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MANUAL OF
OBSTETRICS
MANUAL OF
OBSTETRICS
BT
JOHN OSBORN POLAR, M.Sc., M.D., F.A.C.S.
PIOFERflOR OF OBSTETRICS AND OTNECOLOOT IN THE LONG ISLAND COLLEGE HOSPITAL*.
PBOPESSOR OF OBSTETRICS, DARTMOrTH MEDICAL SCHOOL; OBSTETRICIAN AND
GYNECOLOGIST TO THE COLLEGE HOSPITAL; OYNECOIXKIIST TO THE JEWISH
HOSPITAL; CONSFLTING OBSTETRICIAN TO THE METHODIST EPISCOPAL
HOSPITAL; FELLOW OF AMERICAN GYNECOI^OGICAL SOCIETY. AMERICAN
ASSOCIATION OF OBSTETRICIANS, GYNECOLOGISTS AND ABDOMINAL
^ SURGEONS. NEW YORK OBSTETRICAL SOCIETY, ETC.
WITH THREE COLOR PLATES
AND ONE HUNDRED AND NINETEEN
ILLUSTRATIONS IN TEXT
SECOND EDITION
CONTAINING A SPECIAL SECTION
ON
ENDOCRINOLOGY
NEW YORK
Physicians and Surgeons Book Cohpant
353 West 59th Stbbet
1922
OOPTBIGHT, 1913
BY
D. APPLETON AND COMPANY
COPYBIOIIT, 1922
BY
PHYSICIANS AND SURGEONS BOOK COMPANY
Printed in tlio Tnitfd Stat«'s of America
PREFACE
The object of this Manual is to place the essential facts and
fundamental principles of the Science and Art of Obstetrics
within the easy grasp of the student and the busy practitioner
who wishes to refresh himself on basic obstetric principles. It
is further intended to be a systematic introduction to the more
elaborate treatises, and serve as a guide in following the didactic
and practical teaching given in the college course.
Over twenty-five years' experience in the teaching of under-
graduates and post-graduates in obstetrics, has demonstrated that
if the student can be made to master the elements of the subject,
complete and systematic knowledge of it becomes a matter of
easy growth. In the preparation of this volume special atten-
tion has been given to practical topics ; the arrangement is such
that the reader will, at a glance, be able to get the more impor-
tant points which have been emphasized by being italicised.
Theoretical discussions, matters of merely historical interest
and the elaboration of details, have, in the main, been purposely
excluded.
The general desire, on the part of the practitioner, to know
something of the practical application of endocrines and the in-
fluence which the ductless glands have on the development of
pregnancy, and the toxemias occurring in the pregnant woman —
has led me to review the present status of endocrinology and add
a chapter on this subject.
The author desires to express his appreciation to Dr. Norman
P. Geis, who has aided in the preparation of the chapter on
Anatomy; to Dr. George W. Phelan, for his collaboration in the
work on Endocrinology, and to Dr. Frederick Tilney, for his
chapter on Reproduction and Organology.
Many of the drawings are the work of II. C. Lehman and
W. P. McKenna.
John Osborn Polak.
Brooklyn, N. Y.
January 5, 1922
5344H
CONTENTS
CHAPTER I
ANATOMY OP FEMALE GENITAL ORGANS
PAQK
External genitals: The mons veneris; The labia majora; The
labia minora; The fourchette, or frenulum vulvaj; The fossa
navicularis; The rima pudendi; The clitoris; The vestibule;
The bulbi vestibuli; The vulvovaginal glands; The hymen;
The caruneulaB myrtiformes; Vessels, lymphatics, and
nerves of the external genitals — The vagina — The urethra —
Pelvic floor — Internal genitals: The uterus; The Fallo-
pian tubes; The ovaries; The Graafian follicles; The par-
ovarium 1-24
CHAPTER II
REPRODUCTION
The ovum — The spermatozoon — Preparation of the sex elements:
General development of germinal and somatic cells; Oogene-
sis and spermatogenesis; Ovulation and menstruation — Fer-
tilization and cleavage — Fomiation of the germ layers —
Fetal membranes and implantation : The amnion ; The cho-
rion and decidua — Development of the external fonn of the
body — Organology: The gastrointestinal system; The re-
spiratory system ; The cardiovascular system ; The lymphatic
system; The genitouiinary system; The central nervous sys-
tem— Tabulated chronology of development — Fetal circula-
tion— The effects of pregnancy on the maternal organism
— General changes consequent on pregnancy , , , 25-86
■ •
Vll
,.r,»- -•i^pfcTds •is-a •l>-:it »a-iMt Iile f4n«t
■".HAI'TKR Vt
CONTENTS ix
CHAPTER Vn
THE MECHANISM AND MANAGEMENT OF NORMAL LABOR
PAGE
"he causes of the onset of labor — Signs of the onset of labor
— The stage of dilation of the cervix: Action of
the longitudinal muscular fibers; The bag of waters;
Softening of the cervix; Dilation of the cervix —
Stage of expulsion: The birth of the head; The birth
of the trunk — The placental stage or third stage of
labor — The management of labor: The scheme of the
antepartum examination, to be made when possible not
later than the thirty-sixth week; Method of abdominal ex-
amination for determining the presentation and position of
the fetus; Preparation for labor; Signs of beginning labor;
Examination after beginning of labor; Management of the
stage of dilation; Management of the stage of expulsion;
Management of the placental stage; Treatment of injuries
to the soft parts following labor; Care of the patient at
the close of labor 132-198
CHAPTER VIII
PHYSIOLOGY OF THE PUERPERAL STATE
Condition of the uterus after labor — The vagina — Other pelvic
structures — After-pains — The lochia — Postpartum calls —
Evacuations of the bladder — The bowels — Rest — Antisepsis
of the lying-in woman — Diet of the puerperal woman —
Tardy involution — Regulation of tlie lying-in period — Es-
tablishment of the milk secretion — Care of the breasts and
nipples Contraindications to nursing .... 199-213
CHAPTER IX
THE CONDITION OF THE CHILD AT BIRTH
Ifeasurement and appearance of the nonnal child at birth — Signs
of maturity — The circulation — The stomach — Respiration —
The Wood — The skin — The bowels — The genitourinary
ortBuiK— Tiw-
CILlPTSi; S
CONTENTS
PAOK
anomalies — Anomalies of the umbilical cord: Length; Ex-
cessive torsion of the umbilical vessels; Stenosis of the
arteries ; Knots ; Hernia ; Cysts ; Coils about the fetus ; The
insertion — Pathology of the fetus: Anomalies of develop-
ment; Diseases of the fetus — Fetal death — Abortion, Mis-
carriage: Diagnosis; Prognosis; Treatment — ^Premature
Labor — Ectopic gestation: Frequency; Classification of
extrauterine pregnancy based upon the situation of the de-
veloping ovum; Etiology; Pathological possibilities; His-
tology and pathology of tubal pregnancy; Diagnostic signs
of ectopic gestation in the early months; Diagnostic signs
of an intraligamentous or abdominal pregnancy in later
months; Signs of tubal abortion or primary rupture; Dif-
ferential diagnosis; Prognosis; Treatment before primary
rupture; Treatment after rupture into the peritoneum;
Treatment after rupture into the broad ligament; Second-
ary rupture; Treatment of interstitial pregnancy — Per-
nicious vomiting of pregnancy: Etiology; Diagnosis; Prog-
nosis; Treatment — Ptyalism: Treatment — Anemia; Treat-
ment— Pulmonary tuberculosis — Varices of pregnancy;
Treatment — Pruritus vulvas: Treatment . . . .239-278
CHAPTER Xin
PATHOLOGY OP LABOR
Anomalies of the expelling powers: Excessive: precipitate labor;
Deficiency: prolonged labor — Anomalies of passages:
Anomalies of the hard parts: deformed pelvis; Anomalies
of the soft parts; Developmental anomalies of the uterus —
Anomalies of the passenger: Occipito-posterior position;
Face presentation; Brow presentation; Breech presenta-
tion; Transverhe presentation: shoulder presentation;
Treatment of complex presentations; Anomalies of
fetal development — Anomalies of labor arising from acci-
dents or disease : Prolapsus funis ; Inversion of the uterus ;
Rupture of the uterus; The hemorrhages; Separation of
the symphysis pubis ; Eclampsia ; Diabetes mellitus ; Cardiac
disease 279-360
cuxmat IT
:t iffU/M Ifirn-pa — VvTrvjo Eitrra*) *vr*ia>:
•I'm, tnt*rtnil trnUm — 'KatrUir rmvTj nt tke
' ■-«ir«ian avIVMi . «rliiilijr«irfntij(Bf : Porro «[vt»-
"Ainny. ^uiiVAumy — f.ialtri'Anmy — CraMotoiBr —
' <'|rl»l'Arlf<«}'— KrlwTvmtlAM— DrtapiiAtioo > 376-427
r irAiTHi; xvr
■II WVVM Wli
LIST OF COLORED PLATES
nxrm facimo paob
I. Uterine Circulation 20
IL Ovarian and Tubal Circulation 22
in. The Mature Ovum 64
LIST OF ILLUSTRATIONS
flG. PAGE
1. Vulva of the virgin 2
2. Sagittal section of the pelvis showing relations of the genera-
tive organs, bladder and rectum, moderately distended . 14
3. Section of nulliparous uterus, showing the shape of corporeal
and cervical cavities 17
4. Section of parous uterus, showing the shape of corporeal and
cervical cavities 17
5. Diagram showing fertilization of the ovum .... 26
6. Diagram of a human spermatozoon 27
7. Diagrams representing the maturation of the female sex cells
and the male sex cells 31
8. Vertic'al section of seminiferous tubule in man, showing sper-
matogenesis 33
9. Human ovary opened longitudinally 36
10. Diagrammatic section of placenta 45
11. Placenta at birth, seen from uterine side 46
12. Human embryo of the third week 48
13. Human embryo with twenty-seven pairs of primitive segments 51
14. Ventral view of head of 11.3 mm. human embryo ... 52
15. Ventral view of head of human embryo of eight weeks . . 53
16. Human embryos of 47-51 days, 52-54 days, and 60 days . . 54
17. Lateral view of human embryo with 14 pairs of primitive
segments 56
18. The fetal circulation 66
19. Diagrammatic representation of the urogenital organs in the
"indifferent" stage 68
20. Diagram of the development of the male genital organs from
the "indifferent" anlagen 69
21. Diagram of the development of the female genital organs from
the "indifferent" anlagen .70
XV
xvi 1 1ST OF LLLUSTiUTIONS
rro, p*ai'
2:!. Lateral view o. a niodfl of the brain of a 7H weeks human
euibrjo 13
;i;i. Diagram .if the frtnl nrciiialion 83
^ Hcijrlit of tlw I itddos at differeul periods of pt«gnanc>' - - ^
i\ HrvtisI si^is ol prr$:n(ui^)' Wi
at. T\w |)riiiutr>- and svcuudar}- areolar of pregnantT . . . M
"jr, Ili^str's *4j[« . 9t
^ H«>j:ar's «>;» (wnnpressihility of ite uti^rini! isthmos) . . 97
"JS*. Iiitvnuil b.illotiirnM'iit 9*
;a>. whUIu'v (n^siti.w lit
;>l, WaWhiT i>iv-.iii'>H, tu; inereas*' in anterior
jsteil.Ti.'r iUmiiMi-. 11^
^^. Tl'.c I'l'Eviv hniii, sbiiwinc laiulnip li iti«tDct«¥ .
.vv Yl'.i' t'<''^'>'' iHiilM. tbowuii; Utido ind r«u importuit diain-
«.tN . . Itt*'
-•* r'.ir,.^ .•;■ ihi- hriiM and .>*itl«8. s^'vitur il»f rdw «ies . llS
A\ K«a; sJ.,,n 124
.*\ K.i\-vs nv.-\ ai»ni««* .«( iW <«*l Avli 128
.•" \':"s-.:,-- .' iti," tmxx - - - 13S
-^ V ■- -■". ^t.-mntt iJ^«4"tW p*"'? '^"^ '** "wix «nd
js-iv, \ ;i\H!i itw V<«vr ivvtunct of the Ua}t . . 136
>" I . ^ )■ < 1.- . M^aliMlii'*! •>( ih* ai*<\«r*fxieai w/mm . - 137
-.^ >,;,>> -v.i, vi,i» ill itw thvraMt TierliT:» ia s Wk m«>{mio-
,1.1111) )-w.i)i,>ii ivf thp xvrtvx 141
4', 111 '.,iiii>u 111' lito N^tial *Mi«r* tr, riri: iiwiriinvarierior at
LIST OF ILLUSTRATIONS xvii
no. PAGE
51. Locating the cephalic prominence in thin women by grasping
the fetal head with one hand held transversely across the
suprapubic region 154
52. Examining the upper fetal pole 155
53. Locating the anterior shoulder 156
54. Colyer's pelvimeter 158
55. Measuiing the distance between the ischial tuberosities (the
Bisischial diameter) . . 159
56. The antenor and posterior sagittal diametei-s at the outlet . 160
57. Taking the diagonal conjugate 161
58. Measuring tlie occipito-frontal diameter, from which is esti-
mated the length of the bipanetal in unengaged cases . . 162
59. Management of perineal stage, woman in latero-prone position 179
60. Management of the perineal stage, woman in the dorsal
position 180
61. Grasping the fundus according to Crede 183
62. Effect of Crede's method on the uterus 184
63. Method of repair of primary cervical lacerations . . . 186
64. Suture of an external unilateral tear of the vulvovaginal orifice 189
65. Repair of unilateral second degree tear of pelvic floor . . 190
66. Repair of a third dogree tear 192
67. The locations at which the ovum may be arrested in its transit
through the tube 263
GS. A comual implantation in the uterus 263
69. Male pelvis (typical) 287
70. Sagittal section, showing outlet diameters in funnel pelvis . 287
71. Diagram showing mensuration of anterior and posterior
sagittal diameters by Williams's modification of Klein's
pehimeter 288
72. A short posterior sagittal, arresting the progress of labor at
the outset 289
73. A long posterior sagittal, allovring head to escajje . . . 289
74. The effect of pubiotomy on a contracted outlet .... 290
75. The Naegele ])elvis 291
76. Sagittal section of the spondylolisthetic pehis . . . 293
77. The osteomalacic pelvis 293
78. Thorn method of converting a face into a vertex position . 308
79. Piniu*d's pianeuver for bringing down the anterior leg . . 313
2
xvui JST OK ILLI^STRATIONS
na. I
80. The upper pa I of the Iriiiik Mught by tbe portially dilat«d
81. Manner of gn spiiij,- the Vtrewli vihvii trucliuu in iiwwssury .
82. Mauriceau-SiDE lie- Veil method
83. The Siueilie-V il method used when the heud is low in tbe
pelMs
54. ■\Vifrand Martin method of txIraduiK llie atler-coimng bead
85. The forceps apjiiiod to the afler-coimnn head
8lj. Thret >.( ipes ot invei-Mon
87. Relation of the iilacenta lo the iiilemal ■». m niannnal partial
and eentral | Ini-ontn Tiro-vin
55. Apparent hemoi mralion ot platenta
89. Come.Oed hemonha^e • '■
90. Concealed lienmiTha^e, head <k k iscupe of blood :
fll. Diaprnni slioninR points trom i jleediiig ruaj come
92. Ynf.'iiiil and eervical pack in jtosilion ;
M. Shimiil dilation of cervix with hand lu tlic \airina, fingecs
in llie eernx . ;
!4. Two hiind dilation of t-ffaied lenix :
05. Water bi^"*
!*li. l'omeio\ ba^ in pavili m '.
97. l>i;i^ram "ihownin,' (he r[liiti\e putition of the head in the sev
ei d f irceps ojieralions '.
9S. The Itfi I r ^nH\e blide in position, apphed to the left side of
the |>clii>. Tiid the introduclion of the second blade I
m. The dimlioii of ln.fjcui Li funips at, Iht htjJ j
dilT lent lehtion to the bnth t mil
Kill. r,.nii-. to thi t HI It Ihe l>^l\^l oiitlit
mi. .I.-well ^\L-lIletlOll t-iteis
10± Ki("lii Mivjon
I'l.'i. Hipol.ir ui-Moii
]n4. Iii|„,|;ir v,.i>i..ii
]». Cesafeu;j
IV'. Va-iual (
111. VaL-iiial (
LIST OF ILLUSTRATIONS xix
PIO. PAGE
112. Vaginal Cesarean section 414
113. Vajrinal Cesai-ean section 415
114. Line of section in hebotomy 420
115. Effect on the pelvis of pubic section 420
116. Passing the Doderlein needle 421
117- Gigli saw in position . 422
118. Cleidotomy 424
119. Liisk*s cephalotribe 425
MANUAL OF OBSTETRICS
CHAPTER I
ANATOMY OP FEMALE GENITAL ORGANS
The genital organs are commonly divided into the external and
the internal genitals and the vagina, which connects the two sets
of organs.
EXTERNAL GENITALS
The external genitals, commonly called the pudendum and the
vulva, consist of the following structures: the mons veneris, the
labia majora, the labia minora, the clitoris, the vestibule, the vulvo-
vaginal glands, and the hymen.
The Mons Veneris. — The mons veneris is a triangular pad of
fat supported by trabeculae of fibrous and elastic tissue which run
through the adipose layer in all directions. It overlies the pubis
and is covered by short, crisp, curly hair after puberty. Its base is
the hypogastric crease; its sides correspond with the groins, and
its apex below merges into the labia majora. The round ligament
may be traced into the mons on either side.
The Labia Majora. — The labia majora, or larger external lips,
are two prominent folds, covered by skin, continuing downward
and backward from the mons on either side of the median line.
They are large above, and gradually become smaller as they are
lost in the skin of the perineum. Each is triangular in form, with
its base along the pubic ramus; the external side is toward the
thigh, and the internal side is, in the young nullipara, in contact
w^ith its fellow of the opposite side, except when the thighs are
strongly abducted {vulva connivcns). When the labia are not in
contact, as in old age, or after childbirth, and allow the labia
2 anato:my of female genital organs
minora to protrude between them, it is called vulva hians. The out-
side is roiitj^h and in adult life is covered by heavy hair. The inner
surface is smooth and is sparsely covered with very fine hair. In
j1
EXTERNAL GENITALS 3
The minor lips are covered with delicate integument having num-
berless sebaceous glands on both surfaces and few, if any, hairs.
Bundles of smooth, unstriped muscular fibers, a rich supply of
nerve filaments, and venous spaces in the interior produce the effect
of erectile tissue. Fat is absent. In Bush women and in many
Hottentots the labia minora are excessively hypertrophied.
The fonrchette, or frenulum vulvae, is a transverse, crescentic
fold of skin, connecting the labia majora posteriorly. When the
labia are separated it appears as a tense tranverse fold between the
posterior commissure and the hymen. In the nuUiparous woman
its distance from the anal orifice is 3 cm.
The fossa navicularii!( is a boat-shaped depression, formed be-
tween the fourchette and the h>Tnen when the labia are separated.
The rima pudendi is the median cleft between the labia
majora of the right and left sides.
The Clitoris — The clitoris is situated in the median line below
the anterior vulvar commissure. It is a small cylindrical body, and
is slightly curved, with its convexity outward.
It is made up of two corpora cavernosa and a glans, analogous
to those of the penis, but has no corpus spongiosum, and is not per-
forated by the urethra as is the penis.
Continuous with the corpora cavernosa are the crura by which
the clitoris is attached to the ischiopubic rami. The clitoris is
attached to the pubes by a suspensory ligament. It is concealed
behind the skin and inclosed in a firm fibrous sheath. Its internal
structure is largely made up of erectile tissue, and its mucous sur-
face is richly supplied with nerve papillae. The clitoris is hidden
from view by the labia majora ; the glans, the only visible portion,
lies partly concealed in the preputial fold formed by the anterior
folds of the nymphffi. The thickness of the glans during erection is
about 5 cm., while the entire length of the clitoris is about one inch
or 25 cm. The glans has a few sebaceous follicles.
The vascular supply is from the pudic artery through the dorsal
and the profunda arteries, while the dorsal vein empties into the
vesical plexus. The nerve supply of the clitoris is much more abun-
dant than that of the penis in the male ; it is derivetl from the in-
ternal pudic and the hypogastric plexus of the sympathetic. The
clitoris is the chief seat of voluptuous sensation in the female.
The Vestibule. — The vestibule is a triangular surface, with
4 ANATOAP OF FEMALE GENITAL ORGANS ■
its apex at the glaas elitoridis, bounded iaterallj' by the labia
minora, and below by the aiiterior margin of the vaginal orifice. It
is covered by a iiiul-oiis m«^uibran<-. whieh is markeii by £aint trans-
verse ridges. Tbe external urinary meatus, or meatus uretbnp.
appears as a small tubercle, or proioiueuee. with a median eleft
directly below the center of the base of the vestibule and one iueh
below the clitoris. This meatus has in its posterio- lateral margins
two lips (urethral lips), in which are found Skene's glands or
dads. The duets open just anterior lo the center of the urethral
lips. The "pars ititerme<lia." un inlrieatc plesiis of veins eonneet-
ing the opjiosite vesti atfly underlies the mucous
membram- of the vestibu.i
The Bulbi Vestibnli.— The b> . c^stihuH. or vaginal bulbs,
are two mas.ses eorjtuiniug a pli'xu tvins. couueetive tissue, and
some sinoolli inu.si.'ular fibei-s. situati-il on either side of the vestibnie
anil vaginal oiifice, behind thi; labia minora and immediatclj- in
front of X\\<- triangular ligament. They are pyriform in shape ami
'•i'} em,, or one and one-quarter iiclies, in length. Each is inclosed
in a hbrou.s eiipsule derived from the inferior layer of the triangu-
lar lijratnint. Anteriorly, at their small end. they communicate
will) thr vi-ins of the eliloris. Tliey also communicate with the
veins (if till' hiliiii niiijnra iiiid minora, tiie vagina, and those of the
The Vulvovaginal Glands,— The vnUovaginal glands, or
fjhiniis i\i I'jirtl o!in, iii'i' two cojiiiinunil racemose glands, about
oni'-liair ini-li in li'n;.'lli (llu' aiiiilops of fowper's glands in the
inali'i. siluiili'd <i\\ citl i^r siiir nl' iln' viiginai oritiee, just posterior
to lli>- viij.'i]ij,l hiillis liiillii vvstihiilii. Iiy which they are over-
liipl.i'il, 'Yh'-y ;in' usiially |)l;n-ri| on llir dee]) surface of the in-
l'-ji(ir liiyt-r ol' tln' t rijuifriiliir llnaun'rit. I'rom which they ivecive an
irjvcslin^ sin'hlli. If niit tlms |il;n-.'il, llu-y are locateil anterior to
Ix.ih l;iy..i's oj- llii.s IJKJiiri.'til. Tln^ .hi.'ts of these glands are two-
ihii'ds of ;in in.-li in lrn-:lli. ami run alonjr internal to the bulbi
nstil.iili ;jm.I <,|M.ri. .iiisi ,.xli-ni;il li, the liynii'ii, in the posterior
I'll. I of \\-..- iJiJnnr li|>,s at tl.r siihs r)!' ilii. vatiinai orifice. Their
si--i( fiod is vrllouisli. i.'iiaciiins iinii-ii>i. wliicli is ponrcd out freely
^luiiiJ!.' s.Aual .x.-iiMniTit ajid duiinjr labor.
The Hymen.- -Till' liynn'n is a lliiii si>|itniii or fold of mucous
iii'iiilir.iin' imrlially ur wholly ocL-Iiiding the vaginal orifice. It is a
THE VAGINA 5
thinned outfold of the vaginal wall, which contains a few muscular
fibers. Its shape is usually crescentic, situated at the posterior mar-
gin of the introitus, but it may be annular, cribriform, fimbriated,
or imperforate. It is usually torn at the first coitus. An untorn
hymen, however, is not an absolute sign of virginity, nor is a torn
one necessarily evidence that sexual intercourse has been practiced.
The canmculae myrtiformes are the remnants of the hymen
torn in labor by the passage of the cliild. These appear as small
projections or tags of mucous membrane, three or four in number,
around the vaginal opening, particularly at its posterior lateral
margins.
VESSELS, LY^rPHATICS, AND NERVES OF THE EXTERNAL
GENITALS
Arteries. — The arterial supply of the external genitals is de-
rived from the superficial perineal branches of the internal pudic;
the transverse perineal arteries; the branches of the superficial
perineal ; or by direct branches from the internal pudic and from
the branches of the external pudic arteries which come off from the
common femoral artery.
The veins accompany the arteries. They form large plexuses,
communicating with one another, and empty into the internal
pudic and inferior branch of the small sciatic veins. Varicosities
of the labia majora are common during pregnancy, while the
venous plexuses of the labia become turbid during sexual excitement.
Lymphatics. — The lymphatics of the external genitals empty
into the superficial inguinal glands, which in turn communicate
with the internal and external sets of glands.
Nerves. — The nerve supply is derived from the superficial
perineal nerve, a branch of the pudic, the inferior pudendal of the
small sciatic, and communications from the inferior hypogastric
plexus of the sympathetic.
THE VAGINA
The vagina is a musculo-membranous tube, which connects
the uterus and the vulva. It suri-ounds and is firmly attached to
the uterus above, while below it terminates in the hymen. With
the bladder and rectum empty, its direction is nearly parallel with
/
r:*^ S. iiic -mar
-_- "jit op. TV tiMBn
1 a.-, lai: » il> i
•i r'HtUf-I m potr^to ■»'>mt?ii- Th«? g
-r- i.-t just below
•ir-t^i-vCs into the
••:tij"'iiil wall, for
■L^iti -.) ttie reeto-
■ f 'J'niiiclns. Its
, '-le 7vi-tiim by
■■■■ j;i-.-ri..r wall
■ stru^'-
■i- fialf.
THE URETHRA 7
Structure. — The vagina has three coats, (1) the external or
fibrous coat, (2) the middle or muscular coat, (3) the internal or
mucous coat.
The fibrous coat is a prolongation of the rectovesical fascia,
while the muscular layer is composed of an inner coat of unstriped
muscle fibers, running in a circular direction, and an external
longitudinal layer. It is thin near the vault, but increases in
thickness gradually until at tlie vaginal orifice it is thickest. The
bulbocavernosus, a weak voluntary muscle, encircles the vaginal
orifice. The mucous coat, which is reflected on to the cervix, cov-
ering its vaginal portion to the external os, is of a light pink color.
The mucous coat is arranged in two median ridges, known as the
anterior and posterior columns of the vagina. The mucosa is
thro\vn into numerous transverse folds, the ruga. These trans-
verse rugce, or Cristce, run outward from the longitudinal columns,
being more developed in the lower two-thirds of the tube and near
the vaginal orifice on the anterior wall. The fornices are devoid of
them. They are more or less effaced by childbirth and by inflam-
mation of the vagina. The epithelium is of the squamous variety.
The normal secretion of the vagina is acid, due to the presence of
an acid-producing bacillus.
The arterial supply is derived from the anterior division of
the internal iliac through the vaginal, uterine, middle hemor-
rhoidal, and internal pudic, all of which anastomose with one an-
other and with the rectal and vesical arteries.
The veins form plexuses entirely encircling the vagina. They
communicate with the hemorrhoidal, vesical, pudendal, and pam-
piniform plexuses.
The nerves are from the pudic and fourth sacral and from the
lower hypogastric plexus of the sympathetic.
THE TJBETHEA
The urethra is of obstetric interest. Therefore, while not prop-
erly a generative organ, it warrants a brief description.
The urethra is intimately connected with the lower portion of
the anterior vaginal wall. Heginning at the middle of the base of
the vestibule, it passes backward beneath the pubic arch to the
bladder. The direction of the urethral canal is nearly parallel
8 ANATOMY OF FEMALE GENITAL ORGANS ■
with the plimi' of the pelvic brun. It is imbedded in the anterior
vaginal wall, for thi' lower three- fourths of its course, and sup-
ported by the pubovesieal ligament. It pierces the layers of the
triangular ligament, and that portion oi" the ui-ethral canal which
lira between the layers of the triangular ligament ia encircled by
tlie compressor urethra muscle.
Its course is at arved, with its convexity
looking downwai'd t
In strnolure it it viiig three coats, an outer
museiiliii foat of ur id an ijiner longitudinal
liiyiT. It is lined w jrane whieh lies in longi-
tudiual folds; these folua „ ed near the bladder. The
uiui'os!! is liiuil with s^uanions e|i' Jm. whieh becomes transi-
tional as it approaches the vesical e. Its meatus is a vertical
slit; its vcsieiil end terminates abruptly in the bladder. The
urethra is about 4 em., or l^.'g inches, in length, and has an aver-
age diameter uf <! mm. It is smaller at the meatus and enlarges
near the vesical end. The canal is very distensible.
The viisiiiliir and nervous supply are the same as those of the
Glands of the Uretluv. — The surface of t!ie mucous membrane
coninins nuni.iiius Iticuna' and rneeuiose glands.
Skene's tulmlar glands — first desiTibwi by Malpighi. on either
side ot' the tin.liau liiie, oii the (loui- of the urethra — are two small
lulniUs ill The wall of the urethra, idiout ''i of an inch in length.
TliHi- oriii.'rs li,. jusi at ov Miihin the mr:uus. Th.-se tubnles are
PELVIC FLOOR 9
with the plane of the brim, except that the end of the rectum turns
backward nearly at a right angle with the vagina. The pelvic floor
extends from the pubis to the coccyx, and its lateral limits arc the
rami of the pubis and ischium, the tuberosity of the ischium, and
the sacrosciatic ligaments. The anterior vaginal wall and the soft
parts in front of it constitute the puhic segment; the posterior
vaginal wall and the soft parts behind it the sacral segment of the
pelvic floor. It helps support and maintain the pelvic viscera.
The meeting of the two halves of the pelvic floor in the median
line between the vagina and the rectum is known as the median
raphe; that portion between the rectum and the coccyx is called
the rectococcygeal raphe.
Measurements. — From the coccyx to the anus, in the nul-
lipara, 4.5 cm. (1% in.) ; from the anus to the lower edge of the
vulvar orifice, in the nullipara, 3.1 cm. (IVi in.) ; in the parous
woman, 2.5 cm. (1 in.) ; in the primigravida at term, 3.8 cm.
(li/o in.).
The greatest transverse width on the bisischial line is 10.7 cm.
(4^4 ill) ; while the perpendicular thickness of the pelvic floor at
the anus is 5 cm. (2 in.).
In the nulligravida the average projection of the pelvic floor
below a line drawn from the top of the coccyx to the lower end of
the symphysis is 2.5 cm. (1 in.) ; in the pregnant woman at term,
9.5 cm. (3% in.).
The length of the sacral segment during labor at the moment
of expulsion, from coccyx to the lower edge of the vulvar orifice, is
15 to 17.5 cm. (6 to 7 in.).
Pelvic Fascia. — The most important supporting structures of
the pelvic floor are its fascial sheets and the levator es ani muscles.
Its strength and supporting power depend mainly on its fascial
sheets.
The pelvic fascia is continuous at the iliopectineal line with the
iliac and transversalis fascite. It consists of two parts, the obtura-
tor fascia and the rectovesical fascia.
The obturator fascia is the special fascia of the obturator in-
temus muscle, which it covers on its inner surface. It is attached
above to the iliac portion of the iliopectineal line; in front to the
posterior surface of the pubic bone ; behind to the anterior margin
of the great sciatic notch and the great sacrosciatic ligament ; and
10 ANATOMY OF FEMALE OENITAIj ORGANS
below it joins the falciform process of this ligament, through which
it is attached to the iseliiojuibic rami. This fascia forms tlie outer
boundary of the ischioi-ectal fossa. The internal pudic vessels and
nerves covered by their sheaths are imbedded in this part of the
fascia. From the posterior part of this fascia a thin layer ( fascia
of the pj liforraiB) is continued to the sacrum and covers the pyr-
i form is muscle.
PELVIC FLOOR 11
muscle join the median line, forming the rectococcygeal raphe and
the median raphe.
The Triangular Ligament. — This is a trapezoid, musculo-
tendinous ligament, which is stretched across the triangular space,
bounded by the ischiopubic rami and the bisischial line. This
ligament consists of two layers of fascia making the anterior and
the posterior layers of the triangular ligament. They unite supe-
riorly and inferiorly, forming a slit-like space partly inclosing the
bulb of the vestibule and completely covering the deep transversus
perinei muscles, the sphincter urethrae muscle, and the artery, vein,
and nerve of the clitoris. This fascia arises from the rami of the
pubis and ischium and unites with its fellow from the opposite
side in the median line. The two layers blend at the bisischial
line with each other and with the deep layers of the super-
ficial fascia, which are continuous with that of the rest of
the body and form the perineal ledge or ischioperineal ligament.
These sheaths of fascia are perforated by the urethra and the
vagina.
Muscles of the Pelvic Floor. — Levator Ani Muscle. — Each
levator ani muscle lies superficial to the rectovesical fascia, and is
composed of three parts, or bundles of muscle fibers.
The pubic bundle, puhococcygeus, takes its origin from the in-
trapelvic surface of the os pubis and from the deep layer of the
triangular ligament. Its fibers run nearly horizontally backward
to the coccyx. Some of its fibers are inserted into the vagina, the
perineal body, the rectum, and the rectococcygeal raphe, but the
main body of the muscle goes to the coccyx. The entire bundle of
the muscle is a half inch wide and a quarter of an inch thick, and,
as it passes backward, it runs one-quarter of an inch from the lat-
eral wall of the vagina. The two divisions of the pubic portion of
the levator comprise the pubococcygeus, whose fibers run toward
the coccyx, and the puhorectalis or anterior division, the larger
part of whose fibers unite with its companion of the opposite side
behind the perineal flexure of the rectum.
The second bundle, or obturator-coccygeus, arises from the
white line, and is thin and membranous. The fibers run down-
ward, inward, and backward toward the rectum and the recto-
coccygeal raphe, below the pubococcygeus. None of the fibers
reach the rectum. Some are inserted into the rectococcygeal raphe,
12 ANATOMY OF FEMALE GENITAIi ORGAN'S ■
while the greater part go to the coccyx, reaching it directly or by
an aponeurotie attachmeat.
The thin! poition, the ischiococcygcus. ariaes from the spine of
the ischium, and forms a small, apiurlle-slmped bundle of fibtTs.
thicker and diKtinetly separable from the fibers of fascial origin.
The course of this bundle is nearly transverse, most of its fibers
being inserted into the tip of the coccyx. A few turn forward
upon the I'ectoeoceygeal raphe.
The second and third portions of the levator are often called
the iliococfijgiiis portion of the levator ani muscle.
The coccygius muscle takes its origin from the spine of the
ischium, and is inserted into the sides of the coccyx and sacrum.
This niusule is commonly cousidi'rwl a part of the ischiococeygeua.
None of the fibers of the levator aui muscle crosses the me<lian line
to joiu those of its fellow oil (lie opposite side, except those few-
deeper fibers of the puboreetalis which tnter into the formation of
the external sphincter aui muscle. The aaal fascia below and a
very thin fascial layer on the upper surface of the levator form
INTERNAL GENITALS 13
3 cm. wide, one on either side of the anus, taking their origin from
the tip of the coccyx and the adjacent skin and fascia, and inserted
into the tendinous center of the perineal body ; these are, in part,
derived from the puborectalis muscle.
The perineal body is the term applied to that span of tissue
intervening between the anus and the posterior commissure of the
\'ulva and the lower end of the rectum and the vagina. It is made
up of elastic and muscular tissue. Into this are introduced the
superficial transversus perinei, the bulbocavernosus and the exter-
nal sphincter. Its heifijht is 3.7 cm. (IV^ inches), its transverse
width 3.7 cm. (l^/^ inches;, and the length of its anterior posterior
base 3.1 cm. in the nullipara.
Blood and Nerve Supply. — The blood supply of the pelvic
floor is from the pudics and the hemorrhoidals, the nerve supply
from the internal pudic and the third and fourth sacral nerves.
IHTEBHAL GENITALS
These include the uterus, the Fallopian tubes, and the ovaries.
The Uterus.— Situation. — In the erect position of the woman
the uterus is situated in the cavity of the pelvis between the blad-
der and the rectum, a little nearer to the sacrum than to the pubic
bones. This organ does not occupy a fixed position in the true
pelvis. It is freely movable within the limits of its ligaments and
the vagina. The condition of the bladder and the rectum influ-
ences its position: a full bladder pushes it backward, while a dis-
tended rectum may displace it forward. The position of the uterus
may be said to be normal when it occupies a central position in
the space between the pubis and the sacrum, and is about in the
median line below the level of the brim of the pelvis and above a
line drawn from the summit of the subpubic arch to the tip of the
sacrum, or in the plane of the ischial spines and the cervix pos-
terior to a central position. It is normally in anteversion. Its
long axis is nearly perpendicular to the plane of the pelvic brim
and forms a right angle with the vagina. The peritoneal covering
of the body is as follows : The peritoneum comes from the anterior
abdominal wall and is reflected over the fundus of the bladder.
It then dips down between the bladder and the uterus and is re-
flected on to the uterus, covering the upper two-thirds of its an-
8
ANATOJIY OF FEMALE GF.NITAL ORGANS
terior sulfate Tie space between tie blaller and the uterus is
the anterior cul de i>ac or uterov€><%tal space The pentoueum then
5, 2.— S TT S
1
It T \ OF THE
C.KSKl L N 1
\
1 M E.1MTE11 Dis-
TKNlltJ 1 U t of tl
'' ( u
f 1 rus J Xeck or
oiTvix r 1 ut r 4 1
f 1 r
s 1 f JR i jHirtion of
111.- !,. k ( \dl. \ t.
1 rl
S HI 11 r 1 Irotlru; 10.
Vosicu jgi fli all 1 1 li
1 it
1 ii \ 14 Recto-
vaginal vill li Per u 1
Ul -1 1 Lterorectal
or cul-de-sac / Dougla. IS 1 1
ol
1 1 s jII [ 0 Great lip.
INTERNAL GENITALS 15
pelvis. The space between the uterus and the rectum is the pos-
terior cul-de-sac, or the cul-de-sac of Douglas.
Relations. — The anterior surface of the uterus is usually in
relation with the bladder, though the small intestines occasionally
occupy the uterovesical space. Posteriorly, it is in relation with
the small intestine and sigmoid, which fill the uterorectal cul-de-
sac; laterally, are the broad ligaments and their contents. That
part of the uterus between the peritoneum and the vagina, ante-
riorly, is attached to the bladder by loose connective tissue. The
lower extremity of the uterus projects into the upper end of the
vagina for nearly half an inch.
Shape. — The uterus is a hollow muscular organ. It is pyri-
form in shape, with its larger end uppermost. The posterior and
the upper surfaces are convex, its anterior surface nearly flat, and
it is slightly flattened from before backward. The long axis is
slightly curved, with its concavity forward.
Size. — (a) In the nulliparous uterus the average measure-
ments are 1 in. (or 2.5 cm.) thick, 2 in, (or 5 cm.) wide at the
Fallopian tubes, and 3 in. (or 7.5 cm.) long. It weighs one ounce
and its cavity holds 16 drops.
(b)* The parous uterus has all of its measurements increased
by Vi i^- Its weight is nearly 2 ounces. Marked atrophy takes
place after the menopause.
Regional Divisions. — The uterus may be divided for study
into a body and a cervix.
Divisions of the Body. — The body is approximately the upper
half of the uterus in the nulliparous and the upper two-thirds in
the parous woman.
The isthmus is the slight constriction at the junction of the
body and the cervix.
The fundus is that portion of the body above the level of the
Fallopian tubes.
The cornua are the two lateral angles of the uterus at which v
the Fallopian tubes enter and the ovarian ligaments and the round
ligaments are attached.
Divisions of the Cervix. — The infravaginal portion, or the por-
tie vaginalis, is that part of the cervix below the vaginal roof. In
the parous woman it projects into the upper end of the vagina
for ^^-% of an inch.
16 ANATOMY OF FEMALE OENITAL ORGANS ■
The siijtraraylHal portinii is that part between the isthmus and
the jwrtio vugiiiulia, Its average length in the parous woman is
slightly more than y» Ineli.
Uterine Cavity. — The cavity of the body in the non-parous
woiuau ia somewhat triaugiilar iu shape, its anterior and posterior
walls lying pra<'tically iu contact. It has three openings, one eom-
nmiiienting with the cGr\ieal canal, and one with each of the Fal-
lopian tubes.
The i-arilii of the ciTiix is slightly flattened from before back-
waitl. ami is hitinilly elliptical, thus having an irregular, fusiform
slin]ie.
The !'.< iiil< riiinn is the Mpper opening of the cervix connecting
the oervix tuiii the body, and is about 110 inch iu diameter.
The I'X i^-li niuiii is the lower orifice of the eeirix, and is slightly
INTERNAL GENITALS 17
where on the free surface it is goblet-shaped without cilia. The
gland cells are cuboidal and non-ciliated. In the lower third of
the cervical canal, as well as upon the external surface of the
portio vaginalis, the epithelium is stjuanious, like that of the
vagina. The cervical secretion is a clear tenacious mucus having
an alkaline reaction.
The muscularis constitutes the greater part of the thickness of
the uterine walla. It coii-sists of unslriped muscular fibers. The
muscular wall is composed of three layers; but they can only be
distinguished at or near the end of pregnancy. The center and
inner layers are very thin. The middle layer comprises the bulk
of uterine muscle.
Fig. 3. — Section of Nullipahous Fig. 4.— Section of Parous Utek-
Utbrus, Showing the Shape of us, Showing the Shape of Cob-
Corporeal AND Cervical Cavi- poreal and Cervical Cavities.
TIES.
The outer layer consists mainly of longitudinal fibers. Those
are continuous with the muscular layers of the Fallopian tubes,
the ovarian, round, and utcrosaeral ligaments.
The middle layer is composed of a network of interlacing longi-
tudinal and circular muscle bundles which make np the greater
part of the uterine muscle wall.
The timer Jaifer is made up of extremely tbiu eireuhir niusele
bundles. It surrounds the orifice of the Fallopian tubes and forms
a sphincter at the os internum.
18 ANATOMY OF FEJIALE GENITAL ORGANS
The cervix eonsists maiuly of counective tissue. A well-raarkeJ
band of circular miiscular libera exists iu the cervix at the vaginal
junction.
The Peritoneal Coat. — The utenis is partially enveloped in a
transverse fold of pelvic peritoneum, which invests the upper por-
tion of the uteiTis, extending over the entire length of the organ
Dosteriorlv and to the isthmus anteriorly.
INTERNAL GENITALS 19
oping a few muscular fibers, extending one on either side of the
median line, from the utei-us to the bladder. The space between
them is the anterior cul-de-sac of Douglas, or the uterovesical
space.
The round ligaments are two flattened musculo-fibrous cords
attached to the eomua of the uterus just in front of the Fallopian
tubes. Each ligament passes upward, forward, and outward
through the inguinal canal, and there becomes lost in the tissues
of the mons veneris and the labia majora. The muscular fibers
come from the uterus. Their length is 10-12 cm., or 4-5 inches.
An artery and v^in pass through each. The round ligament,
when passing into the inguinal canal, recovers a peritoneal sheath,
which is usually obliterated during development; when it persists
it is called the canal of Nuck.
The uteropelvic ligaments are bands of muscular fibers in the
base of each broad ligament running outward from the uterus
to the pelvic wall. These are the principal lateral supports of
the uterus.
The Arteries. — The arterial supjily of the uterus is from the
two uterine and the two ovarian vessels. They are remarkable for
their frequent anastomoses and for the tortuousness of their course.
The uterine artery is a branch of the internal iliac artery, while
the ovarian is given off from the aorta and reaches the uterus at
the level of the cornua. Both pass between the folds of the broad
ligament. The uterine artery enters the base of the broad liga-
ment ; it passes under the ureter about one-quarter of an inch from
the supravaginal cervix, and reaches the uterus just above the
vaginal junction, then up along the lateral border of the uterus to
the cornua, where it anastomoses with the ovarian artery. The
uterine artery, in its tortuous course up the side of the uterus,
sends off numerous arterial tufts, whose branches penetrate the
muscle and form spirals within the uterine walls, which break into
a capillary network supplying the endometrium and end in a mesh-
work of capillaries about the utricular glands. Other branches
from the uterine artery run in the anterior and the posterior walls,
but do not cross the median line of the uterus, nor do they anasto-
mose with the corresponding arteries from the other side. The
circular artery surrounds the cervix at the istlinms, and unites the
uterine arteries of the opposite sides with each other.
20 ANATOan OF FEMALE GENITAL ORGANS ■
The eirculai- aiti'ry is made up from the anastomosis of the
anterior and posteiior branches of the uterine arteries given off at
tlie istlmius.
The eervicovag: nal artery is given off from the uterine just
hcfori' it reachoa tlie uterus. This supplies the lower part of the
eorvix nml the ii|i|u'r purl of the vagina. At the junction of the
nlerini' ivilh the ovarian, a fundal and a tubal hranch are given off.
The tirti'i-y of the iiiuml ligament, which is a small one, is a branch
of the vesical givrii off hI the internal abdominal ring. It anas-
toiuiisi's III thi' i-iirnn. ind ovarian.
Tiiv: Vkins.- Tlie veins lies immediately be-
neiitli the perilixnid i-iwii and extemls between the
folds of hioiul linniiieiita. The veif . very large and form pl«-
usi'.s iiii't sinii.-ifis ill till' midille mil r eoat and are encircled by
nmsenhir liiiiidlis. They annstomose with the vaginal and the
vesii'id ph'Mises Their imllel is the liyj>ogastric vein and the
punipinilonii pIcMis from the ovary.
Tiir t,\ MriiATu'--*, — The lymphatics arc very numerous in the
l«i>l,\ iif ihe uterus, aiul ihey eoriiintinicale with the lymph spaces
ef ilu' miiiims uiemhiWiie and of tile muscular coat, and form with
iho liiiii'v a iieiuork of vessi-ls. jusi tK-ni-ath tlie peritoneal coat,
\\lii,h .■..iiiiuunieHte with tlu^se of the Fallopian lubes. The utei^
uii' l\iii|'li,iii.s aiv fully devehn*.-d otdy during pregnaney. Two
.ir tiu'ii' I'l' ihe lyuiphtities of the Nnly of the uterus empty into
ilir ui'i'.'v li> i>.ii;asii-ie giMup of glands. Most of the lymphatics
I'l' iliv 111, ■1111. ■ I'lviv .-mi'iv m;,i i«i> l;l^l^' vi-ssf'ls which leave the
ii]']'.v 111,11 j;iii ,it ill.- I-r,M,i :ii;av.'.. :■.: :,' •.,^ir. :he si.iddle group of
l;i:;;l>,ii- u;l,i:;.K 1'!^,- ..-m,,!'. ^v ■,-:;'l.;i: ^.s :'.-".".>w tV.i' course of the
ii;,i!ii.' avi.^i.v ;,■ ;! ,■ :;pi-.v : > :\»i;,.-: ■;, - v ; i!:,-.: tr;aiids. The
1> ii;pl.,i;;, s ;:,>■;; :'. .■ ii;>;-,-v ',) :■,'. ,■:' :' , \..c": :> "-■"■"* '-^ "he lower
r .■ \-.\' ■'. .,s . , ■ ■ - - "■ y:-v^.is!rie
:ii\,; ;., v.- , y.v. ,-..-, ,■ -> - .- --, .^::-i from
Uterlve Circulation
INTERNAL GENITALS 21
ligament for an inch to an inch and one-half; from here on they
take a tortuous course, passing above, then external to, and finally
beneath the ovary, partially surrounding it. The right is a little
longer than the left. The oviducts serve to convey the ovum from
the ovary to the uterus.
Divisions. — (a) The isthmus is the inner third of the tube. As
the tube runs outward from the uterus, it expands gradually, from
2 ram., or 1/12 inch, to 4 mm., or 3/16 inch, in diameter.
The ampulla makes up about one-half the length of the tube,
and extends from the isthmus to the neck. It is the dilated por-
tion of the tube next beyond the isthmus; its diameter is about 1
cm., or 1/3 of an inch.
The neck is the constricted part of the tube between the am-
pulla and the infundibulum.
The infundibulum, fimhriated extremity, or pavilion, is the
free trumpet-shaped end of the tube, the margin of which is
fringed with fine processes called fimbriae The fimbria?, four or
five in number, vary in size; one is longer than the others, and is
attached to the ovary ; it is called the fimbria ovarica. At the pa-
vilion the tube abruptly expands to about 2 cm., or 3/4 of an inch
in diameter.
The ostium uterinum is the opening of the tube into the uterus
and is 1 mm., or 1/25 of an inch, in diameter.
The ostium ahdominalc, or externum, is the constricted open-
ing at the neck, and is four times as large as the ostium uterinum.
It will admit a small goose-quill 5 mm. in diameter.
Structure. — Each tube is made up of three layers continu-
ous, respectively, with the corresponding layers of the uterus.
1. The outer, or peritoneal, coat is continuous with the serous
coat of the uterus and with the peritoneal fold of the broad liga-
ment. That part of the broad ligament between the tube and the
ovary is termed the mesosalpinx,
2. The middle, or muscular, coat is composed of an inner
circular and two outer longitudinal layers of unstriped muscu-
lar fibers. The outermost layer is limited to the uterine end of
the tube. The muscular coat contains a rich plexus of blood
vessels.
3. The inner, or mucous, coat except in the intrauterine por-
tion of the tube, is thrown into longitudinal folds, which become
22 ANATOMY OF FESIALE GENITAL ORGANS ■
extremely complex in the ampulla. Like the uterus, it lias no dis-
tinct submucous lay'er, and, like the uterus, it is lined by columnar
ciliated epithelium. The mucous meinbraue is i.*outiuuous with
that of the uterus aud at the outer end blends with the peritoneal
covering of the tube. This makes the peritoneal cavity of the
ffmalc open to dtri'ct external infeetiou by continuity through the
vagina, vtcrits, ami tubes.
The arteries of the Fallopian tubes are from the branches of
the uterine and tlie ovarian arteries.
The vkin.s open into the ijawpimfiinn. or orarian. plexus, lying
between the folds of below the tube.
The lvjh'h.vtjus jo.^ e body of the uterus and
the ovary and empty into the luip lands.
TuE NERVES aie derived from 1 terino and ovarian plexuses.
The Ovaries. — ^The ovaries in tne female correspond to the
testicles in the male.
S!Ti.-.\TiON'. — These organs, two iu number, are located one on
eiieh side of the uterus aud are iu the posterior fold of the broad
ligament in a shallow, erescent-sliaped fossil, an inch or more bt-
law the level of the iliopeetineal line. They are about one inch
fi-om the uterus, to which tbey are attaclied at the cornua by the
ovarian liganu'ut.
SiiAi'E. — The usual shape of the ovary is a. fiattened ovoid;
its free border is convex; its anterior edge, or hilum, is nearly
straiEfht. The ovary is thinnest at the hilum, thickest at the eon-
ve.v bnnli'r. The inner end is pointed and merges into the ovarian
lifraiiii'nt, wliii-h connects it witli the uterine eornua ; the outer i;
more obtuso an<l bullions. The shape is variable, and the ovary
enlarges ilnrlng mi-nst ruatioii and prefrmmey.
iizE.— The average ova
ry is :
t.r> em. 1
:»■ 1 1 -■. inches long, hy
1. or ;'l ineh wi(ir. and
1. nr 1 '.
inrh thiek. and weighs
It UK) grains (fl..'^ grji
mist.
(■ and weight increase
iig mens! I'Uiil ion and |'
regnau'
[■V.
>TI{irTI-HL.— 1. l-:.rl.r,w
/.— In .
,.arly ag,
■ i!h' external surface is
ith.orvelv.-fysofln..ss.i
mil of ;
1 pinUisIi
or grayish pearly color.
■r i.nberty il gradually
l>e.-e<r>
• 's nm-vi
■H aiid'wrinkle,!"in a|i-
■anc'i., <>^^itl^' lii <-irat fii-r;
< Infill
niplui'i'i
1 (Iraafian foliicles. Its
1- now is pr;irl-L-iay, hi
<.l.l JIL'.
■ j: l)r.-i>i
ii.ssmall.-r. harder, ami
r ill eulur, Tli,.. fiv.- f-
urfa.T
of 1)
>vary is covered with a
Ovarian amd Ti;bal Circulation
T. Falliipian tiihc
F. Fimbriated oxtrt
of same
O. Ovary
1. Kcniiiant of Wolffian duct
iiity 2, 2. Remnants of cecal tubes
of Wolffian bodies
3. Ovarian ligament
INTERNAL GENITALS 23
modified peritoneum. The epithelium is columnar and non-ciliated,
the germinal epithelium of Waldeyer.
2. Internal. — The stroma is made up of connective tissue, elas-
tic fibers, and a few unstriped muscular fibers.
The tunica alhuginea is a dense layer of stroma immediately un-
derlying the germinal epithelium, or the ovarian surface.
The zona parenchymatosa is the cortical portion of the ovary.
It has a grayish color.
The zona vasculosa, or medullary zone, is the portion about the
hilum, of a reddish color, at which the blood vessels, nerves, and
lymphatics enter.
The ovarian ligament j 0.5 mm., or 1/5 inch, in width, and about
2.5 cm., or 1 inch, long, extends from the cornua of the uterus to
the inner end of the ovary, between the folds of the broad liga-
ment. Its origin is posterior and inferior to that of the tube. It is
made up of connective tissue and smooth muscle fibers from the
outer muscular layers of the uterus.
The arterial supply of the ovary is from the branches of the
ovarian artery which enter the hilum.
The veins issue from the hilum, and correspond to the arteries.
The veins empty into the pampiniform plexus.
The lymphatics empty into the lumbar glands with those of
the body of the uterus and tube.
The nerves are from the ovarian portion of the inferior hypo-
gastric plexus.
The Graafian Follicles. — The Graafian follicles are the sacs in
tl>e cortical layer of the ovary in which the ova are developed.
The follicles are developed from the germ epithelium in the
stroma by the outgrowth of connective tissue. Each follicle
usually contains but one ovum. The number of rudimentary
Graafian follicles at birth is from 50,000 to 70,000 for each ovary.
At any time during the child-bearing period, ten to twenty folli-
cles may be found in different stages of development upon the
ovarian surface. The mature Graafian follicle is 1/100 to 1/16
inch in diameter.
Structure. — The constituent parts of a Graafian follicle are:
1. The theca folliculi. 2. The tunica granulosa, a multiple layer
<»f polyhedral epithelium. 3. The discus proligerus, or germinal
eminence, a heaped-up mass of cells of the membrana granulosa
24 ANATOMY OF FEMALE GENITAL ORGANS
at one side, containing tlie o\iim. 4, Liquor follieuli, a clear al-
buininons lliiid.
The Parovarium, — Tlie parovarium consists of a series of 10
to 20 tubules, running between the folila of the broad ligament
ffora the ovary toward tha ampullii of the Pallopian tubes. It is
the remains of the Wolifian body.
CHAPTER II
REPRODUCTION
The process by which a species perpetuates itself is known as
reproduction. The laws of this process govern all forms of
living matter. These laws themselves vary in many details,
even among the vertebrates, but in the higher mammals and man
they are carried out with striking uniformity. If we were re-
quired to select tlie most fundamental principle involved in the
reproduction of these higher forms, and, for that matter, of the
vertebrates in general, we should at once concede that it depends
upon the conjugation of two sexually different elements, namely,
a female element, the o\^m, and the male element, the sperma-
tozoon. From this starting point we should be led to inquire
into the nature and history of these two elements, particularly
their structural character and physiological peculiarities.
THE OVUM
Structurally the ovum is a typical cell, the largest found in
the human body, with the exception of some of the larger nerve
cells in the brain and spinal cord. It has a spherical form (Fig.
5a) and measures from 0.15 mm. to 0.2 mm. in diameter. Sur-
rounding its generally granular cytoplasm is a thick cell-mem'
branc, while near the center is a large, vesicular nucleus. An-
other outer investment is added to the cell, and this, because of its
pale appearance on section, is called the zona pellucida. On closer
study this zone represents a series of parallel striations extending
from its outer to its inner surface, which, because of their radial
arrangement, constitute the corona radiata. In reality these stria-
tions are minute canals, through one of which the spermatozoon
makes its way into the ovum. The cytoplasm of the ovum has
certain peculiarities. It is coarsely granular and less translucent
than in most cells, for this particular cell has to carry with it a
very considerable amount of foodstuffs to meet the demands of
25
REPRODUCTION
nutrition in the early stages of development prior to the time
when it establishes a permanent base of supply in the parent host.
The coarse granules are fatty ami albuminous compounds, which
WING Febtiuzatio\ of the Ovum. (The somatic
imiiibcr of chrumoHoiiics is four.)
serve as food, and hence are tnown as dcufoplasm. In the Iiuinao
ovum their distribution is not even; many of thera are clustered
about the nucleus and the rest scattered throngliout the remainder
of the cytoplasm.
The nucleus has a distinct tiuclcar mcmbmtic. which incloses
the tiuclcar sap, the chromatin, the achronialic network, and a
single niiclcohis or gcnninal spot. Ameboid movements have been
observed in the nucleolus of the fresh human ovum, hut their sig-
nificance is little understood. A centrosome, although probably
present, has never been observed in the human ovum.
THE SFERUATOZOOH
The male clement differs in certain striking particulars from
the ovum. Although it is a cell, it has become so highly modified
THE SPERMATOZOON
27
as to make us overlook this essential character of its structure.
As a result of its specialization, the spermatozoon has acquired a
type of motility without which it could not fulfill its office in repro-
duction. Structurally it presents a head, a middle piece, or body,
and a tail (Fig. 6).
Acroeome
Head^
Neck
Body
End rlng^y"
Galea capitto
Anterior end knob
Spiral nbers
8heath of axial thread
Main scffmont
of Tall
Axial thread
Capsule
A. The Head.'-This por-
tion of the male germ cell is
3 to 4 micra long and half as
broad ; seen on the flat it is
oval in outline, while on edge
it is pear-shaped, w^ith the
small end directed forward.
The head represents the nu-
clear portion of the cell. A
thin layer of cytoplasm, how-
ever, surrounds the nucleus,
forming what is known as the
galea capitis, or head cap,
while the free edge of this
latter forms the acrosome, or
apical body. In many species
the acrosome is drawn out
into a hook-shaped or cork-
screwlike prolongation, called
the perforatorium, whose
function appears to be that
of perforating the cell-mem-
brane of the ovum.
B. The Body.- The body
of the human spermatozoon
is about as long as the head.
It has a cylindrical form. In
the majority of mammals a short neck connects the head with the
body.
0. The Tail. — The tail varies in length in different animals.
In the human spermatozoon it is from 40 to 50 micra long. It
consists of an axial filament surrounded by a thin sheath of cyto-
plasm. Near its tip the tail is devoid of any cytoplasmic covering.
This portion is called the terminal filament.
Terminal
filament
t!
Fig. 6. — Diagram op a Human Sper-
matozoon (after Bonnet).
36 BKPRODUCTION
oiilritioii ill \\w early stng^'s of ilt'velopmcut prior to the time
whi'ii il iwtiililiaiics r jiermaueut imee of supply in the parent host.
Thi' WHiiti' i;niiuilc8 ur»> futty «inl Hlbuiniiious compounds, which
•
9
1
kV J^ Uvv^vti
tiiaui,vr vl ^■tiw.'Uj
.^-m
l>mt (Thesomatie
'"
■"■™.^
■ -.i •*
■' ■**
r '-'V
itojn.
la the human
u an? tf!uslen?d
the renuiioJer
-'
- ^ ■ ■
■;•' ■
r 'i. and a
.■.:y vrebably
tss
^*;xxi.r
^ros
:; -
- '
^;
•af.:;.- a,,-;;deJ
PREPARATION OP THE SEX EI^EMExXTS 29
the several organs and system of organs of the body itself. For
this reason they are called the somatic or body cells. A much
smaller number is allotted to an entirely different course; they
show but little differentiation and resemble closely the original
cell from which they sprang. These are the germinal, or sex cells,
and it is to them that the responsibility of perpetuating the spe-
cies is delegated. The germinal cells multiply less rapidly than
do the body cells, but, as they grow in number, they become col-
lected into a definite area of the developing individual. At first
this area is relatively large and diffuse, but later on it becomes
distinctly circumscribed, until it forms a well-defined organ, called
the gonad, or sex gland. It seems to be the chief function of
the gonads in the early stages to gather the sex cells together in
one locality and there supply them with proper nourishment.
Subsequently the gonads afford the sex cells a place in which to
develop and mature. So that, in the female, the gonad becomes the
ovary and in the male, the testis. In its inception, then, the male
sex cell differs little from the female sex cell, and it is onlv at that
critical phase in which the gonad in the one case becomes the
ovary and in the other the testis that differences first make their
appearance. If we carefully scrutinize these differences of de-
velopment in the male and female sex elements, we will see at
once that they are more apparent than real, and we must soon
convince ourselves that the evolution of tlie ovum, on the one
hand, and the spermatozoon, on the other, have a common ground-
plan. Although these two cells differ so greatly in their final ap-
pearances, they have passed through fundamentally the same
processes of development, and their differences depend upon cer-
tain adaptations which fit ovum and spermatozoon respectively
for the functions which they have to perform.
Oogenesis and Spermatogenesis. — After the germ cells have
been collected in the ovary or in the testis, they must undergo
certain critical changes before they actually become ova or sper-
matozoa. The most essential of these changes has to do with the
number of chromosomes or chromatin segments in the nuclei of
these cells. It has long been known that the nuclei in the body
or somatic cells of different species differ in the number of the
chromatin segments. Thus, in man, it is 24, in the rat 24. in the
ox7~i6, etc. The original germ cells resemble the somatic cells
4
l.^'
' iffn'-'hitff I iirvlimmarr 'knatttnceot Ihcmimu the two^
iXftnw ,^iTnrtnr*i 'lip mhiiiuij mi nui 'li§appamr. lexr-
'f ••■■• -"t; m Im- rjarft airunni ro firt^Isatu/iL. The
rh .' T -^mariAJtoim a ^ ro "W nncra. Ai-
r'ttf' TmaTOKnain i1dm» not prv-
;fi>--i .uter IIS DinuabifD. In
(f I).- -xt;^ .1 *■ imt m nu in tht? aMnra its tail
I'Mlrri. I imvrf n»m»i«. Til rRuuiODoii. nniler normal
^<<,irn- >)■• rnnrilily in Mir jieminal dnid. tu wpU. as in
Fi J ill! fmmi" ffiitiTMl rmrit ft is ahk' tu travel at an
;. 1. 1 ',t' I I lo -l.'« mm. p^r minute, and at this rate
ii'li III! iili^nin Mtiil (^vuliii^t. altbniich the cilmry wav«
I |..iHii|f» Nrv-inn In lir* •lin-irtitl tu^nKt its process.
I, I.I Dm |lpArl>l|l*'^!"v■n ill ihn fpuial** p-aital tract hAB
1 I'll l"ii(ly I'lflMtiftt"'! In rtup rfpnrtnl i-ase of Jooble
■■■V lu'Kiir <(»'rri»ittiK<>n wr>- foiind in ttie tubes three
I' .1 . 1 hn nflnr rtiiliw
rnrpAnArrON (>F THE SEX ELEIUHTS
'• •• ■ ■ -ii.|i I cf (Iniiiitrml and Somatic Cells. — Recog-
' iiiniFi I).-- -i.-xuLil I'lfiiii-nts noces-
■ ■-'. li -' iii.|iiii.- iTit.i ill. -ir history, with
' ■ ■■■• ' ■• ■ II iiriiiii^ liiui lli.'Sf !i}HH.'iill O^Us
' ■ ■ '■ ' ' ! .j.ir-. Ml 111' ilu' Vxly. so that
I 'umil,' xh,' particular
■ ■ ■ '■ I ■■! ■ .■!.( ilius. as has been
■■'■■'.■ Mliiy upon each
I .!iiTcr('n-
. is called
1 C'Drraing
31
n II Hia-Mimi I
Tlfc riiiwiil iwifc
f .-^'Kraik <-«ilh T^ lanHr «
»uL-i«HaaB«n
34 REPRODUCTION
tozoa. The spermatogonia multiply by orJinary mitosis, and this
process is constantly going on during the maturity of the indi-
vidual, Slany of the spermatogonia cease to proliferate and enter
upon a period of growth. When they attain a size considerably
larger thau the colls from which they spring they are known as
pnmary spermatocytes. From this point Ihe further divisions of
the spermatocytes are concerned with the reduction of the niimher
of chromosomes in tlie nucleus, hi other words, a pi-ocess of
maturation, which, as in the case of the ovum, reduces the chroma-
tin segments to one-half the species number (Fig. 7b). Certain
peculiarities have been described in this process as it is observed in
man and other fornis. Not all of the primary spermatocytes mature
in the same way, and. as a result of this, sex differentiation is
detenuined. Some of the male sex cells acquire two accessory
chromosomes during maturation. These spermatozoa give rise to
female offspring, \vhile the spermatozoa which develop without
the accessorj' chromosomes give rise to male offspring. In this
manner sex is determinetl in the male germ cell, while the female
germ cell plays no part in sex differentiation.
In recent years much study has been devoted to the question
of sex determination. This problem has been approached by
means of three piincipal methods: 1. Experiments in the influ-
ence of external conditions, as affecting the germ. 2, Experiments
on the heredity of sex and sex-limited characters. 3. Jlieroscopic
studies of the sex cells. Some important facts have been brought to
light by this last method. It has been proved beyond question that
the male and female sex cells show a distinct difference in the num-
ber of their chromoaomes. In most animals there are two types of
spermatozoa and hut one type of ova. In a few species there are
two types of ova and only one typo of spermatozoa. In both of
these varieties one sex is digamttic and the other homogametic. In
man the male sex cell is digametic; that is to say, some of the
spermatozoa will produce females and some males. The spermat-
ozoa which arc capable of producing females have two extra or
acces-sory chroinctoiins in Ilieir nuclei. Those spermatozoa giving
rise to males have no itcccixori/ or sr.r chromosomes. The human
ova are also without sex cliiomosomes. The accessory chromo-
somes make their appearance during the maturation of the sperm
PREPARATION OF THE SEX ELEMENTS 35
When the spermatid is formed the cell soon begins to assume
the structural characteristics which distinguish it as the sper-
matozoon (Fig. 6). The nucleus, passing into the resting phase,
acquires a membrane and intranuclear network; the centrosome
divides completely, or assumes the dumb-bell shape; the nucleus
becomes oval, and passes to one pole of the cell, forming the
greater portion of the head of the spermatozoon. The centrosome
enters into the formation of the middle piece or body. From the
more peripheral of the two centrosomes a long delicate thread
grows out, the axial filament^ wiiich is surrounded by a sheath of
cyptoplasm to form the tail. The cyptoplasm surrounds the head,
and, forming the acrosome, is the remnant of the more abundant
cyptoplasm of the spermatid. When the spermatozoon is fully de-
veloped it lies free in the seminiferous tubule.
In order that convention of ovum and spermatozoon may be
accomplished, it is necessary for the two sex elements to leave the
ovary and testis, respectively. The spermatozoon follows a rela-
tively simple course in its egress. After passing out of the semi-
niferous tubule, it enters the rete testis, is carried through the
epididymis and vas deferens as far as the seminal vesicles. Here
it encounters the secretions poured out by the vesicles and for the
first time becomes motile. Its previous transportation has de-
pended upon the ciliary movement of the various tubes through
which it passes. From the seminal vesicles it makes its way to
the prostatic urethra through the ejaculatory ducts, and is finally
expelled from the penile urethra during the act of ejaculation.
Ovulation and Menstruation. — The mode of egress of the
ovum from the ovary is a more complicated process. It consists
of a periodic discharge of the female sex cell from the Graafian
follicle and is known as ovulation. In man, the primates, and
some of the higher mammals, it has long been considered that
menstruation and ovulation are synchronous. ^lenstruation is the
regular periodic discharge of blood and mucus from the uterus,
accompanied by certain changes in the uterine mucosa. It is prob-
ably more correct to consider these two processes as closely asso-
ciated and yet occurring quite independent of each other. It is
known, for instance, that, whereas the two phenomena usually
occur every twenty-eight days, fertilization may occur during lac-
tation, when menstruation is normally suspended; again, young
m
REPRODUCTION
girls have become pregnant before the establish meiit of Iheir
menstrual periods, and the same is true in some instances of women
long after the menopause. The ovum extruded from the Graafian
follicle normally passes into the fimbriated end of the Fallopian
tube, anil Itience into the uterus. In some cases the oviira remains
in the tube and develops after fertilization; or, if it chances to
escape into the abdominal cavity, it may there become fertilized
and give rise to an abdominal pregnancy. Both of these occur-
rences are known as ccUipiv gcxlalioii. At the time when th« ovum
LLY ( Kdlilman's AtUu).
FERTILIZATION AND CLEAVAGE 37
lutein cells. By absorption and degeneration the corpus luteum
gives place to a whitish body, the corpus alhicansy which later is
replaced by a small scar of fibrous tissue. After ovulation not
followed by fertilization, the corpus luteum attains its greatest de-
velopment in about twelve days. In a few weeks it has almost en-
tirely disappeared. If fertilization occurs after any particular ovu-
lation, the corpus luteum becomes much larger, reaches its maxi-
mum at the fifth or sixth month of pregnancy, and is still present
at the end of the pregnancy. This has led to the somewhat arbi-
trary distinction of designating tli6 corpus luteum of pregnancy
as the true corpus luteum, and that o-f menstruation as the false
corpus luteum. As a matter of fact, there arc no actual histological
differences between them.
FEETinZATION AND CLEAVAGE
In man and the higher mammals only one spermatozoon . gains
entrance into the ovum, and the only parts which actually enter are
the head and middle piece, the latter portion carrying in the centro-
somes. Once within the ovum the head of the spermatozoon as-
sumes the appearance of a typical nucleus and is known as the male
pronucleus, while the nucleus of the ovum is termed the female
pronucleus. These two pronuclei draw closer together, their
nuclear membranes disappear, and the chromosomes intermingle.
Fertilization is then said to have taken place (Fig. 5). An amphi-
aster is formed, and the chromatin segments take up positions in
the equatorial plane. From this time the process of ordinary
mitosis is carried forward.
The mitosis immediately following fertilization results in the
formation of two cells, each of which gives rise to two other cells,
and so on. This multiplication of cells is known as cleavage, or
segmentation. The mass so formed is called the morula, or mul-
berry, while the cells forming it are called the blastomeres. In
the cleavage of mammals, two general laws are found to hold
true:
1. Each cell tends to divide into equal parts.
2. Each division j)lf»ne tends to intersect the preceding divi-
sion plane at right angles. After the formation of the morula, the
next step in mammalian development is a differentiation of the
as EEPRODUCTION
saperiicial layer. In this way a single layer- of surface cells is
fonnwl Kurrouuding a soliil mass of cells. The latter soon acquire
a eavity hy vaeiiolizatioii. At this stage the o\Tim prt-senls a central
eavity. au outer covering, or trophoilerm, and an inner cell mass.
FOBKATIOK OF THE 6ERK LAYERS
FORMATION OP THE GERM LAYERS 39
of the former. The space formed in this manner is the amniotic
cavity. It is roofed in by the trophoderm, while its floor is the
inner cell mass, which has now become arranged as a distinct
layer, and indicates the position of the embryonic disk. From this
disk the embryo will develop. The disk, as studied in the dog
and bat, consists of two layers, the outer layer, or ectoderm, which
has just become differentiated, and the inner layer, or entoderm,
which made its appearance at a somewhat earlier stage. The
first sign of development observed in the embryonic disk is the
differentiation of an opacity near its posterior margin. As the
disk grows, an opaque line or streak extends forward from the
first opacity along the median line. This corresponds so nearly
to the conditions observed in the chick that it seems correct to
liken the linear opacity to the primitive streak. At its anterior
extremity this streak has a club-shaped enlargement, which cor-
responds to Ilensen's node in the chick.
The third or middle germ layer is known as the mesoderm.
It arises in part from the entoderm and in part from the ecto-
derm. It first appears in the region of the primitive streak, and
then, growing out in all directions, interposes itself between ecto-
derm and entoderm as a relatively thick layer of cells. In its
subsequent development three main divisions are observed in the
mesoderm: (a) That portion nearest the median line of the em-
brj^o and later to surround the neural tube, the paraxial mesoderm,
(b) the intermediate cell mass or nephrotome, and (c) the periphe-
ral mesoderm. This latter portion of the mesoderm is primarily a
solid plate, extending outward from the intermediate cell mass,
between the entoderm and ectoderm. Later this splits into two
layers; the outer layer becomes the somatic mesoderm. It fuses
with the ectoderm, and the layers thus combined constitute the
somatoplcure. The inner layer becomes the splanchnic mesoderm;
it fuses with the entoderm to form the splanchnoplciire. The split
which determines the splanchnic and somatic layers of mesoderm
becomes the body cavity; it is known as the celam or pleuroperi-
toneal space. The paraxial mesoderm is later subdivided trans-
versely into a number of somatic or body segments. Little is known
of the formation of the germ layers in man. The earliest stages
have not been observed. An ovum described by Leopold shows no
structure which could be interpreted as an embryonic disk. A
moibtT b^n* "f tympmait
'''vn.'ifl^'i'-" and -TyffjUijw IitB&.
MM '(f rMpirsToiT u>] 4wnti*v tracts.
>/al >nlHtitn«l ^IxniA Ux-rr tuui p«iicreas>.
,, ,-; ;if('f ifivr'.M ^tanils. Panithyroids.
,.,1 ',;' hl.-i'l'l"f: iir'i-.T;in'- atnl membranous portion of
1
■ hn-iiK' iiti'l irs il>-rivativps. such as bone,
I'jii I iIjiu'i . filirons ami areolar tissues.
■avitifs. biirsjil sacs,
PI of tilt' pi'i-k-ariliiiju.
[•a ami ilui'ls, ovary, oviduct.
Iftl MlMltUANl-.S AND IMPLANTATION
1, ..,,.„.l. ,.( i'l s. iM. r.iirv, ,.vL,.,.|,t Hsiu-s ami an
FETAL MEMBRANES AND niPLAXTATlON 41
structures. These structures are necessary to the embryo, for they
not only afford it protection, but play an iinj)ortant role in sup-
j)lyiiig it with food, and carrying off its waste products. They are
called the fetal membranes, and, as such, include (1) the am-
uion, (2) the chorion, (3) the aJlantoisy and (4) the yolk sac and
umhilical cord.
In man the fetal membranes are characterized by the high de-
velopment of a portion of the chorion participating in the forma-
tion of the placenta^ the early appearance of the amnion, and the
rudimentary condition of the yolk sac and allantois.
The Amnion. — The earliest stages of this membrane in the
liuman subject have not yet been observed. INIany facts point to
the probability that it is formed in the same manner as in the bat,
dog, and other animals already studied. By a process of vacuo*
lization a single layer of ectodermic cells is delaminated from the
inner cell mass, giving rise to a relatively large cavity between the
dorsum of the embryonic disk and the amnion. This is the am-
niotic cavity. As the disk bends ventrally inward, it carries the
amnion with it, until the cavity of the latter completely surrounds
the embryo. The amnion itself, at this time, is attached only ven-
trally in the region of the developing umbilical cord. By the third
month the amniotic cavity has so nuich increased in size that it is
now in contact with the outer membrane or chorion. It consists of
two layers of cells, an inner ectodermic layer and an outer meso-
dermic layer. Under normal conditions the amniotic cavity con-
tains a thin watery fluid; this is slightly Alkaline, contains one per
cent, of solids, composed chiefly of urea, allmmin, and grape sugar.
The source of fluid is not known. Normally its quantity varies
from two pints to two quarts. If excessive in amount, the condi-
tion is termed hydramnios. If scanty, the amnion often forms
adhesions to the embryo, and thus produces malformation. Even
if the normal amount of amniotic fluid is present, fibrous bands
often stretch across the cavity, and, in many cases, cause such
deformities as splitting of the lip or nose, or amputation of an
extremity. The amnion, with its contained fluid, serves to aid
dilatation of the cervix in the first stage of lab^r. When dilata-
tion is nearly complete, the amnion rui)tures, and the greater por-
tion of the fluid escapes. This is known as the ** breaking of the
membranes," or the ** coming away of the waters." Some of the
43 REpRODrCTION
fluid usually remains iu the amnion and escapes after the deliverj"
of the child. In some cases the amnion ruptures at the beginning
of lahor, and the dilatation must then he aeeompiished by the pre-
senting part. This is called a "dry labor." In rare eases the
amnion does not rupture at all, and the child is born within a bag
of intact membrane. I'nder such circumstances the child is said
to be born with a "caul."
The Chorion and Decidua. — The ovum becomes fertilized in
the Fallopian tube. It tiu'ii enters the uterine canal and attaches
itself to the mucosa on the upper part of the dorsal wall of the
uterus. In some cases this attachment is established with the mu-
cosa of the oviduct, thus causing the fonu of ectopic gestation
known as "tubal" pregnancy. In other instances the attachment
is delayed until the cervix uteri is reached, and, in this way, as
will be seen later, determines one of the most serious complica-
tions of labor, called placiiita prai-ia.
Once in the uterus the fertilized o\-um comes to rest upon the
nuicosu. I'rior to this, however, it has advanced in its develop-
nu'ut to Bueli a degrt'e that it is now surrounded by an outer cov-
ering or nicmhriiue, the clmrioii. This structure is of eetoderniic
uiiKJu, It is eomiHisi'd of an outer layer of epithelial cells, the
tivphinlmn. and an inner layer of somatic mesoderm. This mem-
brane is Ihou^bt to possesi the special function of eroding the
uteritie uuieosa. and excavating & sitiall depression into which the
ovinii makes its way. The mucosa of the uterus has also been pre-
paring ilsi'lf to rii'tive the ovum. The essential nature of this
pripiiitition is a thtekcning of the stratum compaitum, and the de-
vi'liipmi'iit ol' a spiH-iHliKed mucosa, which is cast off at the time of
labiu', bi'iu-e the mum' deeidua. After the ovum has buried itself
ill the iiiiieoMk, nil tiilniHii- plug, i-onsisting of coagulum. desqua-
nmled eelU. and tUu-iii. uinrks the site of the crjpt in which it lies.
.\hiuwt iuiiiiiHlialely fullowitig the attachment of the ovum the
uuu'njwi uiidci>sies changes, which vary somewhat with reference
In tile ivlutiim (bey War to the o^iini in different areas. Thus
thi> iiiiiiH>Ntk u\KW which the ovum rv^sts is the <hcidua basalts or
xtf'lt'ui; thrti CKVcriiiK the siirfsii- which projects into the uterine
c»ivil,v Ihe il.viiluit mfKtularis or n^ttxa: while that lining the rest
of the uici'iiic ctuitv IS the Uxtiitxi pun. .'•tri.v or vtra. The <ic-
K'Mtuit t^i-ittalis extends t»i the iuteriuil os ot the uterus, where it
PETAL MEMBRANES AND IMPLANTATION 43
ends abruptly, there being no deeidua formed in the cervix. In
the superficial layer the uterine glands disappear and their place is
taken by the proliferation of the connective tissue elements of the
stroma. During the latter half of pregnancy the deeidua parie-
tal is becomes very thin and much less vascular.
The deeidua capsularis has essentially the same structure as
the deeidua parietalis. At about the fifth month the rapid growth
of the embryo, with its membranes, has filled the uterine cavity,
and the deeidua capsularis, which surrounds the embryo, is pressed
against the deeidua parietalis at all points. Ultimately it disap-
pears or fuses with the deeidua parietalis.
The deeidua hasalis is that portion of the mucosa to which the
chorion frondosum becomes attached, thus forming the placenta.
It is evident, therefore, that the organ called the placenta has a
double origin, one part coming from the chorionic membrane of
the embryo (fetal portion), the other from the deeidua basalis of
the uterine mucosa (maternal portion).
The chorion, as already stated, forms the outer covering of the
embryo. At a very early period there grow out from this covering
a great number of delicate processes, called eJiorionie villi. At
first they consist of projections from the ectoderm alone. Later
the mesoderm grows into them, forming a core in each, and thus
affording it support and vascularization. When the ovum has im-
bedded itself in the uterine mucosa the villous processes show a
distinct difference in their behavior. Those in contact with the
deeidua basalis grow rapidly to form the chorion frondosum^ which
gives rise to the fetal portion of the placenta ; those which are not
in contact become atrophic and finally disappear; these form the
chorion Iceve.
The chorion frondosum consists of two layers which are not
sharply separated:
(a) The compact layer, which lies next to the amnion and
consists of connective tissue.
(b) The villous layer, which consists of chorionic villi. These
structures branch rapidly, forming a tree-like system of projec-
tions, which presents secondary and tertiary villi. Each
villus is covered by a double layer of epithelium, an outer or syn-
eytial layer, called the plasmoditrophoderm, and an inner layer,
the layer of Langhans, or eytotrophodcrm. The epithelium of the
44 REPRODUCTION
villus surrounds a core of raesoderra. Toward the end of the third
week this mesoilerm assumes the eharaeters of erabr>'onic con-
nective tissue, and in it are vascular channels which connect with
the allantoic arteries and veins. In this manner the fundaments
of the placental circulation of the embryo are laid down.
In the later months of pregnancy the \'illi lose their distinct
epithelial covering and appear to be invested only by a thin homo-
geneoiLS membrane of a syncytial nature. Certain of the uterine
cells become unusually large, giving rise to the so-called decidual
cells. Late in pregnancy they assume a brownish color. They
vary in size from 80 to 100 micra. As each villus grows it makes
a space for itself in the uterine mucosa, probably by a process of
erosion. This space is always larger than the villus which is grow-
ing into it, and ultimately it forms a spacious sinus or blood spac«,
filled with maternal blood. Into this sinus the villus projects and
so becomes bathed in the blood of the moilier. Some chorionic
villi float free in these bloo<l spaces; these are the floating villi;
others are attachtMl to the uterine mucosa ; they are the fastening
villi (Fig. 10). Connective tissue septa separate the villi into
groups or lobules; the septa are the placental septa, and the lobules
constitute cotyledons.
The decidual cells and chorionic villi are of much importance
as proof of pn^gnaney in ceases requiring diagnosis from scrapings
of the uterus.
Hranelu^s of the arteries in the muscular wall of the uterus
pass to the dceidua basalis. Snudler branches empty into the inter-
villous spaces, and thus bring the maternal blood into contact with
the villi. The wall of the villus always serves as a barrier which
prevents the direct passiige of the mother's blooil into that of the
fetus. The interchange betwtvn the bloo<l of the fetus and that
of the mother nuist, tluMvfore. depend on diffusion through the
wall of the villus.
At birth the i>laeenta is a diseoidal mass of tissue, 15 to 20 cm.
in diameter, II to 4 em. thiek, and weighing from oW to 1,200 grms.
Its connection with the fetus is by means of the umbilical cord.
This cord in man is a tortuous, hhiish-gray structure, 50 cm. long
and 1.5 cm. thiek. Great variations in its length have been ob-
served. Its disi>osition during pregnancy is of great importance.
It may become coiled about tlu* fetus and so prevent growth or
iB
REPRODUCTION
produce deformities. It may also cause a sprioiis dystocia during
birth. The umbilical cord is invested by the amnion, and oonsisls
of a substantia propria (Wharton's jelly), three umbilical ves-
sels (two arteries and one vein), and remnants of the allantois
and yolk stalk (Fig. 11),
,M. ■•
f ^ ^^
■*v
Fl(i. 11.- Pl.A<
■ Hm-
I Utehene Side (Bomiet).
Shortly after liirlh the uterine eontractiou usually expels the
placenta and membriine.s. The line of separation of the placenta is
through the deeper ]iortion of the spongy layer of the decidua
ba.salis.
Numerous aimnudies in lite formation of the placenta oc-
eur. The villi may give I'ise to an annular placenta. Per-
sistency of the chorion la-vc fiUises a thin placciila mcnihraua-
vm: this type of placenta is usually very adherent, and thus
causes trouble after labor. The development of the villi, in
groups or patehes, gives rise lo jwlycotytcdoiiary placenta.
Two partially separatetl placentie are called placenta i
tUa. Two completely separated placentie are termed plaat
DEVELOPMENT OP EXTERNAL FORM 47
plex. Placenta succeuturiata is the condition in which a small
accessory lobule develops, and is connected with the main organ
by blood vessels, while an accessory lobule without vascular con-
nection is called placenta spuria.
The yolk sac in the early stages is a large vesicle which com-
municates freely with the intestinal canal. As the body wall of
the embryo develops, this connection becomes more and more re-
stricted, and finally only a small canal marks the original passage-
way. When the placenta is formed the yolk sac becomes imbedded
in it, while remnants of its stalk are found in the umbilical end.
Meckel's diverticulum is the persistence into post-natal life of the
connection between the intestine and the umbilicus by means of
the yolk or vitelline canal. Occasionally the umbilicus remains
patent, in which event feces make their escape at this point; this
condition is called congenital fecal fistula. The allantois is a sec-
ond and later saccular evagination from the intestinal canal. It
arises from that portion of the canal which forms the urogenital
sinus. In birds and reptiles it serves both as a respiratory organ
and receptacle for the emunctories. In man its function is at most
but transient and rudimentary. The extra-embryonic portion of
the allantois becomes incorporated as an atrophic remnant in the
umbilical cord; its intra-embryonic portion forms the urachus of
the adult. In rare cases this last structure, which extends from
the summit of the bladder to the umbilicus, remains patent and so
allows the escape of urine from that point. This is called congeni-
tal urinary fistula.
DEVELOPHENT OF THE EXTEBNAL FOBH OF THE BOBY
It is customary to describe the development of the external
form of the body in three stages. The first stage, or blastodermic
stage, in man includes the first and second weeks of intrauterine
life. The second, or embryonic stage, extends from the second to
the fifth week. The third, or fetal stage, comprises the remainder
of the period of gestation. In the blastodermic stage the ovum ac-
quires the form of a hollow sphere. One of the youngest ova de-
scribed in this period is that of Peters, in which the vesicle meas-
ured 1 mm. in diameter. It had a well-formed chorion; on sec-
tion the embryonic disk was found to be present and measured
48 EEPRODUCTION
0.19 mm. Tliis was in relation dorsally with the amuiotic cavity,
and ventrally with the yolk sac.
The feature of the embryonic stage is the infolding of the disk
in such a way as to outline the future hody wall. In addition to
this, the central nervous system is foreshadowed by the appear-
Vio. r_'. IhxnN Kmukyo of the Third Week (His).
niiw of Iho iituriil t:i"'wvt' fstondinfr fiwu tlif cephalic to the
niudal |Mili' of thf i-nihryonio disk. This gi-oovo is bounded by the
iii'unil loliis. Tlnw Itilth are liijrhiT iiml more prominent at the
hi'iiii I'liil 111" tlif iniliiyo. Tin- ui urtil tolils bwome still more promi-
lu-nt uiilil lluv iii.it iiiitl lii.ii' aft\i.ss ilu- lUHliaii. in this way giving
ri-sc lo Iho lu-iiiiil tiilw. Tlii.s i-miiv striic'uiv is derived from the
wtoihTm. Il t;niilunlly Uhimuos ilf|ir«',ss<i.l below the surface of
the disk and the surface eetodenu grows over it. At the cephalic
DEVELOPMENT OF EXTERNAL FORM 49
extremity of the neural tube there soon appear three dilated vesi-
cles— the forebrain, the midbrain, and the hindbrain. From these
the entire eneephalon develops. A depression in the surface ecto-
derm, between the forebrain and the large ventral protrusion of
the cardiac vesicle, marks the position of the future mouth. This is
the oral pit. During the third week the lens vesicles and otocysts
develop. Later these elements give rise to important portions of
the eye and ear. At about this time, also, certain more or less
parallel ridges appear along the side of the embryo at the junction
of the head and trunk. These ridges are the visceral arches, or
bars. They are separated from each other by well-marked depres-
sions, the visceral clefts (Fig. 12). These are often spoken of as
gill clefts. By the twenty-first day the fundaments of the limbs
appear as buds or sprouts from the trunk. A large ventral pro-
jection between the yolk sac and the forebrain marks the position
of the heart.
As late as the twenty-first day the embryonic body is straight.
By the twenty-third day it begins to show certain flexures of its
long axis. The most anterior of these is the cephalic, or head flex-
ure, which corresponds to the position of the future sella turcica.
A second flexure occurs in the neck region and is called the cervi-
cal flexure. Further caudad there appear the less prominent
dorsal and sacral flexures.
So much of the development of the head depends upon the
changes in the visceral arches that it is necessary to follow their
history somewhat in detail. The morphological significance of
these arches is best understood in the light of some of the lower
forms. In birds and mammals the number of the clefts between
the arches is four ; in fishes it is five, and, in some cases, six. The
arches and clefts in all aquatic animals constitute the gills, or bran-
chias. During the course of evolution the necessity for gills be-
came diminished, as the habits of air-breathing were acquired.
Under these conditions the gills became rudimentary in function
and were transmitted to the terrestrial animals merely as tran-
sient remnants of an aquatic ancestry.
Each arch consists of a dense core of mesoderm, covered on the
outside by ectoderm and on the inside by entoderm. In the meso-
dermic core is an artery, the visceral artery. Each visceral cleft
presents a depression between two adjacent arches. The depression
the pharynx. These pockets are therefore referred to as
pharyngeal pouches, or throat pockets. The two contiguous h
of cells, the ectotlprm on the outaide, the entoderm on the ii
whicli prevent coramunieation between the pharynx and thi
terior, constitute the chsimj membrane..
Although thi^se visceral arches and clefts are traiismitte
the liigher wrti'hratea as vestiges, the metamorphosis of their
ilamoiital structures plays an important role in the differenlii
of the body. The first areli divides into two limbs to form
maxillary ami mandibular or jaw arches. The cartilaginous fr
work of thf mandibular arch is known as Meckel's cartilage
not only aidu in the fonuing of le mandible, but participati
the developmeut of the malleus, and, perhaps, the incus (Fig.
The second arch contains Keieberl's cartilage, which gives
to the stapes, the styloid process, the stylohyoid ligament,
Ifsscr eoiiiii of the hyoid bono.
The third arch becomes the body and greater wing of
hyoid bone.
Of the ectodemiic clefts, the first, in part, forms the exte
car. The remaining three clefts disappear. These latter, togt
with the corresponding arches, sink in, to form a deep fossa it
neck, the shiiis pracirviralis. Occasionally this sinus persists
thin layer forming its bottom ruptures, and so produces whi
known as cirrival fistula. Such a fistula establishes an ope
into the esophagus.
The inner or entodermic |>ouelies give rise to certain def
sirnclures. The first phiiryn<ri'al or entodermic pouch bee
met;imor]>bosed into the midille ejir and Knstaehian tube: the
iiig membrane. wliieJi separjites it from the outer cleft, forms
lympanic mi'mbrjiui'.
Til.' s.'cond .'ulddei-mic |i(iili'Ii jrives rise lo the posterior t
of 111.' t.>ri-rLi.-. From llio tliir.l i^ntodermic cleft develops
tlivmiis, wIilI,' III,' fnurtli srivos rise to the thyroid gland.
'I'll,' litsl hr;nu-liial ai<'h I'lays an iiiii>ortant role in the d
o|>iiuiil 111' ill,' I'ace. As alr,';ii!y slated, the cephalic fiexnre
iluri-s rhi' iir;il |>il. siniali',! I"'lvv,','ji llii' forcbrain and the b
This di-[ins>jiiii at lirst lias no lati'i-al limits, but, subsequei
52
REPRODUCTION
through the development of the first arch, it acquires the bound-
aries which determine the mouth cavity. Soon after its appear-
ance the first arch gives rise to two processes, the cephalic, or
maxillary process, and the caudal, or mandibular process. The
maxillary process is the anlage of the upper jaw, while the lower
Mld-braln
Cerebral hemisphere
Lateral na5al process
Nasal pit
Medial nasal process
Angle of mouth
Eye
Naso-optlc furrow
Maxillary process
Mandibular process
Branchial grooves
Branchial arch II
Fig. 14. — Ventral View of Head of 11.3 mm. Human Embryo (Rabl).
jaw arises from the mandibular process. The cleft or interval
l:(»tvveen these two processes is in part closed in by the cheek, while
the median portion remains as the orifice of the mouth. The
two mandibular processes grow rapidly, and finally fuse with each
other across the median line, to form the mandible. While the two
maxillary processes ai)proach each other, their fusion across the me-
dian line is not as complete as in the case of the mandibular proc-
esses, and ii ])r()cess of mesoderm jj^rows ventral ly from the medial
portion of the forebrain region, the nasofrontal process (Pig. 14).
This i)rocess comes in contact laterally with the maxillary process
DEVELOPMENT OP EXTERNAL FORM 53
of either side. Along this line of contact there is left a furrow ex-
tending obliquely to the region of the optic vesicle, known as the
naso-optic furrow. At this period the oral fossa is a deep depression
bounded eranially by the nasofrontal process, caudally by the man-
dibular processes, and laterally by the maxillary processes. The
Fig. 15. — Ventsal View of Head of Human Embryo of Eight Wekks,
next change of note in the development of the face is the appear-
ance of two secondary projections in the nasofrontal process. One
of those projections is lateral in position, the latiral nasal process,
the other medial, the medial nasal process (Fig. 14). Between tliese
two processes is a depression, the nasal pit. The maxillary process
grows inward and fuses with the lateral and medial nasal
processes (Fig. 15). In this region of the face, however, the maxil-
lary processes do not fuse across the median line, since the more
medial portion of the nsisofrontal i»roce8s interposes itself as the
intermaxillary portion of the maxilla. Failures of fusion may oc-
cur between the maxillary, meilial. and lateral nasal processes, lead-
ing to the malformations known as karc-Up, or cltft palate. This
faulty fusion may only concern the medial nasal and maxillary
process, thus causing a harelip. It may involve the hard palate,
as Wfll, and produce cleft palate, or the entire naso-optic furrow
54
REPRODUCTION
may persist, and so oeeasion a cleft extending from the mouth
through the nose and into the orbit.
The limb- buds appear in the human embryo at the beginning
of the fourth wepk as small protuberances from the ventrolateral
surface of the body. The upper extremities appear earlier than
the lower. By the sixth week the upper extremity is divided into
Fig. 16.— Ht-MAN Embrvos of 47-51 Davs (a), 52-54 Days (b), and C
Days (c) (after His).
an arm, forearm, and hand; the lower extremity is divided into a
thigh, leg, and foot (Fig. ]6).
During the sixth week the head more nearly assumes its nor-
mal position; the anlagen of the eyelids and external ear appear.
The fingers become recognizable as separate outgrowths, while in
the seventh week the nails make their first a|)pearance. In the
third month the face becomes definitely formed ; thick lips, a small
chin, and a flat, triangular nose are present. The limbs are well
fonnetl and in clmract eristic jiositions. The fingei-a and toes are
still imperfectly covered by nails. Sexual distinctions may now
be observeil in the external genital organs. In the fourth month
a fine growth of hair, called lanugo, covers the scalp and some
parts of the body; the iiiteKfiiios protrude less from the abdomen,
and the anus opens. The fifth month is signaliKcd by the inaugu-
ration of fetal movements.
The Mature Ovitm (after runoe)
A. Ut«riiie wall _E. Chorion
B. Placenta F. Amnion
C. Umbilical cord G. Fetus
D. Decidua H. Amnial liquor
ORGANOLOGY 55
Other features characteristic of the different periods of gesta-
tion will be found tabulated at the end of this chapter.
Normal human embr^'os in the fresh condition are more or less
transparent, so that such structures as the heart and liver may be
seen through the skin. This transparency is lost if the embryo
has been long dead or is the subject of'pathological changes. The
average weight of the human fetus is 6 to 7 pounds, males weigh-
ing 10 ounces more than females. The average length is 20 inches.
Several methods have been devised to estimate the age of the
fetus from its length. The results of the two methods here cited
are not absolutely correct in every given case.
According to Haas' method, (a) the length of the fetus in
centimeters equals the square of the age in months, up to the fifth
month; (b) after the fifth month the length in centimeters equals
the age in months multiplied by five.
By Malls' method, for embryos of 1 to 100 mm. in length, the
age in days is fairly accurately expressed in the following formula:
100 V length in mm. x 100. In embryos between 100 and 220 mm.
the age in days is about the same as the length in millimeters.
OBQANOLOQT
THE GASTROINTESTINAL SYSTEM
.The gastrointestinal system in the adult consists of the follow-
ing divisions: 1. The mouth with its accessory organs, the teeth,
tongue, and salivary glands; 2. The pharynx; 3. The esophagus;
4. The stomach ; 5. The intestines with their adnexal glands, the
liver, and pancreas; 6. The voidance apparatus consisting of the
rectum and anus.
Complex as this system appears in the adult, in its primitive
condition it has the form of a single, straight tube extending from
the head to the tail end of the embryo. It is closed at either end
but presents a narrow, slit-like opening which affords communica-
tion with the yolk sac.
The development of the alimentary canal depends upon certain
modifications in the splanchnopleure, which, as we have already
seen, is a thin layer of cells formed by the fusion of the splanchnic
mesoderm and entoderm. At first this layer forms a large ovoid
56 REPRODUCTION
sac whose long axi» is parallel with thai of the embryonic Doay.
Very enrlj. however, this sac hetomes so divitied, by the folding
Pa:k#
>^r Primith-e
.-.;: off. The
■.i.'iy'ther con-
.:■.- taW- and
. :s the yii(
-Sr lies dor-
ORGANOLOGY 57
sal of the sac and communicates with the latter by means of a
long, slitway opening, the Vitteline duct. In the head region the
communication between the tube and the sac is gradually lost and
the gut tract appears as a simple tube called the head-gut, which
opens into the yolk sac by what is termed the anterior intestinal
portal. A similar process of closure goes on in the tail end of the
tube to form the hind-gut, while this latter opens into the sac by
means of the posterior ititestinal portal. The portion of the tube
between the hind and head guts constitutes the midgut, and this
still retains a side communication with the yolk sac (Fig. 17).
We have seen that the cephalic and caudal ends of this gut
tract are closed. The cephalic extremity rests against a depres-
sion of the surface ectoderm situated immediately below the fore-
brain. This depression is the stomodcum or mouth pit. Here
ectoderm comes into direct contact with entoderm to form the
pharyngeal membrane, and it is only after this membrane has
ruptured that the gut tract acquires its communication with the
mouth. The manner in which the caudal extremity of the gut tube
acquires its communication with the exterior is quite similar to
that observed at the cephalic end. In this case, also, the ectoderm
of the surface comes into direct contact with the entoderm to form
a thin plate, the anal membrane. This membrane makes its ap-
pearance at the third week, and is not situated at the exact caudal
end of the tube, so that a considerable portion of the gut tract
lies caudal of the membrane. This is called the postanal gut. By
the fifth week the anal membrane has sunken inward to form the
anal pit or proctodeum. The changes occurring in the gut tract in
the region of the anal plate are of the greatest importance and
may be summarized as follows: 1. Dilatation of the hind-gut
opposite the anal pit to form the cloaca. 2. An evagination from
the ventral wall of the cloaca to form the allantois. 3. The en-
trance of the ureters and Wolffian ducts into the dorsal wall of
the cloaca. The cloaca has thus become a dilated portion of the
hind-gut, serving potentially as a reservoir for the excrements re-
ceived from the gut, which enters cephalad, and from the ureters,
which enter dorsad. In addition to this, the Wolffian ducts pro-
vide a communication between the gonads or sex glands and the
cloaca, while the ventral evagination giving rise to the allantois
indicates an organ which, in some of the lower forms, serves both
M REPRODL'CTIOX
eraunctory and respiratory piir|)oscs. but wliicli, in man, is rudi-
meutary. The postaual giit rapidly disappears and the cloaca
then becomes the actual caudal extremity of the gut tract. A
transverae septum, called the urogenital septum, soon develops in
the cloaca, and by the fourteenth week divides this part of the
gut into a ventral eompartment. the vrogeiiiial sinus, and a dorsal
compartment, the rectum. The urogenital septum also di%'ides the
anal membrane into two portions. The portion ventrad of the
septum is the orifice of the urogenital sinus and that dorsad of it
ia the aual pit or proctodeum proper. The area of fusion between
the anal membrane and urogenital septum rapidly thickens to
form the pcriiiial body or pefineimi. At the fourth month the
anal membrane ruptures; its persistence after birth ia called I'm-
perforate anus.
The Mouth. — ^Tiie surface ectoderm in the region between
the heart and the forebrain sinks inward to form the oral pit. In
the third week this pit receives its lateral boundaries by the ap-
pearance of the mandibular arches and the majiillary processes.
Its roof is now formed by the nasofrontal process. The pharyn-
geal membrane, which separates the mouth from the gut track,
ruptures at about the fourth week; prior to this, however, a diver-
ticidum has grown out from the roof of the mouth. This
is the hypophyseal pouch which will give rise to the glandu-
lar portion of the hypophysis. A ridge appears on the in-
ner side of either maxillary process. As these ridges grow
they approach each other and finali.v join to form the palate.
thus separating the nasal from the oral cavity. The partition
between these cavities is completed by tlie development of the
intermaxillary bones. The uvula appears during the latter half
of the third month.
The Teeth, ^These structures, which may be regarded as
caleifiwl pa|iillii' of the skin, develop from the dental shelf or
ridge. On the oral surface of each ridge a series of protuberances
appears corresponding in inindier to the temporary teeth. Each
of the.se projections is a mass of eetodermic cells which form the
enamel sac or primitire timnn7 organ. At about this time the
dental ridge has become divided into a series of segments, cor-
responding in number lo ihe enamel sacs. The eruption of the
tcmporarji teeth usually begins at the fifth or sixth month after
ORGANOLOGY 59
birth. The following table shows the time and order of eruption
of the teeth:
Temporary Teeth
Central incisors 5i/li-7 months.
Lateral incisors 7-10 * *
First molars 12-14
Canines 14-20
Second molars 18-36 '*
Permanent Teeth
First molars 6th year.
Central incisors 7th ' *
Lateral incisors 8th **
First bicuspids 9th
Second bicuspids 10th
y Canines llth-12th year.
Third molars 17th-21st year.
The Sali\'ary Glands and Tongcje. — The salivary glands de-
velop as outgrowths from the oral ectoderm. The tongue is formed
by the fusion of three elements (a) the tuherculum impar situ-
ated at the ventral area of the first pharynx arch, and (b) the
two lateral processes. Where these three portions meet, they form
a small depression, the foramen caecum lingua?. This foramen
marks the orifice of the thyroglossal duct which suffers oblitera-
tion during development.
The Pharjmx. — In the early stages the pharynx presents itself
as the dilated cephalic extremity of the gut tube. It is especially
characterized by the appearance of four bilateral, symmetrical
pouches, the pharyngeal pockets. In aquatic animals these pouches
participate in the formation of the gills. In most of the air-
breathing forms they undergo certain metamorphoses as follows:
The first pharyngeal pouch becomes the middle ear (tympanic
cavity) and Eustachian tube. From the ventromedian portion of
the first pouch the middle lobe of the thyroid gland arises.
The third pouch gives rise to the thymus and the cephalic para-
thvroids.
60 REPRODUCTION
The fourtli pouch gives rise to the lateral lobes of the!
and the caudul parathyroids.
Certain nijisses of lymphoid tissue develop to form tonsils. The
largest of them' masses appears at the mouth of the second pharyn-
geal pouch, OtJier masstis appear in the roof of the pharynx and
about the linguiil glands. The musculature of the pharynx is
formed from the mi-soderm surrounding the tube.
Esophagus, Stomach, ajid Intestines. — During the fourtli
week certain c-liiiiigi'.s occur in the simple straight tube. The earli-
est and most important of these cJianges are: 1, the dilatation in
the region of tlie head gut, wnic. u.aicate8 the stomach and demar-
cates this viscYis from the intestine and esophagus ; and 2, the elon-
gation and rotation of the intestinal portion of the gut tube. Dur-
ing this process the dorsal mesentery becomes the dorsal ineso-
gastrium and the dorsal mesentery proper. Almo.st as soon as the
stoMiacli ililatfilion appears, this part of tlie tract undergoes rota-
tion first on its long axis, so tliat the left side becomes ventral and
the riglit side dorsal. The second rotation is on a transverse axis
and, as a result of this, fhe caudal end of the stomach is elevated
to nciirly the same level as the cephalic end, while at the same
time the greater and lesser curvatures make their appearance. As
a re.sidl of these rotations the dorsal mesogastrium begins to gi-ow
(lownwjinl to form the great omentum, and the ventral mesogas-
tritun iHTsists as a eonneelion with the ventral body wall. The
iiiti'.stinaj patt of the tube is first drawn out into a U loop, which
jiri'si'rjts a ei'pljjdic jnul caudal limb. Tlie caudal limb, which gives
I'isi' 1(1 ilii' liii'i^e iiiti'sliiie. nilales upward and crosses the cephalic
limb. I'.;. Iliis .■haniri- the ccal porlmii of the tube is swung up-
uiinl fiiuiud till' stiniiai'h. tlins niving deliiiilinn to the following
piiits mT til.' Irai-I: 1. tin- <-.'i-inii : J. til.' transverse colon; ;). the
drs,-,.ii.liii- ,-ol,m. and 4. \\w xiiall itil.'st in,'. The rapid growth
of llii' i-olnii >iiiiii iMn ii's iIk' i-ii'iiiri dnwii Inio Ihi' risiit iliac region.
whilr til. -tiiall iiii.-iin.'. -iMuuiLT .■vii moiv r,i|.idly. fills in the
s|iar.. I.,m.,.l..l ot) ill.- ri-lii In lii-' aM'.ii.liiiL.' .■nl,>ii. on tiie left by
th,. ,1, ■-,■.[.. iiML- ■■..\.,v. an.i ai"i\.. I.y lli.. Iianwrrse colon. Tlie
drvlopui-nr ..I il„. ,loi-,^il 1,1,-, iii.'iA ami flu- miI>s u-iil behavior
(>!■ lUr la ■!;.■ iiii.-snii.' in ii^ ivLiii,.n l.nili i,, ili,. ,i„rsal body wall
and ill.' K'l'ii' oKi.iinini I'lm-niiii.. mn' of ili,. most complicated
pn.,-,.s,s,-i ill il..- rvnliui.iii nf til.- t.n.iy. Tlu' ^llhl,■lLt js thcrcforc
ORGANOLOGY 61
referred to the standard text-books of embryology for a full dis-
cussion of this topic.
The Liver and Pancreas. — In the third week an evagination
protrudes from the ventral wail of the gut tract in the region of
the duodenum. Its cephalic portion, the pars hepatica, is solid,
and gives rise to the liver. Its caudal portion, the pars cystica, is
hollow, and gives rise to the gall-bladder. The evagination soon
detaches itself from the gut wall with the exception of a narrow
strand of cells, the anlage of the ductus cholcdochus. The pars
hepatica also tends to separate itself from the pars cystica, retain-
ing connection with it by means of a short cord of cells, the begin-
ning of the hepatic duct. The hepatic portion grows rapidly, and
in doing so comes to lie between the two layers of the ventral meso-
gastrium. In this way the liver, hepatic duct, gall-bladder, the
cystic and common bile ducts are formed.
At about the time that the liver evagination appears, several
diverticula from the gut tract may be observed which will give
rise to the pancreas. Usually there are two of these diverticula,
one dorsal and one ventral. Somethnes, however, a second ventral
evagination is found. The dorsal diverticulum grows into the
dorsal mesentery; it becomes constricted off from the gut except
for a thin cord of cells, the anlage of the duct of Santorini. A
little later the two ventral diverticula appear, one springing from
either side of the common bile duct; the left evagination soon
disappears, while the right one becomes constricted off from the
ductus choledochus and retains its connection only by means of a
small strand of cells, the duct of Wirsung. At the sixth week
fusion of the dorsal and ventral anlagen occurs and the duct of
Santorini usually disappears, thus leaving the duct of Wirsung
as the permanent connecting channel with the common bile duct.
The head of the pancreas is formed by the ventral anlage; the
dorsal anlage gives rise to the body and tail.
