid
of inflammation without suppuration taking place* In each
variety of the disetise enjoin rej^t in hed with rest of the
inflamed organ by not allowing the child to ruckle from it.
Kcvp down the secretion of milk \\y saline cathartics and
abstinence from fluidj?. A|i|)ly over the entire breast extract
of IfcMadonrja.^^j, mixed with linimentum campborav ,^, or
instt'Uii of this, the leacl and opium wash may be constantly
a|>piied on patent Unt covered with oile<i eilk.
li. Plumbi acet.»
Ext, o|)ii,
Aquili,
gra xv] s
Painting the breast with tincture of iodine once during the
first twenty-four hours is an exctOlent abortive measure. Con*
joine<1 with these medieiual applications, cover the inflamed
organ witli a bandage cushioned inside with cotton wool m as
to make even and systematic eomprfitmon. Add one thing
more, viz., drii cold by keeping conrfantly over the inflamed
breast a bladder c»r thin rnbl^er ba^r fllk^d with cracke<I ice.
Fissures or errjsions aliout the nipple should 1>e made asepti-
cally clean and then painted with a nitrate of silver mlution
(gra^. XX, to wateft ^^j ) before the other applications are put on.
Instead of ice applications, hoi (mes ( flaxseed-meal (KJultices)
are used, liesulution may occur with either plan. The eold
TBEA T3fENT.
637
applications are lietler duriug thu etirly stage of inflammation
aod may he clianged ibr hot ones when siippriralioii i^eems m-
evitiil»le, to hiii'teii that pruoesi* tuul hnii^^ the \fU» toward tlie
surface. But in most mises neither heat nor n>hl will lie
required, the more conveuient systematic €ompre?sicjn of the
inflametl breast with dry cotton bein^ all-snthinent.
In eases where aeeumuhitiou of milk in the iuHumed hreiist
is veiy greats and not relieved by the remediei* given, it may
l)€ necessary to mifigate the tension hy gentle exprt^ion with
the hand, previously anointed with ramphorated oil ; hut on
the whole, breast-pump, suckling, an*i manipnlatimm are not
gen era Hy advis:d>le, «>n aeo<nint of the irritations they j produce.
The child may genendly beallovveii to t*uekle fn*m the Ileal thy
breast, but when the mother is much reduced in i<lrenglh, ur
when suckling the one a|i|^hears to keep up engorgement in the
other intiaineti side, the child should be weaned altogether,
with a iMvssihility of lactation t>eing res^umed after recovery.
Whtn mfftifdomji of suppuration befjin, the lot^^d treatment
eoosists in the t'enj rarhf evacuation of ]*u,s Uy incision, P^veu
before fierceptible fluctuation, and when in clonht m to the
existence of pu>i-forniati«*n, the case should have the l>enetit
of this clonht, eitiier by puncture with an exploring needle or
deep f>enetratiorj by a small lustoury. The pntient having
been anicsthctizeil, and pus having been denumstrrtted In' thin
cxi»ioration, a free ii^cision, sufHeiently large to admit the fin-
ger, is made in a radiating ihret^tion from outside the areola
of the nipple toward the cin*unifereuce of the gland im an ti>
avoid cutting acro^^a the milk dartsA). The fingt^r must then
enter the incision and abscess cavity and fearlessly break up
all pockets of pus, so ai? to leiive imly one continuous sac,
Tliis is then irrigatrd freely with boric acid or normal salt
solution and lightly jiacked with sterile gauze, ami ihe whole
breast bnndaged. The irrigation, replacement of gaii/e, and
handagiug to be re|K\nted once daily until the tlischarge Ik*-
ei>me.s trifling, when the packing may he omittc^d ami a
amaller strip of gauze heing introduced for drainage, the
breast is more tightly bandaged, so a* to bring the walls of the
empty al)srr8s cavity to^'cther. In a few days the cure be*
comes complete.
Should there be two aliscessci^ in diHi*reut parts of the glatid,
each one niuist receive the ^ame treatment ^eparately^ but tLiid
638 lyFLAMMATION AND ABSCESS OF THE BREAST.
is unimiiiiL If^ however, the evticuution of pus waa drJmjcfl,
the whole pnx*ess may repeat \i^\\\ \n\i\ re<^uire the siuiie treat-
ment over again. Heiiee the early inryun for the di^'lmrge
of pus, even In^fore we are absolutely |M)silive that it is pres-
ent, is a most inijKirtant factor iti prouiot'ui;; rapid cure.
liisieail of the ijHuze 1 1 rain after incision, w>nie prefer ruhher
drainage tube's tlirou^di which tin ids nuiy he injected for irri-
gation»
In old neglected eases, timitliy treate<J by small incisiongi,
the jKitieut should he anie,stiH'lij^ed, the iueisiou enlargeil to
admit the linger for tlie l>reiiking up of eoinnmnicating jnis
sac% etc., as already destTibed. Thh it* the otdy |>ropt»r
methwl ; no half-way measures will sneeeeil In i^\ih-mam-
inanf rfffnlithi the line of inci,'*ion mu.st tie at the lower mar*
gin of the ba.ne (»f the Ldand following the circumference of
the Itreast. A^spiralion may he rc«piiretl to detect pus early
in thetse *'a<e4*.
In badly inuuagcil cascsi, when acute .symptoms have sul)-
stded, leaving the hrea.«t Btiif, red, and unevenly indurated,
with weeping fistulie, paint with tificture of iodine ami apply
sy^tetTiatie coniprei^ion with bandages or adhesive (ihii^ter,
leaving n|verture8 over the ti^tulie for drainage^
In every ca*se of considerable duration, good food, iron, qiii-
nitie, and hi iter tonics will W ueceisajiry to prevent debility uml
exhaustion.
The treat nieiit of mammary ittflammation witli a view to
preveni i*U]tpumfion has always been unsettled^ ernhmcing
uiany diflcrent and sometirne^soppjsite method.s. The main priu-
eiplei?are ; (1 > IteM^ i» f*, keeping the child from the inriatneil
hrea^t ; (2) systematic com[ireKsion hy well-|>added bandages ;
( *A } ap[)Iiealion of ice or of aj^tririgeut and antKlyne lotions ; < 4 J
re<fuction of ntilk by laxatives; (5) fcvei% pain, aud nlher
symptoms to be treated ai* I hey arise ; (6) cure of sore ui|ipl«*
and thoroufjh atdi.-*f'pUe efeaulint's*.
Finally* the eni|»loyinent of fld. ext, phxilohicca dtatndra
fptkeroot) in doi*e4S of twenty drop every three or four htmrs
and ui»plie<l to the iiiHanied jireasl lo<;allyi has been extolled
.as a specific ; it i« sai<l to eure in twenty-four hours {J),
LACTATION AND WEANINQ. 639
LACTATION AND WEANING.
No arbitrary rule can be laid down suitable for all cases, as
to the length of time a woman should nurse her child. About
one year is the average time at which weaning may take
place. Many mothers nurse their children longer. With
savages lactation is often continued several years, or until the
advent of another child. With many delicate and sensitive
women in the higher walks of life it is im[)ossible to continue
lactation beyond a few months, and many of those who j)er8ist
in prolonged lactation l)eyond a year, suffer in conseijuence
from anaemia, menorrhagia, and permanent impairment of
their capacity for lactation, as is demonstrated when future
children are born to them.
Besides a general incapacity for producing milk without
exhaustion, there are certain conditions which should prohibit
a mother from nursing her child. These are a strong hered-
itary tendency to cancer, scrofula, and insanity, constitutional
syphilis, great emotional excitability. A violent lit of anger
has rendered the lacteal secretion sufficiently |X)isonous to
produce convulsions in the child. Lesser but more constant
degrees of emotional excitement produce deterioration of the
milk to an extent which may still be injurious.
The return of menstruation and the recurrence of pregnancy
during lactation usually change the milk and make it unlit for
the child. Exceptionally this is not the case. Some pregnant
and menstruating women continue to secrete milk that agrees
with the child. The health of the infant will indicate to which
class the mother l)elongs.
When from any reason the woman is not able to nurse, the
infant must either Iwfed by hand or supplied with a wet-nurse,
the latter course being always preferable when it is practi-
cable. In sele<^ting a wet-nurse it should be ascertained that
she is free from all of the ini|KHliments to lactation just
referre<l to ; that her digestion and ap|x»tite are giKxl ; that
her <lis|)osition is chei^ful and goml-nature<l ; that she is free
from eruption on the skin ; has sound gums and teeth and
inoffensive breath ; and that her own child is healthy and well
nourished. Iler breasts and nipples must be normal, and it
should be known that fulness of the breasts has not been
640 INFLAMMATION AND ABSCESS OF THE BREAST.
artificially contrived by permittiug milk to accumulate for
many hours before the examination. The age of the wet-nurse,
where there is room for choice in this particular, should be
between twenty and twenty-eight years, and the time of her
confinement as nearly as possible coincident with that of the
mother whose child she is to nourish. When no wet-nurse
can be procured, the child must be artificially fed by hand.
Directions for the preparation of its food have been previ-
ously given in Chapter XIII. (page 278).
CHAPTER XXXVIII.
KESU8C1TATI0N OF ASPHYXIATED illlLDKEN.
Children boni dead are said to be *' Hill-born,-* Others
are born in a state of s*us^>eotled animation, uppurently dead,
not really so ; there is no l)reuthiu*,^ but the henrl Htill beuti**
It is a,M[)hyxia ju^t within a fatal degree ; lee Imically a^/Zn/jtVi
ncoiiatonim — the ai^phyxia of uewU^rn ehildretu
Causes. — Fird, — C^>iididons of mother interfering with res-
piratory functions of placenta, viz,, death of the mother ;
extensive pulmonary di«ease» restricting her own res^^piration ;
prol'u.-ie lieniorrhuge ur iirofouuci autemia from other eaui.'^es,
which may leave her without sutfioient red globules to csirry
on re:*pirati()n, etc,
Seromi — Conditions of c/u'W and its afipenilage^ viz,, com-
prest^ion and twialiny: of iimhilk'nl eorfl ; interferenee with pla-
cental circulation by it^ partial or com[>lete separation l>elbre
birthi as in placenta pran^ia, etc. ; prematurity of birth; injury
of chikra head during delivery by coin|>res*iiion of forceps,
narrow jvelvis, etc., [lossibly with intracranial hemorrhage,
slioek, and nervous disturbance, preventing action of inspira-
tory niyjR^les after birth.
Symptoms. — Bfjhrr ift/hmj aii|ihyxia ishould be anticipated
when the above cauiies are known to luive been present* F«etnl
heart (by anftcubation) fouml at firM to lieai with dhninu'*ht;d
frequency, not only during, but Intiveen the pains; later on there
is increawd frequency of the heart-beats. Discharge of metyp-
nium is of great rbngnostie ini|x>rt when not at*connted for by
compression of chihr.^ abdomen, m^ in brt*ech presentations.
Discliargeof meconium al»<» indicate** that brealhitig in utero
has mcurred, which inakcM the case worse from II aids having
been drawn into air-passages. Occasionally air gets into womb,
and child is heard to cry l»efore birth ymfjitu^ uteriniu).
When child's body is partly extrnde<l inspiratory efforts may
be se^n, as may also the lividity* etc., indicating asphyxia^
Syniptonie after birth : The child is born in one of two con-
ti 6ii
642 HESUSdTATlOy OF ASPHYXLiTED CHILDREN,
ditiuns ; it is cither livid in color, with purpie> clui^ky*red» mid
Ciju^^ested skiu, dark iind swotleu ]\\^^ etc., rousthutiii^ tho
earlier and milder form of asphyxiu called uj*pltyria /tViVfo,
or it h pale — of ii c<jr}JSt>Iike wliUeurss — with auromia of the
«kiu, coiistiiutiiig the later and runre fatal form of a.-^phyxia
cal 1 t?c 1 UHp h yjr in pa /// f hL
In the iivid variety the vesssels of the cord are full and
turgid; iu the pale variety tbey are empty, or nearly so. In
llind casei* the limim and mujicle,< retain iiome tonicitVt aod
retlex eontractions may l)e excite*i hy pim'hin^ and other
stimuli ; iu ^xiie cibsea mupelen are totally relaxed, including
the sphincters, and reflex excitidnlity isaV*»M.*ut ; the lower jaw-
drops, the heuil ilan^des hwj^ely, TupiU are widely dilated.
Prognosis. — Mo^i of the lh4d castas may be rei?uficitate<l ;
80 may some of the pnUid one^. While the heart heats tliere
is hope ; it mmj heat when not felt to do so, aud wheii alt
pulsation in the cord lias gone. Excc|)tional cases have
nndoubUdlif heeii resui?eitatctl seven or eight hottr^ after
delivery ; most of these ilie, ailer a few days', imm pulmonary
extnivasatiou, ateleetasii?, anil pneumonia, lait reeo verier are
kuowti. Any eliild that is fresh, i e., not maeernted, or
presenting evidence of havintr been <lead some eousidcrable
time, should be subjected ro treatment ; it satisfies the pa rents.
Treatment.— In miy ca^^e. whether itrifl or pullid, waste do
time in making a diagnosis l>etween life or death. Art as if
the child were afire, but never hurry ; it is not a matter c*f
mtmients, but may recjuire a Jnll Itoitr Indbre abandonment
wonid !«? justifiable, even thotigh the child may not have
breathed during this time.
In alf viii^i^i^ there are hm things to do, viz. :
1. Bvmove forrifjn mtitterit from the air-paiaage9^
2. Get air into the Iftntji^.
In the bad, pallid cases, it may be nere^^ary a^<T removing
foreign matter and before air can lie introduced, to
3. Open thr (jlottiK (The mus<'les, whon^ duty it is to open
the glottis, fail to act ; they participate in the general flao
ciility of the nnisides of the whole VxKly, already noted.)
The methods of accomplishing the.se several objects are
varitnis.
1. Methods of Removing Foreign Matters from the Air-
paflBaipes. — (a) riuce the child on its haek, the heaii a little
METHODS OF OETTIMJ AiR INTO THE LUNGS. 643
lower tliuii lilt' body, hanging over the edge of a table. Pass
{\w litlhi Hijger iutu rht^ faiifes and m wijie out (he manih ami
jiftniyNj; with u thin, 440ft htiridkerrhief, or the child amy be
held by the feet, 8Usj^nded head downward, while iluidb flow
out by gnivitatioii-
(b) To dear out the iravhea, jiluee the child in same posifnm,
gra<*p the ehe^t geutly and eontinuoysly with i>ne hand, and
with a finger of the other stroke the trachea on the outside,
frofu below upward, fiy whieli mucus b.si^ueezed out of it into
jKisterior imres, I^et the hiiger tiow nuiintain pressure at I lie
top of tile trachea, and the other band inaitmiin iLs compres-
sion of the thorax while the obstetrician I down gently into
the ehilcr^ mouth, iirevioody covered with a Imndkerehietl
Muens from the trat^hea is thus forced out at the child's
nostrils.
(r) I'ags a catheter into tlie trachea and aspirate or blow
out rimcns hy application of operator's mouth to other end of
it ; or retiiin catheter in trachea while Schnltze^i^ tiiethiKl (men-
tioned further on) of artificial ret^piration i^ [K'rformed. To
catheteri/A" the tracliea, select a guni-e!aistic male catheter,
the diameter of the external circumference of which shall lie
less than one-eighth of an iucli ; fa^^ten to it a string or tajie,
three and a half inelu-jt from the end to be intixMlucrd ; guide
its |M>int with the finger beliind the epiglottis and into the
glottis, passing it in until the t4q>e» three and a half inches
from the end, touches* the child's lipg» when the point will
remain above the Infurcation of the trachea. To retain catheter
at this |)oint, tie eiiils of taj>e around the back of the child's
neck, Now compress thorax gently with one hand as before
explniued and l»low through catheter. Since the air blown
in crintiot enter luiig while thorax is cTunpressech it will rush
back and up alongside of calheter and mmj rntwii^ dr,» out
of tmrhea into [ihnrynx. Suction of a catheter is a more
unpleasant nielhod, hut not a better one,
2. Methods of Getting Air into the Longs* — (a) The
ordinary ways of exciting natttraf itiJ^piratton by sprinkling
face, neck, and chest witli c(dd water; ruldnng the back or
chest with brandy or svhiskey on a hit of flannel ; flagellate
nates ; dip the child first in hot, then in cold water ; pull the
navel-string downward by gentle jerks ; tject a mouthful of
cold water forcibly against the epigastrium.
644 RESUSCITATION OF ASPHYXIATED CHILDREN.
(b) Schuliie^ 8 3[ei hod of Artijwmt Respiration. — ^The cord
must Iw? cut and tied. The operator stauds Mrith hk legs
FiO,3W.
Fio.301.
