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Full text of "Obstetrics; a textbook for the use of students and practitioners"

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. C'cipymuKT. lnu3, IIM4. lUUT. 
Bv 1). APPLETON AXI) COMI'AXV 



PRINTER \T THE AIM-I.BTON I'RBBS 
NEW yOKK, U. B. A. 



-%> i^ 



X CONTENTS 

SPXTION III 
I'HVSIOUMIV ()!■■ l'UE(;N.\i\CY 

L-IIAITKH PACK 

VI. Chamukh in the Matkiinai. (ImiANirui HKHULTiNii KMoM 1'bb;>a\<t 164 

|Tt«ruB 184 

Tubes atid ovariea Igft 

Vagina .*■ jgS 

Al)domjnal walln 170 

Breantfl 171 

In rest of the body 172 

(ieneral metabolism 175 

AJn. T»iA<m(isiB OF Prbonancy, irt- 180 

SiipiB and iymptoms of pregnancy 180 

Differential diagnoaia of pregnancy 190 

Spurious pregnancy 191 

Duration of pregnancy 193 

Eflimation of date of confinement 195 

VIIl. MANAtiEMKNT OP NoRMAL pRlftlNANrV liJfl 

IX. I'HKHSNTATlllN AND PoSiriON Of FlPTTIIH 205 

Noniciit'latnre 207 

IteanoiiK for the predominance of head pn'NentuliiiiiM .... 2(KI 

McthiNJH of diagnosing presentation and poNlinii iif fci'iiis 211 

sfxrriON lY 

PHYSIOIXXIY OF LABOUR 

X. Phvmcii.oiiv ANn (YiNirAL Cdvhhb Of Labiu'r 218 

rmiHc of the onn't of lalmiir 218 

l'hysiiiliig_v of lalHMir pains 222 

Cliiiiral iimrse of labour 225 

XI. I'liniM (l)NCTCHNED IS Labour 235 

('i-ri'i\ in latter part of pregnancy 235 

I.DWiT iilcrine segment 23(i 

I'hiingi'B in uteniH during first stage of labour 240 

Chiingi'ii in uterus during second Htage of labour 24-1 

KoriTH foncenied in labour 245 

Chiiiiges in vagina and pelvic floor during laliour 247 

XII, Mk'HANIHM of IvABOFR in VbRTEX P resent ATI OSs .... 254 

U'fl and right ocri pi to-anterior presentations ..... 254 

llighl and left occipito-poslerior presentations 'JIWi 

('hangi's in shape of head 270 

XIII. MRriiANiFiM Of Labour in Facr, Bhow, anu Hhkbch Piifj«KNTATioNs 27-t 

l''iiii! pn'H'n tat ions 274 

Brow pr^'Mcntations 282 

Hn-cch presentations 2H4 

XIV. Phvbioi.oijt and Man'aijbment op Third Staor of I.AKorii 2i|2 

Mode of delivery of placenta 2!t2 

Clinical pirlure of third stage of laliour 290 

Management of third stage of laliour 2ft8 



CONTENTS » 

CWAnER PAIIC 

XV, <'(ispii<T OF- Normal I.aboitii JtlW 

l'n.-)iariiHoiiK for lulmiir IMi 

CimAurt iif Vmt Magii o! ]ii\ntui 31)7 

C.V>ii<llii-l iif w.'riHid HtH)^ oF iHlmiir ;)IJ 

Anii-Hthetqu Xll 

Rl-puir of lai«ratvd pcriiiiiiiiti ri^.*) 

XVI. ThI PHEHPEKIUU 332 

Anatomical chanf^s in the puerporiuiii 332 

Clinical aspect of the puerpcriuni :i3-'i 

Care of patient during puerperium 34(1 

XVII. The Xkwly Born Child 340 

Circulatory rhangea 34A 

Carv of the umbilical cord 3J7 

Ciiri' of eyee 349 

SUmJh und urine 3S0 

Aiialomy i>r breaittH and laetulion 351 

NiiminK 353 

Care of breastM 355 

Artilirial feeding 357 

XVin. Mn.Tin.E i'H»MlSAS<-Y ."UIO 

ST'XTION' V 

OBSTETRK^ RURCKRY 

Xl.X. In-dvotios Of Abortion and pRBM.^Timt Lahoi-k .... 371 

PreparatioDB for obstetriral opeTatioiiN 371 

Induction of abortion 373 

Induction of premature lalMnir 377 

.Acrourhement forc6 3B;1 

Vaginal (.':i-HBrean ncction 3H6 

XX. FiiHcEW 392 

Hintoiy 393 

Function« 3B7 

Inilicalioiiii sjrj 

Application of low forc«pH 403 

Applicat ion of mid foreepN .(07 

.Application of forrepe in obliquely poftlerior pn-NcijIiitionx 4(}S 

.^iiplication of high forrepn 414 

Axis t ruction forcfpa 41.'i 

r* of forcepn in face prew-nlat ion 4IH 

r.f of forccpn ill breech prcfviiIatioiiM ||!l 

\XI. Kx-rK\iTii)N A.si> Vehwion 4^<2 

Rxtrui'tinn in breei'h preM-ntutloo!) 422 

rephuJic verNion .J3.-} 

I'odallc vf'ntjon .(jjij 

Coniliined vewion 4;{ij 

XXII. Cl-^-'KKBAN HB(TI0V AND SVMl-H VnK'ITONV 44| 

Hjjrtnry 44] 

IndicationH 443 

Operative teehni'iiic .... ... 44.'> 

I'nq^nxiii 441, 

SyTnph,V"eotomy 4-,j 

PubiotfHny 4_y[ 



XII 

CH*PTEIl 

XXI] I. 



XMV. 



CONTENTS 

PAGE 

7)E»TRrCTIVE Operathinh 46'i 

( 'raniotDiiiy 463 

Embryotomy 469 

Evisceration 469 

Decapitation 469 

Ol'EHATIVB pKlirElll'KKl' WHH'H JMI Nl/T A(M AT DKI.IVKHV 472 

Itourhf 472 

('iirc'ttafci' 474 

Tampon or ]Mick 470 

Maiiiiiil rfiimvul of iilucciilii 47" 



SFXn-ION VI 

PATHOLOGY OF PREGNANCY 

XXV. AcaDBNTAL Complications op PKiixiNA\<T due to Hiskasr . . Aft) 

Acute infectioiu diseat^ii 4R0 

Chronic infectious diseases 483 

DiaeaHes of circulatory and respiratory sysf^-nis .... 487 

Diseases of alimentary tract and liver 491 

Diseases of kidneys and urinary tract 493. 

Diseases of the nervous system 49(i 

Diseases of blood 4UH 

Diseases of wkin . . ' 499 

Surgical operations duriiiR pregnaMcv 501 

XXVI. The Td.x^mias of PriEoNASCY . . 507 

Pernicious vomilinft of pregnancy .^OB 

Acut« yellow atrophy of liver .11.') 

Nephritic lox:i-mia .117 

Pre-eclamplic toxjcmia 518 

Eclampsia 524 

Presumahle tiixjcniias 54.'i 

XXVII. CoMPLICATlDNa DrR TO DlHUARKS AMI) .\1IN1IHSH].1T1K1 ukTHK (iKNBII- 

ATIVB TKACT .V>2 

Diseases of vulva and vii)!ina .I-Vi 

Disean's cif the cervix 55:1 

Ifevcliipmenlal alfiuinnalitics nf uUtiik r>5^ 

Displacetiicnts of iitcniH rtHl 

Dineascs of di'ciduu ,'i(i4 

XXVIII. Disease.-" ant> .\mnohmai.itikj ok Ovl'm .171 

Diseatiea of chorion .171 

Ch<)rio-epithelioma .176 

Diseases of amnion .16 1 

Abnormalities of placenta .187 

Diseases of placenta .191 

Abnormalities of umbilical cord . .196 

Fecial syphilis .199 

XXIX. AnoRTios, MiscAHmAoE, ash Pkewathfie Lahoiiii (ilO 

XXX. Kxtra-Utbhink P«EosANn- (123 



xiv CONTES'TS 

CHAPTER . PAOE 

XXXVII. PELnC ANOMALIE8 DUB TO DlHRAHE OF THE VbRTEBKAL CiiLUMN . 7()(i 

Kyphotic pelvis 766 

Scoliotic pelvis . . . . _ "73 

Kypho-scolio-rhachitic pelvis 775 

SpoDdylolisthetic pelvis 775 

XXXVIII. Pblvic Anohaukb REsui.'nNG frou Ahnohmai, 1)iiif.(TIon oi' ti:k 

FOHCB EXERTED BY FbMOHA 783 

Coxnlpc pelvis 7tH 

Luxation pelvis 78C 

Atypical deformities vt peivin TK8 

XXXIX. nVBTOCTA DUE TO AuNORllAUTIIM IN I )KVKI.1>1'MKNT OK PitKSBNT.t- 

TION OF F(ETWB 790 

Excesmvc development 790 

Malformation of fcctus 792 

Deformities of fcctus 793 

Hydrocephalus 794 

Enlargeinent of the abdomen of ftFtUB 795 

Transverse presentations 798 

Compound presentations 803 

XL. H.GUnRRHAOE 805 

Premature separation of the normally implanted placenta . 805 

> Placenta pnrvia 809 

Post-partum htrmorrhage 818 

Inversion of uterus 823 

XLI. Injuries to Birth Canal 828 

Injuries to vulval outlet 828 

Injuries Ut vapaa 828 

Injuries to cervix 930 

Rupture of uterus 833 

Instrumental perforaticiU of uterus B39 

Perforation of genital tract following; necrodis . , , . 839 

XLII. Prolapse of Umbiucal Cord, etc B42 

Asphyxia 844 

Sudden death during or shortly after labour 848 

SECTIOX VIII 
PATHOLOCY OF THR PUERPKRUIM 

XLIII. PlIEilPBHAL IvFBITIorj B.SI 

XLIV. DlSEAfiE.-' AND AbNOHMAI.ITIE-S OF THE I'l KHr'KHirW . B.51 

Tetanus 898 

Thrombosis of vessels of lower exlremilii's 898 

Gangrene of lower extremities IKK) 

EHseaaes of urinary tract (MK) 

Hirmorrbages during puerperium 901 

Diseases and abnormalities of uteni.i 904 

Obstetrical paralysis 906 

Abnormalities and diseases of brt-asls ...... 908 

Puerperal psychoses .... 915 

Acute infectious diseases during puerperium 916 

Index 921 



Xvi LIST OF IIXrSTRATIOXS I\ TKXT ■ 

Fll!. P*f!i: 

< )var^', iiilult, cnisM-iicctioti of, Klinwiiii; (iriufiuiL fuUicloH . . . (in 61 

at birth, «lnnvinK primnriliiil foUiclcH 72 fi7 

corpus fihrowiiii 80 7.1 

corpuH fibroKiiiii, laltr Hlagd 'if HI 76 

corpus lutcuni, Hhowiug lutein (tlis 79 74 

corpus tuteurii of pr^naoey, with pystic centre 78 73 

diagram Hhowitip funiiution of ti!) fl.'i 

mature follicle, section tlirougli n-nll of 77 71 

of iiow-lMim glr! 71 IHl 

of pig embryo, cortex of, highly iiiagiiifieii 6B 1)5 

ot pig embryo, iection through 67 'U 

of young woman, showing developing foUii Ic 74 09 

of yoimg woman, showing more ailvancc<l foUielc 7-') 69 

of young woman, ahowing nearly mature follicle 76 70 

of yomig woman, showing primordial folliclea 73 69 

section of, through Wollrian body and Miillerian duct 66 63 

Pelvia, adult, diagrammatic reprenentation of section through . . , 2R 21 

Breisky's diagrams for comparing 15-17 13 

diagram showing axis ot 11 10 

diagram Hhowing difference i[i ahape in male and feniale .... 20 15 

diagram showing planes of 5 6 

diagram showing variation of anterior-poHterior diameter of, in various 

positions 14 12 

disarticulated, of three-year-old girl 23 18 

female, front view of IS 14 

frontal section t^'mphysis pubis 12 11 

infantile, diagrammatic representation of section through . . . 27 31 
infantile, section through, parallel to superior Htrait, showing relative pro- 
portions of hone and cartilage 22 17 

male, front view of 19 14 

normal, sagitttil seclioii through 3 4 

normal female 1 2 

normal female, showing diameters o( the sii|)erior strait .... 43 
of newly bom child, sagittal section showing relative pro]>ortioii of Imne 

and cartilage 21 17 

outlet of 6 7 

plane of greatest dimensions of 8 7 

plane of least dimensions of 9 8 

sacro-iliac synch rondrosis 13 11 

sagittal section of, in five-year-old girl 24 18 

sagittal section through, in adult woman 26 19 

sagitta! section through, in newly liom child 25 19 

superior strait ot 7 7 

terminal length of, as seen from above 29 22 

terminal length of, as seen from Iwlow 30 22 

Veits' main plane of 10 S 

Sacrum, drawing Hhowiug it Ih not the keystone of the arcrh .... 24 

Uterus, anterior aspect of 39 39 

blood supply of 56 50 

brood ligament, aection through broad end of . . ... .15 48 

cervical canal of. cross-seption through 48 41 

cervical gland of 49 12 

endometrium, higlily magnified, showing uterine gl:inil iinil simnia . .'>4 46 



UST 0¥ Il,l.lSr»ATI(i.\S IN TKXT xvil 

nil, PA<*K 

I'tenis, enuontctrium, iioniial 51 43 

endometrium. Henilo i>3 44 

cndometriuiu of newly Ixim child , . li'2 ii 

KXtermd (m, parauH 47 41 

extemal os, virginal 4641 

bteral aapvct of 4139 

IrmpbiticH of S7 51 

of fourteen-j'ear-old giri, with a|)iNiiidageii 44 40 

of twenty-year-old multipam, with appcixlaguH 4.'> 41 

of young child, Hith appenditguM 43 40 

poaterior aspect of 40 33 

imgnant, nervous g:iiiglb iit 58 52 

n.Ton!<tniction of, showing sltiix: iif uterine cinily iiriil i-erviiwl <iiniil .iO 43 

vjgiiia und reirix, jiuitliiiii of 42 40 

V:itniui. di;\ulu|)iiit:iit of. iihowii it) Iciiigiliidinii) Muctiiin 34 3J 

H'xha^K^l lumen of 37 3-1 

miicniB of ;i8 31) 

nuRittal nectioii ihriiiiKli hiuer jHirliiui nf 35 32 . 

l'HVSIiH,tniY AM) J)KVKIJH'ML"\T UK THK itVr.M 

liei-idiui. iKm-pregimnt undomutrium, highly nmgnilied. sliiiwiug gluud :uid 

slPOiiia 14.T 123 

reflcxa. Coitte's tbeorj- ot foniiatioii 141, 142 120 

reDexs. Hiuileriuu Iheori- of fomiatioii 139, 140 119 

reAexa in »i/u. in leventecu -days' pregnant iiteruu 146 125 

t«(lei& in itilii. in «ix-weeks' pregnant uteniH 147 126 

Krolina. showing mixture of fu^tal and ttiateniu] rcUs .... 148 127 

vera, fourth month 143 12i 

vara, fourth month, highly niiignilied 144 122 

Kiiibrj-o, human, early development of ...... . I.'i!)-Hi4 144 

human, from fourth to fifth weeks Hi.'V-lRK 14.1 

human, xei-ond month 109-171 146 

nismnialian. Inngitudiiuil section through 106 103 

pLullof new'lxim child, sbowitigfontaneilcH, sutures and diamut^rs 173 15'2 

skull of new-liom child, showing small . sagittal, and large fontanelles 174 152 

t>kull of new-lioni child, sboning sutures and diameters .... 17'2 151 

tr\-uni. bUistndennic vesicle of bat 116 106 

hla.-OiHlennic vesicle of bat, showing also yolk-sack and ectodonn 117 107 

lilastodennic vencle of mouse at end of fourth day lOS 10.'] 

Iila-itodennic i-esicle of nioiuc. fifth day 109 104 

IJasloiiennic vewcle of mouse, Krst half ai.xlh day 1 10 104 

Ijbsloderinic ^-esicle of mouse, in ut«riiic cavity, eighth day 115 106 

Mastodtmiic vesicle of mouse, in uterine cavity, first half of seveiilh day 114 106 

tilsslodeniiic vesicle of mouw, in uterine cavity, second half u[ sixth day 1 1 1 104 
libiStoderniic vesicle of mouse, in uterine cavity, second half of si.xth day, 

more ad\-anced 112 105 

blastiidemiic \'esic1e of mouse, in uterine cavity, seventh day .113 105 

Ha.1t ode mi ic vesicle of mouse, second hnlfof fourth day .... 107 ]|J3 

i>lB.-itodeniiic vesicle of ruiiliit !Mi 1)8 

rboririiiic ^-illuH at fourth month 13.'> I ttl 

cboriofiic \-illu3 at ninth month I3G i ]|) 

chorionic viUub, third week 134 116 



xviii LIST OF ILLUSTHATIONB IX TEXT 

no. PACE 

Ovum, chicken embryo with five segments 101 100 

oonverflion of tut»l epithelium into 137 117 

division of normal cell with four chromosomeg 85 93 

dog embryo, showing formation of amnion 104 102 

dog embryo, showing foimation of amnion and development of somato- 

pleuPB 105 102 

dog embryo, showing graater development of mesoderm .... 103 101 

embryonic area of dog 98 99 

embryonic area of dog, early 99 100 

embryonic area of dog, showing three laytrn 102 101 

embryonic shield of rabbit 100 100 

fertilisation and segmentation of 80 95 

human 97 98 

human, embryonic area of 125 1 10 

hunkan, seven-days', embedded in decidua 124 110 

human, seven- to eight-days' 131 113 

human, seven- to eight-days', embedded in uterus 138 118 

human, section through, shown in Fig. 128 129 112 

human, Spee's older, section through 130 113 

human, Spee'a youngest, section through 126 1 1 1 

human, Spee'a youngest, section through embrj-onic area .... 127 111 

human, two weeks' 132 114 

human, two-weeks', section through, showing chorion and de<-idiui . . 133 115 

human, two millimetres long 128 1)2 

human ^lermaro^oa 87 94 

maturation of, showing reduction in number of chromosomes . 86 93 

miilberry mass, formation of 93-95 97 

of bat, showing amnion and embryonic area 1 IS 107 

of guinea pig, attached to uterine mucosi, seventh day . .121 109 

of guinea pig. burrowing through ulerinc mucosi. seventh day . 122 109 

of aemnopithecua nasicus 119 107 

polar body, fonnation of 82-84 92 

portion of Peters's, highly magnidcd, shoiring early stage in development 

of embryo 123 109 

reduction in chromosomes in sjiecics with four in nucleus . . BS 95 

segmentation nucleus, changes in 00-92 97 

young, of hylobates, showing fomialion of amnion 120 108 

I'larenla. fictal membranes in connection with uterine wall .... 152 137 

mature, ftvlal surf;»ic of 151 138 

mature. maleniBl Mirfnce of 150 135 

section through eight months' 149 132 

I'mbilical cord, epithcliimi of l.W 137 

ftetal end of . 1.>1 137 

of young enibr>-o. aedion through 137 138 

section through, showing stalk of umbilical vesii'lt ..... 155 138 

section through abdominal pedicle of 2.2.>-miUimetre cinbryo 156 138 

stalk of umbilical ^'esicle Iteing included in l.'SS 133 

rMYsltn.i«;v i>k i*iii;i;N.\MV 

.\lHlomcn. fiendulnus. of Tiiiilliiiunni.-^ wiiniiin wilh n»riii:tl )<i'lvi>: . is>> ]K.i 