THE EESPIRATORY SYSTEM
The first indication of the respiratory tract appears as a longi-
tudinal groove or gutter extending the entire length of the primi-
tive esophagus along its ventral surface. This is the pulmonary
groove. It makes its appearance during the third week of develop-
6
BEPBOIMTCTION
^trem^^T^^
ment. Tfae groovt; b most pn>DOaii««<I at hs caudal extr
a process of eonstrictioii, which is cftrri«l oa s>inmiftr)ually from
one eitremity lo th* other. Iht groove is converted inlo a long tubi'
situated veiitrad of the laophagus. SeparsttoD between the esoph-
agus and puSmijitaiy tubt nrxt oecurx. begiiiuuig at the caadsl
extremity of !lie lube and procKcdio^ cepUatsd. Thia separation.
however, is not eomplifte. aa that the tnbe rvmains in eommuniea-
tion ivith tbe gut tract at the phar>^tgeal vml of the esnphagiu.
Prior to the divi&iou the eauila) ewremiiy of the puiiuooary tnli*
has dev<floi>til tn^o divvrticuls. one exteoding towanl the right, the
other toward iLe lej tutg budi or pul»witary
divtrticula from which .uv levelop. These buds rap-
idly increase in size, and dtiriug th week uudet^o further
division, with the result that the n md presents three brancbra
and the Mx »iie only two. From lUis point the development of
the luiig is aeoomplished by a proeess of repeated dioholomous
division iu ihe original braneih-s of the lung buds. The pulmonary
epithelium is derived from the euloderm. while the eartilageit.
luiiscle. etiniu'etive aod vaseular tissue^t have their origfin in the
sphmehuii' m>-sixlenu. At first the sprouts appearing upon the
luug buds are solid, the lumina being ai-<)uire<I Utter. The air tact
or piilm-'i'ai-'i ahtuti first api^ear at the sixth month, and from
this time until the end of gestation the lung gradually acquires its
alcflar {MSS'ujfS and inftii^dibiila.
The Larynx. — Tliis is the spei-ialiied. cephalic e.\treiiiity of
ilie I'liliiioiMiy tul>i- uliiiii o|vns Juti* tLe pharynx. It serves as
tlif oiL,Mii of [ilioniitioii. Ai ilu> ,n-\ of the fifth week two ridges
iiiiiki' tlii'ir ;iiiiH;ir;iiK'e ;it [lie juiii-nou of the esophagus and pui-
iiu'iuiiy iuIh'. Tliv^' riii^is cxtiud vttitrodorsiui and are closely
iiin>ro\iiii;iliil ill friMH but so;;i-, wi;at ^.['aratiil behind. They are
till' .■inlai;i'ti of iln' i'.-\w \.h-.i! .-ov>:s and thf s|iaee befween them
is ilio nnht y'."(i;i,>. A' :'[.[< [■. •::■"[ ;i ■■ ap'-rture of the larynx is
Niiiial.'.l iioi>ad of t't.i' ;■ - ■ - J-.:.:-; of ilie developing tongue
and at al.oul III,' l,'v,to: -■■ :.>.■■ ■.■.:..■[. lal poueh. Tho furcula.
a ruivrd ridi.-,-. hoiui,i- ■] ■ '...■ y j: . .;■• i.liii: in front and Oil the
•siil,'^, al ill,' -am.' '.vw ~ :..-,,-.l; ' :-m;!1 ill.' tongue. It SOOIl
.l.vi'li.p- :\ nudiari . '.i v .,' :.';; v. ■ ■. .■o",.s i!u' epiglottis, while
lb.' .■\ti.iiiiii, ■- .'f :(.■■■-.■.: ,-. J". -■- -.^ ■ •■-• !■ uhir ami cuHiifonii
fa.''. ■.', . ri.- I.iiiia' ii"';."- .'■ : ■ far..-!ila form the ari/tcno-
ORGANOLOGY 63
epiglottidean folds. The thyroid cartilage develops in two lateral
halves, and is considered the derivative of the fourth and fifth bran-
chial arches.
THE CARDIOVASCULAR SYSTEM
This system consists of the heart, the arteries and the veins.
The Heart. — ^According to the recent investigations of
Schulte, a common ground-plan underlies the development of the
heart and blood vessels. Cells from the mesostroma, between the
entoderm and ectoderm, increase in number, both by division and
by additions from the mesoderm. Intercellular clefts appear
among these cells, while the cells themselves become flattened and
thus form small vesicles in loco, which are filled with fluid. This
process is observed very early in the formation of the omphalo-
mesenteric plexus. The heart follows the same general course of
development. In either lateral plate of the splanclinopleure, be-
fore infolding of the body wall has begun, and in the position of
the future neck region, there appears a series of separate vesicles
similar to those just described. Later these vesicles run together
to form two longitudinal tubes on either side. Tluis four tubes
are formed, two on either side and one above the other, though, as
yet, not in communication. The more caudal tubes will ultimately
fuse to form the auricular portion of the heart, while the fusion of
the more cephalic tubes gives rise to the ventricles. The tubes have
not yet acquired a connection with the omphalomesenteric veins
caudad, nor with the ventral aortoe cephalad. The two tubes on
each side fuse, and then by the infolding of the body wall the
right heart tube is brought into contact with the left tube ; fusion
between them takes place, and a single tube is formed lying prac-
tically in the median line. The caudal extremity of the tube so
formed represents the auricular portion of the heart and its ceph-
alic extremity the ventricular portion. This tube actually gives
rise to the endocardium. A second tube surrounds the endocar-
dium, and rapidly increases in thickness to give rise to the myocar-
dium, while still external to this a third tube forms the pericar-
dium. The further development of the heart depends upon the
following changes: 1, the connection of its caudal extremity with
the omphalomesenteric veins and the ducts of Cuvier ; 2, the con-
64 H- BEPRODUCTION
nection of its cep lalie extremity with the ventral aorfaF ; 3, lie
twisting of tlie tu le in an S-shapp<t curve in such a manner that
the auricular portion takes up a dorsal position and the ventricu-
lar portion is vent al to it ; 4, the partial dimion of the auricular
portion by the sep xm priminn into a right and a left auricle — an
aperture in this 8(]itum determines a commuuicatioa between the
two auricles, the fimtnu'ii ovale; 5, the complete division of
the ventricles by the interventricular septum; 6, the con-
striction off of the ventricle from its corresponding auricle
with the formation of the auricnloventricular openings; 7, the
development of Hk r, the aortic, and pul-
monary valves.
The Arteries.— The heart, in ,, forces the blood hy way
of two ventral aorliu into the gills re the blood passes through
a complex network of capillaries; it is aerated, collected, and
finally transmittecl io the body by the dorsal aortie. This simple
arrangeuient of a series of gill vessels arching between the afferent
ventral anrtie and the efferent dorsal aorta; serves the purposes of
aijuatie animals. Hut with the introduction of air-breathing and
a pulmonary sysfenj this gill type of respiration beeame unneees-
Kary. With the gi'ijerol Icudeney to transform rather than to dis-
eitfd, the process uf developnieiit makes use of these gill vessels
wliicli have been passed on to all air-breathing animals from an
ji.|uatie ancestry.
In the early singes the dorsal and ventral aortse develop by the
eonriiH'rn-i> (if iiuU'pc'iident .sjiiices until two sets of parallel vessels
!\vr r..i'(ii,-.l in the head and neck r-e^ioii of the embryo. The veu-
Iriil iiorhe .jdiii the beiirl and presmlly a scries of capillary plex-
iis,.s be-riii \o eoiiiMrt tile d.irsiil jiimI ventral aor1;e. At this period
the ecpnililinns ai'c Dot uulik.' Iliose of llie lish. The connecting
(-apilliiry plexuses liiive aris,i']i ;is tile re-iull iif a ennfluenee of iu-
deprlidrnlly innnrd s|,ans. siieh iis lliose d.^seribed by Schulte in
tile drvelopmi'iil nl' llii> lirafi. hi ilir iiiiiTViil between each bran-
eiiial pnurli tlir |.lr\iis brr.Mii,.s proiioii JK',',!, wl.ilr in tile region of
eaeli ) -ii iisrlf it ilisa|i|>rMts. A >i.-vu-:i of si\ such capillary
pli'xiisi's ap|"-Mrs ii] man in ii winn- ui- Irss ri'i.'ular chronological
order. Ka.'h one ol* this seri<s is laiiidly rr,lii,.,.,l lo a single dis-
eret,' v^'ssfl <-allMd the l.nuuhhl on I. „rl,n,. Six of these bran-
cbial iireli ai'tei'ies di'velop, ami llu- l'olliiwiii>; ebaiises In them
ORGANOLOGY 65
give rise to the ultimate arrangement of the arterial trunks in
upper thorax, neck, and head.
1. The first and second branchial arch arteries atrophy and
disappear.
2. The ventral aorta on either side cephalad of the third arch
becomes the external carotid artery, while the third arch and the
dorsal aorta become the internal carotid artery.
3. The ventral aorta on either side, between the third and
fourth arches, becomes the common carotid artery. The dorsal
aorta, between the third and fourth arches, disappears.
4. The fourth arch on the left side becomes the arch of the
aorta, and on the right side the subclavian artery. The ventral
aorta on the right side, between the fourth arch and the truncus
arteriosus, becomes the innominate artery.
5. The fifth arch is rudimentary and disappears early.
6. The proximal portion of the sixth arch on the right side is
retained as the right pulmonary artery; its distal portion disap-
pears. On the left side the proximal portion becomes the left
pulmonary artery, while its distal portion is retained throughout
fetal life as the ductus arteriosus.
7. The dorsal aorta on the right side below the third arch
disappears while on the left side below the fourth arch it is re-
tained as the descending aorta.
8. A spiral septum divides the truncus arteriosus into the
ascending aorta and pulmonary artery.
The development of the other arteries of the body follows the
same general course as those already mentioned. Because of the
limited space allotted this chapter, the arteries cannot be discussed
in detail here.
The Veins. — The first venous channels to appear are the two
omphalomesenteric veins. Then follow the two umbilical, the two
precardinal, and the two postcardinal veins. These vessels, in
addition to a plexus surrounding the mesonephros, the pcrimcso-
nephroic plexus, constitute the basis from which the definitive
veins are evolved. The omphalomesenteric veins empty into the
sinus venosus. The pre- and postcardinal veins, by their union in
the region of the heart, form the duct of Cuvicr, which also enters
the sinus venosus. The perimesonephroic plexus gives rise to the
subcardinal vein.
REPRODUCTION
ClllCLL.\TION,
In the ht'iiil mui "»'<■'* tfKi"" t
ified to form tlic; mlult wssi-In,
iuterual jnKuli'r "'"' innomiiniti'
The left vein hy u cross iuinstoiiic
jugular veins.
)roranliiiaI vt-ins become mod
I' riglit vein forms the righ
I. aiiil till' suptrior vena cava
forms the left innominate ant
ORGANOLOGY 67
The postcardinal vein in its cephalic portion becomes, on the
right side, the azygos major, and on the left side the hemiazygos
vein. The caudal portion of the right postcardinal participates in
the formation of the inferior vena cava. The left caudal portion
of the postcardinal vein disappears.
The inferior cava is a compound channel consisting of parts
of several primitive vessels. Its most cephalic element is the vena
communis hepatica; then follow in regular order cephalocaudad,
the subcardinal vein, the subcardinopost cardinal anastomosis, and
the right postcardinal vein in its caudal portion.
The umbilical veins in the early stages are subequal, but the
left vessel soon takes supersedence in returning the blood from
the placenta. The left vein distributes the blood to the sinusoids
of the liver, except for one large branch which forms an anastomo-
sis with the inferior cava and is called the ductus venosus. The
portal vein is formed by the persisting portion of the omphalo-
mesenteric vessels. The arrangement of the vascular channels in
the fetal circulation is shown in Fig. 18.
THE LYMPHATIC SYSTEM
The evolution of the lymphatic vessels, as shown by Hunting-
ton in mammals, depends upon the development of two general
anlagen, i. e., the jugular lymph sacs and the systemic lymphatics.
The jugular lymph sacs are two dilated vessels found one on
either side in the neck region during the early stages of develop-
ment. They are derived from tlie venous system. Subsequently
they lose all connection with the jugular veins, but ultimately
establish a secondary connection with them. During these stages
they are entirely independent of the systemic lymphatics.
The systemic lymphatics develop by the confluence of inde-
pendent mesenchymal spaces. Such of these spaces as appear
along the dorsal aorta give rise to the axial lymphatic channel or
thoracic duct, which develops as three independent segments,
namely, the azygos, prcazygos, and postazygos segments. The
lymphatic channels of the outlying parts of the body constitute
the peripheral lymphatics. The iinal union of the systemic lymph-
atics and the jugular lymph sacs determines the lymphatic system.
In this manner the lymph sac serves as an intermediary in estab-
■I
EEPRODUCTTON
lishing connection between the systemic lymphatic and
systems.
THE GKNITOURINAny SYSTEM j
In discussing a system as complicated as tlie genitourinaij ^
apparatus, it will only be possible to trace the simple outlines of
its development iu this chapter. Certain primitive oi^anH of a
;l!"^<>l. Til
r-^. Opening 'uI~~MlintiiiB
UroBWiiial Bin™
- OwalBg ol eloiM
>." (JF THE Urogenital Organs
,i;k (HcTtwig).
iliicis iiiiii'tlie genitourinary
<-(>jii]ili'x system. The prim-
iiDiiliiT, i. L'.. the pronephros:
■/(.-■.- anil 4, the gonad or S(X
r. i. I'., 1, llie proncpliroic or
lutl; and 3, the MuUeriaa
ORGANOLOGY 69
duct. The pronepfaroa or head kidney develops as a series of
urinary tubules from the nephrotorae of the neck region. In order
to convey its excretions to the cloaca a long duct is provided, the
pronephroic duct. The pronephros in mammals rapidly disap-
pears. It is replaced by a larger organ in the abdominal region,
which is likewise derived from the nephrotome. This is the meso-
Fio. 20. — Diagram of the Development of the Male GcNrrAL Organs
FROM THE "Indifferent" Anlagen (Hertwig).
ncphros- The pronephroic duct, having by this time ceased to
serve the pronephros, now acts as the drainage canal of the raeso-
nephros, and is therefore termed the mesoncphroic duct. This
duct at its caudal extremity ami in the region of its entrance into
the cloaca develops a small sprout, the ureteric bud, which grows
rapidly doi'sad until it comes in contiict with a mass of mesothclial
cells, the renal blastema. Fusion occurs between this latter and
pelvis, while from the renal blastema are derived the parenchj-ma-
tous portions of the kidney. On the mesial surface of the meso-
nephros a glandular structure develops, which is kiiown as the
gonad or sex gland. Related to this latter structure a third panal
or duct appears extending from the gonad to the urogenital sinua.
This is the MiUlnrian duct. In the male the gonad becomes the
Y\c.. '21.- Mlacham IIP the Dkvkl..ip«es-t of the Female Genital Organs
^■lfo^E THE "Inliueehent'' Anlagen (Hcrtwig).
Ii'stis, tlic irii'S)i[u'|iliros, in piirt. bi'conit's the epididymis, and the
MiUli'i-iiin duel is Iriinsl'dniu'd iiilo wrliitn vestigeal parts. In the
tViti;ili' Ihf trouad lu'wiin's tlk' ovjiry. the Miillerian ducts become
ihi' F;dliipiaii tul'os and ulenis, wliile the mesouephroic duct is
ivduetil to fi'i'tiiin vesligi's. The iueoinpanying table shows the
metamorphosis in passing from the stage of indifferent sex into
the conditions characterizing the male and the female (see Figs.
ORGANOLOGY
71
INDIFFERENT
MALE
FEMALE
Gennmal epithelium
(mesothelium).
Convoluted seminiferous tubules
with spermatozoa.
Straight seminiferous tubules.
Rete testis.
Part of stroma of testicle.
Ovarian (Graafian)
follicles with ova.
Medullary cords.
Rete cords.
Part of stroma of ovary.
r cephalic
Mesone- 1 part
phros 1 caudal
L part
Efferent ductules (vasa efiferentia).
Appendage of epididymis.
Paradidymis {orgario of Giraldes) .
Aberrant ductules {t^asa aberrantia).
EpoophoroUf transverse
ductules.
Paroophoron.
Mesonephric duct.
Duct of epididymis (vas epididy-
midis).
Deferent duct (vas deferens).
Ejaculatory duct.
Seminal vesicle.
Vesicular appendage
(of Morgagni) .
Epoophoron^ longitud-
inal duel.
Gartner *s Canals.
Miillerian duct.
MorgagnVs appendage of testicle
{hydatid of Morgagni) .
Prostatic utricle (uterus-mascu-
linus) .
Fimbriae of oviduct.
Oviduct.
Uterus.
Vagina.
Urogenital sinus.
Urethra (prostatic part).
(membranous part).
Prostate.
Bulbo-urethral gland (Cowpers).
Urethra.
Vestibule of vagina.
Larger vestibular gland
(Bartholin's).
The External Oenitals. — At about the sixth week the cloacal
fossa is surrounded by a ridge, called the genital ridge. Near the
middle of the fossa there projects a small tubercle, the genital
eminence. On the under surface of tlie eminence a groove soon
appears, the genital groove, which is bounded by two ridges, the
genital folds. In the female the genital eminence becomes the
clitoris and the genital folds become the labia minora. The ven-
tral portion of the genital ridge develops to form the mons veneris,
while its lateral portions give rise to the labia majora. The hymen
begins to form in the fifth month as a small crescentic fold at the
posterior margin of the vaginal aperture. The glands of Bartholin
develop as evaginations from the wall of the vestibular region of
the urogenital sinus.
In the male the genital eminence becomes the penis. The gen-
72
KEPRODCCTION
ital groove deopeos and the g<;iiital folds, which bound it latenllj.
increase in size. The folds then proceed to convert the grooi'c
into a eaiiat, niui in tliis way form the peJiile portion of the malt
urtlhra. The genital ritlges give rise to the fcrotum. The glands
of Cow^ier are developed as evaginations of the terminal pari of
the urogv'nital sinus.
THE CENTRAL XERVOrS SYSTEM
The eomitlexity of detail iu^-oIvmI in the development of the
hrain «nd spiuat eord is great— •'•"d in any of the other n>*steni8
of the IhhIv. and for this rva»>n only the essential features of this
■-•¥ A 7*3 Weeks
r-_:ri. n-^rroHs sv^em
• i— :; rXT-^f.iiug from
. . -,'.: i-:j:,_ At an
.:r. -^^lijri-it^ wirh
Tr_is srviove is
1 - rtl i*i>f ^:» oi the
■ - . U r::::uaitly.
. liz.-;. inl :i:-.is form
ORGANOLOGY
n
the neural tube. The fusion of these folds is not uniform. It is
accomplished earliest in the middle regions of the tube. In the
head region the failure of fusion gives rise to a slitlike opening in
the neural tube, the neuropore. This is finally closed in and the
whole tube, becoming depressed below the surface, is covered over
dorsally by the surface ectoderm. The neural tube is not uniform
in size throughout its length. In several places it shows a distinct
tendency for dilatations to appear. Such dilatations are noticed
in the extreme head end where the optic vesicles are developing as
a pair of lateral evaginations. Again in the region of the future
medulla oblongata and pons a large dilatation appears. Between
the cephalic and caudal dilatations is a constricted region which
PRIMARY
SEGMENT
SECONDARY
SEGMENT
DERIVATIVES
CAVITY
Cephalic vesicle.
Proeencep h al o n
or Forebrain.
Telencephalon.
Cerebral hemispheres.
Olfactory lobes.
Corpora striata.
Lateral ventricles.
Foramina of Monroe-
Diencephalon.
Optic thalami.
Optic nerves and
tracts.
Subthalamic teRmenta.
Interpeduncular struc-
tures.
Pineal and Infundibu-
lar process.
Anterior part of third
ventricle.
Posterior part of
third ventricle.
Middle vesicle.
Mesencephalon
or Mid-brain.
Mesencephalon.
Cerebral peduncles.
Corpora quadrigemina.
Aqueduct of Sylvius.
Caudal vesicle or
Hind-brain.
Isthmus.
Superior cerebellar pe-
duncles.
Superior medullary ve-
lum.
Metencephalon.
Pons.
Cerebellum.
Fourth ventricle.
Myelencepha-
lon.
Medulla.
Inferior medullary
velum.
•
74 ,1 REPRODICTION'
is mnrt> tubular in oiitlinv lliau tlit- n.«t or the prinitiTe brain.
«iul h'pn'St'iits (lu> midbrain. At tLis stage llic oealrat nervoiw
Sj-slfui (tiiisisis i>f t1»' fitrtbraitt (proscDwphaloD) correspoading
to tlu' ifplwlu- ililatHtion; the liimlbniiD (meteneephalon) eor-
nMi)H)iidtii}; to ilif i-miiiIhI ililntslmn. Rmt the intermediate porlioD.
Iho niidbntin ' [in-itoKvpliMlniiK Cattdad of tiie metrjicvphalon is
ttio ltnl»|l^■ of ihi- spinal cord. By a proMss of farther diviraoa
till' llinv priiiuiivi' bnin \-rsii-]t« aiv ruovr-rmi into five secondary
viWIc^ iiain< ly. thv ttlrmctpiiml»m {etui braini, dirmcephaloa
,iniiTl«raiu , ■».*.».■«—*--'— —i-n**-;-! the m<(fmeeplt^am fhind-
brai»\ iho •Ny<i'<i«n >, Tb* adntt drnvstivts
of lhi-A' $«\>.u) .Ur^ wsinrEk ibe tahit vu pagv 73.
lA.-.iii kv the BEAE. ^(I* VASCTLAB ststbm
.. * vNVkliiioi) nt a saMr^- '.raA. •tamiimg in twina.
■irxriof fctt! a ggg^ Aco»«. Om- af Ae twins has
i 1V\T^ i«i^aa. 4C- Ti^:« ■■taari knn
ORGANOLOGY 75
7. Anomalies of the Great Veins:
(a) Double superior venae cavje, due to persistence of
both precardinal veins.
(b) Inferior cava may be right or left-sided, or even
double, depending upon the manner in which the
postcardinal veins develop.
II. ANOMALIES OF THE GASTROINTESTINAL CANAL
1. General Transposition of all the Viscera — Situs viscerum
inversus,
2. Anomalies of Mouth and Tongue:
(a) Defects in boundaries of oral cavity, hare-lip, and
cleft palate.
(b) Defects in anterior portion of tongue.
(c) Micro- and macroglossia.
3. Anomalies of the Pharynx:
These involve the formation of cysts, fistulas, and diver-
ticula from the bronchial pouches.
4. Anomalies of the Thyroid and Thymus Glands:
(a) Persistence of thyreoglossal duct.
(b) Accessory thyroid bodies constituting suprahyoid
and prehyoid glands.
(c) Defective development of thymus may lead to cyst
formation in the anterior mediastinum.
5. Esophagus:
Esophagus in rare cases is absent or defective in cer-
tain parts.
6. Stomach :
Attenuation or dilatation are about the only unusual oc-
currences in this organ.
7. Intestines:
(a) Meckel's diverticulum, which may exist as a blood
pouch extending from the ileum to the umbilicus,
as a fibrous cord or as a patent tube discharging
at the umbilicus, in this latter case constituting
a congenital fccai fistula.
(b) Stenosis or atresia of the duodenum.
(c) Atresia of the anus.
H RRI'RODUCTION
(d) Redundancies of the large intestine, especially of
the sigmoid portion.
(e) Persistence of the eloaca.
8. Liver and Pancreas:
Anomalies of these organs are rare. In one case the gall-
bladder has been reported as congenitally absent. The ducts of
the pancreas are subject to many variations which are not to be
regardeil as anomalies.
III. ANOM.A.LIES OP THE CENTRAL NERVOUS SYSTEM
1. Acrauia and hemic raiiia, complete or partial absence of the
roof of the skull.
2. Craiiiorachischisis, defect in the skull and neural canal.
3. Ccplialoccli; a hernia of the cerebrum, may be of several
varieties.
(a) Enccplmlocele, hernia of brain substance.
(b) Jleningoecle, hernia of the membranes.
{c) MeningoencepbaloceU', hernia of membraDCS and
brain siibstanue.
(d) Ilydri'neepbaloecle, brain ventricles distended by
aeeiimuiation of fluii^.
(c) Ilydronienin^oeele, sae formed by the membranes
distended by fluid.
4. Micrcncrphahi' ami viicrorrphaly, an abnormal siuallness of
skull and brain.
5. Spina bipthi ciistica. due to a cleft in the vertebral column.
generally along its dorsal asjieet. Several varieties have
been observed.
{a) Myelonu-ningoei'le. if the cyst comprises the cord
and membranes,
(b) Spinal uieningoeele, if the cyst comprises the
membranes alone,
fel ilyeloeystocele. if the cord itself is dilated.
6. Spina bifida occulta, in which neither cleft nor tumor is
visible externally, but the position of the defect is indi-
cated by a small, depressed cicatrix, covered with a
small tuft of hair. This is usually situated in the
ORGANOLOGY 77
IV. ANOMALIES OF THE GENITOURINARY SYSTEM
.. Anomalies of the kidneys:
(a) Congenital aplasia of both kidneys.
(b) Ectopia of one or both kidneys,
(e) Horseshoe kidney.
(d) Single kidney with double ureters.
(e) Lobulated kidney.
(f ) Floating or movable kidney.
(g) Congenital cysts of kidney.
. Anomalies of the ureters:
(a) Absence of pelvis.
(b) Double or triple ureter.
(c) Atresia of both ureters.
(d) Opening of male ureter may be into seminal vesicles,
prostatic urethra, or rectum.
In the female the ureters may open into the urethra, vagina, or
terus.
. Anomalies of bladder:
(a) Congenital absence, rare.
(b) Urachovesical fistula.
(c) Ectopia of bladder.
. Anomalies of urethra:
(a) Hypospadias.
(b) Epispadias.
. Anomalies of the testis:
(a) Cryptorchism, testis retained in abdomen. One or
both testicles may be so affected.
(b) Cysts and teratoid tumors of testicle.
. Anomalies of ovaries:
(a) Congenital absence rare, defective development and
malposition not uncommon.
(b) Ovarian cysts and teratoid tumors.
. Anomalies of oviducts, uterus, a\id vagina:
(a) Bicornute or partially divided uterus.
(b) Bipartite or completely divided uterus.
(c) Uterus didelphys which is a complete double utero-
vaginal tract.
M REPRODUCTION
(<I) I'liieoriiiite iitcnis dui' to the failure of one MuUerian
tube to develop.
(e) Itifautile uterus aud imperforate ]iymen.
8. Hermaphroditism:
In sonit* instances one individual will combine the characteris-
tica of both aeses. If siit-h an individual possesses both ovary and
Ii'stiB, the i>onditioD is known as irui' hermaphroditism. If, on the
otlii'i* liniid, siieh an individual possesses ovaries or testes, the con-
dition is tlu'ii called falsi hcnnaphrodilism.
The t,vpcs of true henna pbroilitisin are:
(a* Lateral henna ph rod it ism in which an ovary is present
on one side and n testis on the other.
(b* rnilaloral, in which a testicle aiid ovary are preaoit on
one side.
tet HiliUcral. in which ovaries and testicles are present on
Iwlb sid(-s.
The tym-s of false bcnuapbroilitistu are:
la^ Masi-uline lyjx- in which llic testicles are present, but the
Unl> I liaraelcrisliirs ure tbust- of the female.
vhl Kcniiiiim- tyjv in which the o^Tiries are present, tmt in
which male c I laracl eristics prt^lomiiiate in the body.
V. WOMALUS* or TtlK Rt>irlBATOBr SYSTEM
Wi<iMit^t.« I't tit l*ry»s:
.(•^ HiAl epijrloin.- cjinilacf-
lO^ .Mnwrmallj larp' ^vnl^»ci<■,
,rt' Mwi-iinv .if ir».-hi-«, ^^^•«^f■^.i irisiafr dirwrtlv froni
TABULATED CHRONOLOGY OP DEVELOPMENT 79
TABTTLATEB CHBONOLOOT OF BEVELOPMENT
First Week.
Segmentation of fertilized ovum to form morula while passing
along oviduct to uterus.
Cleavage-cavity present, marking stage of blastula.
Great increase in size.
Cells of inner cell-mass rearranged to form entoderm and
ectoderm.
Embryonal area.
Primitive streak.
Amnion completed at fourth or fifth day.
Second Week.
Ovum in uterus imbedded in mucosa.
Chorion and its villi. Vascularization of chorion and its villi.
Heart indicated as two tubes.
Oral pit. Gut-tract partly separated from yolk sac.
Medullary plate. Nasal areas.
Fourth Week.
Marked flexion of body. Cephalic flexures.
Pancreas begun. Liver-diverticulum divides. Bile-ducts ac-
quire lumina.
Pulmonary anlage bifurcates, the two pouches being connected
by a pedicle, the primitive trachea, with the pharynx.
Anterior lobe of hypophysis begins.
Optic vesicle stalked and transformed into optic cup.
Limb-buds apparent.
Sixth Week.
Nasofrontal, lateral nasal, and maxillary processes unite.
First indication of teeth in the form of the dental shelf. Sub-
maxillary gland indicated by epithelial outgrowth.
Thyroid and thymus bodies begun.
Genital tubercle, genital folds, and genital ridge (external
genitals) .
Semicircular canals.
Concha of external ear.
Fingers as separate outgrowths.
1
80 REFBODUCTION
Eighth Week.
Head more elevated.
Parotid gljind begins.
Anlage of H|ilipn recognizable.
Suprarenal he lica recognizable,
Lens-eapsiilc
Palpebral ton j uiictiva separates from cornea.
Fingers jierfeetly formed. Toes begin to separate (fifty-third
day).
Third Month.
Weight (end of lu^ ; length, 2% inches. At
first eliorion lieve and cb froDilosum present; for-
maliim of placenta,
Union of tislia with canals of «niiRau botly complete. Testes
in fjilse pelvis. Ovaries descend.
Kyes nearly in normal position. Eyelids begin to adhere to
each other.
Limbs have definite sliji[ie, nail.s almost perfectly fonued.
r"urth Mouth.
Weight, 7^.| ounces; length, 5 inches.
Anal iiievubrane disappears.
Se.xiial distinctions of externa! organs well marked. Closure
of gi'nilal furrow. Scrotum. Prepuce. Prostate well
foniieii.
Eyelids iiiid nostrils el.ised.
Fifth Mo»lh.
Weiylii, I lb.: li'Mtrtli. >i iiielirs. .Xclive fetal movements begin.
Twii biviis i<( ile^-iduii euidi'si"', iihliteraling tlie space be-
Dislini-lioii liiluivii Mlri'Ms ;iiid \ ;ii:i]iji. Ilyiiien begins.
FETAL CIRCULATION 81
Seventh Month.
Weight, 3 pounds; length, 14 inches. Surface less wrinkled,
owing to increase of fat.
Meconium in large intestine.
Testes at internal rings or in inguinal canals.
Lanugo over entire body.
Lens-capsule begins to acquire transparency. Eyelids perma-
nently open.
Differentiation of muscular tissue of lower extremities.
Eighth Month,
Weight, 4 to 5 pounds; length, 16 inches.
Testes in inguinal canals.
Vernix caseosa covers entire body.
Lanugo begins to disappear. Nails project beyond finger-tips.
Ninth Month.
Weight, 6 to 7 pounds; length, 20 inches. Umbilicus almost
exactly in middle of body.
Meconium dark greenish.
Testes in scrotum. Labia majora in contact.
Lanugo almost entirely absent. Galactopherous ducts of milk-
glands acquire lumina.
FETAL CIBCTJLATION
During intrauterine life the respiratory blood changes are ac-
complished in the placenta. There is no pulmonary respiration,
consequently only so much blood goes to the lungs as is needed for
their nutrition.
From the placenta, the blood which has been oxygenated in
the placenta passes to the umbilical vein, from which a part goes
directly to the ascending vena cava, by the ductus venosus, while a
part goes to the liver, and, after passing through it, reaches the
vena cava through the hepatic vein. Together with the blood from
the lower extremities, it then goes to the right auricles, and thence
is deflected, through the foramen ovale y into the left auricle y
hy the Eustachian valve, whence it passes through the left ventri-
PREGNANCY AND THE .AIATERNAL ORGANISM 83
cle into the aorta. The larger part goes to the head and arms.
Returning by the descending vetia cava to the right auricle, it
goes to the right ventricle, a very small part passing to the lungs
by the pulmonary artery, the larger part reaching the aorta
through the ductus arteriosus ; a small portion of this mixed blood
goes to the lower extremities via the iliacs ; the greater part, how-
ever, is returned again to the placenta by the hypogastric arteries.
THE EFFECTS OF PBEONANCT ON THE MATEBNAL
OBOANISM
Changes in the Utenis. — The first effects of pregnancy arc to
be observed in the uterus. The most notable, clinically, are the
alterations in size, shape, and structure of the uterus.
Size. — The growth of the uterus begins immediately on the
fixation of the ovum, and its enlargement is continuous and pro-
gressive until the development of the ovum is complete. In the
first two months the enlargement is chiefly in the lateral and an-
teroposterior directions. Subsequently the growth is nearly sym-
metrical. In the early months the development of the uterus is
mainly due to hypertrophy and to hyperplasia of its muscular
fibers, while in later months the enlargement is due to the growth
of the ovum and dilation of the uterine body. The thickness of
the uterine walls at term is usually less than 5 cm., never more
than 10 cm. The internal surface is expanded between conception
and full term from 32 to 39 square cm. (5 or 6 square inches) to
2,256 square cm. (350 square inches). The cubic capacity of the
uterus is enlarged more than 500 times, to 4,000 c. c, or more,
while the weight increases from 43 grams (V/j ounces) in the pre-
gravid state, to 904 or 1,133 grams (or 2 to 2i/> pounds) at term.
DIMENSIONS OF TUE GRAVID UTERUS
Stage of Gestation .
12 weeks
Total Length.
12.5 cm. (5 in.)
Width.
10 cm. ( 4
in.)
16 weeks
15 cm. (6 in.)
12.5 cm'. ( 5
in.)
20 weeks
17.5 cm. (7 in.)
15 cm. ( 6
in.)
24 weeks
21.5 cm. ( Si/oin.)
16.5 cm. ( 6U
•in.)
28 weeks
25 cm. (10 in.)
17.5 cm. ( 7
in.)
32 weeks
29 cm. (lli/oin.)
20 cm. ( 8
in.)
36 weeks
33 cm. (13 in.)
22.5 cm. ( 9
in.)
40 weekj?
35.5 cm. (14 in.)
25 cm. (10
in.)
EEPBODUCTION
Shape. — In the first three
months the shape of the uterus is
irregularly pyriform, the irregu-
larily depending on the position of
the ovum. At the second month the
body of the uterus is a tjatteoed
spheroid — Its anteroposterior di-
ameter being the Binallest, whiie it
is widened from side to aide. Tn
the later montlis it is generally
egg-sliaped, the fuiidal being the
Inrger end. Yet the form of the
uterus in the later months is not
altogether constant.
Structure. — The changes which
take place in the mucosa have al-
ready been described in a previous
ehapter. The muscular fibers grow
7 to 11 times in length, 2 to 7 times
in thickness; there is also some hy-
perplasia of muscular tissue in llie first three or four months.
At the internal os there is a preponderance of circular fibers
in ail tiie layei's. The peritoneal coat develops by tissue growth
in proportion to tlie increasing sine of the uterus.
The arteries increase in iniiuber, length, and caliber. By the
later months of pregnancy the ovarian arteries attain the size of
goose fpiills, and the uterine arteries are still larger. The size of
the lateral branches which connect the ovarian and the uterine
arteries on each side exceeds that of the radial artery. The uterine
venous plexus develops into a system of huge sinuses in the middle
coat of the niuscuiaris and in the suhplHcental portion of the inner
coat. Some of ihe.se vessels attain a diameter of 12 mm. ( Y^ inch).
The ovarian and utei'iiic veins are pi'oportionately enlarged. The
lymiihatie tubes reach the size of goosi' <|uil]s and the lymph spaces
are expandeil. I'nderneath the i»-riloneiiui the lymph vessels form
a plexus continuon.i with the general lyiriphalii' -system.
TIy|HTiro|>!iy nf ihi' m-rvnus stnielures within the uterus keeps
■■A Ule!
Changes in the Cervix Uteri, -
Inini
—The apparent .shortening
GENERAL CHANGES 85
of the cervix during pregnancy is due partly to the softening of
its structure and partly to swelling of the vaginal mucosa and
the loose cellular tissue about the cervix at the vaginal junction.
The cervical enlargement is partly hypertrophic, but is mainly due
to loosening of its structure in consequence of serous infiltration ;
it is progressive to about the end of the eighth month.
Structure. — The softening extends progressively from the lower
border upward; it involves the entire cervix by the end of the
eighth month.
By this time generally the cervical canal has become sufficiently
expanded in multipara* to admit the finger, and the head of the
child may be felt through the membranes.
In women pregnant for the first time the os externum is seldom
as large as the finger, even in the later weeks of gestation.
Changes in the Other Pelvic Structures. — The broad ligaments
adapt themselves to the expansion of the uterus partly by the
separation of their layers and partly by the growth in the number
and size of their tissue elements.
The ovaries and the Fallopian tubes lie in contact with the
sides of the uterus by the time it rises out of the lesser pelvis.
Their vascularity is greatly increased.
The vagiiia undergoes hypertrophy during pregnancy. The
width and length of its walls are increased, and it becomes more
vascular. The papillae of the mucosa undergo marked develop-
ment,
GENERAL CHANOES CONSEQUENT ON PBEONANCT
The Heart. — Most authorities claim that there is a physiolog-
ical hypertrophy of the left ventricle of the heart during gestation,
which is designed to meet the increased resistance in the systemic
circulation brought about by the superadded uteroplacental circu-
lation.
The Blood. — Extreme changes of the blood do not occur in
normal pregnancy. The number of red cells and the proportion of
hemoglobin are slightly increased. The number of white cells is
greater, most so in the last weeks of gestation; the alkalinity is
in-creased and the same is true of the fibrin-forming ferment.
The Nervous System. — In most gravida; there is some increase
m BEPRODUCTION
ID the irritability of the nervous system. Psychic disturbances,
neuralgias, and other nervous disorders are sometimes observed.
The Body Weight. — As a rule a considerable gain in body
weight octurs in the later months, due mainly to an increased
adipose deposit.
The Thyroid. — The thyroid gland is more or less hypertro-
phied during pregnancy in a small proportion of cases. The en-
largement is not constant.
CHAPTER III
DIAGNOSIS OF PREGNANCY
The diagnosis of pregnancy is made upon : .
(1) The history.
(2) The mammary signs.
(3) The abdominal signs.
(4) The pelvic signs.
History. — Cessation op Menstruation. — The cessation of men-
struation in a woman whose previous menstrual history has been
regular is the most valuable of the subjective symptoms of preg-
nancy. Amenorrhea, however, may depend on many other condi-
tions, which must be excluded before the arrest of the catamenia
is to be considered as presumptive evidence of pregnancy. Among
the causes which may produce amenorrhea are change of climate,
mental and nervous disorders, chronic nephritis, exposure to cold,
anemia, chlorosis, tuberculosis, tardy menstruation, acquired atre-
sia of the vagina or cervix, the menopause, and the growth of pel-
vic and abdominal tumors. Amenorrhea is not always available
as a symptom of pregnancy, as it is possible for the woman to
become pregnant during the lactation period, after the menopause,
or before the menstruation is regularly established. There are
cases in which a bloody vaginal discharge may recur with regu-
larity during the first half or even tliroughout the whole of gesta-
tion. This flow, however, differs in character from the usual bleed-
ing of the individual woman. Its occurrence at the end of the
menstrual month results from the influence of the menstrual moli-
men. When bleeding occurs in the later months, examination gen-
erally shows it to proceed from polypi or lesions of the cervix, or
clironic decidual endometritis, or placenta pnevia. It may usually
be distinguished from true menstruation by irregularity in the
amount or the duration of the flow.
Nausea and Vomiting. — Some degree of nausea is usually pres-
87
80 DIAGNOSIS OF PREGNANCY
ent in the majority of pregnaac-ies. This symptom depends either
upon a rertex due to the distention of tiie gravid uterus, in the
beginning of pregnancy, or upon a mild toxemia. It usually be-
gins about the end of the first month, although many notice it
within the first weeks after fruitful coitus. It usually eeases by
the end of the third month. It generally manifests itself as a
morning siekness, or repulsion for food, or by actual vomiting.
The eause.t whieli may produce nausea and vomiting are irrita-
tions of Hie uterus, congestion or inflammation of the tubes and
ovaries, and the growth of pelvie tumors. Functional and organic
disease of the stomach myst be excluded.
Some degree of pti/alism is usually associated with the nausea
and vomiting of pregnancy. While excessive salivation is excep-
tional, hypersecretion of mucus in the mouth and throat is com-
mon. This mucus is clmiacterized by its tenacity and is expecto-
rated with difficulty. The symptom of nausea and vomiting is ab-
sent in a stnall proportion of pregnant women.
Iji'iCKKNiNu. — (.Jiiickeniiig is the sensation of the active feta!
inovonieiils lis lir.st felt hy Ihe mother. This subjective symptom is
usiiidly appiiri'nl by the end of the fourth month. It is noticed in
some vases eitrlicr, iind in some later, while some women do not
experience tiie scnsalion at ail, and others overlook its presence.
Other syniptom.s ii-scerlainable from the history may be the
sensation of increased weight, fullness and tenderness in the
breasts, ami gnulual enliirsemcnl and ])igmentation of the abdo-
men.
Mammary Signs,— The inaiuiuary si^'ns available at the sec-
ond month lire:
tU liicreas,Ht si/e and lulliirss of the glands.
iJl The pritiiary areola.
i;ll Monlir->mevys follivles.
\4) Knhirgi'uii'iil of lUe iiiauiiiuiry glands.
In addition to iliisc are the Inter sitrus:
(Ti) t'olostrum, iipi-eiifiui; in the hieiists at the Ihini month.
^^^ The sivoudary arn'la. wliieii may W demonstrated at the
fifth month,
Ixi-RKviiEit SitK \Nr KiiJNf^-; vf TiiK lli.Astw. — During ppcg-
naney the milk glaiids Ihvmh ll{lr^:^^^ by ihe irntwth of the acini,
swelling ttf the iulerytiindular ei«mwlive tissues and an inter-
MAMMARY SIGNS Sd
lobular deposit of fat. About the second month the glands be-
come distended and stand out prominently from the chest, and the
veins are enlarged and plainly seen coursing under the skin.
Rarely there may be no material enlargement of the glands, though
slender cords (hypertrophic acini) may always be demonstrated
running from the nipple toward the periphery.
Primary Areola. — The primary areola about the nipple becomes
elevated, edematous and pigmented during the second month of
Fio. 25. — Breast Sions of Preonancy.
pregnancy. The pigmentation varies in blondes and brunettes,
being more marked in the latter. In the negroes the pigmentation
is black. The areola becomes soft and velvety to the touch, and
elevated above the level of the surrounding skin. The pigmenta-
tion is the most constant of the.se changes.
Montgomery's Follicles. — Within the pigmented area of the
primary areola may be found sebaceous follicles, 5 to 20 in num-
ber, which appear aa papular elevations, projecting conspicuously
so
DIAGNOSIS OF PRKUXANCY
from the surface of the skin. There niity be an entire absence ot
th««' follicles. They can be best demonstrated while the skin is
hcUl Rf-ntl.v on the stretch. '
Veins. — Owing to Ihe enlargement of the glandular structure
of the breast, the snperiicial veins become fuller and more prom-
inent, and may be seen coursing across the gland and into the
KFiMtla or ent-irctin^ Uie margin of the primary areola.
CV>i<i>STRL'M iMiuK Secbetiox). — Bv manipulation over the
»v- » rw« rK(«o
) >«v-'.\>a.us JUSMLx w r^ II II I
i:r"'J
ABDOMINAL SIGNS 91
The Secondary Areola. — The secondary areola appears at the
fifth month of pregnancy. It is characterized by a series of
washed-out sptots surrounding the primary areola, due to the pres-
ence of non-pigmented sebaceous follicles. This sign is of diag-
nostic value in the woman who has never been pregnant. All of
these mammary signs may be observed independently in the non-
pregnant woman, or may be absent in that condition, but when
present collectively in the primipara, the mammary signs make
one of the positive signs of pregnancy.
Abdominal Signs. — Inspection. — The abdominal signs to be
noted on inspection are:
(a) Flattening.
(b) Enlargement.
(c) Umbilical changes.
(d) Pigmentation. x
(e) Strise gravidarum. /
Flattening. — Hypogastric flattening, due to the sinking of the
enlarging uterus deeper into the pelvis, may possibly be noted in
the first few weeks of pregnancy. This descent of the womb may
be associated with irritability of the bladder, which is complained
of by the patient.
Enlargement. — The enlargement of the abdomen is apparent
after the third month ; when the uterus rises by its increased growth
out of the true pelvis, this enlargement is steady and progressive
until the last month of gestation. The fundus reaches the pubes at
the third month, the umbilicus at the sixth month, and the ensiform
at eight and one-half months. During the last two weeks of gesta-
tion the uterus usually sinks deeper in the pelvis and falls for-
ward. This is more apparent in primiparie than in multipane, and
is known as ** lightening.''
Umbilical Changes. — In the first three months, owing to the
uterus sinking deeper into the true pelvis, the bladder is carried
downward, making traction on the urachus, which retracts the um-
bilicus. At the sixth month the umbilicus is level with the surface
of the abdomen, while during the last trimester it becomes pro-
truded and surrounded by a ring of pigmentation.
Pigmentation {Linca nigra), — Pigmentation of the linea alba
or median line is limited to a narrow band about 3 mm. (Yg inch)
wide, extending from the pubes to the umbilicus, which may be
d2 DIAGNOSIS OP PREGNANCY
observed from the end of the second month. It progresses with the
growth of the uterus. It is more marked in brunettes, and is fre-
quently absent in bloodes. The linea nigra may rise proportion-
ately to the height of the fundus or stop in its abdominal ascent at
the umbilicus. The pigmentation remains after the pregnancy has
temiinated. In brunettes a dark circle appears about the umbilicus,
and pigmented patches are observed over other parts of the ab-
domen.
StruE Gravuianim {Linra atbu:aHtes) . — These are irregular,
whitish, pinkish, or bluish lines over the lower part of the abdomen,
appearing during the last trimester of pregnancy. These stri^
extend to the hips and thighs, and are due to a partial atrophy of
the skiu from tensiou, and separation of the superficial layers of
epidermis, exposing the glistening eoriura. These striie may be
found in eimditions, other than pregnancy, which cause rapid ab-
dominal enlargement, as aseites, ovarian cysts, etc. They persist
after the preguauey has tcrminjited.
Palpatiijn.— Tile signs of jireguuney on palpation are ;
(a) The size of the tumor. "
(b) The ehanieter of the tunioi-.
(c) Intermittent eoutraetions.
(d) Active fetal movements.
(e) Passive fetal movements.
i^izc of tlu; Tumor. — The increiise In the size of the pregnant
ntenis is progressive. Tlie fundus lies, at the third month, in the
]>liine of tile brim, and reaches Iho tiinbiliens at the sixth month
iind the en.sifovm eiirtiliige at the thirty-eightli week.
The length of the graviil uterus is 12.5 em. at 12 weeks, 15 cm.
at. Ifi weeks. 17.5 at 20 wei-ks, 21.5 at 24 weeks. 25 at 28 weeks. 29
at ;J2 wi'i'ks, 3;f at 3(i weeks and :!5.5 eiu. at term. The height of
tli<- fundus in(Tea.srs :i..5 cm. for rufli hmjii' month after the 20th
ABDOMINAL SIGNS 93
month, and may be appreciated by abdominal palpation in the in-
ter\^als between contraction as early as the fifth.
Intermittent Uterine Contractions, — By placing the hand on the
fundus, intermittent uterine contractions may be detected as early
as the fourth month. These contractions occur throughout preg-
nancy at intervals of about ten minutes ; the whole uterine muscle
contracts as it does in a labor i)ain. Contractions may be demon-
strated by bimanual palpation as early as the eighth week. They
cea.se with the death of the fetus; they occur occasionally when
the uterine enlargement is due to causes other than pregnancy, as
hematometra, hydrometra, soft fibroids, and occasionally in the
distended bladder. This sign is of no positive diagnostic value.
Active Fetal Movements, — Fetal movements, as an objective
sign, may be felt as pregnancy advances. The detection of fetal
movements may be considered as a positive sign of pregnancy.
They may be excited by suddenly placing the cold hand upon the
woman's abdomen, or by tossing the fetus from side to side. The
movements of the fetus begin as early as the tenth week, and may
be demonstrated by bimanual palpation at the end of the third
month. As an abdominal sign they can seldom be elicited prior to
the sixteenth w^ek. In excessive liquor amnii, the movements of
the fetus may be masked, occasionally they may cease for days or
weeks without apparent reason.
Passive Fetal Movements (or External BaUottement). — Passive
fetal movements are elicited by placing the hands upon the sides of
the abdomen with their palmar surfaces facing each other; the
fetus is then tossed from side to side, the movement and contact
being transmitted to the palpating hands. Pathological growths
floating in ascitic or other fluid must be excluded.
Auscultation. — Auscultation gives the following signs of
pregnancy :
(a) Fetal heart sounds.
(b) Choc foetal.
(c) Uterine souffle.
(d) Funic or umbilical souffle.
Fetal Heart Sounds. — The fetal heart tones, wiien heard, are a
positive sign of pregnancy. This sign is generally available by
alxlominal auscultation between the fourth and fifth month. It
consists of a rhythmical succession of sounds, which can be counted,
8
M DIAGNOSIS OF PREGNANCY
us. I^H
sunilar to the h>:3n-b«al of the n«r-bMU HiQd. beard whh I
stethoscope dir-^:tly or^r tb« antcnor shoakkr of the fetus,
rate varies from 120 to 150 per minale. Tbe fet«l heart t
are asnaUv aa^iihle over an area uf Uirw iDtbes or mart in diam-
eter, knovn as ihe fotus of amsetiilalivn: rxireptionallj-, there nuv
be a second focus eren in « ain^ fetaiion. doe to the eondaflion of
soond through ^>iav reowte poiot of fetal eootaet with the nterioe
*aU.
The heart ~"und« may he for a time inaudible, oving to s
change in th-^ f>isitioa of the fetoa, as in certain oeeipitoposterior
po&ilions or in ilie pr liquor amnii. or in a tctt
fat abdoDieo »r great pnj_.
When the hf^rt tones remain p> ntly absent upon repeated
examinati"!!. aftrT tber haw on een dtstini'tly heard and
wuiiini. il Giay W presunoj that tike chiW is dead. To anscultatif
the iVlal hiiirt. ihe |>aTirm should be in the borizontal position.
The kvalioii of ihe aalerior teapnta of the fetus most be pre-
vi^HiTily d'l'^irnulnn) bv aUI^iminal palpaii'in. In head-firvt esses
the hean r.:ay U? beard over the anterior seapala. which is nsuallf
within on-, :■' Thrre it>ehes I" the right ur left uf Ihe metlian line
U'K>w :!;- ;i:ub3li.-a«i. In brweh tras*-s Ibe heart ia heard above the
( " I F.:-:' — The riioe ftKal i& a sound produced by the impact
01 iht' i\:al :tu>vrnient, as beard br aQ»-uItatk>n of the abdoraen
nviT ihf \i:< riis. It is elieitiJ by aUlouiiual s^et^.■>v^*[■y liiiring the
fi'iirtii. :•:"::,, ami s;\ r:t>:-.:h<. Vy ;>:;i.;tii the i^tetho^'ope directly
I'v.r :!:.■ ■,:: r,;-i ;i!ul i:iu-.:;i: :!-■ :' !-,i< :■> make a sudden movemeut
by ;■'..!, :■■: -.'■:-: loM !,a:;.! . v r ■": v ;:"-r-.;-, it resembles the sound
[':^-,;■,;^ ,v- :■> i;',r.:',> T,ii-,>.-';." :':- ;-■.-< ■ : ;r.- hand placed over the
f > "" .'•' ',' .' - -. - :^.-' '^r bruit is a sound
;'■-■■--"; -^ ' ^ ■ . ■■■•: - ,-■-■- '■ -' W'Si. the uterine artery
. •■ - ■ ■ - [-■■.- r -,K" of the abdomen
.' . ,•.■,■■■ -■.■ --.- ■.- - ■, r-- !'r\tu<iuni-ed on the
■ - ■ " ; .. ■ - ., ■ -A^Lr^ls the right. It
- ->• - ^' - - " > iT'-nerally available
-; N :■.■]:. Other eoiidit ions,
- ■ > .1 - • : • :-,,.st\; bliKHl eurrent in
PELVIC SIGNS 95
Funic ar Umbilical Souffle. — The funic or umbilical souffle is a
soft bruit, synchronous with the fetal pulse. It results from some
obstruction to the flow of blood through the umbilical veins, from
torsioili, knotting or coiling of the cord. It is seldom avail-
able as a sign of pregnancy, but can usually be elicited in the later
months.
Pelvic Signs. — The pelvic signs by which pregnancy may be
recognized are:
(a) Purplish hue of the cervix and vagina.
(b) Softening "^f the cervix.
(c) Changes in the uterine tumor in shape, size and consist-
ency.
(d) Excessive flexibility of the cervix.
(e) The pulsation of the uterine artery.
(f ) The increased temperature of the cervix.
(g) Internal ballottement.
PuRPUSH Hue op the Cervix and Vagina. — The purple color
of the cervix is due to the marked congestion of pregnancy. The
lividity of the vaginal portion of the cervix may be observed from
the first month after conception. This dusky hue of the cervix is
more constantly present and develops earlier than the change in
color of the vagina.
As pregnancy advances, the vagina takes on a purplish hue.
This is apparent, at first, along the anterior wall, immediately below
the meatus, due to the hypertrophy of the corpus cavernosum of the
vestibule and of the vaginal venous plexuses. This sign is present
in about 80 per cent, of pregnancies at the end of the third month.
A condition which very closely simulates the dusky hue of the cer-
vix and vagina may be produced by pelvic congestion due to other
causes, as incarcerated tumors in the pelvis.
SoPTENiNQ OP THE Cervix. — The softening of the cervix is a
progressive sign and can usually be made out in the primipara by
vaginal touch as early as the sixth week. It begins at the lower
border of the cervix and feels like a thin, velvety layer covering a
firm body.
As the gestation advances, the softening progresses from below
upward, until it involves the entire cervix by the end of the eighth
month. The cervical canal participates in this change and becomes
more patulous as the softening extends.
96 DIAGNOSIS OP PREGNANCY
Goodell has described this sign as giving a sensatioB-
finger similar to that produced by palpating the lip.
Changes in the Utekine Tumor. — The dianges in the skapt,
i»zc, and consistiticy of the uterus make one of the positive ^gns
of pregnaDL'y. This sign is available as early as the sixth or eighth
week. These changes are detected by bimanual examination, Tkt
body of the uterus enlarges with the growing ovum. It fakes 9»
an irregular globular shape and becomes soft and elastic.
The changes in the character of the tumor vary with relaxation
an*\ contraction of the uterus. In relaxation the uterus is soft,
elastic, flaltoifd from before backward, wider from side to side.
and asymmetrical in shape. The elasticity ia most marked in the
anterior wall just above the isthmus.
The coruua are of unequal size and density, owing to the fact
that the ovum in the second month is usually situated in or near
one horn of the uterus. During the contraction which develops
under the stimulation of bimanual palpation of the fingers, the
uterus loses its asymmetry and becomes symmetrical, and somewhat
globular or ovoid in shape.
The eiilai'gi'ment of the uterus due to pregnancy must be dif-
ferentiated from ehrouio metritis or subinvolution by the history,
by the greater density of the uterine tumor, and by the absence of
progressive growlh. A soft submucous fibroid or myoma can gen-
erally be ditferentiated from pregnancy by the history, by the
slower growth of tlie tumor, and by the alwence of the changes iu
consistency, us are demonstrated iu the pregnant uterus durin«;
relaxation.
Hcgnr's sign properly belongs under the changes in consistency.
which take place in the pregnant iiterus. It is available about the
second month of gestation and consists in the extreme compress-
ibility of the median portion of the isthmus uteri. This point in
the non-gravid uterus is the most dense.
In order to elicit Ilegar's sign, the patient should be placed in
the lithotomy position, and the uterus be drawn down with i
sella caught in the cervix, while the thumb is carried int
vagina and pressed against tlie lower uterine segment at itf
tion with the cervix, and the index finger of the same
passed into the ret^tum to a point just above the utcrosai
de-sac ; the lower segment or isthmus of the uterus is
Fig. 28. — Heoar's Sign (CoupREBSifliLiTY of the Uterine lexHMca).
Obtained by the vitgino-abdomiiial method; available in thin women.
98
DTAGNOSTS OF PREGNANCY
tween the thumb and finger, aiid may be eompressod to almost the
thinness of a visiting card (Fig. 27).
This sign may also be denionstrati?d in thin women with lax
abdominal walls by bimanual palpation. Two fingers are intro-
duced into the vagina against the lower segment nf the uterus just
above the cervix, while the external hand depresses the abdominal
wall behind the fundua and the fingers of each hand are made to
meet over the thinned out lower segment (Fig. 28).
Fig. 29. — INTEll.^
Tliinning under pressure to less than one-half a centimeter
establishes a positive diagnosis of pregnancy. Examination under
anesthesia facilitates the detection of this sign.
Excessive Flexibility of the Cervix.- — Excessive flexibility of
the cervis is due to the thinning of the isthmus, and may be elicited
by bimanual palpation at the second month.
Pulsation op the Uterine Abtkry. — Pulsation of the uterine
artery ia due to h.vpertrophy of the artery consequent upon preg-
nancy, and may be detected by vaginal touch during the second
i
PELVIC SIGNS
99
and third months of gestation. The examining finger is held
against the vaginal vault at one side of the cervix, and the pulsa-
tion noted.
The Temperature op the Cervix. — The temperature of the
cervix of the pregnant uterus is from y^ to % of a degree Fahren-
heit above that of the vagina or the rectum. Both of these signs
have only contributory importance, as they may be found asso-
ciated with pathological growths or local inflammatory lesions.
Internal Ballottement. — Internal ballottement — or passive
fetal movements — ^as an objective sign, consists in tossing the fetus
upward in the amniotic sac, with two fingers in the vagina, against
the anterior uterine wall above the cervix, while the other hand
steadies the fundus, and feeling it fall and repercuss the fingers,
thus demonstrating the presence of a movable solid content. Bal-
lottement is available during the fifth and sixth months. Earlier
table of the signs of pregnancy
Mo.
l8t
Sod
3rd
History
Ceflsatlon of menaes.
Mammary
None.
Abdominal
Nausea, ptyalism.
Cessation of menses. 1. Increased sue and
fullness of the glands.
2. Primary areola.
3. Montgomery's folli-
cles.
4. Enlargement of
veins.
Same history as
above except nau-
sea and ptyalism
may cease.
All mammary signs in-
creased. Colostrum
may be expressed
from nipples.
None.
None.
None.
Pelvic
None.
1. Purplish hue of va-
gina and cervix.
2. Softening of the cer-
vix.
3. Changes in shape,
sise and consistency
of the uterus.
4. Hegar's sign.
5. Increased flexibility
of cervix.
Pelvic signs as above.
All increased, except
flexibility of cervix.
5th A: Cessation of menses, All mammary signs
6th
contmues.
Qmckening.
increased.
Secondary areoke.
8th 4c Continued amenor-;All of the mammary
9th
rhea. Active fe-
tal movements.,
Progressive ab-j
dominal enlarge-
ment. I
si^ns more pro-
nounced.
1. Enlargement.
2. Pigmentation.
3. Intermittent con-
tractions.
4. Active fetal move-
ments.
5. Uterine souffle.
6. Choc fuetal.
7. Fetal heart (not con-
stant).
1. Tumor nearly at en-
siform cartilage.
2. Pigmentation.
3. Lineie albicantes.
4. Detection of fetal
parts.
3. Active fetal move-
ments.
6. Fetal heart sounds.
7. External ballotte-
ment.
Purplish hue, softening
of cervix.and changes
in uterine tumor
more marked. In-
ternal ballottement.
The entire cervix is
softened.
Cervical caral patu-
lous. Detection of
presenting part.
100 DIAGNOSIS OF PREGNANCY
the weight of the fetus is too small, while later its mobility is too
limited to permit of its being tossed upward and rebounding against
the vaginal fingers (Fig. 29).
To elicit this sign, the patient should be placed in the half sit-
ting posture, the bladder and rectum emptied, the constricting
waist bands loosened. Two fingers are then introduced into the
vagina, and held against the anterior uterine wall above the cervix,
the external hand steadying the fundus; the fetus is then tassed
up by the vaginal fingers, which are held against the anterior wall,
until it falls again and taps the fingers.
It may be impossible to demonstrate ballottement owing to
scanty licjuor amnii, multiple fetation, transverse position of the
fetus, or a placenta pnevia. The sensation imparted to the vaginal
fingers by the rebound of the fetus in ballottement may be con-
founded with an anteflexed uterus, a large stone in a full bladder,
a floating kidney, or a pedunculated tumor of the uterus or ovar}'.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of pregnancy covers a wide field, for
gestation may be confounded with enlargement of the abdomen
from other causes, sucli as ovarian cysts, fibroid tumors, obesity,
distended bladder, ascites, tympanitis, etc. The most important
point in the differential diagnosis of an abdominal enlargement is
the presence or the absence of the distinctive signs of preanancy,
which may be enumerated as follows :
(a) The mammary signs collectively (in the primipara).
(b) The detection of the fetal parts.
(c) The demonstration of the active fetal movements.
(d) Changes in the cliaracter of the uterine timior, in its size,
in its sliape. and in its consistency.
(e) Internal ballottement.
(f) The detection of the fetal heart.
Pregnancy is the most fre(iuent cause of abdominal enlarge-
ment. It is during the first half of pregnancy, before the fetal
heart, the fetal i)arts, and the fetal movements can be definitely
recognized, that the greatest diflficnilties are encountered in making
a positive diagnosis.
In the early months gestation must be distinguished from fibro-
DIFFERENTIAL DIAGNOSIS 101
myoma, hematometra, hydrometra, pyometra, chronic metritis,
small cystic and solid tumors of the broad ligaments, inflammatory
swelling of the broad ligaments and of the ovaries, and exudates,
while in the later months large myomata, obesity, ascites, distended
bladder and ovarian cysts are the conditions from which uterine
gestation must be distinguished. Pregnancy may coexist with any
of the conditions from which it must be differentiated. All women
presenting an abdominal tumor between the ages of nine and sixty-
one should be regarded as possibly pregnant until proven not to be.
Patients presenting an abdominal enlargement should he cathe-
tcrized before proceeding tvith the examination. Having excluded
a distended bladder, our next step is to establish the presence or
the absence of the diagnostic signs of pregnancy, particularly those
which pertain to the uterus, i.e., the changes in the shape, size, and
consistency of the uterine tumor.
Obesity. — Fat in the abdominal wall gravitates when the pa-
tient is in the erect posture, and lies in folds and broadens the
abdomen when she is recumbent. The fat may be caught up in
folds with the hand and moved over the underlying muscle, when
the patient is in the recumbent position. On pelvic examination
the uterus may be found unchanged.
Tympanites. — Tympanites is a cause of abdominal enlarge-
ment; the intestinal movement may be mistaken for the move-
ments of the fetus. It can be excluded, first, by the absence of the
positive signs of pregnancy ; second, by palpation of the abdomen,
with the patient in the recumbent position. By maintaining firm
pressure with the hand on the abdomen at the level of the umbi-
licus during each expiration, the walls may be depressed until the
vertebral column is reached. Percussion over the entire abdomen
will give a resonant note. Tympanites usually subsides in the
morning.
Ascites. — In ascites, which is a collection of fluid within the
peritoneal sac, when the patient takes the horizontal position the
abdomen flattens at the umbilicus and bulges in the flanks. The
percussion note from the pubes to the ensiform is tympanitic at
the summit of the tumor, while dullness may be elicited in the
flanks. Change in the position of tlie patient changes the location
of the fluid level, which is mapped out by its flatness to percussion.
A fluctuation wave may be transmitted to all parts of the tumor
100 I
the weight of the
limited to permit
llu' vagina! finger
To elicit this s
tiag posture, the
"■aist bands loose
vagina, and held a
the external hand
lip b^- the vaginal
until it falia again
It may be iin|
seanty Jicpior aiiin
fetiis, or a placenta
fiiigei-s by the rel.
founded with an ai
a floating kidney, o
The differentia!
gestation may hi'
from other eouai's
distended bladd.t
point in the dig, ,
the presence or U.
which may be emr
(a) Tfaeniji,
(b) The dH
fc) The.i,
(A) Chan..-
fe) Inte,
Cf) The
CHAPTER IV
MULTIPLE PREGNANCY AND THE ESTIMATION OP THE
DURATION OF PREGNANCY
Multiple Fetation. — Multiple fetation may properly be con-
sidered as bordering on the pathological, for the viability of the
children is lower than in single pregnancies. The fetuses are
usually undersized and of unequal development, malpresentations
are more common, monstrosities more frequent, and anomalies in
the liquor amnii not exceptional. Hydraminos is common. One
fetus or both may die in utero at different periods of gestation.
Labor comes on prematurely in one-fourth of the cases. Twins, or
two fetuses within the uterus, occur once in one hundred pregnan-
cies. Triplets are found once out of 7,900, quadruplets once in
371,000 births, while quintuple pregnancies and sextuplets have
been recorded.
Multiple fetation may result, first, from the impregnation of a
single ovum that contains two or more germinal vesicles; second,
from the impregnation of two or more ova from one Graaffian fol-
licle, or from separate follicles, from one or from both ovaries.
Children developed from the same ovum with a double germ are
always of the same sex, when from different ova they may be of the
same or of different sex.
The origin of the twin pregnancy may be determined by exam-
ination of the arrangements of the membranes and placentas.
When the fetation is from separate ovules there are two am-
nions, two chorions, and two placentas with independent circula-
tions. The placentas may be separate or fused at their margins.
When the twins are from a single ovum having a double germ,
there is one chorion containing two amnions, and one placenta.
Siiperfecimdation is the fertilization of two ova, expelled
at the same ovulation, within a short period of one another, but not
at the same coitus; the fertilization may be by the same or by dif-
ferent males.
103
104 DURATION OP PREGNANCY
SnperfetAtioB is the fertilization of two separate ova thrown
off al difffri'nt periods of ovulation. Several months may iotervene
betwet'U the birtli of the two fetuses.
The authenticity of suiier fetation is doubtful, and it is believed
by many observers that these supposed eases are in reality twin
pregnaiicip^, in whieh one fetus is blighted and east off, while the
other survives ami goes to turni.
The Duration of Pregnancy. — The duration of pregnaney is
not a fixed term, lis we have no means of ascertaining the exact date
at which fertilization takes place. Conception usually occurs either
soon after the last appearance of the menses, or shortly before the
first period whieh is misstnl. This explains the apparent variatieai
in the duration of pregnancy within normal limits.
The average interval betweeu the first day of the last menstroa-
tion and labor is two hundred and eighty days, or practically ten
lunar months, while the interval between fruitful coitus and the
birth of the child is approximately two hundred and seventy-three
days. This rule, however, is subject to many exceptions, as normal
pregnancy may be shortened to two himdred and forty days or pro-
longed to more than three hundred days, with nothing in the char-
acter of the labor or the appearance of the child which would sug-
gest premature birth or overgrowth. The attachment of the ovum
in the la.st week or two of gestation is so insecure that there is little
doubt that delivery occurs prematurely in a large number of in-
stances. Prolongation of pregnaney beyond the average time is
associated with increase in the weight of the child. Winckel has
shown that increase in the length of gestation bears a definite ratio
to the iuiTease in the six.' of tlie rhild.
Rnles and Methods for Predicting the Date of Labor. — No re-
liable means for estiiiiiiting liic exact date al which the particular
pregnani-y will terminate has been suggested. The method pro-
posed by Naegele, and known as "Naegele's rule," is to coiuit for-
ward nine calendar months from the first day of the last menstrua-
tion and add seven days, whieh. as will be seen, is approximately
two hundred and eighty days from the beginning of the last men-
struation: for example, if file last period began on October
we cnunt forward nine ninnth.-; U< July 10th and add seven
which makes July ITtli the probable date of confinement
method for estimating the date of labor is generally ac
PREDICTING THE DATE OF LABOR 105
within a week or ten days, but occasionally a period of several weeks
may elapse before labor occurs. This difference is probably due to
the fact that in one case conception occurred soon after the last
period, while in the other instance impregnation has taken place
just before the missed period. The period of quickening, or the
recognition by the patient of active fetal movements, is not constant.
It occurs in different individuals from the 16th to the 20th week,
and even varies in the same individual in different pregnancies;
hence, reckoning from the date of quickening is also unreliable.
We may measure the length of the uterus or estimate the actual
size of the child as a check to the menstrual history. The former
depends on the quantity of liquor anmii present in a given case,
while the size of the fetus is not constant at any given period of
gestation.
Mensuration op the Uterus. — The duration of pregnancy in
lunar months is equal to the height of the uterus in centimeters,
divided by 3.5 cm. This rule is based on the average size of the
fetus at full term, being 3,300 grammes, and depends on the more
or less regular growth, in the uterus, of 3.5 cm. for each lunar
month, after the fifth month of pregnancy. This estimation is made
with the patient in the horizontal position ; one end of the tape is
placed at the upper border of the symphysis, while the other is held
by the thumb in the palm of the upper hand, the fingers of which
are held at right angles to the fundus of the uterus ; the tape fol-
lows the contour of the uterus, save at the last dip ; this gives the
height of the fundus in centimeters, which, when divided by 3.5,
gives the duration of pregnancy in lunar months.
In order to take this measurement the head must not have sunk
into the lesser pelvis, hence it will be seen that this method of es-
timation is limited in its application.
MENSUR.VTION OP THE Fetus. — The total length of the fetus is
about double that of the fetal ovoid. The length of the fetal ovoid
may be measured by applying one end of a pelvimeter in contact
with the lower fetal pole through the vagina, and the other end
upon the abdomen over the upper fetal pole. The length of the
fetus during the latter months of gestation is approximately as
follows :
Sixth calendar month, 30 to 35 cm. (12 to 14 inches).
Seventh calendar month, 35 to 40 cm. (14 to 16 inches).
106 DURATION OF PREGNANCY
Eighth calendar month, 40 to 45 cm. (16 to 18 inches).
Ninth calendar month, 45 to 50 cm. (18 to 20 inches).
Unfortunately the rate of fetal development is .not uniform, and
accuracy of measurement presents many difficulties, so that data
from these measurements are subject to correction.
Haase's Rule, — For the first four months the length of the fetus
in centimeters equals the square of the age in lunar months. After
the end of the fifth month, the length in centimeters equals five
times the age in months.
Enlargement op the Abdomen (Situation of the Fundus). —
The height to which the uterus has risen gives a rough estimate of
the length of the gestation. The fundus is found in the plane of
the brim at the third month ; midway between the symphysis and
the umbilicus at the fifth month ; at the level of the umbilicus at
the sixth month; three fingers' breadth above the lunbilicus at the
seventh, and reaches the ensiform cartilage at eight an^ one-half
months, whereas in the last month, particularly in the primipara,
when * lightening'* has occurred, the fundus sinks downward and
assumes almost the position it occupied at the eighth month.
CHAPTER V
THE MANAGEMENT OP NORMAL PBEGNANCY
Pregnancy and labor should be normal processes in the healthy
woman, but civilization has wrought changes in the maternal or-
ganism, and the border line between health and disease is so easily
passed in pregnancy that serious conditions may develop and go
undetected until grave pathological changes have already taken
place, unless the woman is under the observation of a competent
physician from the early months of gestation.
The practitioner who engages to take care of an obstetric case
should give the patient specific directions as to the hygiene of preg-
nancy and its proper management. The points upon which the
woman needs special information are:
I. Exercise.
II. Teeth.
III. Bowels.
IV. Sleep.
V. Vaginal discharges.
VI. Diet.
VII. Clothing.
VIII. Care of the nipples.
IX. Urine.
X. Blood pressure.
XI. Marital relations.
XII. Danger symptoms (which should cause the patient
to seek the advice of the physician).
Exercise. — The pregnant patient should be encouraged to
take moderate muscular exercise daily in the open air, and in-
structed to avoid over-exertion or exhaustion. Daily walks, driv-
ing, or motoring afford the necessary fresh air and sunlight ; golf,
in moderation, and sea bathing are safe out-of-door employments
107
108 THE MANAGEMENT OF NORMAL PREGNANCY
during the first and second trimester. When out-of-door exercLsi'
is impossible, nia.ssage may help to keep up the muscular tone, lu
the later months, exercise to fatigue, violent muscular strain, long
journeys, driving over rough roads, etc., .should be avoided, as well
as impleasant mental infiuenees. Tepid or cold sponge batlis, daily.
do much toward improving the action of the skin.
Teeth. — The teeth of the pregnant woman are especially
prone to decay. They should be cleansed on rising, before retiring,
and after each meal, by brushing with a solution of milk of mag-
nesia. The gums are atibjeet to some hypertrophy. A mouth wash
of diluted liaterine or horolyiitol may be naed with advantage in
completing the month tiiilet. Occasional in.spection by a competent
dentist should be the rule. Cavities should be filled, at least with
temporary fillings. Pregnancy offers no contraindication to the
extraction of teeth when such is necessary.
Bowels. — Pregnant patients, owing to the pressure of the
growing uterus and frequent di.sturlmnce of the digestive functions.
are prone to constipation. Daily bowel movements are necessary.
For this purpose, eascara sagrada, phenolthalin and mild saline lax-
atives should be the choice.
Sleep. — The pregnant woman needs eight hours daily of un-
disturbed sleep; an extra hour of repose in the afternoon may well
be added. It is advisable for her to sleep with the windows open,
so that she may have an abundance of oxygen. During the last
trimester, owing to the enlargement of the abdomen; it is difficult
for the patient to rest comfortably. Sleeping alone adds much to
her comfort.
Va^nal Dischargea. — Irritating leucorrheal secretions msf
result fnmi a chronic endocervicitis aggravated by pregnancy.
Cleansing alkaline douches of a borax and soda solution (1 01.0^
each to the quart) at a temperature of 100° Fahrenheit may be
taken night and morning. The patient .should be in the recumbent
position, and the hag or reservoir at low elevation, lest the irritati«»
of the douche provoke abortion.
Diet.- — The diet of the pregnant woman should be siin
nourisbiug and easily digestible. She should observe regular
for her meals. Meats should not be taken oftencr than once
Fried dishes, pastiy, highly sea.soned and rich foods shoi
avoided. Excessive eating is injurious, as overeating may t
CARE OP THE NIPPLES 109
increasing the toxemia of pregnancy. Diet has a decided influence
on the size of the child.
Women who have given birth to large children, or who are the
subjects of slight contraction of the pelvis, can lessen the weight of
the child by strict adherence to a special diet during the last six or
eight weeks of pregnancy. Prochownick has shown us that a diet
free from sugar and starches, and in which the amount of fluid
taken is restricted, will lessen the weight of the child. This diet
consists of a breakfast of coffee and a roll; lunch of lean meat,
salad, crackers, and a small glass of Moselle wine with seltzer; sup-
per, of an egg, green vegetable, salad, and fruit. The adherence to
such a diet will result in a small fetus, in which the plasticity of
the cranial vault is increased. Functionally incompetent kidneys
will contra indicate the employment of so much proteid.
Clothing. — The clothing should not be tight, especially about
the breasts and abdomen. Garments should be himg from the shoul-
ders. The underclothing should be of thin flannel or linen mesh
of light weight. No heavier underwear is necessary in winter than
in summer. A properly fitting corset may be worn in the early
months, while in the latter months a specially constructed maternity
corset or an abdominal supporter will add much to the comfort of
the patient. Outer clothing may be changed to suit the changing
temperature, wraps being added as necessary.
Care of the Nipples. — Proper attention to the nipples during
the last few weeks of pregnancy will obviate many of the difficulties
of nursing. The nipples should be washed with Castile soap and
warm water each night before retiring and thoroughly dried; then,
after the patient's hands have been carefully scrubbed with soap
and running water, the nipple may be drawn out with the thumb
and finger and anointed with sterile lanolin. The follow^ing morn-
ing the nipple may be bathed with a boroglycerid solution, of the
strength of one ounce of boroglycerid to seven ounces of sterile
water. This method of treatment prevents cracking and keeps the
surface of the nipple smooth and supple. Astringent applications,
as solutions of tannin, alcohol, etc., with a view to hardening the
surface, have proven ineffectual in our hands. Small or shrunken
nipples may be drawn out with the thumb and finger, and a small
cupping glass or the breast pump applied for a few minutes each
day during the last half of pregnancy.
9
HO THE MAX.' QEMENT OF NORMAL PEEG.N'ANCT
Urine. — The u -ine should be examined at n-gular intei
throughout prv^iia qov. This examination iUHtuld W botli cbei
and microscopical, aud made at least oot^ a month for the first
months, and once a week during the last four. The preswiee of
albuminaria, tlie e\ idenees of toxemia, edema, renal insuffioieucy, or
nephritis, demand daily examinatitms. This examination shootd
determine th^ anidunt of urine passed in twenty-four boars, its
specific gravity, the total amount of urinarj- solids, the perc«>taire
of urea, the pr>^sfnee or absence of albumin or sugar and of tnbr
easts.
The amoimt of u must be kept up to abont
sixty ounces. When it la uuonnt a greater quantity
of pure water should be taken. ^' ilbumin is detei-led or llie
patient shows signs of toxemia, a t v'-f«ur-hour speeimen sbonUl
be saved and si-iit to a competent pathologist or chemist, for the de-
terniiuation ot the total amouul of urea, the total nitrogen, and the
nitrogen partition. The quantity of urea and the nitrogm parti-
tion afford evidence of the fiinclional activity of the kidnej-a. while
urea alone will vary with the amount of exercise and the qoantit}'
of nitrogenous fiKid taken. The average normal quantity of area
excreted daily is from 20 to :3l' grammes (500 grains}, while the
total solids amount to about 6t> grammes (1.000 grains). The total
solids may be roughly estimated by multiplying the last two figures
of the specific gravity by the nnmlxT of ounces of urine passed in
twenty-four hours, iind tli>- pnHlmi liy Till, For example, if IIjc
spiH-itii- gravity is 1,(I2(X and the numtxT of ounces of urine passed
r>0. wi- nuillipiy 2(t x 5ii. whi.h «-.,uals l.(KXt. and this product x 111)
— l.KHi {Trains total solids. Tlu- urea is approximately one-half the
total solids.
Blood Pressure.— Till- Mood pressure of the pregnant woman
in tile i>;irly in.uitlis M'ldi.in ri-^i's al>ovc l;tO millimeters, but in the
liiliT niniilh-. and at tlu- Ih-irinnim: nf labor, the lilotxi pressure is
markedly in.r.'as.^.i. .\ p,rvisi,.nil.v in.-reascd I.lood pres-sure of
IThi niilliiiirii'fs nr hv.t U!i\y \h- iiinsHicrcti as one of the earliest
Marital Relations.— Mjtritiil r.-lalions are to be restricted, par-
tiriilarl.v ni-:ir tin- i)i,!i-Tni;il d.-iirs. an.l strictly interdicted where
there is ;i 1--i),|.n,-y t>.,a'..ni..ii,
Tlif I'arly naTi>i-a ai)il v-uiiiiim: of pregnancy are often a™ra-
SYMPTOMS REQUIRING PHYSICIAN'S ADVICE 111
vated by sexual intercourse. All relations should be positively for-
bidden during the last month of gestation. Non-observance of these
rules may cause abortion, premature labor, and puerperal infection.
Symptoms Which Should Cause the Patient to Seek the Ad-
vice of the Physician. — The pregnant woman should be instructed
that the occurrence of any of the following symptoms may be the
danger signal of an obstetric complication, and should be communi-
cated at once to her physician.
A. Diminution in the amount of the urinary secretion (scanty
urine) to below 50 ounces.
B. Persistent frontal headache.
C. Disturbance of vision.
D. Appearance of edema about the face or swelling of the feet.
E. The presence of persistent constipation.
P. Blood losses from the vagina, however slight.
CHAPTER VI
THE PHYSIOLOGY OF LABOR
The mechanism of labor depends on three factors, i. e., (1) the
expelling powers; (2) the pa.ssages. and (3) the passenger. A nor-
mal relation between these three faetors, acting jointly, produces
what is known as a normal labor.
EXPELLING FORCES
The espeliing foives arc: First, the contractions of the utema;
second, the expeiiing and contractile powers of the abdominal mus-
cles; third, the adiim of the pelvit' floor and its intiuenee on the
meebanism of nonruil liilxir.
Contractions of the Uterus and Abdominal Muscles. — The
contractions of fbc iiteni.s begin in the coniua at the fundus, and
extend over the entire contractile segment. Tlic uterine contrac-
tions are involimtary-. being largely under the control of the sym-
pathetii! nervous system.
The contraction of the miLscular walls of the body of the uterus
is the chief expelling power. These contractions are intermittent
aud recur at intervals of from thirly minutes to , one minute; the
intervals shorten as labor progresses, wliile tbeJr ihiration is from
thirty seconds to a minute or inore.
During eimtracfion the uterus assumes a more or less cylin-
drical form, the fundus is steadied by the round and broad liga-
ments, and held forward against the abdominal wall, and the entire
organ is forced down so that the axis of the uterus is brought into
line with the axis of the bony inlet. Dilation of the lower uterine
segment is accomplished by these uterine contractions, which open
the cervix to permit the expulsiim of the fetus. At the height af
the contraction the woman holds her breath, which fixes the dia-
phragm and increases the intraabdominal pressure, and the simul-
THE PASSAGES 113
taneous contraction of the abdominal muscles, which action is
partly voluntary and partly an involuntary reflex, and helps to
reinforce the uterine contraction and expel the fetus. It will be
seen, therefore, that the chief expelling force is the contraction of
the uterus, which power has been estimated by Duncan at from 50
to 80 pounds, and by Schatz from 17 to 55.
Action of the Pelvic Floor. — The pelvic floor offers a resistance
to the advancing head or presenting part until the moment of ex-
pulsion, when the muscular action of the posterior segment helps
to carry it upward and forward in the direction of the pelvic out-
let. The pelvic floor has a further influence in completing rotation.
THE PASSAGES
The passages through which the fetus must pass in its exit from
the uterus include the hard parts or bony pelvis, which is made up
of the two assa innominata, the sacrum and the coccyx, and the
pelvic soft parts, which consist of the uterus, the vagina, the pelvic
floor, and the several structures which line the bony birth canal.
The Anatomy of the Bony Pelvis. — The pelvis is a bony basin,
which, from the obstetric standpoint, is the most important part of
the parturient canal. It is made up of the two ossa innominata, the
sacrum and the coccyx. It has four joints, the symphysis pubis,
the two sacroiliac joints, and the sacrococcygeal. A slight mobility
of the pubic and sacroiliac joints is present in the latter months of
gestation. The capacity of the pelvis is slightly larger in the gravid
woman, owing to the softening of these joints.
The posture of the patient has some influence on the diameters
of the bony pelvis. When the thighs are extended, as in the
Walcher position, the upper end of the sacrum moves backward,
while the symphysis is lowered and the brim is slightly increased
in its anterior posterior diameter. Flexion of the thighs upgn the
abdomen increases the anterior posterior diamett^r at the outlet, as
by forward flexing of the thighs against the abdominal wall the
lower portion of the sacrum recedes and the anterior posterior
diameter of the outlet is increased. Flexion in an exaggerated
latero-prone posture further increases this diameter.
Recession of the coccyx to the extent of from twelve to twenty-
THE PASSAGES
115
five millimeters (% to 1 inch) occurs at the moment of expuUion,
lis the fetal head paases through the vulva outlet.
The ObBtetric Pelvis. — The obstetric pelvis is divided into the
faise peh'is, or that portion of the pelvis tyin^ above the iliopec-
tineal line which, with the lateral and anterior abdominal walls,
makes a funnel-shaped approach to the true pelvis and the true
pelvis, which is that part of the pelvic basin lying below the ilio-
pectineal line. This line divides the false pelvis from the true pel-
vis, and marks the inlet or entrance to the true pelvis, which is the
part of the bony structures which concerns the obstetrician in the
mechanism of labor.
C;|^p^
i
t-
TnB^^^^^B^
f^
%
^
L^
^
^^^; ^^
r
Fig. 32. — The Pelvic Brim, Showing Landmarks and Diameters.
The Pelvic Brim or Superior Strait. — Several names are applied
to the brim, which is marked by the iliopectineal line and the upper
margin of the sacrum. It is known as the inlet, the superior strait,
the isthmus, or the margin. It is approximately heart-shaped,
though it may be oval or round.
116
THE PHYSIOLOGY OF LAIJOR
On the fen'm are located the several obstetric landmarks, six in
number. (1) the symphysis pubis; (2) the promontory of the sa-
crum; (3 and 4) the right and left sacroiliac joints; and (5 and Gi
the right and left iliopeetineal eininences. These six laDdinitrks
mark the terminals of the principft diameters at the brim.
The pelvic outlet or inferior strait is described as lozenge-shaped
and bounded in front by the summit of the subpubic arch ; pos-
teriorly, by the tip of the sacrum or coccyx; and laterally, by the
two isehial tuherositips. It presents two obtuse-angled triangles
Fig. 33.— Thi
; Oui
) THE Two Im-
with a eotiiiiiou base, the bjsisehia! line; one apex is at the subpubic
angle and the other at the tip of the sacrum ; the lateral boundarie3
of the anterior triangle are made by the pubie rami, while the lat-
eral borders of the posterior triangle are made by the sacrosciatic
ligaments, which, owing 1o their distensibility, allow of a change
in the conlour nf the outli'1. lOJiking it more oval than angular dur-
mg the c.Ximlsiiin (if tlii> livnd.
The Obstetric Landmarks at the Outlet. — The anatomical tand-
niarks at the miflet are: (1) the iip of the coccyx, or more prop-
erly the tip of the sacrum, as the coccyx is a movable point; (2)
the summit of the subpubic arch or the subpubic angle; (3) the
THE PASSAGES 117
two ischial tuberosities; (4) the two ischial spines; (5) the obtura-
tor foramina (two).
These landmarks are, as at the brim, the terminals of the diam-
eters of the outlet.
In addition to these bony landmarks at the outlet, the greater
and the lesser sacrosciatic ligaments complete the circumference of
the inferior strait.
The greater sacrosciatic ligament arises from the posterior-in-
ferior spine of the ilium and from the side of the sacrum and coc-
cyx, and is inserted into the inner surface of the ischial tuberosity.
The lesser sacrosciatic ligament takes its origin from the side of
the sacrum and of the coccyx and passes in front of the greater, and
is inserted into the spine of the ischium. The spaces formed by the
greater and lesser sciatic notches of the ilium and ischium and the
ligaments are known as the greater and lesser sciatic foramina.
The pyriformus muscle, the gluteal, sciatic, and pubic vessels and
nerves pass through the greater sacrosciatic foramen, while the
tendon of the obturator intemus muscle and the internal pubic
vessels and nerves are transmitted through the lesser sacrosciatic
foramen.
The Cavity of the Pelvic Basin, or True Pelvis. — The true pel-
vis is bounded posteriorly by the sacrum and coccyx, anteriorly by
the pubic bones and their rami, and laterally by the lower portions
of the ilia and the bodies, tuberosities, spines, and rami of the ischial
■
bones.
The brim or entrance to the cavity offers its transverse diameter
as the widest, while the greatest diameter at the outlet is the an-
terior posterior. The cavity itself is irregularly cylindrical in
shape. The posterior wall is smooth and concave from above down-
ward, which favors the descent of the presenting part.
The depth of the posterior wall is from 11.5 to 14 centimeters
(4^4 to 6 inches), depending on whether it is measured on the
straight or on the curve of the sacrum and coccyx. The anterior
wall is concave from side to side ; its depth at the symphysis is four
centimeters (1% inches). This concavity from side to side favors
the lateral rotation of the head in its screw-like descent, as it
adjusts itself to the several diameters of the pelvis. The lateral
wall of the cavity of the pelvis is nine centimeters {3y^ inches) in
depth.
U8
THE PHYSIOLOGY OF LABOR
The obturator forameu is bounded by the bodies and rami of
the ischium and pubis, and closed by the obturator membrane ei-
cept at one point, the obturator canal, through which pass the ob-
turator ner\'es and ve^els. One foramen is situated in each an-
terior lateral wall of the pelvis.
The Planes of the Pelvis.— There are three obstetric planes in
the pelvis. The pliuie of the brim is coincident with the obstetric
Thi- ph
,.rih.ih..,i ^•i.
„i Ihr svmi.li\
THE Pelvic Axes.
iiii iiiiiiiTiu;n-\ Miif;i.-f whii-h vuts the iliopectineal line,
u.'iri:iii .'I iho >;i.*rnm. .uid the top of the sjTiiphysis,
rnissi'il In ill/ iliiipiviimiil line. In the erect posture
un I'f Til.' pliiiio nf 111.' I'rini iu the mimrnl pelvis forms
siM\ .hiiii'i-N Willi ihi' liitriam. Faulty inclination dis-
>niKil iii.vhiiiiiNin
■ ,i\il\. .«r miildli- pl;iiu-. i-uts the upper border
lilt' Nil, niiii. 111.- iin.liili' of ibi- posterior surface
ihi>, ;iiiii iv'iiiis .'t'WtsiU' lo the centers of ihe
THE PASSAGES 119
The plane of the outlet cuts the tip of the coccyx, the ischial
tuberosities, and the lower end of the symphysis pubis. Practically
the plaice at which the head escapes from the grasp of the bony
pelvis is a plane cutting the tip of the sacrum and a point just
above the lower end of the symphysis. The sacrosciatic ligaments,
which form the posterior anatomical boundaries of the outlet, yield
somewhat under pressure of the advancing head, so that practically
the outlet becomes ovoid.
At the expulsion of the head from the bony outlet, the shape of
this plane becomes ovoid, with its greatest expansion posteriorly.
The inclination of the plane of the outlet to the horizon is eleven
degrees, the coccyx being two centimeters above the level of the
subpubic arch. In addition to these planes of the bony pelvis, there
is the plane of the dilated soft parts, or the distended vulvovaginal
girdle, the axis of which looks forward.
The pelvic axis represents the course which the fetal head fol-
lows in its descent through the i)elvis in a normal labor. This axis
is made up of the axes of the several cardinal planes, and the planes
between them. The axis of the inlet, if prolonged, would pass
through the tip of the coccyx and the umbilicus. The axis of the
outlet wcmld pass immediately in front of the sacral promontory.
The parturient axis practically conforms to the shape of the sacral
curve.
The Pelvic Diameters and Their Nnmerical Equivalents. —
Diameters op the Brim. — The diameters of the brim are:
1. The conjugata vera. '
2. The diagonal conjugate. 7"
3. The transverse.
4. The two obliques.
The conjugata vera, or true conjugate, is measured from the
center of the promontory of the sacrum to that point on the pos-
terior surface of the upper end of the symphysis pubis which is
crossed by the iliopectineal line. This is the shortest diameter at
the brim through which the head mast pass. It cannot be accu-
rately measured, but is estimated in the normal pelvis at 10.5 to 11
centimeters (4^^ to 4^^ inches).
The diagonal conjugate is measured fnmi the summit of the
.subpubic arch, or the subpubic ligament, to the promontory of the
sacrum; it is from this diameter that we estimate the true con-
jugate.
jaU THE PHYSIOLOGY OF LABOR
To estimate the true conjugate from the diagonal, we deduct
from % to % of au inch (1.5 to 2 ceutimeters). The amount to be
deducted depends (a) on the depth of the sj-mphysis pubis — the
greater the depth the greater mu»t be the allowaoee; (b) on the
thickness of the pubic symphysis, for increase in the thickness in-
creases the allowance to be subtracted; (c) on the iilciinatioii of
the symphysis and the inclination of the brim of the pelvis, for
when the promonton,- is high a greater deduction must be made.
Tke Transverse Diamcitr. — The greatest transverse diameter at
the pelvic brim is the transverse diameter of the pelvis. It begins
at a point on the brim midway between the sacroiliac joint and the
iliopectineal eminence on one side, and terminates at a correspond-
ing point on the opposite side. It measures 13.5 centimeters in the
dried or static pelvis; this diameter is actually shortened bj' V4 "f
au inch (.5 or .7 cm.) in the d.vuamic pelvis by the psoas and iliacus
muscles.
The Oblique Diamctirs of ike Peh-ic Bnm.— The right oblique
diameter begins at the right sacroiliac joint on one side and ter-
minates at the left iliope<.-tiueal eminence on the opposite side, while
the left oblique takes its origin at the left sacroiliac joint, and ends
at the right iliopectineal eminence. These diameters cannot bu
accurately measured in the dynamic pelvis. In the static pelvis
they measure 11!.7 centimeters (i'j to o inches). The left ia short-
euwl by the presence of the rectum and the more or less filled sig-
niiiid. for cnustipatiiiu is ("ommouly present in pregnancy. This
maul's the right oblinue the jielvic diameter of election, which ia
demon St rat 111 by the large pereentage of verleJc presentations in
which the iH-i'ipul ihvupitw a left anterior jxisition engagiog in the
right obliipic diiiim'tcr.
!Ji.\MtrrKK.-i OK TiiK .Mu<iH.K IVvN-E. — The diameters of the mid-
dle plane hiv:
1. The (inlcrior iHuiicrior.
•2. The tninsv.iNc
A. The two obli,|u,'s.
The mi(. rt.ir fUKiUru-r Wgiiis nt the upper margin of the third
sacral vertelira iiinl eiuh itl the iniddto of the posterior surface of
the ajiiiplivMs pubis
The /ntiiM. '*. (.■iiiiiiiiiii-i m twi> (Hiints in the cavity of the
pelvid. cornftjhHuliiip Id Hie lowei- matins of ibe acetabula. The
THE PELVIC DIAMETERS 121
oblique is measured from the center of the greater sacrosciatic fora-
men to the center of the obturator membrane of the opposite side.
These diameters average 11 centimeters (4V2 in.) in the static pel-
vis. The numerical equivalents of these diameters are only approx-
imate.
Diameters op the Outlet. — The diameters of the outlet are:
1. The anterior posterior.
2. The transverse.
3. The two obliques.
The anterior posterior extends from the lower margin of the
sjTnphysis pubis to the tip of the coccyx. Owing to the mobility
of the coccyx, this diameter should properly be measured from the
summit of the subpubic arch to the tip of the sacrum, which is
about 12.5 centimeters or five inches.
The transverse diameter or hisischial is the diameter between the
inner margins of the ischial tuberosities. This distance, to permit
the exit of the head, should average 10 centimeters or 4 inches.
The oblique diameters of the outlet are measured from the middle
of the lower edge of the greater sacrosciatic ligament, on one side,
to the point of junction of the ischial and pubic rami on the oppo-
site. These diameters are of little practical significance, owing to
the distensibility of the sacrosciatic ligaments.
External Dlvmeters and Circumference op the Pelvis. —
These are :
1. The iliospinal (interspinal).
2. The iliocristal ( intercristal ) .
3. The external conjugate (Baudelocque diameter).
4. The external oblique diameter.
5. The pelvic circumference.
The iliospinal or intcrsinnal diameter is the distance between
the anterior superior spines of the crest of the ilium measured
from the outer borders of the sartorius muscles at their origins.
The measurement is approximately 25-26 centimeters (IO-IO14
inches).
The iliocristal or intercristal diameter Ls the distance between
the widest points of the outer ridge of the iliac crests, and is from
28 to 29 centimeters (about 11-11% inches).
The external conjugate is a prolongation of the true conjugate.
It was first described by Baudeloc(iue, and is frequently called the
122 Tli 3 I'llYSrOLOnY OF LABOR ■
Baudelocque iliamitrr. It is nicasiirod, with the patient standing,
from the deiirrgsioi or suh'us just bdow the spinal process of tho
last lumbar vi'ili'hra to the most prominent point on the front of
the syinphyaiH puhiB. The posterior terminal is found by drawing
an iniaginiiry liin- between the two depressions which correspond to
the postcrioi" siii>erior spines of tlie erest of the ilium, which are
the hiteral bordiTs of tho Michaelis rhomboid, and placing oue tip
of the pelviuii'ter V-. ineli above the center of this line, while the
other tip is phu-cd over tlie most promini'iit point on the anterior
surface of lln' symphysis pubis. Tlic ilistauce lietween these points
avcra(:('s ^1 ccntimeti
The i.rtrnial ohtifjut .. mi Ihv posterior superior
spine of the cri'st of tlii' ilium im '• h- I" Ibe Hntcrior superior
spine of the opimsite side. Tlie estenial oblique diameters
sliouhl be of <-(|uiit lengths.
Till' ;ivi'rjii:>- I'Xlernnt rirrumferruce uf the prhis. measureil over
the symphysis jiobis niiil rAiiii, just below tho iliac crests and across
the middle oi' tin- siienuii. i-s about a meter (37 inchcsl.
The I'XtcciiJil iliatiieters in the normal pelvis should bear a con-
sliiiit ri'bitioii t>> lino another. The iliospiiial is always less thnn the
ilioii'islat. bill should iinl be lielnw nini' im-bes when the iliocristal
i-i i.'o Till' I MiiOiil ciniJHgiite should be over seven inches, or 17.5
I 111 ('h;iinrt ^ in Ihe n-bUivc values of th*se diameters suggest pel-
\:.- ,li-.I,..-liot,
Sexual Differences in the Adult Pelns. — The male pelvis is
hi':i\ ■..'!■. ii:i.'!\i-i-. (ii.'[-i' fiomol-sluipiii and li-ss iir.ufful than the
I'l r';a',.' 'Dn' piibi- ;- d.'.^per, ilif puhir an-h narrower, and the
vwb: ..:-■■ •.h.irivr T:..' I'ftual.' pi'lvi-i is laryi'r and shallower,
::-.i ...V :.N ..■ : i-:i!i" .r,i"!i>ri ;- AVf !.';■-_•.;■. \\w Umes liiihter. and
•:..-. y''. - ■■." ^■■■.:Vv T'. .■■'■■■■•!■-. :-..r-> heart-shaiHHl. The
-;. : \ ■• ■ ■ . ■ -■■ - ■ ■ • : ■'.■■ aiitfrior suiK-rior
-■. ■ s .,- ■ V - ■;■■ - .-..^iry is not as fiiunel-
; - - -■,,-■- „-:A hr-vub-r. The
- - - - - :V:!i s,-v,-iity to
- . - - - : ;■• n.vsiiii's are
■ --- I'ovii'i at-l
1 -. is somewhat
THE PASSENGER 123
diminished by the iliacus and psoas muscles. They encroach upon
the lateral margins of the inlet to the extent of a quarter of an
inch or more on each side. The external iliac vessels run along
the inner borders of these muscles.
In the cavity no muscular structures overlie the median portion
of either the anterior or posterior pelvic wall. On either side of
the median section are the pyriformis muscle posteriorly and the
obturator internus anteriorly and laterally; these muscles are too
thin to affect the pelvic diameters.
The outlet of the pelvis is closed by the ])elvic floor or pelvic
diaphragm, which is made up chiefly of muscles and fascial sheets.
These structures have already been described in the chapter on
anatomy.
The Parturient Axis. — The parturient axis is made up of the
axis of the uterus at term, the axes of the several planes of the bony
pelvis, and the axis of the outlet of the soft i)art or vulvovaginal
ring.
The axis of the brim is a line erected perpendicular to the plane
of the inlet at its center. If prolonged, it would pass through the
umbilicus and the coccyx. The axis of the brim is coincident with
the axis of the uterus at term. The axis of the outlet is a line
erected perpendicular to the plane of the outlet at its central point,
which, if prolonged, would cut the lower border of the first piece
of the sacrum. The axis of the outlet of the soft parts, or the vulvo-
vaginal ring, looks directly forward. The child, in its passage from
the uterus through the pelvis and outlet of the pelvic soft parts,
follows, more or lass perfectly, the parturient axis, which is de-
scribed as an irregular parabola.
THE PASSENGER
The passenger or fetus is the third factor in labor upon which
the normality or abnormality of the particular labor depends. The
fetal head, being the largest part of the fetus, is the part which
concerns the obstetrician. The fetal head is divided into the cranial
vault and the cranial base with the face.
The cranial vault is made up of the two parietal, the two frontal,
and the squamous portions of the occipital and temporal boyes.
Their semicartilaginous character, their plasticity, and the mem-
JS^ THE PHYSIOLOGY OF LABOR
branous fontanelles and sutures whieh unite thpm make the eranial
vault malleable. This facilitatps the passage of the head through
the pelvis, and allows it to be molded by the pressure of the walls
of the birth canal.
The cranial base comprises the basilar portion of the occipital,
the petrous portion of the temporal, and the entire sphenoid and
ethmoid btiues. The base is unyiebting. highly ossified, and tlie
holies arp firmly united.
The Sutures of the Cranial Vault. — The sutures, which are
membranous inlerspaces between the iTiinial bones, allow of a cer-
FiG. 35. — Fetal Skui.l.
tain degree of mobility. The following are of obstetrical impor-
tance :
(1) The fmnliil or the iuterl'rontal, between the two frontal
(2) The interparietiil or sagittal, between the two pariet&l
bones.
(3) The coronal or frontal-parietal, between the frontal s
parietal bones.
(4) The lamboidal or oeeipito-parietal, between the occ
and parietal bones.
(5) The temporal-parietal, between the squamous
the temporal arv]
1
DIAMETERS OF FETAL HEAD 125
At each end of the sagittal suture there is formed a membranous
space hetween the angles of the adjacent hones, which is known as
a fanfancUe. The one at the anterior end is known as the iregma
or anterior fontanelle, the one at the occipital end of the sagittal
suture is known as the posterior fontanelle. Each of these has
distinguishing characteristics, which are of obstetrical importance
in determining position and posture.
The anterior fontanelle or bregma, first, is quadrangular in
sHiape, with the most acute angle pointing forward. This angle be-
comes continuous with the interfrontal suture.
Second, it has four sutures running into it.
Third, it is a distinct membranous space, the transverse diam-
eter of which is about one inch.
The posterior fontanelle is found at the occipital end of the
sagittal suture. It is distinguished by having, first, three lines of
suture running into it; second, it is characterized by the depress-
ibility of the squamous portion of the occipital bone, which is tri-
angular, and is hinged on the basilar portion and can be depressed
so that the examining finger comes into the acute angle formed by
the parietal bones.
The cranial vault is divided into three regions, i. e., the vertex^
the occiput, and the sinciput.
The vertex or crown is that portion of the cranial vault lying
l)etween the anterior and posterior fontanelles, and extending lat-
erally to the parietal protuberances.
The occiput is that portion of the cranium which lies behind the
posterior fontanelle, while the sinciput includes the forehead and is
bounded posteriorly by the coronal suture, anteriorly by the orbital
ridges and root of the nose.
The cranial bones present five protuberances which are impor-
tant as landmarks: the parietal eminences, or protuberances at the
center of each parietal bone, which mark the lateral limits of the
vertex ; the occipital protuberance, which is located about one inch
behind the posterior fontanelle, and is of importance because it is
a terminal of the occipito-frontal and occi[)ito-mental diameters ;
the frontal eminences or protuberances, which are elevations
found in the center of each frontal bone and mark the summit of
the forehead.
The Diameters and Circumferences of the Fetal Head. — The
1A
126
THE PHYSIOLOGY OF LAliOR
diameters of the fetal head are of iraportaiiee because of their re-
lation to the diameters of the peivia during the passage of the head
through the hirth canal.
The biparhtal diamettr is the greatest transverse diameter of
the cranial vault. It is the distance between the parietal eminenees.
Its average numerical eijuivalent is 9.5 cm. {S'/i; inches).
Fig. 3fl.-RE(:iijv.s
I Di
=■ THE Fetal Skl'll.
llii- di.slanco from the center of
I hi' summit of the forehead— 9.5
The frontu-mcilal iVam.l
the lower margin of the chii
cm. (3^,^ inches).
The occipitii'froula! diameter e.xteiids from the occipital pro-
tuberance to the root of the nosi', and is 12 rm. (4% inches).
The (iccip-ito-mriilal diaiiifler is tlie longest diameter of the fetal
head and terminates at the oeeipitnl protuberance and the center of
the lower margin of the ehin. Its uumerical value is 13.5 cm. (5^4
inches).
TRUNK DIAMETERS 127
The suboccipitO'hregmaiic diameter is the distance from the
junction of the nucha and the occiput, which is found just behind
and below the occipital protuberance to the center of the bregma.
Its value is 9.5 cm. (3^ inches).
The hitemporal diameter is the distance between the lower ex-
tremities of the coronal suture. Its average value is 8 cm. (3^8
inches).
The himastoid diameter is the greatest distance between the
mastoid apophyses. Its length is 7 cm. (2% inches).
There are three circumferences to the fetal head. The sub-
occipitO'hregmatic passes through the terminals of the biparietal
and suboccipito-bregmatic diameters, and is the greatest circum-
ference of the flexed head. Its value is 33 cm. (13 inches), being
somewhat less in female children.
The trachelO'bregmatic circumference is the greatest circumfer-
ence of the extended head. This circumference passes through the
bregma and the front of the neck just above the larynx, and has
approximately the same value as that of the suboccipito-bregmatic.
The occipitO' frontal circumference is the greatest circumference
of the vault, which is 34.5 cm. (13V2 inches).
SUMMARY OP THE HEAD DIAMETERS
Diameters of approximately 9.5 cm. or Sy^ inches:
Biparietal.
Suboccipito-bregmatic.
Trachelo-bregmatic.
Pronto-mental.
Diameters above 9.5 centimeters:
Occipito-frontal 12
Occipito-mental 13.5
Diameters below 9.5 centimeters:
Biparietal 8
Bimastoid 7
Trunk Diameters. — The diameters of the fetal body are com-
pressible, and hence relatively smaller than those of the cranium.
Two are of obstetric importance.
128 TI 3 PHYfilOLOGY OF LABOR
The hisacromicl, whicti is the greatest transverse diameter of
the sbouUlers, has i. value of 12 em. (4% inelies}.
The biglrochanteric, or the distauet' between the trochanten,
8.8 cm. (31,1; inchei).
THE PRESENTATION AND POSTURE OF THE PETUS
i
(a) riv.scdlatioii.
(b) I'ostiiro.
(e) I'oNition.
PreBentation.— Preset. tatiou of tin- hint) axis of
(he fiial ovvid to the lotigiludina' of the vlirtis. Wlien the
long axis of the fetal ovoid ia ident with, or parallel to,
the uteriiie axis, the presentation is spoken of as a lougitudinal
presentation. On the other hand, when tlie axis of the fetiis bean
a transverse or oblique relation to the axis of the uterus, it is called
a transverse pri^sentation. Longitudinal presentations are sub-
divided into po<lalic and cephalic: potlalic when the breech pre-
sents: cephalic when the head presents.
The prfstiiling part is that portion of the fetal ovoid which
offers itself to the examining linger, and is felt throngh the cervical
ring on vaginal examination. Conseijuently, when we have a longi-
tndiniil present ii I ion, there may be two varietios: (a) Cephalic, in
which the presMjlinj,' pai-l mjty be either the vertex, the brow, or
the face; (b) iKidalie. in whieh the prL-sunting part may be the
Im-ccli. Ihc knee, or the twit.
AViicn llie I'clus lies willi its hinnUudinal axis transverse or
obli'iin III thill of Ihc ji/tus. Ihi i>nsi ,iliili-i< la transverse, while
the iircscriliii^' p;ii-t niMv be eitiii-r the slii.iildcr, the elbow, or the
hand.
At ti-nii tlic I'ctiis prcMiils }.y fh.> hcikl in iib.nit !»f> per cent, of
tlic .-iist-s. by llic \iv-i-rh ill :! jmi- <-i'tit.. wliilf it is l"oun<l lying trans-
vei'sely in only iibuut 1 jicr .-cut. Tli<> face oi' the brow is the
presenting |.ai't in a little less tiniri f. |() |.ei' eenl. of ec|)balic births.