Pojrttlon ^f tmplmtton. (Witkowsk J. ) Paittlon of cxpimlion. fWjTitowf iti.>
apart^ Ids \mdy leaning a little forward, and holds the child
ill arni*a lencrtb. hanpiti^ f»t*r|K»ndjcukrly, in the following
tnauner : He faces the child's back, puts an index finger into
METHODS OF GETTING AIR INTO THE LUaVGS. 645
each axilla, hh thumbs over the i^hoiililers so that tiieir ends
lap over the ekivirle?? on to the front of tlie che^t, the re§t of
hb fingers ji^^o ohii<jUely over the [mrk of the ehe^l, the ulnar
sitles of the two IhukLs .siipiiort the ehihris heath The whole
weight of the eliililV Imdy now hataji* ott the iitdej- fingera in
the iixillfle which lifYn the rihs, expaucln tiie chest, and producaa
inspiration meehnnieally. (See Fig. -^00, pa^e <>44.)
Inspiratimt having heeti thus aceoniplifihech the second ob-
ject of the of)erator is to produce iiiec'haniea! vxpirafian* This
he d oes by ^ w i n i;i n ^'' t he e h i I d fo r w a ril , soi n e w h a t | m we rf u 1 1 y ,
and at arni'8 length, until bin arms are a httle it hove a bori-
zontai line, wbi^n, by a .lonievvhat abrufit hut earefully ad*
justed arre^^t of the motion, tlie thorax of the ehihl beeonies
stationary, wlide the lower Vnul^a and j>t*lvi>i of the infant
retain just enou^di of the swin^dug ini(»etuH to topple over
toward the o|H^rator and in front of the ehild'^ aI»domeu (see
Fig, HOI ), The bidk of the weight of the child now rests
UjKai the thuuil^w in front of the thorax, while the abdominal
viscera jiress agaiiL^t tlie diajdinit:ni, etc.t niid |)roduce ejy^ira-
tion. At this 8tage of the profve<iinji^ any iiuids that may
have entered the true hen are eopioysly dif^^duirged.
Finally* the t>j>eniti>r again h»wers hi?* arni^ letting them
retrace the curve followed during their elevation, by which
the legs aufl jKdvia of the infant unfold from their doubled
position, and falling down at full length the htxly \» completely
exteutled with eonwideralde inT|»t'tU!a, m that the child again
hangH by the axil he on the index fingers of the ojM-rator, just
a^ it wa8 Indbre the swinging motion began. The whole pro-
cess of each complete act, 4*oiij[)ri.sing IwHh the inspiratorif and
€Xpirator\j mnvements, should ix'cupy almut n^ven Heeonds ;
lien re it may be repeated at the rate of eight or nine times a
mill u te, so m turhnt ns fo 1 1 o w s :
Seconds,
Inspiratory pause, while lH>dy k supjMjrt^ by fingers
in axilla? 2i
Upward swing .... 1
ExpinUory i>auf?e, while tliorax is supported on
thumbs, an<l legs, etc,, topple over ,...,. 24
Downward !*wing * . . . 1
Dumtiou uf one complete act 7
I
G4ti RESUSCITATION OF ASPBrXIATED CIULDnEN,
This chroiinlogical division of each act niuy van\ When
ios[iire<l fluiils rfow i>ul while (he cliihl is ch'vnted, a loii^^cr
pause ill I bat pasitiuri h advisiible, Schullzc'i^ iactiio<l umy
be uschI witli (»r without catheter. Kveu whbotit the ctithctcr,
ami ill the [Mil lid oasict^ witli a chi5<ed ghjttis, it a^^rves hi Home
way to open thf fjl4tffU which otlier methods do uot^
8t*hultze'5! methfxl my^^t not Iw done nnifjfUtf, especially In
premature children ; it has pro<inccd internal hcniorrhiiges,
rupture of the liver, and Iractures of lioncs, when violently
and carele.ssly e^EccutecL
( c) Siffte.ttrr.'i Mrtfutff of Arfijickii lii'^piratiotu — Place child
on itii back^ the t^boiildeis rc^tiuji:; on a little roll or cushion,
just high enough to keep the chin trom falling on the c^hcst.
Se<*ure the feet to sMUiie fixed (mini. Stand U4iind the hen* I :
seize the arni^ (one in each hand) just uhove the elUjw.s aiid
raise them gently and steadily U])ward and forward until they
are fully exterMled along the side.^ i>f the child'* bend, ai the
same time rotate the hunierus ^slightly outward ; mniiitain the
arms thus <mi the strt*tch fur two or three iH?conds, This
secures ini<piratiofi. Next turn down the chihrs arms and
press them tirndy and gently against the sides of the che^t for
two or three seconds. This securer eTpiratiotu It may lie
necessary to pull the tongue forward to open epiglottip, and
this doe!« not always succeed. Shoo Id there l>e dithciilty in
securing patency of the glottis, the only 9ure remedy is the
catheter^ used as In4bre state^l.
((/) Labordr.'f Mttlttnl inj Toittjue Trartion. — An assistant
holds the child in a half-sitting |x>f^ition while the operator
seizes the infaut*s tongue with the tbiiruh and index finger
and a piece of linen as near to the base la* possible, and pulli*
it forcibly forward and then relaxes it, repeating the tractions
alwut fifteen times a minute. Instead of the fingers a |>air of
dressing-forcei>s may l>e mei\. It is sup[K>4ied to excite resjii-
ration by reflex action. This method is new, arul still a nnit-
ter of exj>eriment. It can do no barm. Evidence of itd
value is increasing. It would seem to be esj>t*cially applicable
to premature children in which the thoracic walls an: too soft
ami yielding for the Sehultze and Sylvester metluKLs and in
which iutlatiori of the lungs through a catheter is cnmimonly
necessary, Williams s[ieaks of it as " the most effective meas-
ure at our disptj>sal« and the prognosis l>ecome8 extremely
METHODS OF GETTiyG AIM INTO THE LUNGS. G47
gloomy if \Xb eni|*loynieut i« uot atteiidtnl hy Halijsfactory r*j-
sults within 3 tew ruiuutes" ('* Obstetric^" |n 751, tin*t etlitiou,
i^e) Mdltod of Byrd and Deu\ — l^t the chihj rest on its
buck in the buotU. h» thut the htivk (yf its neck lies l>etwe€n
the thunili lunl imlex linger uf the leJl haml, w bile the other
fin^rer^ of this han<i g'o into the ehild'^ left axilla. Be sure
that the liead dftftfjh'H frftftj bt iricwu id nud ihiV,n\\i\rd ax t^T the
junction IniLweeii the thnnib aud index linger* otherwise the
glottis njiiy ni*t njw n. The right hund hoid,s the chiLTs? thighs
w* that they rent in the palm, witli the right index tinker
lu'tweeii them. Now the ehildV Hpine ie alternately exkaded
ituil jftj-tdy whieh |iroilueei< res[)eclively ith^piratton and fjrpi-
ration^ During Jlcxiun tbe kneei* and chin approach ea<^h
other; during vxirnaion they are jje[>aratt?d i\^ far ait |>ofiiiible.
Tlie body i^ thu.n folded and unfolded, <loubled forward ( knees
and chin togither), s|Hne Hextd, thuu stretched out backward
as if it were suspended transversely tm a lra|ieze^ with the
head and tduvSt haiiLnng ou one side and the jxdvis and legs
n|x*n the other, .^o that tbe spine is extended, tbe rhe*st ex-
|mnded, and air eonsequeDtly inspired. This manipulation is
re|>eated fifteen times a minute. There are several other
TiietbtMis of holdintr and folding the cliild in tbe practice of
this Byrd- Dew method, eijnally effe<;tiveand easy of exe**ution.
f )ne ailvantage of this metboil is that it can be done wbile the
ehihl is in a bat^in of hot or r-ohl water.
( f) Bni^t*H MfihiuL — Lay the chihT?! body (trro/<x the palm
of one hand, face dnwnwjird, with it.s t'eet toward the ojierator,
so tbat the arTii8 ami hi^ad ai' the rbild hang by gravity over
one In^inler of tbe hand and its lower limVie over the other.
Then roll it over (juickly sotbjit ib* l>aek falls arro^ the fmlm
of tbe other band. This motion is re|Hniteil to and fro, the
ehild bcinL' almost tr^sed or tia]>^>ed from one hand to
the oiben It is evident when tbe child's bo^ly thus bangs
across the hand on its fttifrk, inspiration is produced ; when it
hanL*"-^ face downward f»n its ehe.st and abdomeut expinitioti
or(*urs. The hands of the ofierator are held near together, so
that the child is simply rolled from one to the other in the
amnner stated,
(g) Mftr»hali Hnirs MHhod, — Sit down, lay the child acrosB
your lap on its back, iii^ head hanging over one thigh (say
648 RESVscrrATioy of asphyxiated children.
tlie right one, for example i, so tliat its left side is toward your
IwMly, tti^ right townrcl your kuee& Nuw take hold of its left
arm (the ooe towanl you; with your right haoJ aud iti^ left
thigh with your left hiindl Theu njll the child over toward
your kneea until it reettf on ir^ right side^ or a little lieyond
thiii, almo«t on it** abdonien. This eunipreases the chei^t, pro-
ducnng ejpirutton. Then roll the child hack into it^ original
j^Mition* traction on its left arm kieing made forward and
upward towiird its head. Thia causes ex [jangiou of the chest
arjil i^iMpinitioii, Uepeat about ten times a minute.
When aHfihyxia i« re<50gnized before delivery^ labor muM be
exfjedittMi by every available juilH'ious means,
St'htiJtze*^ methmi» wiiile a rough proceeding, and requiring
mmw, rtkill, is ue^ramrif, niJirKt, for the jMiiiid csls*^ but may
be tbi lowed by St^lt^ejitcr^s when the pallid triage is passed.
For »ni?<t firidvtmfs the easier ami gentler method of Sylvester,
Mar^liul) llnll, or Buint iniiy i?iitbt*e.
Ill cum-H whtire the lieart K-arceiy l>eats, its con tract ion a may
iw Htimu lilted by nuikitig slight prt'K^ure with tiie lingers over
the precordial region* l)y injecting: IkjI water ( 105*^-108**
F. J into the rectnnit or by a few drops of brandy or whiskey
i I ij t'cted hy | x « 1 e r m a t i vt\ 1 1 y »
Children that have been deeply a5»phyxiateii require, even
after complete reHn,sfitation, ej-tra warmth, aud in enBe of sub-
net] ueni licart-failuri* — ulways liable to occur — a drop of tinc-
ture of digitally an*! li or 4 drops of brandy, inlernally, re-
jjealed every i\'W hours, or an ot*ten as may be neccjssary. A
gocjtl many will die within a <lay or two, even with the most
watchful care and attention.
CHAPTER XXXIX.
THE JURISPRUDENCE OF MIDWIFERY.
An obstetrician, even when not an acknowledged expert in
medico-legal matters, may, from his professional relations
with patients or persons implicated in legal trials, be compelled
on the witness stand to give evidence of a scientific or quad-
expert character. Under such circumstances a painful lack
of scientific knowledge, often sufficient to defeat the ends of
justice, and coupled with corres{X)uding embarrassment on the
part of the physician, is not infrequently exhibited in our
courts. Hence I have ventured to add, in so far as may com-
port with the brevity of this work, a few rudimentary remarks
upon medico-legal topics of an obstetrical character, which
while treating the subject only superficially, may perhajw
afford some assistance to the unavowed expert or confessed
tin-ex|)ert medical witness. The works on Medical «/Mr*V
pnidence by Alfred Swaine Taylor and by Theodric R. and
John B. Beck are my principal sources of information for
what is to follow.
Duration and Unusual Prolongation of Pregnancy. — The
average duration of pregnancy is ten lunar months (forty
weeks— 280 days). The moral character of a woman and
the legitimacy and consequent hereditary rights of offspring
may depend U|X)n the acknowledged degree to which it is
possible this normal duration may be prolonged, as when a
woman gives birth to a child eleven or twelve months after
the death (or continued absence from other cause) of her hus-
band. It is undoubtedly possible for pregnancy to be pro-
longed four, five, six, seven, or even eight weeks l)eyond the
normal j)eri(xl, and the child be bom alive. ^ Cases are re-
I A rhild may die near ftiU term t after symptoms of labor hav«» boinin and
dlMipiH'arod), and remain in utero months and yean afterward— so-called
" misHed labor " cases.
649
(j50 Tflh' JURISPRUDENCE OF MWWlFEni^
cordfd ill Tayktr'^ Mrdimf JnriitprHdvHce, r>tii Ami^r, e<l, pp,
47^5-4^^1 ; riayfuir'ji Mklwijcnj, 2ii«l Amer. od., pp. 154, l')5;
LiiHk*8 MUhvifenj, Isl t:<L, ji[>. 10!', Hi); Ivt'ii^hmaLi*^ J//#/-
wifenfi 2d Amer. eiU, pp. 17*^-1 Ml ; Muiti^s' Treatue on Olt*
»ietric^ 3d etL, pp. 228-234; Beck's Jitrispradencet 11th t*<L,
vol i.» pp. fJ(H)-*>m.
Thost? whu ajvsert such cas<^^ to be fUljuhtye and uiireimhie
nmy lye Jinsvvered with the stateuieul that the same amount of
prulougatioo Urn* Ijeeii oliserved in auinia!i!» (I'ows and mare»)
ia which tlie thite ol'(^ntii« way jmiiiftithf knotim.
Thti p<)j<8il»lt^ uiiliuiited retention of the <*hild in certain civr^m
of extra-uterine Jft^^tation ninst lie renienaljcreii iu rehilioii
with the dnmtion of prepnuicy, in so far as it may atieet the
rliaraeter uf the wianau. The chil<l, alter full term iu eiueh
cashes, al\vay*s diey.
Children l>on» after over-long pregnaneiei* may be overlarge,
hut are not always h».
The Age of Maternity « — StK'lal hivvs* in most pla«*o-s r<»trict
very t'lirly maternity, Imi in Oriental ('(Mmtne>; whert^ marriage
IB ]>ennitled earlier girls heeome mothers at ten or twelve
veal's of age. Such ease^ ot*cur, rarely, in other climates.
Three easei*^ one at eleven years, one at twelve, and one at
thirteen* well authenticated, are reeorderl in Barnes* Stfsteni
uf OhntHrtr Mrdwtnp a fid Sitrgrnj (l^t Amer, ed,, ]\ 241),
in * Jreat Britain. In one caf^e the girl he^ran to menstruate
while aehild twelve months old, and also had enlarged breasts,
with growth of hair n]M)n the pubes and in the axilla?. She
WHS delivered of a ehild weijrhing fieven pounds before she
w as ten yea rs ol d, (1 jo n c h ai Iai tt r*i, 1 8 H 1 , >
\^ to the hiieM age iit w bich a woman may l>ear a child, a
few eai«es have been recorded at the age of iifty-«>ne and fifty-
two years ( by Fordyee Barker in Philadelphia Medieai TtmrA,
1874), and one at the age of tifty-five years by Davie*, of
Hertf<>rd, England (London MMiml Qiueiie^ vrd, xxxix.V
Barker cleclares that *Mhe laws i>f physiology, the ex|>erienee
of mankind, arid the deeisioni^ of courta of law justify a medi-
<'al niJin in declaring (hot a woman over ffttf-five ijeant uf age
is psist the period of ehihlheiiring.'*
Though it is rare for women to l>ear children after the oee-
Batiou of the menses at the *♦ change of life,'* it is pnmble f«»r
them to do so, as nire cai^es occasionally demoustrala
EXTERNAL APPEAR A XCES OF FtETlM 051
Short Pregnancies with Living Children, — A living ehilii
and one tliat euDtitJiH-.- to livt*, biding horn umt\ v\ji]iU bn-veti,
six, or five iutiar iyi*iitlL'^ mIW T!ijirrinf^t% riuiy Ik' the cnus*^ »»i'
S;UH|M.K'tetl |>rivmariti*l iiirluistity oa ihi^ jmrL uf the mother^
au4 jHh'^ibly of nilegetl jfrouDd t>t' ilJvorre by the huslmod^
together with (Uher h^gul niul sotntil i^miiiii eat ions. The chikl
\» umloiilik^illy vialiU? at thi' end of the seveuth hirijjr nioiith.
Excei>ti<iiially. c'luldreu I M>r a at the sixth aunith have lived
aad heeu rranti C';ijie.s are even reeerded where the intiiat
aurvived a ttlutti tlmt whea Iwrn at the titllh, or eveu at tho
foarth aioath. (See l*iay fairs MldivljVnj, lid Amer. ed., p.
229 ; Beck's Medlrai J ttri^pnttia^re, 11 th e<h, v*iK i., pp* T^i'V*,
600, a!^o [\ 3:]8; Meadowi^' M*nnuiJ of Midirifi'ty, 4th Amor.