.\bdominal enlsrgeiiicnl at ninth month of pivgnancy ISJ 184 

St sixth month of pregnancy 1S3 184 



LIST OF ILLUSTRATIONS IN TEXT xix 

Abdorninal enlargement at tenth month of pregiuincy 185 l&t 

at third numth of pregnAncy 182 1S4 

due to fKt 190 192 

Ibvech preBBntatioiu, dugranui xhowing varieties of .... 205 '206 208 

Kuc prMeattttiona, diagruiu showing varieties of 203-204 208 

Fdslus, in brow presentation 195 206 

in face presentation 196 206 

in foot presentatitm 199 206 

in fnnk breech presentation ,' . 197 206 

in full breech presentation 108 206 

in knee presentation 200 206 

in sinciput presentation 194 206 

in ^'ertei presentation 193 200 

Fundus, relative height of, at varioiu weeks of prvgiiBno' ,101 196 

Henar's sipi, method of detceting 187 186 

MuM-le fibres from non-pregnant and pregnant uterug I7<'i 164 

Vaicinal etamination, diagram showing method of fUfferentialiiig Iwlween 

the fonlaiKlles 208 215 

diagram showing method of lorating sagittal Mitiiro in 207 214 

Vertex preHenlalions. ('iagrams showing varieties cf .... 201-202 208 

Pregnant uteruH, e>temal muscular layer of 178 106 

iutenial iiiuHcular layer of 177 106 

median muscular layer of 178 166 

showing method of detocting Hegar's sign 189 167 

ten-weeks' 188 187 

Priniipara at full tcmi. abdomen of, showing slri:r 181 171 

>t full term in horizontal position 180 168 

at full term in \-ertical position 179 168 

Uoudeii nipple shield .... l»-.> 201 

PHYSIOUXIV OF LAIHUH 

.\lii|rii»eii. composite pirirure showing change of shape in, before ami during 

uterine contraction 209 224 

immediately after birth of child 303 297 

•hnwing ri.iingof fundus following extrusion of placenta into Itmor uterine 

seginent 304 297 

.Vtiierior rotation, from L. (). 1'. (diagram) 2C3 268 

fnim L. r). A 254 261 

Inmi It.O. A 25.'; 2fil 

fniin It. tl. P. (diagram) 2B4 268 

Itirth canal, diagram of, at eiiii of pregnanry 224 241 

■luring ^vcond stage of labour 2'ln 241 

Kinh of huad. deU^-ery by extension 213 230 

L'Xienial rotation 215 232 

fail: falling backward toward anus 214 231 

■icalp appearing at vuU'a 210 227 

vuU-a completely distended 212 229 

^^ll\■a partially distended - . , 211 228 

itr^irt. lacerating 323 3,'>l 

breech preHentati<m, birth of head in 2!*.'>-2tHi Jhm 

dolichocephalic head in 27i> 27i> 

Brow pniBcntation, configuration of head in 2HU -JKi 



XX LIST OF ILLUSTRATIONS IN TEXT 

FlO, rtOE 

Brow presentation, left anterior 287 2S2 

right poBtcrior 288 282 

Caput suceedaneuni, disappearance of 269-271 271 

Cervical canal, complet« obliteration of. ext«rnal oa inlai^t .... 228 242 
Cervix, dilatation of, funnel-shaped obliteration of internal os and rervical 

canal 226 241 

dilatation of, funnel-shaped obliteration of internal og and cer\-ical canal, 

further advanced 227 242 

dilaUtion ot (Saxinger) 231 243 

dilatation of (Schrooder) 229 243 

dilatation of (Tibone) 232 244 

dilatation of (Winter) 230 243 

Cervix at end of pregnancy (Braune and Zweifel) 218 236 

(Leopold) . , . 219 236 

(MiilleHB diagram) 216 235 

CWaldeyer) 217 2311 

Colostrum, human 324 352 

E)elivery, method of holding back head to protect perin:i'um in . 311 316 

of posterior xhouldcr 313 320 

palpating hcud through perinn^um boforo 309 314 

patient in proper position for, and covered by sterile dn»oiingii . 310 315 

traction to bring about descent of anterior shoulder in ... . 312 310 
Direct pressure exerted by fundus after complete evacuation of amniotic 

fluid 235 246 

Engagement does not occur in transverse diameter of superior strait, diagrams 

showing why 247-248 258 

Face presentation, configuration of head in 284 279 

delivery of head in 280, 281-282 277, 278 

diagram illustrating impossibihty of labour with chb directly posterior 378 276 

diagram of. showing conversion Into a vertex by Thorn's iiianccuvrc . 286 281 
diagram showing that when face is on level of ischial spines, greatest 

diatnoter of head is above superior strait 286 380 

diagram showing that wiien vertex is on line joining the ischial spines, 

greatest diameter of head has passed superior strait .... 285 280 

distention of vulva in 279 277 

diatiirtion of face after delivery in 283 279 

occiput long end of head lever 277 276 

tumour of neck in 275 276 

Facia, pelvic and perineal, arrangement of 238 240 

Flexion, diagrams showing effect of, conversion of occipito-fronlul into sui>- 

occipito-brcgmatic diameter 251-252 260 

Foetus, position of, after engagement 246 257 

position of. before engagement 245 257 

Fcctua papyraceua . ^ 332 365 

Frozen section, just after completion of third stage of labour, showing collapse 

of uterine segment and cervix 322 334 

latter part of pregnancy, child in L. S. T 293 285 

second stage of labour, child in R. 0. A., membranes unruptured 250 260 

showing condition of the birth canal in first part of second staee of lal>our 222 239 
showing condition of the birth canal in first part of sorond stucc of liilsmr 

(Braune) 241 251 

showing condition of the birth canal in last month of pregnancy 240 250 

showing uterus immediately after delivery 321 332 



LIST OF ILLl'STHATIOXS .IN TEXT xxi 

ria. r\itr 

t'roien ce<-1ion, third BtaKc of labour, showing twin plarentii- in utenj . . 298 294 

throiitch woiiiaii at end of pregnano% child in R. O. T 244 255 

through woman dying during second stage of labour, i^howing roiitratrtion 

ring 220 237 

ihrougb woman in labour, with child partly delivered 257 263 

H«ad. nbowing suboccipito-bregmatic, iubocripilo-fronlul, uixl oi-tripilo-fmn- 

tal diametera 256 262 

Head lev-er, diagram showing 253 260 

Intra-utcrine prcBsure, diagram showing action of, aftvr nipliin- of nieiii- 

linnes 234 245 

dia^Tani nhoiring action of membranes not ruptured 233 244 

I..ower ulenne segnient, diagrani illustrating main vicwN un 1i> n:iliiru of 221 238 

nbnwing rbomhoidat arrangement of muscle fibres 223 240 

Mtiilo-aiiteriiir prcsentalion, left 273 274 

riKht 274 274 

MilL, human ' . , . 325 a'>2 

Nnnilu holik-r 318 327 

I )h).t<:trical Imk 306 307 

( k-ripito-anlcrior prcMenlalion, left 242 254 

ririit 243 254 

I ■n-ipilo-posterior presentation, left 261 267 

rittht 262 267 

I >vum with double Kcniiinal vesicle 326 .'i61 

Pelvic ftoor. distended by presenting |»ri;, showing nnjierliciiil muocles of 

perin^pura 239 250 

Ken from above 236 248 

Men tmm below 237 248 

Perineal tear, compbte 316 326 

deep 315 326 

needle for repairing 317 327 

repair of, eiciending up to vagina 319 328 

repair of. sutures lied 320 329 

superfinal 314 326 

Placenta, diaipam illustrating extrusion of. by Duncan's mochaniHiii 302 296 

diagram illustrating extrusion of, by Schultie'a mechanism 300 295 

diaeram illustrating later stage in extrusion of, by Schultze's mechanism . 301 295 
iJiagmm diowing relation of, to membranes in double- and single-ovmn 

Viin pregnanri' 328 3ti3 

dfiublc-omm twins, velametoua insertion of cord 327 362 

eipresxion of 305 299 

relation of. to uterine wall in latter part of pregnancy .... 297 293 

relation of, to uterine wall in «coQd stage of labour 298 293 

Pu^erioT rotation, from L. O. P. (diagram) 26.'> 268 

from R. O. P. (diagram) 266 268 

Rotation, internal, showing direction in R. S. r 294 287 

Sacroanterior presentation, left 291 285 

right 292 285 

^\iiclitisni. diagram illustrnting 249 259 

Twins. collLiion Itetween heads of 3.33 368 

Inrked 334 IKM 

potation of, in utero 32!H3:jI .304 

Vaginal examination, method of coi-ering patient Ifefore mukinit . . ,307 310 

spreading apart tbe labia before making 308 31 1 



xxii LIST OF . ILLUOTRATIONS IN TEXT 

/ 

no PAGE 

Vertex preaectation, configumtioii of head in 272 272 

delivery of bead 258 263 

delivery of head 259 264 

delivery of head 260 265 

delivery of head with occiput in hollow of lucnim .... 267-268 269 

UBSTETRIC SURGERY 

balloon, Charapeticrde Ribcx'H 339 382 

Cbampetier de liibes's, ready for introduction 34(1 382 

Basilyst, Simpson'e, articulated 434 4tig 

Simpson's, diearticulated 433 466 

Basiotribe, Tamier'e 431 467 

Tamier's, disarticulated 433 467 

Tamier's, effect of 432 468 

Blunt hook, Braun's 435 469 

Braun's, decapitation with 436 470 

Braun'H, showing mode of action 437-438 470 

Cephalotribe, Tamier's 429 467 

Cianioclast, Braun's 427 466 

head crashed by 428 466 

Curette 440 475 

Dilator, Goodell's, .... 337 376 

Douche tube, glass .... 439 473 

Extraction, breech, delivery of aftcr-coniiug head, back poitlerinr 411 428 

introduction of Angers to free posterior arm 40B 426 

Mauriceati's manccuvre, downward traction 409 427 

Mauriceau's manccuvre, upward traction 410 427 

posterior rotation of shoulder 407 425 

traction upon feet 405 423 

traction upon thighs 406 424 

Extraction, frank breech, linger in anterior groin 412 429 

fingers in groins 413 430 

Rnard's manccuvre for bringing down a foot in 414 431 

Forceps, application of, along occipito-mental diameter, pelvic curve towards 

face 350 401 

application o(, obliquely over brow and mastoid region .... 361 402 

application of, along occipito-mental diamet«r, pelvic cur\'e towards occiput 358 401 
application of, one blade over occiput and other over face, forceps reniain- 

ing unlocked 362 402 

application of, over brow and occiput, showing extension of htnid 363 402 

application of. to face, along occipito-mental diameter 380 401 

Chainbcrlen's, ., 350 395 

English, look of 348 393 

French, lock of 349 393 

French, long 3.54 396 

Hermann's 318 417 

high, diagram showing defect of cephalic application in ... . 395 415 

high, Pajot'a numo^uvre ,197 416 

high. Tamier's diagram showing defects of ordinarj- 3!m 416 

Hulwrt's .399 417 

inversion of, when anterior rotation is attempted in R. (>. P, posilion, 

without rc-applytng instrument 384-385 411 



LIST OF ILLUSTRATIONS IS TEXT xxiii 

Pr<f. PjUik 

Totrvpe, low. boriiontal tnction 368 405 

low, horuontal ttustion, occiput directly posterior 371 406 

low, in pIscB mad artieul&ted 3Q7 404 

low, mtroduction of left bl&ds to left Hide of pelviH 364 403 

low, left Made in place 365 403 

low, left blade in place, introduction of right blade 366 404 

low, upward traction 389 405 

low, upward ttactioD, extreme 370 405 

low, upward traction, occiput directly pouturinr 372 400 

mid, applied in I,. O. A 37ti 377 408 

mid. applied in R. O. T 37K~370 400 

mid. Inod in vafcina seeking poBterior i^ur 373 407 

mid. introduction of first blade 374 407 

mid, introduction of oecond blade 375 407 

mid. inannur of making traction in 381 410 

mid, rotation in It. O. A 380 409 

o\-um 338 376 

P»If>-n'i( 351 395 

position of bead in floating, high, mid and low operatioiiH . . .' , 357 400 

Scanioni'fl nuuuEuvre, first application of instnunenl .... 3H6-387 412 
Scanimii's itianicuvre, showing difficulty in articulating bladcH iti Hcconil 

application of inxtruinent 31>4 414 

Scanznni'H mana-uvrc, showing rotation to anterior po«ilion, in«tnmiunt 

iu^^e^ted 390-391 413 

Scunzoni's niancciiiTC, showingrotation la trauHverHC position 388-3S9 il'2 

Scanzoni's inanccuvre, second application of inKtniment 3U2-393 413 

"bort 353 396 

.^irtipHiin'H, rephalic curve 346 392 

SinipMinS. pcUic cun-e 347 302 

STtKllir's long 355 31)8 

SiiicUic'M short 3J2 39fi 

Taniier'w 403 4 1 8 

Taruier'a. diagram showing traction with 404 419 

Tkniier'ii. traction rods in place without handle-lwr 402 418 

Tuniier'K original axi»-traction 400 417 

Lec-hnlder. Robb's 356 390 

Manual dilatation of cervix. Harris's method 342 3B4 

< >perjtiriri. preparation for showing patient coi-ered with sterile drussings . 336 372 
pn:)Hnklion for, nhowing patient at edge of bed, with legs held in pofdlion 

by les-holder ;l:ii 371 

l'3i-k. i-aidTial and cervix, in puKitioii :m 383 

FWmiIs. manual n■mo^■al of 442 478 

Ptrforaiing of htsd 426 465 

Pii>Moi«niy, inrisions for 423 4.^ 

ptMliim of patient (or, and (iilgi saw 424 4.77 

Rotation of occiput to sacrum, diagram showing 382 410 

to symphyns puliii ,'!83 4|0 

S^««)rs. Sniellit'H .I^.l 4(>4 

Syniphy«ot<iniy. diagram showing effect of 122 4.">3 

fteru.1. packing of, for port -part u 111 hiviiiorrhaw t II 476 

Vaxinal Cu-sorean section, exposure of rervix anil priiniiry inriiiifnis in . :H3 .'(h7 

inciHion of anterior uterine wall after xepnnition uf blmlder in 3.14 ,3^8 

byjug Ailurea in anterior indsioa, posterior incision already sutured 345 380 



xxiv LIST OF ILLUSTBATIONS IN TEXT 

TIG, PAUK 

Venuon, bipolar podalic 421 438 

external cephalic 415 434 

internal podalic, seizure of foot in 416 43.j 

traiiBvurse preseutatiou, back anterior, uuizure of lower foot in . . . 417 436 

transverse presentation, back anterior, neizurc of upper foot in . . 418 436 
transverse prexcntation. back poHl«rior, eeiiure of lower foot in, showing 

arrest ot buttocks at palvi^r brim 420 437 

transverw; proaenlation, back posterior, seizure of upficr loot in 419 437 

PATHOHKIY OK PHKCNANCV 

Abortion, early, Hhtming deciiliui reflexa uiid Herotiiia with degenerative em- 
bryo 4!W 614 

AlbuniinoDiutt'r, Esbat-h's 449 520 

Amniotic adhesions, ampiilatioii by 481 586 

amputation of fillers by 480 586 

cncephalorcio resulting from 479 586 

Blood mole, section through ,501 616 

Chorion, attachment of, to tube n-all JiOG <>32 

Chorionic villi, normal, teased out in salt solution 495 603 

syphilitic, tcaBed out iu mlt solution 496 (103 

Coinpreasion of fcetus in oliRohydraratiios 478 585 

Decidua, uterine, from a case of extra-ut«rine progiiaiicj' 509 636 

Decidua polyphosa 470 46.5 

Decidual cella in right tube, with pregnancy in opposite tube .... 507 633 

Deciduoma malignum, Bfaowingalveolararrangement of primary tumour 476 577 

blowing syncytial masses invading channel 477 576 

Diverticulum from lumen of tube 502 625 

Eclampsia, urinary chart of; death after forty-eight hours after onset . 453 528 

urinary chart of; recovery 454 529 

urinary chart of; recovery 455 531 

Eclamptic liver 456 533 

Endometritis, decidual 472 567 

Endometritis decidua <-ystica 471 46d 

Foetal epiphysis, nonnal 491 601 

normal, magnified 493 602 

syphihtic 492 601 

fyphilitic, nuLgnitied 494 602 

Htcmatoma, tuberous subchorial 500 615 

Hydatidifonu mole 473 571 

microscopic section of 475 575 

microscopic section through 474 572 

(Edema of vulva 443 490 

Placenta, battledore, marginal insertion of cord ... . 490 596 

bipartita 483 587 

cyst of 489 593 

duplex, with two auccenturiate lobules 487 589 

tene«trata 482 587 

mcmbranacea 486 5S9 

marginata ... 488 .$90 

nonnal full-term 497 604 

septuplex, corrosion prepanitioii of 485 588 

syphilitic full-tenn 498 tXH 



IJSr OF ILLl'STHATIONS IN TEXT xxv 

rlarcnla. tripBrlita 4jj.) ly^^ 

HmuiUI giuit cell sad cborionic villmt in Uood-vcHwl of mlie wall Hixiie 

duUnce from plftcmlai Hitu 4.^7 ,^4 

PitfpMncy, broad tipment 515 64^ 

wriy tubal, showiog ovum enibeddiMl in wall t>f tube outside of lumen 608 634 

cftriy tubfti, with sbortioii of ovum into l<mieu of tube 510 637 

* m MOMKWy tubal oRium 503 62.'> 

m bi>m of utenui containod in inpiinal ranul iCiS r))):! 