The iargi- pre|,(»iuieraii<-e <>i ee|.liali.- |.resentat ions is due to adap-
tation, as til.- felul ni;iss ;ineni|ils In iie,-,iiiiiLH»liite itself to the
shajie of tlle ulenis,
Posttire. — I'iisliLre iii;iy )>e lielio.'ii as Die villi Mil which Ibe fetal
PRESENTATION AND POSTURE OF FETUS 129
parts bear to one another. In order that the fetus may adapt itself
to the ovoid shape of the uterine cavity the head becomes flexed on
the body, the thighs on the abdomen, the legs on the thighs, while
the arms are usually carried over the thorax, and the back shows
a marked convexity. The normal posture of the fetus in utero is
one of flexion.
The posture of the fetus is determined b}- the posture of the
head as shown by the presenting part. When the vertex is the pre-
senting part, the posture is one of flexion. When the face presents,
the posture is that of extension. When the brow is the presenting
part the head is in semi-extension. Complete flexion is present
when, on vaginal examination, the posterior fontanelle is found on
a lower plane in the pelvis than the anterior. When the anterior
and posterior fontanelles are on the same level, the head is semi-
flexed.
Position. — Position may be defined as the relation of the pre-
senting part to the quadrants of the pelvic brim. These quadrants
are designated, anterior left, anterior right, posterior right, pos-
terior left. They correspond to the terminals of the two oblique
diameters at the brim, wliich are the diameters by which the pre-
senting part enters the pelvic cavity.
Positions are named according to the particular quadrant which
is occupied by the leading anatomical landmark on the presenting
part, or from the relation which this anatomical landmark on the
presenting part bears to the terminal of the oblique diameter by
which it enters. In illustration, when the occiput, which is the lead-
ing pole of the flexed head, occupies the left anterior quadrant or
confronts the left acetabulum, it is called a first position or left
occipito-anterior ; left, because it is to the mother's left; anterior,
because it points to the mother's front ; oecipito, because this is the
anatomical landmark which occupies this quadrant and confronts
the landmark on the pelvic brim.
When the occiput occupies the right anterior quadrant or looks
toward the right anterior landmark, it is a right occipito-anterior.
In the same way it may be a right occipito-posterior, or a left oeci-
pito-posterior. Right and left, anterior and posterior refer to the
mother.
When the face is the presenting part, the chin is the leading
pole or anatomical landmark. Face positions are named from the
130 Til ■: IMIYSIUlAKiY OF LABOR
roktion which the chin boira to tlie quadrant of the pelvis which
it iMiuiipiiw,
IJrtvoh pnaitioiis nre named with reference to the direction of
the sm't-um. >Vlieii the sai-ruiu of the ehild eonfronts or ooeupiea
the left anterior i|iindraiit, it is called a left aaero-auterior ; when
it hwks towuitl. or iM-einiies, the riglit anterior quadrnnt, it is named
a riphi saero-aiiterior, letc, Shoulder positions are named from the
rt'lnlion whieh the senpula has to tlte quadrant at the mother's
hrini.
We have, tlierefor sitions with their relatiVB
fretiuein-y.
irt'fl or^ipilo-antrri ' percent.
Ri^hl oet'ipito-ante. 10 per e«iit.
Kiiihl (nvipiiivpoKierior, IT per eeol.
i^'fl «»eei pit o- posterior, 3 per cent,
i>it) ihK it will h- «et'H thai lhi> hexd selerts tb« i
:er in ST [ht v«it. \\t 3i\ wrtes eases.
l.fft mewti.*-
Kijrfit ;Keuti»-«uterk>r
PRESENTATION AND POSTURE OP FETUS 131
Frequently in shoulder positions there is by vaginal examina-
tion no presenting part available until labor is well advanced, or
the membranes have ruptured, hence we must diagnose shoulder
eases by our abdominal findings, i. e., by the location of the head
and the location of the fetal dorsum. A shoulder case is designated
as right or left, depending on whether the head occupies the right
or the left iliac fossa ; anterior or posterior depending on the rela-
tion which the dorsum of the fetus bears to the mother — anterior
when it faces the mother's front, posterior when it lies to the
mother's back.
/■HAI'TElt VII I
TIIK MKfHANUM AND MANAGEMENT OP NORMAL LABOB
Xorninl HiiIhii' way be (Ictiiied as a liibor iu which the mechanical
ftu'tors. i. t'., I III' |Hi vt>rs, llie passagi's. huiI the passeager, are DOrnul
or it'hnivi'ly nnnrui I. Any licl'wt in thi'se mechanical factara. whidi
offers ohstmi'tliiii ti) the jirt)^^^^! of labor, whether it be inertia or
inotVii-ioncy im I In' part of the ttterine muscle, an anomaly in the
IH'ivis. or a nialiiositiou of the fetus, nnxlueiag dj-stocia. makes tlw
lalMir {Hlthtitocica! : al labor roust have do eip-
nicnl of liysiiK'ia 1| ider as normal ooly vertci
births, in thi> lirst p ipito-anterior cases.
l^iU>r is a iiaiural |tri-. he noman expek from her
utiTUs the Dinturcit UVUin. It t<i «]' - inln three stages:
Thf rirst f'ti.;,- i.'r AtafK of dU \ W^ms with the first Wiw
)>.i:n ;i:ul I'liili uttli th<^ vumplete cauialtzatiou of the cerrix.
The .« , Mii !>lmtf {w stwpf of w^ptilxiiiif be^DS wh4!D tbe eervix
is «.v;n;'L:iI,v ililatoj and rrnniaat«« with the espufej«« of the ehUd
T:\- •"■ii/ iir i44tettml tta^ iarlihJf-s the dclircnr of the re-
n:,f.- u r o;' :b. ovuia. i. c . th.- placenta and its mr-mbranes sad the
The Causes of Uw Onset of Labor. — Why liKir ojaallr beciia
'.'■ ■ i i-iTl'.ty d.iys aiior tne nr« aay oi lAe ian f
-■- . . : ,i ■^■.- v.lv iii'v^u. Thi? prvbable eansrs am the
■ . - ,. - ; ::-.; -v.-,::; ir. :r.^ :.t:er w?^^fcs of fvstatioa; At
■ ■■-■ ■ — ■,■-:-■■.--■ ■,■•■■-■0.: '.b.-i -jir'a-o-re of period-
- - ■ : ■ -^ - ■ - - :''- iistentxio of the
., ■ - ■ - ■ .--,.■-■- --,----r-^ aioii^te: th«
- ■■ - ZL'iM-lf : tfaie in-
.--.., - - - -i->-s. of --or-
SIGNS OF THE ONSET OF LABOR 133
the intermittent contractions of the uterus in their preparation of
the cervical zone.
The growth of the ovum, which becomes a foreign body, fur-
nishes a sufficient stimulus for continued muscular efforts, and,
finally, the unconscious memory of tissue transmitted from genera-
tion to generation plays an important role in the causation of labor.
Signs of the Onset of Labor. — The signs of the onset of labor
are:
(1) Lightening.
(2) The irritability of the bladder and rectum.
(3) The increased flow of the vaginal and cervical mucus.
(4) The show (a bloody discharge from the vagina).
(5) The expulsion of the cervical plug.
(6) The occurrence of rhythmic uterine contractions.
Three of these signs indicate that labor has actually begun, i. e.,
(1) The regular recurrence of uterine contractions; (2) the escape
of blood-tinged mucus from the vagina; and (3) the dilation of
the cervical os.
By lightening we understand the sinking of the uterus into the
pelvis, which takes place from ten to fourteen days before labor
actually begins, provided there is no defect in the powers or dis-
proportion between the passage and the passenger. The uterus,
with the presenting part, sinks more deeply into the pelvis; the
waistline becomes smaller. As the uterus settles lower in the pelvis
the pressure on the bladder and rectum is increased, and these vis-
cera become irritable, and are evacuated oftener than is the habit
of the individual.
In the primipara the presenting part actually engages in the
pelvic brim as a result of lightening, while in the multiparous
%voman the uterus falls forward, the fundus becomes lower as the
uterus assumes the axis of the brim.
With the onset of actual labor urination and defecation become
still more frequent, and there is a profuse secretion of vaginal and
cervical mucus. As the cervix begins to dilate, the ovum separates
from the lower segment, blood escapes, becomes mixed with this
cervical mucus, and produces what is known as the show (blood-
stained mucus).
As referred to above, the most reliable evidence of beginning
labor is the occurrence of rhythmic uterine contractions, found by
134 NORMAL I.AHOR
placing the esamining hand upon Ihp abdomen of the n'omaa and
feeling the uterus contract. These gradually increase in severity
until they become actual labor jjains, which arc painful uterine
contractions, dttc to pressure of the uterine muscle oh the uene
plaments in the uterus and the nerves in the pelvic cavity. These
contractions occur at regular intervals, which, at the beginning of
labor, may be tweuty or thirty minutes apart. The iutervat
shortens as tabor ])rogresses, until the contractions recur at min-
ute intervals at the acme of expulsion. The duration of the labor
paiu is from thirty to sixty seconds, the intensity progressively in-
creasing until the maximum is reached, as the head is expelled
from the vaginal outlet.
THE STAGE OF DILATION OF THE CERVIX
The first stage of labor includes the dilation of the cervix, and
i.s not complete until the external os is suflicienlly dilated to admit
of the passage of the child. During labor, as the result of the uter-
ine contractions, there are developed two distinct portions of the
uterus, which are separated from one anotiior by the retraction
riitg. The upper segment is the active contractile portion and
Fhickens as tlie labor advances, while the lower segment beeomea
thinned out and opens to alhiw the passage of the child.
Tlie agencies which are concerned in this dilation of the cervix
and Ibinuiug of the lower segmcnl iirc:
(1) The traction of the !oTij.'iludlTi;il libers of the u]iiier uterine
or cdntniclil.' segment,
(1^1 The bydn,,sl;iti<- lu-tu,,, n[ lln- biiu' nf wafers.
fU) The sul'leiiirj;.' ni 111,. iTivind ^1ru,■lll^.•.s liy serous infil-
tration.
(4) The .hluUuu cif the eriTiN, wliieli iiiiiy he divided into two
|iarts:
(n) Tin- alilitiTiLlinii (if tlir r'ariai, whiili i'lTii<-es the internal os
;itid shorh'ns the v.m-:(ii!iI i^niHi.Ti nf lln- m-vis.
lb) Thl- diklli.i ■ Ili.. rNl,.MIi,l ns.
Action of the Longitudinal Muscular Fibers.— The traction of
the hmgitudinal filnTs nl' tbe up|ier segment of the uterus draws
the lower scguicnt upward over llie presenting portion of the ovum.
The obliteration occurs from above downward, beginning at the os
STAGE OP DILATION
135
internum. With the first oceurrence of active labor pains, the ovum
is partially detached from the lower uterine segment. The internal
OS expands, and the detached bag of waters protrudes into the cer-
vical zone, making the cervical canal funnel-shaped and increasing
its depth and width during the pains. In the intervals between
pains the cervical canal partially regains its cylindrical form until
the internal os has been permanently effaced.
VVv'
^^W
Fig. 37. — Dilation of the Cervix.
After the cervical canal has become obliterated, dilation of
the external os occurs, and the progress of labor is indicated by the
degree of canalization. This process differs, depending on whether
the w^oman is a primipara or has already borne children. In the
multipara the dilation is nearly uniform throughout its extent,
while in the primipara the obliteration takes place as has already
186
NORMAL LABOR
been described, atid complete dilatian of the external oa tuoaU]'
follows.
Wlipn the entire 08 and vaginal portion of the cervix have been
completely effiii'cd the second stage begins.
The Ba^ of Waters.^The bag of waters is that portion of the
fetal sac. i\n: membranous envelope, which in the course of labor
protrudes downward into the cervical canal and acts as a dilating
fluid wedge during eaeh labor pain.
The eontained liquor nmnii is divjded into the "fore waters"
and "hind waters" by the ball valve
"fore waters" is thai
of the head or preaentinu ,
waters as Ihe lieiid is driven
ion of the fetal head. The
tiiiied liquor amnii in front
artly cut off from the hind
.IT uterine segment diiriii!;
a pain. By the "hall
valve" action of the head
tile force of each uterine
contraction, which is
Iransmitted to the liquor
atiinii. is lessened as it
ivaeiies the fore waters.
and the protruding bag
i.s not only urged down-
wanl, but exerts an ex-
[laiisive force upon the
walls of the passive cer-
vical canal. The fore
waters are "watch glass"
in shape when the ver-
tex is the presenting
part; "glove finger" in
case there is malposition.
r,[alpositions and mal-
IH'cseiitatioiis favor early
nqiture of the mem-
branes, as the full force
of Uh' ycni'ral uterine
['[■issur.- i.s applied to the
i\[n-\ of Ihe dilating
wiilge liming a pain, un-
STAGE OP DILATION
137
less the pelvis is blocked and the force lessened by the "ball
valve" action of the head. When the membranes rupture pre-
maturely dilation of the cervix goes on more slowly and is
more painful, for the fetal head is not as good a dilator as the
elastic fluid wedge, the
bag of waters, with its
equable pressure. The
dilation is yet more
tedious when there are
ma 1 presentations or mal-
positions, by reason of
the greater inequality of
pressure on the different
parts of the girdle of re-
sistance.
Complete canalization
of the cervix is obtained
by the careful preserva-
tion of the membranes
until they protrude at
the vulvar orifice. The
membranes rupture usu-
ally by the time they
reach the pelvic floor,
though occasionally only
after the head has es-
caped.
' Cervical disease, such
as chronic endocervicitis,
malpresentations or frequent and indelicate vaginal examinatiouB,
favor early rupture, which is termed "breaking the waters."
Softening of the Cervix. — The softening of the cervix is a
prc^ressive process beginning early in pregnancy. Near term the
development of the uterus increases the size of the blood vessels of
the cervix, especially the veins, which, during a pain, when the
walls of the uterus are everywhere compressed by contraction upon
its contents, are unsupported by pressure, and become markedly
engorged. A serous transudation takes place into the cellular tis-
sues, loosening its structure, making it more dilatable.
Fig. 3il. — Complete Canalization op thi
Uterocervicai. Zone.
138 NORMAL LABOR
Dilation of the Cervix. — The retraction ring, or ring of Bandl,
is the line of demarcation between the thickened upper segment of
the uterus and the thinned out lower segment, which becomes de-
fined during a pain. It is developed during the first stage of labor,
as during each contraction of the uterus there is a retraction of the
circular muscular fibers into the upper segment of the uterus, caus-
ing it to become thickened, while the lower segment becomes cor-
respondingly thinned. The retraction or contraction ring rises
higher on the uterus in proportion to the number and the strength
of the pains. While it is demonstrable in every labor during a pain,
near the end of the first stage it becomes more apparent, and its
presence has more significance in connection with fetal or pelvic
dystociie. According to Schroeder and others, the lower uterine
segment is developed in part from the cervix, in part from the
lower portion of the corpus uteri.
During the latter part of the first stage of labor the posterior
wall of the bladder and the anterior or pubic segment of the pelvic
fioor are dra\NTi up as the presenting jiart descends lower in the
pelvis and dilation progresses. The elevation of these structures is
more marked as the head escapes from the uterus. The bladder is
thus lifted partly out of the lesser pelvis away from injurious pres-
sure ; only a small portion of the organ rises above the level of the
. pubic bones; the length of the urethra remains unchanged.
The duration of the stage of dilation is from two or three hours
to several days. The average length of this stage in the primipara
is sixteen hours; in the multipara eleven hours.
STAGE OF EXPULSION
The second stage of labor, or the stage of expulsion, begins when
the head passes through the dilated cervix and terminates with the
expulsion of the child. It is during this stage that the fetus under-
goes a series of passive movements, in the course of its passage
through the bony birth canal, which are described as the mechanism
of labor. These pavssivo movements are necessitated by the fact
that the engaging diameters of the head are larger than those of
any other part of the fetal mass. Therefore, the essential mechan-
ical phenomena of the stage of expulsion are those pertaining to the
birth of the head.
STAGE OF EXPULSION 139
The Birth of the Head. — The fetal head is an irregular ovoid
body, with two leading poles, an occipital and mental process,
whose long axis is greater than any of the inlet diameters of the
pelvis, while its transverse diameter is about equal to those of the
pelvic-brim cavity and outlet and, in typical labor, tightly fits the
birth canal. To enter the brim the head must flex upon the body
in order that the occipital pole may pass into the superior strait.
The essential cause of the head movements is the adaptation of
the head to the varying shape and course of the birth canal. The
movements which the head describes in its course are descent,
flexion, rotation, extension, resiitutiony and external rotation. Res-
titution and external rotation are additional movements which the
head takes after it escapes from the vulva in consequence of the
spiral motion of the trunk and consequent twisting of the neck in
the course of its descent.
Descent does not actually take place until the stage of expulsion,
as before this time, when the waters are intact, the expellent force
of the uterine contraction is transmitted to the head through the
entire uterine contents. When dilation is complete and the mem-
branes have ruptured, allowing the escape of more or less fluid, the
propelling force of the uterine contraction, supplemented by the
action of the abdominal muscles, acts directly upon the fetus, pro-
pelling it along in the direction of least resistance, through the
course of the birth canal. The descent is a progressive process and
is coincident with the other steps of the mechanism. The head ad-
vances with the pains and recedes in the intervals. Under normal
conditions, i. e., a proper relation between the size of the head and
the pelvis, the advance and recession continue till the head is well
in the grasp of the vulvar ring. It is partly due to this phenome-
non that sufficient dilation of the soft passages is attained to allow
of the passage of the child without extensive laceration.
Flexion. — During pregnancy, in order to conform to the shape
of the uterus and bring the long diameter of the cephalic ellipsoid
into conformity with the long diameter of the uterus, the fetus
assumes a posture of flexion, which is the normal posture of the
fetus in utero. This primary flexion is incroastHl as the descent
begins. The head is so hinged upon the trunk that the occipito-
frontal diameter of the skull corresponds to a lever of unequal
arms, the frontal arm being the longer. When labor i)ains occur,
140
NORtifAL LABOR
and the head is forced down into tlie uteroeervieal zone, equal
resistance is met with at both ends of the lever, but owing to the
frontal arm being the longer the upward resistance acts with
greater effect and the ehiu is forced up against the sternum. The
flexion is still more increased when the head encounters the greater
resistance of the bony canal. By the attainment of complete flexion,
whieli is only possible when all of the factors of labor are acting
harmoniously, the subocci[>ito-bregitiatie diameter of 9.5 cm,, is sub-
stituted for the occipitofrontal of 12 cm., which makes it possible
for the head to pass into the pelvic inlet and become engaged,
which means that tJie siibocfipitii-bregmatie circumference, the
largest circumference of the flexed head, has passed into the brim.
The head undergoes slill fiirtlu-r iLci-oiiiiiinihitinn to the passages
by the process of molding, due to tlie uiajleiihility of the cranial
STAGE OF EXPULSION
141
in the longest diameter which is available for its passage, i. e., the
right or left oblique. At the outlet, however, the longest diameter
available for its exit is. the antero posterior. The head, therefore,
as it descends, must rotate about the axi.s of the birth eanal to keep
its longest engaging diameter constantly in the longest diameter of
the pelvis during its passage through it.
(^^fe:^
Via. i\. — Relation OF Fio. 42.^Relation of Fig. 43. — Completb
THE Sagittal SuTi'RE the Sagittal Suture Anterior Rotation,
IN Right Occipito- in Right Occipito- Sagittal Suture at
ANTERIOR at THE ANTERIOR IN CaVITY. OL'TLET.
Briu.
The lateral halves of the pelvic floor shunt downward and in-
ward toward the raeditm line. In normal labor, as the head passes
the brim in complete flexion, the occipital pole of the cephalic ellip-
soid first strikes the lateral half of the pelvic floor, and, as it de-
scends, it is guided forward and inward beneath the subpubic arch.
/( will be seen, therefore, that perfect flexion, a firm pelvic floor,
and efficient labor pains are essential to the completion of forward
rotation of the occiput. The relation which the sagittal suture
bears to the diameters of the pelvis during the descent of the head
from the brim to the vulvar outlet is the obstetric index of the de-
gree of rotation, for rotation has not been completed until the sa-
gittal suture of the fetal head is approximalehj parallel with the
anteroposterior diameter of the pelvic outlet. Clinieally, however,
complete rotation is seldom observed, as the head is usually ex-
pelled in a position slightly oblique to the median anteroposterior
plane of the parturient outlet.
Id addition to complete tiexion. molding of the head and the
development of the caput suceedaneum (an edematous swelling de-
142 NORMAL LABOR
veloped upon tht presenting part of the fetua after mpture
of the membrane) tend to promote rotation by inerenHing tiip
dip of the occipital pole. When the occiput has Huuk betotr
the level of the pubic arch, its further forward rotation is
due partly to the Fact that it follows the direction of Itiast resist-
ance.
Extension. — After tlie occiput has escaped beneath the pubic
arch, and the suboccipito-brcgmatie eirc.uiufercnee is in the grasp
of the vulvar ring, further advance in flexion becomes impassible,
owing to the arrt'st of tlie Bhoiihk'rs by the pubic rami and tlie
contour of the soft F h\T\\\ ciiual. The nape of
the neck resti against lu'. nenf. and the head rotates
upon the nucha as a piviital r - is born by a movement of
extension, the vertex (suboc ^matic circumference), tbe
forcheiid (subncuij)! to- frontal ^.. ferenee), and the face (sub-
occipito-niental circumference) successively passing through the
vulvar ring and sweeping over the perineum. The chin tloea not
leave the stermun uutil the moment of pspulsinn. There is iistuillf
n brief pause f-illmviug the liirth iif the liead. during which rettiiw-
ihii takes place.
7;(.s/,7(W(V-».— Restitution is the untwisling of the neck whici
takes |>ljiee after tbe head is burn, which allows the head to take a
position eor res] ton ding to that in which it entered tbe pelvis. Tliii
step of the meebanisni is bronght about by the shoulders descending
into the pelvi:* and engaging in the oblique diameter opposite to
tlial in wliieli the head engageii. This results in a certain degree
(if torsiiiii of file neck, as the forward rotation of the head takes
place in its descent through the pelvis. Therefore, when ike head
is bom. Ilir iiith uiilwials. and tiie movement is termed restitution.
Tbe iKisilii.u wliieh llie hi ad tiiki-s after lis birth, if left to itself.
eiJiiliriiis the dpiigimsis nC ils |">.-,iiiii[i :is ni^Mie liy vaiiinal cxainins-
tii.h prior to delivery.
h:.,l.,-,i(ii ri.h,li-ii is :i still fuiHier rotation of tlie head after its
ilelivery, wbieb is ulKernd dllHli',' tbe expulsion of tbe l.od.v. It
oei-ilJ-s i Iiseqilellee of tile spiral tii.Helnellt of Ibc trunk as It
follows the rniirse ,.{ ibe |>el\ ie ralial ill tile several steps of tlic
Mieeliaiiism, ivliieb aiv less |.erl'eH tliaii those followed by the
bead.
The Birth of the Trunk. - 'i'lie shoulders ami the breech sue-
STAGE OF EXPULSION 143
cessively engage in the oblique diameter of the brim and rotate into
the anteroposterior diameter of the outlet, but they descend
through the pelvis with a less perfect mechanism than that followed
by the head.
Since the shoulders and breech enter the brim of the pelvis in
the opposite oblique diameter to that taken by the head, the rota-
tion, imperfect as it is, takes place in a direction opposite to that
taken by the head. The anterior shoulder is asually expelled first,
or it lodges behind the pubic bone and acts as a pivotal point about
which the posterior shoulder rotates. In which case the posterior
shoulder first appears at the ostium vagina? and escapes over the
perineum.
A gush of bloody water, the discharge of the *Miind waters,"
generally accompanies the birth of the trunk.
Other phenomena having to do with mechanism are the forma-
tion of the ca])ut succedaueum and the molding of the head, which
takes place under the pressure of the pelvic walls.
As referred to above, the caj)ut succedaneum is an edematous
swelling developed upon the presenting part of the fetus after the
membranes have ruptured.
In a cephalic presentation the caput forms on the part of the
head below the girdle of resistance (the dilating cervix). The
vessels, which at this point are unsupported by pressure during the
uterine contractions, become engorged, a serous infiltration of the
unsupported tissues takes place, and an edematous tumor develops.
Tlie size of the tumor depends on the strength of the pains and the
length of the labor. Early rupture of the membranes in primipane
is always complicated by large caput formations. Its location
differs with the position in which the head has entered the pel-
vis, and, therefore, has a value in confirming the interpartal
<liagnosis.
In left occipito-anterior positions the caput forms on the right
posterior parietal region, while when the occiput has entcnd in a
light anterior pasition the caput will be found on the left posterior
parietal region. On the other hand, when the head has entered as
a right oecipito-posterior, the edematous tumor appears upon the
lt»ft anterior, and in the left occ«])it()- posterior upon the right an-
terior parietal region. A long dehiyed second stage, in which the
heail hiis rested for several hours in the lower portion of the birth
144
NORMAL LAUOR
canal without com ileting its rotiitiim. tends to modify the loeatkn
at which the ea|)uf is found.
Molding of the lieatl is due to (he plaatk-ity of the cranial vault,
The head adapts it olf to the pelvic hones hy molding, during whicli
process the ovoid imder the pressure of the pelvic walls may dimin-
ish in ifsi engapiinj; eircuinferenee. while the long axis of tbe ovoid
is correspondingly increased and the head is elongated in the direc-
tion of tin; birth canal. This Is particularly marked when there i«
a slight di.sproportion between a malleable head and the pelvis it
has to pjiss through.
The last step i
occiput fscapcH from tiie .
t!'.e soft parls. the piwtcrior or
stretchc't «ind pushed dowuwj
vancing li.vid. Its length, froi..
.sure, becomes markedly increased, i
lie perineal stage. As Uie
i approaches the outlet of
,,mcnt of the pelvic floor in
'nnvard in front of the ad-
, jceyx to the posterior commis-
that at the moment of cicpiil-
1 it measures 13 cm. (5' or G inches). The sphincter ani is
rclaxe<l. the anal orifice becomes D-shapcd and gapes widely, and
feces are expelled from the rectum as the head is pushed out
over the stretched pelvic Door. The head escapes from the vul-
vovaginal orifice by the fluboccipito-breginatie. suboecipito-frontal.
and suboccipilo-nii'iilii! circuiLifercnccs. and. as it escapes the
posterior
face.
lit of the tlonr, pi-oiiiptlj- retracts over the
ISC iillcniinii should be iriven to the fetal licart and the ma-
piilM' and tciii|icriitiirc iluriiig the sc<-<)iid stage of labor. It
I- noted lliaf i)niiii;i!ly tile iiiiiletiiiil [>iilsu rate is somewhat
-ii(ed dining the |i;iiiis. Iiiil in Hie intervals between the pains
lid rea.-^Miine llie iiiiiin:il, A pnigressivi'ly (piiekcncd pulse,
llie ivoiiiiin is ;if j-esl, slious i'litiu'iie. Tile maternal tempera-
geiieiMlly v:\Ui-d ;i rieu'tee or Hiori; during labor; the elevation
gilt of the pain, owing
■nlonged labor or early
to greater circulatory
eiri'iilation.
s aiioiit two hours in
■. Ilininrh it may be as
PLACENTAL STAGE
THE PLACENTAL STAGE OR THIRD STAGE OF LABOR
Three distinct physiological events take place in the third stage
of labor:
I. The separation of the placenta.
II. The expulsion of the placenta, the membranes, and
blood clots.
in. The retraction of the uterus.
The placenta is separated from its uterine attachment in the
meshy layer of the decidua by the sudden contraction of the pla-
cental site due to the retraction of the uterus, which takes place on
the expulsion of the fetus and liquor amnii. Further contraction
Fig. 44. — Diaorah Illustrating Separation of Placenta. Extru-
sion Bt Fbtai, Surface. Sclmltze'a Klechanism.
of the placental site continues as the uterus retracts. Its loosening
is also partly due to the extrudinf' force of the uterine rontractions.
There is a moderate bieetlingin the intervals between contractions
until the separation is complete. After the phii'i-iita i.s completely
separated, its expulsion is effei-ted by the expeliiuK force of the
uterine contractions, which recur at three to five-minute intervals.
146
\0R5IAL LABOR
The placenta i,i expelled tlirougli the rent in the membranes,
through which the child has already escaped, like an inverted um-
brella, dragging Ihc laembnines after it and peeling them off from
the uterine wall. H uiay present by its aiiiniotie or fetal surface
1-1.1. 4,->.-^Kxi
,- !■■(;
•oliuitw's .Meehuiiisni.
(SiliTilizi's nifehiniisiiO, or it may be fohieil on itself and be ex-
pi'lli'il I'dp' lirst iDunciin's iinvhiinisiiiK It is probable that the ex-
iriisivi' force of tlic iiT>*rinc I'lintnu-lion is sutticii-nt to propel it
ihroujiii ilie Viigiiia, iu-iiri'r in conjimctioii with the tonieitj' of the
iimsi'uliir sirucliires in tlie posii-rior segment of the pelvic floor.
I{eli;ii-tion of the uienis is the iiiiwt important physiolc^ieal
-lep ef ihe pl:ii-eru.nl si;iL:e. it .-misists of ii thickening and shorleu-
jni: of llie \v:ills of tlie tiIcttk. due. lii^t, tn a rearrangement of the
iim^iulai- lil'.'cs ; Mintui, lo ihe ihiikeniTii; ;ind shortening of the
tih.'i-s tliem-elv,^, Oii!\ llie upper >eL:iiieiit participates in these
,);iu-je-^. :)!.■ lM,h -Aud um.iu- hr,:w,' luinl ;in,l lirm and the mus.-!c
;i!H:>. I'v :y.--.-: v.; im.^oh [■:; i;,- the iihfiiie ves.>:cls which have been
ii>
■ !"
■elila
•A !■■.
1 passive and hang
Fica. 46 AND 47. — Extrusion of the Placenta Edgewise. Duncan's
Mcclmniani.
148 NOU.MAI. LABOR
ill \\m vaginn ns r, bruised curtain, tiacpid and witbonl i
8t'vi>rnl liotirtt,
Tlio dunitii'ii (»f the third utajm varies from a few i
two hoiira. It« iivi-rajtc h-iipth is twenty to thirty minat*s.
The avor»(ri' li'iitftli of noniial labor is, in a primipara, eight«ti
hours, in a iiiiiiM|mru. twelve hours, Variations from two to
twenly-fiHir himi's aro not uncnmniou.
THE "*"■"«"'—• «F LABOR
Tbo otvstrti'irian's obligation to his patieet
aiv often ntid<<n"«|iinh. antppartam. intHrparlBn.
ntid |>ivit]>iirluiii entiiiiliealhiua l» irhild- bearing wonav h
liable uuiy W pr\'Vi>iii«Hl or Mtri proper and intelligat mti-
ieal supervisieti iliirilip mid-i anil in the later Mralhw
rhe pi>'i;>i«ni \tituijiii shtMiIt) be laiigUI th? simple rults of h>giiai:
iit-^>l lo ):i\e ntlt'iitkm to her grniTal htwllh. and instniFlml is to
her tlioi. the anH>niit of ^xrn-isv to tv taken, tbe care of tbe In iifc.
:\:<- u)>p",.-v, t!u trenitniui. and her mantal rvlatnos. Tbr pV.ti"»"
0'>",'.\: ;i.v':-,.-.'.-n Minvir uilh the urinary output of his |— «■■■*. hf
tus -.ur,: .■■,-,.;"v,,i'M- S11.1 gii*DliT*lire exatainations oi tfcf vrmt it
;\i; ■,•,,;•. :■,:,■:*.. v : hrt>tM:K<4it the presswixT- Uti with At icate rf
.... \ - ..... ^„ { thfiWrv^ (\f QurviprtKias osidatM hnrnyKatal
.\. ■ • . . r Kr Mixxl iitvssut* ihirin; ^f *«■ tri^«*^
t*. -^ , ■■ •^' '■'*^' * r.x>;',:h Vfvvrv jhi? eipeifted (i«* rf lifc^
THE IMANAGEMENT OF LABOR 149
finally a computation should be made of the probable date of labor.
Important data concerning the present pregnancy, such as the
occurrence of hemorrhages, leucorrhea, unusual abdominal enlarge-
ment, abdominal pain, fetal movements, etc., should be noted, as
should the character of the vaginal discharges.
The mammary examination should include inspection of the
brea.sts, their shape and development, the condition of the nipples,
their form, size, and development.
The abdominal examination should determine the presence or
absence of complicating abnormalities, as:
(1) The presence of a pendulous abdomen, hydramnios, com-
plicating tumors, or twins.
(2) The development of the pregnancy, as shown by the height
of the fundus and the length of the fetal ovoid.
(3) The location of the placenta.
(4) The presentation, position, and posture of the fetus.
(5) The size and hardness of the fetal head.
(6) The location, rate, and rhythm of the fetal heart.
(7) The external measurements of the pelvis, including the
diameters of the outlet in all primiparae and in multi-
parae with a history of previous difficult labors.
Vaginal Examination. — The birth canal should be examined
for former injuries to the pudendum and vulvovaginal orifice, the
vagina, the cervix (including scars from previous operations), and
for tumors and inflammations in these locations.
The lower nterine segynent should be examined for placenta
pr(Evia and the pelvic cavity explored to determine the relation of
the head to the pelvis, and for obstructing tumors, as incarcerated
dermoids, ovarian cysts, cervical myomata or osteomata.
Finally the numerical equivalent of the internal measurements
should be noted: (1) of the diagonal conjugate; (2) of the depth
of the symphysis pubis; (3) of the bisischial, and (4) of the an-
terior posterior at the outlet. The determination of these measure-
ments should be a routine procedure in every primipara and in
multiparas whose history excites suspicion of pelvic contraction.^
'It is advisod that the student or practitioner familiarize himself with the
routine of the foregoing^ examination, which may be applied to the woman seen
for the first time, already in labor, as well as to the patient who has placed
Iferself under the care of the physician early in her pregnancy.
150 NORMAL LABOR ^^^^M
METHOD OP ABrOMTNAL EXAMINATION FOB DETEBSnNWS
THE PBESENFATION AND POSITION. OP THE FETUS
Position of the Patient.— The woman is placed in tlir; liori-
.zontal posture, pri'feralily oil the left side of the bed or on a couoJi,
with her thighs and legs extended. The abdomen is EiUly exposed,
the limbs may lie eovered with a sheet reaching to the pub^, anil
the upper part of the body protei:ted by the ni^litdress, which is
rolled lip to about the luvcl of tlie cnsiform. or by a scnond sheet
over the chest. Tlie iilKlnineu is llicn inspected, and the h«igiit.
shape, and position of inti'd. The next step is to
proceed with the palpai g this, however, it is well
to bathe the hands in wann wa er the sense of touch s
acute and obviale the reflex coi of the abdominal and nt«
ine muscles, whicli iire apt t( ucd by ihv i-ontuct o£ C
hands. Abdominal or uterine tension interferes with the e
tion.
The sneeessioii of stepK in abdominal examination, whieh wB^
mast easily determine tlie preserilJifion and position of the fetus
and its relation to the pelvis, are as follows, i. e. :
1. Lwate the dorsal plane.
2. ]-ociile till' small pnrtw (these are always found on the
(ipjuisii.' side lo that on whieh the dorsal jilane lies).
;i. Examine the lower felal pole.
4. Locale the cephalic prominence.
;■). Kxiiiuini' the upper fetal polo,
(i. J.ociilc the posititiii of the anterior .shoulder.
7. ],ociite the fetal hciiH.
.■^, Kxtcnial and irilciiial iiclviinct ry and .-cplialometry.
Location of the Dorsal Plane and Small Parts. — To locate the
dorsal jilaiic and small |iatN llic cxaininci' faces the patient and
places the palmar surfai- ol' mic hand lial on tlie median section
of the nlcrinr liitMur at alimii ilic h'vrl <.i the umbilicus. lie tlien
pres.si's lirujly liackward tnuaid lli<- .s|>inal coluinn and the child
h.' !-uU- ti.w.ir.l wliji'h its hmk lies and the
.T. Tlic chill! may lii> felt 1o slip from iindcr
a witli ll<- -illicr [i:nid will n-adily distinguish
liiiil i"^iil "i lie- liniii'i- liy il.s j;rPHter resist-
llic dniMiia In !»■ lui the left or right side »f
will be dis
plac.
fluid ci.ntci
Il In
the dul'T-lMll
lid p
1 tv..
nnee. llav
lUlX
THE JLANAGEMENT OF LABOR 151
le mother, one hand ia placed on the fundus or upper pole, mak-
g downward pressure in tlie direction of the fetal axis. This
esdiea and arches the dorsum and brings it nearer to the abdom-
— The Hand m the Median Section, Displacinq the Child to
THE Side Toward Which its Back Lies,
8l wall, where it may he palpated with the other hand and idcntU
•d by the length and breadth of the resisting plane, and dis-
tiguished from the lateral plane by its greater width and con-
■xity of the dorsum and the absence of a sulcus between it and
e head. Vhcn the location of the dorsal plane ia determined the
nail parts sliould be felt on the opposite side; they give to the
152
NORMAL LABOR
palpating hand the sensation of nodiili?s, which glide freely aboot
under tho touch. Occasionally their outlines may be fully tracwi
and a knee, thigh, or leg recognized. Light palpation, by the Hse
of circular ruhhing movements with the finger tips, favors their
detection.
lu anterior positions the dorsal plane is prominent and in fr«nt.
while tht' small parls iire fell on the opposite side and more or less
iiiaske*).
lu posterior positions the liiteral plane of the fetal body, with
the sulens between the body and heati, is most accessible, and the
small pans are easily aioireeialik' and in the median section of the
abdomen.
Examination of the Lower Fetal Pole. — To examine the lower
fetal !>Mle, ilie e\aiiuiu>r faees tile patient's feet and with both
Jiaiul-i plai'cil ov,r ilif lower uterine sei^iiieiit Just above and to the
inu.T >i.ti' of l'ou|';in"s liu'iiDiriii. liii'.'iT tips toward the mother's
l'.'.:. :iiul p:ilt!i:ir ^ui-t'.ic.'^ !i.:iriy I'.n-iiiLT iMi-li other, grasps the lower
feial p.i'..' li. iM.'. :i llie han^l-, a;iil 1;\ iiiaiiipiiiat ion fiuils the pre-
seiitiiiLT part. W!:,;i ;li,. |i, ,i.l i- in tlf \:n\,-r uterine segment, it is
reeoi:iiJ/i-.l iiy its ;..!■■,/ ,;'. /. .'.;-■ '. . ', ^iii,l tleTe is a lateral sulcus
hetwren ii a:;.i the trunk. I"' ■ '-■<■! ,.-■.(■"..■,■/> /.■in'ii sunk into the
Ihhii .,:Mi('('"ii ('■;'■ '■- ."■r- r ii: !'•■■ ■,■■'■}: -i-.'-^t w'f.n the rdatioHS
THE MANAGEMENT OP LABOR
153
between the size of the head aitd the size of the pelvis are normal.
This is Dot so in the multipara unless lightening has oei-urred, when
the head will be found in the excavation before labor in one-third
of multiparovs women.
Fig, 50, — Examination of the Lower Fetal Pole.
The breech alone is smaller, though with all of its component
elements it is larger than the head. It lacks, however, the hard and
globular feel of the head, presents no sulcus between the presenting
part and the trunk, and is nfi-fr found in the excavation before
labor.
154
NORMAL LABOR
When the small parts can be felt just beyond either fetal pt
that pole is almost surely the breech.
When the head is located in either iliac fossa it suggests a cro
birth or transverse presentation.
Location of the Cephalic Prominence.— \V hen the head,
perfei-t tU'xion, has cntereil the brim. Ilic ce|ihrilie prominence
greater on the side of the sinciput. This msiy be recognized \
placing the hands us wiien examining the lower fetal pole, &£
THE iCANAGEMENT OF LABOR 155
noting tliat the hand opposite to the cephalic prominence sinks
more deeply into the excavation, or in women with thin, lax abdom-
inal walls the head may be grasped with one hand held transversely
across the suprapubic region and the cephalic prominence pal-
pated. Its location affords some aid in deciding whether the child's
back lies to the right or the left.
Examination of the Upper Fetal Pole.— To examine the upper
Fig. 5:
I. Polk.
fetal pole the operator stiinds facing the mother and places both
hands over the upper uterine segment, the palmar surfaces nearly
facing each other, and grasps the content of the upper segment and
attempts to ballott it from side to side. The hard globular head
may be tossed from side to side, while the breech, which lacks the
flexible attachment of the head to the trunk, is less mobile and is
of greater bulk. In the intervals of uterine relaxation the breech
may be broken up into its component parts by <leep circular move-
ments of the flat hand. The ease of palpation is largely dependent
upon Ihc amount of liquor amnii present and the laxness of the
abdominal wall.
Location of the Anterior Bfaonlder. — The location of the an-
terior shoulder indicate.s the position of the child's back and serves
as a check in the alKlominal diatiHosin of posllion. "When the an-
1S6
NORMAL LABOR
terior shoulder is fmmd witliin one or two inches of the medii
line, an anterior position of the child's baek may be aasnmr
When, however, the anterior shoidder is far from the median Jin
in the region of the anterior superior spine of the ilium, a posterii
position of the dorsum is indicated.
PlIOrLDER,
The anterior shniil<l.-i- luiiy ]„■ hv-Mfd hy placing the hand up
the head and moving it upward toward the breech (Fig. 53)
the side of tlie ahilomi'u .iii wlii.-h the dorsum has been found. '
first obstacle fneuuLitcrcd after pjissinir over Ihc siUeus formed 1
the neck is the anterior BhonhU-r, More careful palpation
iimtify its anatomical characters.
THE MANAGEMENT OP LABOR 157
Location of the Fetal Heart. — The point at which the fetal
heart tones are heard loudest is called the focus of auscultation.
The heart is usually heard in its maximum intensity over an area
of about 7.5 cm., or three inches, in diameter. The location of this
area is of importance in distinguishing between right and left, and
anterior and posterioB positions of the child's back. When the
heart sounds are heard on the lejft side of the abdomen, it indicates
a left poBition, while when the heart tones are on the right side the
dorsum^ to the right. The relation of the heart tones to the
median line, whether near to it or far from it, indicates respectively
an anterior or posterior position of the back. In right dorsal posi-
tions too much dependence must not be placed on the location of
the heart sounds for diagnostic purposes, as the trunk may be in
a right dorsal-anterior position and the head in a right occipito-
posterior, owing to the fact that the right oblique diameter at the
inlet is larger than the left and the head elects it, while the normal
obliquity of the uterus is to the right, and the whole organ is
slightly rotated in its long axis toward the left.
The heart sounds are best transmitted through a solid medium.
Therefore, they should be heard at a point where the uterine wall
can be firmly depressed into contact w^ith the fetus. Such a point
is over the lower angle of the left scapula of the fetus, or the up-
per part of the fetal doi'sum, which offers a surface for firm contact.
Heart soimds in the upper uterine segment above the umbilicus
indicate a breech, in the lower portion of the abdomen a cephalic,
presentation. The position of the heart tones is only of positive
diagnostic value in determining presentation in primipane, in whom
the presenting part sinks into the lesser pelvis, for it must be re-
membered that the heart is situated nearly midway between the
ends of the fetal ellipse, and, therefore, in multipara*, in whom
neither pole sinks into the pelvis before lightening, the heart may
be heard either above or below the umbilicus without having a
definite diagnostic significance.
External Pelvimetry. — External pelvimetry should be prac-
ticed on every woman, pregnant for the first time, who places her-
self in care of a physician, and on all multipanc who have experi-
enced difficulty in previous deliveries, as the suggestive value of
the external measurements cannot be overestimated.
In order to measure the external diameters of the pelvis we use
12
158 NORMAL LABOR
a pelvimeter, a large pair of calipers with bhinied tips having a
centimeter scale attached which indicates the distance between tbe
tips. The simplest form of instrument is the one devised by Colyer
(Pig. 54V
Marked pelvic contraction is commonly associated with evi-
dences of body asymmetry elsewhere, such, as the rachitic rosary,
large joints, lameneta.
small stature, spinal ky-
phosis, etc., which are
usually apparent. On
Ihe other hand, the minor
degrees of contraction.
which are comparatively
connnon and cause a large
proportion of the difficnh
labors, can only be recog-
nized by the adoption of
rautine pelvimetry.
^VTien the interspinal
and intercriatal diameters
are both decreased in
li'iigth, general pelvic
contraction is suggested.
Wiion. however, the
length of the interspinal
is equal to or greater
than lliiil of Ihe inltrerislal. some degree of anteroposterior tiat-
li'iting may Ik- nisiimtH). The Ifngth of the external conjugate con-
liniis or disproves this nieiumption. An external conjugate of 18
cm., or seven inches, may Iv taken as the average lower limit in a
iinrnial (vtvis. When ihe cstenial cimjngate is below 16 em., or
sis inches, ihe jvlvis is snrely t-ontraeieil; when above 20 cm., or
eighi inehi's, t\w jh'lvie inh'i is .tlinost alwa.vs ample. External
menxurHtion shonid alw.iys W stipplemeulol by an examination of
ihf unili'l iiit'asiireni<-nl:s; ihi' bisist-htal. (he anteroposterior, and
Ihe depth lit' till' svmpli.viis should Iv fstiniair>d as rontine, as th^
fn'»iue»ey of funnel |vlvis as n e.tu:«e of javood stage dv'atoeia has
shown ihetr iiu)v*rtjuuv
Whi-H Iho »»^Jt^.^•. nnh 1- n..r^.•».^) Oh- clT.-ct on labor is seri-
THE MANAGEMENT OP LABOE
159
ona unless there is a componBating space pcateriorly, as it prevents
the occiput from emerging directly under the symphysis pubis, and
causes it to slide down upon the ischiopubic rami before it can
escape. The distance between the ischial tuberosities is normally
about four inches, or 10 em., while the a ntcro- poster lor, measured
from the summit of the subpubic arch tn the sacral tip, is about
five inches, or 12.5 cm. From the obstetric standpoint this diam-
FiG. 55. — Measuring the Distance between the Ischial Tuberos-
ities (the BisiscHiAL Diameter).
eter has two sections, an anterior sagittal, which is measured from
the center of the bisisehial line to the subpubic ligament, and a
posterior sagittal taken from the center of the bisisehial line to
the sacral tip; it is this latter section which must be ample in
or<ler to accommwlate the head as it emerges from a pelvis with a
deep symphysis, narrow arch, or contracted transverse. When the
posterior sagittal is below 8.5 em., and the bisisehial is contracted,
spontaneous delivery of the average size child is impossible. A
material increase in the length of the anteroposterior outlet diam-
eter may be secured by turning the patient in the extreme latcro-
prouc posture.
160 NORMAL LABOR
Method of Vaginal Examination and Internal Pelvimetry.—
I'reliiiiin;ir,v to ;i Vii-riujil examiiiatioii during prenTiaufy or luI>or
the bladder and rectum must he emptied iuiil antiseplic precautiens
in the preparation of the external genitals and of the obstetrician's
hands should be strictly observed. We then proceed with the in-
spection of the introitus for former injuries, sears, edema, rigidity.
and inflainniatiotis. We also luok for injiirie** and iiiHammatioD of
Fig. ot>.—'['iii. Ami.hiuk amj I'usi'khiou S.M;nTAL Dumetebs at thb
Outlet,
tlie miicOTis ineiiiiiiaiii- of the vagina. \Vf tiien measure the depth
of the -sympliysis. tlie widtli of the subpubic angle, the aacropubic
(anteroposterior), the bisiscliial. and the diagonal conjugate diam-
eters, and note the size and general i-ontour of the sacrum.
The depth of the puhes nin,v be readily a.seertained by placing
the tips of the pclvimclcr at the iipjier and lower margins of the
symphysis. The average deiitb should be about 4.5 cm., or one and
three-quarter inches.
THE MANAGEMENT OF LABOR
161
The width of the subpubic auglc is iisuitlly ostimated from the
lepth of the sj-mphysis, and the lon^ith of the liiftisehial diameter,
or when the symphysis mensurea more than 5.5 cm., or the bia-
schial is 8 cm., or less, the angle is always less than 90°.
The transverse at the outlet has already been refei-red to under
ixtemal pelvimetry. It may be measured externally by placing
he woman in the exaggerati><l lithotomy position with the thighs
orcibly flesed on the abdomen, and taking the disfanee between
he inner aspects of the isehial tuberosities on a line drawn through
he anterior margin of the anus.
The bisisehial (or transverse) may be approximately estimated
rith the hand by plaeing the half hand in the vagina aud turning
t at right angles, so that its greatest width is between the isehial
uberosities, which shows that there is sufficient space for the pas-
age of the normal head.
The diagonal conjugate is measured as follows: The index and
'econd finger of one himd are pas.sed into the vagina (the patient
)eing in the dorsal recumbent position with the thighs flexed on
he abdomen, legs flexed on the thighs, and the thighs abducted)
md the tip of the t
md finger is placed
igainst the center of
:he summit of the prom-
jntory of the sacrum.
A'hile the radial edge of
:be band is brought up
igainst the subpubic
ligament, and the point
>f contact marked with
:he fingernail of the in-
iex finger of the other
land, and the hand
iFithdrawn. The dis-
ancc between the two
points of contact is
neasured. and this
neasurement is the
.ength of the diagonal
»njugate {Pig. 57).
Fio. 57. — Taking the Uiao
tSA NORSIAL LABOR
from wbieh we estimate the true conjugate or conjugate
vtra.
Tlie true conjugate is found by deducting 1.3 to 2 cm. (^^-^
inch) from the diagonal, according to the depth and inclinatioii
of the pubea, 1.3 em. when t!ie depth of the sjTuphysis is 4.5 cm.
or less, and 2 cm. when the interpuhic joint m more than 4.5 era.
The deeper the symphysis the greater is its inclination. Before
removing the hand from the pelvis the other diameters, as the trana-
^
lli'-lt!"\TVl. DlAUETTEB. FROIC WHICH IS
UK Ul;'\IUETAi. IX U.VEXGAGED Cases.
M-i>i' >uu[ .tltti<|ii<\ ;*tid tlif 'vnli'ur of iho [virk- walls may be esti-
OephiJomelry. In itu- foreir^uii^ cliapter we have called at-
THE MANAGEMENT OF LABOR 163
tention to the mechanical factors in labor, the powers, the passage,
and the passenger. At present we have no way of estimating the
actual dynamic force of the labor pains in the individual woman.
We can, however, with comparative accuracy, record the pelvic
measurements, but the estimation of relative size of the head to the
particular pelvis presents a difficulty not easily surmounted, owing
to the fact that what the particular head will do in its relation to
the particular pelvis depends not only upon its measurements, but
upon its malleability or molding power, which is again largely de-
pendent upon the force and character of the labor pains. There-
fore the best cephalometer in borderline cases is the test of labor.
However, the size of the fetal head may be determined with
approximate accuracy by measurements taken through the abdom-
inal wall before the head has entered the pelvis and is perfectly
flexed. The hands are placed upon the abdomen as for palpating
the lower fetal pole, and the head is caught between them. The
poles of the pelvimeter are held against the abdomen between the
middle and the ring fingers of each hand, which overlie the ends
of the occipito-frontal diameter. An assistant handles the pelvim-
eter and, by making firm pressure against the abdominal w^all,
takes the reading. This reading corresponds very closely to the
length of the occipito-frontal diameter. From this measurement
the biparietal diameter is estimated by deducting 2 cm. from the
occipito-frontal when the latter is below 11 cm., and 2.5 cm. when
the occipito-frontal is above 11 cm.
PREPARATION FOR LABOR
Equipment of the Practitioner's Obstetric Bag. — It must ever
be kept in mind by the student and practitioner that the conduct
of labor or of an obstetric operation demands the same surgical
cleanliness as is observed in opening the peritoneal cavity. The
obstetric **kit'' should be equipped w^ith the necessities for secur-
ing this cleanliness, as well as the instriunents and appliances for
meeting the several obstetric emergencies.
The obstetric handbag should contain :
1. Two sterile hand brushes.
2. Green soap.
3. Bichlorid antiseptic tablets and lysol,
4. A Kelly pad.
164 NORMAL LABOR
5. A fountain syringe.
6. A rectal tube.
7. One large glass or metal intrauterine douche tube.
8. A soft rubber catheter.
9. A Robb leg holder.
10. An obstetric forceps.
11. A pelvimeter.
12. A hypodermic syringe.
13. Full curved Ilagedorn needles.
14. Needle forceps.
15. Suture material (catgut and silkworm gut).
16. Three Kocher clamps.
17. Cord scissors and heavy straight scissors.
18. Two 4-pronged volsella.
19. A large Sims' speculum.
20. A Ward placental forceps.
21. Two sponge-holding forceps.
22. A curette.
23. Sterile gauze sponges.
24. Sterile gauze (in a container) for uterine packing (3 inches
X 10 yards), or three or four gauze roller bandages (3 inches
wide).
25. Sterile tape for the navel.
26. An ether inhaler.
27. A thin gum rubber apron.
28. A sterile operating gown.
In addition to the above equipment, the bag should also con-
tain the following drugs:
1. Four ounces of Squibb 's ether — ampules of pituitrin (P. D.
& Co., or Burroughs' Wellcome).
2. One ounce of Squibb 's i\d. ext. ergot.
3. One ounce of a 2 per cent, solution of silver nitrate.
4. ^lorphin sulphate tablets, Vs g^*-
5. Strychnin sulph., 1/50 gr.
6. Ilyosein hydrobromate, 1/200 gr.
7. Sol. of chloral hydrate, gr. xv to the drachm.
8. S(iuibb*s fld. ext. veratrnin viride.
9. Soft capsules (juinin bisulphate, gr. v.
10. A tube of sterile lubricant.
THE MANAGEMP]NT OF LABOR 165
Supplies to Be Prepared by the Nurse. — The nurse should
be supplied with a list of the things which she should have ready,
and this list should include :
A half dozen clean sheets.
One dozen freshly laundered towels.
Two pieces of rubber sheeting wide enough to reach across the
bed (in emergency, table oilcloth may be used for the bed protec-
tion).
One dozen pieces of cheesecloth, 18 inches square, for wash
cloths.
Two or three pieces of unbleached muslin which have been
laundered, one and one-quarter yards long by one-half yard wide,
for abdominal binders.
A pair of scissors.
Two dozen medium size shield pins (safety pins).
An agate douche pan.
Two or three agate bjisins of two-quart capacity.
A slop jar, or waste pail.
Two new hand brushes.
Seven gallons of hot and cold sterile water in sterile containers,
covered.
One yard of strong linen bobbin or a package of sterile tape
(1/10 of an inch in width) for tying the navel cord.
One hot water bag.
One woolen blanket to wrap the child in.
An infant's bathtub.
A bath thermometer.
One sterile package of navel cord dressings.
One-half poimd aksorbent cotton.
Castile soap for child's bath.
Sterile olive oil or vaselin to anoint the child.
Four ounces of liquid green soap.
Four ounces of lysol.
1(X) bichlorid tablets or germicidal discs.
The child's clothing.
The hand brushes, scissors, gauzes, towels, and ligature material
for the child's navel should be wrapped in a towel and sterilized
by steam for an hour before using. It is well to do this at the
beginning of labor and keep them enveloped in a towel until they
166 NORJIAL LABOR
are needed. Great care should be exercised by the nurse and physi-
cian that nothing which is not stenle comes in contact with the
woman's gcnila] tract.
The Lying-in Room. — Unfortunately the obstetrician is sei-
doiJi I'linsiilli'il as to the seleetion of the lying-iu irhamber, Ilnw-
evi'r, ivlii'ii it is liis privilege fo make the selection, he should sec
tliat the room i.s n large, well ventilated one with several windo«-s,
prefernbly with a southern exposure, and that the bathroom ii
easily accessible.
The room, bedding, and clothing of the patient niaat be ab-
solutely clean.
The directions to the nurse sliould include the preparation of
the labor bed, which should be a single bed. The mattress is cov-
ered with a musliu sheet, and that with a rubber sheet large enough
to reach acros.'i thr bed. A tiean muslin sheet is spread over the
rubber sheet and pinned fast to the mattress. This makes the per-
manenl bed upon which the lying-in bed is made, by spreading
over it a second rubber shwt covered with a muslin sheet, upon
which is plucwl sonic t'onti of labor pad. to receive and absorb the
discharges. This may be made of two or three freshly laundered
sheets twice foldinl and piuued to the labor beil, or an aseptic labor
pad one luul a half yards sipiare made of cotton batting, cotton
waste, or |iapcr wool, covered with gauze or linen, may be used,
or a Kelly pail may he snbslituted for the absorbent pad. The top
rubber sheet, musliu sheets. Kelly pad, and labor pad must be
surgically elean.
Antisepsis. — Autiseptie agents are employed in obstetrics to
se<'ure an aseptic Held; furtuualely in the whole i-ourse of labor, as
planned by nature, infiition is guarded against by the cleansing of
the uterovaginal canal from within out. tirst. by the rupture of the
fon' waters, then the delivery of the child, followed by the gush
of ilii- liind waters, and tiually the expulsion of the placenta througb
the rent in the mcndiriun-s by which the child has already escaped
It i.'*, thcrt'fiiri'. evident that it is only by the introduction of infect-
ing agi'iils fn>m wiihout that infei'tion can occur. Therefore, evety-
thing wliieh cnicrs ihe vulvovaginal orilicc must be as near sterile
as it is juisiililT' to niiikc ii.
The means which "e bavi' for securing a relative asepsis are;
Drj- heal, sjeamiug. IviliUET. and chemical antiseptic*
THE MANAGEMENT OF LABOR 167
Dry .Heat. — Instruments, basins, etc., may be sterilized by ex-
posure, in an oven, to dry heat of 284° for half an hour. When it
is impossible to secure steam sterilization for sheets, towels, gauzes,
etc., they may be wrapped in several layers of thick wrapping paper
and baked in an oven for half an hour. Greater dependence may
be placed on their sterility by repeating the baking after an in-
terval of several hours before using. Dry heat does not l^ave the
power to penetrate dressings and sheets as well as flowing steam.
Boiling for ten minutes is equal to a thirty minute exposure to
steam. Both may be utilized for the sterilization of instruments.
The germicidal efficiency of boiling is materially increased by the
addition of one and a half per cent, of sodium carbonate or wash-
ing soda to the water used. The employment of a soda solution
removes the greasy matter from the material sterilized and pre-
vents the metallic instruments from rusting.
The chemical antiseptics used in obstetric practice are:
Bichlorid of mercury.
Biniodid of mercury.
Chlorinated soda solution.
Creolin.
Lysol.
Tincture of iodin.
The bichlorid of mercury (sublimate) solution is used in the
strength of 1 to 2000, and is prepared by dissolving one tablet con-
taining vii ss. grs. of hydrargyri bichloridi, to which either acidi
tartarici or ammonium chloridi is added to increase the solubility
in two pints of water.
The mercuric hiniodid solution is also used in a strength of
1/2000 ; it has an advantage over the bichlorid, in that it does not
irritate the skin or tarnish instruments, but is not so commonly
used, owing to its greater cost. The solution is made by adding
vii ss. grains each of mercuric biniodid and potassium iodide to
two pints of water.
The chlorinated soda solution is used in a strength of 1 to 10,
and is prepared by adding oz. 1 of liquor sodae chlorate to oz. ix of
water; its odor is lasting and disagreeable; it is an efficient anti-
septic for the hands, and does not tarnish instruments.
Creolin and lysol are used in strengths of 1 to 100, and are pre-
pared by adding two and one-half drachms of creolin or lysol to
168 NORMAL LABOR
two pintfl of water. They are non-poisonous antiseptics, and may
be used as (inuL-lu'a. Their chief advantage is that they may be
used for haj>il ami instrument immcirBion and take the place u!
lubricants.
Tiiictiwc of uirliii is used as an antisoptie in the skin prepara-
tion prtHfediiig curtain obstetric operations. It is usually employed
in n 3 per cent, or 4 per cent, solution applied to the skin surface
over the entire operative field and allowed to dry for ten minutes;
n siH'ond colli is Iheii """'i-"! «-iii"i> in its turn is allowed to dry.
It may 1h' usid in ils .,,_ iterilize the cervical canal
ln'fort' opcriilLve intervention. as a vaginal disinfectant
just i)n'ctHliiiK the repair of v d pelvic floor injuries.
Non inctdllii' utensils ina>- leeted with any of the foi«-
KoinK H^^'utK. though ht^at is the most effective.
Metallic iri-itrumcnts are best sterilized by boiling in a 1'-^ per
cent, soda si'lulion, They should, for convenience in subsequent
handlintr. ln> \\ni|'|'«' i" * towel Iwfore their immersion in boiling
water,
hnssinirs. k.-hizcs. IhiI linen, etc., may be sterilized by steaming
in ii pro)Hrly constnictwl sterilizer. The exposure should be for
III K-iiNi one lu>ur. When chemical solutions are employed instead
of sti;ini ilutv must Ix' a eomplete immersion for at least half an
hour.
The olwiiirii'iaii sheuKI. after car\>fnl pr\'paration of his nails,
hiUid-i :ui.l t'enjirtiis. d^'n :» sIit:!.' i>|HT.nini; jrown and sterile rub-
Ivr i:u'\.-. riu- nui-M' -hiniKi \ii':ir .'uly wash dresses rei-^nlly laun-
^tl■t^■^i, ;r.;.l -h.>;-,\l !M>';\ir.' h. r !-,:ir,.is \\i:h liw same carv as dues the
»•!',>■>■,■,;;■-. N ;'.■;>■ .■.■■"■.r-,- :• ,.;:■,;•.■-; \\':'.V. the obstetric [tatient.
Ni":'ir ;■■>-. ■,■■■-- •■.■■.■ ■■■.::v - u- ■ ,,- -v.iriuriil :n ol*>ietric work
s'-., ■■.-.',■ ,.■■■■.■ ■' ■■■ 1 ■■.■■. il; ■-..- ,,^ > - \: . .^ :':■.' :uv'v,>s by handling
■r-.;,>- ■,*■■■ ■ ","- ,,.,.. . ■ .,, :h- ri^h; to ;i.*eptie
,-:■■-- :" -•■/ T'-.<- Who
■- >" kept -thort
si-rubc*^! with
THE MANAGEMENT OP LABOR l6d
minutes, special attention to be given to the finger tips and free
edges of the nails. The removal of the dirt and superficial epithe-
lium is mechanical and takes time. This preliminary scrubbing is
the most important step in the hand preparation.
3. The soap and suds are thoroughly removed by rmsing in
sterile water. When sterile water is not available, running tap
water will suffice, care being taken not to allow the hands to come
in contact with any unsterile object.
4. The hands are then immersed for two minutes in a 70 per
cent, alcohol solution and the forearms scrubbed with gauze wipes
wet with the solution. This helps to remove the fatty matter from
the skin, and by dehydrating the skin makes the antiseptic, into
which the hands are next immersed, sink into it more deeply.
5. The hands and forearms are next held in a mercurial solu-
tion (1 to 2000) for five minutes. A solution of sublimate in 70 per
cent, alcohol is more effectual than the aqueous solution.
The hand brushes used in the preliminary scrubbing with soap
and water must be sterile. Their sterilization may be accomplished
by boiling in a soda or a lysol solution for ten minutes, when a
proper sterilizer is not available. The foregoing method of hand
preparation has proved eminently satisfactory for a number of
years, and has, in my clinics and private practice, supplanted -all
other methods, except the chlorinated soda method, which may he
used when the hands have been recently exposed to infectious ma-
te rial.
Steps 1, 2, and 3 are the same as in the method already de-
scribed.
While the hands are still wet from rinsing off the soap, the skin
is covered with a paste made by wetting with boiled water a handful
of fresh chlorinated lime. The paste is rubbed over the hands with
a crystal of washing soda, making a lime lather, and then the hands
and forearms are scrubbed in the lime paste with a soft sterile
hand brush for five minutes, rinsed with sterile water, immersed •
in a solution of 70 per cent, alcohol, and finally rinsed again with
sterile water.
After the employment of one of the foregoing methods the
hands are covered with sterile rubber gloves and the accoucheur is
ready to proceed with the vaginal examination, the conduct of the
labor, or his operation.
170 ■ NORMAI- LABOR
It is our C01 Iction thai no internal manipuUttimi, vaginal »'!
uterine, should I maile mthout gloi-es. It is not possible to render]
the skin sterile, or. thiiu)^h it nmy be superficially slerilized bjij
(iithor of the fo cfoing metlioda, it does not remain so for Taiailf\
minutes, sinee t. germ.s lodged in the sebaceous glands aud halt
fdllii'Ii'H find the' way to the surface as the hands perspire. 1
Should glove not be worn the hands should be frequently iin
nuTsed in a soli iuii of bichlorid in alcohol, always before ead
inlornal e.\nmin« on. I
After eli'imsinp the bunds or dunning .sterile gloves, to p^e^■e|(|
reinfi-etiim of the eh nothing that is not asepi
lir. A creolin or lysi>. r cent.) may be suhstituteq
for the sublimate at the pU ...e operator. These have the
iidviintnge of supplying a si iciuit. '
I 'riiM ration of h'lilihfr ....... —Rubber glove.s may bo made
idwolulely jiterile by boiling in plain water for ten minutes. Thqf
may then be allowed to Hoat in a '- i>er eeut. lysol sohition until
they are ne<HUHl for use: the lubrieatiou furnished by the iyM
I'ticiliiales drawing the glove on the baud. 1
l.nl'rieanls niv not p'nerally uwiled iu obstetrie practice. uwiii|
t.. the n.itund liibrtt-ntion of the piissiiiitw. However, many i-xan>
iiiaiu'iis ,';ui Ih' faetlitattM by ^nearing the hand with sterile glycei^
\n piv|';iifd by hi<itin(i it for ten minutes to 212° F. A sterile
^y'Uilu-n .'f ijnvn sivip is an exwllent luhrieant as are the more ex-
p.t\si\<- tr;id.- prr'ivi rat ions, sueh as lubrieondrin. K-4, etc.
Prvp«nttion of the Patient for Labor. — At the onset of Uboi
[]-.■.■ ;v-::>:;' s i::v,-u ;ui o;>;u;i. ;t kilb, ,iv.d ;t i-biinffe of clothing. It
!- "i',: ;,' i-uc iV,o >!r>'.rrv,"iT ry'!v..>v,\i ;,i;d f >r the patient to wear
;i -.!■,,•:: Ls\; c'";;. r,;-,^! ■ .'■ ;:■.:; Ktm-. r. r\i:-.i-n-L The nurs* then
;■:^■ :■..■■.- :'- .■ i\!<t;-:u iT; ;; ■.;'-.■':: ■:::.■ r -mt-T:: r* I'f :he thighs, and
;■".■• ■%;,;■ :■:." ».;"' V , - - --i' • :■ r: ;i ^:^ ::v:he pan. The
^ ■ . x-.-,: : , \ ■. V ,...::•. ■•- > .;.:-.•■. .-.v., sy. ssd :he parts
>: - -, ■ ■. - ^ ■■ ■ -.- ■- v. ■' J-—;-. ■i..,-,r -m.i «;imi
- ^ ■. - - - -■ .■■.-■--_- •.--- ".r T.-.,:er ovvr the
.■■■•. ^ -/. --'-irriz:;: the
THE MANAGEMENT OF LABOR 171
secretion being sufficient for its protection. In case of profuse
greenish, yellowish, or fetid discharges, the vaginal and cervical
canal may be f>repared by cleansing with green soap and warm
water, using the fingers of the sterile gloved hand as a scrub instead
of gauze or cotton. Great care must be exercised to use only gentle
friction, as the destruction of the vaginal epithelium by too great
trauma diminishes its resistance to infection . The preparation is
completed with an antiseptic douche of 1 per cent, lysol. This
douche should be continued for at least five minutes, the reservoir
being at a low elevation.
The object of this cleansing is prophylaxis not alone against
infection of maternal wounds, but of the child \s eyes as well.
When the patient has been seen a few weeks before labor, and
is the subject of a profuse or purulent vaginal discharge, disinfec-
tion may be effected by douching twice daily with a 2 per cent,
lactic acid solution, a gallon or more being used at each sitting.
Xo attempt is made to sterilize the eervieal eaual unless intra-
uterine manipulation or instrumentation is contemplated, in which
ciuse the cervix is exposed with a speculum and the canal painted
with the tincture of iodin.
It is well for the nurse, after cleansing the external genitals, at
the onset of labor, as already described, to apply a compress kept
wet with a saturated boric acid or weak sublimate solution, to be
worn during the first and second stage. Hefore each internal ex-
amination the compress is removed and the genitals are carefully
bathed with an antiseptic soluticm.
SIGNS OF BKGINNING LABOR
The precursory signs of beginning labor, as recognized by the
patient herself, are lightening and irritabilihj of the bladder and
rectum, shown by freriuency of urination and bowel movements.
The woman may be conscious of the uterus sinking lower in the
pelvis and her waist bands becoming looser a week or ten days
before the subjective* signs of actual labor occur.
The subjective signs of actual labor are:
(1) An increased frecjuency of urination and defecation.
(2) The occurrence of a bloody vaginal discharge — the show.
172 NORMAL LABOR
(3) The expulsion of the muooua plug from the cervix.
(4) Tlif occurrence of rhythmic pains first felt in the lumbo-
sacral, then in the lower abdominal region.
ESAMINATION AFTER BEGINNING OF LABOE
Should the patient be seen by the physician for the first time
after labor has already begun, and wlien no antepartum examina-
tion has been made, as has been described in a previous chapter, he
should promptly make the following observation.s :
Ou exposing the abdomen he should by examination make note
of the existence of such complications as: Pendulous abdomen,
hydramuios, complicating tumors, or twins; he should also deter-
mine:
{\) The presentation, position, and posture of the fetus.
{2) The lo*-aIion of the placenta.'
i;{l The location, rate, rhjlhm. and force of the fetal heart
tones.
l4> The eondititwi of the bladder, whether full or empty, as
sliown by the prvseuce or alisence of a globe-shaped tumor above
the pubes,
(5) The hanlnrts of the head and vrhether or not it is €ii-
(mgnl. or can be engaged by suprapubic pressure.
He should then, after thonnigh disinfe^-lion of the external gen-
itals of the patient and of his own hauiK which should l>e further
pr»>Ie»-tetl by sterile nibbtr gloves, proceed to make a pelvic exant
iuDtiou. oliser\-iug :
iX'i The (itithmltim. for rigidity, eilenia. former injuries, new
gn>wths. and intlainiuaiiou.
[,'2) The iii;/iHii. .ts to the troudition t*f its mucous membrane,
whether healthy or not. the charaeier .if its s^^reticoi. and the
litvwnw or dtwciu-v .»f former injuries,
^S'| The rt'ndui(>o of ihi- hUdil^T and rvv-tura. whether full "'
entply
<4> The l««>ii.v |<clvis. noliui! whether or iKt the head has C
'TW I'ii.v-ta iK-rvT iwupirt th- silc i-f i!w ^wrw* o« «iurh the dons
THE MANAGEMENT OF LABOR 173
gaged, which should be the case in all primipard at the beginning
of labor if there is no disproportion between the head and pelvis
or other abnormality. Should the head not be engaged, he should
proceed to measure the diagonal conjugate and the other diameters
of the brim and outlet, and note the general shape and inclination
of the pelvis.
(5) The cervix, for the amount of dilation, its dilatability and
for former injuries.
(6) The bag of waters, to determine whether the membranes
are ruptured or unruptured, and, if still intact, their shape and
size.
(7) The presentation, position, and posture, and the presence
of a ca[)ut succedaneum, if the waters have escaped, and its size.
P^inally he should determine the rate of progress in the first
stage, by the degree of cervical dilation, the condition of the bag
of waters, and the force of the uterine contractions. In the second
by the situfition of the leading pole, the occiput, as related to the
landmarks of the birth canal, the degree of rotation as shown by
the relation of the sagittal suture to the outlet diameters,. and the
advance of the head with each pain.
In the internal examination a vertex presentation is recognized
by the hard globular character of the head and by tracing the
sutures and fontanelles. The position of the vertex is determined
by locating the sagittal suture and its two terminals, the anterior
and posterior fontanelles, and finding which end is forward. Pos-
ture is recognized by noting the relative descent of the fontanelles
in their relation to the planes of the pelvis. When the flexion is
pt rfect, the posterior fonianclle is found at a lower level and is
more accessible than the anterior. When the head is semi-flexed
the anterior and posterior fontanelles may be foimd upon the same
level in their relation to the pelvic j)lane in which they lie. Ex-
amine deliberately all accessible fetal parts with a firm touch, for
a pasitive diagnosis of the position, the posture, and the relation
of the presenting part to the pelvis must be made. An anesthetic
may be necessary.
The examination is best begun during a ])ain and continued into
the interval. The frequency and strength of the i)ains and the
g-enoral condition of the patient, includuig her {)ulse and tempera-
ture, should complete the obscTvation.
13
174 NOR!\[AL LABOR 1
The pro^osis aa to the termination of labor must be guarded,
as it ia quite impossible to estimate witli afuuraoy the dilatabilily
of the cervix or the force of the contractions in the individual
woman. All else being normal, the duration of tabor will depend |
on the strength and frequency of the uterine contraL'tions and the j
ability of the patient to help them by her voluntary eflforts. when
the time comes for such exertion. No definite or positive statement
should be made.
MANALIKMKNT or THE STAGE OF DILATION
During this stage, after the physiciau has assured himself of
the diugnoais and the stage of progress, he can do hut little to help
the woman. The patient should be advised agaiust bearing down
with tile pains, and be encouraged to empty the bladder and rectum.
The backache may be relieved, the rectum and sigmoid evacuated,
imd the pains accelerated by the employment of a low soap-suds
enema to which a teaspoonful of turpentine is added. Adequate
rest and nourishment are imperative, and when the pains are well
established and are yood, strong and regidar, much relief may be
given the patient by the adniiuistration of morphin and scopolamin
(Uausl, hypoilermatieally into the arm or buttocte. The initial
di>sc should lie morphia sulphat.. gr. '4- scopolamin, gr. 1/150. fol-
lowiil in one hour by a sci'ond injection containing 1/200 of a gr.
of si'0|H>himin: if the "DiiTiiiiuTschbif " is not produced, the sco-
pohiniin iiiay he ri'|«'iilcd in an hour. The woman continues to
hiivi' hilior luiins, but wlim iimuscd has no recollection of her suf-
I'lTiii;:.
CliU.i-.-il iti:i\ ;il-.,. U- MS,',! 1,1 i,.|icvc the severity of the pains. It
i-i ciii|il,iw,i ni li.'M'.s i,r liv. w ill VMiicr. every fifteen minutes till
Ihi,'.' ,1,'M'-; iiif iriviti. The |i:ilicut iha.'s Iwween the paius and
ih.' r,-.i ,,ii-.,M,N h,r intvoU'* s:ti>ii!!ih. while the p<)wer of the eon-
1111,11, 'o I- ii.l1 iilTecicd IT is iiiiTiiiscl, fhh.ral is not well home
by the .sl,.TMHcIi.
IJcp.tii<il d".-,s iif .'p'iiu-: Nti..tild ..ildiiTii be given, owing to their
nan-i'li/inv: ilV.ii I'li i1j.> .bild, ;iii,l iluii omI\ In event of great pato
jiud ivstl.-«yi,-s.s. 0..-ii^ii.niil|y [,.«;,vd the lerniinalion of the first
.I:ig.-. \»bc.i III.' m,'nil.r;tu.- h,.N.- inptui-,-,1. but the eervix still r*-
.,Ms the pn-vsuiv of the a.l\;m,ini: h-:i.|. n hy,>,,l,.ruiie injection of
THE MANAGEMENT OF LABOR 175
Morphia, gr. Vi; atropin sulpli., gr. 1/150, may ease the severity of
the pain occasioned by the pa&sage of the head through the rigid
cervical ring which it relaxes.
The employment of chloroform or ether (to the stage of gen-
eral relaxation) is very rarely permissible in the latter part of the
first stage to relieve the cervical spasm {when the pains are fre-
quent^ strong, and regular and the canalization is almost com-
pleted), the continued use of chloroform or ether at this time, how-
ever, is almost certain to impair the efficiency of the pains. For,
once begun, it cannot be easily discontinued till the expulsion of
the child. Prolonged chloroform inhalation is dangerous, pro-
ducing organic changes in the liver besides being a cardiac de-
pressant. Chloroform or ether should therefore be withheld until
absolutely required in the latter part of the perineal stage.
In the first stage one careful internal examination w^hich shall
determine (1) the size and condition of the cervix; (2) the condi-
tion of the membranes; (3) the presentation; (4) the position;
(5) the posture, and (6) the relation of the presenting part to the
pelvis, will usually be sufficient. Frequent vaginal examinations
expose the woman to infection. Nothing so surely protects the
parturient against infection as the avoidance of all internal inter-
ference. In many of the foreign clinics labor is conducted to its
termination without a single internal examination being made. The
midwife watches the progress of labor by abdominal palpation.
Careful observation must be made of the maternal and fetal
pulse rate throughout the course of this stage of labor. A rise in
tlie maternal pulse in the intervals between the pains is a sign of
muscular fatigue. A fetal pulse of below 110 or above 160 to the
minute should be regarded as a signal of danger to the child. The
significance of the change in rate of the fetal 2^ulse is greater after
the membranes have ruptured, for the child is comparatively safe
from interference with the placental circulation when the mem-
branes are still intact. Therefore time and patience should be the
basic principles in the management of this stage. It is only in the
event of evidences of suffering or exhaustion on the part of the
mother or the child that active measures are permissible for accel-
erating or terminating this «tage. It is a general rule to remain
with the patient, or at least in tlie liouse, from the time the external
OS has reached the size of a silver dollar (2 inches in diameter).
NORMAL LABOR
MANAfJKMKNT OF TlIK STAGE OF EXPULSION
Tim Mimv 'if {'X|iiilNi<)ii Ix'tfiiiH wht^n the canalization of the cer-
vix In (■(nii|)lrli' niiil llic [iriiKi'iiting part comirenccB to pass through
lliii iMTvix mil. Ill' Urn uterus. Tlic pfttieiit should take the l>ed at
lln> lii'uiiniiiiK (if tliiH Hliiiri' (ir siHUier if the pains are severe or the
riintihniiirK Imv.- rupHnvil.
Nh» KJiould 1)1' tlri'NNnl for (lie bed, with her night clothing
Iiiriii4l lip mill piiiiii'ii iimii-r the arms, or she may wear a short
I'liiilliieiiii'ul jiii'lu't. A etcHii folih-d sheet may be fastened about
till' wiiist like II filtirt iiiiil wrw the purpose of protecting the pa-
lii'iil's eliitliing nml the upper part of the body from soiling with
111!' Ki'iiiliil iliNi'liiirp>s. Otwtelrie leggings supported from a band
III Hie vviiij^l umy be siilistLliititl for the sheet. These preeaations
Niiii)tlify tile <bilies i>f t1i<- iiiii-Ne in clfHusiiig the patient, and make
it ensit'i- l\>t' li.r lo l.avi' ibi' tvoiuiin elemi and dry at the olose of
ItilHir.
Tile Imit of hieiitbraiies sliouKI. when jiossible, especially ta the
prtui>)>Hi'n. W pixwiTveil until it i>r«.itr«dos at the vul\-ar orifice.
Tile Img tif wali'iN is a [H't-fivl hyitrostatie dilator, and its praem-
tHMt iiiNiii>'<!( tvtu|)lelt' tlilati«>u of the er'rvix. the ragina. an! toItbt
(it'ittee. wliit-h hel|vi to luiiiiiiiut' the autinint of iaeeralton. Artificial
rupltiiv Ivftm- tlitN iiith' IS inihlvisjible. If the membTUMs be still
iKibn4v-t< l)ki-,\ shkiuUl bf niptttrvit artitk'i^h* vh&a tbeT icaeh the
iH-lvie tUvr Attxl bi-^m to dtstrtid it- This may be tkoe vith the
tiuK^-niail. or ihf )>uitoUirv iutt,\ tv nuiW with a sterile hairpia «r
M'L-wrv t*»*K»\t m> a^n^iisi Ihif dtstr'uJeit baa; of vslerL witt the
|v»int p»«i'H>! »"*» ihtf rt«>yf- j*s a <:«-ir\l Tti? I
K- ttsi'tur^'*! \hir'ttjr a jni^k. *'\v«t>; "hrti :be h
W tW (v!\X <-.v vxi\-^ llw- bfitt ■» bk^-kni wilk the |
fMi!l !^' xl^Kt-M KU-O e( :i-;'A<r iu»u<- aui>~ t*iTx A>«a mtt ft a
ks«v .'I ii- .■v**\i
V I'.t'it^ •ti^if- ''v •»->: t* 1 ^i-wc law a rupe. aad Am^
"tv It t^,^ ■.■tt\- ni\l A' V\ •■•: voi :-iv t .*rc •>< the WA, gn^ Ai
lM4v«tt %'MfsCl »;;C ' ' *i^ 't'" ''^tioi rttv s*aiSi. ani nwt^mt
»)4 tt itts-cwk-v rt^ 'v .'ith vir. :> •(. :ii.' .-i.tuirarv «S9^nB iAha
v/ \1tv aXkic'i "a. »ii. s. V^L ll^9; ■;!■' 7UiiT ^ftwvM ■■< W 1^
tNUt>iM Ibkytt ;W J^Kt » ■t-'vr^nt-lK, te TI all rf|MB Witt ^» ]
THE MANAGEMENT OF LABOR 177
history of previous precipitate deliveries, for slow delivery is the
surest prophylactic against outlet injunes.
Position of the Patient in the Second Stage. — Intelligent ad-
vice as to the position of the patient in the second stage of labor
contributes largely to her comfort, and has some definite influence
on the course of the mechanism. The latero-prone position, with
the hips slightly elevated, favors anterior rotation, besides relieving
the patient of much of the severe sacral pain experienced at this
time. The patient should lie on her left side in left vertex positions
and on the right side when the occiput is to the right, until the
rotation is completed.
During the perineal stage the left lateral position offers decided
advantages, in managing the escape of the head by preserving a
more perfect mechanism and diminishing to some degree the ex-
pulsive power of the voluntary muscles.
For all internal examinations the dorsal recumbent position is
the best, while an exaggerated Trendelenburg posture aids ma-
terially when the abdomen is pendulous by bringing the axis of
the uterus into that of the pelvic brim.
Examinations. — As in the first stage, vaginal examinations
should be infrequent, a single examination at the beginning of the
second stage usually being sufficient. This should be made imme-
diately upon the rupture of the bag of waters, as it is desirable to
make sure that the cord or a hand has not prolapsed with the gush
of waters and that no other irregularity is present. Once assured
that the head is engaged and all is normal, further interference
within the passages is not only unnecessary but is injurious. To
examine internally in the second stage oftener than once an hour
is unnecessary even for the tyro. The progress of labor while the
head is passing the brim may be observed by palpation over the
lower abdomen. After the head has sunk well into the lesser pelvis,
the rate of descent may be watched by examining through the pel-
vie floor, with the finger on the skin surface near the posterior vul-
var commissure. By deep pressure at this point, the head can be
felt before it rests on the floor. When it begins to distend the pos-
terior segment, inspection will furnish the necessary information.
By they means internal manipulations may be reduct»d to a mini-
mum, and sometimes they may be wholly omitted.
Anesthetics. — During the latter part of the perineal stage an
178 NORMAL LABOR
anesthetic, if properly administered, may be used with advantage
to the woman. Ether should be the choice, administered by the
open method. The aim in obstetric anesthesia is to blunt the pain,
not to abolish it, hence it is given only with the pains for short
periods and intermittently. At the moment of expulsion it may
usually be carried nearly or quite to the surgical degree. When
complete anesthesia is required for obstetric operations, we have
found the employment of ether-oxygen vapor narcosis to have de-
cided advantages, being less liable to narcotize the child. The ex-
cessive use of anesthetics, especially chloroform, is dangerous and
is not infrequently a contributing cause of death in labor.
It is generally a good rule to withhold anesthetics as long as
the pains are well borne without them, as it is beyond question
that they impair the strength of the uterine contractions.
Recent studies have shown that the use of chloroform during
labor is not safe, and is capable of producing serious and even fatal
organic changes in the mother.
^lany untoward results have followed upon the careless and
faulty methods of administration during labor, owing to the gen-
eral impression, which has become traditional, that the pregnant
woman bears an anesthetic better than her non-parturient sister.
This is not so. Care in administration is jnst as essential here as
in the narcosis for surgical operations.
The head should be low and turneil slightly to one side, false
teeth must be removed, the clothing about the neck loose, the eyes
covered with gauze pads moistened in boric acid solution. The
skin about the mouth and nose protected from ether irritation by
smearing with sterile vaselin, the heart carefully examined, and
the pulse counted and recorded before the narcosis is begun. The
open methoii should be employeil. The mask known as the Fergu-
son inhaler affords large evaporating surface and ample air space.
The ether is droppeil upon the mask, using five to ten drops at
each respiration. Whatever effei^t is to be produced must be ob-
tained before the pain reaches its height, for normally at the acme
of the uterine contraction the abdominal muscles rre fixed and
respiration is temporarily suspended.
Begulation of the Expelling Forces. — If the pains aie feeble
they may be stinuUated l)y inassiiire of the uterus and postural
methods, as by the employment of the squatting posture for the
THE MANAGiarENT OF LABOR 179
patient duriog the pain. The jiressure made by the thighs upon
the abdomen augments the expelling force of the abdominal mus-
cles.
■\Vhcn the labor is over-rnpid, the force of the pains may be
moderated by the use of anesthetics and by regulating the action of
the voluntary muscles by the latero-prone posture.
Anffithetics can retard or arrest expulsion according to the
freedom of the dosage. This has a decided bearing on the preven-
tion of pelvic floor injuries, as the chief prophylaxis against pelvic
^oor lacerations during the birth is the slow and gradual delivery
of the head by iti smallest circumferences, allowing sufficient time
for the dilation of the vagina, the pelvic floor, and the vulvovaginal
orifice.
The Perineal Stage. — "When the head begins to bulge the peri-
neum the patient is placed in the lateral posture, and the expulsion
is retarded until the resisting structures have had time to stretch,
Fio, 59.— Manacement of Feri.veal Stage, Woman in I^atebo-phone
Position.
the speed of the delivery being controlled with anesthesia and by
pressure with the fingers against the advancing occiput, for not
only the rate hut the nieclianisui of the expulsion must be regu-
lated by keeping the smallest circumference of the head in the
IW)
NORMAL LABOR
Rriwp of Ihfi rnNiHtinft Birdie. This may be done by maintaining
exuKKfriitrd H«xion, by making pressure on the occiput until the
oceipitiil iirDtuberaucc \h free and the nucha is well up against the
Bubpubif! tiMi. At the wame time, the pelvic floor may be supported
by upward pressure with the
outspread hand, applied to the
distended perineum, so that the
thumb and index finger encircle
the posterior commissure of the
vulva, or by pressure with the
thumb and index finger posterior
to the anus, as in Fig. 59, which
helps to crowd the head further
into the subpubic arch as the
forehead is about to escape, and
so relieve the tension on the
fascial structures of the pelvic
lioor. The suboecipito-bregmatic,
sul>occipito-frontal, and the sub-
mi' ipito-iiicntal circumferences
should succfssively pass through
the vulvar ring. From the time
the pelvic tloor begins to bulge.
I-Vi. tU). Mas.mikmknt ok the the birth of the head should rare-
I^KBiNKU. Stamk, Woman is thk i^. ot^.,ipv l^ss than half an hour.
Shelling out the head l)etween
ivtiiis ar ntlompts to guverii the s}>eeil of the expulsion and pre-
serve lht> lu^i'banisiu with the lingers in th« rectum subject the
l^ttieiit to « danger fr\^m inteotion. without preventing rupture of
tht» »'ft i»arls. rdvie tWr iigurit-s occur in about 34 per cent,
at |triuiit>art>us laK^rs.
|l\ \\,sii-bin>r thi' I'irvulalion in the strt'tehrtl out p»«terior seg-
iwii! v'f tUi- jvlvii' t'liif, we i!;:i_v anticipate an inevitable rupture
i>f the ['.'Ka- sot! parrs ;ukI pnveiit injury t.i the tm[Ktrtant stme*
turxw.'-' ■ '■ ■:'■<. •■.^■.v '■;.■■-■■'■,■■■;■*■ ■'i^'^'i'v.* ^!7«itra%. This
pi\Vi>r.;'.\- ■>; '>;■.«>«-; ;!■< e:>s'et<,'t'.;> T^.«-st' i;[-.-i-i!.>n-i can be best
mavio w.','-. !■■.• ivi;i.:\: tr. ;:-• '.i!t val cvfsTv.r*-, wl.ile the vulvar ring
TK)tui>ttt« of Epii»«t«»ax.
:^ '.v.ade at a p«>int in
182 NORMAL LABOR
blood is probably brought about by the force of thoracic aspiration
in the child.
After the cord is clamped and cut it may be tied firmly with
aseptic narrow linen bobbin, about 2.5 cm. (1 inch) from the um-
bilicus, after the jelly of Wharton has been pressed out from the
part to be ligated, by reclamping the cord at this point ^nth a broad
Kocher compression forceps. The excess of cord is then cut away
with a pair of sterile scissors, about ^/4 of an inch outside of the
ligature, and the end of the stump pressed with a sterile gauze
sponge to see if it bleeds. If any oozing continues, the cord should
be tied again on the proximal side of the first ligature.
Dickinson has suggested and practices excision of the cord at
the cutaneous margin of the umbilicus; he catches and ligates the
umbilical vessels individually with fine catgut, and then sutures the
skin edges over the excised stump and seals the wound with a pri-
mary sterile dressing. This is an excellent disposition of the cord,
but to our mind dangerous teaching for general practice, as its
success d(»pends absolutely on an asei)tic technique.
A second clamp or ligature to control the placental end of the
cord is r(»quired in case of twins, since otherwise, if the placental
circulations communicate, the second child may be lost by hemor-
rhage from the cut end. When we can be sure that there is not a
second fetus, there is some advantage in allowing the blood in the
placenta to escai)e and thus diminish the bulk of the i)lacental mass,
which facilitates its subsequent delivery.
MANAGEMENT OF THE PLACENTAL STAGE
From the moment the head is born the hand of the obstetrician
or the nurse should be held on the abdomen over the fundus of the
uterus till the placenta is expelled and the retraction of the uterus
is complete. There is usually an interval of from three to five
minutes after the birth of the head before contractions are resumed.
During this time the hand on the fundus may make gentle friction
to proinot(» the normal contractions if there is any vaginal hemor-
rhage. If, howcrcr, thire is none, the fundal hand should remain
jyassive.
The placenta is usually expelled spontaneously in the course of
fifteen to twenty minutes. Should this not be the case at the epd
THE MANAGEMENT OF LABOR 183
of half an hour, no hemorrhage occurring in the interim, attempts
at expression of the placenta after the method of Crede may be
employed.
Crede's method is to reinforce the expulsive strength of the
uterine contractions by grasping the fundus through the abdominal
wall, with the thumb in front and the fingers behind, and, at the
According to Cred£.
acme of the pain, mil sotntcr, compress tlio fundus firmly di)wnward
*M the axk of the birth canal. The fundus should he carriid well
back during the man i puliation to bring the vteriiie axis more into
the line of the vaginal asis. This process niHv be repeated with
each pain, at tlie acme of the cimt ruction, until the placenta is de-
livered. Vayinat blidiny will appear in the interval hetwwn con-
tractions when the placenta beginx to xi'iianitr. This bleeding is
friim the placental site, which cannot rctnict untjl the placenta is
completely detached. No traction should he made on tlie cord to
184 NORMAL LABOR
a»t!st the delivorA- of the plaeoiita. Ocrasioually, when the placenta
is in the vaginu or ni the (;niRp of the lower segment, funic traction
is a<!inissible. Tlie separation and expulsion of the placenta from
the upper, contracting segment of the uterus may be recognized by
an upward itioveuient of the fundus, as the placenta passes into the
lower segment and vagina.
Expression by the Cred4 inetho<l may frecjuenlly be aided by
the patient straininp foiribly during the manipulation. Should
1*10, C'i.— EtFEtT OF Crbde's Methou on the Utehus.
expression of tlic placenta fail, and there be no uterine bleeding,
the placenta may 1k^ left in the uteruM fur severid himni, without
injury to the patient, at the end of wbii-li time spotilaneous delivery
may occur or a sinitle expressive effort may cause its expulsion.
Thf«e externni methods lailins. or in event of uterine hemorrhage,
the placenta may be removed niiinually hy seizing its lower edge
with the gloved baud in the va;;ijia and the fingers passed through
the cervix, (ircat eare must be e.xcn-i.sed to see that no fragment
is left behind. A digital exploration of the interior of the uterus
THE MANAGEMENT OF LABOR 185
will determine if the afterbirth has come away complete. On ex-
pulsion of the afterbirth it should be turned into the membranes
with its fetal surface out, that the membranes mav be twisted into
a rope and gently pulled away from the uterine attachment by
slight traction in the axis of the uterus. This traction should onlxf
be made when the iitcrus is in relaxation, as during its contraction
the membranes may be held in its grasp, torn off, and left behind.
Examination of the Placenta and Membranes. — The placenta
and the membranes should be carefully inspected to learn whether
fragments of eitlier have been left behind in the passages.
The membranes are best examined by transmitted light, to see
that both amnion and chorion are complete. When viewed in this
manner, a single membrane is quite translucent ; both together are
somewhat opaque.
Fragments of membrane, wholly or partly in the vagina, should
he removed. When wholly in the xderus they are better left to he
expelled icilh the lochial diseharge, the patient being placed in the
Fowler pasition in order to secure postural drainage.
Manipulation within the passages^ espeeially within the uterus^
for pieces of retained jylacenta or tnemhranes, at the close of lahor
is unnecessary and exposes the woman to infection.
TREATMENT OF 1NJUR1P:S TO THE SOFT PARTS FOLLOWING
LABOR
Cervical Lacerations. — Some degree of cervical laceration
takes place in nearly all primiparous labors; the majority need no
trfatmcnt as spontaneous union takes place if the convalescence is
aseptic and the injury is not too extens^ive. The tear is usually
unilateral, and on the left side when the birth has been spontane-
ous; bilateral when the delivery has been instrumental, particu-
larly when the head has not passed the cervix before the forceps
were applied.
Cervical lacerations which give rise to troublesome hemorrhage
or are extensive should be immediately closed by suture.
Method of Repair. — Frequently no anesthetic is necessary, as
the cervical tissues are insensitive owing to the long trauma which
they have sustained during the labor. If narcosis is needed, ether
should be the choice. The patient is pbiced on a table in the lithot-
omy position with her legs retained by a proper leg holder. A
186
NORMAL LABOR
large Sims' speeulura or Simon rt-tractor is introduced in
vagina to expose the cervix, and the anterior and posterior
tiie cervix are grasped with foiir-prongeti viilsella and draw
down. The traction usually controls the hnmorrhage as i
exposes the extent of the tear.
Fig. 03.— Method
L.4CERAT1
The ,Kiii-l';ii',.s of 1hc .■vrvii-ril wniiiid jiiv then brought to
and Kutiirrd iviih Nii. ■_' i-liruuiir iriit. Ihe first stitch heing
ah(.vc thi' iin^l,- of tin- lenr. tlic siifiires pinned about % of a
apart jiml tied to eoiiptiiti' without I'lm.strii-ting the included
Lacerations of the Pelvic Floor. — Some degree of pelvi
laeeralion occurs iii from 1-"» lo 40 per cent, of all primi;
labors, and some further injury is sustained by aliout 30 pe
of multipariK. Injury to tlic soft ]iiirls is greater in private
THE MANAGEMENT OF LABOR 187
tice and among the better class of patients than in the women of
the working class attended in hospitals. This is due largely to the
frequency of surgical intervention before nature has completed the
dilating process, an unfortunate practice which is common with
many busy general practitioners who attend midwifery cases.
The principal contributing and exciting causes of pelvic floor
injuries may be found in the funnel pelvis with its narrow pubic
arch, which pushes the advancing head backward so that the nucha
pivots on the ischiopubic rami in extension, and thus exposes the
posterior segment of the pelvic floor to greater distention. A rela-
tively small vulvovaginal orifice, or rigidity of the pelvic floor, or a
primipara advanced in years, predispose to lacerations because of
the inelasticity of the pelvic soft parts.
Faulty mechanism, as unrotated occipito-posteriors, in which
the flexion is incomplete, too rapid delivery without previous prep-
aration of the vagina and vulvovaginal orifice, and the unskilled
and improperly timed use of instruments make up the chief ex-
citing causes.
Lacerations of the pelvic floor may be complete or incomplete,
and when incomplete the tear may be external, when only the ex-
ternal structures are involved and the levators are left intact, or
internal, when the tear runs up on one or both sides of the rectum,
along one or both vaginal sulci through the fibers of the puborec-
talis and pubococcygeus but without skin injury, or combined,
when the laceration is both internal and external, beginning in one
or both vaginal sulci and severing all of the structure from above
downward, and from within out between the vagina and the rectum.
When the laceration is confined to one side it take^ nearly a straight
course, terminating below in the perineum and above in the vaginal
sulcus. When the tear extends into both vaginal sulci the tear pre-
sents a Y shape, which allows the anterior wall of the rectum to
protrude into the vagina with each straining effort, owing to the
division of the levator fibers in front of the rectal tube.
Complete tears include a division of all the soft structures be-
tween the vagina and the posterior rectal wall, including the sphinc-
ter ani muscle.
Degrees of Laceration, — A simple classification is one which
divides injuries of the soft parts into tears of the first, second, and
third degrees.
1HH NORMAL LABOR ^^^IH
l''ir-Ml ilcgri'i:: Kxti-rnal U^ars, not iiicliidiiig Ihe aiipjMrtijiR
Srcinnl lii'urrc: Tears involving all the structures between the
viini'i'i n'nl ri'i'tiiin to the sphincter ani inuscles.
Thiril (li'ni-ce: Tears extending into the rectuni, in whii'h there
in ti i'iirn[ili-(i' Mi'vcrance of ail the soft parts of the pelvic Hoor and
iiiiliTior wall of the rectum, including the anal sphincter.
Tntiliiti lit. — All pelvic floor injuries, whether they involve the
prrineiim alone or extend up the vagina tlirougli the levator or
tlihinKh Ihe spliini-ter museles. should be repaired. The time at
whi<-h thix repair slumld be ninde will depend first upon the extent
of llu' injury: swond. on the cundition of the woman; third, on
' operiilor and his ability to secure asepti<?
Ill Ihe vaginal orifice, not invoiviug the
I' and fascial structures, may usually be sutared at
Tliis rfjiair may often be done while waiting
placenta, and thus save the necessity of
' sensibility of the injured parts is more
u>. iiinitcdiHtety following the btrth of ttar
child. Whon, howewr. the deeper structures have beoi injored.
the sphiiii'ttT ani lom IhnnytU, or the s*>ft parts are edematow
fntm the 1r»um.t of a dilTicull instrumt-nlat deliven.-. or the patient
is ci ne)>hriiie or has h.td svrioiis hemorrhages, suture of the tear
gJtotild (■■ t'^ktitHHio) until stinie de^rxv of inrtdulioD has taken
t'littv. Ihc i\)i-iti.i sulisidi^). the deTilxlitrd tbsoes rv^aiited their
vm-uUlovi. tuid thi' |)At)e«I Ims rvacied fnm the shwk of labor.
Thf- ix'stdi-' -if priiiwrj- suiun* aiv N^lttr. in extrasrre injnries.
wliiti llir tv^VRir i> m»l<- aNmi f>>ny-riri)t «<r smolT-tvo boms
aflrr »Mitvr\
Xtvf tv(vmi>i« '4i<'4itd N- itt«i<- :ti A envj li^hL vith the prt*fiil
tn ilv t-iM'VM.^ ixvctn'n >L>a a :iih>. A !^<-e« dmf or m Bobb tag
th^hr u^v W n<<«\I tt> krvp :h« ih:a:hs d^xol a»i aWwttd. Thoe
tMA> K' a)>i^ ixl in iSf i.'.).-m ne =M>&ai^ : TW hifs arc Wwght to
.x*».v »'*■ ^ •«• t* ,*»« N;n'* :af ksrf*. iai the ti
h.. CO
Si I
iipcteni'c of
idiuK^.
|>li' hiccriilio
dccpc.
Ihc ch
sc of hilKir.
for th
delivery of
furl he
iincstlifsia. .1
or l.-ss
ol>tnnd.>tl for
THE MAXAGE-MEXT OF LAliOR 18!)
lestlii'tic is nwc^nary, jiiid ctliiT aihiiinisliTfd hv tlie o|»pri method
jjivfprahli'. When the patient is aiiesthetized and in piisitiim, tlie
O. W. — Suture of an Extkknal L'xilatkrai. '1'kak oe the Vulvo-
vaginal OniKKE.
llvil. piilies, inner surfiiecs of the lliitlhs, and the Viitiina shnuhi In'
cansvd as for ii vaginal openilinn. and tlie disinreelioii ciiniph'led
itli ii vatiinal donelie of a saluratcti horir aei(] soliitinri. A larfje
t-rihi puek of (;aiize is then plaeed in the vtijrina, against the eer-
:x, to [trevent tlie Im-tiia frinii llowiiif; over the Uelil of operation.
m
NORMAL LABOR
The wound is exposed by placing a "guy" suture on each labini
nt the skill niarpin of the tear, and eatrhing the posterior vaglni
Pelvic FUK
\i.ill «iili a volsillii lit what K'f.Kv nipnirv was the center of :
l,.«.-i- fiid. Iij lidins thU i>oiiit iio:irly jo the in^atiis. at the sai
null' rctriK'liiii: tlio labia liy tnit-iUvii t>« Thi* "piij-^" &lrc-H()y placf
(li<- inniitlisitapist uoniid im .'mo .>r hmti sides of the ^-^gioa will
I'laiuly t\|msi\l. .111,1 rt t>tt9.'i)tiiiit iiwy iv placed in the uppemit
aiij;!.- of lliv Xv'M- Thi- woiuul >urfa.f is thrti sponged dry wi
THE MANAGEMENT OP LABOE 191
gauze compresses, and the full extent and character of the injury
made out. We begin the repair by placing the sutures in such a
way as to accurately restore the normal relations of the parts. This
is best done by introducing the first suture just above the upper-
most angle of the sulcal tear, and closing the lacerations in the
sulci from above downward, the plane of each suture being nearly
parallel with the skin surface of the perineum, the deeper portion
of the loop being nearest the skin, so that the severed structures
may be grasped and lifted up and attached to the vaginal septum.
When the lacerations in the vaginal sulci are properly closed the
remaining wound in the skin surface will be insignificant, and may
be brought together with three or four sutures introduced from the
skin side (as in Figs. 64, 65). The stitches in the sulci should
be placed at intervals of y^, an inch, beginning at the upper or
vaginal angle of the wound. A full curved Hagedorn needle, armed
with No. 2 chromic gut, is entered close to the edge and just above
the upper angle of the wound, and given a wide lateral sweep
through the lip, catching the severed ends of the puborectalis,
emerging just short of the bottom of the wound. It is then rein-
serted at the bottom and passed in a reverse direction through the
opposite lip, emerging close to the edge. Care is needed to avoid
passing the needle into the rectum. The loop, as the suture is
dra^Ti taut, should be nearly circular, bringing all parts of the
severed surface into apposition. As the sutures are laid, the oppo*
site ends of each are caught with catch forceps and held up over
the pubes until they are ready to tie ; this brings the deeper por-
tions of the wound into easier reach for placing the succeeding
stitches. When the sutures are all placed, they are tied from above
down and only tightly enough to coapt, not constrict, the wound
surfaces. Before tying each suture in the vagina, the wound is
sponged with gauze and all blood clots removed. When all of the
vaginal sutures have been tied, the gauze pack against the cervix is
removed and the skin edges approximated. No. 2 chromic catgut
should be used to close the vaginal sulci and the deep muscular
structures, fine silkworm gut to close the skin wound. The ends
may be left long and knotted, and the knot covered with a lead
shot. By observing this suggestion their removal will be facili-
tated.
Lacerations of the third degree, involving the sphincter ani
II
192 NORMAL LABOR
m\w\v iiiiii (!(.■ imtt-ridr m-tal wall, are repaired in the followiug
mirrcHMJon of kIcjih: /fr.i/, the closure of the- rectal wall; second.
.^
j^^^^^
^fl|^L '
'
V »y f '^ '
^iM^
1 . --■ ^
f '
t\o »fr *Jv,r\(i; <•' \ tant^ i«t>_Kti li.vs^
»,w.'*f». • *•-» .v.ffr--*l». 1. ^- ft. . i-flV /■- r*< sfAi'- ■" ««jk;«. Mrf
Ih* «. ' '»•• .' '*• r.ttry ••. M>. i-pfltfO- S^-i Mate . r T«. sJb's ttt-
•*.-.,
Tl'i wsV»f)Rj> ^ vi)I\.«rt--l IK'; *• ■:>'i ■ii.ni; T'^'.aftm*^ T.rvTiiisDiw is
».KV K
\v .■.'ir'Kv, :,c- -vj* -nif :>.i .-s^- u^thtsks. i-i«^ tfcal, in 1
_ THE MANAGEMENT OF LABOR 193
tion. An iodoform gauze tampon, to which a sterile tape is at-
tached, is placed in the rectum to protect the field of operation.
We then proceed to repair the rectal wall by clasing the wOund with
sutures of very fine black silk, or No. 1 chromic gut, which are
armed with a full curved, smooth-pointed needle at each end. One
end of the suture is introduced at the upper margin of the wound,
from the vaginal side, passing through all coats into the rectum.
The other end enters at a corresponding point on the opposite side,
and is passed through into the rectum. The suture is tied on the
rectal side and the ends left long. When silk is used, the stitches
are placed about a quarter of an inch apart until the entire rectal
wound is closed, the long ends of silk being brought out through
the anus. The rectal mucous membrane may be closed with a
buried suture of fine catgut introduced from the vaginal side, in-
cluding the muscular coat. After the anterior rectal wall has been
repaired, the ends of the sphincter ani muscle, which may have
retracted wuthin the tissues or may stand out plainly, projecting
above the wound surface, must be isolated and united. The ex-
posure of the sphincter ends may be facilitated by drawing them
oat with tenacula. Two or three No. 1 chromic catgut sutures are
^hen passed through each end of the severed sphincter and caught
^^itl catch forceps drawn taut, and held forward by the assistant
^^ CBxpose the internal sphincter.
Before tying the external sphincter sutures, the internal sphinc-
^^** should be closed with a No. 2 plain catgut mattress stitch passed
^^^^se to the rectal mucous membrane and parallel with it. This
'^^ J' be tied at once and the ends cut short. The external sphincter
*^^^t: ures are then tied, and the tension on them is relieved by placing
^^>^« or two silkworm gut or silver wire sutures from the skin sur-
^^^^*e through the end of the external sphincter on one side to near
*^^ rectal wall and through the opposite end, emerging at a cor-
^'^s^aponding point. These reinforce the deep sutures and, when tied
^^-^^t tightly enough to coapt the surfaces, act as splints for the
^i^lincter ends during the process of healing. The remainder of
^"*^« wound is then closed as in the incomplete operation already
^ ^=*"8cribed.
The tampon is removed from the rectum before the sutures in
e sphincter are tied.
Vaginal Tears. — In labor in which the occiput lies to the
194 NORMAL LABOR
mother's back, dcHi cmJinK to the pdvie floor as a posterio^
and in which aniirior mtalioo Is attempted, or when 1
Htagc is prolonged aiul the vagiua is small, anterior and"!
tears of the vagin;. jin- I'omparativety eommon. These are i
more marked on lli.' left side, and include the muscle and fascia Q
the urogenital triwomun. The anterior vaginal wall aitd anttri
lateral sulci shouhl ahvai/s be inspected for injuries before the let
of the posterior wall are repaired. Immediate suture gi%'es mot
satisfactory results. Careful approximation of the entire depi
of tlic wound, witli interrupt I'd sutures of No. 2 chromic catgut, i
all that is neecs8nry. ri-or leall, unless repair
always result in llie fon,. >cele, which ia difficult t
repair at secondary operation.