&h, pp. 91), ^M ; Tayh>r'j5 Midical Jftrii*prntltnrf, 0th Aiaer.
ed., pp. 4B8-471,) The poio^ihilitii nf exft«ptiniaVI C4»«<^^ mast
id ways he reineaihered sum I Ktale<L It should, Tnoreover. he
borne in aiind that an error of a moath taay oeeur, de]M'adin^
ajwm the sekrted aiethod nf datiai,^ the ht'fjinnlwj of tlie [vre^-
oaacy, /, r., wlietlier frtan the hist aieastrautioa <ir frt»ni the
first titnittrfl aieiisiraatior^ (see j>aj^'e HM ),
External Appearances of Fcetus at Different Periods of
Gestation, — ^A inedieid witTieFs may be asked to ex|)res4! au
opiaion m to the prolmbh duration of a given pregaauey^
from the appeamace of the child. He (^luuol lie pimtitH; «»r
exaet,
Durlntj Fird Lunar Month,— Only a few htimaD einl>ryos
have been ol»ser\^ed diiriag the first two weeks. During
the Bc^eoad fortniirht the /wr/^y of the eadiryo i« very sitailj,
bat with n very large aadiibeal vesicle. During the third
week the ImmIv is eurveil ualero-|xj*>teriorly. the dorsal sarfa<i^
[^reseating a deep coacavity, so that the spine « ur what
is to liecoaie the spine) reseiahles an imperfect letter S. Dur-
ing fourth week this concavity is reversed ; the little kwly is
flexed forwanl, head and tail almost touchiag each other like
the letter C. Toward the end of the aioatb small budding
pr«>jection8 iadieate riidiaieatary lindis. When the month is
eoniplete the body measares 7.5 to 10 mm. (0.3 to 0.4 in.) in
leagih.
Second Month, — Uaihilical vesicle diminishes tn size.
Head enhirges: tail disapjiears. Visceral clefts aad arelies
appear* Fajtas preseats u recognizable hunma form. Km-
652 THE JURISPRUDENCE OF AfWWlFERY.
bryonic body, at end (>!' mouth al)out oue iucb (2.5 cm.) in
length. The eiitirt^ liltistodermit' ve.Hiele is about the size of
a pigeon's egg, Tniees of exlenml ^^enitJilB perceptible^.
Hard Month. — ^y the end cif the rtiouth the entire hlastx>-
deruiie ve?iiele hjis ^^rowii to the idize of a gotj&^'i* egg. The
embryonie IkkIv is H or U crn. (about ^) to 3i in.) lotig. Bex
is |>ereeplilrle ; nlso eyelids, fiugerii, toes, and traces of naila
The uinbibciil vesieh.^ jitro(ihies.
Fourth Month. — Body jj:row9 from ♦SJ to 5 J or 6 inches in
length ( 9 to Itj or 17 euu) by eml of rnoutlL Weight 3 to G
ounces. Sex well defille^i Lanugo npj>eura. Hkull bones
pre.sent Cfunmeueing eeutrea of ossifieutiou.
Fifth Mtmfh.^By end of luonlh body 9 or 10 uiehes (20
cui. ) long. ^ Weight f"^ oiuices. Head orie4hird the length of
whole fretus. Downy eovering of lanugo over the whole
biMly, perhaji^ a few typieal huin« ou (he s<'alp.
Suih Monfh. — Skin wiuklcfi as if Ixwly eniaeiated, preBeut-
iug an *'4ddage*' apfx-arance. Length of body, at etid of
month, UK 12, or Ki inehe8. Weight from 1J to 2 p<^unds,
Veniix c^iseof^ii ap[>arent, Ijaniii^osluxhiiug. Eyelid.s separated.
EyebTf)Ws and eyedawhes api)ear. Testicles still in alwiomen.
A fliild Iw^ru at thi-^ age may move tmd attempt to breathe
but usually mmu iJie«,
Seventh Month. — I^ength 14 inches {%b cm.) ; weight 3 or
4 |x>yn(k. Testielefl cle.scend into sUTotum. Pupillary raem-
brane cli^api^ear^. Nails well formed. When iHiru at end
of month, ehihl breathes, moves, and eriej? feebly ; with eare
it nuiy Kurvive ; it bus reHche^l the age of viability. The
lM>pular idea that a ebild born at the eleventh month is more
likely to live than oue born at the eighth, is an ernir ; no
truth iu it.
E'iijhth Monlfu — Skin red an«l still wrinkled, like old age
in apy)eariiut^. Nails reach to endsof fiugen?. Length about
10 iuehej^ (40 em.). Weight 4 to 4} pounds.
Ninth .Vo«/A.^l^ngth IH inches (46 em.V Weight 4|
to i^i jMiumis at end of month. Owing to iuerea.«e of suIr^u-
taueous fut the ehihl loses itn wrinkled, n^eil ap|H'arauce,
Tenth Monflh — Length at end of tnonth (full terra) 20
1 For thts. nnd the succ^o<!'cllnR monttifl. aUuwInur two Inelicii fnf «*eh
month will (jfivv « rough approximate avermgf of the ch Ua*« tetiKlh : filh,
12 I 7th, 14, etc.
CASES OF SUSPECTED ISFIDELITY.
653
inches, about 50 cm. Average weight 7 p^juods. Miiy be
only ti, or eveu leys; and oncci in tibtjut HMJO cartes may
reach 12 or 13 pounds Mt'conuirii toimd in rectnni, urine in
bladder. Nails project a little beyond (ini^er-tips.
Cases in wMch a Woman Hay be Uiyustly Suspected of
Goiyugal Infidelity .^ — Delivery of a mature r>r premature
eliild having tnkeo phue, the woman (witbout having njejia*
while seen her bushuud, and without having again sLihniitte<l
lu coitus J may, in the (xnirse ^.yi! tme, two, or thn^ inonths be
delivereii of auotber clilld, which may be either mature or
premature* Such ciuses are sasecptibie of explanation in three
way.^ :
Firnt. — 'In twin pregnauciej^ one child may \w expelled and
the t) t her to 1 1 o sv (i r» I y after se ve ra 1 vv e e k.s nt m o n 1 1 lh, { Vi * r
easets, see Tayhu'^s Medical Jarmprudence^ pp. 4Ht»-4Hll ;
KamslMJtbaai's Oi)HUtrW'% p. 468; l^isbnuin*s Midrnjertf, p*
1*J3; Churehiirs J/trfM?/fcr»/» American edition, 1866, pp. 177,
178, etc.)
Sefond, — The woman may lia%^e a doul»le (hidobtHl) uterus,
in each i*i<!e of which is a t<etus the two nlerine e^vitie?* ex-
pelling their c<intents at dilferent times, (Forr-ji^^H. 8ee llay-
fair*8 Midwiferif^ pjt. oH jiuil 1<>1 ; Lei?ihman's j\fidti'iffrif, |>p.
188, inri; fiiyloT's JfinHpnidetiee, p. 4KH ; Churchifr8\l//</-
wif^ry, p. 178. )
Third, — 'A pregnant woman suhmitting to coitus <lnring the
early months of gestation may have a second ovule impreg-
nated (super-fo^tatifjn\ |>erha|i{si, just prior to the subse<]uent
death or departure uf her husbami. The two fcetuaes may l»e
lK>m at different timefi. ( For cases, see Taylor's JtirtJ^yrU'
dtticey \y. 4>^7 ; Ivcishmarri^ Mtdirifrnj, pp. 18f3-188; F^luy-
fair's Midmfenj, \\\x 101. lt>!2 ; (^hurchilTs Midwifery, pji.
178, 178.) The oeenrrence of Hn|w*r-f<:etation ha,s lieen
qnestioned, hut its possibility, and its actual oceurrenw a^ a
matter of fact, are m»w genenilly admittetl.
When the two children are of different race or c*>lor, one
white, the other black (/^sujier-fecundation '' ) the fidelity of
the female may be justly fpic^tioned.
Finally, a womnii mayexficd a chihl from the uterus in the
usual way, anti s^till retnain pregnant, even for yea re afWr-
ward, owing to the retained faHU8 of a coexisting extra-uterine
pregnaney.
054 THE JURISPRUDENCE OF MIDWIFERY.
True and False Moles, — The ditiguimis of iHKlie^ expelled
friini tlie ;^fiiitnl canal, uol due to ini|»rt'gimtiuu, tVotii tho&e
ut'ftassarily the ivsuk of mitui^ lia^ been ulrrntly sufficiently
conHiiiertMl. (See *'Hydttd(liibriu Pregnancies," p. 218» and
" Moles" p. 228. )
Diagnosis of Pregnancy. - { See i»p, 1 40- 1 4H. )
Signs of Recent Abortion in the Living.— When the fcetns
and itii niend)ranes, in a case of su^[KM'ted ahorticm, are con-
cealed, u medical witness may he rerjuired to give evidence lu?
to exiatiD|,^tiitru!^ of recent ah<>rtioti in the Icmale. Alnirti<in
during the tir^'^ thret- nionth,-^ i»f pretrnancy may, even go Hx»n
JUS twenty-four hunr.^ after delivery, lenve no proofi whafetrr
of itjS tw^eurrenee in the living woman that can be rec^ognixed
hy exarni nation.
The ordinary sign??, at In^st amhignonp, viz,, diljiLatioti of
lheo8 uteri, with some hK^iial ( hloody } «li?eharge therefrom,
etdargement of the uterus, swelling and relaxation of llie
vulva and vagimd orifiee, enlargement of the hrea^t^, ?4H're-
tioii of milk, presence of darkeneti iire»>hi arounti tlie nipple,
etc., nnty either he wanting, or on the tJther hand, result
from other caust^i^.
Signs of Eecent Abortion in tbe Dead.- — Even the pont-
motirm signs of al>orlioti during the tinft three months of
pregnancy may so completely dijiiijiiH^ar in the course of a
few days after delivery as to leave no pKHitive evidence.
Htitiafactory proof!* nuiy, however, be obttiitied, if examina-
tion lie mside within forty-eight honrn atVr expulsion of the
ovnm. Then we find usyally some enlargement of the uteni«.
both of its cavity and walls, t!ie latter being thicker and with
larger bloodves-ieIi< thiiti in a iionnal ami unimpregnatetl
state. Cavity of woridr may (?) cnntain remnants of blo«xl-
clot^i, mendtranes^ or placenta. The internal as[)ect of the
uterns may exhibit, nfter and during latter part of thinl
mouih, the (dacenlal site — a darkened and rough surface,
P^iilopian tubes and ovaries of deep color from physiological
<'ongestioQ of pregnancy. True corpus luteum in ovary.
Omtion : Even these evidences of early alxjrtion, however ^ooii
af\er (k^livery, can H-nrt*ely l>e nn>re than pre^itmpiive^ Men-
struation ar»d uterine diseases recjnire to [>e excludeii Soften
very difticnli ) k'fore certainty can \\e attained. The value of
the corpus luteum is cousidertKl more at length on page 656,
SIGNS IN THE DEAlK
655
Signs of Recent Delivery during Later Months and at Full
Term in the Living and in the Dead. Syiuptoms in tiie livinfj
are: Woman more ur le^ weak ami iacapalrle of exert biu
( Exc<5fjtiutis ptJSsjiljlti especially witli womtu iu iower walks
of life, atid amini^ negrt'sst-^, Iiiiliati9» atid savages. For
eadej*, see Bet*k» vol i., pp* o70, 3770 flight piillur of fa<?e ;
eyes a little suukeu and .siirrouiide«i by darkened rings, and a
whik'ne&s of i^kiu re^emblin^ cunvales*<*enee from disea^. The
above syniploriis often absent after three or four days. Ab-
domen soft ; its skin relaxed, lyintf in foldit, and traversed by
whitish shitiin^ lines (lineir aibicanleit), esjieeially extending
from the groin and fnihes to navel. (Exceptions: theiie nmtf
be the result of flr(>|i8y, tumors, or a former pregnancy.)
Breasts, after the first day or two, full, tumid, and i«ecreting'
milk, ( Exceptioui* : iM>me women secrete no milk after
delivery. ) Milk may Im, or may be alleged to be, re^idt of
a previous pregnancy (lietbre the one in cjuei^tion)* Detix*-
tiou of colostrum corpuscle;! in milk shows deliver)' to \m
recent. Nipples present cbaracteristic areola, ej^ii-ecially
** secondary areola," outside the disk. External genitals re-
laxed and tumefied from passage of child. Uterine glolie
felt in hypogastric region through walls of alxlomen. Oa
uteri swollen and dilated sufliciently to admit two or more
fingers, Locbial discharge : its color varying with interval
since delivery ; may Ik? distingiiishe*! from menses and frora
leucorrh<.ea liy its eharacteristic odor, s*jmetimes deM-ribed as
resembling that of 'fish oil." Absence, by laceration, of
fourehette ; but this is persistent after one lalior. Os uteri
fissured by radiating shallow lacerations or resulting cicatrices;
tlie latter being, of course, pertnauent. All these signs niau
he wanting, or tjecome so indistinct in a week or ten days
after delivery as to l»e unrclialde. In other ca^s they are
available for two or even three weeks. Examine as early as
possible in all cases.
Signs in the Dead. — These may be available two or three
weeks af\er delivery. Not reUable later.
They are enlargement, thickening, and softer consistency
of the uterus. During JirM day or two, wouib will l>e found
seven or eight inches long and four broad ; * its walls one or
I Whfn, tuiwever, death titt* fjfvurrrd ft^tn hcmorrhnire, Atiif thi*re U no
fnnfrrt^tion of the UtoniK. the oncitti Will be fouU<l ft« iL l&T^' fllitUflie^l p**lich*
naeojurlug lea ox twelve incticfl iii Lvogtti.
6o6
THE JUmSPRUDENCE OF MIDWIFERY.
one and a half ioches thick, section presenting orifices of
enlarged Uhiod vessels. After one wcek^ folJowiot^ a full-term
labor, womb betweeji five urid inx inches long (about the *^*ai:£e
of two fisti?*' ) ; after two it^ceA'iS, five inehes ; at a month the
orgiui uuiy have routraeted to its uunupreguiited 8ixe. Utenhie
cavifij during tirwt day or two* and [>erhap8 later, contains
bloody Muid or coaguia of blooiL, and pulpy remains of
deeidua. Placental t^ite pre.sents valvular, semilumtrshaped
vaseular openings and loi>kM dark, somewhat rej^embling gaa-
grene iu appearance. Fallopian tubes, round ligament^ aud
ovariei? purple from congestion. Spot where ovum eseajied
from tliL- ovary es{>eeially vascular* Orbicular muscular fibres
around internal opening of Fallopian tubes distiuetly visible
for one or two weeks. All the aliove signs iiectnne less marked
as interval since labor increiises. Ovary present*^ true corpus
lutenm ; value of evidence furtdshed liy it variously estimated
by authorities. Chief characteristica of 'Hrne" corpus luleum
(the corpus luteum oi' pregmtncij) are its large aUc, loug
duraiioih its being usually ^inffk; and its having a distinct
cavitij, either empty or filled with c(»agulated bloo^l^ which is
either substituted or followed by a stellate, ni<liating, puckered
cirafrix. Cavity as birgeas n |>ea ; may remain three or four
inttnths afler conceptioiL Ovary is eidarged ami prormm'tU
at the site of true <^>rpns lutenm. True corpus luteum varies
greatly in size and duration in *lifferent women. During the
first three months its average size is nearly one inch Wig by
half an inch broad, and during remaining mouths of entire
pregnancy it measures about half an inch long and n little
less in wiilth. ( letting smaller towtinl tlie cod of pregnancy,
it still remains om'-third of an inch in diameter for s<nne day*
after parturition, and presc^nt-s a stirt of hardenc^l tul>erelr
even a month or more later. Fahf corpus luteum Tthat fol-
h)wirjg mei}struatii>n ) grows only three weeks, when it meas-
ures a I mil t half an inch by tlireeH:juarters» and then retractjg,
becoming an insignificant cicatrix by the seventh or eighth
week. It is not pro7f}i}ient, has no ravittj, no rftdiaHng cieatrtT,
and is associated with others like itself, |*erhaps iu Ixith
ovaries.
Evidence of pregnancy derived fnmi corpus luteum is cor-
rohorative of other signs only ; taken by itself it cannot furnish
positive proof either way, owing to liability to exceptional
FEtQSED DELIVERY,
657
variations in its devt'lopineiit. It certninly cannot prove chtld-
birfh, for lifter iiiipregaution, fa^tua uiay have been absorbed
and ovum may have degt'uenit^i'd into hydatid iforni mole,
Unconscious Delivery.^lt is easy to imagine crinntial eases
(ex. fjr., infaiitieide) in wbicL a plea of uneoiiseitius delivery
migbt i>e set up. Medical tei^tiBiony would, in sueh lustaoees,
be required as to the |x>9tjiliility of its oecurrence in general,
and also as to tlie likelibood of its having taken place in any
given case, Wumen have un<loubted]y been delivered un-
coueciously during sleep and syncope ; during the com a of
afNiplexy, |>uer^>eral etdanipia, asphyxia, lypfius and other
niuiignant fevers ; alK> while under the inHueiice of narcotic
jM>ison8 and ana*i^theti(«, as \sell ai? after death. Others have
lieen delivered while at stool^ mistaking their sensations for
thfjse of defecation (?).