in mdimentaiy ksfl uterine hnrti iM 555 

intentilkl r^r, mi 

Mhmic; rupture ten days after lunt incnHtnial period ayj ri39 

ovoriui, diai^m iliiistrating ThiinipHon'H Kiieciinen A04 62t< 

rupCureU ampullar 514 e4i 

pRffnant utcruM. liuniia of mg 504 

pTnl»P«d 4G7 562 

TBtroAexed. incarceration of 466 559 

iMrofiexed. aacculation of 465 558 

Tosrfnk, pre-ei'lamptic. urinary- chart of; recovery aftiTaccoucbement 452 523 

pre-eclamptir. iirinari' chart of ; recovery under milk diet .... 451 521 

Tuhai abortion, o\-um beuig extruded through hmbriated extremity . .511 638 

Tubal mole, section through 512 639 

Ureofneter, iJoremus's 450 320 

I'teruB himmis duplex 460 554 

bacomjs «ptuii 461 5.54 

hieomiB mibneptux 402 554 

UcoTDiit unicollis 463 554 

Ucorou uniroUia, with rudimentiiry horn 463 554 

pwudo-didelphys 459 5.'^ 

unicornis 458 .554 

Voiuiting. chart showing ammonia cneKicient in two connccutive (ireKnaiicies 448 .514 

neuroti<'. iirinar)' chart of 445 512 

of pregnancy, liver fnmi raw of, Hhowing antral iic<'roHiH .... 444 510 

loxu-mic. urinary chart of 447 513 

toxirmic, urinary chart of; recovery after induced aliorliiiii 44fi 512 

PATH(»I.<KiY OF LABtirK 

Acromion dorxo-anterior preiientation, right 641 708 

Armminn dono-poMterior prenen tat ion, left 640 708 

.^nencephaliis &3i 793 

Ccrvii. lacerated, drawn down ti> vulva, preparatory tii refiair 655 831 

ChrondrwIvHtrophia fiftolix 581 74tt 

OHJndmajyiitrnphic dwarf 5S2 740 

Cnmpnund prcHcntatioii 646 803 

fmien *>ectioTi through woman dying at end of [ircKnancy .... 645 803 
Diaganal conjugate, diagram nhowinK effect of poxition of promontory' of lu- 
crum upon length of 528 680 

diagrams of, showing it dependent upon heijihtM and inclination of Hvin- 

physui pubis 52ii 527 688 

Dyi«oc«a due to hydrocephalun ... ii36 To.'; 

due to o^-arian cyst 517 G75 

fcJlnwing ventro-HUificnsion ; wcciilHtion of anterior uterine wall . 516 071 

Kfepfaantiasin congenita cyiitica 0.17 7<m> 



XXVi LIST OF ILLUSTHATION'S I\ TEXT 

Fin. PACE 

Kpipliysis, in ad\-aiiec(l stagea of rhachitm, Bection thmiiKh .... 5-13 706 

iinHirlyHtoftesof rhachitiM, section thrt>ug)i 542 705 

nf child, normal, Heotioii throuKli 541 704 

I''irtu(i wilh roiiRunilitl fj'Klii; kidiifys (i;fi( 71(7 

with iiniiieiiHely iliHluiidud bbildur 531) 797 

Fracture of Mkiill, Hpoon-Hbapcd 576 732 

Kyphosis. Iiimbo-Ktcral. front and side view of patient with .... GID 77t 

Luxation of femora, side and rear view of patient with 632 787 

Meamiringantero-posteriordianieterof pelvicoiitlet, Itrciaky'Rnicthoil . 537 KHi 

bia-ischial diameter with WitliamR'N pelvimeter .'i3r> 69(1 

conjt^ta vera with Skutnch's pelvimeter 530 690 

diagonal conjugate 524 087 

dJBtanra between anterior superior spineH 521 0S4 

distance between tubera ischii 535 605 

external conjugate 522 685 

length of diagonal conjugate upon the fingers 526 6B8 

tranaverae diameter of superior strait with Hkutwh'H pelvimeter . 532 693 

Overlapping bones of Kkail 572-573 731 

Palpation of ischial tuberosities 534 694 

of pubic arch 533 693 

Parietal presentation, anterior 565 725 

anterior, showing paaaage of. through niiperior strait 566 725 

posterior 567 726 

posterior, showing passage of. through superior strait 568 726 

PeUis, assimilation, asymmetrical 601 760 

assimilation, generally contrseted rhachitie 552 710 

assimilation, high 5a5-,W7 758 

assimilation, low 600 750 

canal of, obstruction of, by cystic enchoiidroma 633 798 

cbondrodj-strophic 583-584 7-tO 

contracted, due to absence of sacral i-ertebric 594 757 

coxalgic. before and after individual has walked 625 783 

coxalgic, with ankyloaed femur 626-628 7W 

diagram showing significance of dimensions of anterior and posterior sagit- 

tot diameters 604 703 

diagram showing significance of dimensions of anterior, posterior and 

sagittal diameters 602 762 

flat lion -rhachi tin .5.38-540 703 

flat rhachitic 544-546 708 

flat rhachilic, showing donlile proiiionlory 549-551 709 

fractured 634 7Bi) 

generally contnii'ted 578-,'i80 747 

generally coiitruclcd flut rliachitii' .'>.'i3-555 711 

generally conlr.iited rhachilic, child Ixirii upon Inntin inly thnmi;h . .574 731 

generally contracted rliurhilic, Miouliling of hoiid in .571 730 

generally ec|iui!ly contracted rhiichilii- .Wfl-5.58 712 

kypho-scoliolic-rliuchitic OLS-filO 775 

kyphotic, longitudinal section tlin)ujr;i 606 766 

kyphotic, showing elongation of conjugutn >-er.i 607 767 

kyphotic, showing forces concerned in production of . . 009 789 

obliquely contractctl. anterior view . . 587-.588 7.52 

obliquely contracted, due to non-rhnchitic scolioKis 611-612 773 

oblir|uely conlructeil, due tJ> unilnturul luxation of femur (i29-63l 785 



LIST OF ILLrSTilATruNS IX TEXT x.wii 

no. rw.r. 

Pdi-i*. olilkiui:!}' (^nlnrted, ponterinr view of 580 7,i^( 

"'•'«^* tiOS 7(>8 

Dxteonularir ;i«l-.S63 7)8 

(wtMXiuiLirir, inferior Htimit sitH 71!) 

outlet uf, illuHt rating iiB<«nity for Cu-Hknaiii iwi'titHi 005 76.1 

outlet of. illuDtratiug posiibility of BponlsneoiiR labour, uwinjc t» long pott- 

Icriur Hkgittal diameter flO.3 7&2 

pwudo-oiiteonuitario a^ 71.3 

rturhitir. dingntni nhowinK ''liuiiKeH in Hhupc of oHteoiiiulurir .^GO 714 

rharhitir. diofcrani Hhowinfc rhmiKeH in Hhaiw of rhuchitii- .... ,500 714 

urnbr-rluchitir (II:M(I4 774 

*()iii rur'-mt 7.56 

upcHidylnliFthetir 1118-020 777 

■{■■ndj-lolist belie, vertical Hcolion through CI7 776 

tnnitvcrsely coniracted aiwiniUation 5tlH-.')99 759 

truiin-erBely nminirted Robert .TOO-SBl 755 

true dw-ari .58.V586 751 

Fdnmeter. Budin'H 518 liS3 

Hint'* .531 891 

Martin'* 519 683 

method nf holding 5:% 683 

Stein's .529 88tl 

Tlsivnta, preniaiiire Hvparation of, withextemal hninorrhaige 647-048 806 

pRTvia. diagram illutitrating Hoftneier'n theory of formalion of 6.52 812 

pnA-ia. fo'tun partially extracted from patient dying of ... . 653 81.5 

pn-via. in whirh no attempt at delivery luu been made .... 651 ^10 

nirantal iniienion, dilTerent modes of 049-650 809 

Pi^BBiTv marka from promontory .575 732 

Revirrf-itation. Si-hullze's method of 1157-658 847 

Rbmibnid. MirhaeU'ii 523 686 

ijarrum, obliteration of vertical concavity of. in rharhiliti .... .548 708 

arrenttiation of vertiivl rontsvity of. in rhachitiH .547 708 

SpnudyloliiclheKiH. author's aims of; fourth and fifth lumlmr verlebrn- 622 776 

(nmt and back views of woman with 623 779 

>de view of woman with 624 780 

vvrtiral .-cotion through last three lumlHrvertebm- and narntm . 621 778 

.SpoataneoiiN evolution, mechaiiiMm of 643 NOl 

rare fonn of <>44 802 

.■HipenfiT Mrait. rcnifonn, ciit^gcmcnl of hind i:i .560 T2S 

4i(iwine pawugc of after-coming head ,570 7'i7 

TranHverM.- proentalion, frozen Hertiiin through woman ilying in biluiur 

thniiifdi neglect (>4L' NOO 

rienu. invendon of, compleic t>.54 H:>3 

npliiff of. tiingitiidinal wM-tioii through wninan dying from ll.5ii H'i') 

Walrhtr'- hanging poMlioii .577 7r(7 



P.ATHOI/WY OF THI". PriCUPKRII'M 

Ction hwiUtu endometritis; lewocytir wall not int-ade<l by liacteriu 663 86^ 

I.itfle'j lufie for removing uterine lochia ((66 8H2 

Purrppral cndotnetritis due to colon inferlion. showing miirkeil ilcvfloii- 

ment of leucocytic wall iMil ViVi 



Xxviii L]»T OF I LM 1ST RATIONS IN" TEXT 

Puerperal encIomutrLlis due 1i> ntreptoeiimiH iiifci'linii, Kliowint: HliKlit 'levi'I- 

opment of leucocylic wall tiC'J 862 

Streptococcus endomotritin, showiit); invasiod of leiicoi-ytic wall . (i'i4 B(i3 

Thrumbosed pelvic vein, showing Htreplococci fi(i5 865 

UteruH from woman dying ten days aft«r labour from a. iiiixud infection with 

streptococcus and bacillus roll OAd 860 

from witmflii clyinj; ti^n days after Uiimur from streptocoo-uH infi-ilioii OfiO 801 



OBSTETRICS 



ANATOMT 

f|[APTKR 1 
THE P ELV IS 

Hiitorical. — As the mechanism of labour is pssentially a process of 
a<-(-oiiiiiiiHl;Ui<>n Ix'twet'ii tlie fwtus and the pai-siigc through which it must 
[HISS, it is nppan-iit that obstetrics lacked a scientific foundation until 
ihe anatomy of the bony pelvis and of the soft parts connected with it 
was clearly understood. 

We are indebted to Andreas Vesalius (15-).t) for the ftrst accurate de- 
soriplion of the pi'lvis. I'rior to the publication of his observations it 
had /p.'nprally been believed that the birth of the child could not be 
«-ir«-lf<l until the pelvic cavity had become increased in size by the sepa- 
ration anil gaj)ing of the pelvic bonea. Vesalius demonstrated the fallacy 
of this f«nception, and showed that the pelvis, for practical purposes, 
•h'luld Im- considered as an unyielding l>ony ring. His work was still fur- 
ther eialiorali'd by his successor at the University of Padua, Itealdua 
C'olumlius. who also demonstrated that each innominate bone was origi- 
nally comjiosii! of three separate portions: the ilium, ischium, and pubis, 
wlijih fused Ingelher just liefore the age of pulwrfy. Julius Oiesar Aran- 
lius, P^l^fl-.^f^^ of Anatomy in Bologna {155)1), also made inipi>rtant eon- 
trilnitions to the subject, and was the first to recognise the existence of 
"intrHcti-"! jK-lves. 

That the teachings of these three great anatomists did not esert so 
great an inliiience as might have lieen ex|ieeted, was largely due to the fact 
that no less an authority than Ambroisc Pare still continued to adhtTC to 
the doctrine of the separation of the pubic bones during labimr, and pro- 
mulgaliil it in his obstetrical writings. 

Among obstetricians, Heinrich Deventcr was the first to make a thor- 
on^rh study of the anatomy of the pelvis. In his New Light for Mid- 
vivfti ( ITOI ) he dwelt upon it in detail, and also described the main vari- 
• tit-s of e<intracte<l pelves. At that time, he felt called upon to apologize 
for taking up what was apparently so useless a consideration. 

SnitUie wa.f the first English authority to devote particular attention 
lo the subject. In his work on midwifery, published in 1752, he gave a 
most 8«-Hrate description of the pelvis and its various measurements, and 
also introduced the method of determining the an tero- posterior diameter 
which we still employ. A few years previously (1735), Johann Huwe had 
3 1 



OKH-ETRICS 



gonp over somewhat the same i-rmmd, but his work had not received , 
■il}'tlitiig like the ciin*!!)!- ration which wu« aaiiriltil lo Smcllit-*si invmti- 
gat kins. 

AliiioKt ■iimultaueoiisly with Smdiii'. Li-irel. ihc gn-nl Fn-ni'h nhstcl- 
ricinii, iiuhU»ht-il lh« rt'Miiltn of hia oliseirations, and was one of the first 
to promulgate the coac^tion of the axis and Uiv plniK^s of ttic jxjtvis. ' 
Th« vh1ii(> of his vrork, howM'er, was considernbly inipaired hy many inac^ 
curacies. Among the (iemians, Stein the younger wa« apparently the 
fiwt to givo n thomughly atrurali' ikwcrj])! ion of tin- jwlvi*. and sinoe his 
time correct ideas upoo the subject have gradually become popularized. 
Pruclii-aliy. thcreforn, un nllL-nipt to follow the further dt-velnptnent of 
our knowledge concerning the pelvis would resotvo itself into writing a 
luKtory of obKtctriot. To do this would go far Ix-yoiid th« unilxr of tii" 
prcM'iit work; and h-t it here sulVice to say tliat among the more modern 
authors Naegele. LuH-hka, Michuclii^, Litumanu and BrL-UK and Kyillsko in 
<!ennany. and Ifodgi- in Ihi^ country, deserve particular iriention, 

Ocnenl ConRidertitioni. — In both sexcx the pi>lvis fornii' the botiy ring 
llirouj^h H'hii'h ihc l>»dy weight in Lrannniilted to thi: lower extremiues, but 





Flo. 1, — NoiuiAi. Fkmai-r PKtVW. X |. 

in die female it aisume* a peculiar form which adapts it to tlio pnr; 
of c-hildJK'uring, 

It is com|H)spd of fonr bones; the nacnim, the coccyx, and two innomi- 
nate hiiiii.-i. the Inst two hi-ing iinititl hy slmiig articulnfions with the sacrum 
at thfi wacio-iliac synchondroses, ami with one another ut the Kvniphysis 
pubi^ The purely anatomical characteristic!- of the pelvis are dealt with lit 
length in tJio standard wotIch on nnaiomy, m> Ihnt we iihall limit our COQ- 
sidcrations lo the peculiarities of the female jjelvia, which are of importance 
in I'hildlii-aring. 

The Pelvis from an Obatetrical Point of View. — The linca tcrniinalis 
foriuM tint buujidory bi.-twciii the fui.-JC and llic true polviis, tho former 



THE PELVIS 3 

Ivinp above and tho latter bolow it. The fahr pdrin is lx>Hiide<l posteriorly 
by tliv lumbar vertebrffi and laterally !>y the iliac fossw, wbilo in frniit tlie 
biiundary is formed by the lower portion of the "anterior alKlominal wall. 
It pi>.-isi'!ise!? no particular obstetrical significance, but serves to support the 
iiitt^tiof^ in the non-pregnant woman, and the onlarg»l utcrufi in the 
pregnant condition. It varies considerably in size in different tndividuaU, 
according to the flare of the iliac bones; but ordinarily in dried speci- 
mens the distances between the anterior superior spines of the ilium and 
bi-tween the most widely distant portions of the iliac crests measure 23 
and Hi centimetres respectively. 

The true pelvis lies beneath the linea terniinalis, and is the portion 
concerned in child l>earing. It is bounded above by the promontory and 
ala* of the .'acrum, the linea terniinalis, and the upper margins of the pubic 
lionw, and below by the pelvic outlet. Its cavity, roughly speaking, may 
\<e compared to an obli(|iiely truncateil cylinder with its greatest height 
posteriorly, since its anterior wall at the syniphysis pubis measures 4^ to 5 
ci-nlimi'trts, and its posterior wall 10 centimetres. With the woman in 
tlif iipriglit position, in its up])er portion the pelvic canal is directed 
downward and l«ickwanl, while in its lower course it curves and becomes 
diniled downward and forward. 

The walls of the true pelvis are partly liony and partly ligamentous. 
Its |H>sii-rior Unindary is furnished by the anterior surface of the sacrum, 
ii-' lateral limits are fornu-d by the saero-seiutic notches and liginiients, 
um) by ihe inner surface of the ischial bones; while in front it is bounded 
liv the olilurator foramina, the pubic bones, and the a.scending rami of 
ill"- i-<-hial iKines. 

The only |>art of the lateral wall of the pelvis which is entirely bnny is 
mud'- u|> of the liodv of the ischium and part of the ilium, the inm^r surface 
iif which, with the woman in the upright [msition, forms an inclined plane 
wliiih is dintrtcd from al)ove downward and inward, and from beliind for- 
«;if<l. Consideralde importance was attached to these surfaces by Hodge, 
«li" di'sigiiatitl tlieni as the inrlini'd pJanex of the jielvis. ami considered 
that thfv e.xiTcised a good deal of influence in causing intcrmil rotation 
of ihe lufld during lalxmr. This view, however, has since been abandomil. 
If rhi- planes of the ischial Iwnes were extended downward iliev would meet 
Hitrhfwh'Ti' about the region of the kniH'. Kxtending from the middle of 
iln' imsti-rior margin of each ischium are the ischial spines, whii'h arn of no 
hull' obstetrical imjjortance, inasmuch as a line drawn iielw(«'n them rep- 
ri-M-nts the shortest diameter of Ihe pi'lvic cavity. Mori^over, since they 
<-;iii !«■ riwlily felt on vaginal examination, they can Ik- made to serve iis 
vdliiiibte landmarks in determining the extent to wliieh the pnisunting part 
bad d>-s4-cnded into the pelvis. 

TIic sacrum forms the posterior wall of the pi'lvic cavity. lis np[ier 
iiili-rior jiortion, ci>rresjK>nding to the body of th{' first sacral vertebra, 
iiml di-signali-<l as the promontor>', can Ihi felt im vaginal examinalinn. and 
"ff'-r- a liuidmark which serves as the basis of hiternal [Hdvimetry. Nor- 
mally, the sacnim presents a marked vertical and a less pronouneiil lateral 
i-oni-avity, which, in abnormal pelves, may undergo variations. A straight 



OBSTFTRICS 




INK KK%'■•T<l^K nr iiiK Am-u. 
Modili«l from Duiwnn. X {. 



line (IrawB from the promontfiry to the tip o[ the sacmni uhiuiII.v meas- 
ures 111 centimetres, ttliertyw if llit- iiuiKmity In- lollwwt-J lliv difiljinn; 
avfrugds IS cfiiliimrlrt's, 
Tbe Kdcriitii wan formerly 
rogai'dcj aa the " kt'y- 
jiloii«" of Itn! ]icivie iirili, 
but Matthews Huncan 
i^hiiwed IhHt thi« oimwp- 
linn wait crrt>n<.><iiiK, anil 
that it reprosente an in- 
vertt^l kevvtoiie. iimirntji'ti 
»s it is wider aloiip it« an- 
It-rior limn altinj; ilf jms- 
terior i>urfaee, so tliat it 
uonld t^nd tn flip (hiwn- 
wtti-d mill fiirwiinl inln ihe 
polvie ravity uiuUr lli<- in- 
(liifnc-c of lint \mt\y wi-i^'ht 
were it nut held in po- 
HJlion bv the Ktronjr p"W- 
lerior ilto-i^aeral li;,'niiient^ 

(Fifi. 2). 

In llifl female ttii- piiliie arcli prespntu a charaeteristic apyiearanee. The 
(kwendin^ rami of the pubis unitp at an unjfk- of 9(i to 100 depn-es, and 

fonii n mmidrtl npt-ning thmuifli 
which the head can readily pas^. It^ 
timrfriris urc liinn.' di'liciile thini in llii' 
male, iiiiil nre cniKi.li'nililv cvit!''.!. 

Planes and Diameters of the Pelvis. 
— Owin;^' to llii- pci-iiHar ;<liji[ii' «i' Ilie 
pelvic cavity and Ihe iJilliculty espcri- 
I'ni'iil in n'nili'rin;; cleiir llic fxiiot 
location of a Iwdy oeoiipying it. for 
gri'aliT eoiivcnit-nw in di^cription it 
is ciictoniary t<i eoiistnict eertani*im- 
Bflindry plunc« through it. Tho'c most 
fre<)iienLly eniphiytii are desit^iinti-d as 
( I ) the snpci'ior strait, (2) the inferior 
siniit. ('!) the phme of {iniiti-^t, and 
(1) the plane of least, pelvie dimen- 
i^iuuit (i''igs. n nnd b). 

The suppriof strait 
peprespiit* the upper 
iHiundary of the cut- 
ity, and i* freipienlly 
ifpokcn of at) till- pelvic 
iiiIpL It 13 fomenhat oral in shajie, wilh u d(>prfx«iAn on iU |>oi>lrrior Ixir- 
dtr «>rn»piindiiig lo lln- pruiiiuiitorj of the «temm, and is occasionally do- 




Fi<i- 3.— SiorrTAi. Buit-riosi ntuit'oii Nimtm, Tei.tih. 



THE I'ELVIS 

MTibed B« blniit )ii>art-«lia]>i'<l. II iii UniDdMl pnstnrinrly l>}' lli« {iruinnti- 
Innr 4Ui<l al» of tin- niitnnii; Inlcrallv bv tbt linea tLTiuinalU; aithTJurlv by 
the bunz<>iilul mini nt liit- |iuliii' Ikiiica iiinl ■)■<■ .vviiijiliy.«iK [iiti>iK, StricUy 
*fmkin^, it i* iml ii tuullu-timliial plniii", xino- il-* liiU-ral iiiui^iiiv, u* rt-prc- 
dUtttl liy Ui« liiKii l«rniinalis, are at a lowvr level thau its eeolral |>orti(>n 
la^wn.'D tiw pnnuantory and sviuptiyBt^ pul>j». 




.4.'— NoniAb ftlULa Pei.tu kinmivn )>iiuiCti:iu or the Si.-ruii»n tiTFurr. X |. 