Lacerations which liave bei led in a previous labor n
fre<)u<'ntly be repaired during i^., ,,_>rperiiun at about the end o
the first week, tbongh there ia greater danger from thrombophle-
bitis, wheu the denudatiou and dissection are done within a few
days after labor than there is in the primary suture of a fresh tear,
owing to the general enlargement of all of the veins and plexnsn
during pregnancy. New avenues of absorption are opened. Tlie
meth<Kl of operating does nut differ from that i^sually employed in
llie n'>jt"ration of the jpeivie Hoor. The most scrupulous asepsis is
After-care of Pelvic Floor or VaginaJ Operations. — The after-
care is very simple. The patient slinuld l)e plaeed in lb-- Fowlrr
position and eneuurnged to favor postural drainage by assuming
the latero -prone position, both right and left, many times a day.
Should .she be in ^rvM ]iaiii. codein in 1-graiu doses may he ad-
iiiini.stercd by the reeliuti.
The catlieter is usiuilly rei|uired for the first day or i-wo af:«
sntuce of the pelvie llimr. Il should be omitted if possible. t« li*
puerperal woiuiin itnist not be allowed to go longer than mffre
hours wilhout evjieuutiiig her bladiler. <lriat cart mmsr i-e %ji-*
iti riillii I. i-iziilii/ii. as llir pris.siliililif of enslitis is iHcrc*wtf j.f '*'.
i-iH-fi II I'll •lisrliiirn'^ iiliiiiiis pns' lit tiiar llic perineal iri-'*»^- libt
vTilviiVii^'iii:il iiiilii-.- r(lu^l lie iMrefuliy iiTigjited wilh an az.-zb>s^Cs:
sniiiliuri l.rl'iiii: Mud afti'r ''ai-li ■■athed'i'izat ion and unZT-.^m. :z
![■_. ar. .iovs .sli'.uhl III' iiilhiiiiisl.'n-ij in a full gla^ of »^«r feu
times a ilay In icndiT tUc iij'ijn- antisrjilic and ael as a pi-ici.jiio.'iai I
THE MANAGEMENT OF LABOR 195
against infection of the urinary tract. The wound is not dried or
dusted with powders after irrigating.
The bowels are opened on the second day and once daily there-
after. Enemata are specially to be avoided in operations upon the
sphincter. The non-absorbable sutures are removed at the end of
a week or ten days, when the patient may be allowed to sit up. No
douches are given until the end of the second week, as we lAve
found our results to be better since their omission. The douche
when given early only disturbs the normal process of tissue repair.
CAT^E OF THE PATIENT AT THE CLOSE OF LABOR
It is unsafe for the physician to leave the patient for at least
an hour after labor, or until he is sure that good retraction of the
uterus is taking place, and that there is no hemorrhage. Immedi-
ately after the delivery of the placenta, the fundus of the uterus is
found about 5 cm. above the pubes. Gradually the fimdus rises
upward, by the formation of a blood clot within the uterine cavity,
until it is at the level and a little to the right of the umbilicus.
The contained Mood clot acts as an intrauterine tampon, which
stimulates contraction and retraction, and which in the primipara
is so vigorous that the blood clot is promptly expelled and the uter-
ine cavity practically obliterated. To watch the primary readjust-
ment of the uterine muscle fibers and the height to which the fun-
dus risesyi the physician or nurse should keep one hand upon the
abdomen over the fundus for at least thirty to forty minutes after
the delivery of the placenta. Should relaxation occur, the uterine
tumor becomes rapidly larger, and an increase in tlie genital bleed-
ing is noted; gentle friction may promote the necessary contrac-
tion and arrest of hemorrhage. Should the fundus remain low in
the pelvis and the bleeding continue, it is because no intrauterine
clot has formed to plug the vessels. To promote its formation, the
uterus may be grasped by the thumb and fingers above the pubes,
just below the upper segment, and lifted out of the pelvis. Slight
constriction of the lower segment against the sacral promontory
vf'xW check the bleeding and allow an intrauterine clot to form. The
use of ergot and pituitrin favors uterine contraction and retraction.
Ergot may be given hourly as a routine, in half drachm doses of
the fluid extract, until three doses have been taken, or used only
196 iNORMAL LABOR
when there are signs of relaxation, iis a pi-ophylaetie against post-
partum hemorrhage. Postpartum inertia is nut uncommon when
the patient has been the subject of hydramnios, twins, etc., or las
been subjected to a long general anesthesia, or is exhausted, with »
rapid pulse and low biood pressure. Ergot is best used hypodi-r-
matieally in the form of ergone (2ij min.), or ergotole (25 min.i.
coifibined with pituitrin (1 ampoule). The generous use of ergot in
the puerperitim is of value also as a propbylactie against puerperal
infeetion. sinee it tends to prevent the formation and the prolongwl
retention of blood clots within the uterus, and by its action on tlif
muscular fibers tends tn close the lymphatics and blood vesacU
again.st absorption. Jloreover, by thus limiting the blood supply il
promotes involution.
Cleanaing of the Patient at the Close of lAbor. — Special care
musl be taken to cleauNe the patient and leave her in a drj-, clean
bed at the close of labor. The nurse should bathe the external
genitals, and the soiled parts of the patient's body, with a weat
'intiseptic solution, and ehange her clothing and bed tineji if soiled.
Cleansing of the genitals may be best aeeonipiished by placing (he
woman on a douche pan and pouring a pitcher full of water or of
an antiseptic solution over the vulva and the separated labia, to
, remove the blood and clots. Fresh boileil cheesecloths or squares of
sterile gauze ere used for bathing.
After the external genitals are cleansed, a sterile locbial guHid
is applied and fastened at each end to the binder or, in case the
binder is dispen.scil with, to a wide abdominal band with a tailpiece
front and back, to which the ends of the vulvar pad may be pioued
A folded napkin is commonly used for the vulva dressing. It
slmuld be sterilized by stcinning or boiling, and dried before it is
applied. A spceiiit dressing m;iy be secured from the surgical sap-
ply houses or nnide by the nurse, of absorbent cotton, cotton b«t-
ting, cotton waste, or olher Jibsorbent material, loosely folded in t
cheesecloth envelope. It should lie len inclies long, four inches
widi'. and Iwci inches lliiek. A lailiiiece about ten inches long al
each end of llie j>a<l serves for pirniing it to the abdominal binder
or waistbaTid. The pjuls riri> rciiinve.l when soiled and burned.
abdominal bindi'i- slimilii !>.■ used for ihe first few days after Wk*.
h i,s (o b.' iimdc i.r II striiichl 111. I' nnblejicbed muslin, a tmJ
and a (]uurter lung and Inill' a yard wide. When applied it
An
bar. 1
-J
THE MANAGEMENT OF LABOR 197
reach to just below the trochanters and fit snugly, being shaped to
the curves of the body. It should be moderately tight for the first
twelve hours to support the lowered abdominal pressure. Subse-
quently it may be loosened or be wholly discarded, as it is not in-
dispensable. \o pad is needed over the fundus. The support given
by a snug abdominal binder is grateful to the woman as well as
being of some clinical advantage during the period of abdominal
relaxation immediately after labor. The sudden emptying of the
abdomen of its content allows the vessels of the abdominal plexuses
to engorge from lack of support, and materially lowers the blood
l>ressure. After the bowels have moved, and the patient is allowed
the use of her abdominal muscles, the binder is of no further use,
and its continuance may cause harm.
After the woman has been cleansed, the clothing changed, and
the binder and vulva dressing applied, the clean bed may be pro-
tected with a draw sheet made of a clean sheet folded to four thick-
nesses, which is placed under the patient s hijxs, drawn taut across
the bed, and pinned to the mattress. This may be changed as often
as soiled without remaking the bed and disturbing the patient.
Nothing is more grateful to a patient than a smooth, dry surface
to lie upon.
The physician should never leave a patient after delivery with-
out noting the rate and quality of the pulse, the presence or ab-
sence of temperature f the amount of the lochinl flow and the height,
position, and firmness of the uterus. These observations should be
recorded by the nurse, to whom specific instructions sliould be given
with reference to the future care of the pueri)eral patient, particu-
larly in the matter of rest, sleep, diet, evacuation of the bladder,
and the time at which the child shall be put to the breast. She
should he instructed to watch the amount of the bloody vaginal
flow and note from time to time the height and condition of the
fundus,
A drachm or two of the fluid extract of ergot may be left with
the nurse to be given if the uterus tends to relax, or, in the event
of hemorrhage, also a rectal suppository containing opium or co-
dein (gr. i-ii), to be used, if required, for the relief of severe after-
pains.
She should further be instructed as to tlie strength and the
nature of the antiseptics to be used for cleansing the genitals, and
198 MOli.MAL LABUK
directed to inspect the fiavel stump for bleeding at frequent inter-
vals (luring the first few hours after the birth.
Heaides these specific directions, which must never be omitted,
and should be written, it is well to give the nurse general direcUona
UH to the care of the child, which should include when it is to he
bathed, the care of the eyes, the eord, the mouth, the bowels, and
the kidneys, its pulse and teiEiperature, and the position most favor-
able to its respiration.
CHAPTER VIII
PHYSIOLOGY OF THE PUERPERAL STATE
Certain phenomena are normal to the puerperal state which
occurring at other times, would cause alarm:
(1) The postpartum chill.
(2) The slow pulse rate.
(3) Slight elevation or temperature.
(4) Retention of urine.
(5) Peptonuria.
(6) Sluggishness of the bowels.
t7) Activity of the sweat glands.
(1) Within fifteen or twenty minutes after the delivery of the
child the woman experiences a chilly sensation, or suffers from a
distinct chill, which is due to vasomotor causes, and has no patho-
logical significance. A hot drink and a few hot water bottles placed
about the patient usually bring about a prompt reaction by estab-
lishing the vasomotor balance.
(2) The pulse rate as well as the blood pressure falls, shortly
after labor, to below the normal standard. For a week or more, if
there has been no toxemia of pregnancy, or no infection has oc-
curred, it may remain below 60 per minute. In exceptional in-
stances, just after delivery, the rate may be as low as 40.
(3) The maximum temperature for the first four or five days
of the normal puerperium should not be more than 100** P., while
during the second week post partum the evening temperature
shoukl not rise above 99°. A woman who has sustained severe
trauma during her labor, though there be no infection, may have
a temperature for the first two days of even 102°. Any rise, how-
ever, above 100° F. must be considered pathological. Elevation of
temperature has more significance when it occurs in the later days
of the puerperium than when present immediately following the
labor.
(4) Owing to the recumbent posture, to lowered intraabdom-
199
200 PHYwrOLOGY OF THE PUERPERAL STATE ■
inal pressure, to urethral spasm, to the bruised, swollen, and send-
tive condition of the structures about the urethra, the patient in
liable to a retention of urine in the first few days following labor.
The secretion is greatly increased after childbirth, and overdisten-
tion of the bladder not infrequently results.
(5) Peptonuria is normal in the puerperal state, peptone being
a product of uterine involution, while an excess of acetone is com-
monly found in the urine of the first three days — this is probably
a starvation acetonuria. Glycosuria is quite common, and fifty per
cent, of puerpene have a slight albuminuria.
(6) Sluggish action of the bowels is the rule for the first days
of the puerperiuni, owing to the loss of intestinal aud abdominal
tonicity.
(7) The sweat glands after labor become unusually active, the
sweat secretion is profuse, and during sleep the secretion may be-
coiuc I'xci'ssive. This helps to correct the hydremia of pregnancy
riru! keep tlif body sin-farc cool ;ind moist.
Condition of the Uterus After Labor.— At the close of labor
the upper segment of the uterus is thick and moderately firm, while
the lower segment remains thin and relaxed for about twelve hours
after the birth. During the next six days it gradually regains iti
shape and firmness, until at the end of tlie second week the involu-
tion of the cervix goes on proportionately to that of the body.
The l\Tnph spaces aud blood channels are greatly enlarged, a
condition favorable to resorptive activity, which, with the relaxed
condition of the lower segment, constitutes one of the greatest ele-
ments of danger from septic infection in the lying-in period.
Cavity op the Pi'erperal 1'tebus. — After the membranes and
the placenta have been expelled the deeper layer of the decidua
ri-mnuis to be shini piecemeal with the lochial How. Shreds of
the outer superficial layer, too, arc retained to be loosened and dis-
charged with the lochia. The placnilal site is slightly elevated
above the general surface of the interior of the uterus, and is
studded with small bJiwd clots lodged in the mouths of the vessels,
making irregular protrusions into the cavity.
The cavity first cnutHins blond nnd blood clots, and later its walls
are smeurcd witli a mucosnnguiiuijcnl fluid, and the endometrium
beeouics a gniiiiitalint! surface.
Invou'tiun. — Involution is the process by which the
THE UTERUS AFTER LABOR 201
trophied structures of the uterus and other genital organs are re-
stored to the non-gravid condition, normal to the parous woman.
During this process the muscle fibers atrophy by fatty degenera-
tion and shrinkage of the individual fibers, the blood vessels dimin-
ish in size and become more tortuous, and the endometrium, which
has been exfoliated after labor, is wholly renewed.
The uterus measures 18 to 20 cm. (7 to 8 inches) in length by
10 to 12.5 cm. (4 to 5 inches) in width; the thickness of its walls
in the upper segment is 2.5 cm. to 3.7 cm. (1 to P^ inches). The
depth of tlie cavity progressively diminishes day by day under
normal conditions until the involution is complete.
At the close of labor the depth of the cavity is about 15 cm., or
6 inches.
At the tenth day post partum, the depth of the cavity is about
10.7 cm., or 4^/^ inches.
At the end of the second week, the depth of the cavity is about
9.7 cm., or 3% inches.
At the end of the third week, the depth of the cavity is about
S.S cm., or 3VL' inches.
At the end of the fourth week, the depth of the cavity is about
8.0 cm., or 3^^ inches.
From the end of the fourth week the change in the size of the
uterus is very sliglit, and depends largely on the care which is
given to the woman's pelvis. Involution is seldom completed be-
fore the twelfth week, though the duration of uterine involution is
usually placed at six weeks. When it is complete, the thickness, the
width, and the length of the uterus are api)roximately 1, 2, and 3
inches, respectively.
The normal uterus of the parous woman is somewhat larger
than the uterus in the virgin state.
The situation of the fundus serves as a clinical guide to the rate
of the involution.
The situation of the fundus at the close of labor is nearly mid-
way between the umbilicus and the top of the pubic hemes; an
hour or two later, owing to the formation of the intrauterine blood
clot, it is just above the umbilicus and usually more or less dextro-
verted. Its descent from this level is ])rogressive, if the involution
is going on normally, until at the tenth day the fundus is usually
found at the level of the brim. When the position of the fundus
202 IMIVSIOLOGY OP THE Pl'ERPERAL STATE
Ih olwjerved to 8(»rv(* aH an index of the decree of involution the
bladder and rectum must be empty, as the height of the fundus
varieH with the fulhiess of the bladder and rectum.
The weight of the uterus at the termination of labor is about
thirty-five (35) ounces; at the end of the first week it is about
sixteon (16) ; at the end of the second week, twelve (12) ; and at
the end of the third week, eight (8). After the involution is com-
phite the uterus weighs but 10-13 drachms, or about an ounce and
H half. The great weight of the uterus during the first weeks of
the puerperium, and a lack of appreciation of its significance by
th(» pnictitioner and patient, is one of the greatest causes of uterine
dvacvHitus. Normal involution is interrupted by certain interpartal
niul puerperal complications, so that the size of the uterus rather
than the day of the puvrpcrium should be the guide of the degree
of involution and indicative of what privileges may be granted the
wonuin. Involution is slower in non-nursing women; after twin
births, or overdistention of the uteriLs from hydramnias; prema-
tun» labor; much hemorrhage, whether antepartal, interpartal, or
pustpartal; retention of secundines, and septic infection. It is
partially arrested in endometritis and by getting up too soon. The
involution may also be retailed by violent emotional disturbances.
At the close of lalwr the cervix is a soft and shapeless mass,
having mi almust gelatinous consistency, hanging in the vagina as
a bruised curtain, with innumerable minute lacerations in its cir-
eumlVrt»nce, Within twelve hours it logins gradually to be n*-
foniUHl.
The i>s internum is large enough to admit two iingers at the end
of twenty- four v--*^ hours, but closi^s tirmly after the expulsion
fnuu the IhhIv of the inrntaintHl bliXKl clot, which usually takes place
by the end of the s^vond day. The internal os may remain patu-
lous, if then* is any intrauterine eimient, as retained membranes,
placenta, etc.
The iv4 i'\;ernunu however, will admit one tinger even after seven
tv» tv^urtvvu \la\s. When the ivrvix has regained its form, the in-
Xx'lu: or. cvHs on prv*|vr:iv»nately to :hat of the body of the uterus.
uv;Uns^ *: hjis sus:aim\l e\to:isivo tnjury. The lower K>rder is p^r-
•HJi** V * v''.,:\ :o A iT'^dtcr ^r U'ss vu^r^v, m^^ frwiuently on
:hi* \*:t <vlv\ .:'.' :>:'^ s '•. *r* ", o^'uc to laceration of the cer-
THE LOCHIA 203
The Vagina. — The hypertrophied vaginal walls are much re-
laxed after labor. Their involution progresses with that of the
uterus, but the vagina is never wholly restored to the nulliparous
condition, as the walls are permanently enlarged and relaxed.
Other Pelvic Structures. — The ovaries and tubes, the mus-
cular structures of the pelvic floor, of the abdominal walls, and all
other structures which have undergone hypertrophy during preg-
nancy participate in the retrograde process and are partially, or
wholly, restored to their antepartum state. This restoration de-
pends on the amount of injury sustained during labor and the
presence or absence of septic infection in the puerperium.
After-pains. — ^After-pains are periodical uterine contractions
occurring after labor. They may continue for a few hours or for
several days post partum. They are always more or less painful in
multiparas, owing to the greater relaxation of the uterus in women
who have borne children, and the consequent liability to the reten-
tion of blood clots in the uterus at the close of labor. The multi-
parous uterus never retracts so well as the primi parous. Generally
the postpartum uterine contractions are painless in primipane after
the first clot is expelled.
After-pains accomplish and maintain the retraction of the
uterus and are, therefore, conservative, when not too severe. They
accomplish a physiological purpose, and normally cease altogether
by the third or fourth day. Early rising from the bed, for an
hour or so each day, or the assumption of the Fowler position for
postural drainage, favors their early subsidence. *
The after-pains are likely to be intensified by the reflex stimu-
lation produced by putting the child to the breast.
The Lochia. — The lochia are the genital discharges which im-
mediately follow labor. They are more or less bloody in character
for the first four or five days, when they are called the lochia rubra.
The bloody character of the discharge may continue longer if the
retraction of the uterus is not good. Relaxation allows the forma-'
tion and retention of blood clots within the cavity, which shows
the character of its content by a bloody discharge. The lochia
rubra contains shreds of decidua and of i)lacental tissue, blood, de-
generated epithelial cells, mucus, and numberless microorganisms.
The discharges then become serosanguinolcnt, and are called lochia
serosa, A flow of this character continues for two or tliree days,
204 PIIYSrOLOOY OF THE PUERPKRAL STATE ^
when it begins to have a creamy appearance and cuntaiu fat gran-
ules, epithelial cells, Jeukocj'tes and cholesterin, and is temiPiJ the
lochia alba. This continues for three or four weeks, or until the
endometrium has been completely regeiierateti.
For a week or more after labor the reaction is alkaline, then
neutral or acid. The total amount i» estimated to be about three
and a quarter pounds.
In normal cases the lochia! flow continues for from two to fonr
weeks. The quantity, character, and duration of the lochia are
indices of the stage of involution.
Postpartum Calls. — The patient should be seen within twelve
hours after labor, except when a competent nurse is in charge, who
is capable of making a systematic examination of the mother and
child, and reporting her findings to the attendant. For the first
three days the woman should be visited t«jce or twice a day, and
once daily thereafter until the seventh day. During the remainder
of the postpartum month occasional visits should be made at inter-
vals of three or four days.
First Visil. — At the first visit a sj/sleniatic examination should
be made. The general condition of the mother, with her pulse and
tcmperaltirc. should be noted, as well as the amount and characUr
of the lochia. (The loehial guard should be carefully inspected.)
The abdominal binder should be loosened and the uterus examined
by palpation through the abdomen for size (the height of the fun-
dus), for firmness, and for tenderness. The abdominal examination
will also determine the condition of the bladder, whether it is over-
fiiU'd or not. Learn if it has been evacuated and the quantity ol
urine voided, Freqiirtit urination should ahrays suggest the pom-
hitity of ovirdistention. A specimen of urine should be taken for
examination.
The breasts shoidd be inspected and, if large, supported by a
breast binder. The condition of the nipples should aLso have atten-
tion.
Thi; |>liysi.'i;ni s) Id iTii|iiire if llie patient has had .sufficient
sleep ;iih1 I lie pruinT jiirmutit of jKHiri.shinent.
The eoudiliou of the mother having bccu ascertained, the child
should have atteulion; its color, respiration, the caput succeda-
neuiM. if one exists, the eyes, with the amount of swelling and dis-
EVACUATIONS OF THE BLADDER 205
amined for caking or milk engorgement ; the cord for evidences of
bleeding or infection. It should be ascertained whether the child
has passed urine and meconium, which serve as evidence that the
passages are pervious. Should no meconium have been passed, the
rectum may be explored with an oiled catheter or the little finger,
to determine its patency. Finally the baby's rectal temperature
should be taken.
Subsequent Visits. — Especially to be observed at the daily visits
are the pulse, the temperature, the condition of the breasts, nip-
ples, bladder, the amount and character of the lochia, the involu-
tion of the uterus, and the general condition of the mother. Ab-
dominal examination of the pelvic contents should be made at
about the tenth day, before the patient is permitted to leave the
couch, and again at the end of the fourth week.
These examinations should determine the condition of the in-
troitus vaginae, the vagina and pelvic floor muscles; the condition
of the broad ligaments, whether free or the seat of exudate, the
condition of the cervix, whether lacerated or gaping ; and the shape,
size, position, density, and mobility of the uterus.
The patient should never be dismi.ssed from observation until
the involution is complete and the pelvic organs are entirely re-
stored to the normal non-gravid state.
The child should be carefully examined at each visit. Too much
reliance must not be placed on the nurse's record; the responsi-
bility for its condition rests on the physician.
The long continuance of the lochia rubra is usually associated
witli some degree of sepsis within the uterine cavity. A thrombo-
phlebitis in the placental site is a comparatively common lesion.
The persistence of the bloody flow in the third and fourth week,
especially when associated with bearing down and sacral pain,
should suggest a redisplacement of the uterus or subinvolution.
Metrorrhagia in the later weeks of the puerperium always demands
a pelvic exploration.
Evacnations of the Bladder. — Owing to the edema and swell-
ing about the urethra and the lowered intraabdominal pressure
which follows labor, there is danger of overdistention of the bladder
from retention of urine. This should be guarded against by hav-
ing the patient attempt to empty her bladder within six hours after
delivery, and once every six or eight hours thereafter. Should she
206 PHYSIOLOGY OF THE PUERPERAL STATE
1
be iinablt; to void, the retention may sometimes be relieved by the
application of hot fomentations over the hypogastric region, in eon-
jtinetion with a hot irrigation against the meatus urethni". TLis
failing, a rectal injection of warm water may cause the bladder ti>
contract, especially if the woman be allowed to expel the enema in
a. sitting or semi-sitting posture. Suprapubic pressure during the
attempts at uriuation is occasionally of value. Most patients will
urinate, if allowed to get out of bod and use the commode, and un-
less the labor has been operative, and the patient has sustained ex-
tensive pelvic floor in.iuries, there can be no objection to permitting
her to sit up to evacuate tlie bladder. The sitting posture has a
further advantage, that it empties the vagina of clots and favors
uterine drainage.
When the labor lias been unusually severe, the anesthesia pro-
longed, or the pelvic floor badly torn, involving the sphineters, or
where an immediate repair ha.s been made, it is advisable that the
patient maintain a recumbent piLsition for the first few daj-s, as
sitting up imder such cireurastanees is 7iot wilhout danger. It is
in //(is class of cases that the catheter must be used to relieve the
retention.
The use of the catheter is frequently attended with infection of
the bladder and of the vesical neck, resulting in a chronic trigonitis
or tracheloeystitis. It is, therefore, imperative that the catheter be
withheld, if pos.sible. When required, it should be used in the tcA-
lowing manner: Tlie instrnment, if it be used by the nurse, should
be a No. 10 or 12 soft rubber catheter. The catlieter must be boiled
for ten minutes immediately before using, and, after steriliziDg.
mnst be handled only with surgically clean hands.
The patient lies upon the back with the knees drawn apart, and
the external genitals exposed (in a good light). The nurse, after
scrubbing her hands, bathes the labia and surrounding parts with
an antiseptic solution. She then resterilizes her hands and. with
the thumb and finger of one hand, retracts the labia, to fully ei-
pose the meatus, while she disinfects it and its surroundings witb a
gauze sponge soaked in the antiseptic solution {1-2000 bichlorid).
After this is done, while still retracting the labia, she passes the
catheter, smeared with a sterile lubricant, into the urethra, 4 nm.
(about 1'/:; incbesl, or until the urine begins to flow. The labia
are held apart until Ihc eathelvr is in the bladder. The urine nwy
ANTISEPSIS OP THE LYING-IN WOMAN 207
be collected in a cup or small bowl. The evacuation of the bladder
is repeated every eight hours. Care must be taken to prevent the
entrance of urine into the vagina and its contact with the genital
wounds. This is accomplished by compressing the catheter near
its outer end to hold the column of urine in the tube during its
withdraw^al.
When the catheterization has to be repeated for several days,
some urinary antiseptic, as urotropin, grs. vii in eight ounces of
water, or five-grain tablets of salol, should be administered at four-
hour intervals, as a prophylactic against cystitis.
The Bowels. — The bowels are to be opened on the second or
third day and once daily, thereafter. For this purpose a simple
enema of soapsuds and warm water is usually sufficient to produce
a satisfactory evacuation. Subsequently the daily movement may
be obtained by the administration of such mild laxatives as citrate
of magnesia, rubinat, or Pluto water, or cascara sagrada. Strong
cathartics should be avoided, not only because of their disturbing
effects upon the bowel, and their tendency to make the colon bacil-
lus more active, hut they are likely to disturb the child,
[Note. — We have repeatedly produced a marked elevation of
temperature and a leukocytosis in the blood, with a full dose of
oleum recini given on the evening of the second day. So constant
was the effect that this routine has been discontinued.]
Best. — If the after-pains are severe enough to prevent sleep,
they may be relieved by one or two doses of codein, gr. i, w-ith
five grains of aspirin. Since we have adopted the use of the
Kowler position as a routine after labor, w^e have found that the
afterpains have been inconsiderable; as postural drainage favors
the early evacuation of clots.
The drain upon the woman's resources, from the labor and dur-
ing the puerperium, is considerable, and every effort should be
made to have her obtain sufficient rest, sleep, fresh air, and good
food. The diet may be generous, including cereals, milk, eggs,
bread and butter, chicken, lamb, well-cooked vegetables, cooked
fruits; while some tonic digestive, containing iron, quinin, and
strychnia, may be of advantage in improving her general tone.
Antisepsis of the Ljring-in Woman. — Strict cleanliness of the
patient s person, personal linen, and bed linen is imperative. The
vulva dressing should be changed every three or four hours during
208 PHYSIOLOGY OP THE PUERPERAL STATE
the first three days, and thereafter often enough to prevent the
least putrefactive odor. A clean pad should be used after the
woman has urinated, or had a bowel movement. Before reapplying
a sterile pad, the nurse should cleatise (with an antiseptic solution)
the external genitals, and their immediate surroundings and other
parts of the body which may be soiled by the discharges. No va-
ginal douches are to be employed. Sepsis or fetor is controlled by
posture and rigid external cleanliness.
The vaginal douche post partum is dangerous practice, unless it
be given with the most scrupulous attention to aseptic detail. The
nurse should be scrupulously clean. She should wear only wash
dresses and change them frequently. Her hands must aitvays he
sterilized before touching the genitals or breasts of the patient, or
changing the dressing on the navel, or bathing the baby's eyes.
Strict asepsis is as essential for the nurse as for the phj^sieian.
Diet of the Puerperal Woman. — Convalescence goes on more
rapidly with proper feeding. The normal lying-in woman needs
an abundance of easily digestible and well-cooked food, yet an ex-
cess, or too great a restriction, in the diet must be avoided. No
fixed routine should be adopted, as it is better, if possible, to adapt
both the quality and the (juantity of the food to the needs of the
individual patient. For the first twenty-four hours or longer, if
the patient is much exhausted, or has had a prolonged anesthesia
for an operative labor, the diet should be restricted to fluids or
light solid food, consisting of milk, milk preparations, gruels, beef
juice, animal and vegetable broths, eggs (raw, boiled or poached),
raw oysters, custards, well-cooked cereals, tea and cocoa made with
water, the milk to be added on serving.
After the fii'st two or three days, when the bowels have moved,
and in the absence of exhaustion or fever, a moderately full mixeil
diet may generally be permitted. The patient should be fetl six
or seven times a day, taking hot milk, broth, or cocoa, on waking,
between meals, and before retiring for the night.
The heaviest meal should be in the middle of the day. To
establish a daily action of the bowels, cooked fruit in considerable
quantity may be introduced into the diet.
Tardy Involution. — Tardy involution of the uterus is a com-
plication of the i)uerperium, not uncommonly met in non-nursing
women, or women who have had fre<iuent pregnancies and sustained
REGULATION OF THE LYlNG-lN PERIOD 209
lacerations of the cervix, or have been the subjects of postpartum
hemorrhage, retention of secundines, or slight degrees of sepsis,
with coexistent endometritis, etc. To meet this complication, meas-
ures may be used to promote involution, such as massage, in the
form of gentle friction over the fimdus for ten minutes twice daily.
The hand is placed on the abdomen over the uterine tumor, and is
moved in a circular direction over the uterus, or it grasps the body,
through the abdominal wall, with the thumb in front and fingers
behind, and makes friction over the fundus.
Manipulation of the uterus is dangerous in the second week of
the piierperium, and should never be employed if the tardy involu-
tion is due to sepsis, as emboli are liable to be dislodged from the
thrombosed vessels in the placental site, caasing serious results.
Galvanism has a stimulating effect on the muscle and the blood
supply of the uterus. One electrode may be placed over the upper
part of the sacrum, and one upou the abdomen, over the uterus;
tc»n to twenty milliamperes are to be used at each sitting. The
seances last for ten minutes, and may be repeated twice daily.
Faradism can be employed in a similar way, and is, in our opinion,
of greater value in reducing the size of the postpartum uterus than
galvanism.
The continued use of ergot, either in the form of the extract of
ergot alone, in ] -grain doses, three times a day, or in combination
with iron, quinin, and strychnia, making the much used post-
partum pill, aids in reducing the size of the uterus. TJnfortimately
ergot may diminish the milk secretion. A hot vaginal douche, of
two or three gallons, at a temperature of 120° F., given twice daily
with a Davidson syringe, temporarily depletes the pelvic circula-
tion, and is of some benefit when the uterus is large and heavy.
Immediately following the douche, the patient should be placed in
the genupectoral position for five minutes, which permits the uterus
to rise out of the pelvis and further relieve the engorgement.
Douches should not be begun imtil about ten days after labor. The
curette in tardy involution has but a limited field, and should only
he used in ca^e of hypertrophied decidua, when metrorrhagia is
persistent. The use of the curette is dangerous in the puerperium^
especially when the subinvolution is accompanied with an elevation
of temperature or any exudate in the pelvic.
Begulation of the Lying-in Period. — While it is seldom possi-
210 PHYSIOLOGY OP THE PUERPERAL STATE ^
ble in hospital practice to keep the patient in the hospital long
enough to secure involution, in private practice the physician can
regulate the lying-in period, if he u-ill, even among those of mod-
erate means, and keep his patient under observation until the utems
has returned to its normal size, position, and condition.
The First TTcei.— During the first week the patient keeps the
bed, but after the first few hours slie has considerable license. She
may assume the sitting or half sitting posture to take her meals
and to nurse the baby, and, if necessary, for evacuation of the
bladder and rectum. She should assume the lateroprone posture,
both right and left, several times a day, and lie upon her abdomen
for at least an hour daily. Frequent change of position favors
uterine drainage and massages the uterine supports.
The Second Week. — During the second week she has greater
liberty, while the greater part of her time is spent on the bed or
lounge. She may sit up for her meals, to urinate, and for bowel
movements, and she should spend at lea-st half an hour, twice daily,
in abdominal and leg exercises to keep up her muscular tone.
The Third Week. — She may be moved to a chair for a part o£
the day, having the liberty of the room. After sitting up for any
length of time, she should be instructed to take the geuupeetoral
position before lying down. Prescribed exercises for the legs and
abdominal muscles are to be taken daily.
The Fourth Week.—H all goes well, she may leave the room and
have the benefits of air and sun. Physical exercises should be con-
tinued. The duration of the lying-in period and the degree of
freedom to be given the patient after the second week must, how-
ever, depend on the character and amount of the lochia, the gen-
eral progress of her convalescence, and the rate of the uterine
involutinn.
Establishment of the Milk Secretion.— Before the true milk
secretion begins, the mammary gUimls furnish a thin, slightly vis-
cid, yellowish fluid, which contains epithelial cells, fat globules, and
certain bodies called colostrum corpuscles. This substance is rich
in protcids and saline matter, and Is known as colosirwm. For-
merly it was supposed that this secretion was of value to the child,
because of its moderate laxative projHTtiei. Recent observation has
not confirmed this view. No i-olostrum corpuscles should he found
in tl,P \,r^a<t millf i,FtPr tl.n t^.itli dnv Thn trno milk «wvpti/in is
ESTABLISHMENT OF THE MILK SECRETION 211
usually established by the third day in priraiparse, and on the sec-
ond in multipara. Some mammary engorgement always takes
place and causes a slight elevation of temperature, whicb may be
relieved by a breast binder and a saline laxative.
Signs of Deficient Lactation. — Unfortunately, from ten to
twenty per cent, of women are unable to nurse their babies, owing
to deficient milk secretion, the signs of which are that the breasts
remain persistently flabby, and the child is not satisfied, and shows
signs of inanition, the most important of which is loss of weight.
The mother's milk supply may be at fault in quantity or in quality.
The clinical test of its fitness or unfitness is the child's gain and
general condition. To gain normally in weight, the baby should
increase from five to six ounces per week for the first five (5)
months, and a pound monthly for the remainder of the first year.
The child's weight should be taken and recorded twice a week for
the first three months, thereafter weekly. The best time to weigh
the child is just after the bath and before nursing.
Measures for Increasing the Maternal Milk Supply. — Fresh air
and moderate exercise in combination with a generous, mixed diet,
and plenty of milk, are the best galactagogues. Tonics, especially
strychnia, contribute to improve the general tone of the patient,
and by so doing may increase the milk secretion. Faradism ap-
plied directly through the breasts, once or twice daily, with the
positive pole over the nipple, may stimulate the mammary function.
Massage of the breasts, and especially of the abdomen, from below
upward, with a view to increasing the blood supply of the breast,
helps, as does also thyroid extract, in gr. i doses (3 or 4 times
daily), which seems to have some influence on the mammary
circulation and improve the quantity and quality of the secre-
tion.
Special foods have been recommended in case of scanty secre-
tion, such as beans, lentils, parsnips, and vegetable foods ccmtaining
phosphorus. Milk and cocoa, taken as a part of each meal, have
strong endorsements. Innumerable proprietory preparations have
been used and recommended to increase the mammary secretion.
Our experience, however, makes us doubtful whether any of these
preparations have any influence, as when fresh air, moderate ex-
ercise, and an abundance of proper food have failed to produce
suflBcient milk, the substitution of artificial feeding has usually be-
212 PHYSIOLOGY OF THE PUERPEBAb STATE ■
come necessary. Malt preparations taken with the meals aid diges-
tion and may increase the appetite. Coffee aliould be forbidden tu
the nursing woman, as it diminishes the secretion of milk.
Care of the Breasts and Nipples. — Tlie care of tlie breasts and
the preparation of the nipples for nur.sing should be begun six or
eight weeks before labor, as lias been already stated in the chapter
on the hygiene of pregnancy. After the birth, the nipples ueifl
special care to prevent the formation of fissures. The nurse sboiilit
cleanse the nipple before and after each nursing with a bland anti-
septic solution, such as a saturated solution of borie acid, to which
one-eighth (%) part of glycerin has been added; while before each
nursing the child's mouth should be cleansed in a like manner with
a saturated solution of boric acid, care being used to avoid injurj'
to the buccal epithelium from too vigorous handling. Exceasive
nursing must not be permitted, for the nipple is injured by long-
continued maceration, and avenues for infection are opened.
The nurse must be warned of the risk of carrying infection to
the nip]>les, or to the child, when her hands are soiled from han-
dling the lochial guard. The nipple should never be touched by the
nurse until she has first thoroughly disinfected her hands.
"When the breasta are engorged, the engorgement may be re-
lieved by applying hot stnpes to each breast for fifteen raioutea,
or until a superficial blush is produced, when the lactiferous
tubules may be emptied by gentle massage. The direction
of the stroke should be from the nipple outward to unload tlie
veins.
Massage is prohibited in the presence of inflammation, hence
it is important to differentiate between .simpli! engorgement and
mastitis.
Painful disti-iifinn uf Ww brcnsts may be relieved by the free
ej-hibili(in of .tnline rnlhailics in the form of a saturated solution
of niiigncsiuni suli)hate administered in drachm doses, without
dilution with water, by the rcsfriclcd ingestion of fluids, and by
the use of a snugly ap|>liL'd breast binder, making even compression
over the gland. Piiinting the skin overlying the gland with ecjual
parts of glycerin and the fluid extract of pinus canadensis, and
eorrriiig the breast with a thin layer of cotton batting before ap-
]i!ying the binder, i>roiii]itly relieve the pain and cheek the dis-
CONTRAINDICATIONS TO NURSING 213
Contraindications to Nursing. — There are certain conditions
of the mother which prohibit the cliild from nursing. These are
recent syphilis, if the child is not already infected, tuberculosis,
marked anemia, chorea, epilepsy, poor quality, or deficient quan-
tity, of milk, and the existence of pregnancy.
CHAPTER IX
■
THE CONDITION OF THE CHILD AT BIRTH
The weight of the newborn infant averages about 3250 grammes
(3175-3288), or 7 to ly^ pounds. Male children usually weigh
about a quarter of a pound more than girl babies. Children of
very young primipara? are usually smaller than the average, and
weigh less than subsequent births, while those of old primipane
(35-40 years) are larger.
A loss of weight takes place during the first three days amount-
ing to from six to eight ounces, which is due to inanition, conse-
quent upon the absence of the milk supply. Normally the child
regains its initial weight by the end of the first week or ten days,
and from then on should gain from five to six ounces a week for
the first five months, when the weight should be double that at
birth. For the next ten months the gain should average a pound
a month, imtil, at fifteen months, the child should have trebled its
original weight, after which time the gain is slower.
Measurement and Appearance of the Normal Child at Birthr-
Signs of BSaturity. — The length of the child at birth is from 45
to 50 cm. (18 to 20 inches). The suboccipito-bregmatic circumfer-
ence measures 33 cm. (1314 inches), and the length of the foot is
8 cm. (3^/8 inches), while its weight is about 3250 grammes. The
face and body are plump, the eyes are usually open, and the child
sliould cry lustily. Lanugo is almost wholly absent from the body.
The vernix caseosa, as a rule, is present only on the child's back
and the flexor surfaces of the limbs. The fingernails overreach the
fingertips, and the toenails extend to the end of the bed of the nail.
The cranial bones are hard, and the sutures and fontanelles
small, the cartilages of the ear and of the nose have become firm,
while centers of ossification are developed in the epiphysis of the
femur and in the astragulus.
The temi)erature of the child at birth ranges from 98.6** Fahren-
heit to 99° Fahrenheit, but is easily influenced by slight causes.
214
THE BLOOD 215
Disturbances of digestion, malnutrition^ or infection of the navel
cord are the common causes of sharp elevations in the temperature
of the newborn.
The Circulation. — At birth the fetal pulse rate ranges from
120 to 140 per minute. It should be counted by listening to the
beat of the heart. The ductus venosus and the umbilical vein are
obliterated within a week, the ductus arteriosus within a few weeks.
The foramen ovale may not close for several weeks or even months,
and occasionally the upper part remains permanently open. The
umbilical arteries are obliterated in their upper portions within
five days, the lower portions remain open and form the superior
vesical arteries.
The Stomach. — The stomach of the newborn infant is placed
high on the left side under the false ribs ; its axis is almost longi-
tudinal. In a child of normal weight its capacity should be one
ounce at birth and increase about one ounce per month up to the
sixth month.
Bespiration. — The lungs are collapsed at birth and the respira-
tory tract is devoid of air, until the first respiratory effort. If the
second stage has been prolonged, or when the head comes last, as in
breech births, the air tract may contain blood and vaginal mucus,
which is drawn into it by premature efforts at respiration. It is
for this reason (to allow the mucus in the trachea to drain by
gravity) that the child should be held in an inverted position until
respiration is established.
The first respiratory movement is due in part to air hunger,
from the arrest of the maternal supply of oxygen, and in part to
reflex contraction of the respiratory muscles excited by contact of
the air with the moist surface of the skin. The average rate of
respiration in the newborn is 45 per minute.
The Blood. — The blood makes up about 8 per cent, of the
total body weight in the newborn infant. The number of the red
corpuscles to the cubic millimeter is in excess (6,000,000-7,000,000),
and the hemoglobin percentage much greater than in adult life.
(The hemoglobin in the first three days may be as higli as 120
per cent.)
The ordinary jaundice which is seen in the newborn infant dur-
ing the first week is due, according to most authorities, to the over-
abundance of red corpuscles, which are destroyed in the liver, giv-
216 THE CONDITION OF THE CHILD AT BIRTH
ing rise to an excess of bile pigment, thus setting free the color-
ing matter in the blood, which is directly absorbed by the tissues.
The Skin. — The skin of the child's back and of the flexor sur-
faces of the limbs is more or less thickly covered with a cheesy
coating, the vernix caseosa, which consists of lanugo, epithelial
scales, and sebaceous material. During the first two or three days
the epidermis is partly exfoliated, leaving the skin red and irritable.
The Bowels. — The contents of the intestines are meconium,
which consists of intestinal secretions and bile, together with lanugo
and epithelial scales derived from swallowed liquor amnii. The
meconium is gradually passed off, and the stools become fcculenty
with a sour smell and acid reaction, within the first three or four
days. The child has from two to four bowel movements daily.
The Genitourinary Organs. — The bladder usually contains
urine at birth. Tlie urine is of low specific gravity, from 1003 to
1010, containing more or less marked traces of albumin. It some-
times gives a reaction for sugar. It does not, as a rule, stain the
diaper, though uric acid deposits simulating blood stains may often
be observed on the napkin. The child urinates frequently (ten to
twenty times in twenty-four hours).
In boys the testicles have descended into the scrotum. The
prepuce is normally adherent to the glans penis. In the newborn
the preputial orifice is usually too small to permit easy retraction
of the foreskin. If the foreskin cannot be retracted, because of tlie
firm adhesion to the glans, the preputial orifice may be nicked with
the scissors and the foreskin stripped back by freeing the adhesions.
The Nervous System of the New-Born. — The nervous system
is much more iiTitable and the nerve centers more unstable than
in later life.
The sensibility of the skin is feeble at birth, but it is fully estab-
lished within the first two or three days following.
The taste is (mly sensitive to strong impressions, while at birth
the child is deaf, since the meatus is closed and the middle ear is
conse(|uontly devoid of air. Loud sounds become audible within a
few hours. The retina is sensitive to light, though objects make no
impression u])on it.
The Secretions Are All of Later Development. — The lacrymal
and the sweat glands are not, as a rule, developed in the first
few months, and but little saliva is secreted; while the amylolytic
CARE OF THE NEWJ^ORN CHILD 217
function is feeble and not competent to digest starches until after
the sixth month.
The Caput Succedaneum. — The caput succedaneum and the
distortion in the shape of the head from molding disappear grad-
ually, without treatment, and in the course of two or three weeks
the head should have its normal contour.
CARE OF THE NEWBORN CHIID
The management of the newborn child should include a dis-
cussion of the methods for:
(1) Tlie establishment of its respiration
(2) The incubation of the feeble or i)remature infant
(3) The details of bathing
(4) The prevention of ophthalmia
(5) The care of the imibilical stump and navel dressing
(6) The form of clothing best adapted to the newborn
(7) Directions as to nursing and sleep.
Respiration. — Immediately upon its birth the child should
be suspended by the feet to promote the drainage of insi)ired mucus
from the respiratory tract, and at the same time cause a flow of
bloo<l to the brain. If this does not provoke inspiration, gentle
flagellation of the back and buttocks, blowing on the face, dashing
a few drops of cold water on the chest, or the sudden immersion of
the body into a bathtub of cold water, will usually cause the child
to make a deep inspiratory movement.
Asphyxia Neonatorum. — Asphyxia of the newborn infant oc-
curs from a deficient supply of oxygen in the blood, and is gen-
erally the result of injuries which are sustained during birth, dis-
turbing the placentofetal circulation, of compression of the cord, of
premature separation of the placenta, from a short cord or a cord
coiled about the child's neck, or of pressure on the fetal head in
prolonged and difficult labors producing fetal inspiration, espe-
cially in forceps operations and breech extractions. The prog-
nosis varies with the degree of asphyxia (asphyxia livida, asphyxia
l)allida). The chances of the chihl are generally good in the cyan-
otic, and grave in the pallid stage.
Simple measures, such as already referrcHl to for provoking
respiration, are usually successful in the cyanotic stage, particu-
218 THE COXDITION OF THE CHILD AT BIRTH ^
larly if they are supplemented by clearing the throat of roocus
with the finger WTapped with soft linen, or by aspiration of the
mucus with a soft rubber catheter introduced into the trachea, or.
in marked venous congestion, by allowing one or two drachms of
blood to escape from the cord while the child is saspended by the
feet. The fetal heart must be constantly watched during our at-
tempts to establish respiration, as it ser\'es as an index to the degree
of asphyxia. When very slow, the child 's surface temperature must
be maintained by immersing the body and the lower extremities in
water, at 100-105° Fahrenheit. If the child is pale and collapstil
a rectal injection of water at a temperature of 105-108° Fahreii-
licit may be given, should the child make no attempts at inspira-
tion.
Ifoldcn's method of direct insufflation with oxygen should be
used after the throat is cleared of mucus. The child is laid on its
back, in a bath of warm water, with the head partially extended,
to straighten the trachea. The hand is placed under the shoulders
and the neck allowed to rest in the cleft between thumb and index
finger, which steadies the head, A close-fitting mouthpiece, or
small rulibpr funnel connected by rubber tubing to an oxygen tank,
is then iirnily placed over the child's mouth and the oxygen turned
on. Almost immediately the rate of the heart beat will be increaW
iiiiil the cyanosis of the skin changed to pink, while upward stmk-
iug of the chest wall along the long thoracic nerve will cause the
child to make inspiratory efforts.
For several years this method has supplanted alt others in my
clinic. \Vc have combined it with the Byrd and Laborde methods
to be dcscrihcil later.
In liospiltil in'acticc the use of the pulmolor has replaced other
iiirlliiiils (if rcsuscilatiou.
Ill I'dsi' nil oMvj:>'ii is available, the following methods are of
VII 1 1 Lc:
Piriil Insufflation (Mouth to Mouth).— The child is laid on its
hack in a wnnu hhinket upon a table; the throat is cleared of
niucus: Ihe licnd is piirtially extended by placing a fold of blanket
under i|s neck; thi' Face is cleansed and covered with a clean piece
of sterile pilizc. To prevent inliation of tlie stomach, the hand is
held liniily on ihc i-pigaslriuin. Willi the operator's mouth againet
CARE OP THE NEWBORN CHILD 219
lungs by blowing gently into them. Expiration is produced by
compression of the chest wall with the hand. This is repeated
sixteen to twenty times per minute as long as the heart beats.
Schultze*$ Method. — For inspiration the child should be sus-
pended by the shoulders, face from the operator, by placing an in-
dex finger in each axilla, holding the thumb in front and two fin-
gers extended over the posterior aspect of each shoulder, expanding
the chest, while the head is kept steadied and extended between the
ulnar surfaces of the hands.
For expiration the position is inverted by swinging the trunk
and lower limbs upward and toward the operator's face, flexing the
body in the lumbar region. The first movement should he oim of
expiratioriy which helps to rid the trachea of mucus. The objections
to this method are, first, the chilling of the body ; second, the shock
involved, so that in feeble infants, if used at all, it must be done
with great caution. This, and direct insufflation with oxygen, or
by mouth to mouth, are the most effectual methods in asphyxia of
the newborn.
Sylvesier^s Method. — The child is placed in a supine position,
with the head well extended by a fold of blanket under its neck.
For inspiration, the arms are drawn well above the head; for ex-
piration, they are placed by the sides and the thorax gently com-
pressed. The value of this method is increased by making forward
traction on the tongue during inspiratory movement.
Byrd's Method. — The child is held supine upon the hands of
the operator at right angles to the forearms. For inspiration the
radial borders of the hands are lowered. For expiration they are
raised. The child is successively folded and unfolded.
Laborde's Method. — With the child lying in a supine position
on a table, or in a warm bath, with the head extended, gentle inter-
mittent traction is made on the tongue about eighteen times to the
minute.
AVhen respiratory movements have been established hut remain
persistently feehle, a weak Farad ic current, one pole of which is
applied to the nuchal region and the other over the epigastrum,
combined with the continued inhalation of oxygen, may induce
deeper and stronger respiratory efforts.
Should all of the foregoing methods fail, and the fetal heart,
however slow, continue to beat, an injection into the umbilical vein
220 THE CONDITION OF THE CHILD AT BIRTU "
of 30-50 em, of sterile normal salt solution, euutaiiiing 0.5 per cent.
of fructosate of sodium, may be given. The salt solution dissolves
CO,.
Incubation of Feeble or Premature Infants.^The premature
iGfont pivsenis twn jiliysiologifa! abuormii 11 tit's, a sulmorraal tem-
perature aud the inability to ingest and digest a sufficient quantity
of food. Therefore, premature, puny, and anemic children will
generally require incubation. The infant prematurely bom should
be kept in the incubator for as many weeks as it is premature. It
should be removed from it only for feeding and bathing, when it
must he carefully guarded from esposure. Premature and feeble
infants nurse poorly. They may be given sufficient nourishment.
by drawing the milk from the breast with a sterile breast pump,
and giving it to the child by gavage, in a bottle or with a metlicine
dropper. The child should be fed every hour, beginning with ft
drachm at each feeding. The intei-val and quantity should be
gradually increased.
The temperature of the incubator should be at first about 90°
F., and gnidually be lowered to that of the room during the few
weeks preceding the fiiiiil removal of the child. Ample ventilation
must, of course, be provided, and this is extremely difficult in the
several hot-air apparatuses in general use. During the last few
years we have substituted for the regular incubator a square in-
cubating box, 30 inches long, 20 inches wide, aud 24 inches high.
A hot water bottle is placed in each comer, under a feather pillow
which covers the bottom. The jnfnnt, who has been previously
rubbed witli warm oil, is wrapped in a layer of absorbent cotton
and placed in the box. The box is covered with one or two thick-
nesses of clean cheesecloth, and a thermometer is kept in the eoni-
piirtiin'itl with the child, that the temperature may be accurately
The Details of Bathing. — The face is bathed on the birth of
the head, aud the cye.s are cleansed with a boric acid solution imd
carefully dried, as a pniphylactic against ophthalmia.
The body is smeared with warm sweet oil or vaselin to facili-
tate the subse(iU''nt removal of the veruix caseosa. A tub balh i.'
not given until llic cord falls off and the umbilical wouud has
healed, a warm s|inngc bath being substituti'd.
CARE OP THE NEWBORN CHILD 221
morning hour should be chasen midway between feedings. The
temperature of the water should be 98° Fahrenheit by the bath
thermometer; that of the room 75° Fahrenheit. The least chilling
is injurious.
The nurse should have a warm, dry towel laid upon a warmed
blanket ready to receive the child, and dry it on its removal from
tlie bath. The duration of the bath should not exceed five minutes.
A square of fresh boiled cheesecloth serves as a washrag.
Only a bland mildly alkaline soap (Castile) should be used, and
little of that. Special attention must be given to the scalp to re-
iixove the scales of epithelium and sebaceous material.
The full bath is repeated daily in summer and daily or every
ot lier day in the colder months, depending on the robustness of the
eliild. Parts of the body exposed to soiling must be cleansed as
often as soiled.
In puny and anemic children the full bath must be postponed
for several days. They do better if a daily rub with warm sweet
oil is substituted, the face and eyes only being cleansed with water.
If the child is kept clean and the skin thoroughly dried, infant
powders are unnecessary.
' The Prevention of Ophthalmia Neonatorum. — The instillation
^nto the conjunctival sac of each eye of one or two drops of silver
titrate solution, 2 per cent, (or gr. x, 5 i)> or of a 10 per cent,
^^gyrol solution, should be a routine procedure at each birth,
^^'hether in hospital or private practice, as the prevalence of gonor-
''hea among the innocent is so great that the physician cannot take
^he chance of discriminating. When silver nitrate has been used,
^^e excess may be washed away with sterile salt solution.
Argyrol in a 10 per cent, solution is much less irritating than
the nitrate of silver, and is nearly or quite as effective.
The Navel Dressing. — The physician, after resterilizing his
'JHnds, or donning sterile gloves, should dress the stump of the
^avel cord with sterile absorbent cotton, saturated with strong al-
^*^>hol. The stump should be turned to the left side to avoid in-
•lUrious pressure on the liver, and retained in this position by a
loose abdominal binder. Rapid desiccation is the chief reliance for
preventing putrefactive changes in the stump. The alcohol dress-
'**S promotes desiccation, while powders tend to hinder the drying,
^^il are best omitted.
16
222 THE CONDITION OF THE CHILD AT BIRTH
After each batli, if a full bath be given, the navel atuinp should
be carefully bathed with strong alcohol and a fresh sterile dressing
applied. It is better to substitute for the tub bath a sponge bath.
or in feeble children an inunction with sterile sweet oil until the
cord fails off.
This usually occurs on the fifth or sixth day. The navel wound
may then be dressed with a compress of sterile gnnze, spread with
a layer of sterile zinc ointment to prevent its adhesion to the
wound. This is removed daily until the wound is healed.
It is imperative that the umbilical woiuid be kept surgically
clean or septic infection of the navel may result in phlebitis of the
umbilical vein, pyemia, and death. This is one of the commonial
causes of fatJility in the newborn.
Clothing of the New-born Infant. — The skin should be pro-
tected, tile I'xtreiiiilii'S and body alike, with woolen or linen iiii'sh
undergarments of ligiit weight. It is well to have changes for niglit
and day use. No garment must be used until laundered, A ser-
viceable outfit for the first six or nine months of the infant's life is:
(1) A belly band of fine French flannel, 4 inches wide by 30
inches long, to fasten with tapes, or a knitted mesh bunii
supported from the shoulders,
(2) A napkin made of linen diapering, freshly laundered and
dried.
(3) An undershirt of the softest silk and wool or linen meati,
opening in front, without sleeves for summer, with long
sleeves for winter use.
(4) A fine tiannel princess dress, witli high neck and sleeves,
opening iu front and about twenty -five inches long, to be
worn in winter under the muslin slip.
(5) A nuislin ulip made in similar style.
(6) AVook'n socks, long enough to cover the legs to the knee*.
The use of short-sleeved, low-necked, long-skirted lace slips is to
be disparaged; the baby needs protection and comfort during its
early life, not style.
The belly band and all bands in the clothing should be supplied
with tapes for fastening, or should be sewed on. No pins should
be used about au infant's drei^s, except the diaper pin to hold the
CARE OF THE NEWBORN CHILD 223
napkin. All bands should be loose enough to admit two or three
fingers underneath them in order that there shall be no constriction
or restriction of the baby's free movement.
At night the child should have a sponge bath and the under-
clothing changed; the muslin and flannel slip are replaced with a
light flannel or linen mesh nightdress, having a drawstring at the
bottcmi, so that the feet are protected from cold.
Nursing. — The child is put to the breast after the mother has
had rest and sleep, and has recovered from the shock of labor;
usually at the end of ten to twelve hours. Each nursing should
not be longer than fifteen minutes.
I'ntil the milk secretion is established on the second or third
day, the child should not be given the breast oftencr than every
four hours, thereafter at intervals of two or two and a quarter
hours. The milk becomes too rich with too frequent nursing , too
thin when the intervals are too long. One interval at night is
lengthened to four or six hours. It is well to wake the child, if
necessary, on the hour, and thus establish a regular habit. Chil-
dren gain better when brought up by routine.
The intervals should be extended to three hours by the time the
child is three months old, and to three and a half to four when it
passes six months. After the seventh or eiglith month, one or more
artificial feedings daily will be required, together with the addition
of a few teaspoonfuls of fresh orange juice, given just after the
bath.
Should the mother be imable to nurse the child, or should the
child show constant loss of weight from the mother's milk, wet
nursing or artificial feeding must be substituted. It is difficult to
procure a good wet nurse when one is wanted, because she mast
meet certain definite requirements in order to be a good substitute.
A good wet nurse should be of a mature age, between twenty
and thirty-five, preferably a multigravida. It is essential that her
own child be within one or two months of tlie same age as the fos-
ter child. A menstruating woman is sometimes unsuitable; a preg-
nant one is always so. She must be of sound physical and mental
health, and be w-illing to submit to a thorough physical examina-
tion, especially for tuberculosis, syphilis, and other contagious dis-
eases. A Wassermann reaction should be taken of both the serum
and of the milk. The breasts should be of somewhat conical form,
224 THE CONDITION OF THE CHILD AT BIRTH
well developed, with prominent veins, and have well fornipd and
healthy nipples. Her own child should be sepn and exaniiiitil as
to its growth and development, for its condition speaks for tbe
quantity and the quality of her milk. Personal cleanliness is a
factor in the success of a wet nurse.
A properly fed, healthy baby should sleep from eighteen to
twenty houis out of the twenty-four, waking for its nursing. The
child should be taught to lie in its crib or basket, out of doors in
fiummer, in a cool, ventilated room in winter, and should not be
bundled by the nurse or mother.
Weaning. — Weaning should be a gradual process and should
not be thought of while the child shows a weekly gain, until after
it has cut eiglit teeth. Should this period fall in the hot luontlis.
weaning may be postponed until cooler weather.
CHAPTER X
ARTIFICIAL FEEDING
When (constitutional diseases of the mother render Dursing in-
advisable, or when the supply of mother's milk is insufficient, or
the (luality is poor, as is shown by a loss in the weight of the child,
or the persistent disturbance of its digestion, or w^hen a proper wet
nurse is not available, resort must be made to artificial feeding, by
the modification of cow's milk, as a substitute for what the child
should receive from its mother.
Cow's milk should be the basis of the substitute food for at
least the fii*st year and a half of the child's life. Unfortunately,
there are marked differences between cow's milk and human milk.
The most important of the.se are in its gross appearance, its re-
action, its specific gravity, the character of the curd, and the
amount of casein, sugar, and ash which it contains.
A tabulated comparison shows that human milk and cow's
milk differ in the following points:
HUMAN MILK
In gross appearance is yellow-
ish, or bluish, and more or less
translucent.
In human milk the reaction is
alkaline.
The specific gravity of human
milk is 10.24-10.33.
The character of the curd in
Iniman milk is light, flocculent,
and easily digested.
Casein, or proteids, make up
from 1 to 2 per cent, in human
milk.
cow S MILK
Cowl's milk is dead white in
color and opaque.
The reaction in cow's milk is
acid.
The specific gravity of cow's
milk is 10.30-10.35.
The character of the curd in
cow's milk is dense and tough.
The casein and proteids in
cow's milk amount to 4 per cent.
225
226 ARTIFICIAL FEEDING
Human milk contains from seven to seven and one-half per cent
of sugar, as against five per cent, in cow's milk, while the atnoimt
of ash in cow's milk is about five times greater than that found in
human milk. Cow's milk differs further from human milk, in that
the albuminous envL'lope surrounding the fat globule is thicker
and tougher, and cow's milk is the habitat for numberless millioHK
of both pathogeuic aud nun-pathogenic bacteria, while human milk
is usually sterile.
Certified milk from a good dairy is better than one cow's milk.
because it is more nearly constant in quality. In using cow's milk
as the basis of modification, four basic facts must be kept ctm-
stantly in mind: first, the total quantity of the modified mixlurt
required; second, the clipmical difference in the reaction of the
cow's mUk, as compared with breast milk; third, the protein ma-
terial is far leas digestible, and in greater quantity, in cow's milk;
and, fourth, the prevalence of bacteria in cow's milk.
Sterilization by heat destroys the germ content and retards the
fermentative changes. It does not destroy the products of fer-
mentation, but impairs the nutritive value of the milk. Pastenri-
zation, or exposing the milk to a temperature of not less than 150*
Fahrenheit for twenty minutes, will render the milk sufficiently
germ-free for infant food, and produce a minimum injury to the
nutritive value of the milk. I'iisteurization is always advisable
when the cleanliness of the milk cannot be trusted, especially dur-
ing the summer months. When certified milk can be obtained and
kept chilled below 60° Fahrenheit, from the time of milking until
it is used as the basis for modification, no sterilization or pasteuri-
zation is needed.
The ratio which the proteids lieiir to the fat in an artificially
pvepariHl food .should be as follows; In the first montk the pro-
teids should bear a 1 to 3 relation to Ihr fats. After the fourth
vionlh, the ratio is gradually increased until the relation is 1 to 3.
vhicli proporiion may be coiiliuiifd until the cud of the tenth
month, whin Ihi rlnlil's (/i;/r.',7(Vi iipimratus is capable of handling
proteids and j'lit In iibmit niniil i-'-iipKrnon, as is found in cow's
viilk.
In order lo icdiii-e tlu' tendency of casein to coagulate into
large, firm nia^ses on entering the stomach, a diluent, such as
sterile water, or dcxtrinized gruel, or whey, must be added to re-
ARTIFICIAL FEEDING 227
duce the amount of proteid to the proper level. While this dilu-
tion reduces the percentage of casein, it also reduces the percentage
of fat and sugar, bringing the percentage of each below that found
in human milk.
To make up for this reduction in the percentage of fat and
sugar, fat is added in the form of cream, and the sugar percentage
increased by the addition of sugar of milk. In making up the
percentage of sugar to the standard of human milky one ounce, or
about three level tablespoonfuls, of milk sugar may he added to
each twenty ounces of the mixture, which adds approximately 5
per cent, of sugar. Since the cow's milk is acid, while the hvrman
milk is alkaline, the acidity should be corrected by the addition of
5 per cent, of lime water (one ounce to each twenty ounces of the
mixed food), or one grain of bicarbonate of soda to each ounce of
the milk mixture.
In order to obtain milk containing the required proportions of
proteids and fat for dilution, the sealed bottle of certified milk is
placed in the refrigerator and allowed to stand for four hours,
when the milk will be found to have fully creamed; the line of
demarcation between the cream and the under milk will be plainly
risible. The upper two ounces of cream will contain about 14 per
cent, of fats; the upper ten ounces, or the upper third of the bottle,
known as **ten ounce top milk," about 12 per cent., while the upper
half, or ** sixteen oimce top milk,'' approximately 8 per cent. The
percentage of proteids and of sugar is the same in all top milk as
in whole milk. The top milk may be removed with a Chapin dip-
per, or by syphonage of the under milk, leaving only the desired
strength top milk in the bottle.
The strength of the food is regulated by the amount of dilution,
and varies with the age and capacity of the child.
Thin cereal, gruels, or whey, when used as diluents, prevent
the casein from forming large, tough curds in the stomach by
breaking up and softening the curd.
To prepare a dextrinized grucU take a tablespoonful of
barley, wheat, or rice flour, and mix it into a paste with
cold water, add water to the amount of one pint, or in that
proportion, and boil for twenty minutes. After allowing the
gruel to cool to 100° Fahrenheit, a teaspoonful of Foebes'
diastase is added, and the gruel is allowed to stand for ten
228 ARTIFICIAL FKEDING
minutes, permittiDg the ferment to act, when it is ready to be useii
as a diluent.
To pripare whey, a pint of milk is heated in a 8uital)le vessel
to a temperature of 115° Fahrenheit, and maintained at this tem-
perature while 1 or 2 dradims of Fairchild's essence of pepsin is
added. The separation of the curd begins to take place abuosl
immediately, and the curd is formed within a half hour. The
whey is then strained off, through several thicknesses of sterile
cheesecloth, leaving the coagula iu the strainer. Whey contains
about 1 per cent, of proteids, .22 per cent, of fat, and 4 per cent, of
sugar. By stirring the curd before straining, the percentage of
fat may be raised to nearly 2 per cent.
The proteid strengtii may be increased by adding the white of
an egg, which, when added to a pint of the food, adds about one
per cent, of proteid.
Before using whey as a diluent, and mixing it with top milk,
it should be heated to 130° Fahrenheit to check the ferment ; other-
wise the contained ferment will curd the top milk. Whey should
always be cooled to 100° Fahrenheit, or less, before it is added to
top milk.
Spring water rather than boiled water may be used for dilution.
Water thins the milk, but has no modifying effect, as do dextrin-
ized grui'ls. on the curd.
In making up formuliu for the feeding of the newborn infant,
it is well to begin with a lower proteid pereenlage (1 per cent., or
less than 1 per cent.) than is present in mother's milk.
In illustration, for an infant one week old, we may use:
2 oz, iif 10-(iuncc (np milk. 12 per cent, of fat,
17''^ " of wnler, gruel, or whey,
lU '■ milk sii^ar,
\U " lime waltT, or Hi fjcaiiis of soda bicarbonate.
1 oz. lime water,
2 " cream (top), 14%,
3 '■ milk,
14 " of water.
1 " sugar mill;.
Such a mixture is low in fats
and very low in proteids.
In artificial feeding, a.'^ide from the iinality of the mixtore,
ARTIFICIAL FEEDING
229
which is increased by lessening the proportion of the diluent
as rapidly as the child s digestion ^vill permit, the quantity must
be governed by the capacity of the infant's stomach, which is very
small, i. e., about 5 drachms at birth, and an ounce by the end of
the first week; from then on its capacity increases about a drachm
and a half a week during the first five months, while after that age
the rate of increase is smaller ; hence, overfeeding must be guarded
against, and regularity insisted upon, in order that the child may
be trained in regular habits.
The following table may serve as a guide in regulating the
amount of feeding:
Age
Intervals
Amount of Each
Footling
Nunil>cr of Fooiliugs
in 24 Hours
Ist day
2 hours
2 drachms
10
2nd day
2 hours
^o ounce
10
3rd day
2 hours
1 ounce
10
2nd week
2J^ hours
1 ^ 2 ounces
10
6th week
3 hours
23^2 ounces
8
3 months
3 hours
4 ounces
7
6 months
3 hours
o ounces
Cor 7
9 months
3 hours
7 ounces
6
12 months
3}i hours
8 ounc(is
6
Small and feeble children should be fed more frecpiently and
in smaller quantities; robust children in larger amounts, and with
stronger mixtures.
The inter\'al should be lengthened at night to four or six hours.
The space at my disposal is too limited to go into the complex
problem of infant feeding. The student is referred to the text-
books on Pediatrics.
CIIAl'TKR XI
IirSORDKRS OF THK NEWBORN INFANT
CONSTIPATION
Constipatiun in tlif ni?wbom is usually due to a dietarj* error,
therefore its Irealmeiil is to rvgulale the digestion and the feeding.
Knougli eroani may be added to the food to raise the proportion of
fat to 4, 5, or even 6 per cent. This alone frequently overeomra
tlie constipation in ' ----- ~',veii a moderate excess of
fat, liowevee, is not, lOme. The addition of a
little salt to each hot itive eflFeet, 2-5 gr. to the
ounce.
Suitable laxatives are
IJ Kxt. seunie fluit
Sneehai-i lactic
M. — This may ho givei
water, or of syrup of ini
milk.
gr. s
' in a teaspoonful or two of
heil in and given with the
li Kxt. senii;i' fluid., deodorat. (N. F.) Ss.s,
Porassii ct sodii tart rat is 5]
(-ilvf.Tini 3 8.8.
.\<\UA' ad 3iv
M,--l)osf: A Ifaspooiil'ul. p. r. n.
I'hillili's milk of iiiiifriii'sia is an eligible laxative for infants.
Ill' ilii-^c is oiii' li^itspimiil'iil line lo four times a day.
Tsi'lul riH-t;il ini'iisujvs aiv the iujivtiou of equal parts of
lycTiii ami waliT. ."i ij. .-^wi'i^t nil. 7, iv. or warm water, 5 j- The
s,> 111" a siiiiimsiun'v ul' snap or rai-ao ImlttT. or a glycerin or
iulfii siippnsii.ify iTi^ui'iallv pnivnki's iuuuediate action of the
iiwi'Is. Yrt i:ly,-i'riii sui'iiositofL.'s may prove too irritating to
DIARRHEA 231
INDIOESTION
The symptoms are flatulence, sour, green, and curdy stools,
vomiting an hour or more after nursing or feeding, restlessness,
disturbed sleep, colic, failure of the normal gain in weight.
Treatment. — The treatment should consist mainly in the regu-
lation of the nursing or feeding. The food is almost invariably
the source of the trouble. The health and habits of the mother
should be enquired into. It is sometimes useful to dilute the
mother's milk by giving the child a teaspoonful or two of warm
water with the nursing. In acute indigestion all feeding should
be stopped for several hours, and the colon and lower intestinal
tract washed out by colonic flushings with a saline. Whey or dex-
trinized gruel may be substituted for milk. Sometimes the first
thing needed is to relieve the stomach of its contents by lavage.
Four to five 1/10 gr. doses of calomel given at intervals of a half
hour may be useful.
COUC
Colic is always indicative of a faulty digestion.
Treatment. — The treatment consists in removal of the cause,
correction of the digestive error, and regulation of the feeding.
For the pain, chloral is almost a sovereign remedy. The dose
is gr. j in water, 3 j, or in syrup of vanilla and water, aa 5 ss, re-
peated once to three times daily, or p. r. n. ; milk of asafetida, 5 i
by the mouth, or § i per rectum, is generally effective; warm
applications or rubifacients to the abdomen, or warm rectal in-
jections, 3 j» are useful palliatives. The curative treatment must
consist mainly of measures addressed to the digestive disorder.
DIARRHEA
Diarrhea is generally caused by indigestion.
Treatment. — All feeding should be suspended for from 6 to
12 hours, and no milk should be allowiKl for 24 or 48 hours. The
white of egg or a dextrinized barley gruel or whey may be sub-
stituted. The strength of the gruel for this purpose may be 2 to
4 tablespoonfuls of barley flour to the pint. Milk feeding, when
DISOHDIRS OP THE NEWBORN INF A]
■^^1
resumed, must be bogim cautiously. A niihi laxative, preferaWy
castor oil or calomel, iu miuute dosus, or both, may be JudiratoJ
to remove irritating material. Then bismuth siibnitrate, gr. x,
may be givuii e\riy one or two hours to check the movemeota.
Should this fjiil. earn ph o rat etl tincture of opium, drops iij to x.
may be add<d to each dose of the bismuth. Calomel is esprciatig
useful in case of vomiting; opium for pain, frequent stooit or
tenesmus. The number of stools should not be rf?ducetl below 4
daily. Irrigation of the colon once or twice daily with normal
salt solution is indicated only in the presence of putresciblo ao-
cumulations or acid I
Symptoms.— The r . of the mouth ia studded
with white |ialelifs, with an a iKldeneii mucous membrane,
due to the presence of a fun^ patches resemble milk-curds
in appearance, but are disti from them by their firm
adliesion anil liy the detection „ saccharomyccs albieaua and
spores of the parasite under the microscope.
Treatment.^To destroy the fungus, the patches shonld be
sopped tviry two hours with a saturated solution of boric acid or
with a soliilion of sodium sulphite, one drachm to the ounce. For
the stomalilis. which persists after destrnetion of the fungus, a
halt'saliniit'd solntion of |x>tassie chlorate may be used, or better,
as being Ji'ss toxic. soiHe chlorate as a mouth wash. The child
itmst not lu> poniiilli'd to swallow atiy of these solutions. The
jiiTomi'Miiyiii'T gastrointeslitiiil disorders are to be treated as in
■\!lii'in;i or iliatiuir of the skin about the arms
ai-ri.l disiliariTi's or uneleanliness in the care
l';nr- should In- k.].! i-loan. and care taken to
. ;iri- lo !l;,- -.kill l\v iixi nuu-h friction. As an
.ii!i;ivi :it;.| .i\i,l ,11 Am- should be used ia
n :h.- :v?\.-:i-\ >uri';i.'e after first bathing the
ICTERUS 233
soiled surfaces with warm borax water 3 ii-Oi. Talcum powder
is a useful application.
CEPHALHEliATOliA
Cephalhematoma is an extravasation of blood, usually between
the pericranium and the cranial bones, which lifts the peri-
cranium from the bone; rarely it occurs internally. After a few
daj's a hard ridge develops at the margin of the tumor, owing to
a periosteal inflammation. It rapidly increases in size, possessing
the physical signs of a cystic tumor, with sharply defined boun-
daries. Its situation is most frequently over one parietal bone;
it may be bilateral; exceptionally it is the site of the caput suc-
cedaneum.
Prognosis. — In the internal form the prognosis is grave if
cerebral symptoms develop. The external variety, as a rule, ter-
minates in subsidence of the tumor in about three months.
Treatment. — If the swelling grows, it may be strapped firmly
after shaving the head. If pus forms early incision is indicated.
Otherwise no treatment is required.
PREPUTIAL ADHESION
In male children the adhesion of the foreskin to the glans,
which is usually physiological in newborn children, may cause
irritability of the bladder and other reflex disturbances. In such
cases the preputial orifice should be dilated very gently and the
adhesion broken up till the foreskin can be fully retracted. Nick-
ing the prepuce in the median line on the dorsum with scissors
may be required to permit retraction. The prepuce, being drawn
back, is liberated from the glans by the aid of a smooth, blunt,
stiff probe; a dressing of vaselin or of bismuth powder, together
with daily retraction, will prevent readhesion.
ICTERUS
Icterus occurs in a large proportion of newborn infants. It
begins from the first to the fifth day after birth, most frequently
on the third or fourth. It is observed oftenest in premature and
feeble infants and after difficult labor. There are two forms, the
234 disord: rs op the newborn inpa;
mild and tin' grave. Both jiossibly are due to i-esorption of bile,
due to the stiiall lumen of the biliary ducts; yet by most auliior-
ities the latter is attributetl to blood changes, due to streptococcic
iufection of the blood current, producing diaiutegration of the
red blood corpuscles.
In the mild form the conjunctiva! and the urine are not ataintd.
In the grave form the conjunetivir and the urine are atained aai J
the stools art! el ay- colored. This form may be due to genera) |
sepsis or to serious organic disease.
Treatment,— As a rule, no troatment is required. In per-
sistent eases aiii'iitidii !ie bowels being kept open
by enemata. or. if need m a mild laxative, as sodium
phosphate, combined if occasional small doses of
calomel, constitutes tl
In persistent icter ,. g discoloration, and espe-
cially in the presence of sep high temperature, treatment 1
is generally futile. I
OPHTHALML. SATORUM
Cause. — Tlic cause is infection of the conjimctivie, asnally
from the genital tract of the mother. The gonocoecus of Neisser
is the ijil'eeting organism in more than one-third of the cases.
The oi-diujuj- pyogenic bacteria or the LoefHer bacillus may be the
active agent, Ocncrally it begins on or before the third day.
The eyelids are edematous and puffed out, secreting a seropuru-
lent discharge, and the conjunctiva* are red and velvet-like in
a|)pearanee, while llie cornea loses its luster.
Prog;nosis. — Tlie prognosis for the sight is grave in the ab-
si'uee of liiiLt'ly In^iitiiifiil, Jlost si'rious is a mixed infection with
goimeoeeus nnd strejitoeoceus or with streptococcus and LoefBer's
liai-iUus. .\ liiicleriologicid dijignosis is important with relation
1o progiiosis. In ibis eouTitry thirty-two per cent, of all cases of
lolal Mindnes.s in jisylums are siiid to be due to ophthalmia neona-
lornm. .\lmosl wilboiit exeeiiticm, under skillfully conducted man-
iigeiii,-iil. llie siii.|.uriilion is i>roinptly eontrnlled and the sight is
Treatment. I'l-nphiihuti.-. — Tlie iiiitternal passages should be
ilisinlVi-led Iiel'iire ;nid during llie liibor in case of gonorrheal
OPHTHALMIA NEONATORUM 235
infection. The child's eyes should be cleansed immediately after
the head is born. One or two drops of a two per cent, solution of
nitrate of silver, or a ten per cent, argyrol solution, should be
instilled into each conjunctival sac shortly after birth. The latter
is now generally preferred. It is important in preparing the
solution that it be not boiled, and that it be not exposed to light.
Silver is precipitated by the action of heat or light, and the solu-
tion then becomes irritating. The prophylactic use of the silver
solution should be the rule in hospital and private practice. The
eyes of every child should be treated with the solution within a
few minutes after birth. It should never be omitted when the
mother is known to be the subject of leucorrheal discharges.
When properly employed the immunity is practically absolute.
Should the use of the silver solution be followed by much serous
oozing, the latter may be promptly relieved by a single applica-
tion to the conjunctiva of a one-grain-to-the-ounce solution of
atropin, one drop in each eye.
Curative. — At the onset of the inflammation, ice water com-
presses, renewed every few minutes, are useful in the absence of
corneal complications. The eyes are cleansed of pus every hour
or oftener, dayi mid night, by irrigating with a warm saturated
boric acid solution.
After free discharge is established, the conjunctival surfaces
should be brushed, after cleansing, once or twice daily, with a two
per cent, aqueous solution of nitrate of silver, and one or two drops
of a 25 per cent, aqueous solution of argj^rol, freshly made, should
be instilled into each eye several times daily. This is continued
till the discharge loses its purulent character. Frequent cleansing
with the boric acid solution must still be practiced until all dis-
charge ceases. Anointing the edges of the lids with vaselin favors
drainage by preventing the lids from becoming glued together.
The nurse should be drilled in the method of manipulating the
lids.
The advice of an oculist should he had and the responsibility
shared.
236 DISOKDHKS OF TIIK NEWBORN INFANT
■UMBILICAL IlfFECTION
The cause is unpleanliiiesa in the can.! of tlic iiinbilical wound.
The infecting organism is most frefjuently the streplococcufl. The
septic process may result in a mere local ulcer covered with a
grayish di])htheritie membrane, or in umbilical phlebitis arid sep-
ticemia. Ill the latter event tlit-re are fatty degeneration of the
organs, icterus, cyanosis, and hemoglobinuria ; the termination is
fatal, usually by convulsions. Pus may be present in the umbil-
ical vessels from infection through the navel, even wJien the wound
has healed promptly. Cellulitis of the abdominal walls and peri-
tonitis are frequently observed. Septic processes in remote or-
gans arc common complications.
Treatment.— In local sepsis frequent antiseptic cleansing of
the wound surface and dressing with aristol, bismuth powder, or
iotloform and bisnuith suffice. The peroxid of hydrogen is a gooil
antiseptic fur disinfecting the wound surface. It is uou-poisonous
and practically non-iiritant. Inunctions of quinin and the use
of stimulants by the stomach help to increase the resisting ix)wer.
In systemic infection treatment is fulile.
ITKBILICAL FTTNGUS
Uuibilical fungus is iin oviTKrowth of gi-iinulation tissue, which
projects in a mass like a stviiwberry from the navel. It bleeds
readily, and seci-etes a purulent discharge.
Treatment. — It is destroyed by cauterisation with a solid
stick of silver nitnite. or it miiy be ligated and excised.
OMPHALITIS
Omphalitis is a septic inllamumtinn of the navel and the tis-
sues surrounding the uuibilieus, in which the skin and subcu-
tauiMJUs connective tis.suc arc hard, n-d, and infiltrated, giving the
abdomen a conical shapi-.
Treatment. — Tn'iilnn'ul ini'Imli's disinfection of tJie umbilical
wound, radial incisions iii'o \\\r suiTiiunding skin to relieve the
tension, and the employiuent of iuitiseptic poultices. Unfor-
tunately the ]n-oguosis is grave, and general infection can seldom
UMBILICAL HEMORRHAGE 237
TETANUS NEONATOETJH
The disease begins toward the end of the first week. The
cause is infection, generally of the navel, with the tetanus bacillus.
The symptoms are those of surgical tetanus. The termination
is almost invariably fatal within two or three days.
Treatment. — As far as possible all sources of peripheral irri-
tation should be removed. Feeding is maintained through the
nostrils, using predigested milk, or, this failing, by rectal injec-
tions. In feeding through the nostrils the food is poured from a
special narrow pointed spoon. The drug treatment consists in the
use of potassium bromid, gr. iv, every two to four hours, or of
chloral, grain j, every hour. These remedies must be given by a
stomach tube or rectal tube. Sulphonal, gr. iij, every two hours,
by the rectum, has been used with success. Serum treatment,
properly carried out, should be tried.
HELENA NEONATOEUM
Melena neonatorum, gastrointestinal hemorrhage, is an extrava-
sation of blood into the alimentary canal. The condition appears
in the first hours of infant life, and is characterized by the vomit-
ing of blood either in an unaltered state or as ** black vomit,'' and
by the passage of dark, pitchy, and grumous stools^ mixed with
meconium.
The infant shows symptoms of internal hemorrhage.
Treatment. — Between 30 and 40 per cent, of infants so
affected die. The subcutaneous injection of human blood serum,
10 c. c, three times a day, has given the most satisfactory results.
No other form of treatment has seemed to affect the outcome.
TTHBILICAL HEMOEEHAGE
T^mbilical hemorrhage may come from the cord or from the
umbilical ulcer after the cord has dropped off. The bleeding may
proceed from faulty ligation of the cord, syphilis, or acute fatty
degeneration with hemoglobinuria. The hemorrhage usually be-
gins within a week after birth. Eighty per cent, of the children
die.
17
238 ■ DISORDERS OP THE NEWBORN INFANT
Treatment. — In simple cases religate the cord and apply a
compress, or lift the iiinbilieiia, transfix it with two hare-lip-pius.
and apply a figure-of-eight ligatiire. In cases dependent on a dys-
crasia, treatment generally is futile, though the injection of human
blood serum may have some effect in staying the hemorrhage.
MASTITIS
Swelling of the breasts is frequently observed in newbonj chil-
dren during the first week. As a rule it calls for no treatment
If pus forms, which is very rarely the case, it should be evacuated.
A BIOODY GENITAL DISCHARGE
A blooily geiiitid tliscliargc in soriK'tiriies observed in female
children in tjii' HthI few liays after birlh ; no treatment is re<iuired.
DUCHENNE'S PARALYSIS
A paralysis of certain muscles of the arm may result from in-
jury to the brachial plexus during delivery. The injury is most
frequently due to traction ui>on the npper roots of the brachial
plexus from lateral fiexion of the neck. In typical cases the arm
hangs powerless by the side and is partially rotated inward. The
prognosis varifis with the extent of the injury. Recovery usually
t'oliows, but may not be complete for mouths or even years.
Treatment eonsists in massage, and the use of electricity to
CHAPTER XII
THE PATHOLOGY OF PREGNANCY
In the chapter on the development of the ovum, we learned
that the impregnated ovule lies in, and derives its nourishment
from, a decidual bed of hypertrophied mucosa, and that the fetal
ovoid is composed of the chorion, with the placenta, the amnion,
the liquor amnii, and the fetus itself. Therefore, in a considera-
tion of the pathology of pregnancy, we must discuss those dis-
eases which attack the several structures of the fetal ovoid and
the bed upon which it grows, i. e. :
(1) Diseases of the decidua
(2) Anomalies of the amnion and of the liquor amnii
(3) Diseases of the chorion
(4) Anomalies and diseases of the placenta
(5) Anomalies of the umbilical cord
(6) Anomalies and diseases of the fetus, together with
those diseases of the mother, such as the toxemias,
which jeopardize the life of the fetus.
DISEASES OF THE DECIDUA
The decidual mucous membrane of the pregnant uterus may
be the seat of many of the diseases which attack the uterine en-
dometrium in the non-gravid woman. Owing, however, to the
presence of the fetus, decidual inflammation has more serious con-
sequences than a similar affection in the non-gravid uterus.
Acute Endometritis or Deciduitis. — Acute decidual endo-
metritis may be present in the course of any acute febrile disease.
In the course of the exanthemata, cholera, and typhoid fever, the
endometrium participates in the infection. It may result from
septic infection after attempts at criminal abortion, or an acute
gonorrheal infection of the endometrium may occur simultaneously
239
240 THK PATHOLOGY OF PREGNANCY
with impregnation, and be the cause of the subsequeut atwrtion.
Acute decidual iiiHammation is attended with more or less oon-
atitutional disturbance, such as iiid'eased tempei'atiire and puUe
rate, together with local pain and tenderness over the hypogas-
trium and inguinal regions. The uterus itself is seusitive and
limited in its motion, owing to the muscular spasm of the inflamed
ligaments. It is often attended by hemorrhage and frequently
results in abortion. There is no treatment, except to attempt to
decrease the severity of the symptoms by rest, enemata, ice bags.
and opium, until llie Hcute stage is passed.
Chronic Diffuse Endometritis. — The causation is not fully un-
derstood, though a preexisting endometritis usually antedates thi-
■ diffuse intiammatiou during pregnancy. The anatomical changes
in the decidua are mainly hyperplastic; the membrane assumes
unusual proportions. It frequently gives rise to abortion, as a
large part of the nutritive material intended and needed for the
development of the fetus is devoted to the nourishment of the
thickened deeidua. Wlieu abortion does not occur and the greg-
naney goes to term, adiieisiou of tiie placenta and membranes is a
frequent eoiisei|ui'iu'e.
Chronic Catarrhal Endometritis (Glandular Endometritis). —
In catarrhal endometritis there is a glandular liijperplasia involv-
ing all of the gland structures. There is also a persistent patency
of the gland duels, which allows exit for their secretion. It is
atlrndid by a profuse discharge of walcri/ hihchs from the uterm,
termed hydrarrhea gravidarum. The hydrorrhea may occur in
the earlier, but is most eonimou in the later months of pregnancy.
Sometimes the fluid colhcts in considerable quaniiiy between the
ehurion and the dicidua and is discharged in gushes. Repetition
(if this nceiiniulation tends to separate the o^iira from its
decidual bed and is followed by abortion or premature labor,
Ihough this is the exception, as in most instances the pregnancy
is not interrupted. Rarely the uterus becomes excessively dis-
tended by the aecmnuhited liuid. The inflammation most fre-
quently atfei'ts the deeidua vera, though it may also involve the
reriexft. The presence of the sivivtion pn-cllides the fusion, which
normally lakes jihiei' hetwn'n the deeidua vera and the reflexa.
It is utli'uded wiih hypertnqihy of the connective tissue and of ,
the glandular elements, ^oiue olvst'rvers claim that the diseharg* I
DISEASES OP THE DECIDUA 241
of watery mucus is due to an early rupture of the membranes,
high up in the uterus. Repeated examinations of the discharged
fluid have, however, shown its chemical composition to be different
to that of the liquor amnii.
In this condition the hyperplasia of the uterine mucosa, which
is normal to the early months of pregnancy, is exaggerated and
is continued into the later months of gestation. It affects all the
elements of the decidua and results in a greatly increased thick-
ness of this structure. Hemorrhage frequently occurs into the
decidua and small cysts have been observed.
Xtfi^^^'^^ is a preexisting^ endometritis^ which may be of the
septic, syphJlitiCj or gonorrheal type. When the process is rapidly
developed, it is attended with hemorrhage into the decidua, or
with partial separation of that structure; abortion or premature
labor is then the rule.
The hydrorrheal discharges are to be distinguished from liquor
amnii, from urine, and from leucorrheal secretions. The condi-
tion tends to deplete the woman^s general healthy making her
hlood more or less hydremic.
The treatment is to be directed mainly to the correction of the
resulting debility and anemia. The administration of a solution
of the arsenate of iron (Zamboletti's solution), hypodermatically,
or other hematinic remedies and general tonics are indicated.
Above all, proper hygiene is imperative. Uterine sedative meas-
ures are sometimes useful.
Cystic Endometritis. — Cystic endometritis is distinguished by
the formation of retention cysts, due to an obstruction of the
gland ducts by proliferation of the interglandular connective tis-
sue. The decidua about the cysts is hypertrophied, and on section
presents an overdevelopment of connective tissue, an increase of
decidual cells and embryonal tissue. There is a hypersecretion
from the uterine glands, which may occasion a hydrorrhea, as in
the catarrhal type already described.
Polypoid Endometritis. — Polypoid endometritis is rarely met
with. It is supposed to be due to syphilis, though the causes are
unknown. It is characterized by polypoid growths or villus-like
projections, developed upon the ovular surface of the decidua,
which stand out from the mucous membrane, to the height of half
an inch or more, smooth of surface and very vascular. Between
242 THE PATHOLOGY OP PREGNANCY
the projecliona are the openings of the uterine glands. The entire
membrane ia greatly thickened and presents the characteristic
lesions of simple diffuse endometritis.
The pathological lesions are generally limited to the decidua
yera; rarely they involve the serotiua. Death of the fetus and
abortion ia a common result before the' fourth month. All of
these chronic affections of the decidua are unfavorable to the life
and growth of the fetus and increase the morbidity of the mother,
as the woman is more liable to hemorrhage and sepsis.
ANOMALIES OF THE AMNION AND THE LIOUOR AMNH
The _a)iinion is a serous mentbrane and is, therefore, liable to
changes of secretion, to infiammation with its resulting plastic
e.tudate, aud the fonuafion of adhesions and adhesive bands,
which may produce unfortunate results during the development
of the fetus. The secretion of the amnirni is called the liquor
amnii. The normal quantity of the amnial liquor at term is about
two pints. When there is a deficiency of the liquor amnii, and
the quantity is less than the average, the condition is called oligo-
hydramnios.
Oligohydramnios. — Its occnrrence is rare. Occasionally the
quantity is .so deficient as to seriously interfere with the growth'
of the felus, and llie extreme scantiness of the amniotic fluid may
even be attended with adhesions between the amnion and the fetus
^vitb the foi'inalion of aniniolie bands fram the organization of
the plastic exudate.
Intrauterine amputation of fetal extremities and other develpp-_
mental arrests or anomalies sometimes result from these amniotic
bands. It is claimed that bare-lip. cleft palate, navel cord hemu,
and spina bifida may he produced by this agency. We know from
clinical observation that oligohydramnios is one of the causes of
clubfoot and spinal curvature.
Hydranmlos or polybydr&mnios may be defined as the ae-
cunuilatinn of ibe aiunial liquor to an amount in excess of four
pints. Slight increases in llie amount of the liquor amnii are
frequenl Hud pass unnotieinl. In some few extreme cases the
quanlity may rcaeh thirty to fifty pints.
FREtjrEN'cy. — It has been noted, by careful observera, to oceoT
ANOMALIES OF THE AMNION 243
in the minor grade about once in one hundred pregnancies, while
the pronounced hydramnios, which gives rise to discomfort and
pressure symptoms, is observed but once in about three hundred
pregnancies.
Etiology. — The excessive accumulation of the amnial liquor
may be derived from (a) a maternal source^ (b) a fetal source^
(c) from both, or from sources unknown. In about 44 per cent.
of the cases no assignable cause can be found. Among the causes
which are attributed to a maternal source are maternal hydremia
and other causes of general anasarca. It is stated that **the thin-
ner the maternal blood the greater is the quantity of the liquor
amnii." Or it may be due to deficient resorption of the liquor
amnii, as when the origin of the hydramnios has been due to an
associated nephritis or anasarca in the mother. The larger num-
ber of cases, however, in which the cause can be explained at all
are developed from fetal sources, such as (a) the abnormal per-
sistence of the vasa propria (a capillaiy network of the suhpla-
cental chorion) immediately underlying the amnion, which is nor-
mally present in the early months of gestation; (b) abnormal
pressure in the blood vessels of the cord from obstruction to the
umbilical circulation, by the cirrhotic liver of syphilitic children,
a tortuous or knotted cord, or its vicious insertion; (c) acute
amniotitis; (d) the excessive excretion of the fetal urine; (e)
exudation of the fetal skin; (f) fetal syphilis.
Diagnosis. — There is a history of pregnancy, together with the
symptoms of a cystic abdominal tumor, which grows rapidly. The
increase in the size of the uterus is out of proportion to the period
of gestation and the uterus presents a permanent tension. In
acute cases the distention is sudden and painful.
The tumor may usually he defined as the uterus, except in ex-
treme cases, where the outline is lost and the distention is limited
only by the capacity of the abdomen. The fetal heart sounds are
dulled or entirely absent. There is a preternatural mobility of the
fetus, permitting external ballottement, except when the disten-
tion is extreme; the suprapubic edema adds to the difficulty
of palpation. The breathing becomes labored, and the patient
suffers ffom general pressure symptoms. In extreme amniotic
distention the cervix is obliterated and the os externum patulous.
It is to be distinguished from pregnancy associated with ascites.
244 THE PATHOLOGY OF PREGNANCY
ovarian cyst, and twins, by the history of tlie growth, and by
estabJishiiig the exiateuce of a pregnancy, by palpation anil aus-
cultation of the tumor.
Prognosis,— The prognosis ia unfavorable to the child owing
to premature birth, dropsical affections, malformations and mat-
presentations, wliieli are common in hydramnios. The fetal mor-
tality is about ~.5 per cent. Fur the mother the prognosis is grn-
erally good, though it is graver in the acute variety with e^Ltreme
distention.
TREATMENT.^JIany cases require no treatment other than en-
forced rest in bed until the membranes rupture and the head is
engaged, and so firmly corks tbe brim against the descent of a
loop of the cord. In case of alarming symptoms from rapid ae-
cumulatioH of fluid and overdistottion of the abdomen, indueliou
of labor by puncture of the membranes is permissible. This may
be done with a catheter high up within the uterus, in order that
the li(iuor anuiii may drain away slowly, trickling down between
the membranes and the uterine wall. This favors retraction and
prevents shock.
The danger is from shock and hemorrhage, so that on the birth
of the child prfcautions may be needod against postpartum hem-
orrhage. Special care should be taken to promote retraction of
the uterus after delivery. Operative procedures other than ver-
sion or perforation are seldnTii called for, as the child is commonly
non-viable in tlie prcsenec of gmxt ariiniolic distention.
DISEASES OF THE CHOBIOH
The ehorliin'w villi man P' I'slst around the periphery of the
entire oritni: wlien such h tlu' ease tbe fetus is completely en-
veloped by a tJdnned out placental layer called a "placenta mem-
branaeea." Or the villi may undergo either a cystic or a fibNK
myxomatous deg^'neralion.
Cystic Degeneration of the Chorionic Villi,— Cystic degenera-
tion of llu- rlioi'ioiiLi' villi. ,11- r-.vi'i »/.;/■ tii-li. or h ijdatidiform mole,
is due In ;i pnilHiTiit inn nl" III,' I'pitlii-lial cells of the syncytium
and Liirinliaiis' liiy.T i[W epilbrlinm i^nvering the villi). The
hI(KMl vi'ssris 111' Ihi' villi an' oblileniled and. by hyperplasia of
the syncytium and by hypcrinliltraUon of the atructurea within
DISEASES .OF THE CHORION 245
the villus, the extremities of the villi are converted into cysts.
The degeneraitve cliange is usually found equally distributed over
Uie whole chorion. The cysts vary in size from that of a millet
jeeil to that of a grape. Occasionally they may reach the size of
i hen's egg.
Each cyst springs from another and not from a common stalk,
ind is connected with the base of the chorion by a pedicle of i^ary-
vng length and thickness. Tliey may be many thousands in num-
l)er. Tlie ovum grows rapidly, and the total mass may be as large
as the adult head by the end of the third or fourth month. The
embryo surrounded by its amnion may, or may not^ be found
writhin the vesicular mass. Rarely the proliferation of the cells of
Langhans' layer of the villi penetrates into the uterine tissue,
perforates the uterine wall, and leads to spontaneous rupture of
the Uterus and peritonitis. The cyst content is a clear translucent
liquid containing albumin and mucus. The degeneration usually
begins at a period wlien the villi are almost equally developed
3ver the whole ovum, i. e., before the third month.
In twin pregnancies one or both ova may be affected. The
disease may be considered as a true myxoma of the chorion. It
Is met with most frequently in women wlio have borne full-term
children, sometimes in more than one pregnancy in the same indi-
vidual.
Frequency. — It occurs once in about two tliousand pregnan-
cies.
ETiorx>GY. — Very little is known of the etiology. Recent his-
tological studies have thrown no light on the cause, which ap-
parently resides in the ovum. Endometritis, syphilis, and the
absence or deficiency of allantoic vessels, commonly assigned as
causes, probablj^ have no part in the etiology.
The Diagnostic Signs. — The disease is rarely recognized be-
fore the end of the third month. (1) The first point of importance
is to establish the diagnosis of pregnancy by the presence of the
positive signs, the changes in the shai)e, size, and consistency of
the uterus, available in the first few months. (2) The uterus
rapidly increases in size, its growth is out of proportion to the
stage of fJie~gestation; the uterus is too large for the first two
months, later if is sometimes too small. The sudden distention
and rapid growth of the uterus usually cause distressing nausea
246 THE PATHOLOGY OF PREGNANCY
and even vomiting. (3) The discharge from the uterus of blood,
or bloody serum, is more or less constant, the flow is usually not
profuse and docs vot appear until near the end of the third month.
{4) The uterus is usually doughy, it loses its elasticity\. (5) Veh-
icles, or cysts, may escape in the vaginal discharge, though their
presence is but rarely noted. (6) While the uterine tumor may
reach nearly to the umbilicus, no fetal heart sounds, fetal parts,
or fetal movements can be detected, and internal batloitemtnt is
absent.
The presumptive diagnosis is made on (1) the rapid enlargt-
ment of the uterus toward the end of the third month; (2) the
intermittent scrosanguinous discharge and the absence of any
positive sign of the fetus within the uterine cavity. The existence
of a cystic chorion can only be cleterminetl in many instances by
the direct digital exploration of the uterine cavity and the detec-
tion of cysts.
PaoGNOsis.^The maternal mortality is from 10 to 15 per cent.
The immediate causes of death are hemorrhage, sepsis, antT per-
foration of the uterus by a proliferation and penetration of the
syucj-tial ceils of the chorionic \-illi, in which case, when the
vesicular mass is expelleti or removed, there may be fatal hemor-
rhage from the torn uterine sinuses. Except when the cystic de-
generaliou is confined to a very limited area, the embryo invari-
ably dies and disapjtcars by absorption. The chorion may become
adherent to the iiterine wall and be retained for many months.
Usually, however, the chorionic mass is expelled by the sixth
month. Chorioepithelioma is preceded by vesiculaLSjole in about
forty per cent, of the reported cases, hence the importance of
microscopic examination of the uterine contents in every case of
cystic degeneration.
TliE.VTMKN'T. — ^The treatment is mainly expectant, until no evi-
di.nec of a living fitus can be found, or the hemorrhage is con-
siderable, when iinmediate steps should be taken to empty the
uterus. The heniorrJiage may be coiitrotleil and dilation of the
cervix secured by the employment of a cervieovaginal tampon.
Evacuation of the uterus should never be attempted until suffi-
cient cervical dilation is attained, to permit expulsion of the cj/*-
tic mass, or allow of its extraction with the fingers or pi'
forceps. If sufficient dilation cannot he obtained by
DISEASES OF THE PLACENTA 247
interior vaginal hysterotomy may be used to give sufficient space
Eor manual evacuation. Removal, with the fingers in the uterus,
is safer than attempts at instrumental extraction, as the evacua-
:ion may be done more cautiously and the uterine wall is often
extremely thin. Removal with the curet is always incomplete and
i attended with the dangers of fatal hemorrhage and perforation.
A.fter the uterus is emptied manually, the uterine cavity should
|}e firmly packed with gauze soaked in the tincture of iodin, the
excess of which is squeezed out before using. This pack should
remain in the uterus for ten minutes and then be withdrawn.
The iodin destroys the remaining cysts and disinfects the cavity.
Ergot may be used freely, to make the uterus contract. Two
Kreeks after evacuation, when considerable retraction of the uterus
[las taken place, the cavity should be thoroughly curetted and the
3urettings examined by a competent pathologist for evidence of
jhorioepithelioma. The patient should be kept under observation
for several months and the curetting repeated, in case metror-
rhagia should occur. Should any evidence of chorioepithelioma
ippear, an immediate hysterectomy is imperative.
Fihromyxomatous degeneration of the chorion is extremely
rare. It consists of a fibroid degeneration of the connective tissue
>f the villi, forming solid instead of cystic tumors. The symp-
tomatology and treatment are similar to those of cystic degenera-
tion.
ANOMALIES AND DISEASES OF THE PLACENTA
Placenta Membranacea. — A placenta membranacea is a broad,
thin placenta with persistence of the villi over the entire surface
>f the chorion. Abnormal adhesion is common with this anomaly.
Placenta Praevia. — The placenta is prjevia when its attachment
?ncroaches upon that portion of the uterus which is subject to
iilation during the first stage of labor.
Placenta Succenturiata. Subsidiary Placenta. — This term is
ipplied to a wholly or partially independent placental cotyledon.
The anomaly is usually single, sometimes multiple. In the ab-
sence of vascular connection with the main bmly the detached
portion is termed * * placenta spuria. ' '
Cysts of the placenta are of frequent occurrence. The cysts
248 THE PATHOLOGY OP I'REGXANOY T
are amall and are seated beneatli the amuion. Tlicy an; pi-nlittfaly
developed from the chorial villi.
Syphilis. — Tii syphilis of the mother, eontraeted before or
shortly after conception, the placenta is syphilitic in about half
the cases.
In maternal syphilis, contracted after the seventh month of
pregnancy, neither child nor placenta is infected.
In syphilis of paternal origin the fetal structures of the pla-
centa are affcctcil ; when the disease is of maternal origin the
decidua is involveil and the fetus diseased.
The syphilitic placenta is larger and paler than normal, and if
the fetus is dead presents a dull greasy appearance. The size may
exceed the normal by fifty per cent, or more.
Syphilis of tiio placenta is always dangerous, and may be fatal,
to the fetus.
Edema niiiy he present in JLydnitiinios, in oc-lusion of umhih-
cjil veins, or in iiialerniit anasarca.
Apoplexy. — Extravasations of blood into the placenta may
(H'l'iir ill line or several points. Hemorrhages in the early months
(if prctfiiancy occur near the fetal surface, in the later mouths
near the maternal surface of the placenta.
The causes are placentitis, general infectious diseases, nephri-
lis. pelvic congeslion, traumatism. E.xtensive effusions of blood
result in tile deatli of the enibr.vo or fetus, and consequent abor-
lioii iif |iri'tiLii1iLre labor. Kiiiall extravasations generally are tol-
entied tiiili no apparent ill result. Small blood collections may
he I'diiiid |i;irlia)lv nrpLiiiKcd, or may become fatty or calcareoaa
Fatty degeneration may result from endometritis, placental
lieniiin'liiijre, or vln'iiuie iiitlanuiiation of the placenta. Death of the
e, rarely a portion only, of th*
may result from endometritii
or fi-om syphilis or acute sep-
V is replaced by fibroid tissue.
iis of the decidua. Abuomui
hnliil to this cause.
and is unimportant,
il'served in the placenta.
Placentitis
phl.-enh., I'l.i
evisliiiK 'il 1h<
>is, Tlie noru
Hi pi
itVeel th
of eouei
le.'uliil s
whol
at ion
pi ion.
nicTui
seleiii
I'hi re are li\ | i |...,> ......
adiiesioii kI' Ilie pliU'.'iilii is
Calcareous degeneration
White infarcts Jin> \eiy
illvihu
ANOMALIES OF THE UMBILICAL CORD 249
size from one to two or three centimeters in diameter. They are
of no pathological importance when small and few in number.
When numerous and extensive they may cause the death of the
fetus. They have their origin in local hyalin degeneration.
Other anomalies and diseases are fundal insertion, crescentic
shape, bilobed, multilobed, annular, circumvallate placenta, an-
omalies of size, too large or too small, caseous degeneration, car-
cinoma, sarcoma.
ANOMALIES OF THE TJHBILIGAL COED
Length. — The umbilical cord may be abnormally long, six
feet, or short, seven inches.
Excessive length of cord may predispose to prolapse, to tor-
sion, to knots, or to coils about the fetus, and to obstruction in
the funic vessels. A short cord may lead to premature separation
of the placenta during labor.
Excessive torsion of the umbilical vessels may cause partial
occlusion. It is sometimes accompanied with serous effusion into
the peritoneal cavity of the fetus and with edematous swelling
of the cord. In most cases torsion of the cord itself is developed
onlv after the death of the fetus.
Stenosis of the arteries is sometimes observed. The causes
are excessive proliferation of connective tissue in the walls of the
arteries, atheroma, and thrombosis. The lumen of the umbilical
vein riiay be narrowed by thickening of its walls in syphilis. This
is due to an edema and leukocytic infiltration of the spaces between
the muscle fibers.
Knots occur rarely. They result from the passage of the
fetus through a loop of the cord. They are seldom firm enough
to endanger the life of the fetus.
Hei^baa. — Hernial protrusion of the omentum or intestinal loops
may take place into the cord. It results from imperfect closure
of the abdominal walls at the umbilicus, and is usually accom-
panied with other errors of fetal development.
Cysts are frequently observed in the sheath of the cord. They
are due to liquefaction of mucoid tissue or of blood extravasa-
tions.
Coils about the fetus, especially the neck, are of frequent oc-
250 THE PATHOLOGY OF PREGNANCY
eurrence. Soraetimps an arm or a leg is thus encircled. Rarely la
the circulation impeded, either in the funis or the girdled mem-
ber. Extensive coilings may give rise to the dangers of short conl.
Coiling of the cord about the neck of the child sometimes may
he recognized during pregnancy by depressing the abdominal wall
of the mother opposite the child's neck; the fetal pulse-rate is
retanled when the cord is pressed upon.
Tbe insertion may be marginal or velamciitous. In the latter
anomaly the vessels pass for a greater or less distance between
tlie membranes to the edge of the placenta. As the vessels are
more or less separated and unprotected, they are liable to be torn
during labor. Such an accident almost surety results in the death
of the child unless it is bora promptly.
When the insertion of the cord is marginal, the placenta is
sometimes termed a battledore placenta.
Other abnormalities oceasionaily observed are tumors, varices,
calcareous dejiosits.
PATHOLOGY OF THE FETTTS
Anomalies of Development. — Tin- principal anomalies of fetal
deveIo]iriient are brieHy the following:
(a) llEMiTEHiA (literally, half monstrosity). — Under thia
head are incluiled dwarfs and giants, microeephalus. sternal ii*
sure, spina bifida, clubfoot, supernumerary digits, double uterus,
dnnbJe vagina, supermunerary ribs, etc.
(b) I1ktkkut.\xi.\. — Under this head are included transposi-
tion of viscera, hernial protnisiou, imperforate rectum, vagina,
esophagus, etc., jwi-sistent foramen ovale, persistent ductus veno-
Hus, persistent <hietus arteriosus, etc., webbed fingers or toes, hare-
li|i, elcl't palate, epispadias, hypospadias, hermapbrodism.
(el Tkratimm. 1. Eftniiiulic Mouslcr.^A monster having
L'. Siiiii'Iir Mi'iist-r. — A moiiater having its lower limbs partly
;(. <'• liisiiiiiiilif MiiiisU i:^.\ mniister having partial or com-
plete evenlralion.
4. Kyuiii phiitic Mini.-iti >\^]\\ this anomaly the brain is raal-
FETAL DEATH 251
5. Pseudencephalic Monster, — Here the cranial vault and the
Istrrger part of the brain are absent.
6. Anencephalic Monster. — The cranial vault and the entire
bx*»n are wanting.
7. Cyclocephalic Monster. — A monster in which the nose is
wanting and the eyes are partially fused into one.
8. Octocephalic Monster. — The ears meet or are fused in the
me^lian line.
9. Omphalositic Monster. — This monster is one of twins which
has a parasitic existence in utero. Its nourishment is derived
fr-om the companion fetus, and it is incapable of living indepen-
dently after the cord is divided. The anomaly owes its origin to
the fact that the circulation of one fetus has overpowered and
reversed that of its companion.