Delivery during or(/i7itfry sleep is very improbable in prim-
i|Mira^ or in women with smalt pelveB ; less so in those with
(»vt*rdarge t>elvcs. Examine circunistantial evidence and insist
on full statement of iiicts from woman bcin^lf before admit-
ting unc^inscioUH delivery in any particular case. Its posei-
liility, however, is undoubted. (For casee, see Taylor's Medi-
cat Jnn»itTU({frict\pp, 417-419; Beck's Medical Jurispru-
dencf, pp. *57 1-373,)
Feigneii Delivery. — Delivery has been feigned for the pur-
pn,*^^ nf extorting charity* com j»el ling marriage., producing
an heir, or disinheriting others^ etc. When the woman has
fadmittedly) never beeii pregnant before, her fraudulent pre-
tensions may be detected (usually, and ewpecially if a recent
delivery l>e claimed ) by tinding breasts unenhirged and pre-
senting no apfieanmceof niilk j^cHTetioii or ciraract^^ristic areola ;
no iine^e nllMcaiites iifK>n the abdomen ; no enlargement or
irregnlarity of the os titen ; no dist^mrge from vagina ; a firm,
solid, well-contracted, small, and easily movable womb. Com-
pare a llegei I date of delivery with ap|»earance of child allied
to have been delivered, noting skin, vernix caseoe^i, umbilical
corrl, size^ hair, etc, of the latter. (For cases, see Beck's
Medical Juri^jyruden re, pp. 342-855.)
When a pretended delivery ha^ been preceded hj others f one
or more) detection in more difficult Signs of rtH?ent delivery
may or may not be present. Examine for them. Inquire
into any mystery or concealment respecting situation of female
42
I
658
THE JVRmPRUDENCE OF MIDWIFERY.
before alleged delivery, during alleged preguancy ; also
as to her age and tertilily, or previous prolouge*! sterility ;
also iks to age» decrepitude, or i in potency of the alleged
father.
Crimmal Abortion — Foeticide. — A medical witness may
be requireil to «ttUe th^ natural eausci? of aliorliou ju general,
and also his opinion* iu particular, as t<i whether alleged (or
proved) existing natural causes did, tronld, or were likely to
profluce it in a iriven case. iSueh evidence may lie necessary
to eliminate nafural from criminal cause^^ iia for example,
when a teruale, having alx^rted s|M>ntauernwly, attempts to fix
the crime on an innocent (versoti, and in other cases* The
natural causes — ^.-ertaiti fevers, acute intlammation, syphilis,
violent men till emotion, etc* — have already been mentioned.
(See ** Canines of Abortion/' p. liH). ) An opinion as to the
efficacy of one or more of thern in a given C4i,se must depend
(1 ) u^MU their intensity, location (of inflanimation), virulence,
and malignity (of fever), etc., and (2) ujkjh the nervous
irritability or susceptibility ^in fa<"t, pn^dUpoitition to abort —
on the part of the [jatient, espeeially as to history of previous
abortions, and the '' abortion habit"
Medical evidence may be re<]uirerl also as to a/^cidental
causes in general, and their |)rohal>le etiica<*y in given cases.
Such causes are blows, falls, jarring the l>ody Ijy railn>ad and
Btreet-car accidents, joggling over rough jiavementsin vehicles,
horseback exercise^ etc, iVfler blows u|x»n the abdomen, the
uterus, as well as the child, may or may not present evidences
of contusion, lawnition, incisiou, etc. Examine for them*
Bones of child have even l>eeri broken and reunited in nfero.
As to the effir-acy of accidental rauses, the inlluence of predis*
pomiion to abort is paramountr Women have been subjected
to repeated and prolonged rne<^hanical violence without atmru
ing, when twprediftpositwn existed. Books teem with cases*
(For remarkable ones, see Beck's Juri^j/rudenee, n\x 490,491,)
On the other liami, women wilh pretlispogition abort after very
slight causes. Predisposition indicjited by great emotional
excital>ility, nervous habit, sensitiveness and anaemia, by
plethora, with (previous hahituat ) profuse menstruation, by
previous existem^e of other constitutional diseases aeting aa
sptnuaneous causes of abortion, and by existence of tlie
** abortion habit"
I
JUyiPERUS SABINA.
669
Medical Testimony as to Medicinal Abortives and Instru-
mental Metliods. — Mediciil witnesses .should neglect uo op]»or-
tuiiity oi' stutiug (wbat are ai'tuiil t'tn-H, viz, ) that all thej?e
methods are (1 ) itncrrtftin in their ()()eratioiJ u|x»ti the ehihi ;
(2 J always ilaii^enms and often (aial to the mother ; aud (»?)
eometimes fatal to mother withoyt affeetiufr infant. Chihlreii
have survived and lived al'ter the mother's death where pre-
mature delivery had been induced by criminal metiuj^
Kinetics. — Kmettc^ have been given in large dosei?, and in-
duced violent vomiting witht>ut produein^' alnvrtion. The
spasmodic coutnictioiis of the ahdominal walls and diaphragm
aecom|*anying eme^is are more dan^eruus in pni]H»rtion to
greater size and development of uterus ; hence during later
months, l-'illeen grains of tartar emetic have lK>eu taken
without interrupting pregnancy (Beck, voK i, p. 475).
Cathartics. — Purging carried too far, continued too long,
and when acinmipanieti with tenesnjus, ae after administration
of decided draAfirs, may prtHJu(*e abortion, es|H^ially during
later montlis. ( Jathartrcs may l>e given during early months,
es|K*cially when ua prftii^fmHttion exist**, without decided ctft^fM^
Pregnant wcimen attacked with disea^Hc may \w purge<l freely
witliout atiortiou- (Ceases: Beck, vt>h i„ \>\\ 47*^, 47ti )
Diuretics. — A drachm of powdereil aintharides (in one
cai*e) and 100 drops of oil of juuijier every morning for
twenty days (in another), have been taken to prmlnee alK>r-
tion ( Bi^ck, voL ii., p[i, 477, 47>^ ), l>nt in both instjiuces living
children were Iwirn at full term. Cantharides however, has
induced niiscarriaires in s<nne i-ases ( Be<*k, vol, i., p, 478),
These and su^-h other diuretics as broom, nitre, fern, etc.,
exert no specific action on the uterus, and they, together with
mineral and irrihtnt poUoftA snch as arsenic, cor nisi ve subli-
mate, sulphate tif copper, etc., ciin ordy be consi<lered alHvrtives
when they occasion shork or protl nee sufficient irritntioti or
intlamnuition toatfecttbe general system, often at the ex{)eu»6
of the woaian's life.
Junipems Sabina* — This is a j>o[>ular almrtive of undonbte<l
efficacv in some cnsi's from the conseipient irritation or in-
flamnnilion it induces, ft jirobalrly has nodiret-t action upon
the uterus. It has pn>duced death an<l hjis lK*en taken for
criminal pur|^iscs in sufiicientdo»«'S to priKlucc st»vere g,*ustriti9
without abortion f^jllowing, Pimicians administering it to
G*>D
THE JUnrSFEUDENCE OF MWWIFERV.
women suspected uf pregiiaticj, or without being previously
satisfied that preg'iiaDcy di>e3 not exist, would be fairly open
to Buspit'iot* of Orimiuality*
Seckle Comutum. — lu iriub ft»r criminal aliortion a med-
ical wittiL\^ must he prepared tor a clo?^* examitmtiou on the
i*peeit]L' emmemig'ogiie prujwrtii'^of this dru^ (Taylor ). J)e««pite
differeDce-s of opinion on this subjecu tht^ Iate!?t conclusion,
and which seenieiiievi table, is that this luedltine hiiisi a s!|iecific
aetiou as a fiirect uterine excitant, even when the uterus is
not alre^idy in active contraction* Formerly it was suppoe^
to act only when uterine contractiooft had already i>e^un.
J^ar^^c chises have, h(»wcver, been taken Uy prmluce aljt»rlioD
without efiect (see Beck, vol, i., p, 4M8 ). Ita emnieuago^ue
pro[)ertic^ increase as prc^^iiancy advances and are (irohably
more marked at [»eriod.< currei*|K)ndin^ with the former i^ata-
mcnja, ( Fi>r numerous refcreuces and civsei?, etc.» Pee Tay-
lor*8 Jurisprudence^ pp. 433-435* and Beck, vol. i., pp. 482,
4H3. )
Tanacettun Vulgare. — This has acquired |K)pularity aa ao
ttlK>rtive. h |K>*sei!(8e8 no s|)eci fie action upon the oterusi. The
oil in doses of one drachm, tour drachma, and eleven tlrachnis
was tjiken reH|>eetively in three cases, each of the women
dyin^^ in a few hottrs without abortion coniitig on (Taylor, pp.
48n,4M7).
Hedeoma Fulegioides and Polygala Seneka. — The^e are re>
putcd abiirtivcH, but of doubtful eificacy. The former is a
decided emniena^ogue. One case of alwrtion from }tsodtyr{7)
is reported ( Beck, vol. i., p. 481), but I find none due to
seneka.
Mercury* — ( Vude ijuick^ilver (even in quantities of a |K>uml
at rmee ) and medicinal preparations of mercury, ci>ntinued
even until salivation, have been given wilJiout producing
abortion. l*tyalism from mercury may» howev^r» produce it
in those prrdixpased.
Bloodletting. — Bleetlinj^, leeching, and nippintr were for-
merly considered abortives, but there isabimdant evidence to
the contrary.
Inatnimezital Methods. — The reader is already familiar
with tlic melhtNls of inilncini; labor for beneficent finr|NJsi«s,
elsewhere consiflered. Devices somewhat akin lo them uro
resorted to for criminal purpoaes, lu such eatiefi examine
INSPECTION OF CHILD *S BODY.
661
carefully (1) the kiatl and extent of iiijiin% if any, iiifiicteil
ui>t*n the uterus U'81>e<niilly the tm and cervix) and the ehild ;
(2) note hy whiil ^>rt i)f ittslrumeiu f^ueh injury could have
l)ee(i intlirted ; (o) whether it eoukl have lieen done by the
woman hei-self or irnpheil the ititerfereuoe or aRsii^tance of some
other |)erMon ; ami (4) whether it indicuted anaiomienl know-
ledge or a want of it on the [>art of Uie operator. Instru-
ments majf be intrrMlueed into uterine eavity re|»ealedly dur-
ing the fin*t three months of pregnancy without disturbing
amtiiotic sac or diswdnirging ii(pior amnii, and geMalion still
eontiiuie. After rupture of amnion, uterus l>egins t4> act in
ten, twenty, forty, or sixty hours; ^y^metim€^H not for a week.
When contents of uterus are submitteii for insjieetion, lie
eertiun whether or not they crmtiiin a faMus, mole, or hydatidi-
form mass. IHagnose ovum in early ease^si Ivy seeing villi <»f
chorioti under microseiiptN if no fietus he prc^sent. If there
be a foetus, ascertain its probable age (seepp, 651-653). As
to period at which a child in uiero l>e<^onies alive or ** quickens,*'
he ready to state that it in a Uvintj iH-ing from the time of con"
cepiion — as ujuch so at any time during the first month as
during the last. The idea of life being ira|mrted to it in any
given period during pregnatiey is an error long ago dis-
eiirded.
Child Murder after Birth i Infanticide ) . — When a mother
is susj^Kicted of killing her own child, medical testimony is
nece^ssary as to (1 ) whether she had been delivered of a child ;
(2) w^hether signs of delivery agree^ a^ to time, etc, with
a p|>ea ranees of child as to maturity, and length of survival
at>er l>irtlL (For signs of delivery, see |>age B55, ami for
signs of maturity, page 652,)
Inspection of Child's Body.— Original notes (made on the
spot) to he kept as to the follow ing points:
1, Exact length and weight of Ixxiy,
2, Peculiar marks or tlctormities alK>ut it
3, Marks of violence and pn>bable mmle of their production,
4. Umlnlical cord t whether cut. tied, or torn ; its length,
and appearance of its divide*! bloodvessels,
5. Vernix caseosa on groins, axillaj, etc., as indications of
washing and other attentions.
6. Odor, color of ami 2^|>aration of cudcle trom akin^ mi
evidence of putrefactiot*.
m2
THE JURISPEUBEyCE OF MIDWIFERY.
Duration of Survival after Birbh. — Signs uncertain, but
greitt ])rt'<*isioii luu (k^mumleil of mt'tlical wituess. Length of
Burvivul fur ^liurter tirtie thitn twenty-four hours not to he
deterniiut^d hy any sign. Drying, etc\» of navfUstring matj
(XT u r i II the demL L ' ;< i ni 1 h \ i| iciir a uee^ a re d u ri n g —
Second Tnrfitjjfonr Hours. — Skio It^s red than during
lirr^t day. Me^oniuni discharge<l, but hirgo intestiue still eon-
taiui^ gre«n-irohjred mucus. Aruouut of lung-infliitiou unre-
liahle, thcnigh jif rfeet intlation imllcatcf* (niiny hours of life.
lord Hinievvhat .shrivelled, hut still sotl and bhiiMlwx>lored
from ligalyre to skiu.
Third Tn'cntif'jour Hours. — 8kin tinged yellowisht cuticle
Boniewhat cracketL preparatory to desquamation. Cord brown
and drying,
lumrth Tu'tHtij-jftnr llourti. — Skin more yellow ; des^^uania-
tion of ciilicle from ehe^l und alxiomeu. i'onl brownish-red,
sejin-transpareot. Hat and twisted. Skin in contact with it
red. ( blon free from green mucus.
Fifth and Stjih Twctittj-ft*nt' Hours. — Cuticle desfjuanmting
in %*urions part^ in small scales or fine |X)wder, Cord .«epa-
nitcsfiilh day, but may notdoi<4> till eighth or tenth. Ductus
artf^riosyg roritraeted ; foramen ovale [Mirtly closed.
Sixth to Tivf'lfth Day, — Cuticle Bepiiraling from limi>s. If
cord \va*5 small* umbilicus cicatrized by tenth day ; raay not
he healed completely till three i»r four week« ; nuich depends
00 the mode in which it hai* been dre3?4*efl. Body heavier.
Ductus arteriosus entirely clofsed : cx^*eptii>n8 quite jMissible.
Was the CMld Bom Alive? — This question involves several
upcm which medical tf^stin**my ii*ay l>e re<|uired» viau : 1.
Did child Uvr Uis indicated l>y pidse, etc), but wifhout
brtjdhitHj* Children may w^ live for a short f»enod (during
which violence nniy !«' use4l ), but there are no satisfactory
|K»st-mortem medical data to enable a witness to expre«? a
positive opinioo on this jMiint. Absence of re-spiration does
not prove child to have Ijeen lM>rn flea<b for it may have been
drowne<l (in a bath ) or suffocated intentionally at the moment
of birth, Marks of violence mmf afford »«certain [jroof.
Marks i>f faitrehiction in titrrrp prove death Ix^fore birth ; they
are chietly, Haeeidlty of body, w) that it easily flattens by its
own weight; skin reddish-brown* not green; that cowering
hands and feet is white, with cuticle sometimes raises J in
WAS THE aULD BORN ALIVE f 6«
blisters contain in t^ retldlsh serum. Bones movable and readily
sepiiraleil t'rtnn .<otl pirL^, The«e appeamiice^ oceiir after child
huii remained dead in ntero eight or leu days ; j*carcely avail*
alile sooner. Note that the skin may bet^ome greenish when
iMKly is h>ug exposed to uir. 2. Did ehihl breathe as well as
lice f {'A) If sr>, did it breathe pHeetly or imperfeetiy f Evi-
dences of child liaving brenihed are;
1. Thr tStfitic Tt'4. — The al»«*idute or actuat weight «)f I he
lungs h increaiiect after res!|iirati()n, ovvitig to greater quantity
of lihMxl they contaio. Hence 1000 grains have fieen pro-
|Kise«l for average weight of hiDgs after respiratitJU and GOO
grains 6c/are respiration. Actual weight of child anfl of its
organs varii's so much in different individuals as to render
this test totally w?/reliai>le. A second method of its application
( l*louci[uet's tei^t) is to take ilie rtfotivf: weight of the lungs
as c(»nj]>ared with that uf the Inidy, l>efore ami after resjnra-
tion. Different oliservers have obtained tbe following average
results:
Before rcffptmlioQ. AHqt respiration.
Lungs. Itody. lung*. Body.
Ploucquet 1 to 70 1 to 35
S-hmitt I to 52 1 to 42
Chaussier 1 to 411 1 to 39
Devergie 1 to tiO 1 to 45
Beck 1 to 47 1 to 40
Hence this test is certainly nut infallible, but may furnish
eorrohoralive proof.
2. The Ifijdrotftafic Test (iSpecifie Grainty of Limg^). — Its
general principle in thai Ltfare rcBpinition ihc lungs if ink
rapidly when plaeccl in water» afirr res^piration ihey fioai high
in that tluid. They may, however, float from other causes,
viK.. from gai^cs deveh:»f»ed in them during putreliiction, frt>m
artificial intlationi and from em|ihysema. In these ca^«
the <'ontained air (or gas) can be forced ont of the lungs by
txmipresfiion f to be applied m describe*! l>elow )♦ »o that they
afterward sink i this cannot l>e done after perfrct respiration.