Fipur ilrnmi'lrni nn- ukiuiIIt iK^tiU'iI n» trnvi-rsinff tin- *ii|n-rinr "tmit: 
tlw aDIiTi>-|»j?-lrrior, tlw iraibntTM.', aJiil iwo (>Wi(|ue dintitetLn-iK. TiiP an- 
bntk-prwliTtor duinHdin- cxU-ntU fniin tlic niiilclK- of IIk- |irnniniitnry nf th*; 
«cniiu tit iiie U|i|:ii!r mai^iu of tl)i>8yiM)i)iT!jifi puliU. aii<l in <t<-'Ki);iiiili^l an Hip 
r-miiiijuta rmi tir true mnjugnir. Tin* ti-riii was Hr^t firiplnvni l>v Itocs 
(k-nr. wlio liki'iNil iIk' )iu|>i-riiir i>lrnit [n an i-llipM-, w)i<i»i> ^horlir liiwiiKtler 
ran antMo-poKli-norlv. Normally, the conjiipita vera nicu^uiVB 1 1 wiitU 
mrln*. )iul Jt niay livciiitK^ inarkclly Kliohituil in uliiMiriiial (H'lvwt. Prom 
a \ifa*\'tia\ pniiil iif tit'w it is Mw iiio«t iiiiporlaDt clianietor, ina.->iiiiivh as 
it w th*' p>iinl iif tli-juirtiin* f»r nil ullftnptN to i^liniak- Xhv t\?.v of l\tf 
pvtrnt in ai-ntal prai'ticv. The triift^verse diaiiK-tcr Ik cnn^truclul at rl^lit 
asif)'^ to I)m' cfiijii^ata rcn. aihl n-iins^iil*! the ffrLiiliwt ilietatici? tietu'epn 
Ihi* Itu'tt ItrriuiiinliK nn t.-j|)urr tiiil<>; it UKiially iiitiFnuvtM Itii- <>niijitptla •n-rn 
a< iT?ln fr«)nt of thcpfttiiniilory. Norriially it iiicaKiiiVK 

I. . . .< ii of III)' iililiipK* <] iniitcItT!! <-.vli'iii1i frotii oni' of tlio 

vcro-iliae nmchnodm-ws to the ilio-portim-a! ttnlneiiw on the opposite 
mlc of the p«-lvii(i TIm-a- mwiiiHn; Vi.th ocnliim'tn'*. aiwl arc dciiigiiatcd as 
fiflii anil left nwpertively, aiXDrditiK a« tin' starlinji- point in the right 
"T ti-ft arnt-iliar BrnrhondrTwiu. InKlfnd of omptovin? the ti-nn^i rijiht 
and Ifft. the (Jfrmiin" tiMially niwwlc of the fir>!i nnd Hi-oiid ol>lii]iif <iiani- 
«t[inL The nacfo-eotyloid diamcleni are mitietinies dc«rrih«l : they ex- 
(■' ■ ' I Iho middle of the protnontory of tlie Hiiemin In the iliu-poc- 
I.: m'iue '>n vitlier r\Atr, ami nicasnn; from S.iA to 9 ntitimetm. 



f 



OBSTETRICS 



Normally these two diameters are of equal lengtli, but in certain forms of 
contracted pelves they may present marked variations. 

The an tero- posterior diameter of the superior strait is frequently 
described as the anatomical cvtijugata or the conjiigata vera. _This does 
not represent the shortest distance between the promontory of the sacrum 
and nyniphysis pubis, which is along a line drawn from the former to a 
[joint on the inner surface of the symphysis a few millimetres below its 
upper margin. The latter is the shortest diameter through which the 
head must pass in jlescending into the superior strait, and was designated 
by Michaclis as the obstetrical conjugate. It is a few millimetres shorter 
tlian the anatomical or true conjugate, but for practical purjioses the dis- 
tinction is rarely made, and the obstetrician simply speaks of the eon- 
jugata vera. 

Unfortunately, in the living woman, the con jugafa vera cannot be meas- 
ured directly with the examining finger, and various more or less compli- 
cated instruments have Iwon devised for its determination, only a few of 




Fid. S. — Diagram bhiuvinq Pklvic Pt.akes. x J. 



which give satisfaf-lory n-sults. For clinical purposes, therefore, we are 
content to estimate its length iudireclly, \>y measuring the distance from 
the lower uiargin of ilie symphysis to the promontory of the .sncrnm, and 
subtracting fi-om the result 1.5 to 2 centimetres, ac(X)rding to the height 
and inclination of the symphysis pubis. This diameter is the ronjugata 
dingonalis or ohUj/uc conjugate, the importance of which was first empha- 
sized by Smellie. 

The outlet of the pelvis is designated the inferior strait. It is not 
a plane in a mathematical sense, but consists of two triangular planes 
whose bases would meet on a line drawn between the two ischial tuber- 
osities. It is bounded posteriorly hy the tip of the coccyx, laterally by the 
greater sacro-sciatic ligaments and the ischial tubero.sities, and anteriorly 
hy the lower margin of the pubic arch (Fig. G). For the pelvic outlet 



THE PELVIS 



two (liuiirtcrii an' di-i^ribnl : Uk- aiitcro-iKMltTiar and Uit; LraiiKvvn<r. The 
fnrtner extends fmin line lowt-r mai^in of the ^ymphyflis pubis to Uio tip 
nf the (.ttccyx, uad the latter bctwccQ tl>e iiiuvr uiflrginti of tlii; ischial 




Fio. 6.— Pb-vic Outuct. X I- 

tiibrnMntM<'>. Willi tlio emvvx in its normal position, tlie ant<'i«-piwtprior 
duuteUr uunsurps V.5 crnliinvtni*, whicli it im-miN>i to II. 5 ctnitimotres 
tlaring laUtiir t>v the Irackvari) •li^plaremenl of the tip of the coccyx. Tlie 
IraiMTerM' diameter iiKiiMirtv II (ttiiimdrvi^. 

The plain- nf grwl'^' polvip (iitiiensinn-t was fiNt titsk-rilwd hy Lwret, 
■nd. a* itn name impti^fi. repr«.eDt« the roomiest portiou of the pelvic 
eariiy. It L'ltiaids frwiii tin; middle of the piwlixior tiirfaoi- <>f the syin- 



Pubis 



Rndni- 



V-f)««tui 



Of)liiraI<7 
oramen 



[Uirmt 







Sacrum 

Vto. 9. — PukMS or GncATnrr ItauuwiOMa. 



ph.v*» |>uhi* to thu juuction of the second ami third sacral vertebrs, 
and Ul'Tullv pa-.-Ps llironj-h the JHt-hia! IxvnM i>v<'r tUr nii<ldle nf iho itoc- 
taJialanL Its an I i;rff-f "interior aixi transver^- diaincttTM ni<ai*iin> I2.7i> and 
12.9 centimetres, n^pectiTdy. Since ik oliliquu diauifHerH terminate in 



8 



OaSTETRiCS 



the obliirator foramiim and the sacro-sciatic notches, they are snhjpot to 
markiil vitrmtioii» iii It-ngtli. 

Th(- [iliini^ of Ii-a6l jietvii; (liiiu-iiKiaiis fxU<iiil.< tlinni^h Otc Idwit iiiar- 
pin of Ihe svt;i|(li_vsin puljii*, the (ip of the sacrum, ami the ischial sj>iQ«a. 
Its aiitfrn-jK>!-tcrior diaiiictcr incu«urcs U.5. lis Irari^vrrw iliutiulcr ex- 
tends UhviTii On; iwhiiil i'|)irn!K nml iti(iiKure« 10,5 t-eiitiiiiiUnw, U-ing the 
ehoiicBt diamdor in the normal jielvic cavity. 

Ill order to fucililatc the study of the pelvic cavity, Hodfre cniutntcl^fl 
four parallel plam.^, the (ii-»l of which i* the siijienor .ilraif. wtiilc the other 
Ihrtv are parallel to it and pass through the lower inarKin of the *ymphviii« 
pubis, the i-ichial splmw, mid ihc tip "f ihc i-occyx re-*|Hvlively. The siwond 
parulU'I pnicticallj- correj-pouds to the plane of jjreateat pelvic diiiieui^iuii^. 



4 

n 

4 



Ischiuni 




Pubic ramus 



Pubic ramus 



Ohluralor micmus \i 




lum 



Tip of Sacrum 

Flo. 0. I'l.AXK or IjIAflT IhUKXHlimft 

(Veit). 




him 



Sacrum 

FiO. 10. — Veh'h Mai« I'l.LHiii. 



■nd U very clo»«ly relattrd lo that deswrihed hy Veil as the main ptano of the 
pelvic, which vxlends from ihc h>\vi-r iniirgiii of llic nympliy*"'^ ptihi* 
the jiinclioii of llic first and secimd Bacriil vertehric, Acconiiiij; to Veitj 
this, from an obstetrical ftaiid)ioiiit, in the liir^fc-Nt |)lane of llic (mIvIs, inaK-j 
miuJi an it is imt eiicroaclu-il upim by the |>elvic noft parts, but jui^'ii above] 
Ihc obturalor and pyrifoniiis and hclow the itio-p«i>as mti»clcs. 

MoKt [H'lvcB prcM'iil iili^lil indiviiliiii) TiiriMliini!* in r''r.v, iiriil pi'rfi'cfly' 
normal and synunelj-ioal e.\aiii])!ci are rarely ween. The measuivnieiita 
which we have );ivi>n are lhu»c of Schroodcr. and are thv averages obtHini.tlj 
from llic in'i'itr;il(' incnsiinilion of .10 norninl [M'Ivw, 

Pelvic Inclination. — The normal position of the pelvis, u-ilh thai 
woman in i\k cnrt poshire. can be rcprodtienl hy lioldiii;: tlio *perim».'«r 
ill such a way that the incisions of the nci^Iahula look direi^tiy downirard.J 
According to Meyer, the pelvis ia in its normal position when tho ante-| 
rior sii|nTior cpiiics of the ilium and the pnhic spines are in the samv.] 
vertical plane. I'mlir tliese condilioris the promontory of tlio sacruntj 
is 'J.5 to in centimetres higher than llie upper niBi^in uf the sym- 
physis puhiit. 

By Ihc term pelvic inclinaiiim is understood iLc angle which the piano 



THt; I'ELVLS 



9 



nf the ait)wrinr ftmtt fonn* with llio Itnrizou (wo Kig, 3). Thii* roimrpliuii 
HA fint iuLnxlucHi bv •'■ •'. Milller iiu<l KiK^lorvr, end Ihc early aUte- 
ntnt> i-rnicrniiiif; it wi-rc vi-ry (null id in-;. Ai'cordinij; t<i Mvwr, the 
^VttTP "f gravity of ilie Iwtly [mxk*-* uliiijg nil iinaginarv vcrlk-al |iIhiiv jiist 
piiclcrior to lbi> acdabula. m ihnt under tlio infltictici- of Ihv bmly weiglit 
liw [wJviii wiiiili) Uiul to rulati- backward ven it not hold in piKitioii by 
tln! striidK iliti-ft'ninral tigniitMttt. |i \» ()ii'i\-fun- a|iparcnt tlial llie pi?lvi<! 
ini-htiiitKin luiml vary awxirdinp to the dejirpe of tension of IIk'w struc- 
tiirw; i( vil) hi* fiiminiKhti) whi-n thoy art" relascd, and vice vema.. It m 
koAl tnarkiHl v]vea the legs are alijihtly rolated invord and >:prvad a little 
optrt, Mild Kf^^l'y incTpQK'd when the kn<x« are pressed tij;litl> lo^ielher. 
ft wImti ttit' lirfpi an' widely !<)irea(i n[iart or mtiiti-d sirorigly cUIht iiiirard 
ur oitlvard. With I)h' woman in liio upri^^lit jiosition the )>elvit' inidintilion 
is DJtualljr i»tiin»led at 4.'i in iMJ dejfixvj!. bill may tary from 4n to 100 
ikfret» irrarding to the degrcp of tonaion oxerled by the ilio-fomnral lij^ii- 
iiMUit.4. In ei^rUin iliH-:i.«Ml i'(ii)dili(>n>: ir may be ntilileraliil. wlion thi- plane 
of tbr ^npi-riiir himil may Ix-iximc parallel to, or cvvn form sn f>btu.*c atij;!e 
«itk the hiirixoti. 

The fint aociinito work upon tliix Biibjoet was done liy Xaegi'U-. who 
I ni«nL'<iin<il tin* di^tanrf from tlw floor to the lower margin of the syruphysia 
imbid and tI«L' tip of Iho Raenim re.i(H"e1ive!y, and in thin uiiy ootimatid 
llip iiM-tinalion which liie inferior i^lrait fonnrd with the horizon, lie 
I tiwn plat^l a normal pi-lvi* in a nimilar [Mixilion and i.'Kliniali-^l the in* 
[ dination of its superior strait, which was usiially about 60 degrees. 
I In vit'w nf 11)0 markwl variationK to whidi (ho pelvic inclination is 
f •uJijwt. Mever iniiiiil(ice<l a new eom-eplion oonivniing it, and ttlaled 
lliat li wa"- confiiderably intlucnci'd by llie extent to which the sacrum ro* 
I latnl aUiiil ili* tran«voru- axin. A* \h\* pnv-4'x through the centre of Iho 
I U*ly of the thin! sacra! vertebra, it is apparent that this portion of the 
|.'«ertiin fn'latn;' approximately the name jMwitimi, no mailer In what ex- 
I tent it- Djifier or lower jxirtions may be ilii^placixl. Meyer, therefore, eon- 
l *ln«bil « dinmvfrr extending from the upjicr margin of (lie symphysis 1o 
L the middle of i\\» third «acral vertebra, anil desiiirnflted it the normal con- 
} fHti^tlr lu inclination he estimated at 30 degrees, and staled that it re- 
Loutiucil priM-lieally mn-'tiiul in all )MwilionK of Iho liody. 
B^ Kio'fit when marke<!)y ahnormiit, t)ie pelvic inclination po^^e^ses no 
Hn(>l»cal otHlolrii'al «igutfican<'('. ami is of value onlv in Oie study of 
[alyiilrail jwlre* and anthmpoloj:^'. Several complicated instruments have 
I I»VB invi-nlM for determining if. but Pnx-howniek lian suggiwted tluit it 
I Buiy Ih> ap|iri>\iiiiali'tv eslininleil bv drnwiuK a line from tlte spine of the 
\a*t Inmlinr rerlebra to the np|K>r margin of iU« cymphysiti, and estimating 
Itlicatifcic tthieti this forms with the horizon. 

I Hince the lower margin of tlte srmphysi« occupies a lower Ici'cl than 
Mho (ip of III*' *aenim. Ihe plane of the inferior strait is also inclined to 
I Dv horizon, fonning an acute angle, which is nsitally esliniuted al 10 de- 
llEHKL Much more important, however, is Ihe angle which is formed tie- 
I tvioi thf- piKlerior surface of the symphysis pubis and the conjngals vera: 
|(}u» i> UsuaMy «>tinia(ed at W) to Hio dcg^n-es, but varies considerably 



10 



OBSTETRICS 



according to the ehape, height, and inclination of the symphysis pubis. 
This must always be taken into consideration in estimating the length of 
the conjugata vera from that of the conjugata diagonalis, since it is evident 
that the amount to be subtracted from the latter will vary with the size 
of the angle in question. 

The Pelvic Axis.— Deventer in 1701 introduced the conception of a 
pelric axis. Since then numerous methods for its construction have been 
described, the most usual being a line drawn through the centres of in- 
numerable planes extending from the symphysis to the sacrum, thus giving 
a graceful curve (see Fig. 3). This was formerly believed to represent 
the course which the child pursued in its passage through the pelvis, but 
the work of Naegele, Hegar, Pinard, and others has shown that such is 
not the case, and that an aiiis so constructed possesses only an historical 
interest. 

At the end of pregnancy the axis of the superior strait, if extended 
directly upward, would pass through the abdominal wall at about the region 
of the umbilicus, while the axis of the inferior strait would impinge upon 
the promontory of the sacrum. As the pelvic canal is practically cylindrical 
in shape down to the plane of greatest pelvic dimensions, it is apparent 
that the head must descend along the downward prolongation of the axis of 




Fin. II,— DiiOBAM BiiowiNo Pelvic Axis. X J. 



the superior strnit until it has nearly rcaclifd the level of the ischial spines, 
and only begins to curve forward in the region of the inferior strait. 
Therefore the obstetrical pelvic axis should be represented as straight in its 
upper and curvi-d only in its lower portion (see Fig. 11), as was well 
understood by Hodge, and strongly insisted upon by Sellhcim. 

The Pelvic Joints. — .\ntcriorly the pelvic bones are held t^ether by 
the symphysis pubis, which consists of a mass of fibro-cartilage, and by 
the superior and inferior pubic ligaments, the latter being frequently desig- 



THE PELVIS 

■« (m inramcntum areualum [mbts. I.uschka .l.-monstralfti lli« 
111 cavity in the filtnwarliliigio, and tlion-fon- dassed 
Ihp >vmphr«K ■moni; the Inw joinUi (Kig. 13). J«e*wl, on the oUwr 
kUHl, deni«s il:( cxUu-nre, and sta(«i thai r)ie flaid in tlie interior of the 
tynipliysu is simply a prinliit-l "f <li.<«(>ncration. WhulIwT it be a true joint 
or Dcrt, in »ny caw the fiymphvj>iii «<hiiil.i of « i-crlain amounl. of motility, 
which bocomcs partiniUrly marktil during ptvftnniify. This foot wo.i 
dnniinsinititl hy Hudin. wlw shunfd (hnt if ihp Itnjjer were iRj«r(<>d into 
Ihr Taffina of a pre/nant u-omait, and sho wen* mtulo to u-iilk. nnr pould dist- 
tinctly hv\ Ihc t-nds of the puhic bone* mow up and down with etuh Mcp, 



5-ip«rkrPubkm. 














Tht' nrlif'ilnlioii' iB-iwri-n Ibt* wrmn itnd innomiTiati* liimiii wi'rf fnr- 
rlj liiMi-riln'i] as fvitdiond roses, bul I.aMrhka I'oiioliiiivWy di.'riinii'it rated 
pn^mn nf ■ Mynovial i-nvily within Ihcm. Bixl 1h<^r(*fnrf clawH^ thi-m 
ixnuuf; llw trnf joint* (Kij{. 131, Tiiew? artirnlationn poysfiss a n^rtain 
■mouiit of nratility which plays a not iinitii|H)rlnnt )>art in practiojil ob* 

Waldter, in IWt9, ntalnl tltat Ihc diaj^onal conjnixati.- varii>d aliont 1 
nnliiBrIn! in li'n^lh, scconling att it wan invafiunyi with the woinnn in lli« 
ovital oli-te(riral position, or with hvr bultockH rwtinfr on thv cd]^ of tlie 
IaMv and hiT li^ hiiri^'in;tt down without any riup|Hirl, which huK *int.-« 
Imfn known ax iIil' \Valebi>r or hanging fiovition. His ol>wrvu(inn)< have 
t«va MOtfinnnl hy nearly all who have rc|n-aliil bin work, ainon^ whom 
am bf nu«l)on«I Klein. UVhle and Leopold and KUttner. The HuhjiK-t 
w><- ■■as one of llie main throii.-H for diiM7U»§ion at the International 

Ij' _ lal ami Ohslctriral ('oHgn»* held at Am*tcnlam in IW!'. The 

■Ti««lcvr<>. almoot without exn-ptton, ailmitleil l)it> p.>j)eral rorrectntwii of 
Walf-htfr** itljiinneuta. dilToring only as to the extent of the eban>tefi, while 
[kr «■« lh»' onlr one lo d>-ny their (XTurrenM?. 

;tniount of motility i-i ntitiztyl in dealing with contracted 
p-' 1. infn'"iiicnily Ow incrtiiK- in. the »ixe of the conjugatn 



12 



OBSTETRICS 



vt^ra, brought almut liy Walclior's jxisition, has provetl sufficient to permit 
tlie enfta(r<'ini'nt of-tho prciM^nting jMirt, which otherwise could not occur. 
The effect of Wiilchftr's ^lositioii upon the size of the peivic cavity was 

studied verj- carefully by Kiittncr 
in 18!i8, who showed in three cases 
that the eonjugata vera was re- 
spectively 1.4, 0.9, and 1 centime- 
tre longer when measured in the 
hanging than in the lithotomy 
position. Fig. 14 gives a graph- 
ic illustration of the changes in 
shape in one of these pelves. 