10. Double Monster, Two Fetuses United. — There are several
varieties :
(a) Sternopagus, joined at the sternum; (b) Ischiopagus,
J^^ned at the pelvis; (c) Cephalopagus, joined at the head; (d)
-Xiphopagus, joined at the xiphoid cartilage.
Syncephalic. — The heads partly fused, the bodies separate.
Alonocephalic. — The heads completely fused, the bodies sep-
^^ate.
Synsomatic. — The bodi^ are partially fused, the heads sep-
^^ate.
Monosomatic. — The b6dies are wholly fused, heads separate.
Double Parasitic Monster. — One fetus is attached as a parasite
^^ the other, or inserted or included in it.
Diseases of the Fetus. — The fetus is subject to many of the
"^^fectious and other general diseases of postnatal existence. Well-
-•^uown examples are variola, typhoid fever, pneumonia, syphilis,
Scarlatina, measles, erysipelas, diphtheria, septicemia, rachitis,
^V-alvular disease of the heart, serous effusion, etc.
FETAL DEATH
The fetus may die during pregnancy. Its death may occur in
tihe early months or in the latter half of gestation. It is important
%o recognize the presence of a dead fetus ; a fact that is frequently
difficult to determine, especially in the early months, before the
252 THE PATHOLOGY OK PREGXANCT
period when in Ihe living fetna the heart can be heard or active
fetal movements felt. Often the diagnosis cannot ie made unlU
the ovum m expelli-d.
The signs of fetal death are:
1. A recession of the signs of pregnancy : the uterus ceaaea to
grow, the circumference of tfie abdomen no longer increases, sod
the breasts beoome flabby.
2. The ittenis loses its clastivih/ and becomes domjhy in ccn-
sistcHcy.
3. The fetal movements are no longer felt by the mother, nor
ean they be detected by the physician.
4. Tlie fetal heart sounds arc not heard. This sign is diag-
nostic when the heart lias been previously heiird, and its rhj-thra
and rate noted.
5. There is an absence of the "ehoc fetal."
6. The temperature of Ihe eervi.r (,v no higher than that of tte
vagina, ~ "~
7. Peptones arc usuallij present in the urine. Peptonuria is
constant after the fii-st few days, when the dead fetus is retained
within the uterus.
8. Acitiinnria is alwai/s prisrnf vhen Ihe fetus is dead.
9. A dark, sanguineous diseharge from the uterus which is per-
sistent, always suggests the presence of a dead fetus.
10. If the head is accessible to bimanuul palpiition, a looseness
and crepitation of the cranial bones may usually be elicited.
In addition to the above objective signs of dead fetus, the
woman e.xperiences perioils of illness and usually complains of
many indefinite sensations of weight and discomfort referable to
the hy])ogas1rie region, general malaise, depression, chilly seiua-
tions, loss of appclitc, and. if putrefaction has occurred, there is
some degree of septic intoxicHlion. In most cases of suspected
death of Ihe fetus repeaUd i raniintillons mil be required to de-
cide the qnesliiin.
The causes of fetal dealli are numerous, as mechanical violence,
chronic metritis, maternal iir|ilirilis, diabetes, tuberculosis, tox-
emia, anemia, et cetera. Syjihilis is tiie most fretiuent factor iu
causing habitual di-jilli of tlie fetus.
From sixty to eiglity per cent, of abortions occur in the preg-
i of syphilitic parents. A Waasermann reaction should be
PETAL DEATH 253
made in every woman who gives a history of repeated abortions
and the delivery of premature dead children.
Fetal syphilis may be determined at autopsy by the changes
which take place between the diaphysis and epiphysis of long
bones. Dissection shows an osteochondritis, especially at the lower
end of the femur. The liver is enormously enlarged, even to one-
eighth the body weight, and there is some enlargement of the
spleen.
An undeveloped uterus, or chronic endometritis, or metritis,
has a causal relation to repeated premature births. Pronounced
anemia in the mother may be fatal to the fetus, as may tubercu-
losis, nephritis, diabetes, toxemia, and chronic poisoning.
AVhen the fetus dies in utero, it may be expelled or it may be
carried in the uterus for a long period and undergo absorption,
or saponify (becoming an adipocere), or go through the processes
of mummification, maceration, or putrefaction.
Absorption. — ^When the fetus dies before the second month, the
embryo fii*st becomes liquefied and the ovum may be entirely ab-
sorbed, or the ovum may be carried in utero for a long period
after the death and absorption of the embryo, and, together with
the placental structures and organized blood clots, become a dense
niass of organized tissue known as a *' fleshy mole.'* Such a mole
may be retained within the uterus for months, producing no symp-
toms except an occasional metrorrhagia.
- Mummification takes place only when the fetus has died
in. \he middle "or* later months of development. The soft
structures become dried and shrunken, and the skin assumes a yel-
lowish-gray color. The placenta undergoes somewhat similar
changes.
A /c/u5 papyraceus (a paper-like fetus) is a mummified twin
^otus which, after death in utero, has become flattened by the
Pf essure of its living companion. The head in such cases may be
Pi'essetl into the shape of a meniscus lens.
Maceration, — In maceration of the fetus the tissues become
Softened and sometimes swollen, giving the fetus a bloated appear-
^^ce, the abdomen is distended, the head is enlarged, the serous
^^vities contain blood and serum, and the cranial bones are loose
^Uder the scalp. The epidermis is exfoliated and the tissues be-
come so soft and friable that the limbs may be easily detached
18
Iia4 THE I'ATlH)l>OGY OF I'KKUNANCY
from the body by traction. The odor is sickeniDg but not pntre-
f active.
Putrefaction takes place only when the fetus is carried for a
time in utero after the membranes have riii»ture(l and saproph>i**
gain access to the fetus, wlien decomposition rapidly ensues. Tin-
connective tissues become emphysematous, the abdomen is dis-
tended, and the body emits a putrefactive odor. The uterus some-
times is tympanitic and the mother suffers more or less from septic
■jhsorption.
TreatmeDt. — The uterus should be emptied immediately the
diagnosis of fetal death eaiTTie positivery established. The pre*
ence of a dead fetus in utoro is always injurious to the health, and
may even become dangerous to the life of the mother.
The method to be pursued depends on; (a) the period of preg-
nancy, (b) the condition of the een'ix, (c) the presence or ab-
sence of septic absorption.
Before the eighth week, after preparation of the cervix by the
use of the cervicovaginal tampou, the dilatation may be increased
with a steel branched dilator and the uterine cavity emptied with
the curette and forceps. Should the ovum die between the eighth
and fourteenth week, greater cer%-ical dilation is needed to allow
for the expulsion of the fetus and the placental mass. This may
be obtained by the vaginal tam|ion or dilating bags, and the fetus,
its membranes, and tiie placenta removed with fingers and the ring
placental forceps. In the later mouths labor is induced as in ad-
vanced pregnancy with a living child. Spontaneous delivery
should be encouraged and trauma minimized. Drainage and re-
traction of the uterus after labor are secured by the high Fowler
position and the exhibition of good doses of ergot. Intrauterine
irrigation at the close of labor does no good and may do harm.
ABORTION— MISCARRIAGE
The term ahurtioii is upplieil to the expulsion of the ovum dur-
ing the lii-st three uionlhs of gestation.
Preuuilure labor is the birth of a viable fetus before the ter-
uiiuation of i>regnnncy : ils course differs in no way from labor
al term.
Kxpulsion of the uvuu). occurring between the twelfth to tlie .
ABORTION— -MISCARRIAGE 255
twenty-eighth week, presents a clinical picture different to that
presented by either abortion or premature labor, and is referred
to by many authors as * 'miscarriage/'
^liscarriage is the term to be used to the laity for the inter-
ruption of pregnancy before viability of the fetus; while it is
used interchangeably with abortion by the profession.
It is estimated that at least twenty-five per cent, of all preg-
nancies terminate in abortion. Even this large estimate is doubt-
less too small, if abortions from all causes are included.
Abortion occurs most frequently at the end of the menstrual
month, as the attachment of the ovum is least •stable at this time,
owing to the influence of the menstrual molimen. In a large pro-
portion of cases the abortion takes place at the second month, and
is comparatively infrequent after the third, as by that time the
uterus has risen out of the pelvis and the ovum is well biiried in
its decidual bed.
While it must be admitted that the security of the attachment
between the ovum and uterus differs in different individuals and
in different pregnancies in the same individual, and that what
may be sufficient to cause abortion in one may have no effect on
another, the provoking causes of abortion may be grouped and
considered under two general headings:
First, those which primarily cause the death of the fetus, as
conditions which interfere with the uteroplacental circulation; its
separation and expulsion from the uterus being the result of it«
death.
Second, those which act independently of the death of the fetus
and cause premature expulsion of the ovum by their effect on the
active contraction of the uterus.
Abortions of the first class (death of the fetus) may occur
from malformation in the fetus, disease, mechanical violence,
causing fetal death, maternal toxemia or excessive anemia, patho-
logical conditions of the amnion, the chorion, the cord, or the
decidua.
Under the second head (the causes acting independently of the
death of the fetus) are atrophy or hypertrophy of the endome-
trium, placenta praevia, oxytocics, reflex irritation of the uterus,
i. e., from mammary or rectal stimuli, irritable uterus, chorea,
epileptiform convulsions from uremic or other causes, carbon
256 THE PATHOLOGY OP PREGNANCY
dioxid poisoning, placental apoplexies, misplacement of the
uterus from pelvic adhesions, uterine myomata and cancer, over-
distent ion from hydramnios and multiple pregnancy, direct inter-
ference with separation of the ovum, falls or blows, hyperemia of
the pelvic organs from circulatory obstruction in the lungs or
liver, or from valvular heart disease, violent exertion partially
separating the placenta, resulting in retroplacental hemorrhage,
or sexual excesses near the menstrual period, etc.
The commonest cause of abortion is endometritis, fully. 70 per
cent, of the abortions in the first few wrecks being due to an un-
healthy endometrium, while an irritable uterus, syphilis, retro-
displacements, and chronic nephritis are other frequent causes of
repeated abortion.
DiSignosis. — The classical symptoms of an abortfon are hemor-
rhage, pelvic tenesmus, and rhythmical uterine contractions, which
are more or less painful. The pain may be due to rhythmic uter-
ine contractions, having the general characteristics of a labor pain
or only a severe backache and tenesmus, especially in the early
months. The woman may also suffer from associated nausea or
even vomiting, chilliness, and a slight elevation of temperature.
The physical signs are the effacement of the internal os, which
is shown by the obliteration of the uterocervical angle j dilation of
the cervix (os externum), the protrusion or partial protrusion of
the ovum from the uterine cavity, a contracting uterus, and uter-
ine hemorrhage.
In making the diagnosis in a case of suspected abortion, three
facts must be positively established before any treatment is in-
stituted :
(1) Is the woman really pregnant?
(2) Is the pregnancy within the uterus or extrauterine (out-
side of the uterus) ?
(3) // the pregnancy is intrauterine, is the abortion inevi-
table f
Abortion in the first weeks of gestation is not always easily
distinguished from dysmenorrhea or simple uterine hemorrhage.
The diagnosis will depend mainly on establishing the existence of
a pregnancy by the changes in the shape, size, and consistency of
the uterus, and on the presence of fetal structures in the genital
discharges. The ovum when expelled enveloped in a mass of
ABORTION— MISCARRIAGE 257
coagulated blood may escape observation, unless the clots are ex-
amined by breaking them up under water. Free hemorrhage, with
the expulsion of a large blood clot occurring with a contracting
uterus, is significant of abortion.
Ectopic gestation, in which the ovum is in or has been dis-
charged from the ampulla of the tube, is frequently mistaken for
simple uterine abortion.
An abortion may be threatened or inevitable. Efforts at ex-
pulsion of the ovum, which are attended by slight or moderate
hemorrhage and uterine contractions^ without dilation of the cer-
vix or change in the uterocervical angle, may be placed in the
threatened class.
While the presence of the physical signs establishes the diag-
nosis of inevitable abortion, cervical dilation and cffacement of
the uterocervical angle imply a degree of separation of the ovum
frotn the lower uterine segment too great to permit the further
continuance of the gestation. Severe rhythmical pains with hem-
orrhage almost surely forebode the expulsion of the ovum.
Every patient suspected of abortion should be subjected to a
thorough physical examination of the pelvic organs, not only to
establish the presence or absence of the physical signs, but to ex-
clude the presence of a tubal pregnancy. All blood clots and
material cast off must be thoroughly inspected and, when pos-
sible, examined microscopically.
Prognosis. — There should be no maternal mortality in prop-
erly conducted abortions, though every abortion entails some risk
upon the woman, and many deaths result directly from misman-
agement. The prognosis as to both mortality and morbidity de-
pends in great part upon the treatment. The i)rincipal sources
of danger are hemorrhage and sepsis. The hemorrhage is rarely
so great as to be the immediate cause of death, though it con-
tributes to the fatal issue by lowering the woman's resistance.
The presence of necrotic masses of material within the uterus
is a serious menace to life, by offering a culture medium to patho-
genic organisms, and is the cause of pelvic infection in cases which
escape a fatal termination. The danger of sepsis is especially
imminent in incomi)lete abortion.
Treatment. — The treatment of abortion should include a con-
sideration of the following:
258 THE PATHOLOGY OF PREGNANCY
(1) The preventive treatment of abortion in women who are
predisposed to repeated or habitual abortion.
(2) Arrest of a threatened abortion.
(3) Management of inevitable abortion.
(4) Treatment of incomplete and septic abortions.
(5) After-treatment.
Preventive Treatment. — The preventive treatment of abor-
tion is directed chiefly to the cause. Under the etiolog>% we have
referred to endometritis, irritable uterus, syphilis in one or both
parents, retrodeviation of the uterus, and chronic nephritis as
being the most frequent causes of repeated or habitual abortions.
Correction of these conditwns should he begun before conception
takes place f as it is seldom possible to save the ovum by treatment
begun after impregnation has occurred.
Endometritis and endocervicitis may be treated by curettage
and trachelorrhaphy, if considerable cervical ectropion is present,
in the interval between pregnancies. Sufficient time should al-
ways be allowed for the complete regeneration of the endometrium
to take place before coitus is resumed.
In cases of irritable uterus the woman must guard against
physical exertion, mechanical violence, nervous shock, and sexual
intercourse, especially near the time when the menstruation should
occur. She should rest in bed during the menstrual epochs, and
relieve the pelvic congestion by the timely use of bland enemata.
Spasticity of the uterus, associated with nervous conditions,
as chorea, epilepsy, hysteria, et cetera, may be controlled with
proper sedatives.
Syphilis demands active antispecific treatment.
Retroversions, which are repositable, may be corrected and re-
tained in position with a suitable pessary, which, if pregnancy
occurs, should be worn until after the third month, when the
uterus rises out of the pelvis; little can be done for the woman
when chronic nephritis is the cause of habitual expulsion of the
ovum, as pregnancy increases the effect of the kidney lesion.
The Arrest of Threatened Abortion. — Threatened abortion
may be averted by placing the patient at rest in bed, in the recum-
bent position, and quieting the nervous and uterine irritability
by the administration of opium, bromid, and viburnum pruni-
folium. Opium is best administered as morphia, given hypoder-
ABORTION— MISCARRIAGE 259
matically in y^ gr. for the initial dose, and repeated in quantities
sufficient to control uterine contractions. Its subsequent adminis-
tration may be by the rectum, in the form of suppositories con-
taining morphia, y^> gr., or its equivalent. Its sedative action is
increased by combining it with the extract of hyoscyamus and
viburnum.
Viburnum prunifolium may be used in tlie form of the fluid
extract given in V> drachm doses, or the solid extract in pill form
in doses of grs. iv every three or four hours. It acts as a uterine
se<lative, but its use is not well tolerated by the stomach.
The hemorrhage may usually be controlled by rest in bed, but
occasionally a vaginal tampon of sterile or iodoform gauze may be
necessary to check the bleeding. The vaginal iamponadey while it
controls hemorrhage, also acts as a uterine stimulant tending to
make the abortion inevitable, therefore it should not be used in
threatened abortion, unless the hemorrhage is considerable.
The Management op Actual or Inevitable Abortion. — The
management of inevitable abortion includes, first, the control of
hemorrhage; second, the prevention of sepsis.
Hemorrhage may be controlled by (a) physical and uterine
rest, (b) the cervical and vaginal tamponade, (c) the complete
evacuation of the uterus; while sepsis may be averted by (a) the
avoidance of trauma and lacerations of the cervix, (b) strict ad-
herence to an aseptic technique, (c) the timely evacuation of the
uterus.
The conditions which determine the form of treatment to be
employed, i. e., whether the espectant or the radical plan shall be
adopted, are:
(1) The period of the gestation.
(2) The condition of the cervix.
(3) The amount of the hemorrhage.
(4) The presence or absence of sepsis.
The Expectant Plan, — Conditions favorable lo the employment
of the expectant plan are: (a) Abortions between the 8th and
J 2th week of gestation, as during this period the ovum may be
expelled complete; (b) but slight detachment of the ovum, as is the
case when the cervical dilation is slight; (c) moderate hemor-
rhage; (d) and absrnce of sepsis.
The metliod of procedure is as follows: The hair about the
260 THK I'ATHOLOGY OF I'REGNANCY
vulva in ctippL>(l, and the vulvovaginal orifice, the lower abdomen,
Miiii inner xurfaces of the thighs are thoroughly cleansed wiUi
MOHj) anil watiT; the suOb are rinsed away and the external gto-
jlulN Imlhed with a ]-'2{)00 Holution o£ hiehlorid. The bladder is
emptied liy the catheter. The blood and clots are removed from
the vagina with a sterile douche of normal saline solution. Ihe
patient is then plaeed in the Siraa position, and the cervix exposed
with a Hiins' speenlum and the vagina dried with sterile sponges.
Folded piieliiiig gauze in Htrips, two inches wide and five yards
long, iiiakes e."tecllent material for the tampon. With the cenix
expoMcd anil sterilixed with tincture of iodin. the gauze is packed
into Ihe eervieiil eiiiml and into the fornices around the eer\-ix,
llllint; the viiKiniil viiiilt. Care must be exercised not to rupture
the mi'uihrtnu's. Tlu' pack is then placwi against the os externum
imkI hiiill up I'roni this until the entire vagina is filled.
The pnek should lie pressed away from the urethra and the
Imse of the hhidder lo prevent vesical irritation, and held in place
with a T luniilngc. I'hdn sterile gauze should be removed every
twelve hours. A tamiwn impregnaled with iodoform or osid of
Kine iiuiy i-eumiu for twenly.four houi-s. The vagina should be
irri)iHtfd at eiieh removal of ihe dressing, which should be repeated
until the cervix is well dihiltHl and the o\'nni is espelle«1 or is so
well se|mriiiiil fivui the uterine wall that it may be gently ex-
privisitl or easily eMractiil with the tingers. Should a part of the
eiiibr.Mi or its up|H'ni)tii;i'S rx-uuiin liehind in the uterus, evacuation
uiUNt tv ivuipletiil with the linger or forceps.
Vk% nhftViW t^an \<f (r.tir>HtH( m actual abortion should always
^e ole»'ti\l iu the pn-m-itev of the following roovlitioos:
vT When tht' ivrvi\ U: ^iit^ieutly dilated to admit of the
eX)>H)&i\m of the uterim- (^Mll1-nt.
vl" tf the o\uiu t$ doiaclit\l. or prtrst^tiug, or partially ex-
,S' If the hvworrbinjcif »s evtfvssivif.
iV U s»-i\!us is i-T\-*^[i; or iKvuiiwai.
Tho A\tMittv>n t>f :hv- n-rM\ 9J>\ ttv p>nod af gwtatitf vfl
*»ih \V\' <w.\:w. |«'-*vr!A' S,»-v»i'*> -y -•i**'-^
ABORTION— MISCARRIAGE 261
The Technique of the Instrumental Method. — The patient
should be placed on a table in the lithotomy position and the legs
held with a suitable leg holder; the vulva, lower abdomen, inner
surfaces of the thighs, and vagina rendered aseptic. An anesthetic
is usually necessary. When the aseptic preparation is complete;
the bladder may be emptied with a catheter. The anterior lip of
the cervix is caught with a volsella and held gently forward
toward the pubic bones, fixing the uterus. The cervical canal is
freed from mucus and disinfected with the tincture of iodin. The
OMim is detached with the curet and removed with a pair of long
ring forceps (Ward placental forceps), or a straight Keith clamp,
having the joint 2^,/» inches from the distal end. Every part of
the uterine cavity is curetted thoroughly, but lightly, with the
sharp curette. Care will be required to remove all the decidua from
the cornua; this is done with a cross stroke. When the dilation
of the cervix will permit, the uterine cavity should always be ex-
plored with the gloved finger to know that the entire content is
removed. Should sepsis be present or imminent, the empty uterus
may be firmly packed with gauze, saturated with the tincture of
iodin, the excess of which has been squeezed out. This pack should
anly he left in position for ten ininutcs, when it must he tviih-
drawn.
No douche is required, but the uterus must be replaced to its
normal position by bimanual manipulation and a firm pack placed
in the vagina against the cervix to hold it well up in the pelvis,
stimulating contractions and thus securing drainage. A uterus
in the normal position will drain itself.
From the 8th to the 14th week, the manual method, supple-
mented with the placental forceps, is the procedure of choice.
Technique of Manual Method. — After the antiseptic prepara-
tion of the external genitals and vagina is carried out and the
patient is anesthetized, the uterus is crowded down and fixed with
one hand over the abdomen, while the other is inserted into the
vagina, and the cavity is evacuated with one or two gloved fingers
in the uterus. Masses which cannot be removed with the finger
may be withdrawn with the placental forceps under the guidance
of tlie fingers.
The presence of a peri- or parametritis in septic cases does not
forbid interference. It makes it rather more imperative. Sepsis
2G2 THE PATHOLOGY OF PREGNANCY
in the uterine cavity tends to perpetuate the periuterine inflam-
mation, maintaining the supply of seplie material.
Incomplete Abortion. — When the ahortion has been incom-
plete ami portions of the ovnm have been retained, there is always
irregular and persistent iifrriiic lirmorriiagc, which may sometimrs
be copious. The involution is arreBted, the uterus is large, soft,
and tender, the cervix is open, and detritus is expelled oil manipu-
lation. There is usually some elevation of temperature.
In such cases the uterine cavity shouVtl he exploreti to deter-
mine the amount and location of the content. The retained mem-
branes or placental tissue may lie i-emoved with the finger, pla-
cental forceps, or curette, as in inevitable abortion. Evacuation
should always be followed with the iodiu-soaked pack, which must
be removed in ten minutes.
After-tre.vtment, — The patient should remain in bed, in the
Fowler position, for a week or ten days; this secures postural
drainage and so minimizes postabortal infection. Xo interference
with the uterovaginal passages is required. The external genitals
must be kept scrupulously clean, but no douches are &eceBsar>'.
Involution and firm uterine contraction may be favored by the
free use of ergot.
The temperature, the pulse, and the character of the genital
diseharge are to be watched for several days. and. before the
patient is allowed the liberty of the room, a careful bimanual es-
aminaliou of the pelvic organs must be made by the attendant iu
order that uterine misplacements may be discovei-ed and corrected,
and parametritic exudates, if jiresent. recognized. It is just as
important that Ilie woman be under observation until involution
is complete, aftir uburthn iis after labor.
PREMATURE LABOR
Tlip cii
IIS-'S (.f
l"-"i«<"iv
nr -.m- I'ss.iitially tliose of abortion-
cpiirsi'
Hii.l ]i
ii»ii"(!'ni' "
mil ilill'iT ill any iiuiiortant pur-
iilai- i'lr
m, tl],>
«■ .]!• l,ili.,r 1,1
"""■
ECTOPIC
OESTATION
D,),,:!
rn».-.
1 ,„■,,,»„„,,, ,r
/'/<7i ^»myx outside of the vtervtt
■ihj ;.,• 1
y ,»!.</
■■,.,h,u,l,rim;
" or u topic.
ECTOPIC GESTATION 263
Fre^neilcy. — Ectopic pregnancy is oE more frequent occur-
rence than available statistics would lead us to suppose, i. e., it
lias been estimated that it occurs once in 1.200 pregnancies. We
have found that the proportion of ectopics has increased with our
diagnostic power to leeognize them.
Classiflcatlon of Extrauterine Pregnancy Based apon the
Situation of the Developing Ovum. — (a) TrH.\L. — Nearly all ex-
trauterine pregnancies are primarily tubal. In tubal pregnancy
tlif impregnated oviun lodges, and begins its development, in the
Fallopian tube.
The ovinn may l)e arrested in its progress toward the uterus,
(1) in the ampuHa by the neck of the tube; (2) in the tsthmic
Fig. 67.— The Locations at which the Ovum Fig. 68. — A Cornual
MAY BE Arrested in its Tbansit thsouoh Implantation in the
the Tube Uterus
piirliiin; (-3) in the int<rslilial ixirtiim of the tube, which runs
through the uterine wall.
(b) Ovarian Pregnancy. — In an ovarian pregnancy the ovum
is impregnated in the Graafian follicle and develops within the
(c) Abdomi.val Pregnancy.— In primary abdominal preg-
nancy the ovum embeds itself in the peritoneum.
Primary implantation of the ovum upon the peritoneum haa
not as yet been satisfaetorily proven. In the majority of the re-
ported cases the ovum has liad ii tubal attachment and has de-
rived its circulation from this source.
264 THK PATHOLOGY OF PREGNANCY
Etiolo^. — The causfition of ettopic prugnaney is not yet defi-
nitely settled. All eouditions which delay the progress of ilio
ovura from the ovary to Hie uterus, thus allowing it to develop to
Hiieh a size that its transit is interrupted, may be considered a*
causes of extrauterine gestation.
Sueh causes are chronic salpingitis; congenital anomalies, in
length or couvolulions; strictures and diverticula; endosalpingi-
tis, crippling the ])ropelliiig power; and peritoneal adhesions, pro-
ducing atresia. The majority of iny cases have had a historj' of
previous iiillanuiiiilory lesions.
Pathological Possibilities. — The fruit sac may be located in
the aiupiilta or fitt purlinn of the tube, or in the isllimic or iulra-
liganientous portion, or in the inltrstilial or tubouterine portion
of the tube. An ovum developing in either of these locations has
distinct pathological possibilities, with the following terminations:
A. An ovum developing in the ampulla may die in situ and
become absorbed, or form a tubal mole, or the ovum may be ex-
pelled through the fimbriated extremity of the tube into the
peritoneal cavity, as a tubal abortion; iG per cent, of all ec^
topics tcrnniiale in tubal abortion. If the abortion is complete
the hemorrhage is limited. If incorai»lcte — and tubal abortion is
incomplete in the large majority of cases — free (intraperitoneal)
hemorrhage may occur, or it may be slight and the pregnancy
continue as a secondary abilominnl gestation, the placenta retain-
ing, in great part, at least, its tubal attachment, while the mem-
branous envelope is expelled into the peritoneal cavity; or a preg-
naney in the outer portion of the tube may become tuboovarian
or tuliiuilidouiiiial by adhesion of llie finibria to the ovary or
pai'i(l:il jieritoneuni.
It is believi'il that primary rupture of the tube always takes
place before the Ktli week. Primary rupture is seldom fatal,
though the woman may die tVoiii the initial hemorrhage, or the
pevitoiiilis wliieii Nulwei|nentl.v develops. oi' the hemorrhage may
ei';isc spoDtiiii-oiLsly. ;nnl llie ovum iind blootl clots be slowly ab-
.sorh..d.
/;. \\'h,H III- .l.r-h.phuj m-iim /,v firnsl'U in the isthmic por-
ti"ii nf III,' lull' the pregnancy may terminate hy death of the
ovimi. or Uii' fni'iiiiiiinn of a beiuiitosidiiinx. or a pyosalpinx, or a
mole; or it ntaij dtcthp and rupture into the peritoneal cavitu
ECTOPIC GESTATION 265
tcith serious hemorrhage , or into the broad ligament y in which case
there are several possibilities.
(a) It may become an intraligamentous prcgnancyi and con-
tinue to" grow" "the placenta remaining attached to its tubal bed.
This form of ectopic gestation jnay go to term and become one of
the forms of abdominal pregnancy. Should the fetus live and go
to term, spurious labor may occur ; this ends in fetal death, unless
the condition is diagnosticated and the child is promptly delivered
by section.
(b) The ovum may die with the formation of a hematoma be-
tween the folds of the broad ligament.
(c) The ovum may die, and suppurate, and be cast off piece-
meal through the abdominal wall, tlie vagina, the bladder, and
the rectum, or result in septicemia and death.
(d) The ovum may die after the development has advanced to
the latei* months, be carried indefinitely with little or no altera-
tion of structure, or be converted into a lithopedion or a mass of
adipocere.
(e) Secondary rupture may take place into the peritoneal
cavity with serious hemorrhage and shock. Secondary rupture is
usually fatal to the fetus and the danger to the mother is very
great. Rarely the fetus may survive as an abdominal pregnancy.
C. Pregnancy in the interstitial portion of the tube or tuho-
uterine pi- eg nancy is an arrest of the ovum in the interstitial por-
tion of the tube and may terminate:
(1) By death of the ovum.
(2) By expulsion of the ovum into the uterus, in which case
the pregnancy may terminate as an abortion or proceed and de-
velop as an intrauterine pregnancy.
(3) "By rupture_ into the peritoneal cavity, with death of the
mother from hemorrhage and shock. The woman but rarely sur-
ftV65"tftterstitial rupture.
(4) The ovum may rupture into the broad ligament and have
the same possibilities as have already been described under isthmic
rupture into the ligament.
Interstitial or tubouterine pregnancy generally terminates by
rupture Fefore~fKe sixth month.
^^ermmnlxon of Ovarian Pregnancy. — A. The ovum may be ar-
266 THE fATIlOLOUY OF PREGNANCY
rested in its development in the cai'ly weeks, producing a eysbe
tumor of tlie ovaiy.
li. If may iiijiture the containing sac and be attended with
profiiNi' lieinoiTiiagc. ^" J
" Histology and Pathology of Tubal Pregnanqy. — The ovom I
imbeds ilsftf either in the plieations of the tubal mucous mem>'J
brane, when it burrows beneath the mumsa. or directly in the oiiu- 1
cular tissue of the tubal wall. The imiselt; cells are destroyed b!f\
the eroding action of the trophoblast, the site of the ovum beeoia-
ing intramuscular, j ' " "'y of the tube. The blood
vessels am also invaai xtravasatiou of blood into
the peritoneum, through nd porous tubal wall, and ,
into tiio lumen of the mi the fimbriated extremity |
into the cul-de-sac, fo le. This explains the pr«- |
ence of blood in the pento) found even before rupture
has occurred.
The primary rupture is t ' i/rosive process, due to the
penetration of the cells of 11 extending through the tube
wall to the wroua covering, and weakening it until the tube grad-
ually gives way under the pressure of the growing ovum. The
decidual formation in the tube is imperfect, occurring only jn
patehes. in other portions of the tubal mucous membrane, and
wilhin the uterus, where a more or less complete decidua is de-
V('loi>fd, wliieli is cast off with the death of the ovum.
DiagnoEtic Signs of Ectopic GestatloD in t^e Early Months.
—Till- dia^'uosiN is jmssilile before rupture in a large majority
'I'lii llhlonj. — The occurreoee of an ectopic pregnancy is often
jiiTci'iivii by ii juTiod of sterility, or the woman has been the sub-
ji'i-t nl' ii rliri>iiii- inllainiiialory lesinti of the pelvis, or she may have
been jiisl ttiiinifd iiii.l pn'sciit eongeiiitiil anomalies of the pelvic
Tli.-ie is iisiiiilly a ii.^i'in.l of am, norrlua, together with other
.Kfi,'ii>l'"'i--< "f ■Ill-Ill finiiiiiiiiin. IIS nausea or some of the breast
sijrns. llowi'vri'. ibi- imnriiil meiislriLJil jii-rind may not be skippeil.
biLt only 111- iioslji'iii'il. or /.irolimi/nl. nv <iii>,ma1ims in character.
Kvfii liefoii' rnplniT ihe woui.tu friM|uetitly suffers from sharp
knitVlike piiius runriiii},' through Ihe p.-lvis. and there is a sensa-
ECTOPIC GESTATION 267
tion of soreness and discomfort in the lower quadrants of the
abdomen.
The Uterus, — The cervix may he softened and have a dusky
hue, and the uterus may be enlarged and displaced forward or to
one side of the pelvis, according to the size and situation of the
growing fruit sac. The cervix is open and is exquisitely sensitive
to motion and the uterine cainty is empty.
The Tumor, — The growing ovum is found beside, or behind, or
in front of the uterus, displacing it. The characteristics of the
tumor are that it is tense, fluid, tender, pulsating, and rapidly
growing.
It should be routine to make a careful pelvic examination of
every woman presenting an anomalous menstrual history. If the
pelvic findings are suggestive of ectopic gestation, she should be
kept in bed under observation until a positive diagnosis can be
made or excluded by the physical findings. A patient suspected
of having an ectopic pregnancy should never be examined under
anesthesia.
Diagnostic Signs of an Intraligamentous or Abdominal Preg-
nancy in the Later Months. — 1. Mammary signs of pregnancy.
2. Active fetal movements, which are usually more distinct
than iii utero gestation.
3. The fetal parts are more accessible to palpation.
4. The fetal heart tones are more intense.
5. Ballottement is obtainable in the fourth and fifth months.
6. The uterus is displaced upward, forward, and to one side,
and can be differentiated from the fetal tumor.
The most reliable diagnostic point in the later months is evi-
dence of an existing pregnancy, with a uterus which is normal or
hut little developed J and distinguishable from the tumor mass.
Shrinkage of the tumor generally follows the death of the
fetus.
Signs of Tubal Abortion or Primary Rupture. — 1. Special
significance should be given to the history of a postponed, skipped,
prolonged, or anomalous menstruation, which is followed by
metrorrhagia, irregular in occurrence and in amount. The bleed-
ing is observed especially at the time of the painful paroxysms.
The bleeding may be more or less profuse, or be only a persistent
268 THE PATHOLOGY OF PREGNANCY
spotting of a reddish-brown discharge, mixed with mucus whicrb
does uot clot.
2. The pain occurs in ahrupt paroxysms, and is referred to
the pelvis or lower abdomen. There are colicky exacerbations ami
iiiterimls free from suffering. The paroxysms usually 8p|>t>ar
from a few days to several months after a normal or anomalous
menstruation.
3. All irrcnular genital hemorrhage usually follows or occurs
with the attack of pain. lu some cases the irregular bleeding be-
gins witli the conceptiou, and is only moi'e pi-ofuse at tlie time of
rupture.
4. The woman presents symptoms of acute internal hemor-
rhage, with faintness or moi'e or less collapse. The pulse ia rapid,
the blood pressure is low. The face may be pallid and a cold
sweat appears about tiic mouth and forehead.
5. The reetal teniiieratuie nmy be subnormal just after rup-
ture, but is generally slightly eleealed, 100° to 100.4° P.
6. A decidual cast ia expelled from the uterus, either as a com-
plete cast of the uterus or in shreds with the genital discharge.
7. There are abdominal tension and tenderness over the region
of the fruit sac, usually in one or the other iliac fossa ; later tKere
is evidence of a mmlerate peritonitis in the lower quadrants of
the alidnnii'ii.
8. On pelvic examination the physical signs of hematonia or
hematocele may be found. In the former the uterus is displaced
upward and to one side by the mass tu the broaS Ugameni, wkUe
in the Inttir the ntirus is fi.eid and piishid forward and upward
or downward by a scnsiUvc. boggy and ill-defined mass in the cul-
dc-sae. Both mass(s inenas'. in ,»/-e if the hemorrhage does not
cease, spouluiieously.
i). ^Jo^•lmllit of the ctmlc almost always causes exquisite pain,
due to the perif'Diial irrilalion. The blood will sliow a moderate
leukocytosis, a diininutiou in tiie pt-i'eentage of hemogl^obin. and
a rapid rediu-lion in the numlier of red eell.s. The last fwo~ changes
are pi'ogn'.H-sivc if llie inleiiud hiceiiinsr coulinues.
In luhiil aliortiou or rupture witli si'i-ious hemorrhage the
clijiical ]ucture is uniiiistiikjjlile. The ma.jority of cases are typ-
ical, hut We must ever he on our giuird for the atypical ectopic.
Persistent melorrliagia with shiirp attaeks of abdomiiial, pain oc-
ECTOPIC GESTATION 269
curring in a woman at rest in bed should always excite suspicion.
Repeated blood examination will always tell the tale. All doubt
may be settled, and a positive diagnosis made, by making a cul-
de-sac incision via the vagina, and demonstrating the presence of
free blood in the peritoneum.
Uterine abortion and dysmenorrhea sometimes simulate very
closely a ruptured tubal pregnancy or a tubal abortion, and these
must be excluded by the physical signs.
Intraperitoneal rupture is usually distinguished from extra-
peritoneal hy more hemorrhage and by the physical signs of free
fluid in the pelvic peritoneum. The presence of free blood, or even
soft blood clots, in the peritoneal cavity is difficult of recognition
by vaginal touch. When the blood effusion is encysted, the condi-
tion may be confounded with a hematoma in the broad ligament.
Free blood in the peritoneum may be detected with certainty by a
posterior colpotomy.
Extraperitoneal rupture is characterized by the presence of a
circumscribed and more or less firm tumor (blood clot) in one
broad ligament, as revealed by the vaginal touch. The blood
collection may dissect up the peritoneum and burrow behind the
uterus. Examination by the rectum often facilitates the diag-
nosis. A sacculated tube, firmly adherent to the broad ligament,
or an encysted blood clot in the peritoneum, may counterfeit intra-
ligamentous rupture and may be mistaken for it even at an opera-
tion.
Before opening the abdomen, if the diagnosis cannot be estab-
lished otherwise, the uterine cavity may be explored or the cul-
de-sac opened. It should not be forgotten that intra- and extra-
uterine pregnancy may coexist.
Differential Diagnosis. — yterine abortion, dysmenorrhea,
ovarian cyst, intraligamentous cyst, simple fluid accumulation in
the tube, hydrosalpinx, pyosalpinx, hematosalpinx, and a retro-
verted and gravid uterus must he excluded. In every case of
uterine abortion, the possibility of ectopic gestation should be
borne in mind.
The differentiation of ectopic gestation from pregnancy in the
rudimentary horn of a uterus unicornis is difficult or impossible;
but it is practically unnecessary, since the treatment is essentially
the same in either condition. Left to themselves, eighty per cent.
10
270 THK PATHOLOGY OP PREGNANCY ^
of the latter class of cases terminate in rupture and, aa a rule, no
symptoms occur to arrest the atteation of the patient or ph>-si(!ian
before the ulenis ruptures.
Fro^osis. — The prognosis in ectopic gestation depends largely
upon the terrainatiou. A large proportion of tubal abortions and
tubal ruptures recover without surgical intervention ; on the other
hand, the woman may die within a few hours if the bleeding is
not controlled. The prognosis, therefore, depends largely upon
early diagnosis and the institution of prompt treatment. Under
expert surgical management the mortality should not exceed two
per cent.
Treatment Before Primary Buptnre. — The treatment before
primary nii'titrv tihdiild In* an iduiicdiate celiotomy and the re-
moval of ]Uf pri'triiaiil tuhc.
Treatment After Rupture into the Peritoneum. — Wliether an
iraraediali' or ili'laycil ninTiilion MJiall be done when the rupture
has taken plawi in the iifritonLnuii de[>endB upon the condition
of the patient. It is better not to operate during shock, when the
patient shows signs of reaction, as there is usually an interval of
several days between the primary and subsequent rupture.
The immediate indication is to combat the shock and make
preparations for a section.
Hhould the patient be seen in collapse, she should at once be
placed in an exaggerated Trendelenburg posture by raising the
foot of the beil, twenty-four to tliirty-six inches, and morphiii
sulph.. gr. Va. given hypodfrmatieally. All stimiitaiils ynust be
iritliliiltl. The i»ulsu and blood pressure should be taken every
liuur jiiu! rceonled. If the pulse becomes slower and stronger.
and t!u' blood pressure gradually rises to 100 mm., the operation
siiouhl bi' deferred for at least tweuty-four hours to allow reaction
to tiike pliiiH'. The use of a saline solution by the rectum, admiii-
isti'ivd by tliu drop metliod (.Murphy drip), contributes a fluid
content lo the empty vessels. If, on the other hand, under the
above treatment, the pulse rises, becoming more rapid, and the
symptoms ol' iiilernul heujorrbnge increa.se. an immediate celiotomy
may be made. In iin e.\perit'nce of one hundred and sixty-one
consecutive eetopies, the writer has hail to do but one immediate
operation with a movtniity nt \:2 per cent.
ECTOPIC GESTATION 271
no cathartics or enemata are necessary. The abdomen is opened
rapidly and the hand passed at once to the fruit sac, which is
lifted out of the abdomen, and a clamp is placed on the broad
ligament, including the tube near the cornua of the uterus, while
another is placed on the ovariopelvic ligament beyond the free
end of the tube. Compression at these points controls the utero-
ovarian anastomosis and checks all hemorrhage. The field is
partly cleareil of blood ; the tube and fruit sac drawn up and cut
away above the clamps. The ovarian vessels are then tied with
fine catgut between the folds of the ligament, and the two peri-
toneal layers of the ligament are whipped together with a running
suture of catgut.
The blood and blood clots in the peritoneum are removed with
the hand and with large gauze sponges. A detailed search of the
peritoneal sac for clots is unnecessary and only prolongs the
operation. A quart or a quart and a half of normal salt solution,
at a temperature of 105° F., may be left in the peritoneum; this
will not only dissolve many of the overlooked clots, but help to
refill the empty vessels.
When the patient has suffered much blood loss, and the pulse
is feeble and rapid, no time should be lost in the peritoneal toilet.
If the bleeding is recent, little or no harm is done in leaving
some blood in the peritoneum. The abdomen is closed by the
quickest method, with cross sutures of silkworm gut. In septic
conditions drainage may be practiced by the vagina. The anes-
thetic should be discontinued when the peritoneum is closed, a
hypodermic of morphia sulphate, gr. 14, supplying the necessary
analgesia. If saline has not been left in the abdomen, one quart
may be injected into the rectum, sigmoid and colon, while the
patient is in the Trendelenburg position, or a pint of saline may
be injected behind each breast. Saline is very rapidly taken up
from the colon and cellular tissue. Direct infusion into the vein
is apt to cause cardiac dilation and pulmonary edema. By select-
ing the time of operation, we need less heroic measures than when
the operation is done while the patient is in collapse. Direct
transfusion of blood has, in ectopics, with extreme anemia and
collapse, one of its greatest fields of usefulness.
Treatment After Rupture into the Broad Ligament.— 7n the
First Three Months. — Limited effusions of blood do not usually
272 THE PATHOLOGY OF PREGNANCY
require surgical intervention. Should the blood collection become
septic, the sac may be openeti and drained through the vagina.
In large bloo<l collections it is well to make an esploraloii'
abdominal section to observe the limits of the effusion, but. when
possible, the drainage should be extraperitoneal or from below.
If the ovum survives the rupture of the tube into the broad
ligaments it .should be treated as a malignant growth by celiotomy,
ligation of the uteroovarian anastomosis, and extirpation of the
fruit sac. In extrauterine pregnancy the life of the child is of
too little value to weigh against the interests of the mother.
After the Third Month. — While the fetus is extraperitoneal,
celiotomy and removal, if possible, of the entire ovum are indi-
cated ouee the diagnosis is establisheil. When the fetus has been
dead for two or three months the placental vessels will be found
obliterated, and the complete extirpation of the sac generally is
possible. Cutting off the uteroovarian anastomosis by ligation of
the broad ligament on either side o£ the fruit sac usually controls
the hemorrhage. The oozing which generally follows the removal
of the placenta may be taken care of by firmly packing the bleed-
ing cavity with gauze, the ends of which may he carried into the
vagina.
If the fetus is living, it is not always advisable to attempt the
removal of the placenta, as the bleeding is sometimes appalling.
The fetal sac may be stitched to the abdominal wall, and its
cavity |>aeked firmly with washed iodoform gauze, and the pla-
eenta left to separate, which usually occurs within a week or ten
(laj's. The recovery, however, is tedious and attended with more
01' less septic absorption. It may be possible to remove the larger
{Kirtion of the sae by tying the arteries on both sides and ligating
the basi- in sections with mallress sutures.
Secondary Rupture.— ^After secondary rupture into the peri-
toneum, till' tn-atitii'iit is the same as has already been described
in priniiiiy iiilrai'iTUiineal i-nptnre.
Treatment of Interstitial Pregnancy. — When the diagnosis i«
jiossibli' bi'loL*!' rTi[>1iLi'e tlir pruyuaui'y may sometimes be ter-
miiiulcd -sal'cly by emptying lliu fruit sac through the uterine
caviiy. We consider this, however, a hazardous undertaking, and
prefer to niiike an abdominal section and excise the cornua of the
PERNICIOUS VOMITING OP PREGNANCY 273
On intraperitoneal rupture, celiotomy is indicated as in preg-
nancy in the free portion of the tube. Supracervical hysterectomy
will usually be required, as the amount of uterine laceration is
seldom reparable.
PERNICIOUS VOMITING OF PREGNANCY
There are three types of pernicious vomiting: 1. Neurotic;
2. Reflex; 3. Toxemic.
The pernicious vomiting of pregnancy occurs about once in
three hundred pregnancies. It is more frequent in our highly
developed nervous women than among the Germans and English.
Etiology. — In a limited number of cases the hyperemesis of
pregnancy may be neurotic. However, the toxemic element is the
underlying factor in all types; it merely acts as a predisposing
cause in the neurotic woman or the one who has provoking causes
in some anatomical lesion of the pelvic organs, e. g., uterine dis-
placement, anteflexion, detention of the uterus in the pelvis by
adhesions or other causes, decidual endometritis, ovarian cysts,
twin pregnancy, hydramnios, or vesicular mole.
In by far the larger proportion of instances the cause is a
hepatotoxemia, due to faulty nitrogenous metabolism. The failure
consists in imperfect elaboration of biliary constituents, in imper-
fect oxidation, manifested by striking changes in the urine, which
show that the amoimt of urea and total nitrogen excreted is
diminished, while the **high ammonia coefficient'* indicates that
a larger amount of nitrogen is eliminated as ammonia than usual.
Degenerative and necrotic changes corresponding to those of
acute yellow atrophy (necrosis in the central portion of the
lobules), together with multiple hemorrhages, occur in the liver
as a result of the toxemia. The renal changes are secondary, are
degenerative in character, and limited to the convoluted tubules.
The living epithelium becomes necrotic, fllling the tubules with
brokendown cells and blocking their lumen.
Diagnosis. — The diagnosis requires the diagnosis of pregnancy
and the exclusion of causes of vomiting independent of pregnancy,
as the presence of local lesions in the stomach and upper abdom-
inal tract. The neurotic type is not usually difficult of recogni-
tion, usually occurring in women with a manifest neurosis. A
274 THE PATHOLOGY OP PREGNANCY
mild toxemia may underlie the neurosis. Pelvic causes should be
detected and excluded by physical examination. A pelvic exami-
nation should he made in every case of hyperemesis of pregnancy.
The diagnosis of toxemic vomiting is made by exclusion, by the
urinary findings, and the usual clinical evidence of hepatic insuffi-
ciency, as shown by the glycogenic power of the liver to assimilate
cane sugar. Especially important among the urinary changes are
diminution of urea, total nitrogen, and the excess of ammonia.
Indoxyl and skatoxyl are increased. Lucin, tyrosin, albumin,
urobilin, and sugar may be found. According to Sondern, one of
the first signs of the toxemia of pregnancy is acetonuria. Diacetic
acid and betaoxybutyric acid are present later.
Prognosis. — In the majority of cases the symptomatic nausea
of pregnancy subsides by the third or fourth month. In hyper-
emesis of neurotic origin the prognosis is good. In persistent,
uncontrollable vomiting, dependent on toxic causes, it is very
grave, as even the termination of pregnancy will not repair the
intralobular necrosis which has already taken place. A low leu-
kocyte count, which continues while the vomiting persists, is a bad
prognostic.
Treatment. — Treatment in the neurotic form consists of rest
in bed for several days, dietetic measures, nerve sedatives, together
with employment of eliminants; in reflex vomiting, removal of
the cause when possible, such as the correction of uterine displace-
ments, and the treatment of local lesions are in order; in toxemic
cases restricted diet (milk or milk and cereals), stimulation of the
emunctories, lavage, catharsis, diuresis by hypodermoclysis, entero-
clysis, etc., are the main reliance. In most instances the uterus
must be emptied.
Dietetic Measures. — Breakfast in bed followed by sleep, a
small cup of strong coffee before rising; cold vichy or carbonated
water several times daily; to this sodium bromid may be added,
one drachm to the siphon; milk and lime water or vichy, pre-
digested foods, and other liquid foods, all in small quantity and
often ; rectal alimentation, giving one egg in four ounces of milk
every six hours, uncooked beef juice, or predigested foods. Five
minims of deodorized tincture of opium may sometimes be added
to the food with advantage. The injections may be given through
a soft-rubber catheter attached to a funnel. The rectum should
PERNICIOUS VOMITING OF PREGNANCY 275
be washed out twice daily during rectal feeding. Cardiac tonics
may be required.
IjOCAl Measures. — Cervical erosions may be touched with a
twenty-grain solution of nitrate of silver every second day.
Uterodisplacements must be corrected. A vaginal gauze pack,
renewed every two days, or a properly fitted pessary, is sometimes
helpful.
Sexual intercourse should be forbidden.
Copeman's method of dilation of the cervix is sometimes suc-
cessful. The dilation is best effected with the Ilegar's graduated
dilators. It need not exceed one inch. This treatment may result
in abortion, and should be adopted only as one of the last resorts.
General Therapy. — Complete rest in bed is an important aid
in controlling the vomiting. The position with the shoulders low
and hips elevated helps. Occasionally the elevated trunk posture
acts more efficiently.
Useful Drug Measures. — Cocain, gr. % to Y^, repeated three
or four times daily, or hourly, until three or four doses are given ;
a cocain spray to the pharynx or to the nares, in a 1 per cent, solu-
tion; chloral, gr. xx to xxx, in solution by the rectum, two or
three times daily, best given in milk; the bromid of sodium in
similar doses.
Str>'chnin, gr. 1/40 to 1/30, or tincture of mix vomica, Mv, in
water before meals, is indicated in chronic gastric catarrh.
Calomel, in small repeated doses, gr. 1/10, q. y^ h., to 5 or 10
doses, often does valuable service, especially in autotoxis.
Oxalate of cerium, gr. x, q. 2 h., when it can be retained, or
subnitrate of bismuth in similar doses, may be tried.
Ether spray to the epigastrium at the onset of each paroxysm
is sometimes effective.
An ice bag over the cervical vertebra?, or blister over the fourth
or fifth dorsal vertebra, may help.
Oxygen by inhalation has been used with success.
Other measures, such as are useful in vomiting from other
causes, may be found of service.
Induction op abortion is indicated when other means fail,
especially in autotoxic cases. The persistence of a high ammonia
coefficient, the presence of acetone, with a low leukocyte count, in
a woman with a pulse of 100 or more, demand that the preg-
276 THE PATHOLOGY OF PREGNANCY
naney be terminattii. It Blioiild uot be too long withheld. It »
justified only when the mother's life wouhl be endangered seri-
ously by longer contimianee of the pregnancy, and then only with
the concur renee of counsel.
The method of iiulucing abortion depends: Ist, on the period
of the pregnancy; 2ud, on the condition of the cervix; 3rd. on
the general condition of the woman. Between the 8th and 12th
week partial separation of the ovum with a soimd and packing
the cervix with iodoform gauze, which ia renewed everj- twelve
to twenty-four hours, are satisfactory methods. Either may be
relied on or both combined. After the os internum is effaced the
dilation may bo completed digitally or iustrumenfally if the indi-
cation is urgent.
Before the 8th week, in experienced hands the rapid method
of evacuating the uterus with the curette and a Keith forceps will
be found best. The cervix is first dilated with a steel branched
dilator till the curette passes rapidly. The major portion of the
ovum is hrought away with the forceps and the rest, including
the decidua. with the curette. The uterus can easily be emptied
in ten minutes. The patient should be under an anesthetic,
nitrous osid or elher oxygen vapor. When the pregnancy has
advanced beyond the thinl month, owing to the bulk of the fetus
and placental mass, anterior vaginal hysterotomy should be the
method of choice.
PTYALISM
Ptyalism. which frequently is associated with the nansea of
pregniincy. is of suuilar origin. Troublesome salivation is com-
paratively rare.
Treatment. — Treatment is unsatisfactory. The following
meiianres are sometimes of service: A saturated solntion of
potassium I'hlornte usihI several times hourly as a mouth wash;
snlphate of atropin. gr, 1/llHI. ouee to three times daily per os;
tilt' hminids, gr. xxx to cxx daily; tincture of ehlorid of iron,
m v t. i. d. Saliviilion is usually most relieved hy treatment which
VARICES OF PREGNANCY 277
ANEHIA
The anemia which is characteristic in the latter months of
pregnancy may become so exaggerated as to appear pernicious.
The hemoglobin may fall to 30 per cent., and the red blood cells
be diminished to 1,600,000.
Should a pernicious anemia or a leukemia exist prior to the
gestation, the condition becomes aggravated by the continuance
of pre^ancy.
Anemia renders the woman more susceptible to septic infec-
tion and diminishes her resistance to autointoxication.
Treatment. — The pregnant woman suffering from anemia
should have an abundance of fresh air and a generous mixed diet,
in conjunction with the continuous use of such blood makers as
the peptonate of iron, Blaud's pill, the arsenate of iron, and
Fowler's solution of araenic. Pregnancy should be promptly in-
terrupted, if these blood diseases are progressing from bad to
worse.
PTJLMONAKY TUBERCULOSIS
Tuberculous changes in the lungs progress rapidly during preg-
nancy and dormant tuberculous processes may be awakened and
take on a more florid type as a result of gestation.
Hemoptysis occurs in 50 per cent, of the cases. In the ad-
vanced stages, pregnancy hastens the fatal termination. Tuber-
culosis of the larynx is a very serious complication.
Treatment. — The pregnancy should be terminated in the
early months where the disease has reached the second stage, espe-
cially in the presence of urgent symptoms of a cardiac nature,
persistent hemoptysis, and dyspnea. Only if the pregnancy is
near the period of viability should the child receive consideration.
Laryngeal tuberculosis in the early months is a positive indication
for abortion. Vaginal extirpation of the pregnant uterus is ad-
vised by many foreign authorities.
VAEICES OF FBEGNANCY
The veins in the rectum, anus, broad ligaments, bladder, va-
gina, external genitals, and of the lower extremities enlarge and
278 THE PATHOLOGY OF PREGNANCY
may become varicosed (.luring pregnancy, due to the mechanics!
obstruction to the eircidation by the growing uterus. Varicose
veins of the lower extremities are frequently present in the later
mouths of pregnaney, and may rnpture, produce a pressure edema,
or become thrombotic.
Treatment. — The treatment consists in having the patient sleep
in the elevated foot posture and supporting the enlarged veins
with bandages or elastic stockings put on before arising from bed.
Much standing is obviously injurious. Cardiac tonics improve th«
general circulation.
PRURITUS VULV.ffi
Pruritus vulva; may be a neurosis or be due to irritating dis-
charges from the cervix, vagina, or to urinary changes.
Treatment. — TJie patient should he placed in the Sims posi-
tion, till' |insli'rior vaginal wall retracted with a Sims speculum,
and the vaginal and vulvar surfaces dusted with subnitrate of
bismuth. This should be repeated daily or every two days. Ex-
cessive leukorrheal discharges may be removed by alkaline irriga-
tions. Fomentations to the itching parts with plain hot water,
or with a 2Vj per cent, carbolic solution, give temporar>- relief.
Applications of silver nitrate, gr. xv-^i. or of cocain hydrochlorate
are useful. If the pruritus is of diabetic origin, treatment most
be addressed to the cause.
CHAPTER XIII
PATHOLOGY OF LABOR
A labor may be considered as patbological when any one of
the factors, i. e., the powers, the passenger, or the passages, is
faulty, and is not acting in harmony with the other factors.
A. ANOMALIES OF THE EXPELIINO FOWEBS
The powers may be:
(1) Excessive.
(2) Deficient.
EXCESSIVE: PRECIPITATE LABOR
Cause. — The cause of precipitate labor may be excessive ac-
tivity of the expelling forces, or deficient resistance, as, in multi-
parity, large pelvis and small head.
Dangers. — The dangers are for the most part insignificant.
mm
The principal risks to the mother are of lacerations, especially in
primipara?, shock, premature detachment of the placenta, and post-
partum hemorrhage; to the child, asphyxia from the nearly con-
tinuous interruption of the uteroplacental circulation, and the
possible accidejQtajof sudden and unexpected birth, such as falling
on the floor, precipitation into a water closet, rupture of the cord,
etc.
Treatment. — Treatment consists in moderating the expelling
forces by regulating the abdominal pressure by the maintenance
of the lateroprone posture in bed and, if required, by the use of
anesthesia. The patient should be kept in bed from the onset of
the pains.
279
PATHOLOGY OP LABOR
DEPrCIENCV: PROLONr.ED LABOR
Prolonged First Stage: Tardy Dilation
^
Uterine inertia may be due to:
{]) Feeble pains.
(2) Cramp-like pains.
(a) Simple Inertia Uteri: Feeble Pains. — Causes.— The
causes are t'lnotionjil tlisturbance, full bladder or rectum, impaired
muscular tone, frequently seen " in the physically undeveloped
woman and the pliyaicully unfit ; or the uterine muscle may be-
come fatigued, as is often seen in primipanc; or the real cause
may be obscure.
Tbe.\tmeVt. — In the absence of danger to mother or child, the
treatment should be ej:pectant. Simple inertia uteri calU for no
intervention so long as the membranes are unbroken and the pa-
tient is in good condition and gets enough sleep and nounshment.
The bladder and rectum should be evacuated frequently, and other
causes of inertia removed if possible.
Jleasiires for accelerating the tirst stagej_wheii_interyention is
required in the interests of one or both patients, are: keeping the
patient up and moving about; a hot sitz bath; a rectal injection
of glycerin, j^sa; the alternate use of hot and cold compresses over
the abdomen; pituitrin, one ampule (.02), every 2 hours, or.
strychnin, gr. 1/30, every three hours, given hypoderuiieally, to
arouse the nervous system, or quiniu, gr. v to x ; moderate stim-
ulation with wine, whiskey, or other alcoholic stimulants; the
faradic current from the upper sacral region to the posterior
vaginal fornix; uterine massage, manipulation of the fundus;
peeling up the membranes from the lower uterine segment; the
vaginal bag against the cervix; the passage of an aseptic bougie
between the membranes and the uterine walls; artificial dilatiou
with the liHiul or wilh water-bags. Interference icithin the pas-
smj.s. luniurn: shuiihl ijnuraUy he withheld if possible.
(b) Cramp-like Pains. — The uterine eontractions are painful,
liul jtrc ini'llii-iiiil. bi'iiifr luoic Ionic than clonic. There is conse-
ANOMALIES OF THE EXPELLING POWERS 281
cervix, which favor dilation even in the presence of apparently
active pains.
Causes. — The causes are neurotic influences, peritoneal ad-
hesions, myomata, excessive uterine distention, as in hydramnios
or twins, dry labor and the consequent unequable pressure upon
tfie cervix, malpresentation or too firm adhesion of membranes at
fne lower uterine segment.
Symptoms. — The woman suffers excessive pain, yet the labor
makes little or no progress. Mechanical obstruction must be ex-
cluded. The cervix is rigid, and, if the membranes have ruptured,
the caput succedaneum is excessively developed.
Dangers. — The dangers are of exhaustion in proportion to the
severity of the pain and the loss of sleep and nourishment; in
dry labor, pressure-effects in both mother and child and septic
infection. Atony of the uterus is likely to result. Exhaustion
predisposes to ^-almv second stage.
Treatment. — Chloral, oj, in four doses of gr. xv each, at in-
tervals of fifteen minutes, frequently does good service. Still
more effective is opium, gr. j, once or twice repeated, if necessary,
at intervals of an hour, or morphia, gr. 1/6, or pantopon and
scopolamin, gr. 1/120, to drowsiness. These jiarcotics may do
either of two things : they may regulate the action of the expell-
ing powers by abolishing, in part, the inhibitory influence of
pain, or by inducing sleep they may invigorate the natural
forces.
The application of a ten per cent, sterile solution of cocain
to the cervix is said to be followed by prompt dilation, but
such an application subjects the woman to the danger of infec-
tion.
Chloroform or ether is very seldom permissible in this stage
except as an aid to surgical intervention. Rupture of the mem-
branes is indicated in marked hydramnios, peeliiig them up in
undue adhesion.
In dry labor gradual manual dilation may be practiced under
anesthesia, but when time permits the Voorhees, Pomeroy or the
Champetier de Ribes balloon may be used to better advantage.
When efHciency and rapidity are demanded and the cervix is not
obliterated, anterior vaginal hysterotomy should be elected. Gen-
tle traction with forceps may be tried after dilation is nearly
282 PATHOLOGY OF LABOR
complete. This procedure, however, subjects the woman to prest
trautaa.
Beeourse may be had to multiple incisions of the cervix or to
"DUhrsseii's incisions" or vaginal hysterotomy when immediate
delivery is required. In the former method uuraerous shallow in-
cisions are made in the lower border of the cervix with the scissors.
The procedure is at once safe, simple, and efficient. For the tech-
ni()ue of "Diihi'ssen's incisions" and vaginal hysterotomy the
reader is referred to the chapter on obstetric surgery. With a
normal head the space gained is sufEicient for immediate delivery.
"Diihrssctt's incisions" are justifiable only as a last resort, when
the internal os and cerviral canal are completely effaced. In the
writer's practice vaginal cesarean seeliou has replaced both of
these methods.
//. I'rolanged Second Stage
Caitses. — The causes are most of those whicli operate in the
slow first stage. In addition, may be mentioned exhaustion,
pendulous ab<lonit'H. excessive uterine retraction — retraction
ring halfway or more from the puhes to the navel, moulding
of the uterus in dry labor, and faulty action of the abdominal
muscles. ~ ~
Symptoms. — The evidence of inefficient pains is obvious. In
neglected cases the temperature and pulse begin to rise and the
vagina becomes hot and dry. Obstructed labor from a contracted
outlet must be escluded.
I).\NOKRS. — To the mother the dangers are exhaustion, and
after-rupture of the membraues, pressure- effects, sepsis. Vesico-
vaginal or rectovaginal fistulai may ensue from long- continued
pressure of the head in the lower part of the birth-canal; in
uegli.'cted ejtses extensive sloughing of the vaginal walls may
result.
To the child the dangers are chiefly from pressure- effeets. The
fetal mortality is large from intracranial hemorrhage, due to
asphyxia or occurring as the direct result of traumatism in instm-
raeiitul delivery, t'hildren who survive such injuries not infre-
quently are crippled in mind or body, or both.
Treatment. — Obstructive causes are excluded by passing the
ANOMALIES OF THE EXPELLING POWERS 283
hand into the uterus if necessary. The bladder and rectum should
be evacuated. Uterine obliquity may be corrected by manual sup-
port, by the lateroprone posture, or by a tight fitting abdominal
binder.
The help of the abdominal muscles should be summoned to
augment the uterine contractions. Quinin, gr. x, strychnin, gr.
J/30, or pituitrin 2 ampules, may be given hypodermically, or al-
coholic stimulants, to stimulate the uterine pains.
Hot fomentations may be applied to the hypogastric or the
sacral region; thoroughly warming the patient, especially if ane-
mic and weak, may bring on vigorous contractions.
The patient should assume the semirecumbent position or
the squatting posture during the pains, or sit on the edge of the
bed. AhlfeldV birth-stool may be tried. This consists of two
stools so placed as to leave a triangular space between them open-
iiig to the front. The woman sits over the open space until the
head is about to be born.
Expressio fetus may be employed by applying pressure at the
^pj>er fetal pole or to the head only when the latter pole presents.
lavish aside the intestinal loops and press downward in the axis
^f the inlet with one or both hands laid flat on the abdomen. The
lithotomy position may help.
Ergot in full doses is dangerous to the child and even to the
'^^oiher. In large doses it tends to cause a persistent uterine con-
traction. In doses of ten minims of the fluid extract, repeated
hourly, it merely increases the force and frequency of the natural
^lo/'paihs. Its use is seldom permissible, never except in the
-ABSENCE OP OBSTRUCTION and in minute doses such as to produce
formal uterine contractions.
The use of the forceps is indicated when the natural forces are
<;learly incompetent, or longer delay would jeopardize the life of
mother or child. As a rule, intervention is called for when the
head has been arrested a half-hour, after two hours in the second
stage in the absence of outlet contraction, especially if the head is
low down and there is no recession between pains. Failure of re-
cession between the pains is evidence that the normal tonicity of
the soft parts has been destroyed by prolonged pressure of the
fetal mass.
284 PATITOLOOtT OF LABOR
B. ANOUALIES OF THE PASSAGES
I. ANOSfALIES OF THE HARD PARTS: DEFORMED PEL\nS
Classification of Anomalies in the Female Pelvis. — Schauta's
claasificatioii as iiiodifinl hy Hirst is. in my opinion, the? most
convcnii'dt for liotli tfat'liiT .-uiii student, ami is therefore ap-
pended.
ANOMALIES OV TIIK PELVIS THE RESULT OV FAULTV DKVEt^PMENT
Simple flat pelvis.
Generally equally contraeted pelvis | jiistominor).
Generally contracted flat pelvis (non-raehitie).
Narrow, funnel-shaped felal, or undevelopeil pelvis.
Imperfect development of one sacral ala (Naegele pelvis).
Imperfect development of both saeral ala; (Robert pelvis).
Generally equally enlarged pelvis (justomajor).
Split pelvis.
Assimilation pelvis.
.VNIIMAI.IKS DTE TO DilSEASE OK TUB I'ELVIC BONES
Rachitic pelvis.
Osteomalacic pelvis.
New growths.
Fractures.
Atrophy, earii's. and necrosis of tlic pelvic bones.
ANOMALIES IN THE CONJUNCTION OP THE PELVIC BONES
Abnormally firm union (synostosis), which is found in elderly
primipanv. particularly at the sacrococcygeal joint and in the
joints between the coccygeal bones:
Synostosis of tliB symphysis.
Synostosis of one or both sacroiliac synehondroaes.
Synostosis of the sacrum with the coccyx.
Ahnornially loose union or separation of the joints:
286 PATHOLOGY OP LABOR
contracted pelves the narrowing ia,at.the brinij and is most fre-
quently an anteroposterior flattening. Obstruction may arise,
however, from old fractures, exostoses or other bony tumors, or a
contracted outlet.
Description of Forms
Nonrachitic Flat Pelvis. — This probably is the commoner
vanety of pelvic contraction in the white race, though Williams
gives the precedence to the **funnel pelvis.*' It consists essen-
tially of a shortening of all of the anteroposterior diameters of
the pelvis, owing to the fact that the entire sacrum is nearer to
the pubes than normal. The intcrcristal and the interspinal diam-
eters have the same value as in the normal pelvis, or may be
slightly increased. Their relation to each other is the same as in
the normal pelvis or nearly so. The pelvic circumference may,j
or may not, be diminished. The true conjugate seldom falls below
8 cm., or 314 inches. The transvei*se diameter is approximatdy
normal.
The sacrum is rotated forward; sometimes is smaller tban
normal. Occasionally there is a false promontory.
In this form of pelvic anomaly the woman is usually of full
stature and her general appearance presents no evidence of de-
formity.
Cause. — The deformity may be congenital or acquired. In
the latter case it may be due to overwork in early childhood.
Influence of Simple Flat Pelvis on the Mechanism of
Labor. — The head passes the brim in imperfect flexion, with its
long (occipito- frontal) diameter in the transverse of the pelvis
and with the sagittal suture level or nearly so. Below the brim
the head movements are substantially the same as in the normal
pelvis. Spontaneous delivery frequently is possible, occurring in
over 75 per cent.
Rachitic Flat Pelvis. — Rachitic flat pelvis resembles the
nonrachitic flat i)elvis, but presents the following distinctive
characteristics: The interspinal diameter is equal to, or greater
than, the intercristal ; the pelvic inclination is increased; the brim
usually is more or less heart-shaped; the outlet may be larger
than the inlet; the bisisehial diameter is greater than normal;
the pubic arch is more than 90 degrees; the longitudinal curva-
ANOMALIES OP THE PASSAGES
287
ture of the sacrum may be greater or the sacrum and coccyx may
be straight aud flat; the lateral concavity is diminished; the
promontory is lower and pushed forward ; the symphysis is deeper
than normal, and is inclined backward.
Tho cause is rachitis in infancy.
Rachitic Flat and Generally Contracted Pelvis. — The char*
acters and cause are those implied in its name. The degree of
contraction often is extreme.
Jostominor Felvia: Pelvis Eqnabiliter Jnstominor. — This,
as its name impllL'S, is a generally contracted pelvis. Its diameters
are not ii^ all cases uniformly contracted. The conjugate seldom
Fig. 69. — Male Pelvis. (Typical)
Fio. 70.— Saciital Section, Showinq
Outlet Diameters in Funnel
Pelvis. (Williams)
falls below (8.5 to 8 cm.) Sy^ inches. In occasional instances the
narrowing is confined chiefly to the outlet. The juatominor pelvis
is most frequent in women of small stature. Yet its size bears no
relation necessarily to the size of the woman's body. This is a
common form jji contraction. It is due to imperfect development.
By pelvimetry the interspinous, intercristal, external conju-
gate, and oblique diameters are proportionally decreased.
iNFLrENCE OP THE JuSTOMINOB PEI.VIS ON THE MeCIIANISM OP
Labor.— There is usually more or Ifss overlapping of the head at
the brim, and at the beginning of labor, even in the primipara,
the head has not engaged. Flcrion is more pronouncrd. but the
other head movements differ little from those of normal labor.
PATHOLOGY OF LABOR
Justomajor Pelvis. — This pelvis differs from the normal
merely iu being iinifoniily enlareed in all its diameters. It is
observed most frpt^iieritly in women of excessive physicaLdevelop-
ment. A roomy pelvis renders the passage of tlie head more easy
aud favors [irecipitatc labor.
Funnel-shaped Pelvis or Male Pelvis. — The typical funnel-
shaped or male pelvis is n rare deformity. IIo\v<'Ver, moderale
-Di.njHAM iSnnwi\(: Mk.nkihatihn of Anterior and PodTEiuoB
Sagittal Diameters by Willums's Modification op
KuEN'H PELVIltETEll. X|. (WiLLIAMs)
outlet contraction, not associated with general contraction, lumbo-
sacral kyphosis, spontlytolistliesis, etc., is the most frequent abnor-
mality observed in wiiile women. According to "Williams, 44 per
cent, of pelvie contractions are made up of "funnel pelves."
Tlie pelvis is nnrrowe<l at its outleti the tubera ischionim are
approximated, aud the anterior-posterigr_diaineter_at^ the outlet
ANOMALIES OP THE PASSAGES
289
may be shortened. The subpubic angle is narrow, the depth of
the symphysis is increased, and the sacrum is long and but little
cur\'ed longitudinally.
Serious coutractiou of the outlet may occur in pelves which
Fia. 72, — A Short Posterior Sagittai., Arresting the Prooress op
lulBOR AT THE OliTSET
are otherwise perfectly normal in their external and internal brim
measurements. The bisischial or transverse at the outlet is reduced
to S cm., or less.
Influence op Funnei, Pelvis on the Course op Labor. — An
Fio. 73. — ALONO Posterior Sagittal, Allowing the Head to Escape
outlet contraction seriously affects the course o£ labor. When the
disproportion is not sufficiently groat to give rise to marked dys-
tocia, the head, because of the narrow pubic arch, escapes in the
posterior sagittal diameter and extensive perineal tears arc the
rule.
Klein has shown that mensuration of the transverse and antcro-
I'ATIIOLOGT OF LABOR
posterior diameters alone does not furniafi sufficient di^ upon
which to form a satisfactory prognosis ; we must also determine
the widlh of the pubic arch and the amount of available space
"between the center of the transverse diameter and the lip of the
sacrum. The distance between these points is calleii the "pos.
terior Ragillal" diameter of the outlet. The "anterior sa^ttal" is
measured from the center of the bisisehial line to the summit of
■the subpubic arch (5-6 cm.). In order that spontaneous labor
can occur in funnel pelves, the posterior sagittal must be increased
jn length in proportion us the ininsvprse is lessened and the pubic ,
arch narrowed, as is iug table; I
■ diameter. .
, -f
■ sagittal.
Kyphotic Pelvis. — The
backward, while its lower i
10 cm.
:i{ tJie sacrum is displaced
.1 forward. The saerum u
narrowed, its length in-
creased, its longitudinal eon-
cavity diminished, and its
transverse concavity lost.
Generally the pelvic incllna-
tioTi is diminshed until it is
almost parallel with the liori-
The transverse diameter is
•reased in the false pelvis,
d gradually diminishes
nil aliove downwanl until
i outlet is reached, where
? greatest contraction is
ound. The conjugate is
engthened. The brim is ap-
s funnel-shaped, the ischial
■oposlerior diameter at the
rcli is narrow, the symph
ANOMALIES OP THE PASSAGES 291
T^ CAUSE of the defoiinity is kyphosis in the dorsolumbar, or
especially in the lumbosacral re^on, resulting usually from caries
in the body of the vertebra.
Infllience op Kyphotic Pelvis on Labor. — The occipito-pos-
terior position is much more frequent than in normal pelves. Oftr
struction is limited to the outlet of the tony pelvis. Owing to
nan-owness of the pubic arch it is greater in anterior than in pos-
terior positions of the occiput. Without intervention 25 per cent,
of the mothers and half the children are lost. Cesarean section or
pubiotomy is required in more than half the cases.
Fig. 75.— The Naegele Pelvis
The Eyphoscoliotic Pelvis- — The kyphoseoliotie pelvis pre-
sents a kyphotic deformity of the pelvis of rachitic origin, compli-
cated with the effects of scoliosis of the lower portion of the verte-
bral column, and the sacral promontory is pushed over to the side.
The scoliotic may counteract in part the kyphotic changes.
Scoliotic Pelvis. — Scoliotic pelvis is a i>elvie deformity due to
scoliosis. Lateral curvature of the lumbar portion of the vertebral
eoluinn, due to rachitic disease, may give rise to slight asymmetry
of the pelvis.
Inh.ubncb on Labor. — Obstruction usually occurs near the pel-
292 PATHOLOGY OP LABOR
vie outlet. Delivery by the natural passages fri-queutly is impos-
sible.
Naegrele Oblique Pelvis; Ankylosed Obliquely Contracted
Pelvia.— There is complete or partial absence of one lateral mass
of tlie sacrum, aud generally ankylosis of the correapoiiding sacro-
iliac joint, with alteration in the spinal and pelvic curves; thus,
the corresponding half of the pelvis is narrow; the opposite side
is increased in size. The entire innominate bone on the deformetl
side is higher tliau its companion. Tlie shape of the brim is an
obliijue oval; the symphysis is not opposite the promontory, it is
displaced an iueh or more beyond the middle line toward the
sound side. The conjugate is not shortened. The walls of the
pelvic cavity converge below, the sacrum is asymmetrical and
turned toward the affected side. The pubic arch is narrow. This
variety of dcfonnily is rare I Fig. 75).
Inlluence on the nieelianisrii of labor is similar to that of gen-
erall.v eontracti'd ju'lvis.
Obliquely Contracted Pelvis, — Obliquely contracted pelvis is
due to a crippled lower extremity. The shape is similar to that
of the Naegele pelvis, but the deformity is due to disability of one
lower extremity arising from coxitis or other cause in early child-
hootl. The eontniction is on the side opposite the crippled mem-
ber. The sacroiliac joints are somefinies ankyloseti.
Robert's Pelvis, or Transversely Contracted Pelvis. — In
Robert's pelvis there is complete or partial absence of both lateral
masses of the sacrum. The contraction is thus in the transverse
diameter. The cavity throughout is narrowed transversely. The
conjugate also is somewhat diminished. The subpubic angle is
narrow. Sjiontaneous delivery is impossible. The deformity is
exceedingly rare.
Spondylolisthetic Pelvis. — The anomaly consists in a gliding
forwartl nl' llu' Imily iil' the last lumbar on the first sacral vei-tehra
(the proiiioitUiryl. The inferior surface of the former ultimately
rests upon the anterior surface of the latter and becomes firmly
united to it. ^'/^ll;■^ nimj of the ubstetric conjugate and the antcro-
piislfrior itiiiiiu li r nt tlir brim is rxtrenw. I'elvie inclination often
is eulircly absent. Ihc I'lane of the brim being horizontal. The
pi'lvic oullct bfi-oiin's diuiiuislied a ntero- posteriorly. Extreme
lordosis of the lumbar spine necessarily accompanies the defoim-
ANOMALIES OF THE PASSAGES
ity, giving the appearance of tbe trunk haMug Buak down into the
pelvis. The cause is the maldevelopment of the interarticular
processes of the last lumbar
vertebra. Spoudylolisthesia is
very rarely_jnet with (Pig.
70).
Split Pelvis.— The pubie
bones are separated or may be
united by fibrous tissue. This
condition is usually asso-
ciated with extrophy of the
bladder and other genital
malformations. It is ex>
tremely rare in obstetric prac-
tice.
Osteomalacic Pelvis In
osteomalacia the deformity
arises from softening of the
bones in adult life when tlie
reproductive organs are func-
tionating, and consequent
yielding in the direction of
the existing pressures. The softening is due to osteitis and oste-
omyelitis. The osteomalacic
pelvis is sometimes termed
the compressed pelvis. In
well-marked cases the prom-
ontory is pushed downward
and forward and the lateral
pelvic walls inward, mak-
ing the pubic portion of the
pelvis beak-shaped; the sac-
rum is convex from above
downward and from side to
side; the entire pelvic space
is greatly diminished and
Fio. 77.— The Osteomalacic Pelvis the brim may he almost ob-
literated ; the subpubic arch is narrowed from the approximation
of tubera ischioriim (Pig. 77).
294 PATHOLOGY OF LABOR
This is one of the rarest forma of eoDtraction-
Fseudo-osteomalacic pelvis liaa the eharacteristics of the
osteomalacic pelvis, but is due to rachitic softening after the child
begins to walk. *
Narrowing of the Pelvis from Bony Tumors. — Obstruction of
this form eoiiipri.ses simple exostost-s, callus, and displacement of
bones due to fracture.
Diagvosis of I'ch-ic Deformity
Clinical Data. — The clinical data which juggest gelvie de-
formity are: evidence of rachitis iii infancy, such as a historj' of
tarSy dentition and of sweats, pigeon breast, curvature of the
tibia, of the spine, or other asymmetry of the body, a rachitic ros-
j ary, large joints, hypertrophy of second phalanx of the hand, the
I other two being normal, or very low stature. Disability of one
I lower extremity dating from infancy is almost sorely attended
with pelvic contraction. In the case of a primipara, a pendulous
abilomeii, or the prcsmtinj pole remaining pcrsislcnlli/ above the
brim instead of having entered it at the commencement of labor,
or deformities iu near relatives should excite suspicion; in multi-
para?, a liistory of difficult labors.
All prima gravida' should be examined for possible pelvic de-
formity at about the 3.5th week.
Pelvimetry. — The only means of exact diagnosis is the meas-
urement of the pelvic diameters. Frequently the pelvis will be
found contracted, with no other evidence of abnormality than that
aifordeil bj' pelvimetry.
The pelvis should be carefully examined by palpation with
reference to ils shape and si/mmetry.
Jlost essential is the measurement of the external conjugate.
the iiitfrspinal and the iitlercrislal diameters externally, and of
the diaijDiial conjugate and tiie diameters of the outlet internally.
The trausvei-se and the oblit|ue diameters at the brim internally
are estimated with the haml in the passages. The shape and size
of the sacrnm. the width of the pubic arch, the presence or ab-
sence of bniiy tumors, iiud the general conformation of the pelvis
are determined by external and internal palpation. The pelvic
inclination shotild also be estimated.
ANOMALIES OF THE PASSAGES 295
In a limited proportion of cases the value of the external eon-
jugate and transverse diameter at the outlet decides the question
whether or not the pelvis is ample. As a rule, with an external
conjugate (diameter of Baudelocque) below 17.5 cm. (7 inches),
the internal corrugate is small, while if the external conjugate is
above 18.5 cm. (714 inches), the internal conjugate is ample. Yet
exceptionally the internal diameters of the brim may be normal
when the diameter of Baudelocque is barely more than 16 cm. (614
inches) ; and, on the other hand, actual contraction may exist
when the external conjugate measures 20.5 cm. (8 inches).
A pelvis with an external conjugate below 16 cm. (6^4 inches)
is surely contracted ; a pelvis with an external conjugate above
20.5 cm. (8 inches) is almost surely ample; between these limits
the question must be decided by the internal examination.
Internally, a diagonal conjugate below 11 cm. (4^4 inches) in
flat, or of 11.5 cm. (4VL> inches) in generally contracted pelves,
should be considered abnormally short.
If the pubic arch appears to be narrowed, and the transverse
diameter (bisischial) at the outlet is 8 cm. (3Vi inches) or Tess,
the posterior sagittal diameter should always be measured.
In certain types of pelvic contraction the conjugate is not
shortened. It should be routine to take all measurements in primi-
para? and in women who give histories of diflficult previous labors.
Fetometry. — It must not be forgotten that the size and con-
sistency of the fetal head are no less an important factor in the
difficulty of delivery than is the capacity of the pelvis. The size
of the head must, therefore, also be taken into account. The head
measurements cannot be so accurately determined as those of the
pelvis. A very close estimate is possible by measuring the occipito-
frontal diameter of the head through the abdominal wall with a
pelvimeter. The biparietal diameter is obtained approximately by
deducting from the occipito-frontal 2 cm. when the latter is less,
2.5 cm. when more, than 11 cm.
It is also useful to try how far the head can be made to enter
the brim by crowding it down with one hand over the lower paii;
of the abdomen, while the fingers of the other hand are passed
internally to estimate the depth of the descent. The fetal head
is the best pelvimeter. An anesthetic allows more accurate estima-
tion.
296 I'ATHObOCiy OF LABOR
Wheii ueeessary for deter mi uiiig tbe size of the head during
labor tliu half-hand may be introduced iuto the uterus.
In slight disproportiou it is often imixissible to determine defi-
nitely the prognosis for labor till the labor is well establiahed.
All borderline iHsproportions should be given the test of labor.
M<iii>ui>„uiit "f Lnhor In Flat Pelvis
When the Conjugate la 9 Cm. (31/2 Inches) or More. — Under
llirs.' coiiiiilJoDs. Ihr spoiiliiiii'Oiis d.'livi'ry of a living child is gen-
erally possible. The iiu'iubi-aues should be preserved by a col-
peiirynter if required, and full cervical dilation secured. Slal-
positions must be eori-ectcd, aiul the condition of mother and child
eiirefully wiilrlied, Tlic bladder ami the rectum should be emp-
tied.
When iiiiiiin- fiiil«. delivery may be effected by:
(1) Forceps with the aid of tlie Walcher position, provide<!
the head is eiti/tiyiil and the child is living and viable. The for-
ceps operation is liere much more dangerous to mother and cliilil
than ill the noniud pelvis.
i'2) I'tHJalie version ulien the head is not eu^£ed, and the
child is alive and viable aiid other conditions are favorable, i. e.,
etnnplele dilation of the soft parts. Yet version in pelvic coii-
tniction is allendiil with a /i/y/i fetal mortality, and should not
be cleelitl ill llie face iif tbe excellent results obtained by pubiot-
i.'li Ci'iinioliiiiiy, This should be elecleti. if the child is dead.
lliuN^'li l'nre.']>s may he elmsen in easy extractions of the engaged
h.'ml.
i4l I'lyniiilm-e labor. The iiuliietion of premature labor at
Ml.' iliiiiy -siMh 111 rliirt\-eij;rliih week may be considered if the
I'ohijiiiiiiis ;!!■.■ liisi-.iv.rr.l in liitu'. Tiie fetal mortality is high in
In a Pelvis with a Conjugate of 7 to 9 Cm. (2% to SVa Inches).
-Wtuu tile li'liis is iili\e anil viahU-. premature labor. Cesarean
sii'tiiui. iir piil'intomy is indiealiiL
rul'iolomy is best reslrieled to conjugates not below 7.5 cm.
\:\ iuelii'st ttwiny lo the grealer diftieulty in the after-care of
ilie patient and tedious iniiviileseenec in pubic st-ction. Cesarean
ANOMALIES OF THE PASSAGES 297
When the fetus is dead or non-viable, podalic version or crani-
otomy is to be chosen.
Artificial premature labor at or soon after the end of the eighth
calendar month may be considered when the contraction is recog-
nized in time, but the fetal mortality is high in higher degrees of
contraction, and in our experience the morbidity to the mother is
as great as from Cesarean section or pubiotomy.
Sj)ontaneous delivery is rarely possible with a true conjugate
of 7 cm. in flat or 7.5 cm. in generally contracted pelves.
Conjugate, 7 Cm. (2% Inches) or Less, Absolute Contraction.
— At term the Cesarean section or the Porro operation is indi-
cated. Wlien the deformity isT^nown early enough the induction
of abortion may be considered, though it is not advised.
The choice of procedure, however, in narrow i)elvis, must be
determined by the relative, not alone by the actual, size of the
pelvis; the degree of disproportion between the head and the
pelvis must decide. In the medium degrees of deformity several
factors determine whether a particular head can pass through the
particular pelvis under consideration: (1) The degree of con-
traction; (2) the size and consistency of the head; (3) the va-
riety of parietal obliquity; (4) the position of the occiput; (5),
the strength of the expulsive forces.
Management of Labor in Other Pelvic Deformities
The method of delivery must depend upon the kind and degree
of obstruction.
The possibility of a living birth by induced labor should be
considered. At term version or forceps is competent in a small
percentage of cases.
Pubiotomy is applicable when the conjugate is above three
inches and there is little contraction in other diameters.
Craniotomy best serves the interests of the mother if the fetus
is dead or non-viable.
In the higher grades of disproportion, the Cesarean or the
Porro operation is positively indicated, and Cesarean section may
be i)ref erred to pubiotomy except when the condition of the mother
is bad for abdominal section.
In excessive pelvic inclination, or slight outlet contraction, the
S98 'ATIIOLOGY OF LAHOB
woman should be placed on t!ie side to favor (
"head and its subsequent espulsion. ~
\VIien tlie pelvic inclination is diminished the liability to in-
juries of tlie pelvit; floor is greater than in normal condttions. 1
II. /NOWALIBa OP THE SOFT PABTS I
Vulvar Atresia^ — Vulvar atresia may result from inflammatory
ndlivsions or cicatricial cliauges of the labia majora, tt>dema vuhTC,
hematoma, thrombus, carciiiaina, siniule rigidity of the pelvic floor, i
or rigidity of the liy I
Trtatmcnt. — A large omatoma may require in- 1
c is ion, evacuation of and packing the cavity.
Usually nature or for A rigid hymen may call
for single or multiple . .oij . forms of rigidity, as a mle,
may be triisti'ii lo forcfps w ips, episiotomy. .
Vaginal Atresia. — Two v if vaginal atresia are reeog- J
nized, eoiigciiitjd and aequir. narrowing may be annular
or may involve the whole lei ^ the canal. In the annular
variety, artificial dilation, multiple ineiaions, and forceps will gen-
erally he retiuiri'ii ; in complete atresia the Cesarean or Porro
operaliiin is tiit' only resource.
Vaginal Neoplasms. — Cystic, fibromatous, or malignaot tmnora
may arisf from the vaginal walls and cause a dystocia requiring a
seetioii.
Cystocele. — Tlie treatment of eystoeele consists in replacing
tlie proliipsi'd bladder -wall after catheteriziug. Evacuation by the
ciillietiT being im|>ossible. tlie bladder may be aspirated through
tlu' va^in.-d or the abdominal wall, and then reposited within the
pelvis.
Rectocele is repbn-eable with tlie aid of the Sims or the genu-
li.'chmil position. It is rare that delivery is complicated by pro-
Rigidity or stenosis of the cervix may arise from atrophic
rliiin^v's in ii\z<'\ |tijiiu|iiiia'. Irorn liypeilrophy of the portio vagi-
nalis. ,ii- IViiiii ri.*;itri<-rs I'lillimiui: ihe injuries of previous difficult
hiliocs. 'I'lif dilation is tn \h- left to nature except in the presence
of ilannee lo iiiiitlnv or iliil.l. Arlitieial measures, if required, are
Vnorliees bau's, maniuil diliitiiiu. innltiple shallow incisions about
ANOMALIES OF THE PASSAGES 299
the free border of the cervix, or anterior vaginal hysterotomy.
Abdominal Cesarean section may become necessary if the resist-
ance is too great to be overcome by intravaginal methods.
Csjicer of the Cervix. — In cancer of the cervix the induction
of premature labor, cervical incisions through the healthy tissue
with a thermocautery knife and extraction with forceps are some-
times possible. The passages should be irrigated repeatedly with
an antiseptic solution during and after labor. Mercurials, how-
ever, must not be used.
Delivery with the aid of cervical incisions is advisable only
when hysterectomy is impracticable. Generally Cesarean section
is demanded in the interest of both the mother and the child. It
is best done before labor is spontaneously established. The entire
uterus should be removed if the disease has not extended beyond
the uterus and the condition of the mother permits.
When the disease is detected in the early months total hys-
terectomy should immediately be performed.
Occlusion of the Os Externum. — The os is reopened by in-
cision from behind forward. If the depression corresponding to
the OS can be found with the finger, a small opening may be made
with a knife and extended with scissors or stretched with the fin-
gers or with a branched steel dilator.
Tumors. — (a) Vesical calculi may be displaced, or, this being
impossible, removed by vaginal lithotomy.
(b) Vaginal Tumors. — Removal, if practicable, is indicated,
otherwise Cesarean section or the Porro operation.
(c) Uterine Displacement, — Anteflexion, associated with pendu-
lous abdomen, may cause dystocia. This may be corrected with
an abdominal binder. Retroflexion with the body and fundus
incarcerated in the pelvis, may arrest the course of labor and
necessitate anesthesia, with the genu-pectoral posture or celiotomy
for its relief, or dystocia may be due to adhesions from opera-
tions, as ventro suspension and fixation, for the relief of retro-
flexion. Delivery may be effected by severing the adhesion,
allowing the uterus to assume its normal relation, or Cesarean
section.
(d) Uterine Tumors. — Pedunculated tumors, when easily mov-
able, may sometimes be pushed above the head with the aid of the
genupectoral or the Trendelenburg position, or removed with
800 PATHOLOGY OF LABOR ^^^
^raseiir or sc-issoi'a. The Cesarean or the i'orro operation may be
required
(e) Ovarian Cysts. — Generally ovariotomy ia indicated immt
(liately on diseovery of the tumor. If the tumor is discovered dur-
ing labor, reposition with the patient in the knee-ehest pofutibn
should be tried. Cesarean sectiou is the only alternative when
reposition fails. The tumor ia removetl at the same time.
DEVKLOI'MENTAI, ANOMALIES OF THE UTERUS
Uterus Unicornis. — Odv hiteral half of the uterus is absent;
there ia generally but one Fallopian tube. This malformation
arises from failure of development in one of Miiller's ducts. It is
of special obstetric interest from the fact that the uterus Bome-
times has a rudimentary liorii on the defective side in which preg-
nancy may occur. The condition is then very similar to tubal
pregnancy. The rudimentary horn usually ruptures. Pregnancy
in the developed horn of a uterus unicornis does not differ essen-
tially from normal gestation.
Uterus Didelphys.— The uterus ia hilid, oaeh lateral half form-
ing a distinct organ. re|)resentiiig. however, but one-half of a
uterus. The ducts of Jiiiller, instead of fusing as they nonu&Ily
do to form the uterus, do not even come in contact with each other.
Thf v.njriiiii nmy he single or double.
Uterus Bicomis. — Tlie lateral halves are distinct above, united
Inflow — ilii' iippiT jiart of the uterus is bifid. The ducta of Miiller
are lii'vi'lopid, hut are not united in the pails corresponding to
the upper iiortion of tJie uterus. The uterine cavity is sometimes
divided wlioily or partially by a median septum. The vagina may
be single or double.
Uterus Cordiformis.^Tlii' fundus presents an anteroposterior
iiiediiin .sulcus.
Uterus Septus. — The uterine eavity is divided, wholly or par-
liall.v. into two hiloral cavities by a median partition. When the
seiiluiu extends through the h'uglh of the uterus the condition ia
termed uleniM sejitus dujilcx. AVIien the diviaion is incomplete
we have a uterus suhsejilna. Ksternally iln' organ betrays no evi-
dence of (lie aliimrmality. In all double uteri pregnancy may
oeeur in eillicr or' Iiolh lateral divisions. Pregnancy in either '
ANOMALIES OF THE PASSENGER 301
C. ANOMALIES OF THE PASSENOEB
OCCIPITO-POSTERIOR POSITION
Ninety per cent, of oecipito-posterior positions of the vertex
terminate as anterior positions by rotating either above the brim,
in the cavity of the pelvis, or at the vaginal outlet. Exceptionally
the sinciput rotates to the pubes, and the head is born with the
face to the pubic arch. In this position the expelling forces act
at a disadvantage; the long diameter of the head does not con-
form fully to the axis of the pelvis, and labor is impeded. In
persistent posterior positions of the occiput the head not infre-
quently becomes arrested by impaction in the pelvis, unless the
child is very small. An impacted oecipito-posterior position, if
neglected, may become one of the most formidable varieties of
fetal dystocia.
An oecipito-posterior position of the vertex occurs in about
20 per cent, of vertex positions.
Causes. — The causes of anterior rotation of the sinciput or
oecipito-posterior positions of the vertex are: imperfect flexion,
bringing occiput and sinciput to the pelvic floor^at about the same
time; defective resistance of the x>^lvic floor or large pelves and
consequent failure of the mechanism which normally shunts the
occiput forward; certain p(^lvic^eformities, as relatively small
pelvis, or, especially, general contraction, faulty inclination, oblique
[eformity, amTtypliotic pelvis, ^iSfiirbing the normal mechanism.
Diagnosis. — Abdominal Signs. — The dorsal plane is found in
the flank, or only its edge palpated; the small parts are in the
middle section of the abdomen; the cephalic prominence is
marked; the heart-tones are heard over the lateral aspect of the
abdomen well toward the back, or are not heard at all; and the
anterior shoulder is remote from the median line. The large ma-
jority of right dorsal positions arc posterior.
Vaginal Signs, — After the head has entered the brim the large
Eontanelle is easily accessible to the examining finger and indicates
either an oecipito-posterior position or an imperfectly flexed an-
terior position. The posterior fontanel le is felt opposite the sacro-
iliac syachondrosis. Perfect or imperfect flexion is distinguished
by tbe relative situation of the fontanelles to the plane of the
21
PATHOLOGY OP LABOR
pelvis and, if necessary, by palpating the ball of the occiput asd
the eaj-s with the hand in the vagina.
Dangers.— The dangers in persistent occipito-posterior posi-
tion are: to the mother, exhaustion, pelvic floor lacerations, the
risks of operative interference; to the child, those of prolonged
labor. The luenibranes are apt to rupture early and expose th«
child to pressure effect and dystocia from molding of the uterus.
The fetal mortality is 15 per cent. In a relatively large peUis
the 111 111 posit ion is practieally unimportant.
Mechanism. — The steps may be outlined as follows:
Flexion TAnterior in 95 per cent, at the brim, in the
cavity or on pelvic floor.
Rotation - Posterior: 2 per cent, rotate to front in-
completely, 2 to 3 per cent, become in- ;
constant Extension pacted, with occiput to the back. I
factor Restitution '
Kxternai Rotation
Treatment, (a) Above the Brim. — Before rupture of the »ne«-
bravrs the patii-nt should lie in tlie lateral or lateroprone position
with the hips elevated ou the side toward which the occiput con-
fronts; this favors flexion and engagement, and anterior rotation
of the dorsum is thns often possible. The geuupectoral position
still more effectually helps the normal mechanism, but unfo^
tunately the «-oman finds the knee-elbow posture difficult ami
tedious to maintiiin. Kvery effort should be made to preserve the
membranes until full dihilion is effected, ~
Spiiiitaiirdiin rololinn fniling, after sufficient dilation, the mil-
position may be correctwl by eombinetl internal and exterail
manipulation. One hand jilaced on the mother's abdomen pushes
the anterior shoulder inward toward the median line, while the
fingers of the other, passed into the uterus, push the posterior
sliouhler of the fetus outward in the opposite direction. In this
manner the child's dorsum, as well as the occiput, is brought lo
the front, and thfi-e is no temli-m-y tu recurrence of the malpofr
tion. ^Vhell the hmd al/me ix i-alalid it almost ini'ariably revefU
to its former po.'^Hiuii.
liv inaiiv jmlhorities nodaiie version is nreferred, when tlw
ANOMALIES OF THE PASSENGER 303
head is arrested at the superior strait, to the foregoing maneuver.
Our experience shows that manual rotation is possible under full
surgical anesthesia even after the head is partially engaged.
(b) In the Cavity, — Anterior rotation of the occiput may be
favored by keeping the patient upon the side toward which the
occiput looks, or by upward pressure against the sinciput during
the pains to promote flexion, or by use of the hand as an artificial
pelvic floor, hooking the occiput forward. Should these simple
methods fail, we may, under general anesthesia, pass _the_ whole
ha.iid^into the vagina, seize the occiput between the thumb and
fingers, raise ike head out of the pelvis, flex it and rotate it to the
frontj wHile the abdominal hand brings the anterior shoulder for-
wanl.
\yhen_^implerjneans fail, the occiput may be rotated to the
front with forceps. This is only a method for the expert. With
a good grasp of the head over the parietal bones, the head is
rotated by carrying the handles of the forceps well over to one
thigh. Care must he used to keep the axis of the blades strictly
in the axis of the pelvis during the manipulation. Safe control is
assured by keeping the tips of the blades constantly in the center
of the birth-canal. The head should be rotated through only a
small arc of a circle at each effort, thus allowing time for the
trunk to follow. Rotation of the trunk may be favored by carry-
ing the anterior shoulder toward the median line by external
pressure on the abdomen.
(c) AXJJui. vauiiiQl putlet^it is almost always possible to rotate
the ocyjiput into anterior i)Osition by backward pressure with the
fingers against the anterior temple, combined, if necessary, with
forward pressure upon the occii)ut. Only rarely must the head be
delivered in the occipito-posterior position. If the natural forces
fail forceps may be tried cautiously.
FACE PRESENTATION
In face presentations the head is extremely extended, the occi-
put is in contact with the back, while the face looks downward.
Frequency. — The frequency of face presentation is about one
in two hundred labors. Mentoposterior i)osition8 are more com-
monTlian anteriors.
304 PATHOLOGY OF LABOR
Causes. — The extension of the head probably is never pri-
mary; it is developed during tbe labor. Tlie causes are: narrow
pelvis, narrowing of the brim by a prolapsed extremity, large child,
enlargement of the neek or thorax, coils of cord abont the nect,
excessive uterine oblitjuity, multiparify, pendulous abdomen, pre-
ternatural mobility of the fetus, owing to small size or to excess of
liquor amnii, impaction of the occiput in occipito-posterior posi-
tion, dolichoeepbalus.
The preponderance of left mentoanterior positions is due to
the right obliquity of the uterus.
Heobanism. — The oeeipito-mental diameter is in relation with
the axis of the birth-canal, but that diameter is inverted, and the
head descends with the mental pole first, the traehelo- bregma tic
and biteini>oral being the engaging diameters. The values of the
engaging diameters of the head, when the face is the presenting
part, are substantially the same as those in vertex presentation.
The difficulty of posterior face births is due, in the main, to the
fact that the thickness of the neck and a portion of the ehest are
added to the diameter of the face, as it presents at the brim, mak-
ing a total diameter of 16 cm. (6iA inches).
Classification of Face Positions. —
Left mentoanterior — L. M. A.
Right mentoanterior — R. M. A.
Right mentoposterior — R. M. P.
Left mentoposterior — L. JI. P.
Mechanism op Mentoantekior Pusitions : Head Movements.—
1. Extension. — This corresponds to flexion in vertex births,
bringing tbe oeeipito-mental diameter more nearly in relation with
the axis of the pelvis, the mental pole leading. Extension is never
fully developed until the face has passed the brim.
2. Rotatliiti. — Rotation of the chin under the pubic arch un-
locks the difficulty of face birth. Failure here is more serious than
in vertex presentation. The mechanism of rotation is entirely sim-
ilar to that in vertex births {mutatis mulandis).
3. Vtcsifin cori'esponds to extension in vertex presentation.
The lower surface of the inferior maxilla rests on the margins of
the ischioiiubic rami as pivotal points, and the bead is expelled
by a movement of flexion, face, forehead, vertex, and occiput
sweeping in succession over the nerineum.
ANOMALIES OP THE PASSENGER 305
4. Restitution.
5. External Rotation. — The explanation of the latter two
movements is the same as in vertex births. The birth of the trunk
follows the same mechanism as in vertex presentation.
Mechanism of JMentoposteriob Positions. — In typical size of
head and pelvis the birth of a persistent mentoposterior position
is impossible, since it would necessitate the passage of a diameter
of 6V^ inches through the pelvis. Anterior rotation takes place
in the majority of cases.
Diagnosis. — Abdominal Signs. — ^Abdominal signs to be noted
when palpation is possible are the hour-glass shape of the uterus
and a very round cephalic tumor filling one side of the pelvis only.
The cephalic prominence is on the same side with the fetal dorsum;
palpation of the back is difficult, as, owing to the extension of the
head, the back is more in the middle of the uterus and so out of
reach; the cephalic prominence is generally on the same side of
the median line wdth the breech; and a sulcus is found at the
junction of the head and back; the heart and small parts are on
the same side; the inferior maxilla, with its ** horse shoe" like
rim, may be accessible to palpation.
Vaginal Signs. — The face does not fill the pelvis as the vertex
and its outline is less smooth and uniform. The orbital ridges,
nasal bones, malar bones, alveolar processes, and chin may be pal-
pated by vaginal touch if the cervix is sufficiently dilated.
Prognosis. — The prognosis for both mother and child is less
favorable than with vertex positions ; however, mentoanterior face
cases and mentoposteriors that rotate and terminate spontaneously
are but little more dangerous to mother or child than vertex births.
The more formidable difficulties of face birth arise chiefly from
its complications. A disproportion between head and pelvis favors
prolapse of fetal members (cord, hand, et cetera), and failure of
the painis is met with more frequently than in normal presenta-
tion^ owing to the greater uterine force needed to complete the
mechanism. The total mortality is about 4 per cent, of the
mothers and 8-10 per cent, of the children. The face of the child
at birth usuafly^s much disfigured, owing to the effusion of serum
beneath the skin, which may obliterate the features.
The principal dangers to the mother are exhaustion and pres-
sure* necrosis ; to the child, cerebral congestion from obstructed
W6 PATHOLOGY OF LABOR
circulation in tlie veins of the neck, clue to the grasp of the^cerrical
ring. Eotalioii failing, nearly all the children die.
Treatment. — Nature is competent to eft'ect deTivei-y in most
mentoanterior positions as weB as in many mentopostei'ior posi-
tions that rotate. In caaea seen "before engagement of the face,
however, or when the head can be pushed above the brim with the
aid of the lateral, the knee-chest, or the Trendelenburg posture, as
a rule the malpresentation should be corrected. Anesthesia and
posture makes this correction easy. In certain cases of posterior
position it will be sufficient to reduce the position to an anterior
one. The memhranes should be preserved, if possible, until full
dilation.
Mentoanterior Positions. — In the absence of complications
conversion into vertex, while permissible, is by no means impera-
tive. These cases, if the face is already engaged, may generally
be safely conducted as face births. Rotation is favored by keeping
the patient on the side toward which the chin points. Should the
pains fail, delivery may be effected with the forcegs^ Since" tEe
conversion of a mentoanterior face case into a vertex presentation
results in an oecipito-posterior position, if tliis niethotl be chosen,
the operation should be supplemented hy rotating the fetus into
an anterior position by the methods alreaili/ dcsci-ibcd.
Should the head be relatively large, piiliiotomy or section may
be elected or if the eord or arm is prolapsed, "podalic version gen-
erally is demanded, though ver.sion in disproportions of the head
and pelvis is unfavorable to the interests of the eliild.
Mentoposterior Positions. — Mentoposterior positions at brim,
with the face not too firmly engaged, should, as a rule, be converted
into vertex presentation by one of the methods described below.
Reduction of the position into a menloauterior positiou may suffice
in the absence of enmplieations. This usually is possible under
anesthesia with the hfiud in the uterus, the trunk being rotated by
external manipulation at the sjime time with the head. In dis-
proportion between head and pelvis, and in prolap.se of the eord
or an arm, the saioo rule applii-s as in iiieutnanterior positions.
In ^'ociV.i/.— When the fai-e is too deeply engaged for reduction
by displaceuu-nt, nwiiia; to the ])ri'seuee of a spastic uterus or the
high position of the relraetion ring, rotation may be favored by tie
lateral posture and by promotiug extension, by drawing the chin
ANOMALIES OF THE PASSENGER 307
downward and forward during the pains with the half hand intro-
duced into the vagina. Recourse to complete anesthesia, with the
woman in the Trendelenburg position, will frequently allow the
operator to displace the head upward and correct the malposition,
even after the face has entered the cavity.
Forceps for extraction in mentoposterior positions of the face
is one of the most diflScult and dangerous of instrumental deliv-
eries, especially for the child; yet in skilled hands the use of
forceps as a rotator is sometimes permissible. The technique is
substantially the same as in occipito-posterior positions of the
vertex.
When the face is immovably fixed, and the fetus is living, de-
livery is to be made by pubiotomy; when the fetus is dead, by
craniotomy.
Methods for Converting a Face into a Vertex Presentation
1. Schatz Method. — This consists in pushing the breech for-
ward (toward the feet) with one hand, the chest backward and
upward with the other, by external manipulation, and finally
crowding the fetus downward in the axis of the pelvis. It is ap-
plicable only before rupture of the membranes, and even then is
not always practicable unless the fetus is mobile and the abdom-
inal walls are relaxed.
2. Baudelocque Method. — (1) The first method of Baude-
locque consists in flexing the head by pushing upward with the
fingers first against the chin, then the fossa) caninae, then the brow,
with one hand internally, the external hand assisting by forcing
down the occiput by suprapubic pressure.
(2) Baudelocque 's second method consists in hooking down
the occiput with the internal hand, the external hand pushing up
the chest. Anesthesia is generally required for all manipulations.
3. Ziegenspeck Method. — Baudelocque 's first method may be
combined with Schatz 's, with the help of an assistant.
The genupectoral or the Trendelenburg position greatly facili-
tates the foregoing manipulations. ^
Thorn Method* — Under complete surgical anesthesia, the lordo-
sis is converted into a kyphosis by combined internal and external
manipulation. The whole or half hand corresponding to back of
308
PATHOLOGY OF LABOR
child is passed into the vagina. The fsoe is lifted out of the pelvil I
and, if necessary, i he opciput may be drawu down with the fingm J
while the Bincijmt in pushi'd up with thumb. At same time the 1
breech is carrieil in the lUrection of the feet and upward and back- ]
ERTiNC. A Face Into a Vebtex Posi-
THK DiRttTioN or PSESSCSB A^^>
1 assistant is
of the head,
let with, gen-
or faee. By
stiutfi presen-
ANOMALIES OF THE PASSENGER 309
The positions are the same as those of face presentation.
The oeeipito-mental diameter of the fetal head conforms with
the transverse at the pelvic brim, allowing the brow to descend
into the cavity and become arrested.
Causes. — The causes are substantially the same as in face pres-
entation.
Frequency. — The frequency may be estimated at about 1 in
2,000 labors.
Diagnosis. — Abdominal Signs, — The abdominal signs are the
same as in face presentation, but imperfectly developed.