Artificial intlation does not rnereai*e weight of lungs. After
impt^fect respiratirm (aj? in feeble children, or thof^e who lake
only a few ga^pn ) the air van be exf)elled by compreA^ion, m
that this is not to be dii^tinguislied from artificial iutlation.
or>4
THE JURISPRUDENCE OF MIDWIFERY.
Exceptionally, the lungs may sink after respiraticm, from
i*f>iige??tioii, itiflamiuatuin, aud other diseai^ei* having iucreiiscd
their weight Incising tlie lung ami squeezing out its extra
bhiud or cutting it up ami eonipre*i*iing each piet^e will gener-
ally cause the organ, or mme pieee^^ of it, to tloat, iT the chiUl
have breatheth
ApprtcfttUm of Ilijdroaiatic Test, — Having opened chest, note
portion of lungs { before re!!*[ii ration they occupy a jsmall S[iace
at upper and p<Merior parti* of thorax ); their w/w«w? (of
course increa^tl after breathing) ; their shapt' (liefore res[nra-
tion, borders sharp or |xjinted ; after it* rouodedj ; their co/or
(before breatliing, browni.sh-refi ; after it, pale rtnj or pink ;
their appearance as regarda disease and putrefaction ; and
whether they crepitate on pressure (as ihey will after respira-
tion ),
Takeout lungs with heart attached, and place them in pure
water having tem|»eralure of anrrouniling air. Note whether
they tloat (high or low), or sink (slowly or ra|iidiy)» Sepa-
rate them from the heart and weigh thera accurately ; then
place them in water agaiu, nml note sinking or floating, a«
before. Subject each Ujng to pressure with the hantl, and
note sinking or floating again. Cut each Inng in pieces and
test floating again. Take out each piece, wrap it in a cloth, and
ctiniprcss with fingers as hard as ixji^ible, and test tioating»
etc, as lieibre. The crucial test of perfect rfj<piration is each
piece floating after the most vigorous coni](res.^ion*
Valm of Re^piratioit a.* Eindence of Lire Birth, — Respira-
tion does not prove child U> have been l>f*rn o/iiv, for it may
have breathed (imperfectly at least), and even have lieen
beard to cry in the vagina or uterus ' I r* fore birth was 4*0 m-
plete, as in face eases and retained hea<I in breei^i presenta-
tions, etc. Exceptiimally a child may live and even breatJie
(by bronchial respiration only) for hours and even ilays with
partial, and twenty-four hours with actually comphte absence
of air from the lungs, (Ca.s<*s: see Taylor, pp, 38')-887 ;
Beck, ,vol. i„ p, olT, ) The bings retain their ftetal cfmdition
of atelectasis. That they are Dot hepatized is proved by their
* n \b wild Uiat R child bim be^o he*LTd to cry in ultro weekn Ijefim* Ji^livcrr
(Taylor, pp. 35ij. :m : Beek. voL t, pp. ^V7, X^k On this pciliit om- fevU fli!«fHi9c*4
tti nrlopt the rcniArk of Ij* Fontaini^iLti^l Volpt'au : '• Since learn^'^l »nifl crhIHiIc
men Imve heart! It, 1 will botleve ft; but I should not believe it If I beiird it
inynvif."
CAUSES OF DEATH IX XEWBOBN^ CHILDREN. 665
suscepiihility to artificial inflation. Pliysiologicnl ex|»luna-
tioa uf life iiiidt!r such dreuriif^tiuu-e^ still wauliug. IVobahly
com J dele aln^eiice ol:' uir ii« only ajunireiil iusleud of real* owing
to our meJins of (ienioojstmiioti Imng ijiij^>erfect. Here the
hyiirostalif tessL is iimppliculde, IhiL tliLs fact doc*8 uot le^ft^oQ
it^ value in proviug 8ign« of respiration that do exist iu other
eases.
EvideEce of Life from Circulatory Organs. — Thecontnu'ted
or opt-n conditiuo uf the foramen ovale, ductus arlerioi^us, and
dnetui^ venosius furnis^ihes no reliable evidence of live birth.
Evidence from Stomach, — The presence of farinaceous or
other food in the j^tornach proves the child to have lived
after <kdivery wils complete, at least in llie aliH^rnre of any
proof that food was placed iu the .^loriuich alter death.
Natural Causes of Death in Newborn Children. — Thei<*% of
c*)uriie* have a direct beariug^ u|Kin infauticide* atul are : Pre-
maturity of birth, cougeuital disea.se or nuilformatiou, pro-
tracted or difficult delivery, compresisiou of umbilical cord,
hemorrhage from the cord or umbilicuje. (See pagas 281,
Violent Causes of Death in Newborn Children. — These
may be either €i*Tidenla( or criminaL Death, hi>wever, may
fKvur without any marlH of violence, w* irom cohh starvatiou,
suffocation, and ilrownlng. In i?o far as these latter are con-
cerned, an obstetrician nniy lie required to testify as to the
newly delivered female having sufficient strength, knowledge,
sanity, and presence of mind to take pro|ier care of her <'hild,
and prevent tho*ie m'cur rentes. [n a f>riniipara, when de-
livered alone, the hick of the>»e eomlitionf^ may exonerate her
from intentional ^nilt, as when the infant haa lieeu proved to
have died by resting on its face in a [mjoI of I4ood, or some
other rlij%f charge ; or when it has been delivered into a ve^-sel
containing water, on whi<*h the woman wa*» j^nted, while mis-
takjug her symptoms for those of defeimtion, etc. The opinion
of an obstetrician iu thesK? cas^ however, niugl lie very
guarded, esf>ecially with reference to single women and iho^e
delivered of illegitimate clnldren* Thecircumstancee attend-
ing delivery should fiTSt be accurately known, or at least ilili-
gently inquired into. The Rime caution is necessary in death
with markji of violence, a,^ in fractures of the sikulh nllegi^l
to have occurred by the child falling during sudden delivery
k^lfa
mn
THE JUnrSPRUDE^'aE of MmWlFERV.
in the ere<»t ptvsture, or by inutxieut attempts at selMeliTery,
or attempts nm<le by n midwife or otber |K^rson, Marks of
straiigulalioii uniuiid the i]e<:k nniy ]>e mint^ikei) for thuse due
to eoiliiig of the till vrl -string round the same part, and vice
verm. In death from *'oibiiii: of the eord, there are no deep
marks on, extriivasntion of IdtKid beneath, nor ruffling or
laceration of fhe nkin. nor injury of the deep-seated Y>i\rt^j
as there usually are in homieidal i^lraii^^ulation. In titniu^led
rliihiren the lungs have usually Ik^en inflated by rej*pinitiou.
In tieatli from eoilec! eord tbey retain their ftetal eoudition.
Marks i>o the neek may, jKis^ibly, he nuide by forcible effort*^
at 8elf-*leliver)% or Uy ^•a/z-^frrny^/ or by l)ending of the head
forcildy toward the neek s«>ou after death, or as an aecideiit
of hilK»r. The^M.^ nmst he distinguished from homieidal
marks. Pale, shalhnv marks 7tmy be made by eoiling of the
navel-string, but they are not aeeom|iauied with extravasa-
tion ete.
Fractures of the skull fRmi the use of instrumenta during
labor, even from force of uterus without iuBtni meets, and from
fallirjg of *he child when the mother is suddenly deliverer!
w bile erect, <ir while sitting in a waternrlosset, etc., can s^'arcely
be distinguished from fractures or other injury due to criminal
violence, except by cinnimstiintial evidence, or by eompariug
size of child with |>elvi8 in certain case*. The existeuee or
nou-existeuce of puerfieral insatiity ( mania) is an important
question in these cases.
Medical Evidence of Eape, — Medical evidence in rape w
usually only corroborative of circumstantial pniof, but may
be<Mnue leading testimony in cases of false accusation, or of
brutfil attempt>i u|Kni infants and children.
Medinil .witnesses before expressing an opinion as to whether
rape have been per]>etrated, should first understantl the legal
ilchnitiou of rai)e, as to wfielher it meiiu contact, vulvar peoe-
tration, vaginal |>euetration, emissioo, rupture of the hymen*
et<*., one or more. The rule laid down in the riiited States
IB that "there must W smnc entrance proved of the male
within the female organ.** That is enough, Ko matter aliout
emission, etc.
Maxks of Violence upon the (Jenitals.— Thei^e are ecchy-
moflis, coutusiou, and laceration of the parts with or w*ithout
i Thcn\ howwvr, liave been use«l for himiciitui «iinuiguUtlati*
EXAMINATION FOR VENEREAL DISEASE. 667
bleediug» Redness, tendenu'S.s beat, iiud awt^lling from sub-
sequent iulbiinnuitiun. Ail of the.se wutf dis«i|i|x*ttr in two or
three diiy.s atier the net In young children Ineenttion of the
perineum and of the vaginul wall, mul penetnition of the
nlKJominal cavity with fiital re.sult have ix?eurred, Note
that mechiuiieal injury of the parts may result from other
causes. In the abj^ence of additional proof, a physician may
only be able to state that the injuries are such a*? might l>e
pro<luced by ra|)e. Intlanunatiuu, ulceration, imd even gan-
grene of the vulva may also result from di^^u^e, a^ iti tiie
vaginitis and vulvitis of yountj children from worms, scrofula,
uncleanly habit.s, ervf^ipebis, nnilignant fevers, etc. In thet«e,
laceration and dilatation of the parts are absent ; while the
redness and purulent disichari^e are usually greater tlian follow
violence.
Marks of Violence upon the Body.^In women previotisly
accustomed to coitus these are iinjwrtiint, as evidence of
resdstance on the part of the fennile. The genital signs may
l>e wanting. Note extra forni, position, and extent of any
rnarkj* upon the body* If bruises exist, note presence or aln
sence of a»lor ztjues* indicating <htr of allegt^l assault,
ExaminatioE of Clothing.— Cut out stained s(x»ti= from the
clothing, whether dry or moists and pale or colored, place in
a watch-glass with just enough water thoroughly lo moisten
them for tifleen minutes, then s^pieeze out a few drops of tfieir
contents, and examine, under inicra«U'o|ie, for human blood-
corpuscles and s|>ermatozoi*ls of seminal Hnid, The evidence
thus affordeil, it is plain, may or may not he im|x>rtjuit^ ac-
cording to eircumstiinces. The sanjc may be said of ndcro-
gcopieal examination of vaginal mucns for spermatozoa,
whether in tlie living or the dead. Loose fibril of clothing,
examined micrositopically ai* to their coli»r and material, may
sometimes furnish evidence of importance as to p<frs<^)nal con-
tact of persons wearintr such clothing.
Bxamination for Venereal Diaeaae. — The existence of
gonorrha'a or syphilis, either in the male or female, anil its
conveyance from one to the other, may atllirrl cither negative
or positive proof />ro rr ;m/a. It should always Ih» impiired
into, and the time of it^ appearance after the alleged (Hiitvis,
in the jwrson said to have been infected by the otberp duly
noted.
668
THE JUIUSPEUDENCE OF MIDWIFERW
Signs of Virginity. — The presenile of an uoruptured hy-
men alibr<la pret^uiiiptive^ l>ut not al»snlute [irotif that the
female Ls a virghu The hynicu may lje eongeQitiiUy ab«eiit^
or ruptured tr«*m eaiisc^ other thau eoiiu.s ; aud mipreguation
without vaginal peiietratiim during intercourse, may take
pi are, the tijmeii remaining' intaet.
Pregnancy ReBulting from Eape. — It was fornirrly thouj^ht
tii lie imiioKsihhv. The contrary \^ now universally admitted.
Qmeeption may ux may not ^*ciir, \m after onliaary inter-
course.
Impotence. — A niedieal ophiion may be re<[uired as to
sexual ea[meity, in a male at^euse^l of ra|>e» hnytardy^ etc.
Cungeiiilfll imjHitence from defective development of organs
18 very nire. It n^ indieattxl hy the imlividiial being { usually )
fat, without hair on the tace, am! none or Imt little tm the
pnbes, by hi^ tt^^^te.s and jK-iiis remaining snuill : hif< voice
weak, and of the falsetto «jnality. There is wimplele aJii^enee
of sexual dejKire, ami a general deficiency of virile aitrilmtes.
The age of pul>erty varies. It is usually from 14 t<* 17 years ;
exceptionally not until 20 or 21. Ra|K% legally defined to
mean **8ome penelratton/' hii-s hex^n cummitted by boys of
13, 12, or even 10 years (c^'^t'a in Taylor, p. 500). Pnx^rea-
tion, however, is inijiossible until spermatozoids apjijear in the
8eniiiial Unid. They have been recognized micnit^'opieally at
the age of IH, but may undoubtedly a})pear j^ooner. Boya
have become fa the rH at 14, p<*rha|i6 earlier (ca^ of 14, in
Taylor, p, 502). The lieard, voice, development of the organs,
and other marks of virility, should l>e our guides in any given
case, rather than ugr ahine.
A few cases arc on record where puberty developed between
the ages of two and three years. In one cai»e {by Bruce
Clark, Bntwh AfefUmi Journal, Feliruary 6, 1886) hair ai>-
peare<l on the pulses at the age of eighteen months, and at
four years' of age this* hoy was as large a>» one at ten or twelve
yeJirs, the penin being as large as that of a man, with morning
erection, hut the testicles were small, and there were no evi-
dences of sexual desire or seminal emissions. The perineum
and pnbes were well supplied with hair, l>ut it waa abeent in
the axilla?.
Impotence from Advanced Age. — ProcTeative power has
lieeii retained till the age of (30, 70, 80, and ^0 years, Bucli
IMPOTENCE FROM LOSS OF ORGANS, ETC, 669
individuals usually retain also an extraordinary degree of
bodily and mental power. Sexual capacity may be lost much
sooner. Age alone cannot define any limit
Impotence from Loss of Organs, etc. — Loss of both testicles
does, but loss of one does not render a man impotent Ex-
amine for cicatrices, etc, upon scrotum. Even after removal
of both, enough spermatic fluid may remain in the ducts
during the first two or three weeks to confer procreative
power. Per^ns in whom one of the testicles remains in the
abdomen are not usually impotent. When both testicles re-
main undescended the individual may or may not be impotent
— usually the former — according as the organs are or are not
imperfect in their development Medical opinion is to be
based chiefly on signs of virility before stated, and on ex-
amination of secretion for spermatozoa.
As to impotence arising from injury of the generative
organs, brain, spinal conl, etc., or from general diseases, a
medical opinion must rest upon the circumstances attending
each case.
APPENDIX.
Report on Uniformity in Obstetrical Nomenclature, adopted
by the Section of Obstetrics of the Ninth International
Medical Congress, held in Washington, D. C, September,
1887.
A. It is desirable to try to attain to uniformity in obstetri-
cal nomenclature.
B. It is possible to arrive at uniformity of expression in
regard to —
I. The Pelvic Diameters.
II. The Diameters of the Foetal Head.
III. The Presentations of the Foetus.
IV. The Positions of the Foetus.
V. The Stages of Labor.
VI. The Factors of Labor.
C The following definitions and designations are worthy
of general adoption by obstetric teachers and authors :
I. Pelvic Brim DiAMETERa
L Autero-Posterior :
1st. Between the middle of the sacral promontory and
the |X)int in the upper border of the symphysis pubis cros8e<l
by the linea terminalis = Diameter Conjugain vera, CV.
2d. Between the middle of the promontory of the sacrum
and the lower border of the symphysis pubis =: Diameter
Conjugafa (liagona(i% Cd.
2. Transverse:
Between the most distant points in the right and left ilio-
pectineal lines -- Diameter Transversa, T.
670
APPENDIX.
(m
3. First Oblique:
Between rip^ht siirroiliiic syiirhoinlrttsis and left |jeetiiieal
eniineut'e -^ Diameter Jiiatjonaiiu Dexira, I). D.
4. Second (Vhlique ;
Between left .sm-rii-ilme synchondrosis ami right pectineal
eniinence ^ Dlumcler DiagonaUs Lf£va, D* L.
11. iMi^n'AL Hkah I>iAMn*ERa
1, From the tip of the occipital Inme tn the centre of the
lower miir^^dn of thecJiiu ^- Diamdir OcclplUk-Mrntalh^ O. M.
2, From the uccipitjii protubernnce to the rout ot' the nose
=^ Diamrter 0(^dpUo'Fi'*HiUtfh, O. F.
3, From the |K)int K)f nimm of the neck and oociput to the
centre of the uiiterior fontatielle ^Diameter Sub- Occiplto-
Brefjmnticai S. iK B.
4, Between the two parietal protu Iterances - IHamcter Bi-
ParietnlU, Bi-R
5, Between the tw^o lower extremities of the ct>ronal suture
^ Diameter Bi-Ten^pnralls Bi-T,
IIL Presentation or Lie of the Fcetus.