Methods of Comparing Felvea. 
— Inasmuch as the normal pelvis 
usually presents slight individual 
variations in its form and dimen- 
sions, and as contracted pelves 
differ markedly from one another 
in shape, several devices have lieen 
employed to enahle us readily to 
compare their pointf: of difference. 
The decimal melhoil, suggestwl hy Litzmanti, is very satisfactory for most 
piir[>nsi's. In it the viirious dianu'ters are expre.ssed in terms of the con- 
jiigula vera, which is reckoneil as ion. 




Fill, 14.^r>iAonAM siiowiNn VAiiiATtiiv of An- 

TKHO-I'lWTKHirin lllAMKTKH 1>F PkI.VIA IS 

Vakiouh PciHiTiOKK (Kiittiipr). X 1, 

Af Eittintomy; B, hr>hEontii]; C, Walcher's 
|KjT*itioii. 



or NohUAL pKr'ViH nv Lit^manh'h 
Ukcihal Mkthud- 




1IEAUI.7RRA. 




A iilPD^'pci^lpriiir. 


Trannvsme. 


OblUiiH. 




UK) 
ll.'i 
10.').. 5 
ia''...5 


122.7 
113.6 

100 


113 


Planc of greatest pelvifr dimciirtii»ii. . 









Breisky introdiic<'<I a graphic method for comparing pelves and con- 
structed thriH! diagrams, representing a vertical mesial section of the pel- 
vis, the plane of the sii|>erior strait, and a frontal view of the pelvis. The 
fir-it is coiistriicted upon Meyer's normal conjugate, the second upon the 
distant* iK'tween the sacro-ilinc synchondroses, and the third upon the 
tran>:v('rse diamrter of the j>elvie outlet. (Figs, 15-17.) 

Individual Variations in the Pelvis, — With the exception of the skull, 
no portion of the skeleton presents greater individual variations than the 
pelvis. This is due partly to the fact that it is developed from a consider- 
able number of bom-s, and partly to the varying mechanical and devel- 
opmenlal infltienees to which it is subjected during tlie early years of life. 
Indeed, we may say that no two pelves are exactly alike, and that per- 
fectly normal pelves are rarely seen; so that an accurate conception of the 
form and dimensions of wliat may be termed tlie normal type can be 



THE PELVIS 



13 



oltUined oaly from averages basttl upon the examination of numerous 
approxiniatctly normal pelves. 

Owing to the greater emplojiiiunt of the right half of the body, the 
rorrrsponding side of the pelvis is more developed than the loft. Indi- 
vidual variations may be observed in the form, consistence, and general 
character of the pelvic bones, in the angles which the iliac fossa; form with 
the walls of the pelvic bBGin, in the shape of the sacrum, and particularly 
in that of the cavity itself. In view, therefore, of the varying thickness of 
the pelvic hones, and especially of the degree of Haring of the ilia, accurate 
eoQc-luiiiuns cannot be based upon external jmlvimetry. 




t'lr.A. 1j-17.^HrK1«KV'« I )l.tlillAU:< MlB ("' I M P A H 1 Ml I'KI.VKI. 

/ . inrlinalion iif ilisc Ibiih-i; /./'., iliii-pBi'liin'jil'i'iiiiiii'in't-: /'., proiimiitiiry i.f Mirrmu; S,, 
ufrlivriiiikrEinfjf Hynifjliysih: S.\lcrworiiiaT|eJiiiirhyjriiiliy-siH; iS./.. sncni-iJjjii: '^viit'lJoixIrtMi^; 
Sp.. ilisr •iiinPH- 7'., truiu-vcriH.- disniel^r, HUiKnurMmit; '/'./., liibcr lm.-]iii;J, twiiJ iu Ixxly 

<iF tliini luax-ral \-nrfolim 



uf tJiinl AAcrkl vcrtj-'brH- 



Sexnal Bifferencea in the Adnlt Pelvis. — The pelvis prescnLs inark(sl 
M-7iual ciifferencCK. Speaking generally, we may say tliut in the male the 
pelvis is heavier, higher, less graceful than in the female, and presents a 
more conical ap])earance. In the male the muscular attacliirients are much 
more strongly marked, and the iliac bonus arc less flarwl than in the 
female. The pubic arch is more angular in shape, and pre.iont.s an uper- 
lure of 70 to T5 degrees, as companxl to !I0 (o 100 dugrtvs in the female. 
Thi- differenc-c is so marked that one usually speaks of the pubic angle 
in the male and the pubic arch in the female. In the male pelvis the 
rtiperior strait is smaller and more triangular in outline, while the pelvic 
<-avity is dei'por and more conical in shape. These differences are rcndily 
noteil in Figs. 18, 19, and 20, and may be especially emphasized by a c<mi- 
parison of the various measurements in the two sexes. 

Broadly speaking, the external measurements arc practically alike in 
both eex.ee, though the distance between the anterior superior spines of 



OBSTETRICS 

thtf ilium if wmrwhul Ipm in tin- mHli-; while nil tlt>- dinmcWM of the pelric 
cavitv aro Bhi>rt*r. no in thowii Uy lalilo on Mjijimitt page. 

It ]!• lln-n.ToR' iiii|tnri.'iil llml (In.' oiilli-t "f fiir innU- pi-lviK i« cnti- 
trncted lo .iiicli ii do^juv lu to iciidur it very liitlicuil for a living child to 




Fio, 18. — Fmovt ViBW Fkmai.k Prt.vni, x 1, 

(hroiigh it. |iiirlii?iilnrly in licini; fdixttl out tiridi-r ihr puljio ariKK'. 
OccoMiouiiIly Usi' fi'rrialf pi'lvi.-- niav approiidi the iimlp tjiw. and iind<T smh 
«iroi]mstaiices may otTcr in»iuiM-'riil)!c oli-latlf.':^ In llic liirlli o( Ihe pliilil, ami 
n<vL-«jtitHtc raiH<-iil fijwmlivn piocwliiitw lu ellLtl deliver)'. 




Fiu. 10.— FuoKT Virw Mau! Pbvviii. X J. 



NiimeroiiB not very isaliwfaftory attempts liave hern made to pjcplain 
the cau*t' of tlie dilT*Ten(v» Iwtwwn the male and fi-malc pciviit, Acmrfl* 
ing to Fchling and moi't subsequent investigatorit, .lexual dilTi>reno(» make 



THE PELVIS 



15 



niAurrriui, 



CoMrtaiwiK »T HtLE a 


fD FUIALR 




TrHlBVCTK. 




PtLvia. 


An t«ro-pnBt«rinr. 


Oblique. 


t*up«rior strait: 

Male 




10.5 
11 

9.5 
11.3 


12.5 
13.5 

8 pm. 

11 cm. 


12 cm. 




12 75 em 


Inferior stmit: 

M&)e 













ihfir appearance an early as the fourth or fifth month of intra-uterine 
lift', so that the eex can l>e ascertained long before term by examination of 




Fin. 20. — DiAnBAM HHOwrNO DirrcHEKCE is Shape of Male [ ] Asr Tr.v\i.r. ( ] 

Pelvib, 

the pelvis. Arthur Thompsion has recently made llie same statement, and 
mv own investigations have led me to similar conclu.-iions. On the other 



16 ^^IflW^ OBSTETRICS ^^^^^^i^B 

linnd, Schropilor and oiher amhoritiea alirjliutc the charaoieriBtiP shape 
of the fcmulv (K'lvi« lo lliv ijr'x'Iiil- of lliv inliTnal gcDilulia. aud kUiK- timt 
Itit- jH'lvi-n "f fcmali- uuniidij.. as well as lluiik' n! indiviiliiaU in whom lliu 
utLTUs is raiigfuitallv abscut, confonn to Ihe male Iv|io. While the cor- 
recliKjiw of *\ik\i wtjUL'nuMilif cannot iw doiibtt-d, it iiL'Vcrlhdt-ss t-renis prob- 
able that the greater part of the .lexiial differcnccA must be due to inherent 
devdoprncnlal and hereditary factors. 

Kacial DilfercnceB. — ( 'onBideralib' vnrinlions miiv Iw ohBcnix! in tlio 
form of the pelvis in varioutt racei, and espeoially upon comparing tho^ 
obtnincil from uhoriginal and civili«xl pi-opkw. }tiit in «pilc of tlie re- 
ecarches of Wctjer. Stein, Venicau. Topinard, Tiiriit-r, and others, our 
kiKmU-dfie ii|i(>n tliu Kubjctt is still fragtneiiturj. Siciii diKiin);ui»ht.-d four 
grougis of jH'lves: 

1. Itlunl liLurt -shaped , 

2. KIlijiticAl, with i\xv gr«atft»I diaiiiuter ( ransveriie. 

3. Hound. 

4. Eiliptioiil, with Ihc grcatf^t dianidcr iiutoni-jHistcrior. 
Topinard atteniptoil lo classiCy pi'lves awordinfj to their "general 

indt'x "^ — tliut i». the n.'laliiin belwcen Ihcir hei^ihl and width, as repre- 
sented by the distance belween the iliac crests. Hie careful ineasurementa 
sIkiwciI lliat the jH-lvis U'cumes iiK-rt-asinjiIy Iowit uad broader the more 
civilized the raio from which it is obtained. 

Turner base<l hi* ela^sificalion upon the R'hition lK'twc<in tho trausii'crse 
and antero-jKisterior diameters of the superior strait, and divided pelves 
into three groat groups: dolichopellic, in which the eonjugata vera is 
gri'iittT than ihe trHii-'Vi'rst' dianu'ter; niesiitipellic. In nliich the ennjnptlii 
vera and transverse diameteni are of cf|uid length ; and platypellic, in which 
the conjugnta vera is sliorter than the transvtTse diameter. He staled llmt 
tlie first variety had not been observed in women, though it is not infre- 
({ucnt in men; but the investif;ations of Sehnrlaii show that Turner wa« 
in error, as it is frnpientlj' noted in the alionginal women of .\nstraUa. 
The mesatipeUie vnricly is observed in the women of the lower races, 
notably among the Bushmen, 11oltentots>, and the lower classeii of negroes; 
while the plalypellic forms arc found in all the higher races. But even 
among civilinil whites considerable nicial difTere.ni(-> an- not infnipiently 
not<d. and it is generally stated that the jiehes of the Kuglich and llol- 
sli'in women an? broader than llioso of other itationttlities; while the .Jew- 
eeeea living in the vicinity of l)or]iat have extremely amall pelves. Oache 
states that the JK-Ivis i* usually normal in the Argentine Jlepublic, while 
it is iniperftvtly developed and freijiienlly fiinnei-shaped in Mexico. 

While the study of the racial differcne(w in the pelvis presents a marked 
anthro]K>logical inierest. it is, a« yet, of little practical ohstetrieal value, 
as no extended stiidiex have bi-eu nindo concerning the form and sixe of 
the bead* of childii-n which an- )>orri Ihnnigh them. The careful work 
of my assistant, T. F. Kiggs, has sho«-n that eontraetixl pelves occur several 
times more frequenlly among black than white women in Baltimore (.'!-) per 
ivnt lo il per cent), while oja-rativo delivery is more fn-'pienfly reipiireU 
among the latter. This is due to the fact that the negro children nru 



r 

i 



^ 



THE PELVIS 



17 



aave piori' miu[irE»ul>le lieaiU, and thus crtnipen- 
tli- [iir (Ik- niiialltT -mw nf llw {H-lvtii. 

Pelvii of the Hew-bom Child.— The pdri* of Iho t-Iiild nt birtli is partly 
Uin« aiwt |ariU (iiiriiliixN"'"*' 'Hic in nominate bom- dotv not t;xiMt a« »iich, 
■t> pla«v In-ill); Inkvii liy IIh- ilium, iM-hiuiii. aii<l imlii;-, which am iinluil hv 
t larRi* Y-sh»|>ci] ^:a^tilaJr'^ Itn- Itini- Imrn-* niirting in tlic aoolabutiini. 
Ttio iliiif crests and the acclabula, as woll as tlie grmu-T part of tlio 
iM!hi>i-{>u)iic rami, ore 4-ntin>iy ciirtilaginnuif in structure. Fi;;s. 21 

aiu! i'i clearly hhow thi> <-xIc«! 
lu nliicli tliv infuiitik- yuAvu is 
osaiticxi. 




. 2L— #i»tirTr«i. Srmojt nnowivr. Iln.A- 
Ti»« Pwif 'mi'is ■<► il«iM. till ('tnri- 

OtUJi. X I. 



Kio. 33. — SKcnos nmut'cir iKrAxni.K IVi- 
VM Pa 114 1, 1 -t: I. Tt> ifiii*rh>»ii ?rk4IT^ 
MRmiKii Hci.divK PiiowiniioKk iir 

ItuHE *\B L'AnTIUUE. X 1. 

A,, a«-UilniliiiTi ; /,, Ilium: P., piiliic 1iuni>;.S., 
nytiifiliv'-i'i pubii; .'t.A., bIu oI •urruni; 
.S H., body u( MuniRi; ('.<!., vprlvbnil 
arrti. 



The nir1tln]itnitii)i iiorlionf of Ihc pclviM gradnally ft''^*' plnco (n bfMir. 

Ind (iiiniilt'lH uiiiiiD iu Itic nejfjhbourhood <•( the aci-labnium iJoi-s not oarur 

vnlil nUtul ilic nj^t of pulxrly. aitd 'MM-»*innally l-vi'd iit a Inter pt-riotl, 

Ind»n1. «« may Miy tliiit tin- innominate lionet do not liocnnie ivjiniilptcly 

mil] fully d<-vcl(>pi.Tl imtil bfttrei-n (Ih* twcutictli and twcnty-liflh 



Earli innnmtnntv btinc ia devclnpwl fmni H eenln-s of ossification. 

riTiiw nt llifM- nn> priniarr and (fivr rtw lo Iho ilium. i«liium, and pulii*. 

Tli-y nmkc iln'ir ap[K-arance by ilic ond of the first half of pn-jinancy. n«; 

I rwi ' ci-nln-' — tlw^ fo-called epiphytical (vntrcs — are sei-ondary, and 

|(ln 1 I liip itniil a ctxiKUUTuhly lutvr [K'riiid, »oaK "( lli'-tn not unlU 

ifliT tin- al^' of iiuf*rty. 

V riFin al lirrlli is lilipui^o partly tmny and partly csirtilainitou^ 

[t <j}t of 'il di.-<iiuc( biiiM», i-nt'Ii of whii'li i» d<;r(v«il fmin a fiuglc 



18 



OBSTETRICS 



t-pntre of oKsjRratioi'.. Tliu 2! wiitrtw are nrrnngt^l «» follow*: I fur each' 
viTlrbriil IkhIj (."») ; 3 for Ihe ala? on dtlier side (ti) ; sud 3 for the archc* 
of oaoli vorli'bra ( 10), To tlicw must liit aiWdl lln; various I'jiiiilivwa! irn- 
trve which ajifK-ar latijr. Tho (■ariilaKt? gradually bocomce OBsitiwI, and 
the various miiiiioncnt part* of lh« ^orum fnsi' logi-lhcr. Tht^ ala^ araj 
the first porlioiis to become unitp<1. after wliich the vcrtehral bodies grad-l 
uttWy hwditiii woidiid logcihcr, the fusion i?xlL>iidiDg from below upward.! 
Awoniin^ to l,it-timinn. the bodios of the sacral vprtfbrs are not ciitin-lyj 
iiiiiU'd tintii llip wvoiith vcar, and complclc O'viliratiori of Ihi- Mu-ruiii ia 
not pITiii'tdl until the twontv-liflh war. Fig. 
BiJ rt'prw*iits the di^articulatvil pchis of a 
child thitf vi'wrs obi, and dearly shows Ihe 
iMtuiit lo which oi^idcattou biu i>rugro#!'ixl 
ut thai agt,-. 



Flu. 33.:— OtWAaTK-CLATMl PelVIN or 1'NKKlf 
tILAfrCIU) (ilKI. X ). 




Fio, M. — 8*oiTr»i. Sri 
Tiinnroii 1'ki.i-|» or I^i 

IKAK-llUl <.ilHI.. X }■ 



The [iclvia of llio new-ljorn child differs from lliat of the adult not onlj 
iti liein^' Tiiadc u]> of a lar^c- itiiitilier of Ikiiick which are iiiiilid bv rartilu^J 
hilt more parlicutarly iu il« charaeteristic shnpcr. This is clearly seen upon 
conipHriii'.' Vtg^. V-'t and 'i*i, which rejinwid vi-rtieul imwinl cectioiii' thniiigh 
Ibe trunk of a new-bom child and an adult wiunan. In the former the 
verlebrul e'dumri i» almost viTlii-iil, and it* lumbar curvaliire prnclicjilly 
absent. The pmmontnrv U very slightly marked, and ia situated at a muclfH 
higher ievel than in the adult. Ilw Mcrum ii^ alnioiit straight from above 
downward, hut [iriiM-iil-i a more marked transvcrrie concjivity tJiiUi in the 
adult. Its alfe are only (ilightly dcx-eloiied, and an a consequence the pelvis 
ii< ru'lalively iiarniwer. The iliac fos.^a- arc almost vertical, aud the hori-^y 
tonta) rami of the puhin are far shorter than in the adult. The pubii^| 
anOi \» much more angular, while the jx'Ivic inelinnlion is difidedly grentiT 
The superior strait Is narrower and more angular in shnp.>. Ihe rcbdion 
between the conjngata vera iiud the transverne diameter being 100 to inTi. 
inwtead of im to I'i^Jj, as in the normal adult jwlvis. The cavity of the 
pelvis is relatively much smaller, and is distinctly funnel -shaped. The 
an ti-ro- posterior and transverse diameters of llitf pt-lvic outlet, when ejt-^ 
preyed in terms oT tile conjngata vera, are respcotively 03 and 73, instoaij 
of 104.5 and 100 art in the ndnlt. 

A» we have already indicated, sexual dilTerenrti.* nifil<o their apposrani? 
ut ft very early period. Fehling showed that they could be delected as 



he 



20 



OBSTETRICS 



tilt* fti-'tn] pelvis. loHjt lH>rrtfi' it lias Ihwii siibjccU-d to Iho usual mechanical 
inllin-iHiw. llon'ovcT, llie nKtlitiiik-iil iiiiliicini's ttliiili trimn- iiilo jiltiy iiflcr 
liirlh are idcnlic-al in Ijoth m-\c-.«, Iml litfepile thin fact Uie sexual dilTcren«iw 
l>i.-cumc still iiiitrt' aici'ntuatwi a» puliertv* ii- approached. 

The part played bv devdup mental timl hcn-dilarj- iiiHiienci^s was clearly 
di'ninni-lrutcil bv I.il*iiiniiii, who showiil ihat. tlu- fcmtilo Hacnim wii* trliur- 
in-loriwil by a nmrkwl increase in widlli as compared with that of ihe 
male. At birth, ii) Ik)11i se-vivi. the iMiily nf llie PimI xucrn] vi-rtcbra i* twiei? 
ttH hmnd an the ala' (lilO to ,10). hut in the adult the relation lieconipj* 
100 to 7G in the female, nnd H'H h> •>(i in ihv niuk-, inilic-aling u inueh 
more nipid ^'mwlh of thi> ala- in the ffiniior. 

The elTeet eiiTte'i by nieebunieul iiilliieiiew has been particularly stud- 
itsl by Duncan, Illoyor, Veit, and Hchrowlcr. while Keliror ha.* in>i-'<lo<l 
upon Ihe part played by muscular aclioii. Acenrdinj; to Schroeder, three 
iiiiThii nielli fin-ei'.i laku part in bi'injrinjj aleiul Ihe final phapc nf the [m'1- 
vis — namely, Ihe body weight, the U|iward and inward pressnre exerted 
by the heads of the Xenioru, imd the eobwivi; [«rw exvrtt-d at the »ym- 
phyiiia pubis. 