Vaginal Signs. — The diagnosis of the presentation is rarely
made until the os is sufficiently dilated to permit one to feel the
orbital ridges which are within touch on one side, and the bregma
on the other side of the presenting i)art. If the membranes have
ruptured and a caput succedaneum has formed, the diagnosis is
difficult, as the landmarks are obliterated. When there is any
doubt as to the diagnos^is of the presentation, examination should
be made under an anesthetic.
Prognosis. — Delivery in persistent brow cases is impossible
except with a relatively large pelvis. The maternal mortality is
1 in 10; the fetal 1 in 3. Rupture of the uterus occurs in three
per cent, of the cases.
Treatment. — 1. Rectification. — (a) Conversion into Vertex. —
Before engagement the brow is converted into a vertex by seizing
the head, pushing it up, and hooking down the occiput, with the
hand in the vagina and with the aid of anesthesia and the Tren-
delenburg posture. During the manipulation the fundus is sup-
ported by firm pressure with the external hand. Pressure upon
the occiput, applied through the abdominal wall, helps.
(b) Cgnxie.rsiqn^into face may be accomplished by traction on
the upper maxilla with the fingers. This is not admissible in
mentoposterior positions. Unfortunately rectification fails in from
twenty to thirty per cent, of the cases.
2. Version. — Version may be employed for rapid delivery, if
indicated in the interest of the mother or child, and if the head
is not engaged or the uterus is not firmly contracted. Version
should be the method of choice when the pelvis is approximately
normal in multiparce.
3. PuBiOTOMY. — Pubiotomy should be elected in impacted and
310 PATHOLOGY OF LABOR
iyxijueibie brow presentation if the child is living and viable, and
should always Tiave the preference over version iu primipara. If
the child is dead, craniotomy is indicated.
In general the principles apply as for tlie management of face
births.
BREECH PRESENTATION
Varieties. — Three varieties of breech presentation are recog-
nized, at-cording to the part of the pelvic jjole which pre-
sents— breech, knee, and footling. The distinction ia of no prac-
tical importance, so far as the mechanism is concerned. In certain
eases, however, as will he seen, it affects the question of treatment.
Frequency. — Exclusive of premature labors, the frequency of
breech presentation is about 1 in 60 births.
Causes. — The caiises nre: narrow pelvis, tumors of the uterus,
placenta pnevia, hydrocephalus, multiple fetus, and conditions
favoring the mobility of the fetus, such as raultlparity, prematur-
ity, lax uterine walls, hydramnios, shape of the uterus poambly,
and small fetus.
Mechanism.^The breech, shoulders, and after-coming head each
follow a di.stinct mechanism iu their passiige through the pelvis.
Usually the bisiliac diameter engages iu one of the oblique diam-
eters of the pelvis. "We have, therefore, four breech positions:
Lefl sacroantfrior^L. S. A.
Right sacroanterior — R. S. A.
Right sacroposterior — R. S, P.
Lef! sacroposterior — L. R. P.
RolHlidii in breech is not so pronounced as in head presenta-
lioii. As ihe bnvch descends into the pelvis, the posterior hip
first lands ii]niii the pelvic tfoor. and is shunted downward, in-
ward, auil ha.'liwnrd to first appear at the vulva, while the anterior
hip nitaii's forward to the pubic arch, where its advance is cheeked
and tile ]iiisti>rior is delivernl fii-st by a movement of lateral flesion.
Th.' slmuhiers nilal.' more or U's.s eonipletely. The head rotates
as perfectly as in vertex births. In dorsoposterior positions the
oceipui. as a rule, coiu.s eventually to ihe front. The nai>e of the
neek ivstiuir apiinst ibe pnbie arch, the head is expelled by a move-
ment of lle\ion amund this as a iiivot. ihe face, the forehpn*! nnrl
ANOMALIES OF THE PASSENGER 311
the vertex successively sweei)ing over the perineum. Spontaneous
expulsion of the after-coining head, however, is exceptional.
In persistent dorsoposterior positions the head is generally de-
livered by a movement of rotation about the posterior edge of the
vulvar orifice, the mental pole first as in anterior positions. If the
chin catches upon the pelvic brim, delivery is accomplished occiput
first. In this method of expulsion the lower surface of the in-
ferior maxilla pivots against the pubic bones, and occiput, vertex,
forehead, and face sweep in succession over posterior vulvar com-
missure.
Diagnosis. — Abdominal Signs. — (1) The dorsal plane is pal-
pated on the right or left side of the abdomen. (2) The fundal
pole is hard, globular, and susceptible of ballottement, with a
sulcus between it and the trunk. (3) The anterior shoulder and
fetal heart are found above the umbilicus. (4) The lower pole,
irregular iii'sTiape. is not so hard, and in primiparje is found above
the excavation before labor.
When the head is in the lower uterine segment, ballottement is
possible only in multipanc and with excess of licjuor amnii; even
then it is imperfect. In ptimiparar, in the absence of pelvic con-
traction and of obstruction from tumors or other causes^ the head,
ivhen it presents, is always found engaged in the excavation at the
beginning of labor.
Vaginal Signs. — The vaginal signs are : glove-finger protrusion
of the bag of waters (obviously this can be present only after labor
has been for some time established), the absence of the hard globu-
lar head with its fontanelles and sutures. The detection by vaginal
touch of one or both ischial tuberosities and the tip of the coccyx,
anus, genitals, on a line bisecting the bisischial line at a right
angle; the femora; expulsion of meconium — not diagnostic —
sometimes observed in cephalic births.
Frequently both ischial tuberosities may be reached, and from
them the femora be traced for a short distance.
A foot or knee may be identified by its anatomical characters.
In differentiating between head and breech a mere casual
touch should not be relied upon. Every accessible part of the
presenting pole must be searched for minutely, with firm pressure
if it is impacted in the excavation, and its bony landmarks are ob-
scured by edematous swelling of the overlying soft structures.
312 PATHOLOGY OF LABOR
Prognosis. — To the Mother, — The first stage of labor may 6e
more tedious than normal. The second stage often is more rapid.
In artificial delivery laceration of the cervix occurs m>ore fre-
quently than in vertex births; in first labors at least laceration
of the pelvic floor is the rule. The danger to life is not increased.
To the Child. — The mortality, when^tEe delivery is left to
nature, is one in ten, at least in first labors ; with skilled manage-
ment it is but little greater than in vertex births.
The cause of the fetal mortality is asphyxia from impeded
blood-supply, due to retraction of the uterus after the birth of the
trunk, and from compression of the funis after the head engages.
The fetal mortality is increased in dry labor.
Hemorrhages may occur into the lungs, liver, kidneys, and the
muscles of the neck. Duchenne's paralysis and injuries to the
bones and joints are not infrequent in breech extraction.
Indications of danger to the child at the critical moment in
breech delivery are: irregularity and feebleness of the funic pulse^
occasional gasping respiratory efforts, convulsive movements of the
limbs.
Treatment Before Labor. — External version is permissible if
it can be done without violence. While conversion into vertex
presentation is desirable, the indication for changing the presenta-
tion before labor is not sufficiently urgent to justify the risk in-
volved in a difficult external version.
Treatment During Labor. — Delivery op the Trunk. — The
danger to the child arises chiefly from the difficulty of delivering
the after-coming head before the child perishes from arrest of the
uteroplacental circulation by compression of the umbilical cord.
Undelivered, the child will almost surely die within eight minutes
after the head engages and the uteroplacental circulation is cut
oflf. The delivery of the after-coming head is facilitated hy: (1)
ample dilation of the passages, the cervix, vagina, and vulvo-
vaginal orifice: (2) full ficxion of the head, which also tends to
maintain the flexion of the arms.
Cervical dilation is accomplished by preserving the membranes
till they reach the pelvic floor and, as a rule, by a slow and graiual
delivery of the breech; while flexion is maintained by avoiding
traction till the trunk is delivered, or, when traction is unavoid-
able, by external manipulation so applied to the fundus by a
ANOMALIES OP THE PASSENGER 313
skilled assistant as to keep the chin firmly pressed against the
chest.
Bringing Down a Foot. — When the membranes have ruptured,
and the ease is seen before the breech has engaged too firmly in the
excavation, one foot should be brought down (I'inard's method),
ike anterior one should he taken by preference. This is done as a
precaution against arrest of the breech in the pelvia The leg
Flo. 79. — Pinard'b Maneuver foh Bringing Down the Anterior Leg
serves as a tractor, should the expellent forces fail. Advantage
may be had from breaking up the breech in Hat pelvis, large child,
or rigid soft parts as found in the old priraipara.
Delivery op tue Arms and He.vd. — In general, when there is
no disproportion between the child and pelvis, the case should be
Teft to' imfure until the whole breech is bom. When this docs not
occur spontaneously, the patient, as a rule, should be under an
anesfhefKTand on a table. The vulvovaginal orifice should be man-
ually dilated, and the forceps should be ready. A warm, dry flan-
nel or towel should be in readiness for wrapping the child's body
as soon as it is expelled, to help to prevent premature efforts at
respiration. Watch the pulsation of the funis for warning of dan-
314 PATHOLOGY OP LABOR
ger to the child. Pull the cord down and dispose of it, if possible,
io that part of the pelvis which offers the most room.
Extrfiction of the Arms, (a) Arms Flexed. — The .sirjais^ should
be. brought down with the hand passed along the child's abdomen.
(b) Arms Extended. 1. _Delivery of the First Arm. — As soon
as the shoulder-blade can be reached easily, the feet should be
FiQ. 80.— Mannbk or Grasping the Breech When Traction is Neces-
grasped and the trunk drawn downward in the pelvic axis and
carried to the side opposite the occiput. The posteriot-ajm should
be brought down first. The free hand should be pasaed^up along
the child's back and one or two fingers slipped over the shoulder
and along the liuinerus to the elbow. The elbow should be swept
in a circular direction across the face and down. Beware of apply-
ing the force at the middle of the humerus and of attempting to
ANOMALIES OP THE PASSENGER 315
ig the arm straight down, leat the humerus he fractured or the
aider-joint injured.
(2) Delivery of the Second Arm, — The child's trunk must he
light into the long axis of the mother's hody (the position of
dorsum is an index of the position of the shoulders), the trunk
81. — The Upper Pabt of the Trunk Caught by the Partially
Dilated Cervix
ed with both hands and pushed upward in the axis of the
b-canai to release the head and extended arm from the grasp
;he pelvic brim; if necessary, the trunk should be rotated to
7y the undelivered arm opposite the nearest sacroiliac joint,
ation is assisted by drawing the delivered arm gently across
child 's back or by grasping the delivered shoulder. Then, with
816 PATHOLOGY OF LABOR
the trunk held to the opposite side, the second arm is brought
down, the elbow being swept inward across the face and down-
ward, as in case of the first ana. It is seldom that rotation of the
head fails by twisting the trunk as above described. Should it do
so from tlie fact that the head has been driven too far into the
pelvis, the maneuver recommended by Kehrer may be tried. This
consists ill ]HLsliLii^ thr oi'fijiul oulwanl with the external hand,
whili- till' fui'i' is swept inwaivl with tb>' arm by the internal hand.
Kj-trartio,, ,.f tin Afl.r-c.mii,;i Hi(>'l.—{1) Dorsoantcrior Posi-
tii'iix. — Seizing ibi' trunk again with twih hands, the head is ro-
tated, if neeessniy. to bring the face opposite one of the sacroiliac
joints. Th, li.,t,l Must lif r-taliil i.ilo i>»( of the obliques at the
bi-iiH. fiisi.fl. aiiO iiiyayiii lufon ixtraclioH can be accomplished.
ANOMALIES OF THE PASSENGER
317-
Smellie-Veit (Mauriceau) llethoil, — Two fingers of one hand
are passed within the passages and Jield firmly against the fosae
caniniB or the inferior maxilla to maintain complete flexion. Two
fingers of the other hand are hooked over the shoulders astride
the neck. The child's trunk lies on the operator's forearm. The
head is delivered hy traction. The natural mechanism must be
observed, keeping the long diameter of the head in the oblique
Fia, 83. — ^The Suellie-Veit Method Used When the Head is Low in
THE Pelvis
diameter of the pelvb till past the brim. Aa the chin approaches
the fourchette, a finger introduced into the mouth depresses the
tongue for the admissiou of air. Expressio fcetiis by suprapubic
pressure by a skilled assistant is au important aid in bringing the
head through the pelvis (Fig. 82).
Wigand-Martin Method. — Of manual maneuvers this is the
most efficient when the operator must work without assistance.
The technique is as follows: Two fingers of one hand are placed
in the child's mouth or pressed against the fos.sic canine to con-
trol the mechanism, especially to maintain full flexion. With the
other hand the head is driven through the pelvis by powerful
suprapubic pressure (Fig. 84).
818
PATHOLOGY
OF LABOR
Forceps.-
well up over
and engaged
very seldom
-All assistant,
tlie Kiothor'a
The forceps
required, tliis
1
seizing the child 'a feet, holds its body
abdomen the head having been flexed
is then applied to the head. Though
is the most reliable of all methods of
extracting the after-coming head. If the normal mechanism ia
observed aud violence avoided, the danger of maternal injuries i«
no greater than in manual extraction.
(2) Dorsoposterior Positions. — On expulsion of the breech, the
THE AfTEH-COMINO
occiput shoiilii lie votiited 1o the front liy gentle torsion of the
truuk, the back being kept well to the front, with the aid of ex-
ternal pressure applied over the mother's abdomen by an assistant.
Theu delivery is accomplished an in primary anterior positions.
Rotation failing, delivery may be accomplished by traction and
suprapubic pressure, the trunk being carried downward and back-
ward over the ])erineum. Sliould the chin catch over the brim of
the pelvis, delivery niiiy be made, occiput first, hy traction upon
the body dirretiii u]i\vard and forward over the pubea, aided by
suprapubic pressure or by the forceps.
Should 111'- fnreann of the fi'Uis be lodged behind the neck,
the body shnidd lie rotated in the direction from the misplaced
arm, too much torsiuu of the neck being guarded against. The
ANOMALIES OP THE PASSENGKR
319
tatioii of the head may, if necessary, be assisted by external
essurc. Sometimes the inicliat ann may best lie dislodgtxl with
e hand in tlie passages. Having disengagitl the arm, one may
oceed as in ordinary cases.
Bi> TO THE A»TEii-('OMiN<i lIuAD. The body
ri sterile towel and carried over tlie
pubea by an assistant.
In failure of the poivrrs at or above the brim one or Iwth feet
3uld Ih; Iirought down, if this is jiossible without violence. If
^> breech has sunk into the bi'im it may. with the aid of postural
tasurL'S and aoestliesia, be dislodged even aft^T partial engage-
320 PATHOLOGY OF LABOR
When the legs are extended, carrying the feet high up in the
uteruB, the foot may be brought down as follows: Having intro-
duced the hand into the vagina, two or three fingers are passed
into the uterus between the tliighs, one thigh is pressed outward;
the knee is thus flexed and the foot brought down within reach
of the operating hand.
/(( case of impaction, or failure of the powers u-itk the breech
in the cavity, three methods of delivery are available: traction Sy
finger, fillet, or forceps. Even with the breech in the midplane. it
may be possible under deep anesthesia and with the aid of the
Trendelenburg posture to dislodge it and bring down a foot.
The finger hooked in the groin is competent when only a mod-
erate amount of force is required, and the breech is on the pehic
floor.
A yard of strong muslin bandage or a soft handkerchief, which
has been boiled, may be used as a filtet. It is oiled and knotted at
one end. The knot is pushed up over the groin with one hand
and hooked down on the opposite side of tlie thigh with the fingers
of the otht'i hand. Traction is then applied to the fillet with care
to avoid doing violence to the structures of the groin by too great
pressure.
In dorsoposteriar positions the fillet is made to encircle the
pelvis, the free ends depending between the thighs. One end Ifl
passed over each groin from without inward, and the loop slipped
up over the sacrum. Or the fillet may be passed over one groin
and be hehl in place with one hand while traction is made with
the other. The latter precaution is necessary owing to the danger
of fracturing the femur should the fillet slip and traction be made
upon the central iinrtion of the ^haft.
In cases not nuiiiageable by the finger or the fillet, forceps may
be applii'd to the breech. One blade is jilaced over the sacrum
and ilium, llie other over the posterior surface of the opposite
tbigb, or the blades arc adjusted over the ti-ochanters, especially
in dorso posterior positions, pressure upon the ilia being avoided.
Jloderale traction is made and assisted with irpressio foetus. Tke_
forceps is onhi nsiil to briinj the hri eeli leithin the reach of th$
fillet or finger.
The cephalntrilif, jijiplicd lo the breech, may be used to ad-
ANOMALIES OP THE PASSENGER 321
TRANSVERSE PRESENTATION; SHOULDER PRESENTATION
A transverse presentation is one in which the long axis of the
fetal ellipse lies across the long axis of the uterus. Primarily the
presentation is oblique rather than transverse. In a large pro-
portion of cases cross presentations are spontaneously converted
into longitudinal when labor begins. In persistent transverse
presentation the shoulder, or sometimes the arm, becomes the pre-
senting part after labor is established.
Frequency. — The frequency of shoulder presentations has
been variously estimated, but may be fairly stated as 1 in 250.
Causes. — The causes of cross-birth, which is a partial inver-
sion of the fetal axis, are practically the same as those of breech-
birth or complete inversion. This anomaly is, therefore, observed
most frequently in unusual mobility of the fetus, as in multiparse
with large, flabby uteri and pendulous abdomen, twin pregnancy,
fetal tumor, myoma of the lower uterine segment, undue pelvic
inclination, pelvic deformity, and low attachment of the placenta.
Positions. — Since the child's head may lie either to the right
or the left of the mother, and its back may be turned anteriorly
or posteriorly, there are four possible positions in cross-births as
follows :
Left scapulo-anterior — L. Sc. A.
Right scapulo-anterior — R. Sc. A.
Right scapulo-posterior — R. Sc. P.
Left scapulo-posterior — L. Sc. P.
It should be noted that these positions are named according to
the direction of the presenting scapula, or, on abdominal palpa-
tion, from the location of the head and the position of the back,
left if the head is in the left iliac fossa, anterior if the fetal dor-
sum is to the front. When the scapula looks to the left and front
the position is a left scapulo-anterior, when to the right and front
it is a right scapulo-anterior position, and so on.
Diagnosis. — Abdominal Signs. — 1. The abdomen is unusually
wide from side to side, while the fundus frequently does not rise
above the umbilicus. 2. Both fetal poles are absent from the exca-
vation after labor is established.
3 and 4. A third sign is the presence of the head in one or
322 PATIIOLOQY OP LABOR
the other iliac fossa, and a fourth is presence of the br«ech on
the opposite side.
Vaginal Signs.- — There is glove-finger protrusion of the bag ot
waters; the presenting part is smaller, more yielding, and less
distinctly rounded than the hard globular head. Especially sig-
iiificant is absoict, of any presenting part at the onset of labor.
After labor is well established the presenting part is a small,
rounded prominence; it is distinguished from an ischial tuberos-
ity by the absence of a comjianiou ; from it run the humerus, the
clavicle, and tlie spine of the scapula ia radiating lines.
The neck is felt on one side of the presenting part, the "grid-
iron" sensation afforded by the ribs on the other; the axilla md
he made out; the elbow is identified by the olecranon; the posi-
tion is determiued by the location of the scapula to the right or
left, anteriorly or posteriorly. The axilla and the elltow look
toward the feet ; the thumb points toward the head.
When an arm is prolapsed the hand is to be distinguished from
the foot, and the right fram the left hand. On shaking hands
with the fi'tus, the right hand of the examiner fits the right lianil
of the fetus, and vice versa.
Prognosis. — Persistent transverse presentation is almost
surely fatal to both mother and child, yet small, premature, or
macerated children have been born spontaneously. The risks to
tlif mother are from i)res8ure-elfeets. exhaustion, sepsis, rupture
(if Ihi' uterus: t'l tlir i-liild, frniii pressure- effects, prolapsus funis
jLiid o[)iTritiv(' ciciivi'i-y.
Spontaneoas Deli very. ^ — Very rarely spontaneous delivery
■fakes plaee bv iiiic of the following methods:
(a) Spotilnii'iius Vrrsiiiti. — The shoulder presentation Js con-
verted into a bfeech or into a vertex birth by the uterine expul-
sive efforts. Such u ehaiigc of presentation ia common at the
beginning of hiiior. It is favored by having the patient assume
the scjuattiiig posture, with the tlngii of the side toward which the
breech points forcibly Hrxcd mmii llie abdomen. It oecui-s more
frequeiilly in nuiltipiir:e tliaii in pniiiipanr, oftener with a living
thsn with a dead child.
(b) Siioi'Iniii'/i/s Eri'liiliiin. — The lueehauism of spontaneous
evolution is as follows: As the child is driven down by the uterine
contractions, the head rides over the symphysis and the auterit^
ANOMALIES OF THE PASSENGER 323
shoulder becomes fixed under the pubic arch. The other shoulder
is forced down over the posterior wall of the pelvis and is expelled
first. It is then followed by the trunk. The head is born last.
Spontaneous evolution is only rarely possible, and only with
a small child or large pelvis.
Expulsion with trunk doubled on itself (partus conduplicato
corpore) may occur when disproportion between the size of the
pelvis and fetus favors, or when the child is dead and macerated.
Treatment. — Before Labor. — If the pelvis is approximately
normal, the malpresentation should be corrected by external
cephalic version. To retain the presentation as longitudinal a
tight abdominal binder and lateral compresses should be applied.
During Labor. — The membranes should be preserved ; to secure
full cervical dilation the bladder and rectum must be evacuated;
the capacity of the pelvis, the size of the child, the relative posi-
tion of the head and the dorsum, the situation of the retraction
ring, and the degree of thinning of the lower uterine segment are
all to be noted. When the cervix is fully dilated version should
be performed, ceplialic or podalic, by the bipolar or the internal
method, foUowe^by immediate extraction under anesthesia.
// the membranes have ruptured, the degree of cervical dila-
tion, the condition of the uterus, of the patient, and of the fetus,
determine the treatment. If the cervix is only partially dilated,
and the child is alive and freely movable within the uterus, bi-
polar podalic version should be tried, a foot brought down and
allowed to dilate the cervix before the extraction is completed.
If the condition is complicated with prolapse of the cord, the
cervix should be dilated manually or split, and an immediate in-
lemal podalic version and extraction made.
Reduction of the malpresentation is often possible, even in the
presence of a spastic uterus, with the aid of the genupectoral or
the Trendelenburg position and deep anesthesia. In impacted and
irreducible shoulder presentation decapitation will be required.
Cesarean section should be considered as a possible alternative
when the child is alive and the uterus has not been infected.
TREATMENT OF COMPLEX PRESENTATIONS
Head and Hand, or Both Hands. — When possible the hand
should be replaced with the aid of anesthesia and the Trendelen-
824 PATHOLOGY OF LABOR
burg posture. This failiug, and the head engaging pliis the pro-
lapsed member, delivery may be accomplished with forceps, the
arm being placed in the unoccupied side of the pelvis, or, better,
if the head is unengaged and the pelvis is ample, podalic version
should be performed.
Hand and Foot, or Head, Hand, and Foot. — The fetus may be
extracted by one or both feet.
Nuchal Arm. — The diagnosis is made by ancBthetiziiig thf
patient and introducing the hand into the passages.
In vertex presentation the arm is dislodged with the hand in
the uterus by rotating the body from the nuchal arm. Rarely
version will be necessary.
In head-last casi's the nuchal arm is dislodged by seizing the
delivered trunk with both hands and rotating the body from the
misplaced arm. Tlie other arm sJiould first have been delivered.
The reduction of the misplacement may be followed, if neeessao*.
by introdneing two fingers between the shoulder and the ^Tuphy-
sis, and bringing down the arm in the manner practiced in or-
dinary breech extraction.
In complex presentation, if the fetus is dead, delivery is beti
accomplished, as a rule, in the interest of the mother, by ciuni-
OTOMY.
ANOMALIKS OF yr.TAI. DEVELOPMENT
T>rii,.^
Relative situations of twins arc: one above the other, one be-
side the oilier, one in front of Ibe ntlier.
Diagnosis. — (a) Abdominal tiiunx. — Several of the following
ahdominiil .signs may lie observed and a diagnosis made:
(1) Excessive size and tension of the uterine tumor; perma-
nent tension of the tumor, with very limited mobility of the eon-
tents.
(2) Excessive width of tumor and a longitudinal sulcus {the
latter, however, is not diagnoHticl.
(3) Suprapubic edema, which is present also in simple hydram-
ANOMALIES OF THE PASSENGER 325
(6) Three or four fetal poles.
(7) One head in the excavation and one in the upper uterine
segment.
(8) One head in the excavation and one in the iliac fossa.
(9) Distance from the pelvic pole to the fundal pole over 30.5
cm. (12 inches).
(10) Two fetal heart-sounds at different rates.
(11) Two fetal heart-sounds of the same rate, but in widely
different situations and on opposite sides of the abdomen.
(12) Heart tones above the umbilicus when the head is in the
excavation.
(13) The demonstration of two fetuses by the X-ray.
(b) Vaginal Signs, — A rapidly successive presentation of a
head and a breech;
Four extremities offering at the brim;
Two amniotic bags presenting.
Prognosis. — The prognosis in twin births is more serious. The
toxemias are more frequent, cardiac complications more serious,
operative delivery more common and postpartum hemorrhage and
sepsis are more likely to occur. As twin births are premature
many infants die of atelectasis and general debility.
Management of Labor in Twin Births. — The management of
labor in twin births differs in no wise essentially from that of
ordinary labor, save that, owing to the marked overdistention of
the uterus, the pains are likely to occur at long intervals and be
inefficient. The cord of the first child should be ligated on the
placental as well as the fetal side, owing to the possible existence
of a vascular communication between the two placenta?. Since
the passages are dilated by the birth of the first child, the second
birth, except when the first child is undersized, usually is rapid,
or, if necessary, may safely be made so. The delivery of the sec-
ond child, however, should be left to nature except for cause.
Changes in the position of the second child frequently occur dur-
ing, or just after, the delivery of the first; hence the necessity of
making an examination immediately on the birth of the first twin,
to detect any abnormality in. the position of the second. The
fetal heart should be watched, and immediate delivery effected
if it becomes abnormal. As the overdistention of the uterus ex-
poses the woman to postpartum hemorrhage, extra care will be
326 PATHOLOGY OF LABOR
Deeded to secure firm uterine retraction by manipulation and by
the use of ergot and pituitrin.
Interlocking Twins
This anomaly, which is exceedingly rare, presents two princi-
pal varieties: (a) Both presentations cephalic, both heads offe^
ing, one impacted between the head and trunk of the other fetus;
(b) One presentation cephalic, one pelvic, the after-coming
liead of the breech birth being impacted between the head and
trunk of tiie other fetus.
Management. — If it is not possible to disengage by a com-
bined internal and external manipulation, with the aid of aueft-
thesta and the knee-chest or the Trendelenburg position, the fint
child may be perforated or decapitated.
DoubU' Monsters
There are three varieties: 1. Tliosc with slight separation;
2, Those with moderate separation; 3. Those with extreme sep-
aration. The greater the degree of separation the greater the
probability of dystocia.
The diagnosis can scarcely be made except by passing the hand
into the uterus. This exploration will also determine the degree
of separation.
Premature and spontaneous delivery commonly cecum
Usually delivery may be fueilitatcd by podalie version if the diag-
nosis is made in time to opei'ate early in the labor. Forceps some-
times may succeed. Ursurf slionid be had to embryotomy in dtJE-
i-ult cascx.
Ihjdron/.hahis
llydrouepliiihis i.s jilli.*iiiii.cl with a serous effusion into the
cranial eaviry, with eousequent enlargement of the cranial vault
and thinning of the brain tissue to a thiekneas of a few milli*
metere. Tin.' effusion is usuall.v found in the ventricles, very
rarely iu the araeiinoid or subarachnoid cavity. The quantity of
Huid may be several |)iiils. The cranial hones are imperfectly
developed; the sutures and foutanelles are widened and stretched.
ANOMALIES OF THE PASSENGER 327
Spina bifida, hydroencephalocele, and other anomalies of de-
velopment frequently coexist.
The etiology is obscure.
Diagnosis. — (a) Head-first Cases. — Ahdominal Sigtis. — The
best diagnostic evidence is afforded by measurement of the head
as determined with a pelvimeter through the abdominal walls, or
estimated by palpation. Yet mensuration of the head in this man-
ner may be impossible owing to hydramnios. Sometimes the head
presents a distinctly fluctuant feel.
Vaginal Signs. — Vaginal signs are: the size, elasticity, and
fluctuation of the cranial vault; excessive width of the sutures
(the latter, however, is not peculiar to hydrocephalus, nor is it
always present) ;
Fontanelles, as a rule, preternaturally large;
Sometimes a supplementary fontanelle may be noted between
the anterior and posterior;
Unnatural prominence of the frontal and parietal bones.
The size of the head cannot be estimated by the usual method
of vaginal examination, which explores only the presenting part.
Elasticity and fluctuation are not always readily detected
when the cranial vault is rendered tense by firm engagement
in the pelvic brim. When there is doubt , the patient should be
placed under an anesthetic and the hand introduced into the
uterus,
(b) Head-LuVst Cases. — In one case in three the hydrocephalic
fetus presents by the breech, the tendency to breech birth being
greater the larger the relative size of the head. The signs of
hydrocephalus in breech birth are:
Body wasted;
Head arrested after the birth of the trunk;
Fluctuation ;
The size of the head, as determined by measurement or by
palpation through the abdominal wall.
Prognosis. — Mother, — The maternal mortality is estimated at
25 per cent, from exhaustion, rupture of the uterus, and hemor-
rhage.
Child. — The mortality is over 80 j)er cent. Even if the child
is born alive it is of feeble vitality, and is destined to probable
idiocy. Nearly all die soon after birth.
328 PATHOLOGY OP LABOB
Treatment. — Hardy the enlargement of the head may not be
sufficient to prevent spontaneoHS delivery.
As a rule, perforation is required. This should be done u
soon as dilation is complete. Extraction is best effected with the
cranioclast. The forceps is contra indicated because of ita liability
to slip and do extensive damage to the uterus and pelvic atme-
tures.
Aspiration with a small trocar passed through a fontanelle or
suture may sometimes be substituted for craniotomy. The life
of the child is not necessarily lost by drawing off tJie fluid grad-
ually, and a living birth may be ilesired for medico-legal reasons.
In difficnlt head-last eases the head may be perforated or the
spinal canal opened and the cranial cavity catheterized through
it. The perforator can be passed safely beneath the skin, enter-
ing it over the neck.
Serous effusions into other cavities, if they cause marked dys-
tocia, are to be evacuated by a.spiration of the dropsical canities
or by free incision.
Tumors
Hygroma, fibroma, lyinphangionia. myoma, sacrococcygeal
teraloiiiji. sj)ina bifida, enlargement of abdominal viscera, and
oilier tumors are occasinnaily met with.
Treatment. — Delivery of the fetus intact being impossible,
lliiiil tumors may be. reiluci'd by tap[iing or by incision, solid, by
segmciitation.
ANOMALIES OF LABOR AKISING FROM ACCIDEHTS OK
DISEASE
rR(]i,Arsfs FUNIS
7(1 prrilfiiLfiis fnin'x a lixqt of Ihi iiai-fl cord slips down in ad-
vatu'i' "f tin pri HI iiliiii; purl of llir fttiis. As the labor goes on.
the mis]ilaia'd |iorti"!i of the eoiil is compressed between the part
jirescntiiifT ami the walls of the birth-canal, and without relief the
fetus (lies usually williiii five to fight irunules from the interrup-
ANOMALIES FROM ACCIDENTS OR DISEASE 329
Prolapse into the unbroken bag of waters is sometimes spoken
of as funic presentation.
Frequency. — Prolapse of the cord occurs once in about two
hundred and fifty labors. The frequency differs in different climes
from 1-165 to 1-1800.
Causes. — ^Anything which prevents the presenting part from
completely and continuously filling the lower uterine segment pre-
disposes to prolapsus funis. These conditions are:
Hydramnios ;
Deformed pelvis;
Malpresentation (frequency in head presentation, 1 in 304;
face, 1 in 32; pelvic, 1 in 21; shoulder, 1 in 12) ;
Complex presentations;
Twins;
Small fetus;
Large pelvis;
Multiparity ;
Pendulous abdomen;
Uterine myomata;
Low placental insertion;
Rupture of the membranes while the woman is sitting or stand-
ing;
Marginal insertion of the cord;
Excessive length of the cord.
Diagnosis. — The diagnosis should present no difficulty. The
prolapsed cord may be found in the bag of waters, in the vagina,
or protruding through the vulva. Before rupture of the mem-
branes it may be distinguished from fingers and toes by the an-
atomical characters of the latter. The fetal parts will usually be
drawn up out of the way when touched. After rupture of the
membranes there is nothing else which presents from cervix which
feels like a cord or may be mistaken for it.
Prolapse of the cord must be distinguished from protrusion
of a loop of intestine following rupture of the uterus. In the
latter there is more or less hemorrhage, the prolapsed loop is
larger, the mesentery can be felt, and pulsation is absent. The
prolapsed portion of the cord should be examined for the funic
pulse to learn whether the child is living. Absence of pulsation
for fifteen minutes may be taken as evidence of the death of the
330 PATHOLOGY OP LABOR
fetus, Tlic fetal heart should be listened for over the abdomen.
Prognosis. — T)ie prolapse itself entails no additional risk to
the mother; though the coaditioiis which give rise to it and ©ijera-
tive mtasiires necessitated by it may do so.
The fetal mortality may be stated at 50 per cent. It is highest
in vertex presentations and in first labors. The danger is much
increased after the itiembraues rupture.
Treatment. — Before Rupture of the Membb.\nes.^In Lonqi-
TL'DINAL Pkk.sbn TAT IONS. — Of first uiiportance is the preservation
of the membranes if still unbroken. It should be a rule to rupture
tlicm in no case intentionally without first examining for possible
prolapse of the coi-d. For reposition the aid of gravity should be
cnUslal hy placing the patient in the knee-chest, the lateroproHt,
or the Trciidch-nbiirt/ position. In the lateral posture the patient
lies un the side opposite that on which the cord came down. Grav-
ity alone failing, we may attempt to inish the cord up between
pains, with eare to avoid rupturing the membranes, and crowd
the lower fetal pole into the brim to guard against recurrence of
the displacement till the presenting part has firmly engaged. Al
short intervals we should listen over the abdomen for the fetal
heart.
After Rittire of tjie JIembkaneb. — In LoNomiDiNAL Pres-
entations.— Itepositivn should be accomplished at once if the
funic piilm: can be fell; if the pulsation has ceased, but the heart-
lonea ai'c still andilile. the presenting pole should be pushed up
and Ijic cord replaced after pulsation returns. If manipulation
aided by posture fails lo replace the cord, bipolar or internal
podalic vei-sion slmuld be performed promptly.
The niolhrr »)/(,<( not he subjected to the discomfort and tkt
risks of riposilioii iiiihss the •>i>i mlor is assured that the child is
living and cinhlr.
Methodx.— ln) Mnniiul /.■, ,,„s,7 ,*„„.— The patient is placed in
the lateroprone. the gennpectoral. or the Trendelenburg posture
and anesthetized with ctlier. The operator twists the prolapsed
loop loosely into a rope and pushes it up anteriorly, hooking a
loop of tlie eord over iin extremity to prevent it from prolapsing
again, operating helwec>ii the pains, ^lueh handling of the eord ie
dangerous to tlin child; it enfeebles the fetal heart. To retain
the cord, the presenlinj: pole should he crowded tirndy into the
ANOMALIES FROM ACCIDENTS OR DISEASE 331
excavation and held there by manual pressure or with a tight ab-
dominal binder. The patient should lie in the lateroprone posi-
tion, with the hips elevated, or in the Trendelenburg position.
Examination through the vagina shouhl be made from time to
time, lest the cord slip down again as the labor progresses.
The strength and rate of the fetal pulse should be ascertained
frequently.
(b) Instrumental Reposition, — The aid of posture is essential,
as in the manual method. An instrumental repositor is substituted
for the hand. An English catheter, with a tape attached and
loosely looped over the cord, makes an easily improvised and effi-
cient repositor. After complete reposition the catheter may be
left in the uterus.
The instrument is armed with a stylet, which is withdrawn
after replacing the cord. The same measures for retention are to
be used as in manual reposition.
(c) Reposition with a gauze tampon has replaced all other
methods in the author *s clinic. The woman is placed in an exag-
gerated Trendelenburg posture, and anesthetized. The corner of
a yard square of sterile gauze is looscjy tied to the prolapsed loop
(not interfering with the circulation), which is pushed up with
the gauze anteriorly above the presenting part. The gauze acts
as a tampon and prevents further escape of the cord.
(d) Forceps or Breech Extraction, — Should all attempts at
reduction and retention fail, the child may yet be saved by rapid
delivery. This is possible in vertex presentation with forceps or
by version; in breech cases, by the usual technique of breech ex-
traction. The author has saved two children by Cesarean section,
in primiparae with undilated cervices, in whom the membranes rup-
tured early, and allowed the cord to prolapse, owing to non-en-
gagement of the head. The cord, meanwhile, should be disposed
where it will receive the least pressure, opposite the sacroiliac
joint on the side of the pelvis in which there is most room.
As suggested above it is sometimes best to resort to version pri-
marily.
In Transverse Presentations. — Before the membranes have
ruptured, the loop of prolapsed cord may be reposited by postural
methods; after rupture, by podalic version aided by posture and
anesthesia.
PATHOLOGY OF LABOR
INVERSION OF TUE UTEKU8
The inversion may be partial or complete. It begins usnallr
as a cup-ahaped depression at Ibe fundus, which pi-otriides into
the uterine cavity ; or the womb may be turned completely inside
out. In the vast majority of eases it occurs just before, rarely
directly after, the expulsion of the placenta.
OF Inversion. 1. Cup-ahaped depressioD ot
■r.'iion. .'5. Ccniplele inversion, a, fundus
vagina; ''<'. nioulb of inverted portion.
Frequency. — Tbe frequency of puerperal inversion of the
uterus may be estimate! roughly al 1 iu 100.000 to 1 in 150.000,
the rarest of all parturient accidents. In properly conducted
labors tlie accident is well-nigh ijupossible.
Etiology. — The aeeidriit happens with c<|ual frequency before
and nfu-r the di'livery of the placenta. Relaxation of the uterus
iu tbe thiril stage of labor is the ]>rimary cause. The relaxed and
tiabby placenlal site sags down into tbe uterine cavity and is seized
upon by the contracting uteHue muscle and is depressed further
downward as a foruij-'u body. I'nskilled pressure on the fundus,
traetiou on Ibe eord while !be uterus is relaxed, extreme intra-
abdominal pi'essure. an adticreni placenta, or a fundal placental
seat may coulribute to tbe aecideut.
Diagnosis. — Sijiniiloiii.i. — rouiplete inversion of the uterus oc-
curs suddenly, and usually is lolloived by profound shock, .pgJB,
334 PATIIOI-OOY OF LABOR
superior strait to one aide of the sacral promontory. The h«nd i*
held witliin the uterus till eontraetioii forces it out, when llit
uterine cavity aud vagina should be packed with iodofonn gaiiw
until retraction is established.
Another niethoil consists in pressing the fundus upward with
the palm of the hand, while two or more fingers indent the lateriil
wall of the uterus.
When the placenta is adherent the operator should replaee
all; when it is partially detached he should separate and remove
it before trying taxis.
Rigorous aseptic prrcauthiis must be observed to prevent inftc-
Hon.
Kxtri'iiiv lui'HSTii'i's lire iiiiidvisabh- during the puerperium, ami
Mlti'iiipls ;it ri'positiiin should be deferred for several weeks if not
sufi-es-sful williin twenty- four hours.
Rarely in ii'ri'ilucible inversion, with persistent hemorrhage,
vaginal liyHifreeloiiiy nmy be i-tHiuirod. An anterior vaginal hy»
terotojiiy. begun by cutting the cervical ring, will allow speedy
reposiliiin wlun iiianiial inelhods fail. The author prefers this t«
JiystcnTtomy.
RrPTi'iit; OF THE uterus
Nature of Accident. — liarcly rupture of the uterus may occur
during iurgnancy or the puerperium. Spontaneous rupture of
the uterus during pregnancy generally begins in the upper seg-
ment, iuul is due to sonu^ preexisting lesion which weakens iu
iiniseuliir wmIIs. sui'li ;is inynma. fatty degeneration, previous
(i|"Tiiti(Ui si-;its. eT ei'lcr;i. Id i-nrtuial pregnancy, or to vesicular
!ii hilitir usually the teiir begins in tbc overdiatended lowi'f
iirerine sesmcnt. due to soiiie obstruction which prevents the At-
■^^ ■■■ut of tile ebild tlironirli lite pelvic canal. It may take any dirw-
tIoii and reach any extent within the limits of the organ, but
■sually runs transversely when s| inn t.T neons. The edges are raggP"!
;i[id swollen aud the viiirimi or the bladder may be involved. The
poi'tio vaginalis is sometimi's Inrn off. Fissures of the cervix oi
greater or less depth occur in most laboi's. aud in operative labon.
through ineoiiiplelety dilated passages, may be so extensive as W
836 PATHOLOGY OF LABOR
Presentiiig part abseut or receding;
No evidence of fetal life;
Knuckle of intestine in the uterus;
Uterus, firmly contracted, and child forming aepant«
tumors.
Tlic diagiiosia is confirmed on examiniug with the fingers in
till' iit.'ni8.
Prognosis.— Tliis depends on the site, extent and degree of the
tear nud upon the treatment. In complete rupture the mortality
for the niotliers is !!(> to 95 per cent, from hemorrhage, peritonitis,
and septicemia. The I'etal mortality is even greater, from complete
interru|)tion of the iitcroplaeeiital circulation. Under modern
methods (if trcahiienl nearly 50 per cent, of the mothers may be
saved.
Treatment. —1. Preventive. — The cause of obstruction should
be recognized and removed if ])ossible; malpositions should be
corrected. In pseessive retraction of the uterus, shown by Ihe
high i>()Hlti«n of Ihe retraction ring, immediate delivery is indi-
eiiled, iia a rule, even though it necessitate embrj'otomy.
2. Vi'R.\Ti\ E.~l iicoDiplflf liupluir. — The child should immedi-
uleiy be dcHvenii hy forceps, or, if dead, by embryotomy. Should
tile dihition not be eoniplele. manual dilation, or vaginal hyster-
oliiiiiy. if rei|iiiie»l. iiiny he practiced. Small lacerations, with little
or no bleeding, may sometimes be treated by drainage, the blood-
clots me removed and Ihe rent packed with plain or oxid-of-zinc
gauw. The gau/.e is removed in two or three days. Much hemor-
rhage or extensive injury re<)uiivs laparotomy and suture.
In ease of doubt, as between complete and iucomplete rupture,
the question may be decided by manual exploration through a
]K)sterior vaghial iiicLsion.
(''•miilit> liiipliiri. — The indications are to extract the ehiM
and to control hemorrhage, (al When the fetus or larger part
of il is still ill ihi- uterus it should imme<^liately be extracted by
the naliind pas.-yi^es. In vertex presi-ntation delivery is best
effeeliii by perforation in the pra.sp of the eephalotribe or forceps-
The phieenta is removed manually. Rarely small lacerations in
the lower and posterior portion of the uterus may be treated by
dniinngi'- when assurjinee can be had that neither liquor amnii.
miH-ouitmi. nor much blooil has escaped into the peritoneiim. A
ANOMALIES FROM ACCIDENTS OR DISEASE 337
half-inch rubber tube is folded, the limbs of the tube tied together,
the bight of the tube perforated in several places and passed just
through the uterine rent. Instead of this several strands of wick-
ing or a bundle of gauze ropes may be used. Prolapsed intestine
must be reposited. The uterus must be made to contract. The
drain is removed in two or three days on cessation of much dis-
charge.
(b) Celiotomy should be done when the fetus is wholly in the
peritoneal cavity, has long been dead, or when there has been much
hemorrhage into the peritoneum, or when the cervix is not dilat-
able, or the rupture is extensive,, or its site not favorable for drain-
age. The uterine lacerations are closed by deep suture. The peri-
toneum is cleansed by sponging op by irrigation with the normal
salt solution.
Amputation of the uterus, or total hysterectomy, should be
resorted to when necessary to avert sepsis; especially is this ad-
visable if the lacerations are extensive or the uterus is infected.
By certain authorities abdominal section is practiced in sub-
stantially all cases of rupture, whether complete or incomplete,
and regardless of the amount of hemorrhage.
TrEzVtment of Anemia. — If there is much loss of blood the
anemia is to be treated, as in other cases, by bandaging the ex-
tremities, raising the foot of the bed, by hypodermic, intravenous,
3r rectal injections of the physiological saline solution, or by direct
transfusion and the administration of opium, adrenalin, strychnin,
and by other restorative measures.
THE HEMORRHAGES
1. Placenta Previa — Unavoidable Hemorrhage
Definition. — The placenta ia said to be previa when its attach-
ment is to the lower uterine segment and its site encroaches upon
the zone of the uterus, which undergoes dilation in the first stage
of labor.
Degrees of Placenta Prsevia.— 1 . Partial. — The great mass of
the placenta lies on one side of the lower uterine segment, partially
covering the fully dilated os. ^Marginal and lateral implantation
may be included under this variety.
338 PATUOLOGY OF LABOE ^^^M
2. Complete. — The central portion of the placenta wholly
covens the fully dilated os. Full central implantation is rare.
Frequency. — Plaeenta prn'Tia is observed in about one in one
thousand laljors. It occurs four to six times luore frequently in
mullipant' than in primipariK, and is more often met with in the
working classes.
Causes. — Possible causes of misplaced placenta are conditions
giving rise to tardy fixation of the ovum, permitting it to drop
into tlic lower uterine segment; e. g,, endometritis, enlargement
of lilt- uterus, relaxation of the uterus, or multiparity, abnormally
THE Internal OriiM Marginal,
Placenta Pr-evia
low position of the tiil)al orifice; low fixation of the ovum, due to
dfvelopnii'iit of the pluecnta, in part, upon the decidua reflexa;
ri'Hesal iilncrnta is_ believed to be a cause, yet pregnancy with a
reHexal plneenla selitoni goes to term.
The causf of luniorrliafie iliiriuy luhur is the siparalwn of the
luw r iiiiinjiii I'f llic iiliu-iiila, uitiixitig and opening the simisft
ill llir phii-dita sitr. irliirli liil.-',i pUriT as soon as catializalion of
till- f rvix lurjiiis. Ill ci-nlnil iinil partial placenta pnevia the
liemonlmgc mail li<<jiii early in pregiianey. Itemorrhagt' before
840 PATHOLOGY OF LABOR
(3) There is a bogginess of the cervix, vaginal vault, and the
lower uterine segment.
(4) The characteristic stringy feel of the detached surface of
the placenta may be noted on examination through the cervical
canal; the uneven surface of the cotyledon and a gritty feel dis-
tinguish it from blood-clots which are more friable. It should be
borne in mind (hat the portion of placenta over the cervix may be
only an adventitious cotyledon.
In marginal placenta previa the edge may be felt, especially
if detached.
Prognosis. — Without intervention the maternal mortality in
cases that go to the later weeks of pregnancy is one-third to one-
half, including deaths from the sequelie. Two-thirds or more of
the children are lost.
The maternal mortality results from hemorrhage, shock, sepsis,
rupture of the lower segment, and thrombotic affections; the fetal
from asphyxia, the effect of the maternal hemorrhage ou its blood-
supply, from prematurity and operative causes. The mortality
for both mother and child obviously must vary, however, with the
degree of hemorrhage. Maternal deaths from placenta pnevia are
rare before the seventh month. The danger to life increases as
gestation advances by reason of the increasing size of the blood
vessels and the progressive loosening of the placental attachment
Postpartum hemorrhage is common.
Hemorrhage begins eai'lier in partial than in complete pla-
centa praivia, since the small free portion of the placenta in the
former slides more readily than does a placenta, implanted all
about the os.
With skillful treatment the maternal mortality in placenta
prrevia is less than 5 per cent., and the fetal mortality is greatly
reducetl.
Ill 143 eases of prcvial placenta collected by Chrobak, mis-
carriage oi'eiirred in 4 per cent., premature labor in 5 per cent.,
tcniL dflivery in 1 pur cent.
Treatment.— -( a ) Hefoke Vi.vbu.ity. — Generally the pregnancy
should he terminated as soon as a positive diagnosis of a prerial
placenta is made. Excrptinnalhj the inalmcnt may be cxpcdant,
provided the patient is in a hospital under constant observation,
Partial or coinnlete rest must be eninined aeeordin^ to the nmmiiit
ANOMALIES FROM ACCIDENTS OR DISEASE 341
of bleeding, and a general regimen prescribed very similar to that
pursued for the arrest of threatened abortion or premature labor.
If the hemorrhage is copious, the placenta prcevia complete, or the
fetus dead, the uterus should be immediately emptied,
(b) After Viability. — Induction of l^ibor is indicated imme-
diately the diagnosis is made, simple eases excepted.
Management of Labor, — The principal indications in the man-
agement of labor with placenta prajvia are the control of hemor-
rhage and the securing of dilation of the cervix. Hemorrhage
under control, urgent measures are not necessarily required, but
the obstetrician should remain with the patient until she is de-
livered.
Rupture of the metnhranes and the application of a firm ab-
dominal binder may suflfice in simple cases of marginal placenta
praevia. If uterine contractions are efficient, or can be made so by
stimulation, the bleeding usually is controlled in the lesser de-
crees of vicious implantation by the engagement of the presenting
part. The presenting pole acts as a tampon.
If the cervix is sufficiently dilated, forceps, with very moderate
traction, may be tried in marginal cases if required to hold the
head in the lower uterine segment as a tampon. After dilation,
delivery may be effected by forceps if the patient's condition de-
mands it.
Before dilation of the cervix, the vaginal tamponade is a use-
ful measure when there is little or no dilation of the cervix, less
than two fingers, as it not only controls hemorrhage but hastens
the dilation of the cervix. It is best placed with the woman in
the Sims or the genupectoral posture, and w^ith the aid of a specu-
lum. The best material is sterilized gauze in strips; it may be
used plain or impregnated with a nontoxic antiseptic such as oxid
Df zinc. To pack solidly it must he wet, !More than enough to
completely fill the vagina should be used, and the protruding por-
tion held under the pressure of a firm T-bandage. The external
genitals should be cleansed, but the vagina, if healthy, requires
QO antiseptic cleansing before placing the tamponade. The dress-
ing is removed in six or eight hours. It may be renewed if the
dilation is not sufficient for delivery, or resort may be had at once
to bipolar version.
A more efficient means of hemostasis and dilation is the dilat-
342 PATHOLOGY OF LABOR
ing water-bag in the cervix, lir.iiiii'H, Pomeroy's, Voorhees', or the
Champetier de Ribes. A sterile Voorhees or tie Ribea bag may be
introduced through a. cervical canal admitting two fingers. The
membranes should be ruplurcd so that the bag may rest against
the fetal surface of the placenta anil cause it to act as a tampou.
Bipolar podalic i-ersion ia a measure of the greatest value for
controlling the hemorrhage. It is especially indicated in case of
much bleeding with little dilation {external os must be up to two
tingera) and before niplure of the membranes. With one or both
feet down the fetu.s serves as a conical cervical plug. Bipolar ver-
sion can be done as soon as two fingei-s can be passed through the
cervix. The edge of the placenta is pushed aside and the lingers
passed through the membranes. Kveu after sufficient dilation it
is seldom necessary to pass the entire hand into the uterus. After
version the child sliauld not be extracted until the dilation is com-
plete. The delivery must be effected very slowly and with ex-
treme care to avoid shock. Uanally it is better, if possible, to leave
the expulsion to nature. A dead or nonviable fetus should be
deliveretl with the least possible tax upon the mother — <!ramotoniy.
Mainial dilation anil iiuineiiiate extraction of the child, recently
advocatetl by eminent authority, must be rtgardcd as a question-
able proctdurc vlicn the woman is CJ^sanguinaifd or much ex-
hausted. It exposes the woman to greater danger fi-om tramos,
embolism, and si'psis. The writer is opi)osed to the procedure,
Esti'aetion of the cliii<l by perforation of the placenta in cen-
tral or nearly central imi>lantation is better than detaching the
edge and passing the hand around it.
Cesarean six'lioii promises little better results than the recog-
nized obstetric methods. It may be chosen in very exceptional
eases, as in previa! placenta in old primipane, at full term, with
large child, having little previous hemorrhage, mother in good con-
dition, with rigid soft parts.
Other Methods. — Scjmration of the placenta from the lower
uterine segment (Harni's) permits retraction of the part thus un-
covered. The area of delachnunt should be not less than 11.5 cm,
(4I/0 inches) in diameter.
This procedure is not to be recommended except in simple
cases of partial placenta pr.evia, f'ragiu advocates the introduc-
tion of the No, 4 Vooi'hecs hag into the lower uterine segment, in an
ANOMALIES PROM ACCIDENTS OR DISEASE 343
extraovular position, against the maternal surface of the placenta,
without rupture of the membranes. This secures dilation and tam-
pons the bleeding surface and permits retraction of the lower seg-
ment. Delivery should immediately follow the expulsion of the
bag.
Complete separation and extraction of the placenta may some-
times be practiced in case the child is dead or not viable. // the
patient^ s condition is had, a firm cervical and vaginal pack may
be placed to control hemorrhage till she has rallied sufficiently
to permit extraction of the child.
Precautions. — Full dilation of the soft par^5 should always
be secured before extraction is attempted. Too precipitate and
violent interference is to he avoided, especially if there ha^ heen
much hemorrhage. It is largely responsible for the high death-
rate of placenta prsevia.
Shock, infection, and postpartum hemorrhage are especially
to be guarded against. Ergot should be given for several days
after labor.
Treatment op Acute Anemia. — Treatment is often required
after the delivery to combat the effects of the excessive blood loss.
The principal measures are: Elevation of the foot of the bed;
bandaging the extremities (autotransfusion), continued for thirty
minutes; hot applications to the feet; opium, gr. ij, p. r. n., or
preferably a hypodermic injection of morphia, gr. 14 to 14. The
injection of normal salt solution (9/10 of 1 per cent., approxi-
mately, gr. iij, ad 3-t- into a vein, into the rectum, into the cellular
tissue between the scapulae, or behind the mammary glands be-
tween the gland and pectoral fascia, is a most valuable measure.
A. readily improvised apparatus for intravenous infusion is made
writh a glass funnel, a few feet of rubber tubing, and a cannula of
jlass or metal. Apparatus and solution should be sterilized by
boiling, and the latter be filtered. The salt solution should be
slowly injected at the temperature of 100° F. One-half to one
pint may be used intravenously.
The postmammary injection is simple, safe, and scarcely in-
ferior in efficiency to intravenous infusion. For this or other sub-
cutaneous injections a coarse aspirating needle attached to a foun-
tain syringe may be used ; all must be sterile. One quart or more
of the solution may be given in this manner.
344
TATIIOLOGY OF LABOR
Enteroclysis .with the physiological saline solution, together
with suitable nutritnt pnemata, helps materially in relilliug the
vessels. Eight ounces of the solution may be given everj' foiu'
hours.
Liquids by the stomach must be given in small quantities, and
often beginning with 5j, at intervals of a minute or two. Plain
hot water, brandy, or whiskey and hot water are good restora-
tives. The use of nutrient fluids may be begun after a few hours.
When the lirmoglobin is bdoiv 30 per cint. direct tratisfuston
should be i)raclicid.
2. Accidental TIemorrhage
This term applies to bleeding resulting from the partial or
complete separation of a normally seated placenta occurring ia
iit the beginning of labor. For
liii^ suggested the name ablatio
the later moiillis of [uvgii.
this eonditioii Dr. It. \V.
plnci'nl(T.
Varieties. — (a) Appannt. in wliieli the lower margin of the
plaeenla is detaelied and the blood sc'ijjii'jites the membrane from
the uterine wall, and is discharged by the vagina (Fig. 88).
ANOMALIES PROM ACCIDENTS OR DISEASE
345
(b) Concealed, in which the effused blood collects in the uter-
ine cavity. Either of the following conditions may obtain :
1. The placenta may be detached at the center, and the mar-
^n remain adherent (Fig. 89).
2. The placenta may be detached at one edge, partially lifting
:he membranes beyond the margin ;
3. The placenta may be detached at one edge, partially lift-
ng the membranes beyond the margin, when the overlying mem-
iranea may rupture and allow the blood to escape into the amni-
itic sac;
4. Separation of one edge of the placenta and of the adjacent
nembranes may take place, and the lower segment of the uterus
t)e occluded by the fetal head
ind so prevent the escape of
ilood from theuterusfFig. 90).
Canaea. — The causes are :
The loose attachment of the j
placenta, normal to the last |
veeks of pregnancy;
Violent muscular effort ;
Violent uterine eontrac-
,ioQ8;
Short cord ;
Excessive distention of
items;
External violence, as blows
)r falls;
Disease of deciduae;
Placental disease;
Nephritis ;
Toxemia;
Acute infectious diseases.
Diagnosis. — Apparent Variety. — Accidental hemorrhage iiau-
illy occurs before labor begins or in the first stage. It is neces-
lary to distinguish it from rupture of the uterus and from pla-
:enta pncvia. The former occurs later in labor and is attended
Kith recession of the presenting part, with diminution of the
iterine tumor, and the development of a new ab<lominal tumor,
rhe latter is readily recognized or excluded by a physical exam-
FiG. 90.^ — Concealed HEMonuHAOF,,
Head Occludinq Escape of Ulood
346 PATHOLOGY OF LABOR
/ ination. Bleeding from low implautation of the placenta may
, ■ easily be mistakeu for accidental hemorrhage.
Concealed Varieli/. — The principal signs are :
Extreme pallor; shock of some degree; persistent tension of
the uterus, while the rhythmic contractions become weak; a node
or boss forms on the uterine surface at the site of the retropla-
cental blood collection, or the uterus becomes atonic and is dis-
tended by the accumulation of blood. The uterine tumor may be
boggy, or tense, especially in the upper segment; the fetal parts
are obscured to palpation j there may be continuous pain anil
tenderness in certain eases from distention of the perimetrium;
bloody liquor amtiii may be detected by pushing up the presenting
part and allowing a portion of the liquor ainnii to escape; the
fetal heart-tonea are feeble and irregular, or absent.
Together with these signs are the signs of internal hemorrhage,
viz., collapse; pallor; surface, especially of extremities, cold and
clammy; excessive perspiration; respiration irregular; sighing;
sobbing; yawning; pulse rapid, thready, and compressible;
thirst; jactitation; tinnitus aurium; dyspnea; nausea; dimness
of vision ; syncope. '
It should be remembered that a concealed hemorrhage may
coexist with an iiiMigiiiHcant apparent hemorrhage.
Diiferentlal Diagnosis. — Ablation is distinguished from acute
hydramnioH hy absence of unusual pallor in the latter; from pla-
centa pnvvia, by physical signs, and by absence of persistent
uterine tension and pain in previal placenta. Rupture of the
litems rarely occurs before the end of the first stage of labor. A
ruptured ectopic gestation sliould be distinguished hy bimanual
examination, especially by the lesser development of the utenis.
Vrogaosis.— Apparent Variety.^in this form the prognosis
is not so grave for the mother as in concealed hemorrhage, but
frecjuently is fatal to the child.
Concealed Variety. — For the molhei's the mortality is 50 per
cent., from shock due to hyperdisteiilioii of the uterus and opera-
tive causes, from blood-loss before, and iluring, labor, from post-
partum hemorrhage, and the se(|iielie. The fetal death rate is 90
per cent, or more, chiefly from asphyxia, due to interruption of
the uteroplacental circulation. Prematurity is sometimes a cm-
AN0:MALIES prom accidents or disease 347
The prognosis varies considerably in the experience of differ-
ent observers, and depends to no small extent upon the treatment
pursued.
Treatment. — The chief indication is to evacuate the uterus as
speedily as possible, so that the uterine muscle will contract and
close the bleeding sinuses. If the bleeding is slight no immediate
intervention may be required except to rupture the membranes.
The patient should be kept under close observation, and in bed.
Chlorid of calcium, gr. xx, every three hours, is useful by pro-
moting coagulability of the blood. A very tight abdominal binder
and an icebag upon the lower abdomen may help.
Generally in either variety of hemorrhage the cervix should
be dilated manually. After full dilation the delivery is rapidly
completed by forceps or V(»rsion, or in dead or nonviable fetus by
embryotomy. Firm compression of the uterus is maintained man-
ually by a skilled assistant during delivery. Precautions should
be taken against postpartum hemorrhage.
When the cervix rcs^ists manual dilation and immediat ) deliv-
ery is urgently demanded, vaginal Cesarean section may he per-
formed. In exceptional cases an abdominal Cesaro-hysterectomy
may be demanded.
The effects of blood loss are combated as in other hemorrhages.
3. rostpartum Hemorrhage
Postpartum hemorrhage may occur during the third stage of
labor, or in the first twenty-four hours post partum from relaxa-
tion of the uterine muscle, from injuries to the cervix, vagina, and
vulvovaginal orifice, from ruptured vessels and tumors in the par-
turient tract, from relaxation of the uterine muscle.
DefiLnition. — By postpartum hemorrhage is meant hemorrhage
occurring shortly after the birth of the child and having its origin
at the placental site. The accident can seldom happen in well-
managed labors. Bleeding from laceration of the passages does
not come within the meaning of this term in its technical sense.
To distinguish excessive from the physiological flow, it is neces-
sary to remember that normally the blood loss at the birth of the
child varies from two or three ounces to a pint.
Causes. — The causes are imperfect ligation of the uterine ves-
348
PATHOLOGY OF LABOR
sela in coDsequence of inertia uteri or atony frooi exhaustion or
from overdistention of the uterus, badly maiiagwl third stage, ex-
cessive use of chloroform, precipitate labor and sudden expul«on
of the ehiki, nephritis, hemophilia, full bladder, or a rectum
Fig. Ol.^DiAGKAU Showixh Points from Which Bleeding May Covk.
P. Placental site; C. ccr\-ix; V. vagina; P. perineum and pudendum
packed with feees. A partially detached i)Iacenta, the retention
of blood eoagiihi or of fragments of secundines tend to prevent
full uteriue contracliou ami closure of the vessels. Uterine neo-
plasms may have a like effect, lileeding after labor ceases phyno-
logically :
1. Heeause of the increased coagulability of the blood.
'2. Owing to the irregular tearing of the vessels In the pla-
cental site as tbe jilacenta is separated.
3. Because of tlie ligation of tiie uterine dniiBes by refraction
nf Ihe ulerine muscle fillers.
Di&gnosis. — Puinja- S'i'i/ho/s. — A historj- of hemorrhage in
previous labors: an overrapid pulse, above 100; imperfect re-
traction, delii-tiii by palpation over the abdomen; the uterine
tumor remaining relaxed : or the presence of other recognized
ANOMALIES FROM ACCIDENTS OR DISEASE 349
causes of hemorrhage, such as nephritis, hemophilia, long-con-
tinued chloroform narcosis, et cetera, are danger signals.
Signs. — The bleeding may occur before or after the expulsion
of the placenta. The signs are: a sudden outpour of blood, an
atonic uterine globe, which is difficult to outline through the ab-
dominal wall, with the systemic effects of acute hemorrhage, as
shown in the pulse, color, and respiration of the patient.
It must not be forgotten that the absence of external bleeding
does not alone forbid the diagnosis of hemorrhage. Excessive
bloody flow, with firm uterine contraction, does not proceed from
the uterine cavity; it comes from laceration of the cervix, vagina,
or vulva.
Treatment. — Prophylaxis. — The preventive treatment must
be addressed to the uterine retraction. The uterus should be
watched, with the hand continuously on the abdomen, from the
birth of the child and for at least a half hour after the placenta
is delivered. Care should be taken that no fragment of placenta
is left in the uterus. Friction may be used if required to pro-
voke normal contractions. Too early resort to C rede's manipuUi'
tion may cause imperfect separation of the placenta, and produce
hemorrhage from partial separation of the placenta. In per-
sistent inertia, ergotole oss, and pituitrin, 1-3 decigrams, injected
hypodermically, and repeated, p. r. n., is a valuable prophylactic.
It is often indicated after chloroform anesthesia, and in all condi-
tions which predispose to hemorrhage. It is a wise precaution to
give ergot on birth of the head when there is reason to fear post-
partum hemorrhage. It is the abuse, not the proper use, of ergot
that has brought it into disrepute in certain quarters.
Remedial Measures. — (a) In moderate hemorrhage, the re-
medial measures are: manipulation, ergot, pituitrin, and the hot
intrauterine douche.
Bleeding may be controlled by manipulation of the uterus with
one or both hands over the abdomen; or conjoined manipulation
with one hand over the abdomen and two or three fingers of the
other hand in the posterior vaginal fornix, forcibly anteflexing
and compressing the uterus; or, by lifting the uterus out of the
pelvis, constricting the lower segment, by grasping it and com-
pressing it against the sacral promontory, while the fundus is
pressed against the vertebral column, in conjunction with the
350' PATHOLOGY OF LABOR
fluid extract of ergot, or ^rgotok and pituitrin, Sas, best t&^
jected into (he muscle of the thigh, or a hot intrauterine rfoiicke^
continued for not more than two niinutc-s, at a temperature of
118° F.
. (b) Severe henorrhage can be cheeked with the gloved hand
in the uterus, eoi ipressing it against the abdominal aorta; Uie
acetic atid douehi , the uterine tamponade, or the Sloraberg com-
presaion belt; cot}\pressio)i aud kitrofiing of the uterus, with oiu
hand in the cavity and the other on the abdomen ; hi'l intrauterint
douche, temperature, 1:^0" F.. containing three per cent, of occHe
acid, U. S. P.
A most efficient mta^ itrol of severe postpartmir
hemorrhage is a J?r«t vith sterilized strip-gaiUtj
about four inches wf ays be used in hemorrbafSi
not promptly contrc nares. One or two steriU J
roller bandages may 3 obstetric bag ready for
immediate use. The ' a douche, as he has found
that bleeding ifhich is by manipulation, ergoloit,
and pituilrin euii ""t I. ^..t, ^A by the intrauterine Um-
pon.
To tampon thr uterus lliu patient is placed in the lithotomy
iwsition. the eervix caught with a volsella and drawn well down.
The gatixe is carried into the cavity of the uterus with a uterine
dressing forceps over the palmar surface of the gloved hand as a
guide. Lacking instruments, the packing may be placed, though
less sjitisfjK'toriJy, with the fingers alone. It should be removed
canliousjy liy withdrawing a little at a time, within twelve to
twi'uty-four hours.
Mmiibi ry'a cfiiiprrssiuii bdt consists of a rubber tube, which
is placi'd jiioimd the wiiist above the fundus uteri, and tightened
until till' femoral pulse cJin not be felt; such forcible compres-
sion (if lln> jiortii cannot be made without danger.
Ailililiiiiial iir(((\if/v.v are the following: application of the
child lo the breast jis a rellex e.xcitomotor ; compression of the
alMlomiiial aorta with the band on the abdomen; flagellation ofthe
lower alidoitien with a wet towel; faradisin to the uterus, one
eleetroile within the uterus and one ovei- the abdomen or the upper
sacral reijion, or, belter. fi'Oiii the standpoint of asepsis, both
electrodes over the abdomen, one on either side of the utenu;
ANOMALIES FROM ACCIDENTS OR DISEASE 351
'abbing the entire uterine cavity with tincture of iodin.
Hemorrhage from a lacerated cervix is best controlled by
suture. The first stitch should be passed just above the angle of
tlie tear. Vaginal hemorrhage may also be arrested by suture-
ligature. The resulting anemia is treated as in other cases.
Secondary Postpartum Hemorrhage
Definition. — By secondary postpartum hemorrhage is under-
stood hemorrhage from the placental side occurring within the
postpartum month later than six hours after labor.
Causes. — The usual causes are retention of membranes, placen-
tal fragments, or blood-clots; congestion of the uterus from mis-
placement, dislodgment of thrombi from the uterine sinuses, uter-
ine fibromata and polypi, or other causes; getting up too soon;
violent emotion.
Treatment. — The patient should be kept in bed and the causes
I'emoved, if possible. Uterine displacements should be corrected.
Hot vaginal douches, two or three gallons at a temperature of
120° P., are often effective. These measures failing, the uterine
cavity may be digitally explored for retained fragments of placenta
S-O-d packed with gauze; the packing to be removed in twelve to
t'Wenty-four hours.
SEPARATION OF THE SYMPHYSIS PUBIS
Barely rupture of the symphysis pubis may occur spontane-
^'ttsly, owing to the excessive relaxation of the joint which some-
les develops in the later months of pregnancy. It is more fre-
.ently the result of unskillful use of forceps. The vagina and
*^l^dder are sometimes lacerated. Tears of the anterior soft parts
^^^«y extend into the peritoneum.
Diagnostic Signs. — The diagnostic signs are: intense pain re-
"^^Tred to the joint ; mobility of the pubic bones upon each other ;
^*Xe presence of a sulcus between the bones, and locomotion im-
t^^ded on getting up. The mobility of the bones is readily made
^Xat by forcibly flexing and extending the thighs and by rotating
^^^e knee outward, the patient on the back, or by requiring the
l^^tient to rock the body from side to side while standing.
352 PATHOLOGY OF LABOR
Treatment. — Keeping tfie patient in bed and immobilizing the
joint for from four to six weeks by the use of a iinn pelvic band-
age of Z. 0. plaster encircling the pelvis, if begun directly after
labor, may generally be trusted to bring about union of the bones.
Neglected eases may be treated by vivifying the joint surfaces
Biibcntaneously and applying the bandage for four weeks, the
patient maintaining a recumbent position in a hammock be<l. Su-
turing the bone with si Ik worm- gut, catgut, or silver wire is seldom
advisable.
ECLAMPSIA
Kelampsia is the result of an acute toxemia oecnrring in the
pregnant, iiarturient, or puerperal woman.
Definition. — Puerperal eclampsia is synonymous with puer-
peral convulsions. The convulsions are epileptiform in character,
and attended with loss of consciousness and followed by coma.
They occur most frequently toward the close of pregnancy, or
during the labor, or in the first few days of the puerperiura. Con-
vulsions ill child-bed from hysteria, epilepsy, or cerebral lesions.
inLlependeut of the toxemia of pregnancy, are not includMi under
this term.
Frequency. — The frequency is variously estimated at about
1 in 'AM eases of advanced gestation. The disease, however, ap-
peal's to be more prevalent at certain times and iu certain local-
ities. Eclampsia is three times more frequent in primipane than
in multipanv. and ten times more so in multiple than in angle
pregnancies. Hydramnios seems to be a predisposing factor. Il
is observed oftenest in very young and in very old priraiparff.
Jloderate albuminuria, if persistent, is more likely to be followed
by ei'lampsi.'i than when the wlbnuiinuria is extreme.
Etiology. — The primal cause of the convulsions is a profound
loxeniia, whieii is probably metabolic in origin, with aecondao'
lesions of the kidneys and imperfect elimination by these and otlnT
emunetories. The toxemia is analogous to that of hypereinesis.
and is characterized by striking lesions in the liver similar If
those of aeuto yellow atrophy. Vomiting and eclampsia probabl.v
are not identical in origin as some authorities have assumed.
Toxins in the maternal blood are conveyed first to the liver, where
ANOMALIES PROM ACCIDENTS OR DISEASE 353
Tby the kidneys. If the liver fails in its functions, incompletely
^)xidized waste products will circulate in the maternal blood, which
aire irritating to the kidneys, the central nervous system, and the
capillaries everywhere. The kidney complication is usually sec-
ondary, and may be nothing more than acute insufficiency, or it
may be a degenerative lesion, or an acute parenchymatous neph-
ritis. Sometimes an acute supervenes upon a chronic nephritis.
Some degree of hepatic degeneration is always present in the
post mortem findings in eclamptic patients. These vary from
thrombosis of the perilobular veins to necrosis in the lobule. In
some cases the degeneration reaches tlie grade of acute yellow
atrophy. While a small proportion of cases display no renal in-
sufficiency prior to the eclampsia, some form of renal disease is
discovered post mortem in a large majority of eclampsias, evi-
dencing the increased load put upon the kidneys in their at-
tempt to eliminate the maternal toxins. In more than 4/5 of all
eclamptics albuminuria or other sign . of a kidney breakdown are
present. In 368 cases examined post mortem, nephritis was pres-
ent in 46 per cent.; in 54 per cent, there were degenerative
processes; the latter doubtless were, in part, secondary to the
eclamptic seizure (Prutz). Schmorl, in 73 cases, found parenchy-
matous and fatty degeneration of the secreting epithelium of the
kidney in all but one. Apparently the immediate cause of the
convulsions is spasm of the arterioles and consequent anemia of
the brain, induced by the toxic material in tlie blood. Reflex irri-
tation from the uterus is a potent cooperating factor in precipi-
tating the eclamptic attack.
Premonitory Symptoms and Signs. — The premonitory signs
Qnd symptoms are:
(1) An increased blood pressure of 150 mm., or more;
(2) Scantiness of the urinary output, with diminished elimi-
nation of the total solids;
(3) Edema, especially of the face;
(4) General lassitude and muscular weariness;
(5) Headache, generally frontal, suboccipital rarely;
(6) Nausea and other digestive derangements, as flatulence
and constipation. Functional inactivity of the liver is a usual
accompaniment of pregnancy;
(7) Contracted pupils;
354 PATHOLOGY OF LABOB ^^H
(8) Yisiial (listurbanceH, amaurosis, et cetera.
(9) Persistent epigastric pain;
(10) Albuminuria. This is an early danger sign of tone
irritation in about 75 per cent, of the cases, and is often apparent
before other evidenees of toxemia are observed;
(11) Deficient f of urea and of other urinarj' solids;
(12) Tulie ca; ts in the urine.
Differential DiagnoBJa.^Oenerally puerperal eclampsia is (g
be distinguished from hysteria and epileptic convulsion by the
urinary cxiiiiiiniitiou and by the history.
Clinical Fhenon 'anger signals always prt-
cede the oeeurrL'uce ot a -izure. The patient eith«
complains of severe ar dache or some visual ilii-
turbanee, which is p v the convulsive paroxymt
in which the eyes I rently upon some distaol
object. Consciousnes The spasms begin in the j
facial muscles, tlien ) The convulsion is at tint I
tonic, then clonic. Foi lent is asphyxiated, owing ,
to the tonic spasm of ....^ t- ,. muscles. A few secoudi
later tin-' hrcalliing ln-coiiics stertorous. Frolh oozes from tlie
mouth and nostrils. The tongue usually is bitten during the con-
vulsive seizure, and the frothy discharge is blood-stained.
The duration of the convulsion is usually one or two minutes.
The interval between the attacks may be a few minutes or seTeral
hours.
Coma follows the eclamptic seizure, generally subsiding within
a half hour. The coma, iis a rule, deepens after each successive
convulsion, owing to inerea.siiig edema of the meninges or cerebral
congestion. I'sually the ])u!se is rapid, often reaching 140 or
more during the attack.s. The temjjerature in different eases
varies from noniial or suhiionual to 105° F., or more. The tem-
peraliii'e ris{>s witli each repetition of liie convulsion. The pyrexia
prohahly is of toxie oi'ifriu. (ItiifraUii labor begins on the occur-
reiiir of ••'tiriihiiiii.i. if not already established, when the pa-
tient is jiilaeked near term. Tliis is not the rule, however, irhea
llie seiifures neeiii' iii tile midtriinester before any cervical efface-
meiit liiis tiikrri phiee.
Prognosis.— The prognosis is the more grave the earlier the
attack in pregnaney or labor. The danger increases with the nam-
ANOMALIES FROM ACCIDENTS OR DISEASE 355
ber of convulsions. Recovery is exceptional after fifteen or twenty
seizures, and seldom occurs after a temperature of 105"* F. A
s^niall and feeble pulse is a bad prognostic. Profound coma, com-
plete suppression of urine, marked icterus, high temperature,
105° F., or paralysis, indicate an unfavorable prognosis. A nor-
mal or subnormal leukocyte count is a fatal prognostic. A high
count, if persistent, is favorable. Impairment of the mental fac-
ulties sometimes follows. Psychoses result in about 6 per cent.
of eclamptic women.
The toxemia of pregnancy in women pregnant for the first
time, after forty years of age, is almost invariably fatal if the
pregnancy is allowed to go to the later months.
Pregnancy in primipara3, the subjects of nephritis before con-
ception, is uniformly fatal if not interrupted before term (Tyson).
The maternal mortality of eclampsia varies from 25 to 39 per
cent, from exhaustion, asphyxia, sepsis, cerebral hemorrhage,
edema of the lungs. The percentage of deaths from eclampsia
may be roughly estimated as follows: convulsions beginning be-
fore labor, 39 per cent. ; during labor, 25 per cent. ; after labor,
19 per cent. The fetal death-rate is from 50 to 80 per cent.,
mainly from asphyxia. The toxic material is transmitted to the
fetal blood, and a certain proportion of children die after birth
from this cause, usually from convulsions.
Treatment. — The treatment of this toxemia should be based
on the following principles:
(1) The products of metabolism requiring elimination should
be minimized;
(2) The elimination of metabolic products should be favored;
(3) The high blood-pressure should be reduced;
(4) If the toxemia does not show improvement under the pre-
ceding principles of treatment, or if a convulsion occurs, the
uterus should be emptied.
(5) All methods of treatment should be avoided which will
reduce the resistance of the patient or seriously damage any of
her organs.
Prophylactic. — A milk-diet limits the toxemia. In marked
toxemia it should be given to the exclusion of all other food, at
least for a time. Farinaceous food and fish may be allowed to a
limited extent as the symptoms improve.
356 PATHOLOGY OF LABOR
Free catharsis by salines aud diaphoresis by hot air tdl
packs, and th« use of sweet spirits of niter rouder importMt
service by supplenientiiig the crippled elimiuatioii.
Water is esseiilial for diuresis; it may be given hot or hall-
cold, plain or mildly alkaline; from four to eight pints may b(
taken daily, or a pint of normal salt solution may be iujected
behind each breait every four to six hours. Colonic irrigatioB
with hot normal salt solution, using a double cannula, is an effi-
cient diuretic measure- J'ifteen to twenty gallons may be iia«L
It may be repeated once or twice daily.
Dry cups follow ions over the kidneys are
useful.
Nitroglycerin in fu' )ie, not only aa a diuretia
but as a direct anti-i
Fluid extract of ■ |uibb), miij to mvj, t. i. d^
or enough to hold tli ty, is au efficient prophy-
lactic. Veratrum alw ilood pressure.
Chloral, ^j to 5ij i imid of sodium in similar
doses, is one oE the luo. ii, .> for subduing the reflexes.
To suuiKiarizc: (1) Elimination through the skin is induced
by sweating, by the hot-air biith, or the hot wet pack ; (2) through
the urinarj- tract, \<y pliysiejil rest and the iotfcslinii of hiry (|ii;in-
tities of water; (3) through the intestinal tract by saline cathar-
tics and colon irrigations, while (4) the blood -pressure may be
reduced with veratrum, cliloral, and nitroglycerin.
Iron is frequently indicated. Basham's mixture is a suitable
preparation.
Marked nervous manifestations, or scanty urinary secretion,
not promptly relievtHl by dietetic aud medicinal measures, call for
tlie iiuIiK'tiou of labor.
Kkmkehal.- — The jiriiicipal reliance for controlling the convul-
sions is on the combined use of ether-oxygen inhalation, veratrum
viridc. or iiitroglyi-erin, catharsis, diaphoresis, active diuresis by
hypodermodysis, and the pronijjt evacuation of the uterus. For
vcratniin, chhiral may scKiu'times be sub.stiluted.
Elhir-nj-ijijin I iilialiilii-ii. — I'l'iiding the action of other rem-
edii's llic ]i;i!ii'nt shimid lu' pjiu-i'd at once under ether-oxygen,
m-arly. or (jiiiio, tn ilio smgical dt'};rce. Kther-oxygen by inhala-
lion if! an almost Cfrtain iiiili-eclamptie. Its use is always im-
ANOMALIES FROM ACCIDENT OR DISEASE 357
perative during operative interference. Yet prolonged narcosis
is dangerous; one or two hours usually should be the limit.
Veratrum Viride, — Fluid extract of veratrum viride (Squibb),
m X to m XX, is to be injected subcutaneously with morphia sul-
phate, gr. 1/4, which increases its efficiency. If, at the end of a
half hour, the pulse is not below 60, another ten minims should be
injected. In order to use veratrum viride efficiently, the blood
pressure should be taken before and after the administering of
each dose. A convulsion is substantially impossible while the cir-
culation is sufficiently under the influence of veratrum to hold the
pulse-rate below 60, and the blood-pressure to 120 mm., or less.
The patient should be required to maintain the recumbent posture
while using the drug in large doses. Tumultuous action of the
heart ensues immediately on rising. Collapse under veratrum is
successfully combated by the use of morphin hypodermically, or
by w^hiskey administered in similar manner, or by the bowel.
Veratrum, by its effect as a vasomotor relaxant, not only con-
trols convulsions, but it acts as a diuretic and a diaphoretic.
Morphin. — The addition of morphin, gr. i/4, to the veratrum
adds to the efficiency of the treatment. The combination of mor-
phin with veratrum is especially recommended when the pulse is
feeble.
Chloral is best given by the rectum in a teacupful of milk.
The dose may be 5ss hourly till 5j or oij have been given. Or
the drug may be introduced into the stomach through a tube,
after washing out tlte stomach. One drachm in 100 drachms of
water may be exhibited in this manner.
Catharsis. — For catharsis, calomel, and salines, elaterium, gr.
1/4, or croton oil, m j to m ij, may be employed.
Diaphoresis. — The free action of the skin is to be maintained
by the same measures as suggested in the prophylactic treatment.
Diuresis. — Valuable measures for this purpose are hypodermo-
clysis, the injection of a pint of normal salt solution,^ behind each
breast every four hours, or enteroclysis, or the irrigation of the
* The following saline solution increases the quantity of the urine and of
the urinary solids (Jardine).
I^ — Sodii acetat
Sodii chlorid aa 3ij
Aquffi Oij
358 PATHOLOGY OF LABOK
bowel with a hot uormal salt solution every four hours. Fifteen to
twenty gallons may he used for colonic irrigation, using b. double
curreut eaunula, as a Kemp cannula. The use of the saline solu-
tion, if carried too far, may overload tile right heart.
Other Measures. — Other anti-eclamptic measures of repute are:
nitroglycerin, gr. 1/50 to 1/25, hypodermically, p. r. n.; ainyi
nitrite, m.v., by inhalation; the inhalation of oxygen; the appli-
cation of ice to the head and the carotids; in marked cyanosis,
venesection, taking sixteen ounces of blood. Zweifel ruptures the
membranes as the tii-st thing in the treatment. Lumbar puncture
for withdrawal of cerebrospinal fluid has yielded no definite good
results.
Prompt Evacuation of the Uterus.— V^hare it is decided to
empty the uterus, the pregnancy should be terminated in Huch ft
manner as will not reduce the resistance of the patient, or seri-
ously damage any of the organs. The method to be employed
depends; Jst, on the patieiit'.s general condition; 2nd, on t^t
period vf pregnancy; Srd, on the condition of the cervix. Labor
usually sets in on the oeeurreuce of eclampsia. Measures are in-
dicated to accelei'ate the labor if it has already begun, or to in-
duce it if not spontaneously established. Convulsions cease in
more than 60 per cent, of cases after deliverj'. Recourse may be
had to manual or hydrostatic dilation of the cervix, multiple in-
cisions, or to vagiual Cesarean section in extreme eases. Vaginal
hysterotomy finds its largest field in tlie midtrimester or the first
two months of tlie last, where the cervix is rigid and no efface-
ment has taken place.
It should he stated that the induction of labor for the preven-
tion of eclampsia is opposed by certain obstetric authorities. Its
wisdom, however, either as a prophylactic or a curative measure
can scarcely be (juestionwl when other therapeutic measures have
failed,
Frecaiitions. — A cork or a folileil najikin may be held between
the patient's teeth during the eonvnlsive attacks to prevent biting
the tongue. If the tongue obstructs respiration it sliould be drawn
forward. It is sometimes useful to renmve the mucus from the
throat wilh a swab held in the grasp of forceps.
CardiiH- Supports. — If cardiac supports are called for, whiskey
and strychnin are to be given p. r. n. Inhalations of oxygen an
ANOMALIES FROM ACCIDENTS OR DISEASE 359
useful. The subcutaneous injection of the normal saline solution
acts as a stimulant as well as an eliminant.
Restoratives. — During convalescence the anti-eclamptic and
the eliminant treatment are to be continued for two or three days,
as required, and later iron and general tonics are indicated as
restoratives.
DIABETES MELLITUS
Sugar is found in the urine of women shortly before child-
birth in about four per cent, of cases, commonly in the form of
lactose, seldom as glucose.
Diabetes is a serious complication of pregnancy and the puer-
peral state. It is dangerous to the mother and even more fatal
to the child. Sometimes the disease is aggravated by pregnancy
and may end in death during, or soon after, the puerperium. The
prognosis is better in diabetes developed during pregnancy than
in cases in which there was preexisting diabetes. Hydramnios is
often present. Abortion occurs in at least one-third of the cases.
Half the children born alive perish soon after birth, and those
who survive are likely to be undersized and poorly developed.
Fortunately diabetes is rarely encountered in childbed.
Treatment. — In true diabetes the pregnancy, as a rule, should
immediately be terminated. For anesthesia ether-oxygen vapor
is preferable to chloroform, since it induces less acetone. The
less used the better for the prognosis. A morning-hour and a
sugar- free period, if possible, are to be chosen. Bicarbonate of
sodium should be given for several days before operation till the
urine is alkaline.
CARDIAC DISEASE
Most valvular heart lesions are aggravated by the extra tax
put upon the heart in the later months of gestation. They cause
abortion or premature labor in more than 20 per cent, of preg-
nancies so complicated.
Advanced cardiac disease is a dangerous complication of labor.
Engorgement of the right heart and edema of the lungs often
supervene. Tlie danger is greatest at the close of the third stage,
when a large volume of blood is abruptly thrown on the venous
360 PATHOLOGY OF LABOR
side from the uterine sinuses, overloading the right heart, pfo-
diicing cyaiiosis and puhnonary etleina. Statistics show that mul-
tiple lesions are attendLnl with the greatest mortality. Jlitral in-
competence, or especially stctwsis of the viitral orifice is almort
equally fatal. Nest in gravity is aortic incompetence. Yet the
prognosis depends mainly upon the condition of the cardiac mus-
cle. Tuberculosis and nephritis are grave complications of heart
disease.
Treatment — A woman with uncompensated valvular disease
of the heart should not marry, at least sliould not heconiL- pr^-
nant.
During pregnancy, among the more important measures in
matter of treatment are the avoidance of overexertion and excite-
ment, together with regulation of the bowels and the use of car-
diac tonics and physical rest as the symptoms may require.
Strj'chnin, and, in broken compensation, strophanthus and digi-
talis serve the latter purpo.se. Other measures failing, the preg-
nancy should he terminated by the easiest method for the woman.
Premature delivery is oftenest demanded in multiple lesion or in
mitral stenosis, and in the presence of nephritis or tubercuioaia.
During labor the heart should be relieved as far as possible
of the strain of labor by the use of artificial aids for delivery.
such as forceps as soon as dilation is complete. Ether-oxygen
vapor, precinied by ^4 gr, of morphia hypodermatieally, should be
used in preference to chloroform as the anesthetic, and this only
during the severer pains. Of great value in combating Tenona
engorgement in the third stagi' of labor are aiuyl nitrite by in-
halation and nitroglycerin by hypodermic injection. Alcoholic
stimulants may help. Rrsort mail hi; had to phlebotomy in the
presence of any cyanosis or other evidence of right heart en-
go rgeitieTit, yet this can scarcely be ri'<|uired if proper use is made
of the vasodilators. Ei'got may be withheld, and moderate geni-
tal bleeding eneourageii. Kxcrxaivr hloud loss is dangerous. Ca^
diac .suiJjiorts will usujilly hi- ih'imIwI during the puerperium. Lac-
CHAPTER XIV
PATHOLOGY OF THE PUERPERAL STATE
PUERPERAL INSANITY
The mental disorder may begin during pregnancy, though it
occurs more commonly during the puerperal period. In the puer-
perium the onset occurs most frequently in the first or second
week, seldom after five or six weeks. It is more often observed in
primipanv. The psychical disorder very comiuonly takes the form
of melanchQ\j^ sometimes of mania.
I'requency. — Puerperal insanity occurs in about one in 400
puerperal women.
Causes. — Causes most frequently assigned are hereditary pre-
disposition, bad mental hygiene, violent emotional disturbance,
eclampsia, anemia, exhaustion, autointoxication, sepsis. Of these
the predominating cause is sepsis. Recent investigations go to
prove that in more than 80 per cent, of cases the puerperal psy-
choses originate in autointoxication or in septic infection.
Prognosis. — The prognosis is better in the maniacal than in
the melancholic form. It is not so good in lactational insanity as
in cases beginning during pregnancy, A marked heredity is un-
favorable. The outlook is good in cases following eclampsia. Re-
covery may be expected in 60 to 80 per cent, of septic cases.
The mortality does not exceed 5 to 10 per cent, of all cases.
Nearly 70 per cent, recover their reason.
Treatment. — If proper nursing can be had, home treatment
is, in mild cases at least, better than the asylum. The writer be-
lieves in institutional treatment, Avhere the proper mental and
physical hygiene may be had. In the puerperal forms nursing
should be suspended. Iron, in the form of pil. Hlaud, one or two
t.i.d., or arsenate or iron, gr. 1/10 t.i.d., is indicated for the anemia.
The hypodermic injection of the hydrobromate of hyoscin, in
doses of- gr. 1/100 to gr. 1/25, two or three times daily, is a useful
361
362 PATHOL 3Y OF THE PUERPERAL STATE
sedative in maniacal forms. Chloral, the bromids. chloralamid. oP
paraldehfd, 3s8 lo oj, may be required as sedatives and hypnotioi.'
Chloral, however, is contraindieated in marked MDcmia. Morphin,'
gr. \^, is sometimes permissible. Intestinal fermentatioti and sep"
tic infectioii are to be treated as iu other cases.
aALACTORBHEA
This trrm apjilies lo an exeefwive seeretiou of milk, which per-
sists after weaning, t"''" f...u"t;(.- ...u^ veadi several quarts dai]]r>.
The quality is thin disease may affect one pr
both brca-sts. It often i. s impairment of the
eral health, prodneing: » lia. '
Treatment.— Trea the use o£ a compressiOB
breast-bind IT, nnd re; Potassium iodid, gr. x ~
to XV, t.i.d., nn<! full ct of ergot, may be tried.
The topical use of i ay be of service. Coffee
dimiuishcH Ihe secretion of purgatives is essentisl.
Tonics and general rest. -i are especially indicated.
HimiTIS
Frequency. — Mastitis occurs in 5 to 6 per cent, of norsiBg
women. It is met with oftener after first than subaequent labors,
ii('iirl\' fiS per cent, occur in the former. It is commoner in btondee
than in brunettes.
Causes. — The predisposing causes of mammary infection are
bad general health, lowering the resisting power; t«t(it stasis, i«-
juriiiij till' rilalitji of flu- ipitluliiiHi 'if the lactiferous ducts;
lesions ol' tin- nipplfs. opening avenues for absorption.
77u i.n-ilitut <\iii.<. ix .<. psis. The pus-producing organisms
lUiiv gjiin iieeess to tlie ghind through nipple lesions, such as lis-
suri's, ihroiigii the milk-duets, or exceptionally by the blood-chan-
n.ls from r.'iiioU' sijiiie foei Stapbyloeoi'ci albi are found in the
uulk of Icaltliy nui-sing women, in SO to i>4 per cent, of cases.
Types of Inflammation.— ■ n Siibcutaiuoiis. (2) Glandular,
IT ;i.f(-r ).. • 'niiiil'ius iiKi.-'tiiL-'. wiiieli is. in ihe majority of cases, ft
lynii'li;inL;itis. ■:t' Siih'j\iHilii!<tr. paiamastitis. Two or all of
MASTITIS 363
osis. — The subcutaneous form presents the characters of
ordinary phlegmon ; it is usually a single pustule and found near
the areolar.
The glandular form is characterized by more pain and more
constitutional disturbance than the subcutaneous; marked en-
gorgement usually precedes the inflammatory trouble ; it is gener-
ally ushered in by a chill, and there is more or less elevation of
temperature ; it is often multiple ; the gland is indurated, its sur-
face reddened.
The Subgla7idular Form, or Postmammary Abscess. — In sub-
glandular suppuration the temperature is persistently high, the
pam is deep-seated, the gland is not indurated, it is lifted off the
ohest and floats on the underlying fluid. The constitutional dis-
turbance is severe. The diagnosis may be confirmed by passing
an exploring needle beneath the gland.
Treatment. — Prophylactic Measures. — Prophylaxis consists in :
(1) Care of Jhe nipples — cleanliness &nd avoidance of fissures;
(2) management of the engorgement by resting the breast or, in
simple engorgement without inflammation, by massage. The breast
should be stroked gently from the apex toward the base; the
£imount of liquids ingested should be restricted. Hypersecretion
may be relieved by saline cathartics, or in nonnursing patients by
the topical use of oleate of atropin. Engorged breasts should first
le painted with a sterile solution of equal parts of pinus cana-
densis and glycerin, and then be supported firmly with a com-
pression binder. A pad of sterile cotton wool is placed under the
l)inder over each breast to distribute the pressure evenly. An
opening in the center of each pad relieves the nipple of injurious
pressure. The use of a compress as tight as can well be borne is
of great value as a prophylactic and a curative measure. The
^lurphy binder, made of a straight piece of muslin with a deep
notch cut for efich arm, and a shallow one in the center for the
neck, is recommended. A skilfully applied roller bandage is most
suitable when but one breast requires compression. Tonics, espe-
cially quinin, are useful. The aseptic management and curative
treatment of nipple lesions are an essential i)art of the treatment.
Abortive Measures. — Absolute rest of the gland for one or two
days by takingi^the baby off the breast, restriction of liquids, saline
cathartics, the application of pure icthyol locally over the in-
364 PATHOLOGY OF THR PUERPERAL STATE
flammed area, covpfpiI with sterile rubbt-r tifisne, and quinin,
gr. V to X, twice daily, are the principal abortive measures.
Treatment of Suppuralioii. — The pus-cavity should be opeoed
early and freely, with antiseptic precautions. The incision should
radiate from tlie nipple, the areola being avoided, and pass
through tiie entire thiekncss of the breast to the chest wall, which
allows for retro-manuiiary drainage.
The writer fretjuently incises a parenchymatous mastitis be-
fore evidence of suppuration appears, making a radial incision
through gland substance iu line with the lactiferous tubules, and
thus preveuta deatruetive suppuration of the gland itself. The
linger should be passed into the cavity and all septa broken down.
Counter-openings often are necessarv for satisfactory drainage.
Dmiiiage should not be canud through healthy areas of the gland,
but behiiiil the gland. The absce^ cavity is to be thoroughly
cleansed and disinfected A diainagc-tube should he left in each
opening; luitisoptic drissmgs and conipressiou applied to obliter-
ate the cavity. The ea\it\ (.hould be cleanseil antiseptically once
or twice daily, and the dressing renewed.
Trealiiiiiit vf Sore ^ipplis. — The nipples are to be cleansed
after each imrsing with an aqueous solution of boroglycerid, 1-8.
Excoriation is souietiines relieved by the following:
IJ Amyli glyeeriti 1 .. ^
'^ ,,. r. , . . '- aa ^s.
Ilisiiiutlli subnitnids |
The niiqili's should lie eleanseil with the borie acid solutioii
lifter nursing and the bisuuitli mixture reapplied.
A 1* per etul. miuiHius solution of carbolic acid is a good anti-
sei>tif nipple lotion. "^
Slinuld these uiensuves fail, the nipple- should be rested for
tu; i\l>hf"ur »r Ihirln-sir hours, or the child should tiurse through
a glass iiii>iili nhiild. The rubber nipple should hdve a sufSciently
liirgi- o|iruiiij: to d.-livev freely. After nursing a gauze compress.
wi't with « sjiturjited Imrie aeid solution to which glycerin has been
iiddid in a prn|iorliiiu of 1 : S. should be applied. Equal parts
lit sterile liistor oil luul bisnuith suliearlwuate may be used insteftd
of the glyeiriiie lotion,
I'liiu during luii'sing is relievt'd by applying, five minutes b»-
PUERPERAL INFECTION 365
■
fore nursing, a 1 or 2 per cent, lotion of eucain hydrochlorid pre-
viously sterilized by boiling. Or a saturated alcoholic solution of
orthoform may be used. This should be washed off immediately
before nursing.
Fissures may be lightly touched once a day with a stick of
nitrate of silver, first penciling with the eucain solution.
Penciling with a 1 per cent, solution of silver nitrate is effi-
cacious, and has the advantage over the solid stick of being prac-
tically painless.
An argyrol solution, 3j to §j, may be substituted for the nitrate.
Painting the affected surface with compound tincture of ben-
zoin, or with ichthyol, several times daily, is useful; or the fis-
sures may be cleansed with a 1 per cent, bichlorid of mercury
solution, and, after drying with sterile cheesecloth, painted with
tliiol collodion, 10 per cent. The opening of the milk ducts must
riot be closed. A nipple shield may be worn till healing has taken
I>lace.
PTJEBPEEAL INFECTION
Puerperal infection is primarily a wound infection, due to the
^rx trance of infective organisms into wounds of the genital tract.
Tt is identical with that of surgical practice. The synonyms, puer-
r>e^ral fever, puerperal septicemia, metria, et cetera, are mislead-
^^^^, as they do not convey the fact that the several localized in-
^^otive processes post partum are . distinct pathological entities,
^lid should be classified according to the anatomical distribution of
^lx« lesions.
Frequency. — In preantiseptic times puerperal fever was a
^^^mmon affection in childbed. The mortality from this cause in
'^ospitalaLwas from 2 to 6 per cent., and so-called epidemics with
^ deathQfte of 10 per cent., or even more, were of frequent occur-
^^nce. To-day, in well-managed maternities, less than a fourth of
■*- per cent, of puerperal women die from septic infection.
Bumm found a morbidity of 20 per cent., assuming 100.5° F.
^^ the normal limit of temperature.
In general private practice, owing to imperfect asepsis, to-
feather with a tendency to undertake operative delivery^ often in
^^ € absence of any absolute indication, before complete dilation
366 PATIIOI-OGY OF THE IMEEl'ERAL STATE
of the passages is obtained, the morbidify and mortality are rela-
tively high. There is about 1 per cent, of aejttic deaths, and a
large proportion of women who survive infection are seriously,
often permanently, crippled in health from the morbid proeesa
From 15 to 20 per cent, of women dying during the ebiH-bcaring
age die of puerperal fever. Under a strict asepsis there rfiould
be practically no deatJiB from puerperal infection in family prac-
tice, and the morbidity does not exceed 10 per cent. ; even that
is usually of a mild type. The disease is observed more frequenlly
in primipor^ than in multipariE.
Etiology.— 7'/( ts cause is the introduction of septic germt tnto
the ivoinit/s of the birth-canal during labor or the puerperium.
Conditions which impair the resisting powers, as hrmorrhagt.
trauma, and toxemia, act as complicating causes. The puerperal
state at best is one of lowered resistance.
Bacteriology. — The organisms most constantly concerned are
the streptocoeci : staphylococci are frequently found. The bat
lerium coli commune, the gonocqecus, the bacillus of diphtheria
and terfain other microilrganisiiia are oceasjpnal factors in tlie
pathogeny. Putrefactive bacteria generally are present. Putre-
faction of the lochia produces a soil favorable for the development
of pathogenic organisms. The putrefactive bacteria act solely,
others largely, by the effects of their chemical products, tosiiw
Most puerperal infections are mired infections.
The sources of the infecting organisms are the lochia of puer-
peral fever jiatients, a secretion from suppurating wounds, erj'-
sipelas, diphtheria, and in certain cases scarlet fever or typlioid
fever, owing tn complications involving the presence of wound-
iufeetion germs, also cadaveric tunl other dead and decomposia;
animal Tniitter. Gonorrhea is fi'eijuently a complicating sourw-
Tlie term self-infection — autoinfeetion — is applied to infection
from i>yogenie organisms j)rirnarily present in the genital tract,
IiitV-clioii from the latter source is very rarely possible.
I'm rp' rill infection is contact infection. Vehicles of infeclio*
an- llie hand.-i of the ob.ilelrieian or the nurse, instruments, ultn-
.vil.i. eliilhx. yirm-lailen du.it. c.opuhiHon just before, or during,
labor. I't cetera.
The avenues of iui'usion are Ilic obstetric wounds of the vulva.
vagina, the cervix, and corpus uteri, and even intact surfaces of
PUERPERAL INFECTION 367
the genital mucous membrane. Systemic infection and that of
the uterine adnexa spring most frequently from the cavity of the
uterus, especially from the placental site.
The channels of diffusion usually are the lymphatics, less fre-
quentlji^ the veins. Through the former \vc get parametrial .exu-
dates^ peritonitis, etc. When the infection travels through the
veinfiu thronibo-phlebitis and bacteremia result.
Special Manifestations. — The most common lesion is putrid or
septic endometritis ; this may be followed by salpingitis ; oophor-
itis; metritis; parametritis; perimetritis, or pelvic peritonitis;
diffuse peritonitis; uterine lymphangitis, and phlegmonous lymph-
adenitis— generally accompanied with peritonitis ; phlebitis —
uterine, periuterine, and crural; colpitis; pure septicemia; acute
ptomain poisoning — putrid intoxication; sapremia; pyemia; cys-
titis; ureteropyelitis ; pneumonia; pleurisy; pericarditis; endo-
carditis; nephritis; arthritis; subcutaneous phlegmons, and
others. Each lesion has a distinct symptomatology and physical
signs.
Diagnosis. — General Symptoms op iNPECTiON.-^Usually the
first symptoms appear on the second or third day after labor ;
rarely later than the third, excei)t when the lesion is due to a
mixed infection in which the gonococcus is present, since the ob-
stetric wounds have by that time begun to granulate, and the
granulation layer (leukocytic zone) acts as a barrier to the in-
vasion of the pyogenic organisms. In the majority of cases the
disease begins insidiously. The attack is sometimes ushered in
by a more or less pronounced chill.
The most conspicuous early symptoms are rai)id pulse, 100 to
140; rise of Jemperature, 102° to 104° F., faulty involution of
the uterus, and Jetid lochia — yet sepsis often occurs without fetor.'
The had odor is due to the presence of putrefactive bacteria or of
the colon bacillus, and is often absent at the onset of sepsis in the
most virulent forms of streptococcic infection. A complete blood
count, blood culture, and intrauterine culture should be obtained
in every suspected infection. Malarial pyrexia should be excluded
by quinin or better by microscopic examination of the blood for
Plasmodia malaria}. Pneumonia, typhoid fever, fecal retention,
emotional, mammary, and other nonseptic causes of high tem])era-
ture should also be excluded.
is the lesion most constantly present iu puerperal sepsis. It may
be of the jiutrid or septic variety. The uterus is more than nor-
mally .aensitjve on palpation over the lower abtiomen ; the eervii
is more patulous than normal for the time, especially iu the putrid
type; the uterine lochia are often foiil, and the bloody flow i§
usually prolonged. Generally, owing to a greater or less degree
of accompanying metritis, the uterus is somewhat boggj', tender
on presKure. and involution is faulty and retarded. A relaj:e<l
uterus favors spread of the infection through the patent lymphatk
chamicls.
The septic process may be limited to the endometrium, the
organisms not penetrating beyond the granulation zone, which
is well developed in the milder forms of endometrial infiammatiou.
When, for any reason, that protection fails, the sepsis becomi-.s
widespread ami the systemic disturbance proportionately greater.
Occasionally in profounil general sepsis the endometritis may be
insignificant, owing to early and rapid migration of the oEfendiug
organisms into other structures. Usually, however, when the
uterus is the seat of a [lutrid or a mixed endometritis, a thick
layer of necrotic material is found lining the uterine cavity. Be-
neath this, separating the infected area from the more or less
normal underlying tissue, is a thick layer of leukocyte and smatl
round Hsme cell iitfiltralion—a reaction zone.
In septic endometritis, the protection zone is thinner and not
so well defined, which allows the microiirganisms to pass throu^
the deeidua and along the lymphatics beyond the uterus.
Metritis. — This originates iu a lymphangitis of the uterine
walls. It is generally secondary to an endometritis, sometimes to
infection of a cervical laceration. After-pains are severe and pro-
longed. The uterus is large, boggy and teniler to the touch. Por-
tions of the muscularis may slongii — dissecting metritis.
Paranmlritis and Perimetritis. — Parametritis frequently fol-
lows infected tears of the cei-vix, or is secondary to puerperal en-
dometritis. There are pain and tenderness at the seat of iufifliu-
miuux, because of the markeil intlammatory edema of the pars-
poderatG tympanites, frequently nausea ; the lochii
) found in one or both broad ligamenli
i examination; the uterus is more
in-
■biB
ff J
PUERPERAL INFECTION 369
fixed, sometimes displaced; fluctuation generally may be made
out at the seat of the exudate if pus forms. Abscess results in
less than 20 per cent, of cases of parametritis. The pus collection
may be in the broad ligament, extraperitoneal, or it may be intra-
peritoneal and encysted, the result of a circumscribed peritonitis
and agglutination of surrounding structures, or of walling off by
exudate.
Diffuse Peritonitis, — Peritonitis is respons^ible for the largest
number of deaths in puerperal infections. The route by which
the pyogeni<j organisms reach the peritoneum is almost invariably
the lymphatics. There are exquisite abdominal pain, tension, and
tenderness in the early stages generally; later the tenderness may
partially, or wholly, disappear if the infection is very virulent.
Tympanites usually is extreme. There are vomiting of greenish
fluid, diarrhea, and finally collapse. The termination is almost
surely fatal within a week.
Phlegmasia alba dolens, milk-hg, sometimes results from
parametritis. The inflammatory process, extending by the lym-
phatics along the courses of the great blood vessels of the thigh,
gives rise to i)eriphlebitis. Most frequently the process is pri-
marily a thrombophlebitis of the pelvic veins. The left uterine
vein is most commonly involved.
The period of invasion varies from two or three to four weeks
after delivery, and is almost always preceded by evidences of poor
uterine retraction, as metrorrhagia, temperature, and a large
uterus. The attack is sometimes ushered in with a chill, and is
always attended with pain and swelling in the affected limb. The
pain is first felt in the groin and usually extends throughout the
h»ngth of the thigh and leg within a few hours. The limb becomes
swollen, tense, hard, white, glistening. The affected veins may
sometimes be felt on palpation, as hard, irregular cords. They
are frequently nodular, owing to the formation of thrombi. The
fever is at first of a remittent, then an intermittent type. Resolu-
tion generally begins after about two weeks. The duration of the
disease may be many weeks; abscess- format ion or gangrene some-
times supervenes. There remains more or less edema on standing
or walking, with impairment of muscular power. In a certain
proportion of cases the disability may last for months or indefi-
nitely. A possible termination is sudden death by pulmonary
370 PATHOLOGY OF THE TfERPEKAL STATE
embolism from the detaahraent of a fragment of blood-clot. Re-
ciirriDg t^hiliH are a signal of metastatic affectious. The diseaae
may extend from one Hmb to the other.
Colpitis. — The usual evidences of vaginal intiammation, catar-
rhal, phlegmonous, ulcerative, or diphtheritic, are present. In
ulcerative vaginitis the labia often are edematous. In the phl%-
monous form abscess may result. Jlembranous exudates are gray-
ish white an<l are very rarely due to a true diphtheria, usually to
infection with jiyogcuic organisms.
I^Hif septivemia, or bacteremia, is characterized by fever and
canliovascular deprissinii, with absence of appreciable orgaaie
lesions; cocci may fre<|uently be isolated in the blood; the eoun-
teunnce is sallow, sunken, and anxious. Occasionally there is
delirium or coma; diarrliea ami vomiting of dark gnimous ejecta
freipiently are observed. It runs a rapid course, often terminat-
ing within two or three days.