The Pre»enih}tj Pari is the ywirt which h touched by the
finger through the vafirina, or vvhiclu duriug lubor, is bounded
l)y tlie ifirdle of resistance.
The Occiput h the iM>rtiou of the hend lying behind the
pjisterior fontnnel Ic.
The SittnpHf is ihe jicirtioti fjf the hend lying in front of
tlie hrfijma (i>r anterii»r foiitauelle i.
The Vertcjr is the fitjrtiun of the hend lying belweeri the
ff»titanellet« and extending laterally to the |)4irietal protu-
be nine -e.^.
Three gronp8 of PreiH^ntution^ are to be recognizcfl, two of
whieli have the long axis of the fcetus in corresjxindence with
the long axis of the uterus, while in the third the long axis
of the fiHus is more oblitjne or transverse to the uterine axis.
L IjongitndinaL
(Ij Cephalic, including —
Vertex anil its niodtfiaitiuns.
Face and its niodiheatioua.
672 APPENDIX.
(2) Pelvic, including —
Breech.
Feet.
2. Transverse or Trunk, including shoulder, or ann, and
other rarer presentations.
IV. Positions of the Fcetus.
The positions of the foetus are best named topographically,
according as the denominator looks— /r«<, to the left or the
right side, and second, anteriorly or posteriorly. When ini-
tial letters are employed it is desirable to use the initials of
the Latin words.
In the case of the Vertex positions we have —
Left Occipito- Anterior = Occipito-Lasva- Anterior , O. L. A.
Left Occipito-Posterior = Occipito- Lizva- Posterior, O. L. P.
Right Occipito- Posterior = Occifnto-Bextrar Posterior, O. D. P.
Right Occipito-Anterior = Occipito- Dextr a- Anterior ^ O. D. A.
The Face positions are :
Right Mento-Posterior = Mento-Deztra- Posterior, M. D. P.
Right Mento- Anterior = Mento-Dextra- Anterior, M. D. A.
Left Mento- Anterior = Mento- Ij(Bra- Anterior, M. L. A.
Left Men to-Posterior = Mento- Lcpva- Posterior, M. L. P.
The Pelvic positions are :
Left Sacro- Anterior = Saero-lAPva- Anterior, S. L. A.
Left Sacro- Posterior = Sacro-Ixrva- Posterior, S. L. P.
Right Sac ro- Posterior = Sticro-Dextra- Posterior, 8. I). P.
Right Bacro- Anterior = Sncro-Dcxtra- Anterior, 8. D. A.
The Shoulder Presentations are :
^ Right Scapula-Posterior = Scapula- Dextra- Posterior, Sc. D. P.
' Left S{!ii\m]si-xS.nteriOT = Scapula- Lceva^ Anterior, Sc. L. A.
' Left Seapula-Poaterior = Scapula- Lcrra- Posterior, Sc. L. P.
* RightS<-apula-Anterior= Srapn la- Dextra- Anterior, Sc. I). A.
• U*fl and Rl^ht n'for. in this section, in all positions, to the leftfmd rijrht
side of the mother, without regard to that side oi the child.
APrKXiitx,
\\ Tim 8taui» or L.\BPit,
H, i\\%> iHiitittii*iief^tmml of re^lar paiu^
rnmi dilntiilkin tvf 00 •xlefitiini ttmil
I hiUI >^*< .V #f £i;piiJfMMi.
«fhim V 'if rkiUi to cwpfcii ^-
\L IPnii^ PArmw or
7««IMltv
^M
^Bm INDEX.
1
^1 BDChMKN, enlar>?i?mmt of, iti
Aninlotii^ Oitkl, 89, 92 ^^M
UM^s of, 2;il ^H
^^AUlMiitiiiiit Ji'ojtKy, ctiup^osiiB of,
A tin- m it! uf pregnitm>% 170 ^^H
^Hl fiinij |>ri*iiriuim'V« 141!
Atiiipsthelies, u»e uf, In inidwifcrv^ ■
^B puliation, 120, 123, '24:^'250
570 ^m
^m p\»uis, 80
Atieri(ujthiilu«;^540 ^^M
^H ureifniitioy ( extra-uterine )«
Atitt'fk'xion of uterus during |>reg«- ^^H
V 'Mn-2M
nmuTt 173 ■
^■kbortiiyi), li)€^2iK)
A i 1 1 <>|m rt u 111 beitior rl i a |ki% 490, 497 1
^m C»UKe8 nf, 11»0
bour-glntw tMimraetion af ■
^H erlniinul, 058
uterus* 5tn», 519, 545 ■
^1 diagrR]»i8 of, h^^-lU
AnteverniMn of ulenw durinj^^ l»t*g- 1
H inipeKect, 11»3, 199
num-y, 172 1
^B mLsscHi, mi
Anti,Heptii-8, itse of, in midwifery, ■
^B iiKliirtinii uf, 4M
239, 0()«5 ^H
^H {inj|:nrwN of, UM
Aiitit<trt'ptoecx^ic )K!nim, 017 ^^H
^H Higii^ of tt^'^ntt i\^il
Anntoxni, itlrvpiM-fK^cic, 017 ^^M
^H siir^^*:!! tmitiiiiiii uf, 19H, 482
Apftentlit on ott^tetric nomencla* ^^M
^^V svni{>kiiriis of, 102
^^M
^M tn^nitmni of, 11*4-200
Anolu ot brtttstH^ 131 ^^|
B^ ItiUiL 20H. 24)4
Ann pn-^>mutioTi, 34<V349, 391 ^^H
^H^hH-ot^, iiiiininiiin% 0*^i-040
AniiNj ilorNil diHt>ltu'enient of, 39(J ■
extnu'tiofi t»f, 393 ^^m
^Bif'« i<1ent:il ht.'iiti)rrl):i^a% 4(>7
AccfHuiii'tneTit forc*^* '^84
A rto riii 1 I li rt »n 1 1 n ml h, 025 ^^H
Aciitr yellttw almphy of the liver
ArticulutionH of fu^al litud, 38 ^^H
<liirin^ (iriejri»Hiirv, IHS
of }k4\ i.'^^ 23 ^^^1
A<lher«-nl pl!it4-rilii,'4fn. 509
ku >H.>n i n^ of, 528 ^^H
1 After-birth, di4ivcrv of, 237,263-
Artificisil Uhu\ for infant^ 278 ^
1 200
nspinition in aNphvxiole<l in-
Jant-s 043
rHoulion uf» 501-509
Aftoi^pains 273 !
Aecitea^ tlinpno*<i« of, from preif-
Ap^' ivf piiU-rty, 08
nnncy, 142
AlUtunin, u**^u for, 101
i>f tnfunt obfitrueUng biK»r,
1 Aibtitni nit rill in prefciiiincy, 158
Ml
W^L etktU>ii\ uf, 159
\s|ihyxift nf newUtm infant^F, 641
^^DlnriloiH, ihi% 1)3
Am^srn i*f rervix uU'ii, 560
^^B»en(^rrh(L'»» diti^oKis of, fri»m
of vii^tnii, 557 ^H
^^Hpi^^iiiMi'v^ 142
of vulva, 5i')7 ^^H
HRmnioi), ilu', 89
Attendants dtjriiiK lalK>r, 255 ^^H
f ilr..»|Nv nf the, 223
Atieniiaiis to ncwboni ehild, 261, 1
^^ rupiuiv of the. 234, 254
2*i9 ^J
L
1
676
INDEX.
Attitude of child in uteru, 283
Axes of parturient canal (of pel-
vis), 25
Axis-traction, forceps for, 36&-372
Ayers* symphyseotomy operation,
404
BAG of waters, 92, 231
rupture of, 234, 254
uses of, 231
Ballottement, 121-123
Bandl's ring, 519, 545
Banies' dilators, 484
Bartholin's glands, 44
Basilyst, 434, 435
Basiotribc, 436
Basiotripsy, 434-437
Bed, preparation of, for labor, 242
Binder, use of, in labor, 267
Bipolar version, 380-383
in placenta pncvia, 493
Bladder, calculus in, obstructing
labor, 559
distention of, obstructing labor,
541,544,548
irritation of, during preg-
nancy, i:^, 166
prolapse of, during labor, 557
Blastodermic vesicle, 77
Blastoiwre, the, 78
Blunt-hook, 351
use of, in breech cases, 336,
337
Body-cavity, 92
Boss'i's dilator, 589
Braun*s decapitation hook, 438
Breasts, abscess of, 63.*M)40
changes in, during pregnancv,
131
inflamed, of infants, 281
inflammation of, 633-640
iwinful, during pregnancv, 175
structurt* of, 03
Breech presentations, 315
diiignrwis of, 324
frank, 315
mechanism of, 315-324
positions of, 316
prognosis of, 326
tn»atme!it of, 326-337
use of fillet in, 333, 337
Breech presentations, use of for-
ceps in, 315, 334, 375
with legs extended, 332,
337
Broad ligaments, 48
Hroca'g pouch, 40
Bromide of etlij^l, 579
Brow presentation, 313
Bruit placentairCy 123
Buist's method of artificial respira-
tion, 647
Bulbs of vagina (or of vestibule),
44
C.ESAREAN section, 406-420
fundal incision in, 419
vaginal, 420
Calculus in bladder obstructing
labor, 559
Callii)ers, 465
Canal of Nuck, 40
the parturient, 25
Cancer of uterus obstructing labor,
560
Carbolic acid, use of, in obstetrics,
240
Carunculai myrtiformes, 42
Cyrus's curve, 25
Catamenia, 66
Oitheterization of infant's trachea,
643
Cellulitis, puerperal, 595, 599, 613
Central venous thrombosis, 621
Cephalotribe, 430
Cephalotripsy, 428
Cervix uteri, atresia of, 559, 560
hv|)ertrophic elongation
'of, 663
laceration of, 524
Chap|Hxl niy)ples, 275, 276
Child, washmg of, after lalK)r, 269
diildlK'd fever, 591
diild-murder, 661
Children, asphyxiate<l, resuscita-
tion of, 641
Chloasmata of pregnancy, 181
Chloral hvdrate, use of, in labor,
578
Chloroform, use of, in midwiferv,
577
Cholera during pregnancy, 185
INDEX.
677
Chorea during pregnancy, 180
Chorion, 89-92, 99-102
cystic degeneration of the, 218
Chorion-epithelioma, 221
Circulation, fcutal, 110
Cleidotomy, 441
Clitoris, the, 40
Coccyx, the, 19
Ciclio-elytrotomy, 421
Otliohysterectomy, 415
( Velio-hysterotomy, 406
Celiotomy, 406
C<i»him, or body-cavity, 87
Cohen's method of inducing labor,
486
treatment of placenta praevia,
496
Coiled funis, 260, 513, 574
C^ollyer's pelvimeter, 462, 465
Colostrum, 65
Complex (** complicated") labor,
3:^9, 574
Conjugal infidelity, suspected, 653
Constijmtion of infant, 279
of lying-in woman, 274
of pregnancy, 157
Convulsions during labor, 581
during ni-egnancy, 162
Cord, umbilical, coiling of, 260,
513,574
dressing of, 269
ligation of, 261
presentation and prolapse
of, 566
ring-applicator for, 261
short, 513, 574
strength of, 574
souffle in, during preg-
nancy, 129
structuix* of, 109
C<)rona radiati, 71
Corpus luteum, 60
Corn ►sive sublimate, use of, in mid-
wifery, 240, 606
Cough of pregnancy, 179
Coxitis, a caiLse of |H?lvic defonn-
ity, 458
( 'mmp in thighs during labor, 255
Cnmioclast, 426
Cmniotomy, 422
forcejw, 433
Cranium, ftetal, 34
Credd's expreaiion of placenta, 263
ointment, 620
Cross-birtlis, 340
Crotchet, 432
Crural phlebitis, 623
Cul-de-sac of Douglas, 44
Curette, use of, in puerperal septi-
cemia, 607, 611
Curette, use of, in abortion, 197
Curve of Cams, 25
Cutting oi)erations in deformed
pelvis, 407
on child, 422
on mother, 398
Cystic tumors obstructing labor, 262
Cystitis during pregnancy, 167
Cystocele obstructing labor, 557
DATE of delivery, calculation of,
229
Death, causes of, in newborn child,
natural, 665
violent, 665
Decapitation, 437
Decapitation hook, 438
Decerebration, 426
Decidua vera, refleza, and serotina,
96
Deciduoma malignum, 221
Deformity of pelvis, 442
Deliver}', feigned, 657
signs of recent, 654, 655
unconscioas, 657
Dental caries of pregnancy, 151
Diabetes during pregnancy, 166
Diagram for finning date of labor,
22i>
Diameters of fwtal head, 37, 671
of i)elvLs, 28-32, 670
Diarrh(ra of pregnancy, 15S
Diet, artificial, for infants, 278
of lying-in woman, 275
Differential diagnosis of pregnancv,
140
Difficult labor from obstruction of
soft parts, 552
Diphtheria, puerperal, 594, 610
Discus proligenia, 60
Diseases of pregnancy, 149, 181
intercurrent, 182
^^^^^^^^^^^^^B
■^■i^H
^1 678 IKDEX. ^M
^H Dts|>]acemetit8 of iiteni^^ during
External jBt>iierative organs, 39-43 J
^^H i>ivi^im€>% l(iS
version, 378 ^^H
^^m IX^rMil tlispLtfcfuent of arni^ 390
Exlrtt-utcrine Ke**tatian, 201^217 ^H
^H plate^ H5
lupar^iioiuy iu, 2U8, 216 ^^H
^H Doubtful f<igiif< of ppejr?vjiney, 130
^^H
^H EKju^cWs t"ul-de-tiju% 41
PACE pre>q?nta 1 icm, 3(X* ^^
r cuuse>* of, 3iHi 1
^H l>n-sNing of 1151V tUtntij^', 2Li9 |
^^^^^ l)ro|»Hy »tf riiunion* 22-^
correinioji of^ hv cxter- 1
^^^^L wil li ultnuniiuim diiiitig- preg-
mil inunipiilation, 310 ■
dia^'lUl^4iH of, 3t>8 J
^^^^V
^^^^ Duration of kbor, 238, 254
nici'liMiiiNm of^ 30*^-308 ^^1
^H of pivffrinni y, 228, ti50
poHitionH of, 301 ^^M
^H t*stiriiii iv iif, 111 each luonlb,
prognosis of, W\) ^^H
^m 139, i>5i
trciiinicnt of, 301) ^^H
^^H Dyspna^i* dunng jireKtianrv, 179
use of Onx'i^jjH in, 374 ^^B
^H Dyjitocia, 543, 552. < ^k-e ttlJw> ** 1 W-
FaiiJtingtbiriiij: pregnancy, 176 ■
^H funiiity of i)elvLV 442.)