So lonfi aif the child rcmainti conxtnntly in the ropumhonl position thew 
fonts' art^ in ala-yamr, hut ux »oi.ji a.-* it nits up or walks, Ihe h-xly wei^'ht 
is transniilleJ through the vertebral coluinn to the saennn. and. as the 
w-ntrt- iif gravity is anterior lo iu prrtinonlDry, iho fintv tranjTiiitted i;* 
resolved into two comjwnents, one of which ie directed downward and the 
other fiir*iinl. Aemnlinglv, lln- luo logi'lher lend In force the pninmiiLitry 
of Ihe faeruiM ihiwnward and furHHitl toward the syinjihysiN pulii;*, a prnei?*! 
which can only be aceoniplishcil by the Bacrum rotating slightly abntit it* 
transverse nxi.s so thai its tip tcnils lo Ix.'conie displaced upward and 
backward. This displacement, howwcr, is limited, ae it is resisted by the 
slroH;; sjiero-seJHtii- ligann-nls whieh permit of only slight cxlcnsioii. with 
the resnU Ihat the jiarlly canilagiumis saennn becunies iH-nt up'in it.-*lf 
just in front of its ti\i(i — i.e., alwut tlic middle of its third vertebra — so 
Ihat iu anterior surfai^e lit'comi's niarkutlly eoneave fnioi fllmve downwanl, 
instead of Hat as it was j)reviously. At the same time the ImkIv weight 
forees Ihe lirHlie-i of ihe >aenil vertebra fiirwaiil. mi ihat. they pnijtTt slightly 
lH>yond Ihe ala.* and thus tend to diminish the transverse cavity- of the 
racruin. 

As the anterior surface of the sacrum is wider than its posterior, the 
bom; tend* to sink dmvii into Ihe pelvic cavity nmlcr the inlluciicc ot the 
body weight, and would prohipst' edinjilelely inl» it were it not held in 
place by Ihe strong posterior ilio-suerul ligaments which suspend it, so to 
flpoak, fmm the posterior snpcrior spines of the ilium. Acmrdiiigly, as 
the «iiTum is piishiil downward info the ]M'Ivic ejivity it exerts marked 
traction ujion the ilio-sncral ligament.*, whieh in turn drag the ponterior 
superior spines inwani towards the uiiihlle line, and consequently tend to 
nitatt; the anterior portions of the innominate boncif outward. E-vccssive 
outwanl rolatiou is jirevi-nted. however, by the cohesive forec cxcrtwl nt 
the symphysis, but partieuhirty liy IIk- npwanl and inward preeeUTO exerted 
by the heads of the femora. I'raelicallv, then the iliac bone become* 



■ 



22 



ORSTETRICS 



niitvri»r onil of llie pubio boDfe 'J'heiro portions ineasiir(> G.5 to T, 6 to 0.5,' 
and t to 1.5 cpultmctrfs rw[n.vtiv<'lv, and tluT(-fiir(> ure pmcticolly of mguAl 
k-iigtl). Duriiiji; tliB [wriod of dMelopnieot, the snoral portion irrowa from 
[ItL- (vi'tilii>£L> foverin^ tln' iliac crol, the iliuc.])orlioii from iho upjwr limb 
of th« *■ V " simpfd i;iirti!iif£« of llw HrfilAUiiliim, aiid tii« piibic ]M>rlio] 
from llio IntliT n.^ will a.* from thi' jivtnphv*?Al caHilajte. 

I')) to Oio seventh or eighth year tho sacrum increases eteadily in widt 
and then pi.'iii'i-s 1" prow iirili! jiwt bi'foro piibiTlv, when it riipidly attfliii* 
ils full devf-lopniont. DiirinR the former period the superior strait jirowB 
Tclolivi'ly mon? rapidly in iljf Iraiicvdrw diiimek-r. nnil thiTofore {i>viim 
a flatlenwl shape. Normally, Iho iliac portion of the innominate bone in- 
cn-asus ifU'iidily in length, until it Iiuk uttuiiKil it« fid! d'-vHopm^-nt jitK' 



lb 

1 





Ftti. H).— tiiioniKo 'I'KniiiNAL l,jc»oni 

A9 BKKM I-IUIM AUUVK. X ). 



Via. 30. — ttiiawma Trbwihal Liuidim 
jw hbew rnoM Bkuuw. x ). 



heforo pulKTly, whilo the sin-ral and pubio portions j^ok' niiu'li more ^sluwlj 
AcToniiujiiy. a« U n-sidl of i1u--m* vnrialioibi, conihiiKt) wilti the nrri'slt>d 
growlii of llie i^acrnm, the antero-posterior diameter of the suprior siraiji 
will eipiul or oMi'i-il tin- lrHMsv«TW dirtmftvr in length. «i tiiat witni- titno" 
helu-ii'n llif ei;;liili ami Iwilflli y'nr ll'<' pelvic inlH will lniiMni- round 
nr won oval in i-hapc, wilh iln long diameter cxtondinf; aiilero-posteriorl) 
Tliis, liowoviT, i* only a trnnnienl plicnHnii^non, n» fhoilly before pnlHs 
tliv Kucrum (suddenly liej^inH to inrrcosc rapidly in width, and the pubiq 
Iwnes in li'iijith, so lliiil tlic snpi-riiir »lmit wicn rvawunn.'!' its typical flat 
Iwifd iiliii|H? "-ith llie lonj{ diameter oxtendinj; transversely. 

Brcu.4 and Kolisko llRrifori! contend that ihise variations indicatp thai 
the chanst^ in shape of the y^Wm mnut bo alLributed to sonietliin;; mor 
llian men- mi-rlmnical inlliK'niv*. sintv the latti-r eonic into play in infano] 
and rontintie as lonj; as the individiiHl is abhr to cit wp or walk. AVerR th< 
IIh- i>nly factors coiicernL-d. the pelvin nould necessarily eontimie to heeoi; 
more and more flalti'Ded, until il liuil nlluitKi] its ultimate form, vbe 



THE PELVIS 23 

the (KTurrence of a roundod Rn))Grior strait between the eighth and twelfth 
vi-ar cloarly indicates that some other factor inuut be concernod. As yet 
ihtry have advanced no explanation for the variable rate of growth of the 
eat-nim and the coniponent parts of the innominate bone, but they nevcr- 
tliele<ti liold that its occurrence should preclude tiie acceptance of the 
mechanical theory to the esciusion of all others, while at the came time 
ihey admit that the latter may play a prominent part in the development 
of the pclvig. 

The efffct of the mechanical factors is particularly emphasized in cer- 
tain abnormal types, more especially in the production of certain varletlos 
of ranlra<-tcd pelves, and has been exhaustively studied by Von Meyor and 
Schroedcr. In rare instanecs, as in a case rcconlwl by (Jurlt, none of the 
nieehanii-al force's came into play, and then one lins an ojiiiorlutiity of 
ttudying the (level o| mi en t of the pelvis in their absence. In (Jiirlt's case 
of a thirty-one-year-old hydrocephalic woman, who had Ijccn Ix'dridden 
fiace infancy and had never sat or walked, the autopsy showeii that the 
pt-lvis had rctaineti its foetal characteristics. 

The cohesive force esertc^l at the symphysis pubis cannot act hy itself, 
is it is niunifeste<l only when the force exerted by Ihe body weijrht causes 
a tendency towards gaping of the pubic lK)Ues, Likewise the effect of the 
Djiward and inward force c\erte<I by the femora cannot be observed l>y 
JN'lf, as this force comes into play only wiu^n it has to react a<;ainst that 
rvulting from the bo<ly weight. Thus far the action of the Iwidy weight 
»l'ine has never been observed, though theorclically it might be noted in an 
inilividuai presenting a split pelvis (congenital lack of union at the sym- 
plivsis pubis) who bad ncv<!r walked. Its action, however, has been studied 
f\[MTpnicntally by Krennd, who suspended a cadaver by the iliac crests 
afliT cutting through the sympliysis, and found that the innominate bones 
ppiil wiili'ly. 

The ctTi'tl of the combined action of the l>ody weight and Ihe force 
eiertiil by the femora has been studied by Litzmann in cases of congeni- 
al alr~ence of ihe symphysis pubis. In such pelves there is a marked 
tran-iverse widening of the ]>ostorior portion, wbile tiie force exerted by the 
fi-mora can-*'-: the anterior portions of the innominate Inines to liecoiue 
ahii'r-t parallel. 

The action of the body weiglit and Ihe cohesive force exerted at the 
-ymjihy-is, without the upward and inward pressure cxiTled by llie femora, 
«in !>■■ fluditil in individuals whose lower extiemilies are nb-^eiit, anil oeca- 
'ionallv in cases of congenital dislocation of the hips. Hoist has descrih(>ii 
B CHH- in which Ihe lower cxtremilies were congcnitally absent, the pelvis 
ln-inj; characterized by a marked increase in width and a nuirked decrease in 
iu anicro-jxisterior diameter. Owing U> the excessive pressure exerted upon 
the tulx-ra ischii in the ab^^ncc of the counteracting force exerted by the 
fi-mont. the innominate Iwncs were rotated in such a numncr as lo turn 
tln-ir cn>-ls inwart] and the tultera ischii outward, tliui producing a ninrkiil 
transverse widening of the inferior strait. More or li"ss siiuihir changes 
may be ohsc-rvcd in the cases of congenital dislocation of the hip iu Hhicli 
the fntients have never walked. 



24 



OaSTETRirS 



The effect of the various irnvhanicni iulhniU'M is jinrUi'iilnrly pjnplis 
nxfd whi;n tlioy ftrc r;£Crlcd upon )h>Ivii^ wIiomc Imkh-s nrr unflcntil by lUs 
case, as iii rliiiciiitls ami oHli-dmalai-ia. Itiil flii' wiiHi>lt'raTii)n 'if tin 
otiuiifrt* «» [inHhu'cil will W ilcfiTrw] until llif *hiil_y i>f llu- ik'TiJi'iiiw 
pelvcA ifl takt;n up. 



LITERATritE 



AnAVrrrs. Anatnmii 



I oliHcn'Bt.ioiiex. Venetii". 18.17, Tap, s\xiic. 
ILiUANuiK. Kliiiin'-liL' Vortrnciv Wl. iVtpml.iirj:. 188,1. lU-fl I. 
IlAit. Indut-n™ dp In |)fj«tic)ii dv lu ffinnip nur In toniit-. I'inc-liiiuiaiui et l<« dtinvnrinna 

dii tKiMiin. r.'()liHf4(lri(|iii>, I8!K>, iv,.\2i) .'.12. 
BuKUKt'. Zcil^irifl dt-r (it-sellKcli. cIlt Acmli-. Wk'ii. IRIl.'i. i. 'Jl. 
Dkevh and Koi.inKi). Die pnlholoKii^'^hc Bct-kunfomiDn. Lvi\>aii u. W'irii. ltd. 1. 1'b 

I, ItWO: Tlicil -2. UMM. 
rnLVMBTi'. IX' I* iinntumkii. Lilni XV, Vpnt-liU. 1S59. 
1)b t'HBMBiiv. Dp miitnlionihiix fiiiixni' privia. 1). 1., I.iisd. liatav., 170a. 
Devuan. All InlnnJiiHiuii in vhv PraMitw iif Midiiifvrv. I,<iii(i..ii, I7H7 I7'.','>. 
I)K\'>:VTCH. Ncue.i lli'hnnimcnlii-ht, ell-. III. .tuti., .Ii'nii. I~:i8. 
l)iTNr*x. RcMWirclifji in OlMtWrirw. I'MiiiliiirBh, IHIilt. 
(thi the Ofi Siirriiiii, .1.1-82.) 

(< In th<: IVvolopmpnt of thit Kmuilp IVIvin, flfl 1 IS.) 
Fehfj.vi;. I'll" I'Vinii dim IWki-iiK U'iiii I'iiliii" iinil NciiKi<linrcni'n. Art-tii*' f. Clj 

1871!. \, 1-80. 
PkbiiMi. Uflvr lUi* MOKcn.iiiiilo kyiiholincho Ik'i-ki't). Hi', (iynuknloxiirhi' KIinilw| 

les.'i.i. I-I13, 
OxniK. I* RnrhtliuiH! m .\Tii/-ilqiie, eti-. Aniiuk-ii dv Rj-n. i-t d'ohsi,, ItMW, li 

1 75- 10.5. 
tinii.T. I'pIht i-iniisi! MiraKPnIidtiinEi-n iJt-n wiTililirtii-n IV-c-Venn. Hcrliii. t8M. 
IIbuar. Ziir CJcl'iirlmiiiicliiiiilk. (iJi'.' lWkfiia\f.l Ari'liiv f. nyii.. 187", i, 11)3-^28 
lIoiHiH. Thf I'rilinplt-s iii"l I'mrliw." "if Olintplrirv I'litliirlplphiii. IKfiO, 
Hauyr, TkiwhivilmnK tic* IWIicii* ii. ilor (li-ViiirlMln-ilc cliwii 41) Jiiliiv allisi wcilJIch 

Ami-liiH. Hoist ■« Itt-ilram-. IsM. Thfi J. ll.V I4H. 
IltJwft. nndorwyji <\m vrmmm, pte. Haarlem, 17:tS, 
JulMARi.und Wai.uktkii, Ix'lir1>urhdor UipoKniphiHrh-chLriiri^Hrhpn Anatomic, Ttuiiii, 

I8!«l. II. Thoil, IJiu Bi'i-kt-n. 
JURaBKS. B»itrujci) isiir iioniiiilcii iiiid pnih. Aiinloniin dwi nimwldlclipn Ilwkpiie. 

VJTPhiiw'M FMlwIiritl. ItL-rliii. I8tl[. 
IvEiriiEii. ItrilruffR xiir vernl n. rxprr. Grhiirbihldfc. IMt!), tltfl .1; und 187,'), Iloft Ji. 
Ki.eiM, Kiir Mi't'ltunik dv« ll*'0«iUTid|CPlc?'riL(«. Kcilw-lir. f (h'Ii. u, Cyn., IKlll, xn 

74 118. 
Kt'TTSRii. l-'\pi'riiiicntH!-aniil. PiitorMirKiiiiKrii iilicr die ViTjiriilBrliciiki'it diui Itcol 

enmuini'n lifliiin-nrirr. I(i-uiir'it llpil riiKi-. IWIS, i. "JHJ-2'JU. 
I.KVKKT. I.'.irt dcH iii'roijcUriiii-iils. I'uriK. I7.'i!, , 

Ijtzmivn. Dk- Fni'iiifii di-H Rorkens. IVrlin. 18111. 

Iliw XDiqiidlfiir Brclipn. Arrhiv (, CJyn,. 1872. iv, 2«fl-2(M. 
IKu Oehiirt Ix-i rnjwni nei-kni. I.oipi!)(, 1881, 
I.tr!*mKA. Die Anatnmii-' dt* mcnwliUrhfTii Iti-cki-nN. Tiilunp^n. I8(H. 
MRrEK. fltulik iiiid MivhHiiik il(vi rlli'ri>H-li1i<')ii.'ii Kiiorhi'li)ri~'*ll''t<']i, I'MpriE. 187^, 
MiiiiAEU^. Dim vniR' lli>rk('ii. I,vii>/,is. IS.'il. 

Mi i.t-KK. J. J. Diw. aiiil. <mnini r»rl>wiiiiiiTii <ii'-ri in p:irtu nipli. IIiu>iIc3io. 1745, 
Nabhi^lk, Duk wt^dJicIii.- IVx-kni, etc. Ciirlnridii?. 182-1. 
I'Rori'oWMCK. Uelwr IWki^inwiRiing. Arohiv f. Oyn., IMli, xix, I flfl. 



THE PELVIS 25 

Rimw. A Comparative Study of Whitt; :knil Negro Felvus. Jnhna Hopkins Hoepilal 
RenirtB. IIKM, xii, 42H54. 

ItuEUEHKK. IX- axj pelvia. (ioetlin|»ie, 17S1. 
□ementa artix obHU-tritiiit:. (iocttinpie, I7<16. 

ft-HARL-H'. Daa Auslrulier-Becken, Itcrlin. liHW. 

SmBoeDEK. Lchriiuch dur OvburUhiilFe, XIU. Aufl., I89S. 

Slllhum. Die Bcziehuugrai den (Icnitalkanalva und dea (ieliiirtsolijektes zur Ge- 
liurttaiierhaiiiNiiius. Lmpzig, 1906. 

^VELUE. A TreatiHo on the Theory mid Pmetice of Midwifery, Londop, 1752. 

9HJ>. D. J. l^hre der GeburlBhiilfe. Elberfeld, 1825. 

Thuhmok. The Sexunl IHfTerencea of the t'cctol Pelvis. Journul of Ai;at. and Phys- 
iol., 189a, xxxiii, 3.'i9-3»l. 

TiviNAKti. l)eM proportioHH |E;£n^ralc(> dil bufitiin L-hez rholntne, etc. Bull, de k Soo. 

d'Anthropott^, 1875, 504-S21. 
TruNEic The Index of the Pelvii; Briiti an a Kuhis of CUuwiKcutioii. Journal of Anat. 

aiid Fhyciol., 188B, xx. 
tuT. Die pjitstehuiig der Font) des IteckenH. Zeitsrhr. f. (<eb. u. Uyn., 1883, ix, 

ai7-;i7-.;. 

I>ie .\iuitoniie den llei-kenit. Stull^rt, 1687. 
^uxE-ki'. I« luMtiiii daim lex nexex et dans Uv rai-CK. Pariii, 1875. 
Ve-djirt. Ih; huiimni tor|M)riii falirira Ijliri stptuni. Kasibiu. 154;t. 
■'.iLcMER. Die (.^iijugutu tiiiuM eugeii BeckuuH ist keitie koiiHlttnU; (irilsse, etc. Cen- 

lr:iil.L f. (lyn., 1S8U, 89-2. »93. 
A EHEK. i)ie Lehre von L'r- uud lluL-eiironniin dvH Si'hiidelH mid KtH^ktina dvu Meiischen. 

l>utM.'Idorf. IB.m 
Aehle. I>ie H'alcher'M'he Hiingelaiie und ihre pruktiHche Verwerthung liei );eburt»- 

biilflicbcn Oiiemtionen. Archiv f. Gyn., 1H!H, xlv, 323-aac. 
'Kiuj.uis. The Freijuency o( Contruttud Pelves, etc. Ubstctri™, 1899, i, Nob. 5, 6. 



CHAPTEK II 
Tl/Ji FEMALE OUGANS OF GENERATION 

Foil convenience in (lescrii)tion and nn atrount nf their differences in 
function, tlie female organs of fjenoralion are divided into two groups — 
the external and the internal— the viigina being uKually ctaBfied with the 
former. The esternal organs, tojrether with tlie vagina, serve more espe- 
cially for eopiilalion, while the internal organs are directly concerned with 
the development and birth of the feetus. 

THE EXTERNAL GENERATIVE ORGANS 

The term |>ndendiim is occasionally applied to the external organs 
of generation, although the more common designation is the vulva. This 
includw everything which is visible externally from the lower margin of 
the pubis to the |Kirina;um — namely, the Mons Veneris, the labia majora 
and minora, the clitoris, vetitibule, hynien, urethral opening, and various 
glandular and vascular structures. 

Moiu Veneris. — The Mons Veneris is the name given to the fat^ 
cushion which rests upon the anterior surface of the symphysis pubis. 
After puiierty the skin over it is covered l>y a thicker or thinner growth of 
crinkly hair, wliieb is souietimes descriliod as the " escutcheon." Generally 
speaking, the distribution of the pubic hairs differs considerably in the 
two sexes. In the female they occupy a ti'iangular area whose base cor- 
respond.^ to the ii|)per margin of tlie symphysis, while a few hairs extend 
down over the outer surface of the labia majora. In the male, on the 
other hand, the escutcheon is not so circumscribed, as the hairs composing 
it extend triangularly upward towards (he umbilicus and downward over 
the inner surface of the thighs. These differences were described in 
detail hy I'loss, and iit one time it was Iwlieved that they might be of value 
in determining the sex in doubtful cases. But Schultze showed that such 
variations were not absolulelv characteristic, and my own experience has 
convinced nic lluit the female escutcheon not infrequently approaches the 
male type. 