/',(/' iiti'rt.^i'ycmia originates most frequently in infection of
the uioulhs nf ihc veins at the placental site. The phlebitie proc-
ess may he liniiU'd or diffuse. By the breaking down of infected
thrombi, scptie emboli and metastatic abscesses in various parts
of the boily nuiy result. Septic pneumonia and septic endocarditis
are eomuion compliealions.
I'yemia is distinguitlied by irregularly recurring chills, marked
irregularity of the temperature, and metastatic development of
inirulenl foei. The duration may be many weeks. Often it pro-
gresses to II riipidly fatal termination.
t'l/stilis is aiienditl with vesical tenesmus aud increased fre-
ipii'hry rif iiriiuition. In the acute stage the tenesmus is almost
eon.stnnl. ami is not n-lieved by emptying the bladder. Pain is
-Mimelimes excessive, and ibeiv is usually some elevation of tem-
peniture. The urine is cloudy aud of feebly acid reaction; some-
iinie.t it i!i fetid.
rrfl,roitii>tili.i. — In urotero pyelitis there is frequent desire to
nriti:ite. >viih |>i)in aud lenden»>ss along the inflamed tract and
lend.nirs.s .m pressure at the vertebrocostal angle. Pressure
»u the nn-ii-i- through ihe vagina by conjoined manipulation
elii'iis i>nin and ihsire lo urinate. The urine is acid and con-
Irtins pus :ind bliHvl. Tiu- lemperature is very high in the acute
PUERPERAL INFECTION 371
In most cases of puerperal infection several of the lesions above
described coexist.
Prognosis. — As a rule, the earlier the attack the more un-
favorable the prognosis. It is gravest in acute putrid intoxica-
tion, diffuse purulent peritonitis, streptococcic bacteremia, and
pyemia. Generally the prognosis is best when the septic process
is distinctly localized and there is extensive exudate formation.
Treatment. — Prophylactic. — To prevent infection, rigorous
asepsis of the hands, instruments, utensils, and of everything that
comes in contact with the genitals during labor and the puer-
perium should be enforced. The external genitals, lower abdomen,
and inner surfaces of the thighs should be cleansed antiseptically
before internal examinations. The vagina and cervix should be
disinfected before, and during, labor for cause. Examination by
the vagina during labor should be made as seldom as possible,
sterile rubber gloves being worn. In many cases vaginal exam-
inations may, when, for any reason, more than ordinary care is
required, be omitted altogether. All preventable injuries of the
passages should be prevented. Under modern methods of prophy-
laxis there should be practically no mortality from puerperal in-
fection in private practice.
The principles of treatment may be summarized as follows:
(1) The destruction of the infecting organisms or the diminu-
tion of their infective powers at the site of the primary infection.
(2) Stimulation of the resisting powers of the patient.
(3) The destruction of organisms already in the blood stream
by the production of antibodies.
(4) The consideration of operative measures.
Remedial. — Vaginal Exploration. — Essential as a preliminary
to treatment is (f careful digital and speculum examination to de-
termine (1) whether the infection is confined to the genital canal;
(2) the site of the local lesion, whether in the uterus or beyond
the uterus — when the infection is in the genital tract the primary
focus may be in the vagina, cervix, or uterus; when outside, in
the parametrium, peritoneum, pelvic veins, or in the blood-stream.
Vaginal ulcers and necrotic or pseudodiphtheritic patches on the
vaginal w'aIT~or the portio should be touched once or twice daily
with tincture of iodin, a 50 per cent, chlorid of zinc solution, or
with strong carbolic acid.
372 PATnOLOGY OF THE PUERPERAL STATE
Before interference within the passages, as rigorous an anli-
aepiic preparaiion is required as for a major surgical operation.
The examinations and treatment should be conducted on a table,
and stei'iie rubber gloves should be worn for protection of both
physician and patient.
In the absence of appreciable lesions below the body of the
uterus the probable seat of infection is the endometrium.
Intrauterine Exploration. — A weU-contracted uterus with a
closed cervix is vot to be explored. When the cervix is open the
cavity of the uterus may be explored with the finger to determine
the presence or absence of placental fragments and shreds of mem-
brane. An intrauterine culture of the uterine lochia may be ob-
tained with a Diiderlein tube. This will help to define the prog-
nosis, and the findings may have some bearing on treatment.
When the finger demonstrates that the uterine cavity is empty,
the interior of the uterus may be left alone or be firmly packed
with sterile gauze which has been soaked in the pure tincture of
iodin. the excess of iodin having been squeezed out before using it
as a tampon. This pack is left in the uterus for twenty minutes,
and then withdrawn, and no further intrauterine iustrumeutation
or medication resorted to. In all pelvic inflammatiojt occurring
post partum, the maintenance of the patient in a high Fowler
position will favor postural drainage, which dimiuisbes the source
of infection. The free use of eigot helps to maintain a contracted
uterus and thus offers a barrier to bacterial invasion.
Curetting. — Curetting is indicated .only in the "presence of
gross necrotic material iti pregnancies before the eighth Keek,
never in acute streptococcic infection. Better than the curette for
clearing the uterus is a Ward placental forceps or the finger.
The curcitr has been a large factor in the death-rate of puer-
peral sepsis. The mortality in curetted cases is from 32 to 59 per
cent. The mortality in wholly neglected cases of streptococcic
infection ]»robably would not exceed 10 per cent. The writer, for
the past two years, has treated all cases of sepsis without intra-
uterine crploration. except to make a uterine culture, using the
high Fowler position, fresh air and sunlight, an icebag over the
uterus, stimulation, supportive treatment, and vaccines, with a
mortality of only 2 per cent.
Systemic measures are ordered mainly with reference to elim-
PUERPERAL INFECTION 373
ination arid support. Something may be done in combating gen-
eral infection. Tonics, stimulants, forced feeding, and fresh air
are of first importance. Strychnin, gr. 1/40 to 1/20, hypo-
dermically, every four hours, and brandy to the extent of a pint
or quart daily is to be given; instead of brandy, whiskey, or an
equivalent of wine, may be preferred. To realize the full benefit
of the alcohol, it should be pushed, if possible, to the point of in-
toxication. Large doses of sodium citrate, gr. xx-xxx, in lemonade,
several times a day, help to maintain the alkalinity of the blood.
The subcutaneous injection of a pint of the normal salt solu-
tion^ or of artificial serum, two or three times daily, is sometirhes
of great service as a stimulant and an eliminant as well. The
addition of acetate of sodium, 5j to Oj, increases the diuretic
effect. Enteroclysis and the free use of water by the stomach are
useful aids as eliminants.
Plenty of pure air is essential. Oxygen inhalations may be
used.
On the first rise of temperature, two or three bowel movements
should be secured by large enemata. It is inadvisable to use
hypercatharsis ; a daily enema is sufficient.
Antipyretics. — The temperature should be reduced by tepid
sponging, tepid packs, or the use of a cold coil.
The coal-tar antipyretics serve only to mask the symptoms,
and are depressing and otherwise injurious. Quinin is useless in
purely septic fever except in small doses, gr. ij or iij, t. i. d., as a
tonic. Even for the latter purpose it is inferior to strychnin.
Narcotics. — An occasional opiate in small doses, morphin, gr.
%, or codein, gr. I/4, may very rarely be required in case of ex-
treme nervous excitement or sleeplessness, but should be withheld,
if possible.
Other Measures. — Five per cent, nucleinic acid solution, mv-xx,
given by the stomach, for hyperleukocytosis, may be repeated
every 3 to 6 hours.
Collargolum, in 1 or 2 per cent, solution, may be used; dose,
per rectum, oij-viii, morning and evening; the bowel is washed
out before each injection; intravenous dose, oj-iv of 2 per cent,
solution every 12 to 48 hours.
Vaccines have a definite field, and are valuable adjuncts to
the fherapeutics of puerperal infections. Mixed vaccines of poly-
374 PATHOLOGY OF THE PUERPERAL STATE |
valent strains used early positively increase the leukoej-te resist-
ance. Autogenous vaccines are of most value in subacute and
chronic infection. The leukocyte count is the beat index of the
value or valuelesauesa of vaccines.
Aiitistrcplococcic srriivi, 300 c.e. every 12 to 24 hoursi, may Iw
given hypoderraically ; but is of tittle value for the reason thai
the infection usually is a multiple infection.
TRE.iTMENT OP PERiToNiTis.^The treatment of peritonitis eon-
siats in the employment of the Fowler position, the cold coil or
ieebags to the abdomen, large eueraata to secure a bowel evacua-
tion daily, the withdrawal of all food by mouth for 48 hours, and
the continuous use of the Murphy drip. A moilerate use of opium
may rarely he permittttl for control of extreme paiu and restless-
neaa.
Definite pus collections should be evacuated promptly as in
other conditions, picferably by vaginal incision and drainage.
Tre.vtment of P.vr.vmetritih. — Hot vaginal douches, several
gallons at a temperature of 110° to 120° F., may be given two or
three times daily. Local antiseptic and general tonic measures
are indicated as in other septic conditions. If an abscess forms
it should be evacuate<I early and drained by the vagina or by
extraperitoneal abdominal incision. Operation by the vagina gen-
erally is safest, and it best eifcets drainage. This route should be
chosen e.xcept when the pus cavity cannot safely be reached from
below. In the latter event the incision should be made just above
Poupart'y ligament and parallel with it, and the pua collection
reached extraperitoueally.
Tre.vtment of Phlegmash Alb.v Dolens.^ — The limb should
be kept at rest in u horizontal position. Ichthyol and lanolin, 1 : 4,
applied twice daily over the entire limb, and covered with rubber
tissue, usually yield good results. If rciiuired for a few days,
pain may he subdued by the local application of oli-ate of mor-
phia. Afler tile a|iplieation the limh is enveloped wilb a siiiglr
thickness of muslin wrung out of liot water, and this is covered
with oiled silk.
Massage is to he avoided during the active stage of the disease;
it may cause embolism. Should ahscL'Sses form they should be
treated by carl.v and free incision, followed with thorough cleans-
ing and drainagt?. Thu patient may leave the bed when the swel-
SUDDEN DEATH IN CHILD-BED 375
ling subsides and the fever has long since ceased. From that time
the affected limb should be supported by a flannel bandage or an
elastic stocking. The support should be continued so long as much
swelling occurs on standing or walking.
Treatment op Pyemia. — The general treatment is essentially
the same as in septicemia. Metastatic pus foci should be opened
and drained if accessible.
Treatment op Cystitis. — A mildly alkaline water should be
drunk freely as a diluent. The bowels must be kept freely open,
and the diet should be nonstimulating. Sweet spirits of niter, four
to six times daily, helps to relieve pain. Urotropin, gr. vi to viii,
in a full glass of water, three times daily, is most useful.
Treatment of Ureteropyelitis. — Water is to be used freely
by the stomach or by high rectal injections to flush the septic tract
by increased secretion of urine. Salol in doses of five grains every
three hours, or urotropin, as in cystitis, are the best antiseptics
for the urinary tract. Vaccines in mixed polyvalent strains of
the colon, streptococcus, and staphylococcus, have had a decided
beneficial effect in pyelitis cases.
SUDDEN DEATH IN CHILD-BED
Among the principal causes of sudden death in childbed, those ;
most frequently encountered are shock, syncope, apoplexy, ad- \
vanced cardiac disease, acute pulmonary edema, pulmonary em-
bolism, and thrombosis. The latter two are the most frequent.
Phlebitis, varicose veins, prolonged labor, anemia, hemorrhage,
sepsis, cancer, and syphilis predispose to embolism and throm-
bosis.
CHAPTER XV
OBSTETRIC SURGERY
DIDUCTION OF PREMATTniE X.ASOB
Indications. — Tlie iDdications for tlie induction of premature
lahni- jiTV iH'rtniii eases of narrow jielvis. in which the deliver^' of
a living am! viable child is thus possible; flattening between 7, a
ami 9.5 cm., or eqiiivaleut contraction of other forms; fetal death;
habitual death of the fetus iu the last month of gestation from
other causes than syphilis; toxemia of pregnancy, drug, and die-
tetic measures failing; dangerous cases of placenta pnevia after
the period of viability, and accidental hemorrhage; certain casei
of hydrainnios. with danger to mother or child ; also cardiac lesions
in which tlie compensation has been broken during pregnancy. anJ
rare eases of tubereidosis and ciioi'ca.
1. Pelvic Con traction. — Here the most difficult problem is
to flx the proper time for iutcrference. Operating too soon, the
interests of the child, too late, those of the mother, are imperiled.
Tiie most reliable data for deciding the question are afforded by
careful measurements of the pelvis and of the fetal head. The
operator should crowd the head into the pelvic brim, with one
haiiil over the nlKlomeu while the other is passed internally to
learii how far and with how much freedom the head descends.
Tlie estiininalious shoidd be re|>ealed at intervals of one or two
weeks. The labor should be brought on as soon as the head is
found to I'nier ihe pelvis with difficulty.
Till np'ri]! it'll is -ttlii-iu f„ b< i/x.swi i'h preference to its aiter-
iialiiu!'. ('..^(irinii si<(i'>n ami luibiotomi/. in pelvic contraction.
Whilf it.i iiuilirinil liitlth-ratt i.< marly nil. the fetal mortalily,
iTiiiil ill i>pti-itti"iii iritliiii lire to four tvreks of term, it pro-
hibiiiv.
■2. H \mTr,\i. nE-\Tii ok the Fetis. — Oi»eralion should be done
a w.vk or two lufore the usual periml of fetal death. The strength
INDUCTION OP PREMATURE LABOR 377
and frequency of the fetal heart, and the vigor of the fetal move-
ments, must be watched closely as the fatal period approaches.
3. Toxemia. — The pregnancy should be terminated on the ap-
pearance of grave symptoms, especially if the fetus has reached
the full period of viability, and medical and dietetic treatment
have failed.
4. Hemorrhage. — In placenta praevia, after the period of via-
bility, and in accidental hemorrhage, it should be the rule to in-
duce labor as soon as the diagnosis is established. In pre vial pla-
centa, with much hemorrhage, the uterus should be emptied before
viability.
5. IIydramnios. — Here interference is called for when the life
of the mother or child would be jeopardized by longer continuance
of the pregnancy, owing to the pressure effects of the growing
tumor.
Methods. — Catheterization of the Uteri;s: First Step. —
The first step consists in separation of the membranes from the
lower uterine segment by means of a uterine sound or with the
finger. The operation must be aseptic.
Detachment of the membranes with the sound may be done
with the w^oman in either the left lateral or dorsal recumbent
position. For the use of the hand the dorsal position is best.
Second Step. — The second step consists in the insertion of one
or more No. 12 English bougies, or a sterile rectal tube, between
the membranes and the uterus.
No anesthetic is required. Usually the bougie or rectal tube
is most readily passed with the aid of the Sims position, the Sims
speculum — exposing the cervix, which is drawn forward and held
with a volsella. The bougie is sterilized by boiling or steaming,
the proximal end is cut off, and a stylet inserted. To facilitate
introduction the bougie is bent to nearly a right angle at about
three inches from the distal end, giving it a large curve. Great
care must be used to avoid rupturing the membranes. The in-
strument is then pushed up gently and in the direction in which
it passes most easily. After it has entered between the mem-
branes and the uterine wall, the stylet is drawn down about one
inch. The flexible tip of the bougie finds its way readily with
little risk of perforating the membranes. The bougie fully in
place, the stylet is withdrawn. A second bougie may be inserted
878
OIJSTETRIC SrRGERT
if it can be pushed iuto place without too much difficnity.
Bleediug is probable evidence that the instrument has passed be-
hind the placenta. The lieraorrhage may occasionally be exe^ssivt
It is theu beat to withdraw the instrument and pass it in another
direction. A light tampon of gauze may be packed in the vagina.
but it is not required to 8ii|)port the bougie. The instrument a
. lf-\— V.V
i Co
ncAL P.iCK tN' Poi^tnoN
lefi M W- rxivlli>I with the ohiM, Labor usually is e^abUdieil
witbji) iwiHiiy-foiir hours. TbU meihfti is not suited to esses in
wliii'li iimiit\li«!i* •i«-liverj' is o.illtil frtr.
t'lKM«"M. TxMivNAPt — Wiih llif aiil of the Sims posture and
a Sims s|KviiUini. thf ivrvix and \-agiu:i an? packetl firmly with
/ill.' irtiil iir Kiratrti stri|>-inuif S^ituraimg th*- gauze with gl,v-
wriii aiiils i»» iis fftk-irtu-y. Th*- nai-k is rmovvd after 12 or ?4
INDUCTION OF PREMATURE LABOR
379
hours. It may then be renewed or dilation be completed manually
or instrumeiitally {Fig. 92).
The cervical tampon is a useful measure for beginning dilation
when time permits.
Manuaij Dilation op the Cervix. — ^lanual dilation should
never be attempted unless the cervix canal is obliterated. The
woman is placed in the lithotomy position uuder an anesthetic.
The usual aseptic preparation is carried out.
The operator then lubricates his gloved hand well with aseptic
glycerin. Coning the fingers, the hand is introduced into the
Fig, 93, — Manual Dilation of Cervix with Hand in the Vagina,
Fingers in the Cervix. (After Harris)
vagina. One finger is passed through the cervix. After a time
the cervix relaxes till a second finger can be passed, then one
finger after another until the whole hand is introdnced. The fist
is then slowly and cautiously closed in the grasp of the cervix.
By this time the dilation is sufficient for the passage of the head,
and, at the same time, active uterine contractions have been estab-
lished (Fig. aT).
The dilation must be done with the least possible muscular
effort to prevent cramping of the hand. To i)revent laceration of
the cervix, extreme care must be used, taking plenty of time for
each step. The (laiu/i-r of frnrhiy ix ifrmtrxt in thr. latlrr pari of
380
OBSTETRIC SURGERY
the dilation. The uterus is steadied by counter-pressure over the
fundus, lest by pushing the uterus upward the vagina be exposed
to too great strain.
Should the indications warrant, immediate extraction may be
undertaken by version or forceps. Delivery is thus possible within
fifteen minutes to two or three hours, according to the rigidity of
the cervix and the difficulty of extraction.
When the cervical canal is too small to admit the finger easily,
the dilation may be commenced with a branched steel dilator.
Fig. 94. — Two Hand Dilation of Effaced Cervix. (After Edgar)
Or, if time permits, a cervical and vaginal tampon may be placed
and left for twenty-four hours. By the end of that time the cer-
vical canal will be found sufficiently expanded to receive the
finger.
Edgar dilates by hooking one or two fingers of one hand in
the cervix anteriorly, and one or two fingers of the other hand
posteriorly, and pulling in opposite directions (Fig. 94).
Artificial delivery by rapid dilation of the cervix is danger-
ous except at the hands of a skillful operator, and is to he
reserved for emergencies. The writer prefers vaginal hysterotomy.
No important injury need result from lacerations of the cervix if
proi)erly sutured at the close of labor, but the tear may extend
into the lower uterine segment and even into the peritoneum.
Instrumental Dilation. — ^Vater'hags ( Champetier balloon,
Voorhees, or Pomeroy bags). — Dilation of the cervix by means of
INDUCTION OF PREMATURE LABOR
381
'T'hags is tedious, but generally safer, and is to be preferred
^i the indication for delivery is not too urgent,
Branched Steel Dilators. — Dilation may best be commenced
Pomeroy Bag
Champetier de Ribes Balloon
Balloon in the grasp of Bag Forceps
Voorhees Bag
Fig. 95. — Water-Bags
the Ilegar graduated sounds of the kind commonly employed
ynecologic practice. The risk of infection is less than with
3nged use of water-bags and cervical packs. AVhen the indi-
>n is urgent, the dilation may be comi)leted rapidly with the
26
882 OnSTETRIC SURGERY
Bossi dilator or some of its modifications. As a rule, dilation
once established, it is better completed with the hand. Instru-
mental and manual dilalion are daHgcrous, and always prothtr
more or less cervical injury.
JIuLTiPLE Incisions. — Manual dilation may he supplemented,
when required, by several shallow incisions made at different
points ill the eircuToference nf the external os.'
Fiti, 91).— I'oMEKUv Bag in Position'
VAfirNAi. Ces.\re.\n Section should be the method of ehoics
when' it in ni'efssary In rajiiiily terminate the pregnancy, and the
ciTvix is iLiiiiilatcd and rigid.
Care of the Chlld.^(!t'nuriilly in ease of premature children
the use of au incubator will bo re(|uirt'd. In hospital practice, an
Auvard's, Crede's, Roteh's, or Marx's apparatus should be pro-
vided. For use in private practice an improvised incubator may
be made out of a box ao inches long by 20 x 20 inches, of wood or
metal. It should have a removable cover and a false bottom. The
child is placed in the upper ehjiiiiber and hot bottles or a metal
water tfink heated by an alcohol hiiiiji in llic lower. Air admitted
l-tiay obstetriM bj
INDUCTION OP ABORTION 383
to the lower chamber flows into the upper through several half -inch
perforations at one end of the false bottom, escaping by similar
perforations at the opposite end of the top or cover. A thermom-
eter in the upper chamber should register constantly about 90° F.
A glass window in the top of the incubator permits observation of
both child and thermometer. The usual period of incubation is
from one to three months. Meantime the child is removed from
the warm chamber only for nursing, bathing, and changing of
clothing.
Recourse must be had to gavage, feeding through a soft stom-
ach-tube, when the child is unable to nurse the breast or bottle,
or to be fed from a spoon. Better than the stomach tube is feed-
ing through the nares by means of a narrow-pointed spoon. By
incubation and gavage 20 per cent, of children born at the sixth
month may be saved. The viability is correspondingly greater
in more advanced stages of gestation.
INDUCTION OF ABORTION
Indications. — 1. Toxemia of Pregnancy^ with Grave Symptoms
Not Yielding to Other Measures. — ^ledicinal and dietetic measures
failing, the uterus should be emptied before the occurrence of
serious, symptoms. In grave toxemia, as a rule, evacuation of the
uterus is the only method of treatment.
2. Chronic Nephritis, — In chronic nephritis the termination of
the pregnancy is demanded because development to viability and
the birth of a living child are exceedingly rare, and the child, if
born alive, is puny and feeble. The mother's life, too, is seriously
jeopardized by the continuance of the pregnancy. Even if she
survives the pregnancy and the labor, grave injury will have been
done to the crippled kidneys.
3. Extensive Vesicular Degeneration of the Chorion. — The
diagnosis established, and no evidence of fetal life being discov-
ered, the uterus should be evacuated promptly.
4. Irreducible Retroversion of the Gravid Uterus. — The retro-
verted gravid uterus is very rarely irreducible before the third
month. Before resorting to abortion, the usual measures for re-
duction, with the woman in the Sims or genupectoral position,
should have had a fair trial. The writer on two occasions has
384 OBSTETRIC SURGERY
made an alKlotninal section for the reposition of an irreducible
gravid uterus; both pregnaneies proceedeti to term.
5. Abs'ilide Cuntraclion of the Pelvis. — Tlie termination of the
pregnancy in the early months is tleraanJed, on election of the
mother, especially iii conLlitions unfavorable for eeliotomy. Thae
aru extremely rare. The patient shonlil gt'nerally be allowed to go
to term and be delivered by Cesarean section. This applies to
contraction of the soft parts and to obstructing tumors, as well ix
to deformity of tlie bony pelvis.
G. I'rrnkiiius Anemia, or Leukemia.
7. Cliorra. — Chorea, as a complication of pregnancy, is ften-
erally an intractable disease and sometimes dangerous to lite.
The maternal mortality is variously estimated as from G to 25 per
cent., the infantile at 1<* per cent. Spontaneous abortion or pre-
mature labor oeenrs in 30 per eeut. of cafiea.
,S, D,iilli (./ flu- iiriiiii i'hIIs for evacuation of the uterus imme-
iliiili'ly 1bi' diij;^[Lo.sis of di-ii1h of the fetus can be established pm-
liv.ay.
9. I'linitiic Iliarl Distiisc. — In advanced cardiac disease the
hi'iirl suffiTH impHinneut. owing to the extra tax to which it is
sul>,jri-li.'<l in the later months of ju'eguancy, and the life of the
palLi'ut is si'riounly jeopardiziil at labor.
111. Tiihiniili'six. — Kreiiueiitty pregnancy in tuberculous
woiiU'U is prejudieial: labor is attended with a considerable mor-
lidity. Abortion ia indicated in eases in which the condition of
thi' lungs biis obviously grown worse during gestation.
Methods. — 1. l>t:rAcii.MKNT of the Ovim and Tampon.u>k of
TiiK Chu^i.x. — .\borlion nniy be indueinl by partially detaching the
ovum wiih H ulerine sound aseptieally. or by the use of the cer-
vical and v:)};inul iHmpouHde, with plain or boric acid gauze, aa
already di'tnilnl uiider indnelion of premature labor, or thtse
proi'fdiires may be emi'loyed conjointly. The tampon is reneweii
alter iw>hi' Ui IweuTy-l'oiir luiui-s. The strictest asepsis must be
oliserveil.
•2. Immi:i>i\tk i;v vn \tiiiN" i-k the i teris with the ci'hette
is the imtb.Ml preferred by ili,- writer when the pregnancy has not
iidviiueiil beyond tile seeinid inonlli. The patient ia placed under
an anesihetic in the liihmomy or in the Sims position. The usoil
nut isi'pl ii- ptv|>ftr«tii>u is earrirtl out-
ABNORMALLY ADHERENT PLACENTA 385
The cervix is now dilated sufficiently to admit easily the largest
curette to be used, care being taken to avoid lacerating the tissues.
When gestation has not advanced beyond the second month,
the ovum may be broken up and the larger portion of it brought
away with a Keith forceps; the remaining fragments and the de-
cidua are then removed with the curette.
The curetting is best done with a sharp curette. The operator
knows, by the peculiar grating sound and by the harsh feel, when
the instrument has reached the uterine wall. The ovum and the
decidua have a smooth or spongy feel, and give out no sound as
the curette is drawn over them. The sharp curette does its work
with much lighter pressure than the dull instrument, and, there-
fore, with less injury by bruising; with proper care it will not
cut too deeply.
A half drachm of fluid extract of ergot or ergotole may be
given hypodermically as a precaution against hemorrhage. In
aseptic conditions no pack is required and no vaginal dressing.
When the contents of the uterus have become necrotic the
cavity should be packed w^ith gauze which has been soaked in the
tincture of iodin. This pack may be left in situ for twenty (20)
minutes, and then withdrawn. The patient should then be placed
iu the Fowler position to secure perfect uterine drainage.
When the gestation has advanced much beyond the second
month, the dilation may be begun with the steel dilator and com-
plete<l with the fingers, or sufficient cervical opening may be ob-
tained by a vaginal hysterotomy. The fetus is brought down and
extracted by seizing the feet, and the secundines delivered by
conjoined manipulation. For manual evacuation, the patient
should be in the dorsal recumbent position.
For the protection of the physician, it is a rule of practice
never to induce abortion except with the approval of competent
counsel.
ABNORICALLY ADHERENT PLACENTA
The existence of abnormal adhesion of the placenta may be
assumed, as a rule, when the after-birth cannot be deliv(»red entire
by ordinary external and internal manual methods within two
hours after the birth of the child. Mere retention, however, by
386 OBSTETRIC SURGERY
partial closure of the retraction ring, must not be mistaken for
adhesion.
Etiology. — The etiology is not definitely understood. The
cause of pathological adhesions of the placenta resides probably
in a diseased condition of the endometrium antedating the preg-
nancy and resulting in deciduitis and placentitis. The decidua
serotina may be almost entirely absent, and the chorionic villi be
in direct contact with the uterine muscle. It should be remem-
bered that an abnormally retained placenta is, as a rule, at least
partially adherent, and that the adhesion is very seldom patho-
logical except in persistence. Unnaturally firm adhesion of the
kind which is attributable to inflammatory causes is extremely
rare.
Treatment. — The treatment is separation and extraction of
the placenta with the hand in the uterus. The patient should be
placed in the lithotomy position upon a suitable table. A rigid
asepsis must be observed. The separation is begun at the portion
already detached. Care must be taken that no fragments remain.
After evacuating the uterus, a hot intrauterine douche of a 2 per
cent, solution of creolin, or of hot saline solution may be given.
Thirty minims of fluid ergot should be injected hypodermically.
The removal of an adherent placenta with the naked hand,
even though carefully disinfected, is always attended with serious
risk of infection. A safeguard against infection in intrauterine
manipulation is the boiled rubber glove with gauntlet. For years
the writer has employed the following method, i. e., firmly packing
the uterus, plus the placenta, with washed iodoform gauze, on the
removal of the intrauterine pack, in 24 or 36 hours, the placenta
may be expressed without difficulty.
FORCEPS
The Instrument. — The obstetric forceps consists of two crossed
arms locking at the point of intersection. Each arm has four
parts, handle, shank, lock, and blade. The blades are shaped to
grasp the fetal head as with a pair of hands. They are also curved
in conformity with the direction of the birth-canal. For lightness,
as well as for wider distribution of the pressure, the blades are
fenestrated. When the instrument is locked the handles fall
FORCEPS 387
nearly together, affording a convenient grasp for the operator's
hand in applying traction. A forceps for general use should be
about 38 cm. (15 inches) long, and should have a moderate pelvic
curve and an elliptical cranial curve, 17 to 18 cm. (about 7
inches) long, and 7.5 cm. (3 inches) in width externally, at the
widest part. The space between the tips of the blades w^hen the
instrument is closed should be 1.3 cm. (about Y2 inch). To admit
of sterilizing by heat it is best made wholly of metal.
It should be thoroughly cleansed with soap, hot water, and a
brush after using; should always be sterilized, best by boiling in
tlie soda solution, immediately before using. It should be kept
free from rust and well polished, and the nickle plating must
occasionally be renewed.
Mechanical Action. — The essential function of the forceps is
traction.
Its use as a lever, by means of a pendulum motion during ex-
traction, is a mechanical gain, but is liable to injure the maternal
soft parts.
The use of forceps as a rotator is considered under treatment
of occii)ito-posterior positions of the vertex and of face presenta-
tion.
Compression of the head with forceps is attended with danger
to the child, and but little mechanical advantage for extraction.
In most seizures compression of one is compensated by elongation
of another transverse diameter. More may he gained by slow
delivery, permitting time for molding of the head under the pres-
sure of the pelvic walls. The pressure of the blades should be
kept at a minimum, and, if possible, should be light enough to
leave no marks upon the child.
Indications for Forceps. — 1. Forces at Fault When the Head
Is Engaged or Engagable. — The use of the forceps is indicated in
cephalic presentation in which the natural powers are clearly in-
adequate, and generally — not always — when the head has remained
stationary for a half hour after two hours in the second stage.
2. Passages at Fault, — Forceps is indicated in the following
conditions :
Flattening, to not less than three and one-half inches, in the
true conjugate, or equivalent obstruction;
Partial obstruction in the soft parts.
388 OBSTETRIC SURGERY
The forceps is permissible only after the head has engaged, or
can he made to engage. In most instances pubiotomy, or Cesarean
section, is better than a very difficult forceps extraction.
3. Child at Fault, — Among the indications for forceps pre-
sented by the fetus are:
Arrested occipito-posterior position;
Arrested face presentation in anterior position;
Moderate hydrocephalus ;
After-coraing head;
Impacted breech;
Fetal pulse above 160 or below 100.
Complicated Labor, — Forceps are often required in emergen-
cies arising from other causes than faulty mechanism, and in
which immediate delivery is indicated in the interest of mother
or child. This indication may be present before the herd engages.
Under this heading may be mentioned certain cases of accidental
hemorrhage, prolapsus funis, rupture of the uterus, and eclamp-
sia, for rapid d(?livery; or of placenta prievia to hold the head
down as a tampon.
Contraindications. — The contraindications are: Head incapa-
ble of engagement, pelvic contraction below 3Vi> inches, c.v., fetus
dead, head hydrocephalic, macerated or perforated, cervix not
fully dilated and undilatable.
Danger of the Forceps Operation. — (a) To the Mother,^
Possible injuries, especially in unskillful use of forceps, are: In
the low operation, vaginal lacerations and injuries to the pelvic
floor; in the high operation, contusion and laceration of the cer-
vix, or even the body of the uterus, shock and sepsis. Separation
of the pelvic joints has resulted from the use of excessive and
misdirected force.
(b) To the Child. — Brain injuries, and especially rupture of
cerebral vessels by compression, are not infrequent. Permanent
mental and physical infirmities and even death sometimes result
from difficult forceps delivery. Temporary paralysis of the facial
nerves frequently occurs. Duchenne's paralysis may result from
the effect of stretching the nerve trunks that enter into the brachial
plexus. An undcanly and unskilled forceps delivery is a danger-
ous operation for both patients, especially in high applications.
Preparatory Measures for Application of Forceps. — The pa-
FORCEPS 389
ttent is usually placed on the bed, or better on a tabic, in the dor-
sal- recumbent posture — the American obstetrie positiou.
In difficult high forceps operations the Walcher position may
be utilized as follows: The patient lies Hat on her back on the
table, with the hips overreaching the edge, and with the thighs
hanging in extreme extension. lu this position, owing to nutation
of the sacrum, there is a perceptible lengthening of the antero-
posterior diameters of the pelvis at the brhn. On the other hand,
at the outlet of the bony pelvis, the lithotomy positiou offers the
greatest advantage, tilting the lower end of the sacrum backward.
Fig. 97, — Diaoram Showing the Kei,.»tive P(isition (
THE Several Korcei's Operation s
The woman should bo anesthetized and the hips bronght close
to the edge of the bed or table. The blatlthr and rcctiiin must be
empty. The fcfal heart must be cj-amuiid before, and oceaaionaUij
during, the, operation. The abdomen, the tliigli.t. and the esternnl
genitals must be cleansed and disinfected- as for a major surgical
operation. The vulvovaginal orifice must be dilati'd. The cerrix
must be fullif dilated, the membranes rupturtd, the head engaged
or engagable. and the position and posture aeeuratihf known. No
vaginal autisepsis is reijuired except after recent uiieleanly con-
tact or in the presence of a i)atliologieal viiginal scerelion, puru-
lent, greenish, yellowish, or ill-smelling. The instrument must be
aseptic and the operator's hands covered with sterile gloves. The
388 OBSTETRIC MUKGERY
The forcepa is pemiisiiiblc onip after the head haa engaged.or
can be rnadc to engage. In most inalances pubiotomy. or CiMwrewi
sectioa, is better than a very diffieuit forct-ps extraction.
3. Child at Fault. — Among the indications for forceps pre-
sented hy the fehia are:
Arrtistfd occipito-poaterior position;
Arrtol^-^l taw iresi'ntation in anterior position;
ModiTiilr li.vilrocL-phalus;
Afti'T'-i'iimiiig head;
Impiieted brwL'h;
Petal |)iiIki' ahovi
Complitattd Labor.- fteii requii-ed in emergen-
cies arising from othis" aiilly inechanisin, and in
which iiiimtHHate del in tlie interest of mother
or cliikl, This indica ,t before the he?d eogagn.
I'nder this lieadiiiR Bertain cases of acctdeotol
hemoiTliH^i', prahip» f the uterus, and eclamp-
sia, for rapid di'livt pra'via to hold the head
down lis a tampon.
OontnuJidicatiom. — J'iie t.-(,uwuiiidica(ious mi-c: Head iwMpa-
bli- of I tiiiiiiji mnit. pihic coiitraclion below 3V1; inches, c.t., fetus
dead, hrad Itydi-oivphatie. macerated or perforated, cervix vol
f>i!l„ ,liht..{ „<»/ uin/ilalabh.
Danger of the Forceps Operatioti. — (a) To the Mother.—
I'iis-mIiU' iiijiuii's. espirially in unskillful use of forceps, are: In
l\w low i)|uT;itii>n, Viiirtiiiil laeerations and injuries to the pelvic
tliHir; ill ihv Iiisili (ipfratioii. eontusioii and laceration of the cer-
\i\. or .'\i'ii tlic luxiy of ihe iiterus. shock and sepsis. Separation
o( liu' I'olvii' joiiils luis rfsulli'd fixim the use of excessive and
in>dir,vUHl I'oiv.-.
I' /' '■■ '■'■("'/.— Kraiii injurii's, and esi>ecialty rupture of
i-.'rt'val \i"/.-i I'v i'ivu]'ns.-iioi!. aro not iul're<|ueut. Permanent
\:\r'.::.>\ ,iM.l p; > -'.ral iirirnii: ii's and even death sometimes result
l';v'i .■^■^\",i'.: sivic]'-; :f.!iv,vy. T<'t[ii>oniry )iaralysis of the facial
ti.'VM - '■.■■■■■.■.■.^-.\:'-y o.v,r--i nu,'l:.'iiih>"s paralysis may result from
■.\\ i'"i .■ ,i:' -:■■■■! ^ :■;:■;■•■!:. v\. rr'.-Liik-i that enter into the brachial
■,v,\ > 1 , . ..■ - ■,,,!>• (/./ii'trj/ IS a danger-
■ ■ ■ '•. -: ■ : " ' ii' liiijh appliealions.
Prep,-»raton- Measures for Application of Forceps. — The p*-
FORCEPS 391
the head and the wall of the birth-canal, following both the pelvic
and the cranial curves, hugging the head. After the blade has
entered the passages the handle usually may best be held in
the full hand.' No force must be used. The right blade is in-
troduced in similar manner, the left hand serving as a guide.
The blades are then adjusted in the best possible grasp as
nearly over the transverse diameter of the head as possible. The
blade is pushed sidewise into position by the use of one or two
fingers against the posterior edge of either rim of the fenestra.
In high applications the handles should be sunk as far backward
as the perineum will permit. If the arms do not lock readily the
blades should be readjusted till they do. The locking must never
be forced. The operator should guard against pinching the skin
or hair of the vulva in the lock of the instrument. Before making
traction a reexamination should be made to see that the blades are
correctly applied.
Extraction. — The handles are held liglitly near the lock, with
care to avoid compression of the head.
The traction should be intermittent — a pull and a pause. The
pull should coincide with a pain, if possible, and should last one
minute. Each traction should be reinforced with expressio fcjetus,
applied by an assistant. In the intervals of traction the instru-
ment should be unlocked to relieve pressure on the head and allow
the head to mould.
Guard against Slipping, — The blades should be readjusted to
a better grasp if they begin to slip. When the head cannot be
caught primarily over the parietal eminences it may be necessary
to change the grasp as the head rotates in course of descent. The
force used must be such only as can be applied with the arms with-
out bracing the feet.
Line of Traction. — The force must act in the direction of the
birth-canal. In order to do this, at the brim, the handles are
grasped with one hand, and with the other downward pressure is
applied upon the shanks near the lock (Fig. 99). With forceps
of moderate pelvic curve, a straight pull on the handles answers
after the head reaches the pelvic floor.
Until 'the head rests on the pelvic floor,* the direction is prac-
tically a straight line parallel with the posterior surface of the
symphysis pubis. Then the line of traction turns almost directly
392
OIJSTKTRIC SrRUKET
forward. The handles are swept upward until the anterior edges
of the blades hug the ischiopubic rami as closely as possible with-
out crushing the intervening soft parts.
Wheu there is doubt as to the tine of traction, the operator
should let go the handles at frequent intervals; the direction in
which they point will be that in which the pull should be applied.
Vm. U'J.— The \)i
SVMES ITS Ull
Force. — Tile foi'ce i'e(|uired \'aries from ten to tifty pounds.
Time is an iiuportHUt element in a safe forceps extraction. It is
a familiar prineiple of mechanics that the resistance of a moving
body increaNea as tlie s(|uare of the rate of motion. This is not
altogether inapjilicalile in the I'dreeps operation. At least half
an hour shouhl !"■ lak<-i] i'nr ;i hw forceps deliveiy. more' for a high
operation.
T'triinal Sluiii-. — Tlie instrument may, or may not, be remOTed
FORCEPS 393
during the passage of the head over the perineum. Beginners
may siieeeiti hetter without forceps.
A half hour or more should be given to tlie perineal stage of
delivery except when prompt extraction is denianded in the in-
terest of the child.
Removal of the Forceps. — When the blades are removed be-
fore the birth of the head the right blade ' is removed first, the
Fig. 100.— FoRCEi'9 to the Face at the Pelvic Outlet
handle being eairied well up over the opposite groin, and the soft
parts protected with two fingers placed between tlio isehio)iubic
ramus and the anterior edge of the blade: the left is then with-
drawn in correNpniiding manner.
Oocipito-posterior Positions. — Here ihe fonepN operation is a
dangerous and difficult one. Persistent po.sterior positions of the
occiput imply iniperffct tli'xion. The beginning traction should,
therefore, be made in a somewhat forward direction, with a view
t6 increasing Hesion.
iThat on the mother
right.
3M OBSTETRIC SURGERY
For the tochiiiqiit: of rotatiou with forceps, the reader is re-
ferred to ihc cliaptiT ou oceipito- posterior positions. 2 '' ^
Face Presentation. — In mentoposterior positions, as a rule, the
use of forceps is not permissible. la arrested anterior positions
of the face the traction should be directed forward to carry the
chin under the pubic arch (Fig. 100},
Breech Presentation. — Here the blades are applied over the
trochanters, or one over tiie posterior surface of one thigh, the
other over the opposite ilium and the sacrum. Application over
the iliac crests is unsafe, owing to the danger of injuring the
child's abdomen by the pressure of the blades, and even of aerioiu
injury to the bones.
AXIS-TRACTION FORCEPS
The Instrument.— The axis-traction forceps is a plain forceps
with the a<k)ition of traction rods, one attached to the heel of each
Axi»-Traction Forceps (Tiemann).
blade by a movable joint. The lower ends of the traction rods are
bent backward and attached by a universal joint to a cross-bar,
which Serves as a traction handle (Fig. 101 ) . By this coustructioa
the pull is directly in line with the axis of the blades, and, there-
fore, witli the axis of the birth-canal.
Advantaj^es. — It reduces the traction force to a minimum by
applying it in the line of descent, and hence to the best mechan-
ical advantage. It permits the normal movements of flexion and
rotation as the head descends.
VERSION 395
Position of Patient. — If the patient lies on a table, the position
is dorsal recumbent; on a low bed, the lateroprone is better.
Application. — The blades are adjusted to light pressure and
may be held with the fixation screw. The latter is seldom neces-
sary.
Traction. — The pull is applied at the traction bar. The
handles of the forceps serve to indicate the line of traction, which
is regulated by keeping the traction rods nearly parallel with the
forceps handles. The traction force should seldom, if ever, ex-
ceed fifty pounds. It is sometimes advisable in high operations
to protect the pelvic floor during traction with a Sims speculum
or other perineal retractor. The extraction is best conducted by
using the tractors throughout the delivery.
Choice of Instrument. — The obstetrician will best depend
solely on one forceps, and that the axis-traction forceps. This
answers all purposes for forceps operations.
VERSION
Version, or turning, consists in partial or complete inversion
of the long axis of the fetal ovoid by manual intervention, sub-
stituting the cephalic or pelvic pole for a less favorable presenta-
tion.
Cephalic version causes the head to present.
Fodalic version causes the feet to present.
Tlie term pelvic version applies when any of the elements of
the pelvic pole of the fetus is substituted for some other present-
ing part. In its restricted sense it refers to a version which causes
the breech to present, an operation which is seldom, or never,
called for.
Indications. — The indications for (a) cephalic version are:
breech presentation, if the conditions are favorable (external
method before labor), and shoulder presentation.
The indications for (b) podalic version are: flattening of the
pelvis not below 9.5 cm. (3% inches), c. v.; and equivalent con-
traction of otiier forms {version should never he considered as an
elective procedure in contracted pelvis' ^tt rather an emergency
procedure; certain cases of placenta pnvvia; prolapsed funis
not otherwise manageable; certain face cases before engagement;
396 OBHTKTRIC SURGERY
irreducible ocetpito-posterior jJoaitioDs before engagement; Most
complex presentations; shouldei" preBeutations when cephalic ver-
siou is impossible; certain emergencies demanding rapid delivpff.
when the licail is not ingnged. Tlie dead child may eeiicranyTSf j
delivered by jiodnlic version in contraction to 7.5 em. (3 inchea)^ 1
c. v., though iierforation is preferable.
Contraindications, — The contraindications to version are firm
ctigagi in< III of llir hniil: iiiifUfatit) passoyrs; high poxition of
fj>e~retrnrli"ii riiiij: pirsislriil rinilriivtitin of iiif uUru^f iSpcdaUg
in drii'Tdbiirs. lutnrriiil viTsinn should ho niiderlaken only after-.
the 08 is fidly diUitw dilafahle. The alJSt-nce'oF J
liquor aninii. wbih- noi tion. greatly cmhftrr.iaiel i
the a|)fi-a1iim. I
Dangers of Versii fc — In external and in \
bipolar version the di insigiuEtant. "Riipture of
the uterus has occur a.
In inlerunl vcrsio. )f uterine rupture and in-
ei'casi'd risk from sepsi* tion followin£_ vf reion in-
creases (he danger of lac _ j of shock.
To ihi' r/i/W.— The dangers vu L.ie child iiijulernal version are
|i08sible fraclure of the boucH. eompresBioii o^The spine, and the
iisumI risks nf ordinary breech-birth.
Operation.— .Vttjii essential is an exact knowledgn of the
iiipiii'ilij iif Ihr pelvis, flie size of the fetal head, an3 Jh'epresenta-
Hull iDiil ptisiliriii of Ihi filiis. A tbomugh exjimiuatiou should W
made iifti-r Hie pati-'nl is nuestlieliKed. For internal version the
cervix must he fully dilated or easily dilatable. If immediate
lieliviry is inti'odi'd, llie vulvovaginal orihce must be thoroughly
ililiited and the usuiil preparations for a breech extraction should
be made. Thi' opi'ralioii is best conducted on a table. Two assist-
ants besides Hie aiii'stbctist sjiould be had if i
A. KXTfORNAL VERSION
ICxtii'iial v.Tsidu is }i)ii>licalili', as a rule, only before labor or
Just al'h'r ihr paius nvr rsliiblislifil. It is permissible when it can
Method.— Witb llie luinds placed ujion the abdomen, one over
eacJL IVlal jinle. the jioles are pushed in opposite directions, the
cad toward the occiput and the bi-eech tutcard the feet. The'
laiii pill lit ion is practiced between the pains. During the pains
le fetns is lielcl to prevent reversion to the former presentation.
[o. 102. — Uii'uLAR Vkksiu.s'. The hand is placed m the vagina, aud the
fingers arc passed through the cervix, displacing the head in the
direction of the occiput
inally. after the version is complete, a binder and lateral eom-
ressos are applied over the abdomen to prevent recurrence of the
alpreseutation.
OBSTETRIC SURGERY
B. BIPOLAR VERSION
Advaiitag^ps of the bipolar over internal version are : A mtiii-
■iw <if fminiKitlsm anil shock, beeaiiae of tHe presence of tlie
i'IliIl' iliu brct'C'li i:
feet
■ licMil is liclil out of the exca^-ation,
iji'iiig caiTieil in the direction of the
with tlie external liand
|iior ainiiii; '(.s-.s- duii^iir of iiifirlioii. as only, two fingers enter
e iitenis. The fuel Hiat it iiiiiy he iloue early in the first stagf
lal)or is a distinct pain in plaeenta piievia. The bipolar should
preferred to the iulenial method when practicable.
VERSION 399
Method. — As a rule, anesthesia is neeessary. The bladder and
rectum must be empty. The patient is plaeed in the dorsal recum-
bent position. The manipulation is conducted between the pains.
A strict ase^is is imperative. The operator wears rubber gloves.
The hand is placed in the vagina and one or two fingers are passed
through the cervix, and the other hand is placed over the opposite
fetal pole externally. With the external hand, the breech is
pushed toward the side on which the feet lie (Fig. 102). With
Fig. 104. — Bipolar Version.— Displacing the shoulder a
the internal hand the head is tossed out of the excavation into the
iliac fossa toward which the occiput points (Fig. 103) ; the truuk
is pushed along in the same direction, inch by inch, till a knee
presents. The knee is drawn down and the foot extractetl (Fig.
105). The other foot also may be broiielit down if easily acces-
sible. The labor is henceforth to be conducted as in spontaneous
breech cases. The operator should cease manipulation during
uterine contractions.
A bipolar manipulation is applicable in cephalic version also.
C. INTERNAL VEHSION
Method. — The patient is placed in the lithotomy position
under an anesthetic. lu difficult cases the knee-chest, lateroprone,
400
OBSTETRIC SURGERY
or tin; Truinlfleiiburg poshion may Ix' utilized. The cervix and
vulvnvaginal orifice should be completely dilated.
The clothing of the ojierator is cbvcreil with a sterile rubber
apron ami gown. The paHsaRes, tlicir approachi-s. ami Ihe opera-
tor's liamlH must he surgically t-leau. The operator should wear
rubhiT gloves with gamitlcts.
One hand is pa.ssnd into the uterus over the abdoir
child, palmar surface toward the child. Either foot
OBSTETRIC SURGERY OF THE ABDOMEN 401
are seized and tl^e fetal ovoid is inverted by traction. The other
hand of the operator may be used externally to steady the fundus
or to assist the rotation of the child by pushing up the cephalic
pole. If a hand is within reach, it is snared and held down suffi-
ciently to prevent extension. A prolapsed arm should be pushed
above the brim. The operator relaxes the hand and desists from
manipulation during the pains. To prevent cramping of the hand
the manipulations should be carried out with the least possible
muscular effort.
The completion of the birth is managed as in ordinary breech
extraction.
OBSTETBIC SUBGEBY OF THE ABDOMEN
CESAREAN SECTION: CELIOHYSTEROTOMY
Definition. — Cesarean section is an operation for extraction of
the child by section through the abdominal and the uterine walls.
Historical Note. — This operation antedates the Christian era.
The earlier Cesarean sections, however, were postmortem opera-
tions, done a few minutes after the death of the mother to save
the child. The earliest Cesarean section upon the living subject,
of which we have any knowledge, was performed in the year 1500.
Possibilities of the Modem Operation. — Timely operations
under the modern (Sanger) method and in favorable conditions
should save not less than 95 to 98 per cent, of the mothers, and
the chances for the children should be as good as in spontaneous
births. The maternal mortality is much higher in operations de-
layed till the woman is exhausted by long labor and by attempts
at delivery by other means, especially if exhaustion is complicated
with sepsis. The fetal death-rate also is increased in late opera-
tions.
Indications. — With a living and viable fetus, the woman in
operable condition, the head being of average size. Cesarean sec-
tion is indicated in flattened pelves when the conjugate is below
7.5 cm. (3 inches), and in other foriris of contraction in which
there is equivalent disproportion between the head and the pelvic
space; generally, with dead fetus, when the conjugate is below
6.3 cm. (21/* inches), and in cancer of the cervix, when delivery
per vias naturales is ii!ij)racticable.
402 OBSTETRIC SURGERY
In lesser grades of obstruction, 8 to 8.5 cm., Cesarean section
may be cliosen in preference to its alternatives, pubiotomy, induced
premature labor, and even very difficult delivery by ioreepB or
version if all conditions are favorable.
When the degree of obstruction is such that the delivery of a
living child is impossible by other means, 7 cm. or less, c. v., the
indications are said to be absolute. When other operative methods
arc practicable in a given case, and the Cesarean operation is
elected, it is said to be done on the relative indication. Section
has also been suggesteil as the best method of delivery in certain
cases of eclampsia, complicated by undilated and rigid cervix, as
well as in certain cases of central placenta pnevia in primiparse.
The preferred time for operating is a few days before the
expected date of labor. Operation at an appointed time before
labor permits better preparation, the patient's condition is better,
the uterus retracts as well as in operation during labor, and
di-aiiia^e is all-sufficient or can be made so. There is a distinct
advantage in operating before rupture of the membranes, since
tluMv is hvss traumatism, the child is more certainly viable, and
extraction is easier.
In border-line cases of pelvic contraction the labor may be
permitted to ^ro on about an hour into the second stage. If the
head docs not cubage. Cesarean section nmy be performed with
little or no prejudice to the woman's chances by reason of the
delay, provided internal interference has been withheld.
Preparatory Measures.— If necessary, the patient's strength
shouhl he I'einforced hy tonics and hygienic measures. The bowels
aiv opened hy i-neniata tlie day before operating.
Tlu' hhiddei' is emptied and tlu» rectum agaia washed out
iinniediately het'oi'e tlie op(M'ation.
Instiuiiients aie stei'ilized hy boiling for ten minutes in l^^
pel' eiiit. solution of washinij: soda.
Opeiatiu" and assistaiUs earry out the usual aseptic precau-
tions ]C((uir«'il in e.Mpitid op«*i"ations.
The jilwhunen is prepai'ed as follows: A few houi^s before
(ipeiMtion. ;!i":rr a toinl l>atii and ehanp* of linen, the entire abdo-
iiK-n i-N >ci*uhlM d t'or i.'ii niinutt-s with iri'eeu soap amLhot water, a
sot'i hi'u^h ov al»soi-l>ent eotton wrappt'd in gauze Inking used as a
seruh. Tile cut in* surface is then shaveil with a sterile razor, the
OBSTETRIC SURGERY OF THE ABDOMEN 403
suds rinsed with sterile water, and the surface dried with a sterile
tow^el. The soap and fat may then be removed with ether.
When the skin has dried, the entire abdomen, from the pubes
to the ensiform, is painted with tincture of iodin, allowed to dry,
and covered with a sterile towel which is held in position with an
abdominal binder.
Immediately before the first incision the field of operation is
given a second coating of tincture of iodin, which is allowed to
dry.
In emergency cases the antisepsis must be as complete as the
limited time permits.
The temperature of the room should be 75° to 80° F.
The patient is placed in the horizontal position and the body
and extremities are wrapped warmly with clean flannels, except
the operative field. The clothing about the field of operation is
covered with dry sterile cloths or towels, and finally a laparotomy
sheet, provided with an opening to expose the field of operation,
is spread over the patient and top of table.
A sheet of Murphy's adhesive rubber dam over the entire
abdomen next the skin is a valuable precaution against infection.
The incision is made through it.
Assistants. — The first assistant stands on the left of the pa-
tient, opposite the operator. Another gives the anesthetic; a third
stands opposite the operator and holds the uterus firmly against
the abdominal incision ; while a fourth assistant stands ready with
two Keith clamps to clamp and cut the cord and to resuscitate the
child.
Instruments. — The instruments needed are: scalpel; straight
scissors; two thumb-forceps; six to twelve hemostat ic- forceps ;
needle-holder and needles; a long catch-forceps for holding
sponge compresses; a large, thin- walled rubber tube, 1.25 meters
(about four feet) long, as a constrictor for the neck of the uterus
(this is seldom, if ever, necessary) ; a steam sterilizer for steriliz-
ing cheesecloths, towels, etc. ; twelve No. 2 chromated catgut
sutures for the deep uterine suture; a long No. 1 plain catgut
suture for the superficial uterine suture; a plain, continuous 0
catgut suture for suture of the i)arietal i)eritoneum ; twelve No. 2
catgut sutures for closing the fascia, or a single continuous catgut,
J8 inches lon^; twelve silkworm-gut sutures, etc.
404 OBSTETRIC SURGERY ^^^
Summary of the Conditions of Suocoaa. — The conditions of
success ure: elective opiTutiou; aseptic teelmiqtie; deep uterine
sutures, tliree to the inch; superficial or half deep sutures; main-
tenance of the natural temperature of the abdominal contents;
the least possible hanilling of peritoneal surfaces; hemostasia;
operation coiriplutt'Ll witiiiit thirty to forty minutes.
Steps of the Operation. — (1) ^ledian incision of the abdom-
inal wail ;
(2) Protection of the abdominal incision from soiling with
moist gauze pads, while an assistant, making upward lateral pres-
sure on the abdomen, holds the uterus firmly against the abdom-
inal wound ;
(3) Sledian incision of the uterus;
(4) Extraction of the child and placenta;
(5) Closure of the wounds and application of the abdominal
dressing.
Technique of ^e Operation. — Fluid extract of er^^, m xx,
is injected into tiie tliigh muscles just as the anesthesia is begun.
The operator assures himself that there is no loop of intestin?^"
between the uterus and abdominal wall, beneath the field of in-
cision. Should a coil of intestine be found there, it is pushed
above the fundus.
An assistant holds the uterus in central position. The skin
incision extends one-third above and two-thirds below the level
of the umbilicus. It is best made tlirough the right rectus muscle.
The external layer of the veetuti sheath is diviileil, the muscular
bunilles separated with handle of scalpel and the fingers, and the
deep layer of the sheath and the peritoneum divided after lifting
them with tis.sue foree|)s. Bleeding vessels are controlled by
gauze sponge pressure, or held by catch-foiceps before opening
the peritoneiun.
A short longit lulinal median incision is made in the uterine
wall hegiunhig at the fundus {Fig. IW), avoiding the membranes
If still unbroken. This is extemleil downward with fingers, scis-
sors, or scalpel to a total length of about six inches.
The hand is thrust thruugli the membranes and the child is
extractetl by the head or the feet, wliif-hevor is most accessible.
In case of aiitei'ior iiiiiilaiLliition nf tlir jilacenta, usually tt?
OBSTETRIC Sl'RGERY OF THE ABDOMEN 405
The cord is clamped at two points with catch- forceps, cut be-
ween them, and the child is passed to an assistant.
The uterine incision may be made wholly at the fundus in the
to. 106.— Cesarean Sectios, The uterus
abduiiiinal incision, while a short median
uterus wall
firmly held against the
made in the
agittal plane (Miiller) or transve
i'allopiau tubes (Frit«ch), but the
dvantage.
■scly, extending between the
le incisions offer no material
406 OBSTETRIC SURGERY
The uterus slips out of the abdomen as the child is extracted,
and the intestines are kept back with hot sterilized towels placed
over the upper part of the incision. The coverings help also to
protect the peritoneum from soiling. The uterus is wrapped in
FiQ. 107. — Cesarean Section. Enlarging the uterine incision
hot moist cloths. As a rule, it is better not to wholly eventrate
the uterus.
The placenta, if not sirantaneously separated, may be peeled
off by grasping it with one hand like a sponge. If the cervix is
not sufficiently open for drainage, a large rubber tube or gauze
strip is passed down through it and withdrawn from belQW,
OBSTETRIC SUBQEBY OP THE ABDOMEN 407
Irrigating or mopping the uterine cavity is unnecessary. Asep-
Gis is promoted by leaving it as nearly as possible untouched.
The peritoneum is sponged dry with the least possible friction
or handling.
Fig. 108. — Cesarean Section. Introduction of the deep sutures, closing
the musculur coat of the uterus. (Author's method)
408
OBSTETRIC SURGERY
The uterine wound is closed with deep No. 2 chromated eatgul
sutures at intervals of 1 cm. (about '/^ inch). They are griveD a
wide sweep laterally through the muscular wall, falling short of
the decidua.
The peritoneal coat of the uterus i.s closed with a Xo. 1 con-
Inlermplcd superficial sutures betwet'ii
ics. (.Author's method)
iniKui-i piiiiii catgnt suture, foriiuug a welt over the deep suture
i(ie, Thr luiiiorrhage is inconsiderable and ustially ceases with
lie iiHroducTion of the tirsi sulurt^s— a hypodermic of ergotole
hoiild he givi 11 beinn lieginniiijr llie 0[i.Tation. and one of ei^tole
iiud piluitrin on the delivery of the ehild. Retraction of the uteras
f
OBSTETRIC SURGERY OP THE ABDOMEN 409
is ensured by manipulating it, if necessary, through a liot towel,
or- by faradism.
When there has been much blood loss, a quart or two of warm
St: ^rilized 0.9 per cent, salt solution may be left in the peritoneum.
The parietal peritoneum is closed with a plain running No. 0
catgut suture.
Interrupted silkworm-gut sutures are then passed at intervals
(^f 2 cm. (about % inch) through all but the peritoneum, from
v^rithin outward.
The fascia is brought together with interrupted No. 2 plain
e-^^tgut sutures, or with a continuous suture.
The silkworm-gut sutures are now tied. The abdomen is
(^ 1 caused, and the wound covered with a dressing of several thick-
nesses of dry sterile cheesecloth ; over this is placed a thick com-
^■ress of sterile absorbent cotton. The dressings are secured with
t rips of zinc oxid adhesive plaster, and all held in i)lace by a
cjultetus binder.
After-treatment. — One quart of normal salt solution is in-
^cted into the bowel before the patient leaves the table. Whiskey,
ij, and black coffee, ^iv, are added to the injection, if required.
he bed is warmed with hot-water bags. Keeping the head warm
^ wrapping in flannel helps to combat shock.
An eighth grain of morphin, or twice as much codein, may be
iven subcutaneously in case of much pain or restlessness. As a
iile, this should not be repeated and none is needed after the first
>^ight.
The bladder should be emptied every eight hours, but the
Catheter should be withheld if possible.
After the first night, if all goes well, the child is put to the
\)reast as in normal cases.
Feeding is begun with light liquid food as soon as it can be
:retained, within twelve to twenty-four hours usually.
The bowels are opened with enemata on the third day after
operation, sooner should evidence of infection appear.
The silkworm-gut sutures are removed by the fourteenth day.
After ten days usually the patient may sit up in bed while
taking her meals and for use of the bed-pan. and may leave the
bed after the fourteenth day. A firm abdominal supporter may
be worn for six weeks after operation.
410 OBSTETRIC SURGERY
Postmortem Cesarean Section. — In case of sudden death of the
mother in the last month of gestation, the child usually may be
delivered alive by abdominal section, if extracted within five
minutes after the mother's death. It is stated on good authority
that in exceptional instances the child may survive in utero for
several hours after death of the mother. The child has been
saved in only a small percentage of postmortem Cesarean sections.
Extraperitoneal Cesarean Section was suggested by Frank
in 1907 for infected cases. This procedure is done through a
transverse incision in the abdominal wall just above the sym-
physis, and the peritoneum is separated from the posterior surfaee
of the bladder and anterior face of the uterus; this is sewn to the
parietal peritoneum, exposing the lower uterine segment, through
which the incision in the uterus is made, and the child and pla-
centa delivered. The experience of American obstetricians is not
favorable to the extraperitoneal method.
PORRO OPERATION: CELIOHYSTERECTOMY
Definition. — A Cesarean section, supplemented by supra-
vaginal amputation of the uterus and removal of the tubes and
ovaries.
The operation is named after Edward Porro, of Pavia, Italy,
who was tirst to perform it. in 1876.
Tlu' mortality is substantially the same as that of the Cesarean
opt'ration.
Indications. — The indications are rayoraata of the uterus; dis-
cast' of tln' utt'i'us 01" apprntlajres requiring their removal; marke<l
purrpiTal ostt'oinalafia : probable uterine infection; uncontrollablf
luMiioirhaiTi' at'tiT (\'san»an section; vaginal atresia obstnietinjr
(Iraiiiaire.
Steps of the Operation. — (1^ Long abdominal incision, falling
one aiiil oiir-halt' inch short of the symphysis; (2^ eventration of
the uieius: :^ plariiiir the eervieal eonstrietor, a thin-walled, fin-
ircr tliitk. lul^hrr uihr the loi^p is passed over fundus, ovaries
aihl tiihis h. iiii: I'l'l up. aihi eoiistrietor left temporarily loose;
\ ]»;u kiui: h.o; !in\. Is about tiii- eervix to protect peritoneiiin
fieir. soiliiiLT \vi:h h'.eol i\:u\ li<jUor amnii : (5) incision of the
utri'.is ;M..i (\";ii:io!. '^'' :]i. rhiKl anil placenta; (6) tightening
VAGINAL CESAREAN SECTION 411
and tying of constrictor; (7) transfixion of the cervix by pass-
ing two knitting needles or hatpins through the constricting rub-
ber tube and the cervix; (8) amputation of the uterus 2 cm. (%
inch) above the constrictor; (9) ligation of the uterine arteries in
the stump or at the sides of it; (10) stitching the entire circum-
ference of the stump in the lower angle of the abdominal incision
with the free surfaces of peritoneum in contact; (11) suture of
the abdominal wound; (12) mummification of stump with per-
chlorid of iron solution; abdominal dressings as in Cesarean
section.
This operation is practically superseded hy the usual modern
method of supravaginal amputation. The technique, after the
uterus is evacuated, does not differ from that of abdominal hys-
terectomy as done for fibroids. The after-treatment, too, is the
same.
VAGINAL CESABEAN SECTION
Vaginal Cesarean section is delivery by sagittal section of the
anterior and the posterior uterine wall per vaginam. It was first
proposed by DUhrssen in 1895. The operation demands consider-
able surgical skill and, in the opinion of the writer, should be
limited to hospital practice.
fadicatjoni. — Conditions requiring prompt delivery, such asr
may be present in toxemia after the eighth week, eclampsia, acci-
dental hemorrhage, placenta praevia, threatened uterine rupture;
or conditions of the cervix causing obstruction, e. g., rigidity, ste- >
nosis, myoma, carcinoma or old cicatrices.
Technique. — An intramuscular injection of ergot may be given
shortly before operation. In primipane room is obtained by a
right lateral vagino-perineal incision. The field is exposed by
retractors. The cervix is drawn well forward with two traction
forceps, one caught in each lateral aspect of the anterior lip. The
anterior vaginal wall is incised longitudinally from a little behind
the urethra to the anterior lip of the cervix. The bladder is de-
tached from the uterus as in vaginal hysterectomy. If required,
the anterior vaginal wall may be separated from the bladder. The
bladder is held up with a suitable retractor passed beneath the
pubic arch.
Fig. 110.— VAcrSAi. Cesarean Seitiuv. Cervix drawn clown with two
traction forceps; iinlcrior lip split to vesioouteriue junctioii
Fig. 111.— Vaoinal Cesarean Sectio:j. Bladder bcinR detached from
its anterior uterine attaelintent by the finger
414
OBSTETRIC SURGERY
The anterior uterine wall is split in a sagittal direction from
the lower border of the cervix to a point above the internal os. a
distance of about 6 to 10 cm. The single anterior incision affords
sufficient bpace for the extiaction ot the child up to the eighth
month. \ poBteiioi utLnne incision also is required in full tenn
deliverii'i> Tin amniotic sac at onct protrudes. Mcmbrani'S are
riuitable
ruptured am! cliild extraeti'd. ^rl'U^■l■ally by version, or, when the
head is tixcd. or ciiii \w engaged by forwps.
The placenta is removed and Ibc uterus finnly packed with
gauze until the sutures are placc-d.
The uli'riue incisions are closed witli .sutures. The vaginal and
Fio. 113.— Vaginal Cebabban Section. Suture of the uterine incision
by interrupted sutures
416 OBSTETRIC SURGERY
perineal incisions are sutured, a di-ain of gauze or rubber t
being left between cervix and bladder. The drain is removed i
24 hours.
In myoma or cavcinoiua of the uterus the operation is followed
by vaginal hysten-etomy.
In moderate pelvie contraction, Diihrssen has combined vaginal
Cesarean section with hcbotomy.
STMPHYSIOTOIfT
Historical Note.— Divisiou of tin; pubic joint for the purpoas I
of facilitating dcliviTy in narrow pelves was lirst done on the Uf- J
ing Avoniau lu Frnnit-. hy Jean Rene Sigault, in 1777. McetingJ
partial acceptance for a time, tlie operation, after half a cetitury,
had become practically obsolete. Revived by Morisani, of \a])l<%
Italy, in ISGii. it was taken up in the country of its birth by Pinard
early in lSil2. His success and advocacy led to its immediate
adojition thi-ougliout the world.
Results.— The material mortality differs little from that of
OesHireau si'ction uniier e^Hally favorable conditio^ ~ The fetal
ileathtiite at the In-st is somewhat greater. The mortality for
iMith patients, lunvcver, has Ixvu increased by operations performed
on pelves tiH> small. Restoration of the SA'mphysis, as a rale, is
complete. I'lis-sibte i.-v»uplications of the operation are laeeratioD
of the anterior soft parts, ineliiding the urethra and bladder, and
hemorrliiiire. tunre rarely suppuratiou of the ^mphysis and injury
Space Gained.— Tlie luaximum pubic separation permissible
i-i 7 .■.;; -■' : uu lie,< ; « iiii an interpnbic o[>eHing of that extent.
t'-,e i'.':;;-,:i.-,;:a \.!;i trains a little more thau 1.3 cm. (^-j inch).
Tl e :v;i^.-v.>e a: :!:e brim irains one and a half, the oblique about
:"■.■! a- ••■ iv':. a* :ie ■.eu.'.israte dites. The parietal boss projects
i:::o :: , ;■ ' ■' . '.v -iiM ]■ ;.:.xi this is eriuivalent to a slight addi-
Indi canons >■.■,:•.". \\;:" ::; a :;'\v yosrs, the indications were
,;^ :, :-A- > , ■■..- : :■ i; o: •■e tvSis not below 7 cm. (2%
::■.■' - -■■"■, •.:,.■.■■■; ::. :re ei^njogaie. or eqaiva-
■,;■■.■,: .-.■.•.r-.v.v.:-..;: :-\--.--. o: ■ r vM-.-.^s ; irrevfueible oceipito-poBteriM
SYMPHYSIOTOIMY 417
positions; firmly impacted mentoposterior face cases; irreducible
brow presentation ; and dystocia due to funnel pelvis.
At the present day, symphysiotomy is seldom chosen in prefer-
ence to Cesarean section. Its chief disadvantages are the narrow-
ness of lis anatomic field and the consequent difficulty in selecting
cases which fall strictly within its limits, the fact that it does not
effect delivery but only prepares the w^ay for it, and that the after-
care is exacting and convalescence prolonged and tedious. The
fetal mortality, too, is higher than in the Cesarean operation.
Rarely division of the pubic joint may be better than Cesarean
section, when the woman is too much exhausted for transperitoneal
delivery, or the head is impacted deep in the pelvis.
The operation is contraindicated in ankylosis of one or both
sacroiliac joints. The fetus must be living and viable. With a
dead or nonviable child craniotomy should be substituted.
Method of Operating. — The patient lies in the dorsal position
with the thighs strongly fiexed and the knees held apart, under
an anesthetic. The antiseptic preparation of the abdomen is the
same as for celiotomy. The vulva is prepared wuth the same care
as the abdomen.
The cervix nuisl be fully dilated. A metallic catheter is passed
into the bladder by an assistant and pressed backward and to one
side. This helps to protect the urethra and vesical neck from
injury, and, at the same time, keeps the bladder empty. Either
the open or the subcutaneous operation may be chosen. The ad-
vantage of the former is that the steps are conducted under direct
inspection; it is claimed for the latter that the wound is less
exposed to infection by the lochia. The open method is recom-
mended.
In the open method the division of the joint is conducted as
follows: The incision exposes the entire length of the joint, ex-
tends an inch above it, and opens the space between the recti
muscles. The clitoris is drawn down with a sharp hook caught
just above it, its suspensory ligament cut, and the bony margin
of the pubic arch laid bare by detaching from it the triangular
ligament with a few strokes of the scalpel.
The retropubic structures are pushed back with the finger
passed down behind the symphysis, a broad, strongly curved
director (Farabeuf 's) is passed immediately behind the joint from
43»- OBSTETRIC SXIRGERY
below upward or from above downward. The clitoris anil other
vascular structures at the lower end of the symphysis are thus
held back during the division of the joint. This prevents much
hemorrhage, which is otherwise sometimes a trouble-some compli-
cation.
The joint is located hy finding the notch at the top between the
pubic bones or by forcibly flexing and extending one lower ex-
tremity while the other is held stationary. With a strong, slightly
eiirvcd, blunt-pointed biNtoiiry, the symphysis is then divided from
behind forward or from before backward.
The bones are cautiously separateil and held apart to the ex-
tent of 7 cm. (2% inches), the lateral halves of the pelvis being
firmly supported by the assistants to prevent further separation
as the head comes down.
In the subcutaneous method the incision is from 2.5 to 7.5 cm.
(1 to 3 inches) in length, according to the thickness of the ab-
dominal wall, and it terminates below at the top of the symphj'siB.
The rectns muscles are separateti, the finger passed behind the
symphysis, and the joint divided by the bistoury from behind
forward and from above downward, the finger serving as a guard
and a guide.
Venous hemorrhage, which is sometimes profuse, is controlled
by pressure by packing the wound, and, if necessary, the vagina,
with sterilized gauze or by hemostatic suture. The short incision
may be extendLnl, should it become necessary for the control of
hemorrhage or by reason of other complications.
\Vheii. owing to bony ankylosis or to the sinuous course of the
syniiihysis. division with tiie knife is impossible, the joint may be
opened with a metacarpal or chain saw.
The child is extracted with the forceps if it is not promptly
expelled by the natural forces. Bilateral episiotomy may be done,
if necessary, to lU'eveut laceration of the anterior soft parts at the
vaginal outlet. Great care must be used during delivery lest the
anterior vagina! wall be torn through.
After delivery of tlif ciiild and placenta, the bones are brought
together firmly, the iireliira and liie vesical neck being meantime
held backward to avoid pinching between the bones.
The soft parts are closed wilh silkworm-gut sutures, which, in
the open method of operating, should include the fibrous StiVSc
HEBOTOMY. PUBIOTOMY 419
tures in front of the joint. Two or three strands of silkworm-gut
may be carried down from behind the joint as a drain. This is
removed in twenty- four hours. Zweifel sutures the fibrous struc-
tures with catgut and leaves the superficial wound open for 8 or
10 days, packing it w^ith gauze.
The pelvis is immobilized by means of two or three strips of
rubber adhesive plaster, reaching obliquely from one side of the
pelvis to the other, above the w^ound, and over these a firm binder.
Moreover, during convalescence, the patient lies on the back, in a
hammock-bed (Ayers), or on two firm cushions (sand bags), ex-
tending from the axillie below the great trochanters, which sup-
port the lateral halves of the body and tlie pelvis. A canvas
binder provided with straps and buckles for fastening makes a
firm and easily adjustable support.
An ounce or two of boric acid may be left in the vagina. Pubi-
otomy hcui practically supplanted symphysiotomy in this country.
After-treatment. — For three or four weeks the patient should
lie on the back with the limbs outstretclied. The urine may need
to be drawn with a catheter for the first two or three days after
operation. A trap door in the hammock-bed provides for bowel
evacuations and for urination. Surfaces soiled by the dejections
must be cleansed promptly.
The binder is changed as often as soiled. The sutures are re-
moved by the eighth or tenth day. The patient is kept in bed for
four weeks. The binder remains six weeks.
HEBOTOMY. PUBIOTOMY
This was first suggested by Gigli in 1893. The pubic bone is
divided vertically just to one side of the symphysis. The side
chosen is that which the occiput confronts. Pubiotomy actually
comes in competition w^ith Cesarean section in border line cases,
when the test of labor has shown that the head cannot engage.
Indications are the same as for symphysiotomy.
Results. — The number of recorded operations to date is over
800, with a mortality of a little over 2 per cent. Williams reports
38 consecutive pubiotomies without a maternal death. The opera-
tion should be performed solely in the interests of the child.
OBSTIOTEIC SURGERY
Bladder injuriea ami vaginal laceration are possible comptti
Final results gentTall.v havf been satisfactory. The disad'
udvantagdTS
I'll.. 114. -Line ni in Hebotdsiy
of the ojH'ratiou iiiv sulistaiilial., same as those of syraphysi-
otoniy.
Technique.— Till' palii-nt is l.n.ui-lil t(i lln? edge of the table
I'lBic Section
and till- li'gs an' lu'hl liy assistiints. The field of operation is pre-
pari'ii in the usual manner. The bone may be exposed by the open
method by a vertical incision extending from just within the pubic
IIEBOTO.MY. PUBIOTOMY 421
I to a point immediately external to the labium majus. or the
>n may be made by the subcutaneous operation of Dvderlein,
h is now gencralbj adopted. A horizontal incision is made
the pubie spine inward, long enough to admit the finger,
retropubic soft parts and those about the lower margin of the
are then pushed back with the finger. With a large atroug
Fio. lllj. — Passing the Duderlein Neeule
d needle (DJiderleiii needle) or other suitable carrier, passed
to the bone, a thread or narrow tape is carried behind the
bis, emerging at a point just without the labium majus,
Gigli saw is drawu into place and the bone sawed through,
freat separation of the bones is prevented as in symphyai-
'. The child is delivered with forceps. Bilateral episiotomy
onserve the integrity of the structure in the anterior or pubic
!nt. The bones are brought together, as after median see-
422 OBSTETRIC SUBGBRY
tion, and the wound in the soft parts closed with one or two
sutures,
Alter-treatment — ^The wound is dressed with sterile game
and a long strip of Zinc Oxid adhesive plaster 6-8 inches wide, it
passed around the body to make firm and equal pressure on the
sides of tbo pelvis and upper part of the thighs. The patient it
allowni .
hy t.(iiiy
wi'eks. I'nioii of the bone takes place
I'uhiotomy permanently enlarges the
EMBBT0T0U7
^I'lii'Tiil toim for all obstetric operations
ililiviiy ilirongii the natural passages by
CRANIOTOMY 423
Indications are hydrocephalus too large for safe extraction
without perforating, and not manageable by aspiration of the
cranial cavity; obstructed labor with a dead or nonviable fetus
or a fetal monstrosity, conjugata vera exceeding 2^/4 inches; im-
pacted shoulder, face presentation, and other complications, rup-
tured uterus, ablatio placentae, etc., if the child is dead.
It is very rarely that embryotomy will be justifiable on the
living and viable child. The sacrificial operation must be con-
sidered as an alternative of Cesarean section or pubiotomy when
the condition of the mother is unfavorable for the latter opera-
tions, and especially if she elects the former with a full knowledge
of the facts.
CRANIOTOMY
Definition. — An operation for the comminution and removal
of all, or a portion, of the cranial bones to facilitate delivery.
Steps. — 1. Perforation, — The field of operation should be
cleansed and disinfected and the woman placed on the table in the
obstetric position and under an anesthetic. All but the operation
field is covered with an aseptic sheet. The instrument may be a
Smellie's scissors, Naegele's perforator, or, preferably, the
trephine. In emergency, a long, sharp-pointed surgical scissors
will serve the purpose. The bladder and rectum should be empty.
An assistant steadies the head by grasping it and holding it firmly
against the brim with the hands placed over the abdomen.
The point of the perforator is pressed against the head, per-
pendicularly to the surface of contact, just behind the pubic bones,
the fingers of one hand serving as a guide. Except when the
trephine is used, the puncture is best made through a suture or
fontanelle.
The point is fixed in the tissues by a screwlike motion, and the
perforation is then effected by a similar motion.
The blades are separated in different directions to enlarge the
opening.
The most approved method of perforating is with the trephine.
It removes a button of bone, leaving a permanent opening through
which the cranial contents may readily be evacuated.
The after-coming head may be perforated through a skin
421
OBSTETRIC SURGERY
\
iiifisioH made at the base of the neck posteriorly; the perforator
is passt'd subciitaneoiisly.
The brain is brokcu up with the perforator and washed out
with II strt'atii of sterilized water forcibly injected with a David-
son K,vriiige.
2, ('omiiiiiiiition. — With the craniotomy forceps passed within
Ihi.' acalii, the cranial bones are seized, one by one. dislodged by
rotating the forceps about ita long
-T i»- ^ axis and then removed. In mod-
\ '\ \ crate obstruction the head may be
a i 1 crushed and extracted with i
I i\ C- * J eephalotribe.
■Ifc'.". ■« 'J In the higher grades of pelvic
'.lUi J ^gy contraction the cranial base, as well
^1 ^im ^^ *^^ vault, may be broken up.
\ H -S^V^ Tarnier's basiotribe was devised for
\T /'.^w^^^ ^'''^ purpose. Between its blades tg
/yia^HHH^ ^ screw perforator, which is made
to perforate the head, while the
blades crush it. With the resources
of modern obstetric surgerj\ basiol-
rip,sy is seldom justitiaWe.
;l. h'xlractioit is effected with
tho cranioclnst. or, when space per-
mits, witli ilie eephalotribe. guard-
iuir (-iiretully iigaiust laceration of
tile passages by projecting spiciiln
of Uirie. 1 1 the cranioclast is useil.
I'ue blade is passtil within and oue
wiihout the eraiiial cavity. In ex-
treme iianvwinsr the cranial ha*' is
besT d'Iivt-re,I erlg^wise by drawing
chin.
CLEIDOTOMT
■■-L'.v:..-'^, whieh dimiiiishes
\--:i 't'.:- shoulders olksiniet
::: ;i;e middle thinl with
EVISCERATION 425
CEPHALOTRIPSY
Cephalotripsy is an operation for reducing the size of the head
by crushing the cranial vault. In moderate degrees of contraction
a good cephalotribe is Tarnier^s or Lusk*s.
The metliod of application does not differ from that of the
obstetric forceps. An assistant crowds the head firmly into the
excavation if it is not already engaged. The head is perforated,
and the cephalotribe is applied with care to secure a good grasp.
Fig. 119. — Lusk's Cephalotribe
The skull is then slow^ly crushed by turning a powerful screw
at the handles. The head is brought down with the cephalotribe,
used as a tractor. Since the cranial vault is expanded in one
direction as it is crushed in the opposite, care must be used to
guard against laceration of the passages by projecting spicula of
bone. The elongated diameter of the head must be kept in the
long diameter of the pelvis.
Cephalotripsy is practicable only in moderate contraction.
EVISCERATION
This term applies to all operations for reducing the size of the
trunk by removal of its viscera. The operation is limited almost
wholly to cases of impacted shoulder in w^hich decapitation would
be difficult or impossible.
Perforation of the trunk may be done with a craniotomy per-
forator, or through the bony coverings of the chest w^ith the tre-
phine or heavy scissors. The viscera are then broken up wuth the
perforator and removed with craniotomy forceps, with stout
426 OBSTETRIC SURGERY
dressing-forceps, or with the fingers. The bony walls, if neee*
sary, may be cut away piecemeal with stroug scissors.
Sometimes the trunk is divided into sections with a chain saw,
or stout, blunt scissors, and delivered piecemeal. The head is then
crushed and extracted with the cephalotribe.
DECAPITATION
Definition. — Separation within the uterus of the fetal I
from its trunk.
Methods.—!. Blunt Hook and Scissor*.— While i
draws the neck firmly down with a blunt hook or a atroug tape
jiassed around the neck, the ueck is gradually severed with blunt
jKiiuted scissors, guarded by two fingers of the other hand.
2. Braim's hook is a convenient and safe instrument for de-
capitation. The hook is passed flatwise on the hand as a guide-
It is carried up between the head and the pubic bones till it can
be hooked over the neck. The neck is then firmly engaged in the
hook by traction. By a to-and-fro movement of the handle the
neck is readily severed.
;). Ecrastiir.~A tape is passed around the neck as follows:
It is first well oileil and knotted at one end ; the knot is pushed
up over one side of the neck with the fingers of one hand, the
fingers of the other hand catching it and pulling it down on the
other side. Another melho«l of earrjing the tape into place is
with an English bougie properly curved and armed with a stylet.
The chain of the eeraseur Ls attached to the tape and drawn into
place. The net-k is then cut through by tightening the chain.
-V wire eeraseur armeil with piano-wire or common picture-
wire may be usiil for the purpose, or a chain saw may be snbsti-
tuti'il for the eeraseur.
Extraction.— 'After decapitation the head is pushed up ai>d
the trunk delivered by traction on the arm: then the head is ex-
trncteil. chin first. Two fingers of one hand are hooked in the ia-
ferior maxilla and the head iTowdiil througii the pelvis by supra-
pubic pressure with the other baud or delivered with forceps or
cephalotribe. In a narrow pelvis it may be neeeasar>' to crash the
head before it can W delivered. Perforation may be done in flie
DECAPITATION 427
grasp of the cephalotribe and the cranial contents then be broken
up and removed in the usual manner. Care must be taken lest
the uterus be ruptured in these manipulations or the vagina be
lacerated by projecting bone fragments.
CHAPTER XVI
THE DUCTLESS GLANDS IN PREGNANCY
OENEEAL CONSIDERATIONS
The importance of the endocrines and their bearing on prop-
nancy, labor and the puerperium, have had little or no consecu-
tive study, yet, as the physical and mental development of each
individual are dependent on the action and interaction of the
ductless glands, it is apparent that these internal secretions must
play an important part in the development and life of the child-
bearing woman. Mendelism teaches us that the determiners of
the traits of the father and the mother are brought together in
the offspring: and as these are governed by the activity or in-
activity of the several internal secretions, one can readily see
that perfection or imperfection of development in the parents
will have a large bearing on the mental and physical develop-
ment of the offspring.
Before puberty the metabolism of girls is probably not very
different from that of boys, the chemical processes of both are
for the most part engaged in promoting the growth of the body,
at puberty, however, a wide differentiation occurs and further
development is due to the activity of the reproductive functions,
for the ovary dominates a woman's life during her sexual
activity, both in her physical development and mental processes.
The difference in the skeleton as instanced in the shape and con-
formation of the pelvis in the female is an evidence of the
modifying influence of the ovarian secretion on bony growth.
It is generally admitted that the hypophysis, adrenals, and
thyroid apparatus, are the principal secretions which activate
and control the calcium metabolism and bony development. The
action of the hypophysis in inhibiting prolonged -^aetion of the
thymus, inhibits the early development of the sex glands. When
their activity is postponed the skeleton takes on more of the
male attributes.
428
GENERAL CONSIDERATIONS 429
As a rule growth ceases at puberty, for with the advent of
menstruation, there is a larger excretion of calcium and other
substances which were previously required for the formation of
the skeleton, which are now no longer wanted until pregnancy or
lactation occurs.
Patients with a delayed ovarian secretion are tardy in their
sexual development. They are usually the subjects of consider-
able obesity, of large bony frame, funnel or high assimilation
pelvis with general hypoplasia of the uterus and adnexa. On
the other hand, the early ripening of the ovary seems to have
the opposite effect on the skeletal growth, with the result that
these women have more perfect sexual organs and ample pelves.
// we can know what the ductless glands ha/i^e done to an in"
dividual up to the time of puberty, we can prognosticate her develop-
ment during adolescence; for the physical and mental development
of a growing child is dependent on the activity of the hypophysis
and the thyroid. Perfect balance between these secretions is
imperative in order to produce the perfect organism.
In hypo-pituitarism, if there is a diminished function of the
posterior lobe during infancy, and before puberty, there is a fail-
ure of stimulation of the uterus and ovaries, and sexual infan-
tilism is the result : while if the hypo-pituitarism of the posterior
lobe occurs after adolescence, general distrophy is the result.
The action and interaction of these glands continue throughout
life, as is shown in the pre-menstnial nervous symptoms so often
seen in a poorly balanced endocrine system. In these same
women clinical experience shows that this disarrangement of
glandular interactivity produces a stormy menopause. A placid
climacteric denotes a well balanced interglandular relation, for
throughout the endocrine system, one gland at one time or
another assumes the work of another, provided each functions
properly, so that the transition from sexual activity to senility
should be so gradual that no internal secretion becomes suddenly
dominant.
The thymus also has a marked influence on ovarian develop-
ment, for it is supposed this gland has an inhibiting effect on the
gonads and determines the time at which sexual development is
perfected ; namely the time of puberty.
29
430 THE DUCTLESS GLANDS IN PRECNANCY
/( is, however, the thyroid which has the ividest influence on Ihf
female organs and their action in pregnancy, labor, and the puer-
perium. The tliyroid governs the ftrowth of all cells and siistains
their functional activity. It is the thyroid and parathyroid which
control ealeium metaboliam, and it is the thyroid which is a
katabolie stimulant faeilitatinp. the breaking down of exhausted
cells and governing the elimination of the waste products of
their disintegration. This gland also exercispB a protective anti-
toxic and imninnizing action defending the body, not only agaimt
the toxic produets of its own metabolism, hut against disease
producing micro- organ isms and injury by their products. These
metabolic antitoxic functions are attended by the discharge into
the lymph and blood stream of a complex secretion which eon-
tains the active principles or hormones; its antitoxic function
is hilt a part of the thyroid's major function of regulating
metabolism, for by its action in maintaining the nutrition of ail
body cells and those of other hormone producing organs, the
liver cells in particular, it regulates the production of protective
substances and maintains at a high level the defensive mechanism
of the body. This fact alone demonstrates the necessity of proper
thyroid function during pregnancy, for in no other state is the
organism so taxed, nor is it asked to adjust itself to so ranch
increasi'd waste or defend itself against the invasion of micro-
organi.sms, as in the first and last trimester of gestation and
during the pucrperium.
The thyroid regulates the oxygen intake and the carbon-
dioxid output of the body and maintains the constituents of the
blood, the red cells, the white cells, the hemoglobin and salts, at
a proper level. It also exerts its influence in regulating the body
temperature and controls the metabolism of those metallic ions
necessary for cellular activity. It influences arterial tone and i«
thus concerned in the regulation of blood pressure: it maintain
the activity of tlie sympatlietic and central nervous systems: it
eontrnls kidney excretion by its physiologic diuretic action on
the renal e]>ilheliuni. and by its action on the liver cells and
other excretoE-y orgiiiis i)f the body, and by stimulating eerUun
other hornnme lU'odncinL' organs, secures and controls their
eo-o|)eriition in n-gnlatin<r metabolic processes. If'licn propffly
fuiicliunatitig it keeps at a proper level every body function.
GENERAL CONSIDERATIONS 431
The thyroid is specifically associated in the exercise of its
function with the generative organs, the liver, the pancreas, the
adrenals, the pituitary and the thymus gland ; and besides main-
taining the nutrition of the cells of these organs and their
sympathetic nerves, through their agency controls body growth
and metabolism. Interacting with the pituitary it is thought
to influence skeletal growth. The thyroid stimulates and is
stimulated by the adrenals thus indirectly controlling the blood-
pressure and securing the supply to all parts of the body of per-
fectly oxygenated blood. The profound influence which it exer-
cises over calcium metabolism is exerted through the medium of
the gonads, thymus, pituitary, and other endocrine organs.
From the foregoing statements, it will be seen how dependent
the process of gestation is upon proper thyroid function. For
gestation increases the body waste and calls for more perfect
metabolic action on the part of all of the glandular system, con-
sequently defective thyroid function prevents the perfect
correlation and interactivity of all of the ductless glands neces-
sary to sustain the body mechanism in a perfect state.
Pregnancy is the result of the fecundation of a matured ovum
which is the product of the healthy functionating ovary. In
individuals growing normally and developing properly, the
ovaries come to maturity and develop properly if they are sus-
tained and nourished by a proper secretory relation on the part
of the thyroid, the adrenals and the hypophysis. On the other
hand a disturbance in the nutritional functions of the thyroid, the
hypophysis and adrenals, interferes with the proper development
of the female genitalia and the ovaries.
When the impregnated ovum comes into the uterus and
imbeds itself in the overgrown decidua, by the enzyme action
inherent in itself, menstruation ceases; for one function of the
true corpus luteum cells is to retard ovulation by inhibiting the
maturation and breaking through of follicles during the period
of pregnancy. The cells given off from the outer layer of an
impregnated ovum are thrown into the circulation as soon as
the ovum is imbedded. Slight as this amount must be in the
early days of pregnancy, it is sufficient through the medium of
the circulation to reach the ovary, stimulate the action of the
corpus luteum, and acting on the uterine lining to inhibit men-
432 THE DUCTLESS GLANDS IN PREGNANCY
struation. It is supposed that the trophoblast cells of the
impregnated ovum are primarily responsible for this. These
cells produce a reaction in the corpus luteum which does not
regress after the premenstrual congestion as it does ziHten preg-
nancy does not take place; but continues its growth for a period
of many months, which in turn continues its nutritional effect on
the uterus and decidua, inhibits menstruation, and aids continued
attachment of the ovum.
The nutritional action of the true corpus luteum is of far greater
importance in the first months of pregnancy than after the placenta
Ims formed, for after placentation the placental secretion is added
to the blood and plays an important part in stimulating the fur-
ther growth of the uterus. The trophoblast secretion next affects
the action of the hypophysis, and the anterior lobe begins to
hyperfunction and actually increase in size. Like changes take
place in the thyroid, adrenals, and other ductless glands which
help to provide the patient with certain protective substances.
The secretions of the trophoblast and placenta are entirely new
elements thrown into the blood, and either activate the other
glands to reaction or so over-stimulate them that this protective
resistance is overpowered. The irritating effects of the tropho-
blast and the placental secretion are ezidenced by the nausea and
vomiting of pregnancy. The placental substance apparently irri-
tates the central centres and the posterior lobe of the pituitary
body, disturbing the functions of the gastric mucosa, the pylorus
and the liver, and temporarily inhibits the production of the
protective endocrine secretions which normally in the well
balanced organism overcome the disturbances in metabolism con-
sequent upon the appearance of these irritants in the blood.
The secretion of the corpus luteum of pregnancy which continues
in varying degree throughout gestation, is generally considered
as the chief reaction to the irritations produced in the blood, the
ductless glands, and the uterus by this placental hormone. It is on
this theorj' that corpus luteum extract has been so extensively
used for the control of the nausea and vomiting of pregnancy
when this is employed ; the preparation used should be made from
the corpus luteum of pregnant animals and given for a relatively
long period. Usually after the placenta is fully developed and
has assumed the nourishment of the ovum, the so-called physio-
GENERAL CONSIDERATIONS 433
logical nausea ceases; this, however, is not the case if the pro-
tective substances produced by the ovary, the hypophysis, the
liver and the thyroid are insufficient to maintain the proper body
metabolism, for it is the thyroid which maintains the balance
between the internal secretions during pregnancy and activates
the other ductless glands to increased function. This explains
the early toxemia of pregnancy with its epigastric pain, acid
eructations, and the transient albuminuria in the presence of
hypo-thyroidism ; for in the absence of the inhibiting action of
the thyroid, the placental secretion over-stimulates the posterior
pituitary body which becomes the basic endocrine factor in the
toxemia of the early months. All authorities admit the stimu-
lation of the pituitary body during pregnancy, and in many cases
an actual increase in growth takes place ; this is specially evident
where the thyroid hypo-functions or is diseased. This stimula-
tion is ezndenccd clinically by acromegalic hyperplasia winch is
shoum in etiiargement of the bones of the face and extremities of
some pregnant women. Transient hyperfunction of the posterior
lobe of the hypophysis may also account for the intermittent
glycosuria so often noted during the routine examination of the
urine in pregnant women. Many times, however, lactose and not
glucose is the substance which gives the sugar reaction ; but this
is usually a condition of the later months and may be due to the
stimulation of the mammary gland. This gland is always stimu-
lated by pregnancy. Experimentally the function of the mam-
mary gland has been increased by the injections of corpus luteum,
placental extract, and pituitary liquid; that is, a hyperemia has
been produced, but not until after labor has occurred and the
stimulating action of the ovary and hypophysis is no longer in-
hibited by the placenta and its secretion does the mammary gland
secrete milk. This does not, however, explain the many reported
cases of milk secretion in males and in non-pregnant women pro-
duced by prolonged suckling. There is no question in the writer's
experience that the routine use of the endocrine glands materially
aids in increasing the mammary secretion.
One fact must be constantly borne in mind, that the ovum
and the placenta are parasites which depend for their nourish-
ment on the resources of the mother, and in turn eliminate the
waste fetal products through the emunctories of the mother ; this
434 THE DUCTLESS GLANDS IN PREGNANCY
is an ever increasing load as the pregnancy advances. This tax
on the basal nietaboliani is met by a compensatorj' hypertrophy
of the thyroid, heart, kidneys, and if these organs are function-
ing properly by an increased liver combustion: it is apparent
therefore, that dysfunction in any of these organs from disease,
or over- or under- stimulation, will disturb the harmonious inter-
action of the others and result in a toxic state. This may be
transient or permanent, when the latter there is a lasting path-
ology which is more or less dependent on the cause of the
dysfunction.
The Parathyroids. — No general considerations of the ductless
glands and their relation to the pregnant woman and fetal de-
velopment is complete without reference to the parathyroids.
These glands form an integral part of the thyroid apparatus, and
although differentiated to some extent in their function from that
of the thyroid, they contribute to the antitoxic function of the
thyroid apparatus and there is reason to believe that they assist
in protecting the central nervous system from the action of
certain toxic products of bacterial growth in the alimentarj'
canal. In pregnancy there is normally some hyperplasia in the
parathyroids which is important because they are also concerned
in the regulation of the calcium and uranidine metabolism ; there-
fore just in so far as the mother's thyroid and parathyroid
apparatus potentially possesses the inherent power of response t"
every demand of body metabolism, so far may we expect the child
to be born normal.
CHAPTER XVII
THE THYROID IN PREGNANCY
The thyroid grland normally increases in size and in activity
during: pregnancy. This enlargement is due to the storage of
coHoid in the vesicles — from 65 to 90 per cent, of iall pregnancies
show a concomitant hypertrophy of the thyroid ; this is probably
due to a stimulation by the substances in the blood 'derived from
the fetus and its envelope. The parathyroids also participate in
this hypertrophy.
Richardson states that in Southern Italy, that it has been the
custom for the parent to measure the daughter's neck before and
after marriage, an increase in circumference being considered an
evidence of conception.
The enlargement usually commences about the fourth month
in primipara?, and somewhat later in multiparous women. This
hypertrophy continues until the termination of pregnancy; but
after delivery in normal women, the gland commences to diminish
and quickly recedes, but seldom returns to its normal size until
late in the puerperium, and sometimes the hypertrophy continues
throughout lactation.
Clinically there seems to be a definite relation between the
thyroid function and kidney elimination ; for cases which shozv no
hypertrophy of the thyroid are generally the subjects of some degree
of hypertension with diminished urinary output and albuminuria.
In a study of 133 cases Lang found 25* in which there was no
thyroid hypertrophy. Of this number 20 had an albuminuria,
therefore, it may be argued that relative insufficiency of the thy-
♦roid during pregnancy has an influence on kidney function. The
thyroid also has some action on the mammary secretion and on
the production of milk. The continued internal administration
of the fresh gland may increase the secretion, but lactation seems
to have no influence upon the size of the thyroid.
435
486 THE THYROID IN PllEGNAiNCY
SnCPLE GOITEE COMPLICATIKG PBEGSAWCT
ITS EFFELT ON THE OFFSPRING
During prepnancy the thyroid frlnitl neftrly always inoreasta J
in size and iiKreasea in activity. This hyper-fuHcHon is f>hysiologit I
and activates the other ductless glands, and so aids in protecting -j
the individual from the toxic effects of the increased metabnlie j
processes which are conseciuont upon prppnancy. This nona^ ]
enlargement continues more or less marked throughout the puas 1
peral period, and often ren -permanent. Increase in the I
volume of the sjland occurs i 65 per cent, to 90 per cent
of all cases of prepnaney. study and observation of a
long series of prefrnant wome ler cent, showed a glandular
enlargement. Should goitre en already pri'sent prior to
conception, there is commor "rease in the volume of the
goitrous enlargement durinL icy and particularly during
delivery.
While some observers da. r the glandular hyperplasia
takes place snoncr in mnltipara, than in priinipnra, in the rspcri-
ence of others, this observation has been reversed. The increase
in volume is due to the hypertrophy and hyperplasia of the
parenchymatous elements. Colloid and cystic nodnles when
present are only slightly involved. It is presumed that this
hyperemia and hyperplasia increasing the volume of the gland
is due to the action of the placental products on the thyroid.
This glandular hyperplasia with its increased function is appar-
ently intended for the destniction of the products of auto-intoxi-
cation, and the changes in the blood serum caused by pregnancy.
The clinical value of this observation seems to show that
women who do not present any hyperplasia of the thyroid are
very apt to becnme toxic during pregnancy: develop an albumin-
uria. Jind if the hypo-fnnotion of the eland persists, finally have
eclampsia. That the latter part of this statement is not merely
supposition, and is not based on simple coincidence was shown*
by Lanp in a scries of experiments in which partial thyroidectomy
Wits done in cnfs. In those that were not pregnant, a fifth of
the plnnil coulil be removed without any ill effeots, but in the
pregnant eat, the same operation, namely; the renioval of on?-
SIMPLE GOITRE COMPLICATING PREGNANCY 437
fifth of the gland at once induced an albuminuria and a nephritis,
while the administration of the thyroid to these animals caused
the symptoms to recede at once.
Similar observations have been made by Nicholson in the
l>re<?nant woman suffering from albuminuria and pre-eclamptic
toxemia. The administration of thyroid extract in four of these
patients, caused a prompt subsidence of the toxic symptoms and
almost immediate relief from the albuminuria. On the other
hand, no less authorities than Doederlein, Seitz and others, be-
lieve that eclampsia is not dependent upon thyroid function, but
has its origin in the parathyroids; for the parathyroid exercises
a special influence on uranidine and methyl uranidine metab-
olism. Tetany has been attributed to the accumulation of
uranidine in the body, in the presence of certain gastro-intestinal
poisons. It has been proven experimentally that after the partial
removal of the parathyroids or the impairment of their function,
when anaerobic cultures from the feces or fecal filtrates from
goitrous subjects are injected, that the animal has tetany, but
tetany is not similar clinically to the eclamptic picture; so we
believe and admit that w^hatever the cause may be, thyroid hyper-
plasia in pregnancy is a physiological process which is probably
intended to deliver the organism from waste products, products
taking their origin in the mother and in the child. This hyper-
plasia is further intended to counterbalance the temporarily lost
function of the ovarian secretion -which is held in abeyance
during the entire period of pregnancy.
In the majority of cases, during labor, and especially during
the strain of delivery, the goitre increases in size. It may attain
such dimensions that the neck would seem to burst : and dyspnea,
and cyanosis enter the field of complications. In fact a goitre
may take on such an exaggerated development during pregnancy,
that asphyxia is threatened from tracheal pressure. It is seldom
however, that the dyspneic symptoms become such as to necessi-
tate surgical intervention.
The pressure effects produced by large goitres are evidenced
during the expulsive pains of the second stage when severe
straining efforts are being made. At this time the pressure may
be so great as to cause the carotid pulse to disappear as is shown
by taking the pulsation of the temporal artery. Guyon consider^
438 THE THYROID IN PREGXANCY
that this phenomenon is a salutary attempt on the part of nature
to regulate the cerebral circulation, and thus avoid cerebral
hemorrhaffe by preveutincj an increase in the cerebral pressure
during the acme of the pain.
In goitres of long standing, the goitre heart is always present
and has a clinical significance in making the prognosis more
grave in cases of pregnancy complicating such goitres, for the
tachycardia may become a very troublesome and an alarmio?
symptom.
Goitre has a definite influence on the cellular content of the
blood, and the blood changes which occur in endemic goitre may
be considered as fairly constant. It is usual for Ihe number of
red cells as well as the hetnoglobm index to be somewhat diminished,
while the coagulability of the blood is increased. The total number
of Ihe leucocytes is reduced and the polyniorphomiclear leucocytes
are constantly below the normal limit. This reduction is absolute,
not relative, and it has been repeatedly noted that the polymor-
phonuclear leucocytes have been reduced to 50 per cent, of the
normal, and they may form as -small a part of the cellular elements
of this tissue as 30 per cent, of the leucocytes in the periphenil
blood. The average differential connt in 73 cases was only 46.5
per cent. On the other band, the small mononuclear cells are
usnally above the normal limit, the absolute increase in their
number may be twice that of normal, and in the differential
leucocyte count they may form as large a part as 45 per cent,
of the total leucocyte connt of the peripheral blood. The
average count in 73 cases was 32.2 per cent. These eosinophile
cells are usually increased in number and may form as high a
proportion as 20 per cent, of the total leucocytes in the peripheral
blood. The mononuclear cells are usually within the normal
limit. These blond changes have a far reaching bearing on the
resistance of the individual woman in her defense against
toxemias and infections. It is during pregnancy that the
organism baa to meet and combat toxic and infective elements
to a greater dcirree than in any other physiological process, hence
impairment of the thyroid function and the loss of the activating
hormones on cell activity means decreased resistance for the
woman. This is notably true in puerperal infection; in this
complication the woman with goitre or hypothyroid fuDCtiPfl
SIMPLE GOITRE COMPLICATING PEEGNANCY 439
a
always has a more serious prognosis than her more normal sister.
The influence of the child-bearing period of life is very great on
the development of goitre. In illustration; in localities where
goitre is not supposed to be endemic, the thyroid gland enlarges
as a consequence of pregnancy in about 50 per cent, of all those
conceptions which continue beyond the fourth month, but the
added strain of goitrous influence greatly increases this propor-
tion and converts these physiological swellings of pregnancy into
pathological processes.
Congenital goitre is an entity which must be admitted. This
is shown in the children born in certain Himalayan villages
where every woman and almost every man is goitrous. In these
localities congenital goitre has been found in over 60 per cent,
of breast fed infants. In these villages the infant mortality as
well as the percentage of abortions are also very high ; hence the
actual number of children born with goitre is probably con-
siderably higher than the actual figures will show. On the other
hand, in villages where the endemicity of the disease is lower,
congenital goitre is not so frequent. The mothers of children
born with congenital goitre are often myxedematous to some
extent and they commonly suffer from tetany. Congenital goitre
in the oft'spring is more commonly found among the poor and ill
nourished classes than amongst the well-to-do. The pernicious
influence of goitre in the parents on the development of the
fetus is further shown in the study of cases of endemic cretinism,
for in almost every case of endemic cretinism, goitre is present
in one or both parents; the mother was the subject of thyroid
disease in 96 per cent, and the father presented a definite goitre
in over 40 per cent of the cases examined.
While it is admitted that cretinism can arise in the child of a
woman free from goitre, it must be established as a rule that
maternal goitre ; that is to say, thyroid impairment, is in endemic
localities one of the most essential conditions for the develop-
ment of cretinism in the child.
The experiments of Ilalstead which were later confirmed by
Edmund throw an interesting light on the influence of maternal
thyroid impairment on the development of the fetal thyroid, and
enable us to understand the train of events which gives rise to
cretinism and congenital goitre.
440 THE THYROID IN PREGNANCY
Halstead found in the puppies of a bitch from which the goitre
had been removed, and which was sired by a dog that had been
in part deprived of its thyroid gland, that the thyroid lobe in the
puppies was twenty times larger than those of normal puppies.
This apparently shows that in the case of the partly thyroidec-
tomized bitch there were more toxins circulating in the blood
than her impaired thyroid apparatus could deal with. These
toxins, therefore, called forth an abnormal development on the
part of the puppies' glands with a resultant congenital goitre.
Had the bitch been fed on fecal anaerobic cultures, we have no
doubt that some of her puppies would have been cretins.
Similarly in the goitrous pregnant woman, it is the failure to
meet all of the demands of the increased body metabolism which
constitutes a temporary ineflSciency of the thyro-parathyroid
apparatus, that places her in a position comparable with the
partially thyroidectomized bitch of the experiment; but in her
case, the added action of the goitrogenous influences is the final
factor in determining the destruction of the fetal gland.
Goitrous women frequently exhibit some signs of thyro-para-
thyroid insufficiency during pregnancy. Of these the most com-
mon in froitrous localities is tetany. If they are sub-thyroidic
before thoy become pregnant, the pregnancy may benefit them,
the fetus taking in the excess of the thyroid secretion ; conse-
quently this benefit is dependent upon the extent of development
that takes place in the child's thyroid, for just in so far as the
mother's thyroid potentially possesses the inherent power of re-
sponse to every metabolic demand, so far may we expect the
child to be ])orn normal.
Ill the presence of congenital thyroid instability or congenital
goitre, or cretinism, all of which are to be regarded as but stages
in the same prorc^ss or as evidence of the minimal, mesial, or
niaxiiiial action of the toxic stages in the unborn child's appar-
atus, we s(H' wiiat toxicity and dysfunction on the part of tho
niotlier can produce in the oflfspring.
Summary. — From this study of the influence of the thyroid
and of LToitre on ]>!"eLniancy, and of pregnancy on goitre, certain
clinical facts stand out: d") That a normal functionating thy-
roid is essential foi* the perfect development of the o\iim. (2)
That in normal ]u-(^ijrnancy in the normal woman, the thyroid
SIMPLE GOITRE COMPLICATING PREGNANCY 441
hypertrophies in order to compensate and activate the increased
demand for cell activity. (3) That sometimes this normal hyper-
trophy is exaggerated by pregnancy into a pathologic process
and goitre develops. (4) That pregnancy usually aggravates the
goitrous condition and finally ; that mothers with a sub-thyroidic
function are frequently subjects of toxemia and a direct influence
on the thyroid development of the child.