Frtlclfonii constriction of nienis ^J
^^m
inifHiliii^ lnHi>i, '>44, 54H, 550 ^^H
^H PARLY drngnosisof ppe^^mmf-jr,
^K £i 117
Fallo[iiun pregnancy, 201 ^^M
LiTmrotomy in, 20S ^^H
^^H EclaiupHiti during labor, 581
tubc'H, 53 ^^1
^^f during |)n'^arK% 162
Falt4e pains, 253 ^^§
^^H f^'lodemi, 70, 81
[>reffiiaucy, 143 1
^H Ectopic ^^tul ion, 201-217
FecvH, irtJiiactcti atMlrnctini: labor, ^J
^^m KI1k)w pR'si'ntution, 340
^^M umi^imi^ of, :M9
^M
Evcundittion, 73 ^^M
^^1 Electricity in cclo]tic Kcslation, *2t>S
FeciUni;. artiBcial, of child, 278 ^^M
^H Enibivo, size of. ut diilerent pericxls^
Ft^ I . n r*'M' n t a 11 r >n of, 337-339 ^^H
H
Feigrie<! delivery, <i57 ^^B
^^H Enibryotomj, 422
Fevers, i^peci 6c, d u ri ng pregtiancr, 1
^B EnccjtliiilrK-elc, 53tl
^^1 English [ ID'S) t ion for force(M«^ 361
1K2 . ' 1
Fibroid tumor, din^wlf* of, from J
^H EutiHJiTTn, 7G, 81
pr<?f2:nancyT 141 ^^M
^M EpihUiKi,76, 81
obntru cling lul>or| 502 ^^H
^^M Episiotoniy, 260
Fillet, the, 351 ^H
^^M Er^tC^ Mf^ea of, in midwirerTi 260,
Flexion in bilior, 286 ^^M
^m 327, 45*4, 49(v .502, mi
cau«4e^ of, 287 ^^H
^^M Ethctv Hill ph uric, Uf^^s of, 576
Ftomling after lalwr, 500-50$ ^H
^H Ethyl bmniidc, uses of, 579
before dcliver>% 4^, 497 ^H
^^m EviKCfnition f cxvisccnition ), 440
^i-condar^^ or i emote, 508 ^^H
^^1 Evolutio c«iiidupliaitncorfM>re, 345
Floi>r (»f |h4v1»s 32 ^^H
^^1 Evolution, spontantH>iis 344
Fu'tnl circuliilion^ 110 ^^H
^H ExaniinntioiiH in hilxir, 243, 254
bend, 34-39, 671 ^H
^H ordiT of, in prej^iancy, 144
hean«^HindM, 118 ^^H
^^1 Exccrebmtion, 426
shock, 130 ^H
^H Exentcmtinn, 440
Fa4icide, lihH, 661 ^H
^H Exophthulniic ^itre during preg-
Fa?iu», !ijti>eanincis of, a! differenl ^^%
^M nancy, IMS
IH'riMs r»f prt^g^nancy, t\*A 1
^H Exo+foiis of pelvis, 450
motioiiH **f, I2<J M
^H Expri^'^ioTi (if placenta, 263
nuiritii.n of, in uii?^, 109 1
^H ExUiiiHion in labor, 2tM)
8ign>i<»rdi'nlli, In iiIj'I-o, li+3,47i^ ^^B
BBSS
B
^^^^P
^H FonUnelles *^^*
G:ttl]erc<] hreaai, GliS, 640 ^H
^H FonJ, iirtiHotal, lor infant, 278
UftvugL*, 489 ^H
^H Foiiirmaf riivs<.MUution, tliuxrumb of,
(icueiulive oi*gaRH, external, 39- ^H
^1
^1
^H trcatrriLntt of^ 3»8, 574
internal, 43-63 ^H
^m^ Fo^cep^^ 3o:t
(ieriii-c«U, the, 57, 72 ^H
^^^^^ H54
Genninalivt* vesiclt-nrul »5pol, 58 ^^M
^^^^^^ Bpplicutuui t)f. to head, at in-
(itwtation ( »ee ** PreKiia"ty»" I>. ^^4 1
^^^^^^ ^tntitf 554-
of index). ^^m
^^^^^B
Glitniis nmnimitry, 03 ^^B
^^^^^^^B KUiHTior stniiu
of ua-tlim, 42 ^^
^^^^B
viilvo-vngimil, 44 ■
^^^^^^^1 in f»i« pruHcnUitloit, 309|
Givi-erin iryeciions for imiiieing ■
^^^^H
ralior, 4JS() ^M
^^^^^^^H ill jielvic
(itycmiiri:! during pregimncy, 160 ^^M
^^^^^^^^H m L^liinL>4 '>5^5
(foitrt! diirln^r prc^niincy, 1^ ^^M
^^^^^^^p ill :irter-ronaittt; heiiil, 375
GnwilisiTi follicle iind vts^icie, 58 ^^M
^^^^^ to bree«'K, 332, :?:J7
(iuanUTolclit*t, 4:i3 ^^H
^^^^F axb-tnytioM, :{4>9^73
^^H
^^^^^^^- BixnLH s.
TT A NI>A XI>Ft M )T pre8enlAlic»n, ^B
n 283-2*H), 574 ^B
^^^^^^^H cami» for, .151
^^^^^^H ikiif^m nf, 373
IIeiid» iViHJil, 34 30 ^B
^^^^H Ltink^is 360
iMTKt? i*iav of, 519, 63H, ^1
^^^^^H MeFermn'^s
541 1
^^^^^^^^H StrrijHon's,
premature otjsificMtioa of, ^H
^^^^^^HH SiepheriHon\ 370
^B
^^^^^^^^ Tnmici*'s :\m
prfienlntton, diagnosis af, 243, ^^|
^^m Kh«irl ami lon^« 354
^B
^m Forcen of lubur, 230
mci'hanism t>f, 2S6 ^^B
^^m Forniulin, ii»e of, (\0H
Iltuirt clot, 02 r ^_ 1
^^M FosHsi nnvitriiljiri^ 10
dimfii8e duriiiR pr^inuinev. 175, ■
^H Frit'^ch'!« niethtxl nf CaBBttrean see*
18t> ^B
^m ihm, 419
fa'tal, Hounds of, llS ^^M
^H Funi^, cuLlmg of, 200, 513, 574
1 1 effvt r' A tti^n of pre|^ia ney , 1 27 ^^|
^B drt^inf? of, 209
Ilpiuatonictni^ 141 ^^|
^^^^^1 li^tion of, 2til
Hi^rnaturin during pivminnry, T08 ^^|
^^^^^k CitseH, 5.S4
neniorrhagt', aiTiilenial, 497 ^^H
^^^^^1 pre^ntiLtion atnl iniobtrMe of,
after luhir < [H>st-(MirttMn 1, 500 ^^M
^^^H
anlf-imrtnni, VMK ii*7 ^^M
^^^^H refKNtitinn of prolH^merl, r»00
fruiii invention i*i uterus 513 ^^M
^^^^1 nti|^'3iptiiiai(or for, 2B1
fiecondury or " rt^mote/^ 508 ^^B
^^^^B
from umbilicus, 281 ^^B
^^^^^H Aontflc in, iliirin^ pn^ancv,
OeuiorrhoidH during pn*|^iiH^?, ^^|
^^^B
^B
^^^^B R(reni;tti of, 574
llernia during Inbor, 505 ^^B
^^^H stnicture of, lOQ
of piVkmuiU uteniH, 54U ^^B
umhiliintt. of inrant, 2>M> ^H
^^^^^r
^B n X L ACTornonors <iuct^, 04
^H \j C{iMtro-elytrotom\% 421
Herpes ^estjitionis 181 ^^H
nip di^-wane, oii^itrueiod kborfroro, ^^|
458 ^B
^^m IhiMtnT-hystort'i'lorny, 415
^^m GniiLro-hy^iemtotiiy, 406
HW^ ciiibr%'o, 106 ^^M
^^^^^^^^^^^^m
S3
■I^H
^m 680 INDEX. ^H
^^^ IIour-gksB eoiilraction of utenis,
Intermittent uterine contrnctions a 1
^^^^H^ aiite^imrtiim, 54o,
sign of pregnancy, 124 ^^fl
^^^^P
Internal generative orpine, 4:i-Ci3 ^^^H
^^^^H pOHt-p^rtUiii, 509
Interstilkl pregnancy, 211 ^^H
^^V HiigiUf rV gliinds, 44
Inim-lifpimenton.H pretcuftiiey> 21Q V
^^H H HI fill 11 enihrytis <^:irly, 103-K)6
Invet^ion uf uterus, 513 1
^^m IJyilaiidiform pix^ipiunovT 218
InvoloHon of uterus jifter labor, 53 ■
^^H llydiiimnicm dmimrnnios), 223
Iwloforui'jjiiuzc tampon, 5<i4, 506 1
^^m Hydnx-ej (bill lis, congenital, oli-
Iron, uiie of, in poe«t-piirtum hemor I
^^H Htrufting lubor^ 519, 538
rhlige, 505 1
^^H nyc)i-«jmL'trti, 142
^^fl
^^B Hydmirbri^ ^'ifividanmij 225
I A L'NDirK r.f infant, 284) ^M
ft of lootlier during nn^rmnev^ ^^M
^^B llyitn (Sialic test, tJHH
^^H lIyrlri»t!nmL3t and hydrnm'plinj^is
^M
^^H of inJxuit itbitrurdnt: liilxir, 041
Jurwprudcnce of midwifery, 1^9 ^^M
^^H Hygiene «if [jregiiancv, 144- 14U
JustOToajor jielvi!^, 459 ^^^|
^^B Hymen, 42
Justo-niiuor (telvis, 447 ^^^|
^^m iniperromte, 556
Juvenile )x4vk, 450 ^^|
^H }Iypol»)a»^t, H\ HI
^^H
^^H Ilvsterirtil c-onvulsiona during
^M 'bbor,582
17 EL L< K tG ' S f uni s-ring n ppl ica- ^^B
MX iMi, 2rd 1
^^H
Kidney, rli»H:u^ of, during pivg- ^^M
^H liTERl'S mMimitornni, 280
naiicy, 158 ^^M
" Kidney of prej^iiney," the, Wi ^^M
^^M liniiacieti fet-esi ol3**triicting liilwr.
KmH> prcHt^ntation, t'i^t-:i39 ^^M
^H
Kyplu^tic lx4vt^ 455, 4G8 ^^H
^^H Tni|>i>rfei't aKu'tion, IW
^^^1
^^H Iinpierftirutv liynien^ 55(^
T ABIA funjom, ^9 ^H
U tlirondfus i>f^ 178 ^^H
^^B Impnten<x\ 1>liH
^^H Inipre^intion, 7'^
minom, 40 ^^^H
^H Im-lttiLnl {jknes uf ^H^ilviN, 20, 21
Lah^r, 228 ^H
^^B I ntTmt inenee of urine d uring preg-
antiseptic mana^ment of, S
^H naiiry, H>8
239-243 1
^^H lne«ib:iic)r>4, 48H
biig of wateni in, 92, 231, 234, |
^^B ItHliiction ii( piiemature l«lx)r, 479
2.54 J
^^H 1 nertiii uteri a t^tiR* oi ila<xlin^, ntXl
birth of bead tn, 23«>, 2«5.V2I>1 ^M
^H Infjtntidde, 058, m\
enuR' of, 229 ^^H
^^m liiruntile jaimditxs 28fl
complex ( '^crmip) tented 'M, ^^H
^^H Infant^i, pixMmitiiro, treitimenl of,
574 ^H
^m
dale of, 228 ^H
^H Inferior Btmit of |H'ki$3, 22
difficnU ("dvModfl"), 543, V
^^H Infidelity unjustly sus|H*c'te«J» 653
552 1
^^H Injections, intni-iiU^rine^ 48t>
dumtion of,238 ^^H
^^B Iiuiomiruite hNines, V^
exaniinaliouH tn, 243^254 ^^H
^^m Insiinity of r)ix'gniim% loctulion,
^^B nnd IsdMir, t)27
forcert of. 230 ^H
lin^erin^, 543 ^^^|
^H ItisirtitueriLs nl>itetrical» I^'jO
ojanjit?vnu'nt of natural, 238 ^^W
^H Intei-ftimiit difieaBeK of prt?j^nancv.
mechnniHm «vf, 283 ■
^H 1 82-189
"niif**ed InlMir/' 100 imtie to ^J
^H Intomuttent fever during prepr-
unf^^ r»49u ^H
^H nuncy, 1H2
fi«iin^ of, 234) ^H
^M
IND
EX,
681 J
Labor, fjalpation in, 243-250
VfALACCKTEON pehk 451 ^|
lU iMtilprtjieiitutions 283, 340 ^^M
j>ostiiiv *>f woniuii ill, 251, 343
Mumitiury ((IuikIh, Go ^^H
[jowcrless, ^5(>
nrtcrics and nerri*^ of, 65 ^^|
|ji^cil>italL\ .">oO
diangeh in, rlurin|r pre>^- ^^|
pi^emamix^, J1*U, 20()
niincT, 131 ^^1
indiKtiuii (if, 479
in Hani mat ion and absct;^ 1
prc|iamtion i>f Wh[ Un\ 242
of, l»33, MO M
for emergen ek*ii in, 2S8,
pninn in, 175 ^^H
502
Mammiti^ t>:^3, (HO ^^H
puriXK!^*s of exumiiuitiori in.
nf infanU, 2^1 ^^1
2rj2
^ 1 a n »fre i n i' n I of I a hor, 2:^8 ^^H
Btagfj^ tf)f, 231
Mania, juierjiLnil, *!27 ^^^B
Byinj>toriiH of, 231
Marshall Hairs nielhml of artilitjal 1
tetlious, M'\ 552
n^pimtiim, ti47 ^^M
dnie i»f delivery in, 228, 2^
Martin's ireplilne, 42l\ 427 ^^H
twin Liises of, 530
MaMindini? tR^>lvi8, 450, 4lUI ^^H
uiiconscifni<, (>57
MiLstitis, li:i3, r)40 ^^M
vrtt'al otitery of, 237
Mateniity, u^e of, 650 ^^H
LtilK>ixk'*H iiilIImhI of ttrtififial ms^
Matnrsition of ovnk\ 72 ^^^|
pinttioii, (HO
Mfa.sk-H dinrinik; pri'pmncV) 184 ^^^H
La(*eRifuin *>f eervix uteri, 524
M vm ntvu wi\ I w o f j »- 1 v i k, 28 ^^H
of iw?riTJc*ijni, 255-2tiO, 52«
Mm hanisni of labor, 28:i ^^H
uf uti-nis, 517
^tedidlary foldn, 85 ^H
of v{i>^inu and vulvsi, 525
^ixHive, H5 ^^H
infinity nf, (i21l. 1*35
Melnni'hoUii, t)27 ^^H
MeifdnTint% rtipiiire of the, 234, 254 ■
Liinitnjf niHloniiniiHs >*<>
Menu! run linn, tm 1
ilnrHnliH, i»r ** nit<li»lbrv fuKls,"
|mH-o<4ous 09 ^^B
85
ipjfinlitv and qnntitie« i^f Hon, ^^M
IjingbniVs layer, 98
^H
Ltipu ro-elyirtttuniy , 421
Houi^ee of, 69 ^^H
Liipari>liyslernlnnu% 406
Kiipprt-shiim of, tlurin^c preg- ^^M
J^lenil folds, 8<i
13H ^^H
Le n to r rln m d u ri n ^ p regnnncy , 1 73
fiiiKpensilm of« 70 ^^H
Li^imentH of j»f Ivik^ 21
f)ymptl»m^ of, 09 ^^H
of nterns, IS
vk'arionN} 70 ^^H
I l/upior anniii» 92
Mental phcnometva of pre^^ntinrv, ^^M
aelicienr, 225
^H
€»xce*w of, 223
Me^^xlrrm, Ok-, H<), 81 ^H
uses of, 231
Mi^tritis pnerpenil, 594* 591», GIO ^H
LithopjitliMii, 215
Milk, tietii'ient How of, 277 ^^H
Liver, diRnt*»eK of. dtiriri^ pi^iT*
e^ree^ftiive Ho\t^ tA\ 277 ^^^|
niinrv. 1K8. 189
f< ) rn 1 lit i« »n o f J >3, ( 'A ^^H
T^mJiih (liM'fiiut ilint'hargc), 272
!iee nation of, (luritif^ pr<?gnnnev, ^^U
I^nrkt"*! twins 535
^M
LtHiwninjj of iielvic lK)n€«in labor.
^nik-fevcr, 275 ^M
528
Milk Iei|£, 023 ^H
j«»inm dnrin^ nregnancv,
MiHi-;uTia^e, 100 ^^H
27
Mij«^'d utHirtion, If^O ^^H
Lyinjj-in, diimtion of, 278
1
hik^r, im (note to pag^ 649)« ^H
682
INDEX,
Molar pregnancy, 218
Moles, true and false, 223
Mons veneris, 39
Monstrosities, 531, 538
Monthly sickness, 66
Morbid longings of pregnancy, 133
Morning sickness, 132, 152
Motions of foetus in utero, 120
Mailer's' method of measuring
head, 480
Multiple i)regnancy, 530
Murmur, uterine, 123
Muscles of pelvis, 32
Myrtiforra caruncles, 42
NAE(iELE'S defomiity of pelvis,
452,467
obliquity of foetal head, 470
Natural labor, 228
Navel, polvi>us of, 280
secondary hemorrhage from,
281
sore, 280
Navel-string, the, 109
coiling of, 260, 513, 574
dressing of, 269
ligation of, 261, 534
presentation and prolapse of,
566
short, 513, 574
souffle in, 129
stixjngth of, 574
Nervous ti*oublesof pregnancv, 138,
179
Neural canal, 85
Neuralgia of face during preg-
nancy, 152
Newlwni child, washing of, 269
Night-dress, preparation of, for
labor, 243
Nipples, chapped and flat, 275,
276
during pregnancy, 131
sunken, 276
Nomenclatui-e, unifomnty in, 670
Normal sjilt solution, 165, 507
in st»pti(wmia, ()17
in uraemia, 165
Nuck's canal, 40
Nuclein in septicaemia, 616
Nynipha*, 41
OBESITY, diagnods of, from
pregnancy, 142
Oblique deformity of Na^gele, 452,
467
Obstetric sui^^ry, 350
uniform nomenclature in,
670
Obstetrics deflned, 17
I Obtumlor foramen, 22
Occipitiwinterior pasitions, 286
tixiatment of, 297
Occipito- posterior positions, 292,
295
treatment of, 297-299
Occlusion dressing, 268
of 08 uteri obstructing labor,
559
Oedema of uterus, anterior lip, 255,
556
of vulva, 557
Oligohydramnios, 225
Oosperm, the, 75
Operations, cutting, on child, 422
divisions of, .'ioO
on mother, 398
Ophthalmia neonatorum, 263, 281
Organ of Rosenmuller, 62
Oisittcation of pelvis, age of, 21
premature, of fietal head, 541
Osteomalacia, 451
Os uteri, changes in, during preg-
nancy, 136
occlusion of, 559
rigiditv of, 552
Outcry, vocal, during labor, 237
Outlet of |)elvis, 22
i Ovarian (extra-uterine) pregnancv,
I 213
tumor, diagnosis t)f, from preg-
I nancy, 140
imiMxling lal)or, 562
I Ovaries, anatomy of, 57-^2
Ovaritis, puerperal, 595, 599, 604,
, 615
Ovule, stnicture of, 57, 72
Ovum, development of, 75-116
t^AINFl'L breasts during preg^
nancv, 175
Pains, false, 253
I oLlal)or, 230
INDEX.