Vulva. — In t!ie restricted sense, the term vulva (from the Ijatin valva, 
a folding-door), or rima piidendi. is applied only to the structures lying 
heneath the Mons Veneris. Its position varies according to the inclination 
of the [)eivis, hut it usually runs horizontallv when the woman is in the 
erect jmsition. It presents marked individual variations in appearance, 
26 



THE KXTERN-U. CKMiHATIVE UKU.WS 



\ii 



but iU ni'n'l itolrworlliy (lilTcTi-iicrs are (Ii'])en4liiit upon llic agu of Uil> 
p'ruin ;iiiil Mlii-llit^r (ir mil Ave I)m.-< (lornt* cliiJOn.-n. 

Labia Itajoni. — On t-itlior xidv af thi* tuIv« Rxlt^ilii ■■ r<>uitikti maiM 
of lisriu'. tilt- laliiuii) tiinjiu'. Tin- lubia luujura vury niurliMlly lu ii|i|H-Hr- 

anrp. i\< Ill llu- nini'iinl uf fal k-myiUi lln'iii. Thty un? U'Wi pniiiit- 

otaxV «n ii-warinj;, ami iii ulil up- iisnully aK^univ u nhrivdli-J uppi-ur- 

aan<. Onliniiritf tlii^ mnimrv 7 to 8 centinietTt» iii Iciixlh, £ lo 3 
cmtiinvtn^ in wijtlu ami I tn 1 .5 dtitinictrcf in thickiH«H. They flro i»mc- 
wtut l»n>i>):<->liii]H<il. ami Int-oiup imrrnwir »t tbwr Itiwor (-\ln:inici4w. In 
rJuldrm and virginal a*]iilt< lliejr uouallj Uv in dow u[i{>wiliati and com- 





1 IX LV>»T*CT. 



wiDV* Wonis. I.AiiiA KmEAp ArAm. 



plMpW HNiniil till' undfrrh'in^ (uirtu, nWrau) in mtdtipiimiis wnmon llivy 
'- - viiK-Iy. I'ntii n^mitly it »«« it'imlly I'Inlcd lliat lln-y witp «>n- 

•' nml l<eliiw Ity llti- unhTior and pofti-Hor lomiiiiiisiirci' of 
llir tuKu. loit l.iiN-lika Ua« sh'iu-n ihal lliry iin< direct Iv (-oDlinuotiA 
mtli tin; M<m.-i Xim-ri* iiUiVt'. uml fad*- away into lli« jH-riiia-um jxis- 
Irnnrly. 

RhtIi laliiuin majtis I'remititj' two sarfat^w, nn miter nnd an innrr. "Wi^ 
oiibfT -tiirfarp mriyypnmi' in KlrtK-tnrc tn tho ndjni-ont i^kin. and after the 
•*r of pnl-crty i« mon" t hi** thickly covpppd uifli hair. In woiiten who 
Imv Drvi-r Itnron L-hildn*n iIk' inm-r xurfacv ii' rhoist ai»t n-si-itdilv a 
atimiib> niciuhrani' in aitpi-araitco : vhcrea^ in multipara' it bwoinps more 
■r\A with hiiir. It in richly Mippiifnl with w^w- 
I . i ■' ^kin there is a laytt of dt-nw- t-mirnvtivf' li.wiie, 

■luch u rtcli to cla^c Ifhmt and wli|>()«e liwui-, but does not contain mas- 



30 OBSTETRICS 

markedly refiombie the penis, and not a few cases of SQ-called herinapliro- 
(litifim are to be explained by this condition. 

Vestibule. — The vestibule is the almond-shaped area which is inclosed 
between the labia minora and extends from the clitoris to the fourcliette. 
It is the remnant of the uro-genital sinus of the embryo, and is perforated 
by four openings — the urethra, the vaginal opening, and the ducts o( 
Bartholin's glands. Considerable uncertainty exists as to its boundaries, 
for the reason that the French anatomists usually describe it as a trian- 
gular area, bounded above by the labia minora and below by the vaginal 
opening. The posterior portion of the vestibule, between the fonrchette 
and the vaginal opening, is called the fossa navicvlarix. It is rarely ob- 
served except in nulliparous women, as it usually becomes obliterated after 
childbirth. 

Vestibular Glands. — In connection with the vestibule, certain glandu- 
lar structures — the giandulte rextibulares majnres and minoren — are usu- 
ally described. The former are designated as Bartholin's glands, or the 
glands of Diiveniey, who first described them in the cnw. They are two 
small structures varying from a pea to a small bean in size, and are 
situaletl beneath the vestibule, opposite the lateral margins of the vaginal 
opening. They lie under the constrictor muscle of the vagina, and in a 
few instances are found to be partially covered by the vestibidar bulbs. 
They are compound racemose glands; their ducts, from 1.5 to 3 centimetres 
long, open upon the sides of tbc vestibule just outside the lateral mar- 
gin of the vaginal orifice. In calibre they are usually small, and tbo lumen 
will admit only a bristle. Uniler the influence of sexual excitement the 
glands secrete a small amount of yellowish material. The ducts not infre- 
quently harbour gonococci, which may gain access to the gland and cause 
it to suppurate, so that the entire labium becomes markedly distended by 
a collection of pus. ' 

The glandula; vestibulares minores are a nuniijcr of small mucoua 
glands which open u[Km the upjMir portion of the vestibule. Their ori- 
fices are occasionallv several uiilliuietres in diameter, and in such cases 
they are designated as lacunar. 

Urethral Opening. — The mouth nf the urethra, or vrinary mealtis, 
is ^'tuated in the mi<ldle line of the vestilmle, I to [.,"> eentimeire below 
the pubic arch and a short distance above the vaginal o[>ening. It usually 
presents a puckered appearance, and its orifice apjicars as a vertical slit, 
which on distention is 4 or 5 millimetres in diameter. The para-nrethrai 
(Iticis open upon the vestibule on either side of the urethra, and oecasionatlj 
upon its posterior wall, just inside its mouth. They are of small calibre, 
i millimetre in diameter, of varying length, and in this country are gener- 
ally known as Skene's duets. They were, however, described by Malpighi 
in the last century. Oonsiderable discussion has arisen as to their origin. 
and certain observers, notably Tvocks, believe that they represent the lowoi 
extremities of the Woltlian ducts. Most authorities, however, do not shan 
this view, and believe that they are simply exagp'rate<l lacunre. 

Vestibular Balbs. — T.ying beneath the mucous membrane of tlie vestl 
bule, on either side, are the vestibular bulbs. These are almond-shaped 



THE EXTERNAL GENERATIVE ORGANS 31 

Pwiile Ixxlies, 3 to 4 centimetros long, 1 to 2 centimotroa wide, and 0.5 
<« I wntinic'tre thick. They lie in close apposition to the ischio-pubic 
"^nii, and are partially covered liy the ischio-eavernoaus and constrictor 
'■gins muscles. Their lower ends usually terminate about tlio middle of 
'ie vaginal opening, while their anterior estremities extend upward to- 
wards the clitoris, where they are united by the pars intermedia through 
•"hkh the blood from them reaches that organ. They were first described 
^y Kobelt, and their vascular connections have been exhaustively studied 
*>• Gnssenbauer. 

Embryo logically they correspond to the corpu.'; spongiosum of the 
P^9w. During parturition they are usually pushed up beneath the pubic 
•■>^, but as their posterior ends partially encircle the vagina, they are 
'*«*ble to be injured to a greater or less extent, and their rupture may give 
'"*'*« to a haematoma of the vulva or to profuse external haemorrhage if 
^**« ti.^sues covering them are torn through. 

Ttfinal Opening and Hymen. — The vaginal opening occupies the lower 
y*"-*rtion of the vestibule and varies markedly in size and shape in different 
***dividuals. In virgins it is entirety hidden from vi.ew by the overlapping 
**Miia minora, and, when exposed by folding them back, appears almost 
'^■'^mplelely closed by a membranous structure known as the hymen. 

The hymen presents marked differences in shape and consistence. In 

"*lie new-born child it is a redundant structure which projects considerably 

*-*tyoi>d the surrounding parts, while in adult virgins it is a membrane of 

^arjing thickness which closes the vaginal ojicning more or less coin- 

"lil*'iely. and presents an aperture which varies in size from a pin's point 

Xti a calibre which will readily admit the tip of one or even two fingers. 

The hymeneal opening is usually erescentic or circular in shape — hymen 

■M^milunarin or annularis. In rare in.stances it may assume other forms, 

which have been studied more particularly by Dohrn and Budin; the most 

important varieties being the cribriform, septate, and denticulate or fim- 

Wiated hymen. In very rare instances the membrane may be imperforate 

and It^d to the retention of the menstrual discharges. Dohrn devoted pjir- 

lit-ular attention to the fimbriated variety, and stated that it might be 

mistaken by an inexperienced observer for a ruptured hymen, so that this 

tvpe possesses some little medico-legal interest. 

According to the embrj-ological researches of Nagel, which have biwn 
•■onfinneii bv (Jellhorn, the hymen represents the lowest portiim of the 
vajnna. which in early embryos is composed of a solid mass of epithelial 
cftls. After proliferating rapidly for a time the most centrally situatiKl cells 
bt-gin tn degenerate and a lumen is produced, except at the lower extremity 
of ihe ma.-is, where the cells persist and give rise to the hyrricn. The 
Imnen. then-fore, is a fold of tissue presenting a structure similar to that 
of the vagina — namely, a connective-tissue core with numerous elastic 
fibres which is covered on either side by a layer of stralifiwl cpilheliuni, 
in which are numenms papilla.' containing ves.sels and occasionally nerve- 
endings. 

The h'i-men may vary markedly in consislenic in ditforent individuals. 
According to Dohrn, many types are observed — from a delicale structure 



32 



OBSTETRira 



iMi 



Mil 




Kill. 34. — I.i^<tni-n-i>iKiii. f*irrTuiv 

hlbllll^tO TnANB|TI<lN KKIill IKK 
ClUNIlRllAl. Kl-mlKl.ll'H HI' 

Tiir L'rj.lii-.i TO Tin; t'liiioiuAi. 

I^pmtEI.I l.-M or 1TIR Vaqi>c«. 

Froin n lO-priilimrlminlirj-ri iSn- 

gd). U., uUnix; r., iiixiuii. 



reM.'[iil)liD^ a spulcr's wri) to a liiwliv.' liKiliiipntniin. or ptpii cartil 

men I brum.-, uhii-li in raR- 

In the matter of «lai»ticitjr ag&iu, wiclnj 
tioii^ arf mot with, tnmc hyaun\s 1)0| 
di-licbti' that Hwy rujilun* ii|>i«i tlu: silij 
ttmfli. wliiii- "IIkt^ tlunigli capabtc of 
xiiJci'iilile tlUlculion, .-itill rc-taaiii tmL 
and later may wen ri.-gain Uieir tx 

i\s a Koncral rule Ihe hynion nipti 
till- firsi (■oilii--'. Ii-Mriiij; at wviri*l p 
Uflually in ita ijosu'rior |x>rtion. 'fliej 
of tlif ttiars JKXiii cicalrizf. anil the fi 
IjfloonieH pf-niiani'iillv diviiU-ii into t^ 
Ihrw j)orli<iiiM. whitrli an? >^-]'arnUHl b; 
row 9lit> f.\t(-ii<lin^ il(iu-» to ji.t ))«»& 
11.) Tiio extt-nt to which rupture 
varicH witli tbo Klmi-tnir nf ijit; Imnc 
thp (li'-in?)? to which it is (listfiiilt'i!. 
iiiiiKt mnrkiil when it Ih dolii-aldy fomti 

AItliaii«h it is RPiiorally heliwed 

laity Hinl its rujUure is nB^K-iatctl willi 

ori'hap'. this is by no lui-anx aiwny» U 

llimifrh in rare instaiiots such a pmfm 

of bliiiid may im^nr a* In k-ad f" pr 

aiueinta ami even (l<fath. ThU iilea i 

ably IiHuisI ujwn Ihe biliticnl ulatoniiiit lltiit him of virginity t" aluay 

ciattNl with ioft« of t.Iooii. N')>r is it uurfasonabk- to !iii|i]to>>i- ilial 

frabk- blwdmg iiKiially w- 

flurrwl aiiion;i: Iho llekri'wn of 

Um! biblical pctriroi. innMnuch 

a» tJie girl* iniiriii'd very 

ynunp, and nut infn-niicnlly 

iK-hirc llii- agi' of piilii'ili-. *o 

that market! di.-'pro portion 

must often liavo o.\i«lcd Ih-- 

iw<vii till- Nixi- of the malo and 

female orftans, Oli tlw nthrr 

liaix], it inuKt \w rcnicmlKTiil 

th«t whare We&lern dvilijta- 

tion prevttiU full scvuni dc- 

Vflopiiifnl litis usuiilly been 

atlaiiiiHl tiefore innrriasc 
In rare inntjinww the 

njeinkmnp may l>o vpri- resist- 
ant and Jilirgical intirftT- 

Hnw be refjuiifil Uiffire coilii'* 

re(>i>r1«'d a case in wliicb tin- 




Fia. 35. — Waoittai. i^r.i-nnx TtrrKit'<i(i ntn 
Poimux or Tin; Vaiiiha or A H-C»M 

L'., urMlim; It.. Iiymcn; Va^., mglfi 

can be a<rnrnpli<hcd. (HifrtaukT. in 
)ivrnt*n vin* sn lough Ihiil il cn'akeiir 




HUuWUfG AKVEHCaL VAl!l£Tlli:« OP JIVU£.V 



THE EXTEBXAL fiENERATIVE OROASri 



33 



Omi»iouiill,v, inxU-iiil iif giviny way in tlie iiii(I<IIi\ it mnv Ih- 
taini U'm- fnitri JU \i»fc in tlx* iitli-iiijit al (tiiliiK, iiiiilc in ollu>i- fOrt-n Dio 
[»-nis luar dilute tin- urullinil cmial inMvnil of oiilorin;,' tlic rii)(tiiii. Nt-'ii^ji- 
■ •aiRT luw iii4li<i:li-il ail tnliTcutiu^ M'ritis <if iiijuriui w«umiig (lurin;>; (M>iiu:>, 
luuiv iif wiiifh Vfsv iliii' to tlM^ prescjjcw o/ a vttr)' rt'jiixliiiit lijtiicn. 

Ttit- clum^t™ in tlie Uymcn following coitiitt arc nfu-n nf nu-iliio-h'^t 
inint^t. a* till' plivsii-inn ik ixvaMniiiilli iiillii) iijHm tu tti^liry iis ti) Uiv- 
Tirgiiiity of an ijiilividiml. I'nrortiinatW.v, iioircwr, it iii not ulwiiji« po»- 
•tltltf Ut arrit-t* III a ilirtxivo mm-Iui'ioii a« to tliis point, in occnsiuual 
iBBtaiii<<H U»B liynien may be clc- 
itniiiil in farly rliiliilio)"), t.'illHT 
a> Um' n^uit '•( riiaiturljatinn or 
w a conM'qiienc« at nUtfmpling 
In frt rill iif M-al-HortiH. Among 
tvruin l^Mf-tern riuMv, aj^ain, it 
I* ni{)tiinHl ill inrlv I'liililli'viil for 
[mrj*>i-*% of cUnnliiKw. Oil the 
ottMTT lianil. tlH* lijrmcn may nut 
lir liira, i)f>|iile rcpiiitu) coitus; 
ubi-rvni', in otlii-r inviamiv, iW 
th-nlM-uliitv or fliiil>riatrd t^iiio 
may \ic mistaken for a hyiiit-n 
*hich haa benn ru|ilured. Ila- 
l»^la, tbt I'mfp-^r of L(^al 
IImIm-jdi- in Viimmi, kIaIiiI tlini 
tir «a« alilc to make a poi^itivc 
dwen't-iJl of liv« of virginity in 
•■»U aUtuI Ml iM-r cont of tti« 
at' ■\ fnx^ which \k had 

fiiii III IIk' (viiirM.- "f five 

pmt*. He lM<li<;Tfw that in mnny 
Otftanre* il i« im|"i«»ihl<' ii> do- 
imniiM* Kthi^lbKr coilu.'' liaf> lalipn 

r not. iinb-s* ihr iit<li\iilunl tii M#n iii)ni<-<tiiil<-ly nflor tW ntli'inpt. 

iIk- txro riurfacv^ ti^vi? tiad an nppnrtinnty |i> iiiiitc. AchcitlnH'h, 
in s TTOrtil dittfcrtabon. collwti-d 2-1 insiuiiit*:" of [in>)[Rani'y owrurriiic in 
•ofufn *ilh uiiruptiirti) tiyini-nA: wliilo Kiimmy han (^tlhvUil 43 similar 
tvfvirts fniHi thi' hn'ratnn-. Simc ywir* njio I wiw n oawe in U'hich «m- 
■*-|tii>in hail iBriimii 1liroU);h a tivmi-ii which provnli-il only a ptn-fmiiit 
Kpmm)!. ami nmn' n-c-enlly one in nhifh an cla^tio hyiiwn had I>woiiih 
nniVinat^ MiHiciBntly to nilroit tlic pi^iiw. and did not rnptnre ntitil it 
jialdMl to Itic adtam-ing twwt at liilwnir. 

Thf rhunco* pn-liiml l»y ihiidl.irlJi are much more markftl than 

QMMf riiDiiwinu milii?. ami, as a rnle. an> rmdily n-ropliiicd. .\s tho 

f»-Hlt .tf llic dii-rcnlinn incidmi I" ll«- tdrlti of tho child, tli-' liyinon 

RjidrrBia^ pnrjt«Tirt> nwntaU in vnrioun pla«w. an*! aftir llir pnerpftriaid 

' Ti-^'oti-ii bv n niindHT tif rii-atriTt'il nmhilt-B nf riirytng 

. nii/rli(<frmfx ( Piait? II). Tbcir .vij^iufiiance wad lirst 




FmI. 3A, ALWI-IT rMIVI-TT'l.l I. Ihui.N ll-IIII 

CllllJII'IMTII ll'oliiO' 



34 OBSTETRICS 

einptia.sized by Schrootlcr. Prnetically speaking, they are infallible signs 
of previous childbcariny, though occasionally they may follow the marked 
distention and long-continued prcssnre incident to the removal of large 
tumours through the vagina. In rare instances the injuries resulting 
from childbirth are extremely slight, and very exceptionally are entirely 
lacking. Such cases have been reported by Hyerneaux, Tolbei^, Hyrtl, 
and Budin. Fig. 3(i shows the external organs of one of Budin's patients 
wlio had given birth to a full-term child. 



LITERATURE 

AcHEXiiACH, 25 Fiille von SchwangerHchaft uinl Geburt bei undurchliohrtcni Hymen. 

I). I.. Mnrbnrs. 1810. 
Bi'DiM. RcrherchcH «ur I'hymen ct I'orifice vaginale. I« PropSs MMical, aciut, 1879. 
Description li'un ens dans leiiu«l I'accourhoment ii'a diUsrm'ini, ehcz une primipare, 

que dc l^g^rcH nmiirca dc I'cirincc hymenal. Femmes en couches et Nouveau-n^, 

Paris, 1897. 1-1. 
Cahhard. BeitniK zur Anatoniic und Fathologie dcr kicinen Labien. Zeitschr. f. Geb. 

u, Gyn., 1884, x, 62-i>3. 
CULUNfiWoKTH. A Note on the Anatomy of the Hymen and on that of the Posterior 

Commissure of the Vvilva. Journal of Anat. and Physiol., IBg,!, xxvii, April. 
IXiHBN. Die BiUlunfistchler des Hymens. Zcitschr. f, Geh, u. Gyn., 1885, xi. 1-19. 
(iELLHORN. Anatomy. Pathology, and Development of the Hymen. Trans. Am. Gyn. 