Treatment. — In all pregnant women the condition of the thy-
roid and its functional activity should receive careful attention.
This entails a study of the basal metabolism especially during the
first and last trimesters of pregnancy. If this gland is found to
be manifestly enlarged or altered, or if there is clinical evidence
of thyroid insufficiency, the active principle of the gland should
be administered in one of the available forms. On this point all
authorities agree; furthermore, that in administering thyroid to
these women, the dosage should be small, and should be con-
tinued for several weeks or months. Thyroid-organotherapy is
especially valuable in patients with hypertension and diminished
urinary output.
It has been found that where thyroid-organotherapy has been
started in the early period of pregnancy, that undue thyroid
hyperplasia has been prevented. It has also been shown experi-
mentally in thyroidectomized cats, that the administration of
thyroid extract or its active principles, prevent albuminuria and
nephritis in pregnancy. These experiments have been so conclu-
sive that coupled with the clinical work of Nicholson, it would
seem to be advisable to feed the woman on some form of thyroid
extract in order to prevent those serious complications of preg-
nancy; such as the toxemias that so frequently result in renal
disease and eclampsia.
In every case of pregnancy complicated with goitre, be it
simple or thyrotoxic or both, the wishes of the parents regarding
the life of the child, and the importance of that child should be
carefully ascertained, and the influence which the pregnancy may
have on the goitre, and the effect of thyrotoxicosis of the mother
on the unborn child should be fully explained to them; for ive
have seen that goitre lias an influence on the unborn child, and that
pregnancy does subject the mother, zvho is the subject of subtlty-
roidic function to greater toxic risks.
443 THE THYROID IN PREGNANCY
Reeetitly we have subjected several women with marked
thyrotoxicosis, to thyroidectomy, and the patients have continued
their pregnancy and been delivered without complication at term.
When pregnancy complicated by simple goitre has reached an
advanced stage without marked toxicosis, as may be shown ty
basal metabolism studies, there is no cause for undue alarm, and
lliire is no occasion far interruption of the pregnancy ; as in the
greater majority of such cases everything will terminate to the
satisfaction of both patient and physician. Great benefit may
be attained by the relatively free use of morphine and scopola-
mine during the dilatation stage, this controls the tachycardia
and mental apprehension ; conditions which frequently obtain in
deficient thyroid function. In the presence of pressure symptoms,
cyanosis and dyspnea, which seem to threaten the life of the
patient during the straining efforts, the labor would better be
terminated by Cesarean section.
In those women in whom before labor the dyspneic symptoms
are marked or where tachycardia has been a prominent symptom,
we may feel sure that l)oth of these symptoms will be increased
in severity during labor; such a patient should be delivered by
section before the actual labor pains start in. Of course if the
dilatation has progressed and the cervix is already obliterated.
and the presentation is normal, and the presenting part has
descended well into the pelvis, the labor may be terminated under
morphiue-scopolamine with the forceps. The woman is thus
saved the strain of the second stage. The administration of a
general anesthetic is always dangerous in goitrous women, hence,
it has been our custom to rely chiefly upon morphine and scopol-
amine analgesia and the local novocain injections into the
perineum. These may be supplemented with light gaa-oxygen
anesfhesia. Wherever possible, local anesthesia should be the
method iif choice. We feel that thyroidectomy during pregnancy
should only be elected when the growth is of such dimensions as
to cause pressure symptoms and produce congestion of the entire
cervical region, or where the patient is suffering from such severe
thyro-toxieosis that the usual patlintive measures are of no avail.
// must always be kept in mind that llic thyroid during pregnancy
is in a state of compensatory liyf'crlropliy, and that before opera-
tion is elected, a careful study of the basal metabolism should be
EXOPHTHALMIC GOITRE 443
made. The early termination of pregnancy by therapeutic abor-
tion has but a limited field, and should be decided upon' only
when repeated studies of the basal metabolism show that the
pregnancy is increasing the toxic load.
EXOPHTHALHIC OOITSE
That a woman afflicted with Graves' disease may become
pregnant, or that thyro-toxicosis may develop either during or at
least in connection with pregnancy, is a well-known fact. The
point of interest does not lie therein, but how do these two con-
ditions influence each other, and what shall be our attitude in
the given case? Fortunately, the occurrence of pregnancy in the
course of an active exophthalmic goitre is very uncommon. Goetsch
states that even when the patient suffering from this disease does
not practice contraconception, the coincidence of pregnancy with
exophthalmic goitre is not frequent. In further support of this
statement we find in the service of Sir Haliday Groom, in the
3Iaternity at Edinborough, but one case is noted in a series of
15,000 pregnant women. However, he reports 12 other cases
which he has taken from his private case records, and concludes
that pregnancy in Graves* disease is found more frequently in
the rich, than in the poor. Bonnaire agrees with this conclusion,
as he observed only two cases of exophthalmic goitre in 30,000
cases of pregnancy. These observations, however, are in direct
variance with the fact that goitre occurs more generally among
the poor and illnourished than among the rich.
Seitz collected 112 cases of exophthalmic goitre with preg-
nancy from his own material, and from the literature and cir-
cular letters. In this study he has carefully tabulated the men-
strual history, the appearance of the first symptoms, the history
of previous pregnancies, the therapy employed, and the results
as far as the mother and child were concerned. In this study
he found that hyperthyroidism was not affected one way or
another in 40 per cent, of the cases. A very small number were
improved by pregnancy; while 67 out of 112 or approximately
60 per cent, of the total were made distinctly worse as a result of
the gestation. In one-fourth of the pregnancies in consequence
of the thyrotoxicosis produced became a serious menace to the
444 THE THYROID IN PREGNANCY
health and life of the woman. Seven patients died, 5 needed a
therapeutic abortion, and in all, 11 premature labors occurred—
3 miscarriages and 3 macerated fetuses were observed, and in 7
thyroidectomy was performed during the pregnancy. On the
other hand, VouBeck in reporting 260 oases of Graves' disease
complicating pregnancy, saya that he felt compelled to perform
thyroidectomy in 5 eases ; but in no ease did he find it necessary
to interrupt the prefrnancy. This is indeed a remarkable record,
and must be explained by the fact that these thyro-toxie condi-
tions were secondary to previonsly existing goitre, and that tbe
goitre was endemic and that these cases were not truly exoph-
thalmic goitre.
It is generally conceded that pregnancy makes Graves' dis-
ease worse, and only a very small minority are unaffected by the
occiirrcnee of pregnancy. Therefore, we must come to tbe con-
clusion that Graves' disease is generally unfavorably influenced
by pregnancy and often has its origin in gestation. It predis-
poses the woman to uterine hemorrhage, and may result in death
of the fetus. These cases are often complicated with albuminuria
and other evidences of toxemia, the tachycardia is always greatly
increased during gestation : the heart action becomes slower soon
after labor, consequently we can conclude that the great majority
of all patients sufTering from Graves' disease are made worse by
pregnancy, and that pregnancy must be regarded as a serinns
complication in all thyro-toxic patients, and in patients sufTering
from this condition we may lay down the dictum: Girls no mar-
riage. Women no pregnancy. Mothers no nursing.
ECLAMPSIA
Recent investigations seem to point to a placental origin in
many cases of eclampsia, Obata following the investigations of
Dold found that when an extract of fresh human placenta is
injected into mice, symptoms resembling those of eclampsia are
produced and that there is no difference between the eflfect of
placenta from a norma! case, and tbe extract of placenta from a
case of eclampsia. He further observed that fresh serum from
the blood, either of a normal person, or of an eclamptic patient
produced similar symptoms in mice; but no increase in the
toxicity was noted in regard to the serum of eclamptic patients.
ECLAMPSIA 446
When, however, the extract of a placenta was mixed with the
blood serum from a normal person, and it was found that sex or
pregnancy did not affect the issue, the toxic effects of the placental
extract and also of the serum ivere neutralized; but on the other
hand, the serum from the blood of an eclamptic patient failed
to neutralize the toxin of the placenta. At first it seems curious
that this substance is present in the blood of males as well as
in the blood of females, until we remember that the fetus is the
product of the male no less than the female. The clinical appli-
cation of this observation is supported by Blair Bell in the report
of a case of eclampsia delivered at full term of still-bom twins;
the convulsions continued after delivery and only two ounces of
albumin laden urine were obtained by catheter. During eighteen
hours subsequent to her admission, she was semicomatose, jaun-
diced, and had a pulse that was hardly perceptible at the wrist.
This patient was transfused with 500 c.c. of her husband's blood;
the response was almost immediate. Within the next sixteen
hours the woman passed fifty ounces of urine; the convulsions
ceased, the coma cleared up and her recovery was uneventful.
In this case whole blood was used and thrown into the
woman's circulation in order that an antitoxin might be intro-
duced into the blood-stream of the patient to neutralize the toxins
from the placenta. Certainly the happy result can hardly be
attributed to any other theory than that resulting from Obata's
investigations. Notwithstanding the striking evidence supplied
by this case, the consensus of opinion at the present time is that
eclamptic convulsions are the result of an auto-intoxication, and
that the conditions existing are an increased blood-pressure, a
perverted metabolism, a decreased elimination by the kidneys
with, in the majority of cases, an albuminuria, with or without
casts. The pathologic findings being fatty degeneration of the
liver and kidneys.
The placenta may be looked upon as a digestive organ pre-
paring the nutrition for the fetus; it may possibly also have a
hepatic function and destroy the toxic products of fetal metab-
olism before the fetal blood enters the vena cava, consequently,
it is argued that pathologic conditions of the placenta may im-
pair this function and toxic fetal products entering the mother's
blood cause toxemia in the mother. In contradiction of this last
80
446 THE THYROID I\ PREGNANCY
statement Obata's experiments showed that it was the introduc-
tion of placental extract that produced the convulsion, and that
it made no difference whether it was the extract of a normal
placenta, or the extract from the placenta of an eclamptic: hence
it would seem that we must look to some of the p^lands of interaal
secretion to furnish the blood with the necessary antitoxic sub-
stance to comhat the toxicity of this placental toxin.
From both experimental and clinical evidence it is in all proba-
bility the thyroid-paralhyroid apparatus which supplies this SDti-
toxin. We know that the thyroid normally increases in size and
hyperfunctions durinc prefinaiicy. in response to the excessive
demand made upon it by the increased metabolism, it is there-
fore, reasonable to assume that it is the normally active thyroid
that activates the blond cells to combat the effects of the placental
toxins. In support of this, it has been sho«ni by Gamier and
Roger, that it is by no means uncommon for the thyroid to be
affected by the acute diseases of childhood, and consequently in
the first pregnancy, especially in yonnp women, there may be a
deficiency of thyroid secretion, which may be a factor in pn>-
ducing eclamptic convulsions in these yonnp primiparte, but the
excitation of the d'and dnrinc this prcfrnancy will have a tend-
ency to increase its function and thus prevent a recurrence of
the sjonptoms at the next prennancy. In other cases the gland
never acquires a sufficient secretin)! power and eclamptic non-
^^^lsions occur at every successive labor. In those who have no
eclamptic symptoms at the first pregnancy, but in whom they
appear in later pregQancies, it may be assumed that the strain
upon the gland during the first pregnancy or some intercurrent
disease has affected the proper functioning of the gland.
From the foregoing statements it is fair to draw the following
conclusions:
(1) That eclampsia in all probability has a placental origin
and that the placental toxin is the irritant in the blood which
prodnces the convulsion.
(2) That this toxin is neutralized by normal blood which
contains some unknown antitoxic substance.
/^^ Tl.nt- H.P tlii-rnlrl-ii.i™tlivi-(>ir1 .1 riiiiirn tiis bv its incrpMed
ECLAMPSIA 447
function activates the cell activity of all of the ductless glands
and helps to supply this antitoxic substance in the blood.
Therefore in the administration of thyroid extract during
pregnancy, and the employment of transfusion in eclampsia, we
have two exceedingly valuable agents added to our arma-
mentarium.
INDEX
Abdomen, enlargemert of, in prcg- i Abortion, conditions determining
nancy, 91
dattening of, in pregnancy, 91
pigmentation of, during pregnancy,
91, 92
striap gravidarum of, 92
surgery of, 401
umbilical • changes in, during preg-
nancy, 91
Abdominal binder, after labor, 197
Abdominal examination, 149
external pelvimetry in, 157
location of anterior shoulder in,
155, 156
location of cephalic prominence in,
154, 155
location of dorsal plane and small
parts in, 150
location of fetal heart in, 157
location of upper fetal pole in, 155
position of patient during, 150
post partum, 204
successive steps in, 150
Abdominal muscles, contraction of,
during labor, 112
Abdominal pregnancy, diagnostic
signs of, 267
Abdominal section, 337
Abdominal signs of pregnancy, on
auscultation, 93
on inspection, 91
on palpation, 92
Abdominal viscera, enlargement of,
328
Abortion, 111, 254
after-treatment of, 262
arrest of threatened, 258
causes of, 255, 256
treatment in, 259
contributing causes of, 248
control of hemorrhage in, 259
dangers of, 257
diagnosis of, 256
distinguished from hemorrhage,
256
endometritis as cause of, 240
examination in, 257
expectant plan of treatment of,
259, 260
facts to be established in diagnosis
of, 250
fetal death in, 255
incomplete, 262
independent of fetal death, 255
indications for: absolute contrac-
tion of pelvis, 384
chorea, 384
death of ovum, 384
leukemia, 384
pernicious anemia, 384
induction of, 275, 276, 383
competent counsel in, 285
in chronic heart disease, 384
in degeneration of the chorion,
373
in nephritis, chronic, 383
in retroversion of gravid uterus,
383
in toxemia, 383
in tuberculosis, 384
methods of, 384
inevitable, 257
instrumental treatment of, 261
management of inevitable, 259
' manual treatment of, 261
449
460
INDEX
Abortion, percentage of, SSS
Alveolar passagea of lung, 62
ppnoil of possible, 255
Amenorrhea, causes of, 87
phjarcal signs of. 256
symptom of pregnaucf, 87
preiention of stpHia lu, 259
Amnion, 41
pretentne treatment of, 2j3
anomalies of, 242
progress of, 257
Amniotic cavity, 39, 41
radical plan of trealinent of,
360
Amaiotic fluid, 41
sjtnptomB of, 256
Ampulla, of the FaUopian tnbta, £1
syphilis and, 253
ovum develope<l in, 264
threatened, 257
Anal fascia, 10
treatment of, 257, 2S8
Anal membrane in the erabrjo. 57,
ejjpeclant, 239
5S
radical, 260
Anal pit, 57, 58
tubal, 264, 267
Acardia, 74
67
Accidental heoiorrha^ie, apparent, 344,
Anemia, during pregtuuiejr, 277
345. 346
pernicious, 384
causes of, 345
treatment of, 337
concealed, 345, 346
treatment of acate, 343
Anenccphalic monster, 251
differential diagnosis of, 346
Anesthesia, complete, 307
with forceps, 389
treatment of, 347
Anesthetics, in labor, 177, 178
^a^letles of, 344
Acetone, excess of. after labor.
200
care in, 178
Acetonuria, slanation, after
labor.
■ in emulsive stage, 179
2no
in repairs to peMc floor bwtn-
AchromnliL network of Ilie
o^um,
tions, 188, 189
26
Ankyloaed obliquely contracted peivia,
Acramu and heoucraaia. 76
292
Acrosome. of apermatoEoor, 27
35
Anoraaliei, in organology, aevdii,
Adherent placenta, 3S6
74
After birth, expulsion of, I'l
double heart, 74
Aftercare of patient at close of
hermaphroditism. 78
labor, 195
malpositions of heart, 74
fundus and 195
of bladder, 77
of pelvic iloor 1^14
of brain, 76
vaginal operali ns an 1 194
of cardiac septa, 74
After-pains 203
of central nervous system, 7<
nursing liunn;: 2U3
of cerebrum. 76
purpose of 203
of esophagus. 75
relief of ll" 203 207
of gastrointestinal canal, "5, 76 '
Air saos in the fetus, bl
Albuminuria after labor. 200
of heart. 74
INDEX
451
Anomalies, in organology , of liver,
76
of lungs, 78
of mouth, 75
of neural canal, 76
of ovaries, 77
of oviducts, 77
of pancreas, 76
of pharynx, 75
of respiratory system, 78
of skull, 76
of stomach, 75
of testis, 77
of thyroid and thymus glands,
75
of tongue, 75
of trachea, 78
of ureters, 77
of urethra, 77
of uterus, 77
of vagina, 77
of valves, 74
of vascular system, 74
of vascular trunks, 74
of veins, 75
of vertebral column, 76
transposition of viscera, 75
of the amnion, 242
of cervix, 298, 299
of fetal development, 250, 251,
324
of labor, 279, 284, 328
of the liquor amnii, 242, 244
hydramnios, 243, 244
oligohydramnios, 242
polyhydramnios, 243, 244
of ovaries, 299
of the passenger, 301, 310
breech presentation, 310
brow presentation, 308
face presentation, 303
mentoanterior positions, 304
mentoposterior positions, 305
of the pelvis, 284
of the placenta, 46, 47, 247, 249
of the umbilical cord, 249
of the uterus, 299, 300
Anterior posterior diameters of pelvic
cavity, 120
of pelvic outlet, 121 '
Antipyretics in puerperal infection,
373
Antisepsis, in labor, 166
in the lying-in-woman, 207
of genital after-birth, 197
Antiseptic agents, 166, 167
bichlorid of mercury, 167
boiling, 167
chemical, 167, 168
chlorinated soda, 167
creolin, 167
dry heat, 167
lysol, 167
mercuric biniodid, 167
tincture of iodin, 168
urinary, 207
Antistreptococcic serum, in puerperal
infection, 374
Anus, atresia of, 75
of embryo, 54
Aorta, arch of, 65
ascending, 65
descending, 65
dorsal, 65
in embryo, 64
ventral, 65
Apical body of spermatozoon, 27
Aplasia of kidneys, 77
Apoplexy, 248
Arterial supply, of ovaries, 23
of vagina, 7
Arteries, of the embryo, aorta, 64
of external genitals, 5
of Fallopian tubes, 22
of uterus, 19
Arteriosus, ductus, 65
Arteriosus, tr uncus, 65
Artery, branchial arch, 64, 65
common carotid, 65
external carotid, 65
innominate, 65
internal carotid, 65
pulmonary, 65
subclavian, 65
452 INDEX
Artetj, uterioe, pulsation of, in preg
Bacteremia, 370
nanej. 98
Bag of membranea, 176
Tisteral, 49
Bag of wstera, hydrostatic action of,
Artificial feeiling. cow's milk basis
134
of, 223
preservation of, 176
proteid p^rcentago in, 22S
Ball valve action of head, 136
regulating strength of, 229
Batlottement, external, 93
ivhen ncccEsarj, 225
internal, 99, 100
ArtificUl foml, casein io, 223, 227
Band), ring of, 134, 13S
diluents in, 226, 227
Bartholin, glands of, 4
fat in, 227
in embryo, 71
procuring proper proportion of pro-
Bathing of eKicrual genitals, 170
teids and fat in, 227
of neivborn chUd. 220, 221
ratio of proteids to fat in, 226
Baudelocquc diameter of pelvis, 121,
strength of, S27
122
sugar in, 227
Baujelocqiie method of converting a
Archenteron or primitive gul, 38
Arches, branchial, 50
307
mandibular, 58
Bed, preparation of, in labor, 166
visceral. 49, 30
Bichlorid of mercury. 167
Areola, primary, in pregnancy, 89
Bicornis, uterus. 300
secomlBry, in pregnane)-, 91
Bile duct, in embryo, 61
Argvrol, use of. 221
Bimastoid diameter of fM>l bad,
Arm. o£ embryo. 54
127
Arytenoepiglottitlwin fold*. 62, 63
Binder, abdominal, after labor, 197
Asraris megnlocephala. 30
Ascites, itifferenliation of. from preg-
126
nancy. 101
Bipolar version, advantages of, 393
Asepsis, means of secaring. 166. 167,
method of. 399
16S. 169. 170
Birth of head. 139, 140, 180, 181
of nnrs.'. 20S
nilh caul, 42
Asphyxia neonalonim. 217. 21S
Bisacromial diameter of fetal ahool-
Atresia, of anus. 13
dera. 128
of duodenum. 75
Bisischial (or transrene) disnttw,
-nginal. -JUS
161
vulvar. 29>
Bistrochantertf diamet«r «f felsl
Au^eullniion, focus of. il4
trunk. 12S
Asial fitameni of ibe spermatozoon.
33
Alls, parturient. 12.1
Bitemporal diameter of fetal bead.
Bbddrr. anomaliM of. 77
Axii-ltxrtioti fori"i>ps. advantafes of.
.-varualions of, post partua^ 203.
3»i
2»>6
applieaii..^ of. 393
deseriprion of. 394
irritation of. during labor. 133
pofiTion nf patient for U9c «f.
39o
soe
INDEX
453
Bladder, sitting posture in evacuation
of, 206
use of catheter to relieve disten-
tion of, 206
Blastodermic stage of development,
47
Blastomeres, 37
Blastula, 38
Blood, effect of pregnancy on, 85
of the new-born child. 215
passage of maternal, to fetus, 44
Blood changes in fetus, 81, 82
Blood channels, enlargement of, after
labor, 200
Blood clots, acting as intrauterine
tampon, 195
Blood losses from vagina in preg-
nancy, 111
Blood pressure during pregnancy, 110
Blood supply of pelvic floor, 13
Bloody genital discharge, 238
Bloody vaginal flow, attention to, by
nurse, 197
persistence of, 205
Body, development of external form
of, 47
of embryo, 49, 50
of spermatozoon, 27, 35
of lUerus, cavity of, 16
divisions of, 15
mucous membrane of, 16
perineal, of pelvic floor, 13
polar, 30
weight of, during pregnancy, 86
Body cavity, 39
Body cells, 29
Boiling, 167
Bowels, care of, during pregnancy,
108
of new-born child, 216
postpartum evacuation of, 207
sluggish, after labor, 200
Brain, of embryo, 49, 74
table of development of, 73
vesicles of, 74
Branchial arches, 50
arteries of, 64, 65
Breaking of the waters, in labor,
137
Breast binder, 204, 211, 212
Breasts, care of, after birth, 212
in pregnancy, 212
engorgement of, 212
fissures of, prevention of, 212
massage of, 212
painful distention of, relief of,
212
postpartum attention to, 204, 205
Breech extraction, 331
Breech positions, diagnosis of, 311
prognosis of, 312
Breech presentation, causes of, 310
delivery of arms in, 313, 314, 315
delivery of feet in, 313
delivery of head in, 316
delivery of trunk in, 312
forceps in, 394
frequency of, 310
mechanism of, 310
rotation in, 310
treatment of, 312
varieties of, 310
Bregma, 125. See Fontanelle, anterior
Brow presentations, 308
causes of, 309
diagnosis of, 309
frequency of, 309
progrnosis of, 309
pubiotomy in, 309
rectification of, 309
treatment of, 309
version in, 309
Bulbi vestibuli, 4
Bulbocavernosus muscle, 7
Calcareous degeneration of placenta,
248
Calomel, use of, 275
Canal of Nuck, 2
Canalization of cervix, 135, 137
Cancer of cervix, 299
Caput succedaneum, 141, 143, 217
Cardiac disease, 359
treatment of, 860
454 INI
Carijiac septa, impcrfectiooB of, 74
Cariliac supports in cclampitia, 35S
CarilJovascular Bvatcm, 63
arfcriea, G4, 65
heart, 63
CamnculiB myrti formes, 5
Catharsis in eclampsia, 356, 357
Catheter, use of, 206
Catheterization, 191
of nterua, 377
Caudal process, 52
Caul, in birth, 42
Cavitj, amniotic, 40
uterine, ]6
Cecum, of embryo, 60
CeiiohyBtereclomy. See Porro opera-
Celiohy sterol omy. See Cesarean sec-
Celiotomy, 337
Cell membrane of the ovnm, 25
Cells, body, 29
deciUnal, 44
(ievelopment of, 28
differentiation of, 28
germinal 29
lutein 37
sex 29
somatic or body, 29
sperniatogenic 32, 34
Buatentai-ular 32
Celosomatic monster 250
Celnm, 39
Central nervous system anomalies of.
Centco
B of the spcrmatoEodn,
Cephalometry, 162
Cephalopagus 2 '51
Cephalhematoma prognusis of, 233
uvmploms of 233
treatment of 233
Cephalic flexure 41
fcphulic presentation 128 143
Cephalic process 52
Ctphalic prominence, location of, 154,
155
Cephalic version, indieations for, SIS
Cephalocele, 76
CephaJotripsy, 425
Cervical canal, obliteration of, 134,
135
preparatiou of, for labor, 171
Cervical fistula, 50
Cervical fleiure, 40
Cervical lacerations, methoi] of repair
of, 185
stitcbea in, 186
treatment of, when necessary, I8S
Cervical plug, expulsion of, in Ubor,
133
Cervical structures, Boftening of, 131
Cervii, 15
anomalies of, 29S, 299
canalization of, 135, 137
cancer of, 299
cavity of, 16
changes in size of, during preg-
nancy, 84
conneetiTe tissue of, 18
dilation of, 41. 134, 138
divisions of, 15
excessive flexibility of, in pr^
nancy, 93
infravaginal portion of, 15
Instrumental dilation of, 380
involution of, 202
manual dilation of, 379
mucous membrane of, 16
portio vaginalis of, IS
purplish hue of, in pregnancy, 95
rigidity of, 208
softening of, in labor, 137
in pregnancy, 95
stenosis of, 298
structural changes in, during pref
nancy, 85
supravaginal portion of, 16
tamponade of, 384
temperature of, in pregnancy, 99
Cesarean section, 296, 297, 299, 347,
376
of, 409
INDEX
455
Cesarean section, closing of uterine
wound after, 408
conditions of success of, 404
definition of, 401
extraction of child in, 404
extraperitoneal, 410
historical note on, 401
in hemorrhage, 342
incisions in, 404
indications for, 401
instruments in, 403
possibilities of, 401
post-mortem, 410
preparatory measures for, 402
steps of, 404
technique of, 404
time of, 402
vaginal, 382, 411
Champetier balloon, 380
Cheek of embryo, 52
Chemical antiseptics, 167, 168
Child, now-born, appearance of, 214
asphyxia neonatorum in, 217
attention to, 204, 205
bathing, details of, 220, 221
blood of, 215
bowels of, 216
caput succedaneum of, 217
care of, 217
circulation of, 215
clothing of, 222
condition of, 214
disorders of, 230
genitourinary organs of, 216
incubation of, 220
jaundice of, 215
lungs of, collapsed, at birth,
215
measurement of, 214
navel dressing of, 221, 222
navel stump of, attention to, 222
nervous system of, 216
nursing of, 223, 224
ophthalmia neonatorum in, 221
premature, 220
respiration of, 215, 217
skin of, 216
Child, new-born, stomach of, 215
temperature of, 214
urine of, 216
weight of, 214
secretions of, later development of,
216
weight of, normal gain in, 211
Child-bed, death in, 375
Chill, postpartum, 199
Chin of embryo, 54
Chloral, use of, 174, 275, 356, 357
Chlorinated soda, 167
Chloroform, in labor pains, 175, 178
Choc foetal, in pregnancy, 94
Chorea, 384
Chorioepithelioma, 246, 247
Chorion, 42, 43
degeneration of, 383
diseases of, 244
myxoma of, 245
Chorion frondosum, 43
Chorion Iffive, 43
Chorionic cystic degeneration, 244,
245, 246
Chorionic villi, 43, 44
cystic degeneration of, 244
Chromatin of the ovum, 26
Chromosomes, accessory, of male sex
cells, 34
sex, 34
Circulation of new-born child, 215
Circumference of pelvis, 122
Circumferences of fetal head, 127
Cleanliness, 166
of hands, 168
of lying-in woman, 207
surgical, 163
Cleansing, object of, 171
of patient, 170
at close of labor, 196
Cleavage, 37
general laws of, 37
Cleft palate, 53
Cleidotomy, 424
Clitoris, 3
frenum of, 2
of embryo, 71
456 INDEX
Cloaca, in embryo, 57, 58
Corona rodiata of the orum, 25
persistence of, 7S
Corpora cavernosa of the clitoris, 3
Cloning tiipmbrane, 50
Corpus albicans, 37
Clotblug, during pregnancy, 109
Corpus hemorrhagicum, 36
of uew-born child, 222
Corpus luteum, 36, 37
Cocain, use al, in pernicious vomit-
Cotyledons, 44
ing, 275
Cowper's glands in embryo, 72
Coccyx, 113, 116, 119
in male, 4
Colic, in nfiv-born infant, 231
Crampiiko pains, 281
Coilargolum, in puerperal infection.
Cranial base of fetal head, 124
373
Cranial bones (fetal), proluberaocet
Colon, in embryo, 60
of, 125
Colostrum, DO, 210
Cranial vault of feliil head, 133,
Colpitis, 370
124
Complex proaeiilations, craniotomy in,
malleability of, 124
324
regions of, 123
hnnd and foot, 324
sutures of, 124, 125
bands, 323
Craniorachischisis, 76
head and band, 323
Craniotomy, 296, 287, 307, 324, 4S3
head, hand and tool. 324
steps in, 423
nuohai .irm, 324
Compression belt, Momlwrg's, 350
extraction, 424
Conjugata vera, 119, 161, 162
perforation, 423
CoHJUEate, diagonal, 119, 120, IS!
Crede'B method of eipulsioa of plir
internal, of pelvis, 121, 122
cents, 1S3
(n.e, 1!9
Creolin, ltl7
Constipation, in new-born infant, 230
Cristic, 7
in pregnancy, 111
Crnra of the clitoris, 3
Contractions, of placental site, 145
Cul-de-sac, anterior, 14
uterine, after labor, 185
of Douglas, 15
during labor. 134
posterior, 15
ConlraindicalionB to nursing. 213
Curette, use of. 209, 2-17
Conversion, of broiv, into face pres-
in inducing aliortion, 3S4
entation, 309
Ciirptting. in puerperal infection,
into \prtei[ prcsentutioQ, 309
372
of fate into vertei presentation.
Cyclocephalic monster, 251
307
Cystic ducts in embryo, 61
ConiTilsionK. Sre Eclampsia
Cystic tumors of kidney differentiated
Cord, ombili.-!.!. Dickinson's treat-
from pregnancy, 102
ment of, 1«2
Cystitis, 370
ligalion of, 181
danger of, 194
inanugeiiient of ISI
prophylactic against, 207
treatment of, aftrr liRatinn, 1K2
treatment of, 375
witli twins, 183
Cystocele, 298
Cnrdiformis, uterus, 301)
Cysts, placenta], 247
Cormia, of iitenis. 15
umbilical cord, 249
pregnancy in, 96
I'ytomorphoais, 23
INDEX
457
Cytoplasm, of the ovum, 25, 26
of the spermatozoon, 28, 35
Cytotrophoderm, 43
Death in child-bed, 375
habitual, of fetus, 376
Decapitation, 426
Decidua, 42, 43
deeper layer of, shedding of, 200
diseases of, 239, 240
Dei*iilua basalis, 42, 43
Decidua capsularis, 42, 43
Decidua parietal is, 42, 43
Decidual cells, 44
Deciduitis, 239, 240
Defecation, increased frequency of,
171
Deficient lactation, 211
Degeneration, calcareous, of placenta,
248
cystic, of chorionic villi, 244
fatty, of placenta, 248
Delivery, slow, advantage of, 177,
179
spontaneous, in transverse presen-
tations, 322
Dental shelf or ridge, 58
Dentoplasm of the ovum, 26
Derivatives of germ layers, 40
Descent of fetal head in birth, 139
Development, blastodermic stage of,
47
embryonic stage of, 47, 48, 49, 50,
52, 53, 54, 55
from branchial arches, 50
from visceral arches, 50, 52
Dextrinized gruel, preparation of, 227
Diabetes mcllitus, 359
Diagonal conjugate, 119, 161
Diameters, of fetal head, 125, 126,
127
of fetal trunk, 127
of pelvis, 119-122
Diaphoresis in eclampsia, 357
Diarrhea in new-born infant, 231
Didelphys, uterus, 300
Diencephalon, 74
Diet, during pregnancy, 108, 109
of puerperal woman, 207, 208
source of indigestion, 231
Digametic sex cell, 34
Dilation, management of stage of,
174
manual, in hemorrhage, 342
of cervix, 134
amnion in, 41
artificial delivery by, 380
danger of tearing in, 379
in placenta pra»via, 341
instrumental, 380
stage of, 132
tardy, 280
Dilators, branched steel, 381
Diluents, dextrinized gruels as, 227
in artificial food, 227
whey as, 228
Direct insufflation, Byrd's method of,
219
Holden 's method of, 218
Laborde's method of, 219
mouth to mouth, 218, 219
Schnitzels method of, 219
Sylvester 's method of, 219
Discharge of **hind'' waters in birth,
143
Diseases of the chorion: fibromyxo-
matous degeneration, 247
of the fetus, 251
of the placenta, 249
of pregnancy: acute endometritis,
239, 240
chronic catarrhal endometritis,
240
chronic diffuse endometritis, 240
cystic endometritis, 241
deciduitis, 239, 240
of the chorion, 244
of the placenta, 247
polypoid endometritis, 241, 242
Disorders, infant: bloody genital dis-
charge, 238
cephalhematoma, 233
colic, 231
constipation, 230
458
INDEX
Diflordors. infant: .lisrrhea, 231
Duct, thoracic, 61
Diiehenne's paralyBis, 238
ureteric, 69
ictwus, 233, 234
vitteline. 57
indigestion, 231
DuctTiB arterioaua, 65
iolertrigo, 232
Ductus choledochDa. 61
mastitis, 238
Ductus venosuB. 87
melena aeonatarum, 237
Diibrssen 's incisions, 282
ompbalitiB. 238
Duncan's mechauiam, 146
opblbalniia neonatorum, 234
Dystocia, in birth, 45
preputial adhesion, 233
in labor, 132
thrush, 232
Ear in embryo, 49, 50, 54, 59
umbilicat fungus. 236
umbiiical hemorrhage, 237, 23
umbilical infection, 236
danger signala of, 354
Diuresis, in eelampsia, 357
(iefinition of, 352
Divcrtii-ula, from gut traet, Gl
fiitTerential diapiOBia of, 354
Dorsal flexure, 49
etiology of, 352
Dorsal plane and small purtN,
tion of. 150
loca-
maternal mortality in, 35S
Doraoanterior posit ions, 3 16
preeaotioDB in, 358
Dorsopoaterior positionH. 311, 318
premonitory Bigna of, 353
Double monster, 251, 326
prognosis of. 354
in pregnancy, 108
Douglas, cul-de-sue of, 15
Drainage, ia mastitis. 364
Draw sheet, after labor, IBi
Dre
n of. I
Drugs, In eclampaia. 358
in labor pains, 174, 175
Dry heat, 167
Dry labor, measures in. 281
Duchcnne *s paralysis, 238
danger of producing, 181
Duct, bile, 61
cystic, 61
hepatic, 61
mesonepliroic, 69
Miillerian, 69, 70
of Cuvier. 65
of Sai
of Wiraung, 61
pronephruie. 68
61
treatment of, 355
Ectoderm, 38
derivatives from, 40
Ectopia of kidneys, 77
Ectopic gestation, 36, 42, 257
Mriesthcflia contrsindicaled in,
267
causes of, 264
classiBcation of, 263
diagnostic signs of, in early months,
286
differential diagnosis of, 269
etiology of, 264
frequency of, 263
history of, 266
intraligamentous pregnftDcy, 285
pathological possibilities of, 241
prognofiis of, 270
tubouterioe pregnancy, 265
tumor in, 267
INDEX
459
Edema, about the face, in pregnancy,
111
placental, 248
Egg, white of, in infant feeding, 228
Emboli, dislodgment of, 209
Embryo, accessory structures of, 40,
41
alimentary canal of, 55, 56
allantois, 57
anus of, 54
arm of, 54
arteries of, 64, 65
body in, 49
external form of, 55
brain of, 49
cardiovascular system of, 63
central nervous system of, 48, 72
cheek of, 52
chin of, 54
cloaca of, 57
ear of, 49, 50, 54
encephalon of, 49
esophagus of, 60
Eustachian tube of, 50
external genitals of, 54
eye of, 49, 54
face of, 50, 53, 54
fingers of, 54
foot of, 54
gastrointestinal system of, 55
genitourinary system of, 68
hair of, 54
hand of, 54
head in, 49
heart in, 49
hyoid bone of, 50
incus of, 50
intestines of, 54, 60
jaw of, 50
larynx of, 62
leg of, 50
limb buds of, 54
lips of, 54
liver of, 61
lung buds of, 62
malleus of, 50
mandible of, 52
Embryo, mouth of, 49, 52
nails of, 54
nose of, 54
outer covering of, 42, 43
palate of, 58
pancreas of, 61
perineum of, 58
pharynx of, 50
placental circulation of, 44
rectum of, 58
respiratory system of, 61, 62
sexual distinctions in, 70, 71
stapes in, 50
stomach of, 60
styloid process of, 50
teeth of, 58
thigh of, 54
thymus of, 50
thyroid gland of, 50
tongue of, 50
tonsils of, 60
transparency of, 55
tympanic membrane of, 50
ureters of, 57
uvula of, 58
veins of, 65
Wolffian ducts of, 57
Embryonic disk, 39
in blastodermic stage, 47
in embryonic stage, 48
Embryonic stage of development, 47,
48, 49, 50, 52, 53, 54
Embryotomy, 326, 422
indications for, 423
Enamel sac, 58
Encephalocele, 76
Encephalon, of embryo, 49
Endocardium, of embryo, 63
Endocerv'icitis, treatment of, prior to
pregnancy, 258
Endometritis, 368
acute, 239, 240
chronic catarrhal, 240, 241
chronic diffuse, 240
cystic, 241
glandular, 240, 241
involution after, 202
4G0
INDEX
Endometritis, polypoid, 241, 242
treatment of, i)rior to conception,
258
Knemata, contraindicated in opera-
tions on sphincter, 195
Entoderm, 38
derivatives from, 40
Entrance plug, 42
Epididymis, in fetus, 70
p]piglottis, of embryo, 62
Episiotomy, 180
technique of, 180, 181
Equa)>iliter justominor pelvis, 287
Erectile tissue, of clitoris, 3
of labia minora, 3
Ergot, after labor, 195, 19G, 197, 209,
247, 254, 262, 283, 349
Esophagus, anomalies of, 75
in embryo, 50, 60
Ether, in labor pains, 175, 178
Ether-oxygen, in labor, 178
Ether-oxygen inhalation, in eclampsia,
356
Ether sprays, use of, 275
Eustachian tulH.\ of embrj-o, 50, 59
Evagi nation, of liver, 61
Evisceration, 425
Evtdution. spontaneous, in transverse
presentations, 322
Examination, abdominal, 149
external pelvimetry in, 157, 158,
159
location of anterior shoulder by,
155, 156
loi*ation of cephalic prominence
by, 154, 155
loi*ation of dorsal plane and small
(tarts by, 150
lix*ation of fetal heart by, 157
Ktcatiou of up|>er fetal jn^le by, 152
location of upper fetal pole by,
155
pi>sition during, 150
successi\-e stepe of, 150
after beginning of lalK»r, 172
history of pregnant woman in. 14S,
149
Examination, in second stage of labor,
In
internal, 175
when begun, 173
mammary, 149
of fetal parts in labor, 173
of placenta and membranes, 185
pelvic, in labor, 172
post-partum, 204, 205
vaginal, 149, 175, 177
method of, 160
Excoriation, 364
Exencephalic monster, 250
Exercise during pregnancy, 107
Expelling forces, anomalies of, 279
deficiency of, 280
excessive, 279
failure of, at brim, 319
with breech in cavity, 320
pelvic floor, 113
regulation of, 178, 179
uterus, 112
Expressio fetus, 283
Expulsion, anesthetics in, 179
beginning of stage of, 176
length of stage of, 144
management of stage of, 176
of after-birth, 185
of fetus, 138
head, 139
■ trunk, 143
I of ovum, 254
precautions in stage of, 176
preparation of patient for stage of,
176
regulation of, by flexion, 179, 18C
retarding of. by anesthetics, 179
stage of. 132
tnink doubled on itself in, 323
Extension of fetal head, in birth, 141
I
External genitals, arteries of, 5
bathing of. for labor, 170
bulbi vestibuli. 4
cleansing of. at close of labor, 19(
clitoris, 3
fossa naWcularis, 3
I fourchotte. or frenulum vulvae, 3
INDEX
461
External genitals, hymen, 4, 5
in embryo, .54
in fetus, 71
in lying-in woman, 208
labia majora, 1, 2
labia minora, 2, 3
lymphatics of, 5
mons veneris, 1
nerv^es of, 5
preparation of, for labor, 170
rima pudendi, 3
veins of, 5
vestibule, 3, 4
vulvovaginal glands, 4
External oblique diameter of pelvis,
122
External pelvimetry, 157
External rotation of fetal head, in
birth, 142
External version, method of, 396
Extraction, by perforation of pla-
centa, 342
forceps or breech, 331
Extraperitoneal Cesarean section, 410
Extraperitoneal rupture, 269
Extrauterine pregnancy, classification
of, 263
frequency of, 263
Eye of embryo, 49, 54
Pace presentation, causes of, 304
classification of, 304
conversion of, to vertex, 307
forceps in, 394
frequency of, 303
mechanism of, 304
Face, of embryo, 50, 53, 54
Fallopian tubes, 20
ampulla of, 21
arteries of, 22
changes in, during pregnancy, 85
coats of, 21
division of, 21
fimbria; of, 21
fimbriated extremity of, 21
in fetus, 70
infundibulum of, 21
31
Fallopian tubes, isthmus of, 21
lymphatics of, 22
mucous membrane of, 22
neck of, 21
nerves of, 22
ostium abdominale, or externum, of,
21
ostium uterinum of, 21
pavilion of, 21
structure of, 21
veins of, 22
Faradic current, 219
Faradism, use of, 209
Fascia, anal, 10
obturator, 10
pelvic, 9
rectovesical, 10
Fatty degeneration of placenta, 248
Feeble pains in labor, causes of, 280
treatment of, 280
Feeding, artificial, when necessary,
223
Feet, swelling of, in pregnancy. 111
Ferguson inhaler, 178
Fertilization, essential parts to, in
spermatozoon, 28
periods of, 35, 36, 37
process of, 37
Fetal anomalies: double monsters,
326
hy<lr()cephalus, 326
interlocking twins, 326
tumors, 328
twins, 324
Fetal body, diameters of, 127, 128
Fetal circulation, 81
Fetal death, 251
abortion in, 255
causes of, 252
processes of, 253
signs of, 252
treatment of, 254
Fetal development, anomalies of, 32^
tabulated chronology of: first week,
79
second week, 79
fourth week, 79
'462
INDEX
Fetal developmenty tabulated chronol-
ogy of: sixth week, 79
eighth week, 80
third month, 80
fourth month, 80
fifth month, 80
sixth month, 80
seventh month, 81
eighth month, 81
ninth month, 81
Fetal head, 123, 124, 139
ball valve action of, 136
circumference of, 127
descent of, in birth, 139
diameters of, 125, 126, 127
extension of, in birth, 142
external rotation of, 142
flexion of, in birth, 139, 140
hard, globular feel of, 152
molding of, 143, 144
pelvimetry for determining, 163
restitution of, in birth, 142
rotation of, in birth, 140, 141
size of, eephalometry for determin-
ing, 162, 163
summary of diameters of, 127
sunk in pelvic excavation, 152, 153
Fetal heart, attention to, in birth, 144
location of, 157
Fetal heart sounds, during pregnancy,
93, 94
indications of. 157
location of. 157
Fetal moinbnines. 40
allantois. 46. 47
amnion. 41
chorion. 4l\ 43
decidua. 4'J. 43
unibilioal o«>r<l. 44
Fetal moveiiiriiTs. ^^. 9.*^. 99. 100
rippt^arMTii-e of. r»4
Fotal ntik. untN\istiu^ of, in birth,
1 V2
Fotal .'rirar.dloijy. development of,
tal'::lat«-.l rlironoloiry of. 79
Fota! yy\-. h'Wi-r. «xaminati«Mi of. 15-
upptT. exauii nation oi, I'>o
Fetal pulse, at birth, 144
in labor, 175
Fetal stage of developmeat, 47
Fetal syphilis, determiiuitioB o^
253
Fetal trunk, birth of, 143
Fetation, multiple, eaaaea of, 108
eonsequenees of, 103
Buperf eeundation and, 108
Buperfetation and, 104
Fetometry, 295
Fetor, control of, 208
F^tus, 123
Fetus, abortion and, 255
anomalies of, 250
dead, absorption of, 253
maceration of, 253
mummification of, 253
putrefaction of, 254
death of, 251, 252
causes of, 252
signs of, 252
treatment of, 254
developmental anomalies of, 250
diseases of, 251
fiexion of, 129
head of, 123, 124, 125, 126
infiuence of diet, on sixe of, Itt^
length of, 55
mensuration of, 105
papyraceus, 253
passages for, 113
pathology of, 250
position of, 129
posture of, 128, 129
presentation of, 128
trunk diameters of, 127
Fibroma, 328
Fibromyoma, 101.
subserous, 102
Fibromyxomatous degeneration, 247
Fillet, use of, in delivery, 320
Fimbriae of Fallopian tubes, 21
Fimbriated extremity, of Fallopian
tubes. 21
Finger, use of, in delivery, 320
Fingers of embryo, 54
INDEX
463
Fistula, cervical, 50
congenital fecal, 47, 75
congenital urinary, 47
Flat pelvis, management of labor in,
296
''Fleshy mole,'' 253
Flexion, exaggerated, 180
of fetal head in birth, 139, 140
of fetus, 129
complete, 129
perfect, 141, 173
Flexure, cephalic, 49
cervical, 49
dorsal, 49
head, 49
neck, 49
sacral, 49
Focus of auscultation, 94, 157
Foebes' diastase, 227
Follicles, Graafian, of the ovaries, 23
Montgomery's, in pregnancy, 89,
90
Fontanelle, anterior, of cranial vault,
125
posterior, of cranial vault, 125
Foot of embryo, 54
Foramen CKCum lingua;, 59
obturator, 117, 118
sciatic, 117
Foramen ovale, 64
Forceps, 386
anesthesia with, 389
application of, 390
axis-traction, 394
contraindications for, 388
danger of, 387
extraction by, 331, 391
force, 392
guard against slipping of, 391
in breech presentations, 394
in face presentations, 394
in occipito-posterior positions, 393
in perineal stage, 392
indications for, 387
Kocher compression, 182
mechanical action of, 387
preparatory measures for, 388, 389
Forceps, removal of, 393
traction with, line of, 391
Fore waters, shape of, 136
Fornix, anterior and posterior, 6
lateral, 6
Fossa navicularis, 3
Foiirchette, or frenulum vulvs, 3
Fowler position, 254
after labor, 207
for postural drainage, 185
Frenum of the clitoris, 2
Fronto-mental diameter of fetal head,
126
Fundus, 15
after-care of, 195
attention to, by nurse, 197
no pad over, 197
postpartum examination of, 204
situation of, 106
treatment of, after birth of head,
182
Funic souffle, in pregnancy, 95
Funnel-shaped pelvis, 288, 289
influence of, on labor, 289
Furcula, 62
Galactorrhea, 362
Galea capitis of spermatozoon, 27
Gall-bladder, congenital absence of,
76
in embryo, 61
Galvanism, use of, 209
Gastrointestinal canal, anomalies of,
table of, 75
Gastrointestinal system, adult, di-
visions of, 55
esophagus, 60
in embryo, form of, 55
intestines, 60
liver, 61
mouth, 58
pancreas, 61
pharynx, 59
stomach, 60
Gastrula, 38
Gastrulation, 38
Gavage, 383 /
464
INDEX
Qonital ominonce, 7
Uonital folds, 71
Genital jfroow, 71
Uonital orj^ans, table of development
of, 71
Uonital rid^^s 71
Oonitab, fonialo, divisions of, 1
oxtornal, 1
intornal, 13
vagina. 5
of embryo, 54
extornal. 71
Genitourinary organs of new-born
child. 217
Genitourinary system, anomalies of,
1 1
ducts of, ^, ^
external genitaUsk 71
foundation of. 6$
glands of, i2^
structurvs of. primitive glaadolar, '
Genu layvRk bUstula, 5S
vIot:\:^:*.\v* of. 40
;V>
cv,'''or'r. ,*>
cr'.-'-.-.r-.rt. .»S
.^>
j-as:-,: -i, .'S
r■^■S^.^in,'r:•^ ,'iJ
S*.iw^V"S I- T.T
••■JlTi
,'i of. 3*
v
, -■' • .*.' ,' S.
V*
^ v-
*
*
>^. • -^
*
*
Si \ ' ^
*
is. .^S. '
M
" ». "■•■«■,•.
>■% V .
Glandular hyperplasia, 240, 241
GljeoBuriay after labor, 200
Gonad, 29, 68, 70
Graafian foUkles, 23
structure of, 23
Gut, postanal, 57, 58
primitive, 38
Gut traet, developmeBt ol^ m
56, 57, 58
Haase's rule for date of
Hair, of embryo, 54
Hand brushes^ steriliiatiam ai.
Hands, antisepties is
160
cleansing of. 168, 1», 17i
of embryo, 54
of obaletrieiaB mmd wmam.
Hare-lip, 53
Head, birtt of, 130, IM, Ml,
ISO
cmbrroaie, 49
fetaL 139
management of Isrtk oC ISI
of tbe spermatoaooB. ±7. 39
Head cap. of spenBasomiim^ ^
Heart, auricles of. 6X #t
111
«. *4
■i.'cbJe. 74
ei-f^t of rr*«Txaairy -m.
f-?caL- arreati-'o r.j. il:*
T-?3~ri:!»f* :f. "K. -f*
li-jjr. iisvu:*. ;anmc
:f. "^ioie rr. ^-iw
[f'NT-ii!- >r F'ibu'ni
■ Ci-' ^ -^iiTi 'f ?'*¥'
i«. IT
INDEX
465
Hematosalpinx, 264
Hemicrania and acrania, 76
Hemiteria, 250
Hemorrhage, accidental, 344
arrest of, after labor, 195
causes of, in labor, 338
checking of severe, 350
in abortion, 262
control of, 259
in pregnancy, 339
indicating premature labor, 377
internal signs of, 346
involution, after, 202
irregular genital, 268
post-partum 196, 347
source of, in labor, 339
unavoidable, 337
Hemostasis, means of, 341
Hepatic duct of embryo, 61
Hermaphroditism, true and false, 78
Heterotaxia, 250
HiUim of the ovary, 22
Hind waters, discharge of, 143
History of pregnant woman, 148, 149
Holden*s method of direct insuffla-
tion, 218
Homogametic sex cell, 34
Hydatidiform mole, 244
Hydramnios, 41, 103, 243
danger of, 244
diagnosis of, 244
etiology of, 244
frequency of, 243, 244
indicating premature labor, 377
involution after, 202
prognosis of, 244
treatment of, 244
Hydremia, aid to correction of, 200
Hydrencephalocele, 76
Hydrocephalus, 326
diagnosis of, in head-first cases,
327
in head-last cases, 327
prognosis of, 327
treatment of, 238
Hydromeningocele, 76
Hydrometra, 101
Hydrorrhea gravidarum, 240
Hygroma, 328
Hymen, 4, 5
carunculse myrtiformes, 5
in embryo, 71
Hyoid bone, in embryo, 50
Hypogastric crease, 1
Hypophysis, 58
Hysterectomy, 337
Hysterotomy, 385
vaginal, 380
Icterus, 233
treatment of, 234
Iliocristal diameter of pelvis, 121
Iliopectineal eminences, 116
Iliopectineal line, 115, 118, 119
Iliospinal diameter of pelvis, 121
Imperforate anus, in embryo, 58
Incubation, 220
Incubator, 382
temperature of, 220
Incus, in embryo, 50
Indigestion in new-born infant, 231
Induction, of abortion, indications
for, 383
of premature labor, indications for,
376
Infant feeding. See Artificial feed-
ing
Infarcts, white, placental, 248
Infection, exposure to, 185
introduction of, 166
in nursing, 212
of urinary tract, prophylactic
against, 194, 195
prophylactic against, 194
puerperal, 365
prophylactic against, 196
Inferior strait, 116
Infravaginal portion of cervix, 15
Infundibula of lung, 62
Infundibulopelvic ligament of uterus,
18
Infundibulum of Fallopian tubes, 21
Injuries, cervical lacerations, 185, 186
pelvic floor lacerations, 186
466
INDEX
InjorieSy prophylactie against, 177,
179, 180
treatment of, in soft parts, 185
Inlet. See Pelvic brim
Instrumental deliveries, 307, 320
in breech positions, 317
in placenta preevia, 341
Instrumental reposition, 331
Instruments, Kocher compression for-
ceps, 182
Sims' speculum, 186
Simon retractor, 186
sterilization of, 167, 168
use of, in labor, 296
volsella, 186, 190
Insufflation, direct, Bjrd's method of,
219
Holden's method of, 218
Laborde's method of, 219
mouth to mouth, 218, 219
Schultze's method of, 219
Sylvester's method of, 219
Intercristal diameter of pelvis, 121
Interlocking twins, 326
Internal examination^ 175
Internal genitals: Fallopian tubes, 20
ovaries, 22
uterus, 1^{
Internal interference, avoidance of,
in labor, 175, 177
Internal pelvimetry, bisischial (or
transverse), 161
method of, 160
of diagonal conjugate, 161
of pubes, depth of, 160
of sacropuhic or transverse at out-
let, 101
of subpubic angle, width of, 161
Internal version, methcxl of, .'i99,
400
Intersi)lnal diameter of pelvis, 121
Interstitial j)regnan('y, treatment of,
070
Intertrigo, treatment of, 2'.\2
Intestine, small, in embryo, GO
Intestini's. anomalies of, 75, 76
Intraligamentous pregnaney, 265
diagnostie ngna of, in later oMmtlii^
267
Intraperitoneal rapture, 269
Intrauterine dot, formation of, 195
Intrauterine tampon, blood dots t%
195
Introltus, indsion of reirintiwg ring
of, 180
Introltus yagins, 6
Inversion of uterus, Hi«fifigni«iiiiig
features of, 333
etiology of, 332
frequency of, 332
infection in, prevention of, 334
physical examination for, 333
preventive treatment of, 333
prognosis of, 333
reposition of, methods for, 333
symptoms of, 332
Involution, 200
after endometritis, 202
after hemorrhage, 202
after hydramnios, 202
after premature labor, 202
after septic infection, 202
after twins, 202
cervix and, 202
degree of, guide to, 202
duration of, 201
in non-nursing women, 202
measurements during, 201
OS externum and, 202
OS internum and, 202
pelvic structures and, 203
premature rising and, 202
promotion of, after labor, 196
retardation of, causes of, 202
tardy, 208, 209
vagina and, 203
Irritable uterus, treatment of, prior
to conception, 258
Ischial spines, 117
Ischial tuberosities, 117, 119
distance between, 161
Iscliiopagus, 251
INDEX
467
Isthmus. See Pelvic brim,
of Fallopian tubes, 21
of uterus, 15
Jaundice, in new-born infant, 215
Jaw in embryo, 50
Jugular Ijmph sacs, 67
Justo-major pelvis, 288
Justo-minor pelvis, 287
Kidneys, anomalies of, 77
cystic tumors of, differentiated
from pregnancy, 102
Kocher compression forceps, 182
Kyphoscoliotic pelvis, 291
Kyphotic pelvis, 290
influence of, on labor, 291
Location of anterior shoulder, 155
of cephalic prominence, 154
of dorsal plane, 150
of fetal heart, 157
of lower fetal pole, 152
of small parts, 150
Labia majora, 1, 2
fossa navicularis, 3
fourchette, or frenulum vulvae, 3
rima pudendi, 3
Labia minora, 2, 3
in embryo, 71
Labor, abdominal muscles during, 112
after-care of patient in, 195
anesthetics in, 177, 178
anomalies of, 279, 284, 328
eclampsia, 352
hemorrhages, 337
inversion of uterus, 332
prolapsus funis, 328
rupture of uterus, 334
separation of symphysis pubis,
351
bag of waters in, 136
beginning, signs of, 171
birth of head in, 139, 140, 141, 142
birth of trunk in, 143
breaking of the waters in, 137
causes of onset of, 132
Labor, cervical canal in, obliteration
of, 135
cleansing of patient at close of,
196
complications in, 42, 46, 148
contraction during, 112
date of, 104, 105, 106
death in, cause of, 178
defecation during, 133
dilation of cervix in, 134, 138
dilation of external os in, 135
dry, 41, 281
expelling forces of, 112, 113
expulsion of cervical plug in, 133
lightening before, 133
liquor amnii in, 136
management of, 148
in flat pelvis, 296
in pelvic deformities, 297
in twin births, 325
mechanism of, 112
mucous flow during, 133
passenger in, 123
pathology of, 279, 284
pelvic floor in, 113
physiology of, 112
placenta previa in, 42
placental stage of, 145
precipitate, 279
premature. 111, 254, 262, 296
preparation for, 163
prevention of complications in, 148
prolonged, 280
''puller" in, 176
retraction ring in, 134, 138
show in, 133
signs of onset of, 133
softening of cervix in, 137
stage of expulsion in, 138
stages of, 132
subjective signs of, 171
traction of longitudinal muscular
fibers in, 134
twins in, 325
urination during, 133
uterine contractions in, 112, 133,
134
468
INDEX
Labor bed, preparation of, 106
Labor pains, cramp-like, 280
drugs in, 174, 175
feeble, 280
moderation of, 179
ueceHsity of, 141
relief in, 174, 175, 176, 177
Htiiiiulatiun of, 178, 179
Laburde's method of direct insuffla-
tion, 219
LaciTatious, cervical, 186
of pelvic floor, 186
VHKiiial, 193, 194
Lactation, deficient, signs of, 211
measures for increase of, 211
Laughans, layer of, in chorion, 43
Lanugo, 216
in embryo, 54
Liaryux, anomalies of, 78
iu embryo, 62
Lateral procesHOH, of tongue, 59
Layer, roctal, 10
rct'tovagiuul, 10
vesical, 10
vuHicuvaginul, 10
LuxativoH in new-born infants, 230
Lug iu (Muhryo, 50
Leukeuiia, 3H4
Lu\utor uui fuHcia, 6
lAivuiur ani nuiscic, 11
Ligumeut, ovarian, 23
the triangular, 11
Ligumoutti of the uterus, broad, 18
changes in, during pregnancy, 85
iufuudibulopelvic, 18
(ivariojHdvic, 18
round, 19
utcropclvic, 19
uterosacral, 18
utcrovesical, 18
liigliteuiug during pregnancy, 9
1 jiiib bu<ls, in embryo, 54
Liui^a albicantes, 92
Liiicu nigra, 91, 92
Li|iii, in embryo, 54
IJijitur aninii, anomalies of, 242
il«:lii:it;nry of, 242
I
Liquor amnii, divisions of, in labor,
136
excess of, 243, 244
Lithotomy position, 161
Liver, anomalies of, 76
in embryo, 61
Lochia, attention to, 204, 205
character of, 203
duration of, 204
Lochia alba, 204
Lochia serosa, 203, 204
Lochia rubra, 203, 205
Lochial discharge, 185
Lochial flow, attention to, after labor,
197
Lochial guard, at close of labor, 196
Longitudinal muscular fibers, 134
Longitudinal presentations, 330
Lung-buds, in embryo, 62
of new-bom child, 215
Lutein cells, 37
Lutein granules, 36
Lying-in period, duration of, 209, 210
Lying-in room, selection and prepara-
tion of, 166
Lying-in woman, antisepsis of, 207
bladder of, 205, 206, 207
bowels of, 207
cleanliness of, 207, 208
diet of, 207, 208
external genitals of, 208
rest for, 207
Lymph spaces, enlargement of, after
labor, 200
Lymphangioma, 328
Lymphatic channels, axial, 67
peripheral lymphatics, 67
Lymphatic system, 67, 68
Lymphatic vessels, evolution of, 67
jugular lymph sacs, 67
of the external genitals, 5
of the Fallopian tubes, 22
of the ovaries, 23
of the uterus, 20
segments of, 67
systemic, 67
Lysol, 167
INDEX
469
Mallens in embryo, 50
Mali's method for determining length
of fetus, 55
Malpositions, 136; 137
Malpresentations, 136, 137
Mammary examination, 149
Mammary infection, 362
Mammary signs of pregnancy, 88
areola, primary, 89
areola, secondary, changes in, 91
colostrum, 90
milk glands, 88
Montgomery's follicles, 89, 90
veins of breast, changes in, 90
Mandible, embryo, 52
Mandibular arches, 58
Mandibular process, 52
Manipulation, of uterus, danger of,
209
within passages, 185
Manual dilation in hemorrhage,
342
Manual reposition in prolapsus funis,
330
Marital relations during pregnancy,
110, 111
Massage, of breast, 212
over fundus, 209
Mastitis, 238
abortive measures in, 363
causes of, 362
diagnosis of, 363
drainage in, 364
excoriation in, 364
fissures in nipples in, 365
frequency of, 362
glandular, 362
inflammation in, types of, 362
parenchymatous, 362
prophylaxis of, 363
sore nipples in, treatment of, 364
subcutaneous, 362, 303
subglandular, 302, 363
treatment of, 363
treatment of suppuration in, 364
Maternal condition after labor, 204,
205
Maternal mortality, in eclampsia, 355
in placenta praBvia, 340
Maternal organism, effects of preg-
nancy on, 83
Maternal pulse, attention to, in birth,
144
in labor, 175
following labor, 204, 205
Maternal temperature, attention to, in
birth, 144
following labor, 204, 205
Maturation, 30
Mauriceau method of extracting the
after-coming head, 317
Maxillary process, 52, 58
Measurements, determination of nu-
merical equivalent of, 149
pelvic, necessity of taking of, 158
Meatus urethrae, 4
Mechanism, Duncan 's, 146
Schutze's, 146
Meckel 's cartilage, 50
Meckel 's diverticulum, 47, 75
Meconium, 216
Medullary zone of ovaries, 23
Melena neonatorum, 237
Membrane, cell, of the ovum, 25
closing, 50
Membranes, anal, 57, 58
artificial rupture of, in labor,
176
bag of, preservation of, 176
breaking of, 41
early rupture of, 137, 143
examination of, 185
expulsion of, from uterus, 185
fetal, 41
nuclear, of the ovum, 26
pharyngeal, 57, 58
renioval of fragments of, from
vagina, 185
Meningocele, of the cerebrum, 76
spinal, 76
Moningoencephalocele, 76
Menorrhagia, 102
Menstruation, 35
anomalous, attention to, 267
470
INDEX
Menstruation, cessation of, in amenor-
rhea, 87
in pregnancy, 87
Mensuration of fetus, 105
of uterus, 105
Mentoanterior position, extension in,
304
flexion in, 304
mechanism of, 304
restitution in, 305
rotation in, 304
external, 305
treatment of, 306
Mentoposterior position, abdominal
signs of, 305
diagnosis of, 305
mechanism of, 305
prognosis of, 305
treatment of, at brim. 306
in cavity, 306
vaginal signs of, 305
Mercuric biniodid, 167
Mesencephalon, 74
Mesoderm. 39
derivatives from, 40
Mesonephroic duct, 69
Mesonephros, 65, 68, 69
Mesosalpinx, IS
of Fallopian tubes, 21
Metamorphosis of sex organs. 71 |
Metanephri^, 6S, 69
Metencephalon, 74
Metritis, 368
chronic, 101
differentiation of, from preg-
nancy, 96
Metrv^rrhagia, :^>5
Micrvn<vphalT, 76
Micrw^^phaly, 76
Miliu <^rti^\l, ii!6
cow 's, basic facts in u^* of. 226
ditfereiKT's NMwi^n human and,
xabulatcv) c\>ai}^an<on i>f hnman
and, 22-"^
pastour.«i::v>n of. 226
sti^riUsA:^^ \>f. 226
Milk secretion, deficient, signs of, 211
establishment of, 210
measures for increase of, 211
Milk feeding in diarrhea, 232
Milk glands, in pregnancy, 88, 89
Milk-leg, 369
Miscarriage, 255
in placenta pnevia, 340
Mitosis, 37
Molding of fetal head, 143, 144
Monoccphalic monster, 251
Monosomatic monster, 251
Mons veneris, 1
in embryo, 7
Monster, anencephalic, 251
cclosomatic, 250
cephalopagus, 251
cyclocephalic, 251
double, 251, 326
double parasitic, 251
ectromelic, 250
exencephalic, 250
ischiopagus, 251
monocephalic. 251
monosomatic, 251
octocephalic. 251
omphalositic. 251
pseudencephalic. 251
stemopagus. 251
svmelic, 250
syncephalic, 251
synsomatic, 251
xiphopagus. 251
Morphin. in eclampsia, 357
in labor pains, 174
MomUu 37
Month, anomalies of, 75
in embryo. 49, 52, 57. 58
salivary glands and tongue, 59
tc>f:h in. 5S, 59
Mouth to month, dinct insufflation
21S. 219
Mucx^35 coat of Fallopian tubes, 21
Mucxvis pillar, expulsion of, 172
Mu^u;*.. c>^rv*raL in laboTy 133
vaurl^aL in labor, 133
o«
INDEX
471
Mullerian duct, 69, 70
Multiple incisions^ 382
Multiple fetation, 103
causes of, 103
consequences of, 103
superfecundation, 103
superfetation, 104
Muscle, levator ani: coccygeus, 12
iliococcygeus portion of, 12
ischiococcygeus bundle, 12
obturator coccygeus bundle, 11
pubococcygeus bundle, 11
uterine, 17
Muscles of pelvic floor, 11, 12
Muscular coat of Fallopian tubes, 21
Muscularis, 17
Myelencephalon, 74
Myelocystocele, 76
Myelomeningocele, 76
Myocardium in embryo, 63
Myoma, 328
differentiation of, from pregnancy,
96, 102
Naegele oblique pelvis, 292
Naegele's rule for date of labor, 104
Nails, in embryo, 54
of obstetrician and nurse, 168,
169
Narcotics in puerperal infection, 373
Nasal pit, 53
Nasal processes, lateral and medial,
53
Nasofrontal process, 52, 53, 58
Naso-optic furrow, 53
Nausea, and vomiting, during preg-
nancy, 87, 88, 111
Navel, infection of, 222
Navel dressing in newborn child, 221,
222
Navel stump, attention to, 198, 222
Neoplasms, vaginal, 298
Nephritis, chronic, induction of abor-
tion in, 383
treatment of, prior to conception,
258
Nephrotome, 39
Nerves, of external genitals, 5
of Fallopian tubes, 22
of ovaries, 23
of pelvic floor, 13
of uterus, 20
of vagina, 7
Nervous system, anomalies of, 76
central, 72
in embryo, 48
effect of pregnancy on, 85, 86
of newborn child, 217
Neural folds, 72
Neural groove, 72
Neural plate, 72
Neural tube, 73
Neuropore, 73
Newborn infant, bloody genital dis-
charge in, 238
cephalhematoma in^ 233
colic in, 231
constipation in, 230
diarrhea in, 231
disorders of, 230
Duchenne's paralysis in, 238
icterus in, 233, 234
indigestion in, 231
intertrigo in, 232
mastitis in, 238
melena neonatorum in, 237
omphalitis in, 236
ophthalmia neonatorum in, 234
preputial adhesion in, 233
tetanus neonatorum in, 237
thrush in, 232
umbilical fungus in, 236
umbilical hemorrhage in, 237, 238
umbilical infection in, 236
Nipples, care of, 212
during pregnancy, 109
fissures in, 365
postpartum attention to, 204, 205
treatment of sore, 364
Nitroglycerin, in eclampsia, 356
Non-nursing women, involution of, 202
Nonrachitic flat pelvis, 286
Nose, in embryo, 54
Nuclear membrane of the ovum, 26
472
INDEX
Nuclear sap of the ovum, 26
Nucleus, of the ovum, 25
of the spermatozoon, 28
Nulliparous uterus, 18
size of, 15
Nurse, after-care of patient by, 195,
197
asepsis of, 208
directions to, 197, 198
hands and forearms of, 168, 169
nails of, 168, 169
preparation of, 168
Nursing, after-pains and, 203
contraindications 'to, 213
diet in, 211
infection in, 212
newborn child, 223, 224
relief of pain in, 364
wet, when necessary, 223
Nursings, number of, 223
Nympha?, 2
Obesity, diflferentiated from preg-
nancy, 101
Obliquo iliamotor of polvic brim, 120
of ]H»lvic cavity, 121
of ]>(»lvie outlet, 121
Obliquely contracted pt^lvis, 292
Obstetric equipment, 163, 164
Obstetric haii<l-bag, equipment of, 163,
164
Ohstetric laud-marks, 116
Obstetric surgery, 376
Ol>stelri«'iaii. hands and forearms of,
ir)s, 109
antist'ptirs in |»rei>aration of. 160
nails of, lOS. 1(59
prefjaration of. 16S
Obturator fascia. 9
Ol>turati»r f(»ranuna. 117, IIS
Obturator iiitfrnus. 12.')
Ocoipito frontal rircumference of fe-
tal hr:ol. 127
Oeei]>ito-fioiital «lianieter of fetal
hea.l. 12»;
(Vcipilo -posterior po>ition. ab'loininal
si^ns of, .■'."•I
Oecipito-posterior poritiosy taaun of,
301
dangers of, 302
diagnofliB of, 301
forceps in, 393
mechanism of, 301
treatment of, above the brim, SOS
at vaginal outlet, 303
in cavity, 303
vaginal signs of, 301
Occiput of cranial vault, 125
Occlusion at oa extemom, 290
Octocephalic monster, 251
Oligohydramnios, 242
Omentum, in embiyo, 60
Omphalitis, 236, 237
Omphalositic monster, 251
Onset of labor, expulsion of eervieal
plug at, 133
increased flow of mucus at, 133
irritability of rectum and bladder
at, 133
"lightening" at, 133
''show" at, 133
uterine contractions at, 133
Oocyte, primary, 32
secondary, 32
Oogenesis, 29, 30
Ophthalmia, prophylactic against, 220
Ophthalmia neonatorum, cause of, 234
curative treatment of, 235
oculist in, 235
prevention of, 221
projjnosis of, 234
]>rophylactic treatment of, 234
Opiates, repeated doses of, in labor,
174
Opium, use of, in threatened abor-
tions, 258
Optic vesicles, 73
Oral pit, 49, 50, 58
Organology, 55
canliovascular system, 63
central nervous system, 72
gastrointestinal system, 55
^'onitourinarj' system, 68
lymphatic system, 67
INDEX
473
Organology, respiratory system, 61,
62 '
Os externum, 16
involution of, 202
obliteration of, 135
occlusion of; 299
Os internum, 16
expansion of, in labor, 135
involution of, 202
Osteomalacic pelvis, 293
Ostium abdominale, or internum, of
Fallopian tube, 21
Ostium uterinum, of Fallopian tubes,
21
Ostium vaginae, 2
Ovarian cystomata, differentiated
from pregnancy, 102
Ovarian cysts, 299
Ovarian ligament, 23
Ovarian pregnancy, termination of,
265
Ovaries, 22
anomalies of, 77, 299
arterial supply of, 23
changes in, during pregnancy, 85
Graafian follicles of, 23
in fetus, 70
lymphatics of, 23
nerves of, 23
ovarian ligament, 23
shape of, 22
situation of, 22
size of, 22
stroma of, 23
structure of external, 22
internal, 23
veins of, 23
Ovariopelvic ligament of uterus, 18
Oviducts, 20
anomalies of, 77
Ovulation, 35
Ovum, 25
ameboid movements in, 26
arrest of, in progress, 263
arrested in isthmic portion of tube,
264
centrosome in, 26
Ovum, death of, 384
detachment of, 384
development of, in ampulla, 264
egress of, from ovary, 35, 36
expulsion of, 254
form of, 25
maturity of, 32
size of, 25
structure of, 25
trophoderm of, 38
Oxalate of cerium, 275
Oxygen, use of, 275
Pack, use of, 385
Pads, sterile, 208
Pains, after, relief of, 197
labor, 134
cramp-like, 280
drugs in, 174, 175
feeble, 280
moderation of, 179
relief in, 174, 175, 176
stimulation of, 178, 179
rhythmic, occurrence of, 172
Palate in embryo, 58
Pancreas, anomalies of, 76
in embryo, 61
Paralysis, Duchenne's, danger of pro
ducing, 181
Paramastitis, 362
Parametritis, 368
abortion in, 261
treatment of, 374
Parathyroids, caudal, 60
cephalic, 59
Paraxial mesoderm, 39
Parous uterus, 18
size of, 15
Parovarium, 24
Pars cystica, 61
Pars hepatica, 61
Pars intermedia, 4
Parturient axis, 123
Passages, anomalies of, 284
Passenger, anomalies of, 301
in labor, 123
Pavilion of Fallopian tubes, 21
474
INDEX
Pelvic anomalies; ankylmied obliquely
I'elvic brim, relation of, to soft parn,
contratted pelvis, 292
122
caneec of cGrvJi, 299
I'elvic cavity, diameters of, 120
cjstocele, 29S
plaae of, 118
diwase of booea of pelvis, 284
relation of, to soft parts, 123
faultj duvelopmeot, 284
Pelvic conjugate. 7-9 em., 296
frequency of, 285
7 cm., or leas. 297
general character of, 285
Pelvic coDl^nts, postpartum eiamin*-
gravity of, 285
tion of, 205
juBto-niajor pelvis, 288
Pelvic contractions. 376
justo-minor pelvis, 28T
Pelvic deformity, clinical data of, SM
kyphoscoliotic pelvis, 291
fetomctry in, 29S
kyphotic pelvis, 290
management of labor in, 297
Nuegele oblique pelvis, 292
pelvimetry in, 204
narrowing of, 294
Pelvic diameters, at brim. 119. 120
nonrachitic flat, 286
Dunierical equivalents of, 119
obliquely contracted, 292
Pelvic eiaraination in labor, 172
occlusion of oa externum, 299
Pelvic fascia, obturator, 9
of skeleton, 285
rectovesical. 10
of soft parts, 298
I'elvic floor, 8
osteomalacic pelvis, 293
action of, during labor, 113
ovarian cyafs, 299
after-care of, 194
pelvis equabiliter juato- minor,
2S7
blood and nerve supply of, 13
faacin of, 9
rachitic flat pelvis, 286
firmness of, necessary to rotation
rachitic flat am) generally cout
aet-
of fetal head, 141
ed pelvis, 287
injuries to, prophylaxis of, 179, ISO
rectocele, 298
measurements of, 9
rigidity or stenoais of the ee
Vin,
muscles of, U
298
perineal body of, 13
Robert's pelvi
scoliotic pelvia, 291
split pelvis, 293
spondyloliathetic pelvis, 292
transi'ergeiy contracted pelvis,
tumors, 299
uterine diapiucenient, 299
titerine tumors, 299
vaginal atri'sia, 293
vaginal neoplaams, 298
vulvar atresia, 298
Pelvic axis, 119
Pelvic basin, cavity of, 117
Pelvic brim, 115
dianictera of, 119
ubslelri.' landmarkB of. 116
triangular ligament, 11
Pelvic floor lacerations, 186
nncsthelica in repair of, 188, 189
causes of, 187
complete tears, !87
degrees of. 187. 188
incomplete tears. 187
method of suture of. ISS, 189
preparation for repair of, 192, 193
repair of third degree, 191, 192
Blitehea in, 191. 193
? of.
t of,
INDEX
475
Pelvic outlet, boundaries of, 116
diameters of, 121
in labor, 116
obstetric landmarks of, 116
plane of, 119
relation of, to soft parts, 123
Pelvic signs of pregnancy, 95
Pelvic soft parts, relation of, to brim,
122
relation of, to cavity, 123
relation of, to outlet, 123
Pelvic structures, involution of, 203
Pelvimeter, Colyer's, 158
Pelvimetry, external, 157
internal, method of, 160
pelvic deformity and, 294
Pelvis, absolute contraction of, 384
ankylosed obliquely contracted, 292
anomalies of, 284
bony, anatomy of, 113
circumference of, 121, 122
conjunction of bones of, 284
diameters, external, of, 121
diameters of cavity, 120
diameters of outlet, 121
disease of bones of, 284
equabiliter justo-minor, 287
false, 115
faulty development of, 284
funnel-shaped or male, 288, 289
justo-major, 288
justo-minor, 287
kyphoscoliotic, 291
kyphotic, 290
Naegele oblique, 292
narrowing of, 294
obliquely contracted, 292
obstetric, 115
osteomalacic, 293
planes of, 118, 119
pseudo-osteomalacic, 294
rachitic flat, 286
rachitic flat and generally con-
tracted, 287
Robert's, 292
scoliotic, 291
sexual diff'erpnces in, 122
Pelvis, skeleton, anomalies of, 285
soft parts, anomalies of, 298
split, 293
spondylolisthetic, 292
transversely contracted, 292
true, 115, 117
Penis, in embryo, 71
Peptonuria, 200
Pericardium, embryo, 63
Perimetritis, 368
in abortion, 261
Perineal body, 13
Perineal stage, episiotomy in, 180,
181
in birth of trunk, 144
of labor, 179
Perineum, in embryo, 58
Peripheral lymphatics, 67
Peripheral mesoderm, 39
Peritoneal cavity, external infection
of, 22
Peritoneal coat, of Fallopian tubes, 21
of uterus, 18
Peritonitis, diffuse, 369
treatment of, 374
Pernicious anemia, 384
Pernicious vomiting, diagnosis of,
273
dietetic measures in, 274
drug measures in, 275
etiology of, 273
general therapy in, 275
induced abortion in, 275
local measures in, 275
neurotic type of, 273
prognosis of, 274
reflex type of, 273
toxemic type of, 273
treatment of, 274
Pharyngeal membrane, embryo, 57, 58
Pharyngeal pouches, 50, 59
Pharynx, anomalies of, 75
embryonic, 50, 59
Phlegmasia alba dolens, 369
treatment of, 374
I'honation, organ of, embryo, 62
Physician, after-care of labor by, 195
476
INDEX
Physician, care of patient by, after
labor, 397
postpartum calls of, 204
responsibility with, 205
Physiology of labor, 112
Pit, anal, 57, 58
mouth, 57
nasal, 53
oral, 49, 50, 58
Pituitrin, use of, 195
Placenta, adhesion of. See Adherent
placenta.
after-birth, 46
annular, 46
anomalies of, 46, 47, 247, 249
apoplexy of, 248
at birth, 44
calcareous degeneration of, 248
Credo's method of expulsion of,
183
cysts of, 247
diseases of, 247, 249
double origin of, 43
e<lema of, 248
enforced expulsion of, 183
examination of, 185
expulsion of, 145, 146
failure of expression of, 184
fatty degeneration of, 248
fetal portion of, 43
maternal portion of, 43
natural expulsion of, 182
perforation of, 342
polycotyledonary, 46
respiratory blood changes in, 81
separation of, 145
subsidiary, 247
syphilis of, 248
white infarcts of, 248
Placenta bipartita, 46
Placenta duplex, 46
Placenta pnevia, 42, 149, 247
causes of, 338
definition of, 337
degrees of. 337
distinguishing features of, 339
frequency of, 338
Placenta pnevia, maternal mortality
in, 340
physical signs of, 339
precautions in, 343
prognosis of, 340
symptoms of, 339
treatment of, after viability, 341
before viability, 340
Placenta membranacea, 46, 244, 247
Placenta spuria, 47
Placenta succenturiata, 47, 247
Placental septa, 44
Placental site, elevation ©f, after
labor, 200
Placental stage of labor, 132, 145
duration of, 148
management of, 182
Placentitis, 248
Plane, dorsal, location of, 150
Planes of pelvis, 118, 119
Plasmoditrophoderm, 43
Pleuroperitoneal space, 39
Plexus, capillary, 64
perimesonephroic, 65
I venous, of labia majora, 2
Potlalic presentation of fetus, 128
i Podalie version, 296, 297, 302
Polar body, first and second, 30
Polyhydramnios. See Hydramnios.
Pomeroy bag, 380
Porro operation, 297, 299
definition of, 410
indications for, 410
steps of, 410
Portal, anterior intestinal, in embryo,
57
posterior intestinal, in embryo, 57
Portal ^ein, 67
Portio vaginalis of cervix, 15
Position of fetus, 129
! breech, 130
determination of, 129
dorsoanterior, 316
dorsoposterior, 311, 318
face, 130
mentoanterior, 304
mentoposterior, 305
INDEX
477
Position of fetus, occipito-posterior,
301, 393
scapulo-anterior, 321
scapulo-posterior, 321
shoulder, 130, 131
transverse or shoulder, 130
vertex, 130, 132
of patient, for abdominal exami-
nation, 150
Fowler, 254
in labor, 173
in second stage, 177
lithotomy, 161
Walcher, 113
Postanal gut, 57, 58
Postmammary abscess, 363
Postmortem Cesarean section, 410
Postpartum calls, 204
Postpartum chill, 199
Postpartum diet, 207
Postpartum hemorrhage, causes of,
347
checking of, 350
danger signals of, 347
definition of, 347
diagnosis of, 347
prophylactic against, 196, 349
remedial measures in, 349
secondary, 351
signs of, 349
treatment of, 349
Postpartum inertia, 196
Postpartum rest, 207
Posture of fetus, 128, 129
of patient in labor, 113, 173, 178
Precipitate labor, cause of, 279
dangers of, 279
treatment of, 279
Pregnancy, abdominal, 263, 267
abdominal signs of, on ausculta-
tion, 93
on inspection, 9
on palpation, 92
anemia in, 277
anomalies of, 241
anomalies of umbilical cord in,
249
32
Pregnancy, areola in, primary, 89
secondary, 91
bladder in, 91
blood losses frpm vagina in, 111
blood pressure during, 110
bowels, care of, during, 108
care of teeth during, 108
cervix during, 95
choc foetal during, 94
clothing during, 109
colostrum in, 90
complications of, danger signals of,
111
diabetes, 359
constipation, persistent, in, 111
dccidua, diseases of, in, 239
diagnosis of, 87
diet during, 108, 109
differential diagnosis of, 100
differentiated from ascites, 101
differentiated from cystic tumors
of kidney, 102
differentiated from ovarian cysto-
mata, 102
differentiated from tympanites, 101
differentiated from uterine myo-
mata, 102
diseases of, 239
diseases of the chorion in, 244
duration of, 104
edema about face in. 111
effects of, on maternal organism,
83
examinations during, 148
exercise during, 107
extrauterine, 262
fetal heart sounds during, 93, 94
fetal movements in, 93, 99, 100
frontal headache in, 111
general changes consequent on, 83,
84, 85, 86
Hcgar's sign of, 96
hemorrhage during, 339
hygiene, importance of, during, 148
interstitial, treatment of, 272
intraligamentous, 265, 267
lightening'' during, 91
( (
478
INDEX
PregiiBne7. mammary nignn of, SS
108,
incubation of, 220
109, 110
Premature labor, 254, 263
marital relations daring, 110
111
artificial, 296, 297
raenstniatioQ ia, cesaatioo of,
87
contributing cauaea of, 248
milk glaoJB durioff. 88, 89
induction of, 376, 377
milk Hecretion in, 90
catheterization of uterus in, 377
Montgomery's follicles in, 89,
90
nausea and vomiting in, 87, 89
habitual death of fetus as indio-
nipples, care of, during, 109
tion for, 3T6
normality of, 107
ovarian, 283, 265
in hydraumioa, 377
pathologx of, 239
in placenta previa, 340
pelvic signs of, 95
in toiemia, 377
pernicious vomiting of, 273
instrumental dilation of cerra ia,
placenta in, anomuliea anil Oiseases
380
of, 247
manual dilation of cervix in, 379
positive signs of, 91, 93, 98
multiple inciaiuns in, 382
proofs of, 44
pelvic contraction as indieaUoD
pruritus vulvn; in, 278
for, 376
ptjalism in, 276
involution after, 202
pulmonary tuberculosis in, 277
Premature rising after labor, 202
quickening in, 88
Premature rupture of membranes, 137
sleep during, 106
Prepuce, 2
souffle, funic or uinbilieal, in.
95
Preputial adhesion, 233
uterine, B4
Preputial fold of the clitoris, 3
spurious, 102
Presentation of fetus, 128
swelling of feet in, 111
breech, 310, 394
symptoms of, 87, 88
brow, 308
table of signs of, 99
cephalic, 128, 113
toiemia during, 109, 110
com pies, 323
tubal, 42, 26.1, 266
face, 303, 394
tobouterine, 2G5
longitudinal, 330
urine, attention to, during, 110
111
mi-lhods of conversion of, 307
uterine artery in, 98
podalic, 128
uterine contractions during, 9
shoulder, 321. See also traiis\-erse.
uterus, during, 92, 93, 96
transverse, 128, 321
vagina during, 95
Primary rupture in ectopic pregnanrj
vaginal discharges tiiiriiig, V)S
signs of, 267. 269
INDEX
479
Process, maxillarj, 52, 58
nasal^ 53
nasofrontal, 52, 53, 54
Proctodeum, 57, 58
Prolapsus funis, 328
causes of, 329
diagnosis of, 329
frequency of, 329
prognosis of, 330
treatment of, 330
Prolonged labor, cramp-like pains in,
280, 281
feeble pains in, 280
first stage of, 280
second stage of, 282, 283
simple inertia uteri in, 280
Pronephroic duct, 68
Pronephros, 68, 69
Pronuclei, union of male and female,
30, 37
Pronucleus, female, 32, 37
male, 37
Prosencephalon of embryo, 74
Pruritus vulvae, in pregnancy, 278
Pseudencephalic monster, 251
Pseudo-osteomalacic pelvis, 294
Pseudocyesis, 102
Ptyalism, in pregnancy, 88
treatment of, 276
Pubcs, depth of, 160
Pubic ramus, 1
Pubiotomy, 296, 297, 307, 309, 376,
419
after-treatment in, 422
indications for, 419
results of, 419
technique of, 420
Pubis, 1, 122
Pudendal sac, 2
Pudendum, 1
Puerperal infection, 111, 365
antipyretics in, 373
antiseptic preparations in, 372
antistreptococcic serum in, 374
avenues of invasion of, 366
bacteremia in, 370
bacteriology of, 366
Puerperal infection, channels of dif-
fusion of, 367
collar golum in, 373
colpitis, 370
curetting in, 372
cystitis, 370
diagnosis of, 367
endometritis, 368
etiology of, 366
frequency of, 365
general symptoms of, 367
intrauterine exploration, 372
metritis, 368
milk-leg, 369
narcotics in, 373
parametritis, 368
perimetritis, 368
peritonitis, 369
phlegmasia alba dolens, 369
prognosis of, 371
prophylaxis of, 371
pyemia, 370
remedial treatment of, 371
septicemia, pure, 370
special manifestations of, 367
symptoms of special lesions in, 368
systemic measures in, 372
treatment of, 371, 375
tympanites, 369 •
ureteropyelitis, 370
vaccines in, 374
vehicles of, 366
Puerperal insanity, 361
Puerperal pathology : galactorrhea,
362
insanity, 361
mastitis, 362
Puerperal phenomena, acetonuria, 200
after-pains, 203
blood channels, enlargement of, 200
bowels sluggish, 200
cavity of uterus, 200
chill, 199
glycosuria, 200
involution, 200, 201
lochia, 203
lymph spaces, enlargement of, 200
480
INDEX
Puerperal phenomena, peptonuria, 200
placental site, elevation of, 200
retention of urine, IW), 200
slow pulse, 199
sweat glands, activity of, 200
temperature, high, 199
uterus, condition of, after labor,
200
Puerperal state, physiology of, 199
Puerperal woman, diet of, 207, 208
regulation of, 209, 210
Puerperium, metrorrhagia in, 205
"Puller," in labor, 176
Pulmonary alveoli in embryo, 62
Pulmonary diverticula in embryo, 62
Pulmonary groove in embryo, 61
Pulmonary respiration, absence of, 81
Pulmonary tube, 62
Pulmonary tuberculosis in pregnancy,
277
Pulse, fetal, at birth, 144
mntornal, attention to, after labor,
197
in birth, 144
in labor, 175
slow rate of. after labor, 199
Pyemia, 370
treatment of, 375
Pyometra, 101
Pyosalpinx, 264
Quii'koninij lUirinjj pregnancy. S8
Karbitii- llat pelvis. 2S6. 2S7
l\aplu\ iiu'ilian :uu\ reotiH'oooygeal, 9
Koartion 7oiu\ iUiS
KorTal iiu^asuros in iiewK^rn infants,
Keotovole. •J9>
Kootovosival fascia, 'ayors of, 1"^ I
luHti'v.i 1". t'::;l'rvo. ."S ,
li 1 l.«i« ftV^il \*« l*^«i i*-«^ «*ti'l«« fti^i*
Krj:r.'.;i:i.v. ^^f o\vtV..ri: '.rvC-!. ITS.
I\ < i I 1 . I . , > \ . • • . . . . • ^ V • t ^
Benal peMo, 70
Bepontion in prolapsat f ani% iutm-
mental, 331
mannal, 330
with gauxe tampon, 331
Beprodnetion, 25
arteries, 64, 65
cardiovaBeolar system, 63
eellB of, 29
central nervooB system, 72
cleavage, 37
development of external tagm of
body, 47
ectopic gestation, 36
external form of bodj, devielopnMBt
of, 47
fertilization, 28, 37
fetal circulation, 81
fetal development, tabulated chro-
nology of, 79
fetal membranes, 40
gastrointestinal system, 55
genitourinary system, 68
germ layers, formation of, 38
implantation, 40
lymphatic system, 67
maturation, 30
oogenesis, 29, 30
organology, 55
ovulation, 35
ovum, 25
pregnancy, effects on maternal or-
ganism, S3
respiratory system, 61, 62
sex elements, preparation of, 28
spermatogenesis, 29, 30, 32
spermatozoon, 26, 35
veins. 65
Rt^piration in newborn child, 215, 217
Respiratory blood changes in fetus,
SI '
Respiratory system, anomalies of, 78
first indication of, 61
larvni. 6-
voins, 6o
Ko5t. postpartum. 207
Kt\i::itution of fetal head in birth, 142
INDEX
481
Betention of urine after labor, 199,
200
Betraction, uterine, after labor, 195
in labor, 145, 146
Retraction ring, high position of, 335
in labor, 134, 138
partial closure of, 385, 386
Betroversions, treatment of, prior to
conception, 259
Bima glottidis, 62
Bima pudendi, 3
Bobert's pelvis, 292
Botation of fetal head, 140, 141, 142
external, 142
in breech presentation, 310
Bound ligaments of the uterus, 19
Bubber gloves, sterile, 169, 170
Bugse, 7
Bupture of ectopic pregnancy, extra-
peritoneal, 269
into broad ligaments, 271
into peritoneum, 270
intraperitoneal, 269
primary, 267, 270
secondary, 272
of membranes, in placenta pra)via,
341
in prolapsus funis, 330
of uterus, complete, 335
curative treatment of, 336
danger signals of, 335
diagnosis of, 335
etiology of, 335
exciting causes of, 335
frequency of, 335
incomplete, 335
predisposing causes of, 335
preventive treatment of, 336
prognosis of, 336
signs of, 335
spontaneous, 335
Sac, enamel, 58
Sacral flexure, 49
Sacrococcygeal joint, in labor, 113
Sacrococcygeal teratoma, 328
Sacroiliac joints in labor, 113, 116
Sacrosciatic ligaments, 116, 117, 119
Sacrum, of bony pelvis in labor, 113,
116, 118
promontory of, 116
tip of, 116, 119
Sacs, air, 62
Salivary glands, in embryo, 59
Santorini, duct of, 61
Scapuloanterior positions, 321
Scapulo-posterior positions, 321
Schatz method of converting a face
into a vertex presentation, 307
Schultze 's method of direct insuffla-
tion, 219
Schutze's mechanism, 146
Sciatic foramina, 117
Scoliotic pelvis, 291
Scopolamin in labor pains, 174
Scrotum, in embryo, 72
Secondary rupture of ectopic preg-
nancy, 272
Secretions, later development of, in
child, 216
Segment, pubic and sacral, 9
Segmentation, 37
Sepsis, control of, 208
of uterine cavity, 205
Septic infection, involution after, 202
Septicemia, pure, 370
Septum, interventricular, 64
rectovaginal, 6
urethrovaginal, 6
vesicovaginal, 6
Septum primum, 64
Septus, uterus, 300
Serotina, 42, 43
Sertoli, cells of, 32
Sex, cells of, 29
determination of, 34
gland of, 29
Sex differentiation, 34
Sex elements, cells of, 28, 29
maturation of, 30
oogenesis, 29, 30
preparation of, 28
spermatogenesis, 29, 30, 32
Sexual distinctions, in embryo, 54
482 INDEX
Shoulder, anterior, location of, 155,
156
tail of, 27, 35
Shoulder presentations 321 See also
viability of, 28
Transverse presentatioDB.
Sphincter, avoidance of eneniata in
Show, m labor 16i
operations on, 195
Spina bifida, 323
Silver nitrate use of, 221
Spina bifida cystica, 78
Simple inertia uteri, 2S0 See also
Spina bifida occulta, 76
Feeble pains
Spinal cord, in embryo, 72
Sineiput of cramal vault 125
Splanchnic mesoderm, 39
faiDua in uterine mucosa 41
Splanchnopleure, 39, 55
urogenital m embrjo 58
Split pelvis, 293
Sinus pnecervicalis 50
Spondylolisthetic pelvis, 292
Smus venosua 6^
Spontaneous delivery, 323
Situs iiBcerum inversus 75
Squatting posture in labor, 178
Skene s glands or ducts 4 S
Stapes, in embryo, 50
Skm of newborn child 216
Stenosis of the duodenum, 75
Sleep during pregnancy, 108
Sterilization, 16.5, 166
Small parts location of 151, 152
of dressings, etc., 168
Smcllie\eit method of extraction of
of hand brushes, 169
after coming head 317
of instruments, 16T, 168
Sodium bicarbonate efficiency of, in
of akin, 168
boiling 167
of utensils, 168
Somatic celts 2<)
Somatic mesoderm 39
Stitchen in cervical lacerations, 186
Somatopleure 31
in pelvic floor lacerations, 191, 1S3
houlfle fume m ] reguuiicy, 95
umbilical ID pregnancy 95
in embrj-o, 60
uttriUL in pregnane} t*
in neiTborn child, 215
Spermatagania 32 34
Stoniodeum, or mouth-pit, 57
S|«rinatiila 32
Stratum compactum, 42
Spermatocytes 3"
StriEE gravidarum in pregnancy, 92
maturity of 34
Stroma, of ovaries, tunica alfauginea.
primary, ii
23
Spermatogenesis, 29, 30, 32
zona parenchymatosa, 23
Spermatogenic cells, 32, 34
£ona vasculosa, or medullary lone,
Spermato^ioiin, 2a, 35
23
niial filament of, 35
Strychnin, use of, in pernicious vomit-
body of. 27, 35
ing, 275
characteristitB of, 28
Stvbhjoi.1 ligament, in embryo, 50
egress of, from testis, 35
Styloid process, in embryo, 50
essential to fertiliEation, 28
Subinvolution, 205
female offspring from, 34
head of. 27. 35
of fetal head, 127
iimle offsprinp from, 34
SulHwcipito-bregmatic diameter sf
INDEX
483
Subpubic arch, narrowing of, effect
on labor, 158, 159
summit of, 116, 119
width of, 161
Subsidiary placenta, 247
Sulcus, lateral, between head and
trunk, 153
Superfecundation, 103
Superfetation, 104
Superior strait. See Pelvic brim.
Suppository, rectal, of codein after
labor, 197
of opium, after labor, 197
Suprahyoid glands, 75
Supravaginal amputation, 411
Supravaginal portion of cervix, 16
Surgery, abdominal : celiohysteroto-
my, 401
CsBsarean section, 401
obstetric, 376
abdominal, 401
celiohysterectomy, 410
cephalotripsy, 425
cleidotomy, 424
craniotomy, 423
decapitation, 426
embryotomy, 422
evisceration, 425
forceps, 386
hebotomy, 419
Porro operation, 410
pubiotomy, 419
symphysiotomy, 416
version, 395
vaginal Cesarean section, 411
Sustentacular cells, 32
Suture, **guy," 190
in pelvic floor lacerations, 188, 189,
190, 191, 193
in vaginal tears, 194
Sutures of cranial vault, 124, 125
coronal, 124
frontal or interfrontal, 124
frontal parietal, 124
interparietal, 124
lamboidal, 124
oecipito-parietal, 124
Sutures, sagittal, 125
temporal-parietal, 124
Sweat glands, activity of, after labor,
200
Swelling, edematous, 141
Sylvester's method of direct insu£9a-
tion, 219
Symelic monster, 250
Symphysiotomy, after-treatment in,
419
extraction of child in, 418
historical note on, 416
indications for, 416
method of, 417
open method of, 417
results of, 416
space gained by, 416
subcutaneous method of, 417
Symphysis pubis in labor, 113, 116,
118, 119, 120
separation of, 351
Syncephalic monster, 251
Syncytial layer of the chorion, 43
Synsomatic monster, 251
Syphilis, fetal, determination of, 253
of placenta, 248
treatment of, prior to conception,
258
Tail of spermatozoon, 27, 35
Tamponade, cervical, 378
for inducing abortion, 384
Tardy dilation, 280
Tardy involution, measures against,
209
Teeth, fetal, development of, from
dental shelf, 58
maternal, care of, during preg-
nancy, 108
permanent, time of eruption of,
59
temporary, time of eruption of, 58,
59
Telencephalon, 74
Temperature, fetal, attention to, 218
maternal, after labor, 197
after trauma, 199
484
INDEX ^^^^
Temperature, matpmal, in
birth,
Ui
(nmk doubled on itKlf, 323
of newborn cUild, 214
frequency of, 321
elevation of, 215
positions of, 321
Teratism, 250
prognosis of, 322
prolapsed cord in, 331
in the fetuB, 70
BpoolancooB delivery in. 322
Tetanus □eonatomni, 237
Tetrads, 30
spontaneoua version in, 322
Thigh, in embryo, 54
treatment of, 323
Thoracic duet, 67
vaginal signs of, 322
Thorn method for converting
a face
Transxersely contracte.1 pelvie, 292
into a vertex position,
07
Trendelenburg posture, in labor, ITT
Throat pockets, 50
Trigonitis, 206
Thrush, svmptoma of, 232
Trophoderm, 38
trentmeVt of, 232
True conjugate, 161, 162
Thymus, in embryo, 50, 59
Truncua arterioaua, 65
Thymus Rlaads, anomalies of,
75
Trunk of felua, birth gf, 143
Thyroglossal duet, persiatence
of, 75
cxpulaion of, 181
Thyroid cartilage, 03
Tubal abortion, 264
Thyroid glamis, anomaiica of.
73
sign a of, 267
effect of pregnancy on, 86
Tubal pregnancy, 42
in embryo, 50, 59, 60
tiistology of, 266
Tincture of io.lin, 168
pathology of, 266
Tongue, anomalies of, 75
Tubercles, cornicutar and cuneiform,
in embryo, 50, 59
62
Tonsils, in embryo, 60
Toiemia, during pregnancy, 109, 110
Tulierculum impar, 59
eclampsia, 355
Tuboulerine pregnaacr, 265
Tumora. cystic aud solid, 101
in-ilietion of abortion in, 38
3
cystic, of kidney, differeotiated
milk diet in, 355
from pregnancy, 102
Trachea, anomalies of, 78
fetal, 328
Trachelocystilis, 200
phantom, 102
Tract, gut, 56
uterine. 299
Traction in cervical laceratic
na. 1S6
i-aginal, 299
of uterine asis. 1S5
Tunica sibuginea of ovaries, 23
on cord. 183
Trans\ersc diameters of pcl>
c brim,
double monsters. 326
120
interlocking, 326
of pelvic cavity. 120
involution after, 202
of pelvic outlet. 121
Transi-crse preseolation. 154
prognosis of. 325
vaginal signs of, 325
causes of. 321
Tympanic membrane, in embrro, SO,
INDEX
485
Tympanites, 369
differentiated from pregnancy, 101
Umbilicaf arteries, stenosis of, 249
Umbilical changes during pregnancy,
91
Umbilical cord, 44
anomalies of, 249
of length of, 249
coils of, about fetus, 249
cysts of, 249
Dickinson's treatment of, 182
disposition of, during pregnancy,
44
formation of, 46
hernia of, 249
insertion of, 250
knots in, 249
ligation of, 181
management of, 181
treatment of, after ligation, 182
with twins, 182
Umbilical fungus, 236
Umbilical hemorrhage, 237, 238
Umbilical infection, 236
treatment of, 236
Umbilical souffle, in pregnancy, 95
Umbilical vessels, excessive torsion of,
249
Unicornus, uterus, 300
Ureter, in embryo, 70
Ureteric bud, 69, 70
Ureteric duct, 69
Ureteropyelitis, 370
Ureters, anomalies of, 77
in embryo, 57
Urethra, 7, 8
anomalies of, 77
glands of, 8
male, in embryo, 72
structure of, 8
Urethral canal, 7, 8
Urethral lips, 4
Urination, frequent postpartum, 204
increased frequency of, 171
Urine, amount of, excreted during
pregnancy, 110, 111
Urine, examination of, during preg-
nancy, 110
of newborn child, 216
retention of, after labor, 199, 200
Urogenital septum and sinus, 58
Uterine anomalies: bicornis, 300
cordiformis, 300
didelphys, 300
displacement, 299
septus, 300
tumors, 299
unicornis, 300
Uterine artery, pulsation of, in preg-
nancy, 98
Uterine cavity, 16
Uterine contractions during labor, 134
intermittent, in pregnancy, 93
Uterine displacement, 299
Uterine inertia, 280
Uterine muscle, layers of, 17
Uterine myomata, differentiated from
pregnancy, 102
Uterine segment, traction of fibers of,
134
Uterine souffle, in myomata of uterus,
94
in pregnancy, 94
Uterine tumors, 299
Uterine walls, 17
Uteropelvie ligaments of the uterus,
19
Uterosacral ligament of uterus, 18
Uterovesical ligament of uterus, 18
Uterovesical space, 14
Uterus, amputation of, 337
anomalies of, 77, 299, 300
arteries of, 19
attention to condition of, after
labor, 197
bicornis, 300
body of, 15
broad ligaments of, 18
cavity of, 16
cervix of, 15
changes in, during pregnancy, 96
character of, in pregnancy, 92
coats of, 16
486
INDEX ^^^^
TTtenia, condition of, after labor,
200
Uterus, aitontion of, 13
MDtraetion of, after labor, 195
size of, 15
in labor, IIB
in pregnancy, 83, 92
^«8ticitj of. treatment of, prior to
eornuft of, 15
conception, 258
didelphjs, 300
structure of, 16
83
changea in, during pregnancy, 84
effects on, of cyatic dcgcnera
on.
sabinvolutiou of, 205
SIS, 246
tartly involution of, 208, 209
emptying of, 346, 247
unicornis, 300
evacuation of, in eclampsia, 358
uteropelvic ligamenta of, 19
fertilized ovum in, 42
uterosacral ligament of, 18
fundus of, 15
iuimpcliato evacuation of, 384
veins of, 20
in fetus, 70
weight of, during involntion, 208
18
Uvula, in embryo, 58
invcraion of, 332
involution of, 200, 201
Varcines in puerperal infection, 374
irritable, treatment of, prior to
on-
Vagina, 5
ception, 2o3
anomalies of, 77
ifithuiuBof, 13
arterial supply of, 7
ligaments of, 13
bloody diaciiarge from, daring la-
lymphatics of, 20
bor, 133
manipulation of, dangct of, 209
moasiiremonts of, during jnvolut
on.
coal a of, 7
201
columns of, 7
monaiiration of, 105
Bbrous coat of, 7
mucosa of, 42
involution of, 203
ucrvos of, 20
mucous coat of, 7
miUiparous, ]8
mucous discharge from, daring la-
ovariopdvic ligament of, 18
bor, 133
peritoneal coat of, 13, IS
porous, 18
nen-es of, 7
postpartum esamination of,
04,
purplish buo of, in pregnancy, 95
205
relations of, 6
puerperal cavity of, 200
rugtt., 7
shape of, 6
I'ogional diviaions of, 15
relations of, 15
structure oi, 7
retraction of. after labor, 195
veins of, 7
in labor, 145, 146
Vaginal atresia, BBS
retroveraion of gravid, 383
Vngiual bleeding in separatioa of pla-
round ligaments of, 19
centa, 183
rupture of, nature of, 334
Vaginal canal, preparation of, for ta-
septus, 300
bor, 171
INDEX
487
Vaginal Cesarean section, indications
for, 411
technique of, 411, 414
Vagina] discharge, treatment of, dur-
ing pregnancy, 108
Vaginal douches, when avoided, 208
when used, after labor, 209
Vaginal examination, 149
infrequency of, 175, 177
method of, 160
Vaginal hysterectomy, 416
Vaginal neoplasms, 298
Vaginal operations, after-care of, 194
Vaginal orifice, 6
Vaginal tamponade, in threatened
abortion, 259
Vaginal tears, 193
suture of, 194
Valves, anomalies of, 74
Varices of pregnancy, 277, 278
Vascular system and heart, anomalies
of, table of, 74, 75
Vascular trunks, anomalies of, 74
Vasomotor balance, 199
Veins, anomalies of, 75
azygos major, 67
hemiazygos, 67
innominate, left, 67
right, 66
jugular, left, 67
right internal, 66
of breast, in pregnancy, 90
of external genitals, 5
of Fallopian tubes, 22
omphalomesenteric, 65
ovarian, 23
portal, 67
postcardinal, 65, 67
precardinal, 65
subcardinal, 65, 67
umbilical, 65
uterine, 20
vaginal, 7
Vena communis hepatica, 67
Vena cava, 66
inferior, 67
Venous plexus, of labia majora, 2
Veratrum viride in eclampsia, 356,
357
Vernix caseosa, 216
Version, 309
bipolar, 398
bipolar podalic, in hemorrhage, 342
cephalic, 395
contraindications to, 396
dangers of, 396
external, 396
internal, 399, 400
operation of, 396
pelvic, 395
podalic, 395
spontaneous, in transverse presen-
tations, 322
Vertex, of cranial vault, 125
Vesical calculi, 299
Vesicles, brain, primary, secondary,
74,
Vesicular mole, 244
Vestibule, 3, 4
Vestigeal parts in fetus, 70
Vestiges in fetus, 70
Viburnum prunifolium, use of, in
threatened abortions, 259
Villi, chorionic, 43
Viscera, transposition of, 75
Visceral arches, 49, 50
influence of, on head development,
49
metamorphosis of, 50
Visceral artery, 49
Visceral clefts, 49
Vision, disturbance of, in pregnancy,
111
Vitteline duct, 57
Volsella, 186, 190
Vomiting, during pregnancy, 87, 88
pernicious. See Pernicious vomit-
ing.
Voorhees bag, 380
Vulva, 1
commissures of, 2
connivens, 1
hians, 2
Vulvar atresia, 298
{
488
INDEX
Vulvar dressing at close of labor
196,
Whey, preparation of, 228
197
Wbite infarcts of placenta, 248
Vulvavaginal glands, 4
White line, 10
Wigand-Martin method of extracting
Walcher pQsition in labor, 113
tho after-coming bead, 317
Wasaermann roue ti on, 252
Wirsung, duct of, 61
Waterbag, dilating, in hemorrhage.
Wolffian body, 24
342
Wolffian ducts, in embryo, 57
dilation of cervix by, 380
WatMH, bag of, in labor, 136
Xiphopagus, 251
breaking of the, in labor, 13T
coniing away of, 41
Yolk sac, 47
fore, 136
in embryo, B6
hind, 136
Yolk stalk, 46
hydrostatic action of bag of,
34
presprvatiou of bag of, 176
Ziegenspeck method, 307
Weaning, 224
Zona parenehymatosa of ovaries, 23
Weiglil, normal gain in, 211
Zona pellucida of the ovum, 25
Wet nurse, requirements of, 223
Wharton's jelly, 46
01E4 Polak.J.O. 53446
P76 Manual of obstetrics
1922
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