683
Palpation, abdominal, 243-250, '
308, 324, 347 '
in twin cases, 532
Palpitation during pregnancy, 175 ,
Par4dy8is during pregnancy, 180 j
Paix)variuni, 62
Parturient canal, 25
I^arturition, 228
Panteurization of milk, 278
Pelvic presentation, 315
Pelvimetry and pelvimeters, 462,
465
Pelvis, articulations of, 22
loosening of, during labor,
528
axes of, 24, 25
changes in, during pregnancy,
27
deformed, 442-478
dangers of, 469
diagnosis of, 460-469
induction of ))remature 1
labor in, 476, 480
mechanism of labor in,
469
modes of deliverv in, 422,
472-478
symptoms of, 460
varieties of, 442-459
diameters of, 29-31, 670
false, the, 20
floor of, 32
inclined planes of, 20
joints of, 22
nuiie and female, compared,
26
measurements of, 30, 31
musclw of, 31
oHsilication of, 21
planes of, 24
sti-aits of, 19, 22
the true, 20
lumoreof, 18,459
Perforation, 424
in hvdixxx^phalus, 539
Perforators, 424, 428
Perineum, anatomy of, 32 I
laceration of. *255-260, 526
rigidity of, 554
support of, in labor, 255-260
Peripheral venous thrombofiiH, 623 i
Peritonitis, puerperal, 600, 604,
613, 614
Petere* ovum, 102, 103
Phenomena of natural labor, 233-
238
Phlebitis, cniral, 623
puerperal, 593, 600, 615
Phlegmasia alba dolens, 623
Phthisis during pregnancy, 185
Physometra, 142
Pierce crane, 424
Pigment deposits during preg-
nancy, 138, 181
Pinching of anterior lip of os uteri
in labor, 255, 556
Pityriasis gravidarimi, 181
Placenta, adherent, 491-509
delivery of, 2:^7, 263-267
expression of, 264
formation and anatomy of,
100-102, 105
functions of, 110
partial separation of, before
labor, 497
pra'via, 490
causes of, 490
dangers of, 490
diagnosis of, 491
prognosis of 492
treatment of, 492
by Kiimes* method,
'495
by Ca^sarean section,
'495
by 0»hen's method,
'496
by de Ribes' bag,
'494
by Simjwion's method,
496
by version, 493
retained, 501, 509
Placental expression (Cred^), 264
murmur, 123
Planes of pelvis, 24
Plethora of pregnancy, 177
Plug, vaginal, 196, 492
Plural births, 51^
Pneumonia during pregnancy,
185
Polyhydramnios, 223
684
INDEX,
Polypus, diagnoflis of, from in-
verted uterus, 515
impeding delivery, 561
of navel, 280
Porro*s openition, 415
Porix>-Muller operation. 407
" Position " of presentation deiine<l,
285
diagnosis of, 296
Post-partuni hemorrhage, 490, 497
Posture of child in utero, 283
English, for forcep**, 361
Walcher's, 368
of woman in labor, 251, 361,
569
Power of labor, abnormalities of,
543
Powerless labor, 550
Precipitate labor, 550
Pregnancy, abdominal, 213
differential diagnosis of, 140-
143
diseases of, 149
albuminuria, 158
anfemia, 176
anteflexion of uterus, 173
ante version of uterus, 172
bladder, irritable, 166
chloasma, 181
chorea, 180
constipation, 157
convulsions, 162
cough and dyspnoea, 179
diabetes, 166
diarrha»ji, 158
Graves' dist*ase, 188
glycH)suria, 166
hematuria, KVS
hemorrhoids. 178
herpes gestationis, 181
iuc(mtinence of urine, 168
ins;inity, 179
intercurrent, 182
acute yellow atrophy
of hver, 188
ague, 182
cholera, 185
heart disease, 186
icterus (jaundice),
188
measles, 184
Pregnancy, diseaaes of, intercur-
rent, phthisis, 185
pneumonia, 185
relapsing fever, 183
scarlet fever, 183
small^x, 184
typhoid and typhus
fever, 183
varioloid, 185
yellow fever, 183
leucorrha*a, 173
mental derangement, 138,
179
nervous derangement, 179
neuralgia, 152
painful breasts, 175
palpitation. 175
paralysis, 180
pitynasis gravidarum, 181
plethora, 177
prolapsus uteri, 168
pruritus, general idio-
mthic, 181
vulva*, 1/4
retroflexion of uterus, 171
retroversion of uterus, 169
salivation, 150
sciatica, 180
syncope, 176
thrombi, 178
toothache, 151
toxaemia, 158
varicose veins, 178
vomiting, 152
doubtful signs of, 130
duration of, 228, 649
early diagnosis of, 117, 129
extra-uterine, 201-217
Hegar's sign of, 127
hydatid iform, 218
hygiene of, 147-149
" intra-ligamentous,'* 210
" kidney of pregnancy," the,
161
late diagnosis of, 140
pluml, 530
l)Ositive signs of, 118
prolonged, 228, 650
short, with living child, 651
signs of, their chronological
order, 139, 140
INDEX.
685
Pregnancy, si^s of, their claasifi-
cation, 117
spurious (false), 143
Premature infants, care of, 486, 641
labor, induction of, 479
treatment of, 200
Preparations for labor, 238, 242,
502
Presentations, arm, 340, 391
breech, 315
brow, 313
complex, 339, 574
face, 300
feet, 315, 337, 339
head, 285-300
knee, 315,337, 339
number of, 283, 671
shoulder, 340
umbilical cord, 566
Primary inertia, 543, 548
Primitive streak or groove, 83, 85
Prolapse of funis, 566
of womb during pregnancy,
168
Prolonged pregnancy, 228, 650
Pronucleus, male and female, 73,
75
Pruritus, general idiopathic, 181
vulvte, 174
Pseudocyesis, 143
Ptvalism of pregnancy, 150
Pu'berty, signs of, 69, '650
Pubic ai-ch, 22
Pudenda, 39
Puerperal cellulitis, 595, 599. 613
convulsions, 162, 581
fever, 591
causes of, 596
• prognosis of, 602
symptoms of, 598-602
treatment of, 604-620
use of antitoxin in, 617
varieties of, 592
hemorrhage, 508
insanity, 628
mania, 628
metritis, 594, 599, 610
I)eritoniti8, 600, 604, 613, 614
phlebitis, 593, 600, 615. 623
septica?mia, 591
state, 270
Puerperal tetanus, 631
tetany (tetanoid contractions),
632
vaginitis, 594,599, 610
QUADRUPLETS, 530
Quickening, 120
f^uinine, use of, in labor, 253, 549,
580
Quintuplets 530
RACHITIC pelvis, 443, 461
Rape, evidence of, 606
Rauber's layer, 79
Rcceptaculum scniinis, 74
Retcoct^le impeding labor, 559
Reichert's embryo, 103
Relating fever in pregnancy, 183
Respiration as evidence of live
birth, 664
artificial, in asphyxiated in-
fants, 643
Restitution in labor, 291
Resuscitation of asphyxiated in-
fants, 641
Retained menses, diagnosis of, from
pregnancy, 141
placenta, 501, 5()9
after abortion, 192, 193,
197-199
Retraction of uterus, 267
ring, 519. 545
Retroflexion of uterus during preg-
nancy, 171
Retroversion of uterus during preg-
nancy, ir)9
Rickets, deformed pelvis from, 443,
461
Rigid OS uteri, 552
perineum, 554
Ring of Biindl, 519, 545
Rolx»rts pelvis, the, 454, 469
Rotation in labor, 289
external, 291
RulK'ola during pregnancy, 184
Ruj)ture of perineum, 255-260,
526
of uterine cervix, 524
of uterus, 515
of vagina, 525
of vulva, 525
68G
jyj)Ex.
SACRO-ILIAC synchondroses, 23
Sucro-Kciutic ligaments, 21
Sacrum, 17
Salivation of pregnancy, 150
Salpingitis, puerperal, 595, 599,604,
615
Scale of inches and centimeters,
477
Scarlet fever during pregnancv,
183
Schatz's metiiod in face presenta-
tion, 310
Schultz's method of artificial res-
piration, 644
Sciatica during pre^ancy, 180
Scolio-rachitic jwlvis, 447, 458
Secondary hemorrhage from navel,
281
post-i«irtum, 508
inertia, 544, 550
Septicaemia, puerperal, 591
Shoulder presi^ntation, 340-349
imiKictcd, decapitation in,
437
•* Show," the, 2,32
Sigaultian oj)eration, 398
Signs of ffptal death in utero, 193,
478
of pregnancy, douhtful, 130
monthly onler of, 139
|K)sitive, 118
of pulierty, 69
Simpson's basilyst, 434
forceps, 353, 3r>7
Smallpox during pregnancy, 184
Smellie's scissors, 424
Somatopleure, 87
Sore navel, 280
nipplc»s, 275
S|K*e*sovum, 102
Spermatic fluid, 73
Splanchnopleure, 87
Split i>elvis, 459
S|>on(lylolisthetic |)elvis. 455, 469
SjM>ndylot(miy, 441
S|K)nt:me()us evolution. 344, 437
version, 342
Spurious {Kiins, 253
pn'firnancy, 1 13
Stajfps of lalnir, 231
Static test, ti63
Sterilized glycerin, use of, for in-
ducing premature labor, 486
Straits of pelvis, inferior, 22
superior, 19
; Streptococcic antitoxin, 617
I Subinvolution, diagnosis of, from
pregnancy, 143
Suckling, 279, 639
Sunken ni])ples, 276
SuiHjrfecundation, 653
SuiHjrfcetation, 653
Sup]>ressi(m of menses in preg-
nancy, KiO
Surgi»ry, ol)stetric, 350
Sutures of ftetal head, 35
Sylvester's method of artificial res-
piration, 646
Symmetrically contracted pelvis,
443, 447
enlarged pelvis, 450
Symj)hyseotomy, 398
Ayers* operation for, 404
Syncope after flooding, treatment
of, 506
during pregnancy, 176
T AM TON in abortion, 196
in placenta pnevia, 492
in secondary post-iiartum hem-
orrhage, 509
iodofomi-gauze, 504, 506
to prtxluce premature labor,
483
Tamier's basiotribe, 434
forceps, 366
perforator, 428
Tedious labor, 543
Tests for albumin, 161
Tetanus, puerperal, 631
Tetanv (tetanoid contractions),
632
Thrombiwis, arterial, 625
central venous, 621
^)eripheral venoufi, 623
Thnnnbus of vulva, 178, 625
T(M)thache during pregnancy, 151
Toxaemia, hepatic, 189
unpmic, 158, 162
Transfusion of blood after flooding,
507
of salt solution, 507, 617
n^^m
^^1
^^^H
687 ■
^^^^l* Tmnsvcfsc prfsentiilion, 340
C'nrmic convulsion^ 158, 162, 581 ^M
Trvji, t^uuniiutive sirtnly.Hii^ of, 161 ^H
^^^■^^ cau?<^ of, 34. 'j
^^^^^^^^1 Jiii|friMsi» iii\ 'Hi\
V n.'t 1i m . ;;htitdK *}(, 42 ^H
^^^^^^^B iiiLH-tjiinisni
I njii% LillniioiM) in, 158-1(11 ^H
^^^^^^^B ptinitiun^
^loixly, during jini^nanrv, 168 ^H
^^^^^^^^^
^^^^^^v uj; :hu
tiiiucy, [HH ^H
retention of, after IiIkh, 274 ^H
in yonnji^ infant, 27*J ^H
^^m Trc^phnl.lilHt, llll%<J8
Utii^rine mimnur uir ^oulHi'lt 123 ^H
^^H TuUiL iiiH>rtiMii, 20'A, 204
ITtenis* action of, in hilKJr, 230 ^H
^^^H prt^grmiuy, L^n -2IU
Hnatoiny of, 44-53 ^H
^^^B Li|mri>tority in, 207-210
nrleriiN^ of, ftl ^H
^^^^1 Tiuiiorn otjHtnuaing lutmr, /j61
chan^eti in, during tneti#*w, 67 ^H
^^^^H Tunicii aUiugiiiL'Ji,
dont)^ pre^ancVf 127- ^H
^^^^H ^ninuliMti. i)7, 00
i2^». 145 H
^^^H TuniiniTt '577, ( Sc^ " Verrioti;* p.
contmctionst of, during preg- ^H
^^H ri88 of index )
nnrii'V, 124 ^H
^^^H iti i)l;icetUii pnpvi», 493
d Is placeman Is of, during ptvg* ^H
nancy, lt>8^173 H
^^B ltK*ke<i, TM
fitnctions of, 52 ^H
^^^l Tvmp.iniH'K nf child ittipLHiitig
hiTHtn of frmrid, 564 ^H
^^^^ ' latM)r,541
im*rti*i of, n oiuw i>f tioodinjr, ^H
^^^^^^H dtiignof^u* of, from nrcgnanry,
^1
^^^^^
invi't>ion of, 513 ^H
^^^V Tvphciid fever during iiregnaxicy,
involution of, after labor, 53 ^M
^^H
UfituuenU of, 48, 49 ^^^H
^^^H TY|diita fever during pn.*giinnt:y,
lyutpltutio of, 52 ^^^^H
^^H
rif, 53 ^^^^H
^^^^H
nniroU!^ fallick*;^ of, 48 ^^^^^|
^^B flMBILK AL lord, coiliog of,
^^H U 2(50, ol.H. 574
TliTVCS of, 52 ^^M
retrMclion of, 267 ^^^^H
^^^H dri'siHiiif; of, 209
rnptnn> of, 517 ^^^^H
^^^^^^^ \igi\li m*}(, 20 1 , 5:U
striviiiiv of, 519, 544 ^^^H
^^^^^^^H piT^^ntution ami prt>-
veiuA of| 52 ^^^^|
^^^^^1
^^^^H
^^^^^^^H
VTAGl X A , mMiU >tny of, 40 ^^^H
f Htrvtita of, 557 H^^^^H
^^^^^^^H
^^^^^H
color of, in preifnanoy, ISTT^^^^B
Inicrntion i>f 525 ^H
^^^^^^^H
^^^^^H !$triKUiro
t li roni hns of, 178, 525 ^1
^^^^H
V«iin'i'd douche for Jtiductni? hdN.>r, ^H
^^^^^^m
■
^^^^f litiibilicii.s secnndnrv hemorrliage
ex3tinmatioti» in lnlH)r, 25U«^H
^^^^^ from,
^M
^^^^^^^^L of, 2H0
** Osarenn sjcrtimi ,'* 420 ^H
^^^^H
ViiiriniHrtntK, 557 ^H
Va^nttiii, puerpenil 5^4, 5fH)|^H
^^^^^^^P 1 lt« OtIM'tOIIN
^1
^^^^^^^ ritifurnutv in nnmeticlatnre« 070
VancQtH* viMn8 during prcgnancjr, ^H
^^V Hr^rnid, 158, 162
H
^^^^^^H
688
INDEX.
Variola during preguancj, 184
Varioloid during pregnancy, 185
Vectis, the, 852
Ventral gestation, 565
Veratrum viride in eclampsia, 583
Vernix caseosa, 269
Version (or turning), 377
bipolar, 380-383
in placenta prsevia, 493
cephalic, 377, 391
difficulties of, 391
eztei-nal method of, 378
in breech cases, 326, :i35
in face cases, 309, 310
in head cases, 379, 381, 383
in pelvic defonnity, 474, 476
in transvei-se cases, 378, 387
internal method of, 383
podalic, 377, 383
spontaneous, 342
Vertex, obstetrical, 37
presentations, 285
Vesical calculus impeding labor,
• 559
hemorrhoids, 168
Vesicle, umbilical, 87
Vesicular mole, 218
Vestibule, 41
bullw of, 42, 44
Vicarious menstrualion, 70
Villi of chorion, 92, 99-102
Villi of chorion, cystic degenera-
tion of, 218
Violet color of vagina in preg-
nancy, 137
: Virginity, signs of, 668
Vitelline membrane and vitellus,
i 58,71,72,98,109
; Vocal outcry during labor, 237
I Vomiting of pregnancy, 132, 152
I Voorhees' water-bags, 495
Vulva, 39, 40
atresia of, 557
cedema of, 557
pruritus of, 174
rupture of, 525
thrombus of, 178, 525
Vulvitis, puerperal, 594, 599, 610
Vulvo- vaginal glands, 44
WALCHER'S position, 368, 371
Weaning, time of, 639
I Wet-nurse, selection of, 639
! " White leg," 623
I " AMiites" during pregnancy, 173
YOLK-SAC, 87
Yellow fever during preg-
; nancy, 183
ZONA pcllucida, 57
mdiata, 71
71
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