Soc, 1S04, xxix, 4a'i-i40. 
Gubsenbaueh. Uelier das OefiissHyHtem der aiisseren weihlichen Genitalien. Sitzungs- 

bcricht der k, k. Akad, der WisHcnBchuften. Wien, 18fi9. Ix. 
Hahrkua. llcbcr den anat. Bewcis der eri'olgten Defloration. Monatsschr. f. Geb. u. 

Gyn., 1<HX). xi, 09-88. 
Kanonv. lie la fre<|iien<^ dcs eas dc persist.inee de I'hymen et de leur importAnee en 

ni&licino I^Kale. Thine, dc Montj>ellier, 1899. 
KoMKi.T. Die rnunidii-hc uiiil weibliche Wollvmtorgane. Freiburft, 1844. 
KoCKB. l'clM;r die Gartner 'sK-hen (.liinKc bt'im Wcilie. Archiv f. Gyn., 1882, xx, 4B7- 

492. 
Khause. Die NervcnendiKiiiiE innerhalb dcr terminalen Ki'irperchen. Archiv f. mikr. 

Anatomic, 1881, xi\. 
Nai:ei,. Die weiblirhcn (iCHilileclilHorKane, liurdeleben's Handbuch der Anatomie, 

1890. 
I'elxjr die EiitwickclniiR dcs I'tenis und dcr Vagina beim Menschen. Archiv f. mikr. 

Anat., H<l. X.VXVII. 
NEUiiEHAUER. Ein IV'ilraK zur l:ehrc von den Verlclztrngen der weiblicben Sexualor- 

gane sub coitu. Mit Ku^iiLKtlk von 1.^)7 Beobachtungen. Monatjischr. f. Geb. u. 

Gyn., I8!«, is, 221. 
Pi,()ss. Daa VVcib in der Natnr und Volkerknnde. IV. .\uf!.. Ixipzig, 189.'), Bd, I. 
SiHHOEUKH, The Condition ot (he Hymen and its Reniaina after Cohabitation, Child- 
bearing, etc. Tmnn. IJlinhurEh Cb^it. Soc, 1878. 
Sciiur.TZE. Ziir forensisi-heii Diiignone dea (icschlechtB. Jen. Zeitschr. f. Heditin und 

Natiini iwcnsoh., 1B08, iv. 
Skene. The Anatomy and Pathology of Tnn Important Glands of the Female Ure- 
thra. Amer. Jour, of (lliKt., 1881). \iii. ■ir..S-270. 
Wkiister. The Nerve-Endings in the Labia Minora and Clitoris. Edinburgh Hed. 

Journal, 1891. 



THE VArilSA 



35 



THE VAGINA 

The ragina i8 a masculo-iii^nittninntiR tulH* wtiicli ojcIviiiIi' from the 

Jyii to till' uti>rii>. and is inler|Kiw(l Ix-twcon ihe lilatldiT and tlie rwtum. 

Il wrvc* Ihnv iniimrliml rum'lioii!>: il ri'jirx-xrntN thi- cxvTviciry dutt of tlit' 

^ulrru*, thruu^li whUh iiti stiTi-lion and the Tiii-nslrunt lluw (?x'ii{h-; il ix the 

faualt- urjjiUi of rojiulatton ; aixl, fiiiulU,, it iorms part of the hirth caoai at 

bbmir. It» i.-otirM.> mni' uliiKiHt t-nlircly witlitii Ihu iidTic fliior. and it is 

Itht-n-forr [inti-lically <iiiir.i<!c of the |K>!vic caviiv. The va^iiml canal pre- 
■r_aiA a goHipwluit S-hajwd c-urvaliire. Tile common statement that its 
iDurw cfirresiwind* in <linvti<>n to thitt of thi- p('l»ic nxtx in jneorrivt, since 
it- ifiwer third in parallel to tlie plane of (he superior strait, while its upper 
pprtiun priwnli' a fonmvily OTri-sponding to Ihc ciir\-c of llw rfclum. 

Anli-TiorU. iIh* vii;,*ina i.^ in oonliict «ith Ihc hliiddor and itn-thra, from 

ibicfa it i-^ wparat^xl hv the VLtiifo-raginal iK-plinii. I'wtcriorly. iK-twi-cti 

UM lowfT portitxi ami tlio r«'tn»i, wrc )iavK thii pi>riiiifum and ix^-tivFUjiinal 

[•rplaiu: ID its median portion it lira in clotte apito^ition with the rtvlunt, 

Ivluir it» apiKT [H>rtii>n is M-piiralt-d from it l>v ihin^duH's riil-ih'-Miir, In 

of iheK- rt'Ialionii. Si^tiaiila, for (ho piirfH>-i'?i ol de^riptton. hus 

it* anli'Hor wull into two part* — nn-lhnil and viwitiat — and it^ ]>»*- 

[l>!Tinr wall into three — iteritieal, rectal, and 

f|»Titnatra) iv'pix'tivcly. n»i' nrothral portion 

[ufjW rajfina in flntdy uniictl to llu- urvthra 

«t-TnKin.il septum, from whieh it cuu 

iti^ only «iitli wmiedillifulty; whcns 

tlie Tiwieal portion is lowely attudied to 

IW hiarlihT am) can W nwliiy dvtavlnMl 

fnm iL 

The anterior and poj^tcrior ualh of the 
nitina lix in cnnlai-t, a Hli>.'hl Apai^'e IiiIit- 
rauDK taetwrpn tlitir lateral oiarcinM, Wi><:n 
i IIh- canal (in>nit-» an tl-Hhii|Mi| 
■ III tninM'eive stfiion. ac wa* lii>t 
' pijtitprl <rut liy Ilrnle. Th« VH)j;inii i* ciiixilde 
•t narkci] ilii'tention. as is iiianifivled at 
|<UMhlrlh or when omr allempln to \mek it 
tith piuze. Tlie Ta^ina and nleniK ine**t at 
«> acnt4' ant;l<!, with tli^ ojienin^: liHtkin^ for- 
nix Tiu! upper eo'l of the vagina end^ 
latiKnl vault into which Ihv lower portion 
\*t Ibe cerrix uti-ri prrtjcets. Tl)c vaginal 
•ittlt. or, as it is nsnallr dceif^iated, tlw 
Umir, for (»nvenietu« of dcNripiinn, in 
•abdiTuled into the anterior, pnstmor, and 
twn lalrral fomi(w. A*- Ihc va;nna is atlachKl lii;:lKT up upon the pos- 
trrior than upon the nnlerior wall of the ccrTix, the posterior fornix in 
nuM'li'raltly d'l'pcr than ttic anterior. 

TfaE *a^Da pre.j'iits mnKiderahlv individual vftiiationH in lengtb. Sinrc 




Fia, 37. — n-uupR(> I.tmKX or 
Vauijca (lli-jile). 



36 



OBSTETRICS 



riie , 

I 



it is uniU'd to tli^iteroiT at un m-nU; imgli-, it-t nnli'rior i« alwftv:i «hfi3[?r 
l)i«R il.t |irj»li!ri"r wall— li li> W amt T to 10 tviitiiin-trL'ti rcspt-ctively. The 
farina is ri'lnlivdy luti^T in llm m-w-lxirii vliilil timii in ttic ailult. n 
orcunliiiji til litL-iclika faniip abi^ul { of ibe body Ivngtb in Uie former 
compari'ii with ^ in the laltt-r (Kigs. 25 and 8t!). 

I'roji-clinj,' fnnii th^■ iniiltile liiie nt liolli tin; aiiti-rior ami [MwttTi'ir 
wall* in II imMiiiiient li)u;;itii(iilial riiip:* — the anicrinr and postt'rior vagim 
columns, the lattor not iurnx|uiiitly Iwiiig ilividc-d into two part« by 
Iniigitwlinal furrow, in woiiitn who have not hornp i-hililron, nuini'io 
Irawsvtrsi.' ridges or rinja' e.Mond outwaixl fmni ami almost at riijht anjilcs 
lu llif va^iiiiil ctihinins jfrii'liiallv failing awny as tiny ap|>roiii-fi tin- hit* 
walU. 'I'lujy civf to tiie surface a corrujtaiwl ii|i]>L-araDt«, which is mo 
ninrkitl in llic cnrly yean of life, and i^radnstly bc(.-oinc» oblitvrutiHl at 
r<.-p(<ati-d i-liiltltjirtii, m that in old multipHni- llit: vaginal wails are oft 
pi'if'rily ^miKilh, 

The vBfjiiial wall it-«?lf is wmijuiswl of thnt' Ih«t!* — the niueous, tho 
mui^cultir, and tin.' conni;ptivt-tL*>ue layers. The niu(»;i'.i is covered h^^ 
DunicmiiH Inyei^ of ^tnitillcil qjilhvliurn^ and elowi-ly rc*(rnil>l<u' the skin i^H 
structure: but, ai^ its surface is not rxiw^^xi to ihe air, tho lioruy !ayo^^ 
i.-" alin^nt. The lowest layer of epithelium i» distiiicHy coliiinnar in aj)- 
IMMrance, while the n-ll.i iinniHiiitcly almvc it are ]K>!y;;onal in fhapi', am 
griiititally bvLonie more and more Baltcnett a^ the free siirfuec in a 





'' V...-. 






let. 



ffL, r[iithd»iiii, ;i.. |Juj-lUn; r,{., ciinim:llvo Uiwun. 

pnuietuMl. BenL'Hih the epilhelium U the submuowa, a thin layer of con 
neetive liNmc, vrlticb is tolernbly ricb in btood-vcivcU. t)fF»l)noU from it 
extend ii|i inhi Ihe cjiilheltum and form papilla', jnst a* in the fikiii, and 
itcuttered hei'e and there thmii^h the «uhiiiiief)isa are small lyuiplioid 
noduliiui. The mucosa is very loosely attaehed to tin: iiiideriying eonr 
ive lioAiie, tt* h nianifcsted by Ihe case with which it ran Ih,- jmx'M oIT 
opera! ion.4. 

.Xccnnlinir to Kppinper, Na^'el, tJehhard. I'retli. and Waldeycr. 
vaginal tiiueo.nii is jihsiihitely d<.'\'n)d nf glands, iu>r ha.-i the wriler, in 



THE VAGINA 37 

of the large number of epecimen^ examined, ever encnuntercd them. Hen- 
Dig, PreuiiclieD, and Cullen, on tho other hand, at!irin that they are not 
iofivquently present. It is true that in rare in.stances Yeit aud David- 
:sohn found a ft.>w structures which the latter considered repretvntul alx-r- 
nmt cervical glands, but I do not believe that typical glands lined by 
cuboidal or cylindrical epithelium can be considered as normal con.stitu- 
mts of the vagina. In women who liave borne children one oecaHionally 
finds imhedded in the connective tissue masses of stratified epithelium, 
vhich may present a central cavity, and sometimes give rise to cyst forma- 
ttML Thet«, however, are n<it glands, as they simply represent tags of 
mucosa which were buried in the repair of vaginal tears following labour. 

The muscular layer is not very sharply marked, and is usually ' de- 
wribcil as being composed of two layers of non-striated muscle — an outer, 
Ini^Htudinal, and an inner, circular, layer. At the lower extremity of the 
vii(;ina. Luschka describtil a thin band of voluntary muscle, the constrictor 
urtfAincter inifinte. This can always be found in perineal dissections, but 
for practical purjioses the levator ani muscle is the real closer of the vagina. 

Itutfide of the muscular layer is a layer of connective tissue which 
"WTc^ to connect the vagina with tho surrounding parts. It is quite rich 
inclar'tic fibres, and contains an abundant venous plexus. 

in the non-pregnant condition the vagina is kept moist by a small 
imount of secretion from the uterus; hut in pregnancy a well-marked vagi- 
m1 twretion is present, which, according to Diklerlein and most suhsc- 
•joent observers, normally consi.sts of a dry, thick, white, curdlike nia- 
brial cnniposfi) of cast-off epithelium and many bacteria, and presents a 
njirkitlly acid reaction. A great deal of work has l»een done u]>on the 
Incti-rial flora of the vaginal secretion in pn-gnancy, and ail observers 
igrce that baeillary forms pre<lominale. though cocci are not infretjuently 
iwn. The consensus of opinion is that the ordinary pyogenic organisms 
»re never prew<'nt in the vaginal secretion of healthy pregnant women 
(Kriinig and Williams). The subject will he considered in detail in the 
tiaptcr on l*ueri>ernl Infection. 

The vagina possesses an abundant vascular supply, its upjH-r third 
Wnp riupplied by the cervico- vaginal branches of the uterine arteries, its 
mtildle third by the inferior vesical arteries, and its lower third by the 
nuiliaii h^morrboiilal and internal pndic arteries. Immediately surround- 
ing the vagina is an abundant venous ple.xns, the vessels from which 
Mlow the course of the arteries and eventually empty into the hypogastric 
tfin-. 

The di.-'triliufion of lymphatics has been very accurately studiwl by 
P'lirier. who found that the lymphatics from the lower third of the vagina 
•nipty into the inguinal lymph glands, those from its middle third into 
tin; hvpogastric, and those from its upper Ihini into the iliac glnnds. 

TIic vat^ina is formed by the fusion of the terminal ends of l!ic Miil- 
Inian duct*, which, according to Nagel, reach the «ro-genilal sinus in em- 
bryos i.ii to 3 centimetres long. As has already l)een said, when i-onsider- 
ing the development of the hymen, the vagina is originally solid, ami is 
Bade Dp of a maus of polygonal epithelial cells, its lumen resulting from 



38 OBSTETRICS 

tlu'ir ilfgonordtion, which cominuupcs at about the third month of gesta- 
tion. (See Fig, 34.) 

LITERATURE 

Ci'i.LEN, Vaginal Cysts, TraiiK. Am. <lyn. Soc., IWM, xxix. -159-483. 

Daviuhuhm. Zur Kcimtiiiss der Srheiiieudrusen, etc. Anjhiv f. Gyn., ItKX), lxi,.418- 

4;i:{. 

DiinEHLEis, Dim Scheidenmikret. Ijoipzig, 1892. 

Epri.-<i<!Ei(. ZuilHrhr. !. HeilkimUu, Ud. III. 

GKbHAKD. I'uth. Anatomic der wi^iblichen Sexualoi^;ano. Ijcipag, 1809, 494. 

Henlb. Eingcwcidelehre dcH Monat-hcn. Braunschweig, 1873. 

I'Liii'iNic mid Mence. Bakt«riolof^e dux iveil)!ichcn (ici'lt^lkannles. Leipzig, 1897. 

LiiscHKA. Die Anotomie dca ineiisrhlii-hcn Beckens. Tiibingcn. 18ljl. 

Nagel. Diu weiblichcQ Uetichlechtsorgaiie. (Bardeleben'a Handbuch der Anahmiie.) 

Jena, 1890. 
FoiRiER. LyiiiphiitiqiicH dcB orgaiies g^nitaiix de la feinmu. Pari?, 1S90. 
Prettl. HeitraR inr hisWilogischen Verandcrunfien der ^rheide. Zoitachr. f. Oeh. u. 

(iyn., 18«8, xxxviii. ■J.'HK269. 
iSniATiTA. I^hrbiich der cicsammten Gyiiakologie. I^ipaig u. WIen, 1896, 51. 
Vbit. ('.vs'*-" der Schoidc. Handbuch der Oyii., 1897, i, 341. 
Von PiiEirscHKN. Viri'how'a Archiv, Ixx. 
WALL>KVKit iiiid Jdi-^sel. Iiehrbiich der topographisrh^i.-hirurg. Anatomic, H. Theil, 

819. Bonn, IHm. 
Williams, J. WmTLoiMiR. The Bacleriaof the Vagina und their Prar Ileal Kigiddcance. 

Amer. Jour, of Obs!., 1808, xxxviii, 449-183. 



INTERNAL GENERATIVE ORGANS 

The Non-pregnant Uterus, — 'I'iie uti-rus is a muscular structure, par- 
tially cttvorcd hy ptTitnniCuiii, and prciioiit!- a small cavily lined by miicouH 
membrane. Tt is the orj^au of menwtruntinn, and during pregnancy serves 
for the roi'optinn, ivtention, and niitritino of the ovum, which it exjwls 
al the time of Inliour by its contractions. 

The uterus is situated in the pelvic cavity Iwtwecn the blailder and 
rectum, its inferior e.\treniity proJL'ctiii}; into the vagina. Almost its 
entire posterior wall is covered hv peritonieuia, the h»wer portion of which 
forms the anterior boundary of Doiiglas'H ciil-dc-sac; while only the upper 
jKirtion of the anlcrior wall is so covereil, its hiwer portion being united 
to the posterior wall of the idadder by a tolerably thick layer of connective 
tissue. 

Roughly speaking, the uterus resembles a flattened pear in appear- 
ance, and consists of two nnequal parts: an upper triangular portion — the 
corpus — and a lower, cylindrical, or fusiform jmrtion — the (?prri>. The 
anterior surface of the corpus is almost flat, while its posterior surface is 
markedly convcN. In view of the fact that the former, which looks down- 
ward and forward, rests upon the bladder, while the latter is in contact 
with the inteslinos, His has suggested that the surfaces he described as 
vesical and intestinal, instead of anterior and posterior resju-ctively. The 
Fallopian tube;; come off from the cornua of the uterus — i.e., at the juno- 



INTERNAL (IKN'ERATUVK ORGANS 



30 



6»f the siiivriiir ami I.iIithI nmrgiDs mi Htl»T (iNlo — ihe ponrpx upper 

Ix-tu-fii lli< ir [Hiiiit'i <'( inst-nioi) |»-inj; kiumii ni' llw funiliu tilrri. 

Tir laUTiil margiiM cxu-n»l from tlic inwrtion of Uie Fallopinn tnlxw ua 



I 







■I fmiim. 



Via, 'llX^PiiHn:iiii>ii A>I'Ik-t or tlvKMrs. 
XI. 



' •iiir III llu- {iAv'k- llo«r. Tltcy are not wivtifeil liy ptTUonitutt). htit 
"nw- iW iiiUcliiiiwilH of tltp l.irwl licaiiK-nta. 

tIr u((ini^ pn^MNiU ninrknl vuriulj<in» in eiz** nnd i^hapo, a4<conlin); lo 

ll*:«gi-nf iJti' tiiijiiiiliiiil, uml Nhi'UH-r nr not .■>)!•- h]i.-> Utme cfatMn-ii. 'I'he 

ttbiitlr nr««i] tuno frnm S.-^ lo .1 ceDlimctres in 

''Vti: thai iif niltilt t'iryini' mfji.-iiini' fmin h.a lo 

* " 1^1 'J lo 'i.Tt cetitinielrE^ in it= j;rMt(^l 

»'. . ..ii-ra!, mill nn1i>r<i-|ii>*UTi"ir iljiimi-lfni 

nnty, u miii|»i)rnl villi !> to 9.'t. Tk^ to C. 

'■T (u ,1,5 itTitinii-lTi-:* in itmllipiimiK' wonnii. 

^ItiBiI «nil pan>ii« utori alto <lifTor mmtidoratilv 

"■"Kilt, ttw fomiiT nint'inp from H> In .10, «iKi 

'^l«iw fmin tWI t" Tn ;^)iiiiiit!s. 'nio ri'btion 

***"n ibi- Icnxttt of llio ooqiitff ami ItiiiL of iW 

""» liliiriM' varifti wiiMv. In IW miiiiK chilli 

'^ 'onwT t* only Iwlf as Inn^r as tlw cerriK: in 

-^H *irjtin- (In- In" iin- "f tipiiil li-iiplti, nr (Ih* 

'•'pn fiuiv i"* nIikIhIv lon;:''r. In luuliiparotiii 

"mm, nn llii'* iitlit-r tmnil. IIh> rplnlion is n-vvntiil, 

I <W ■' iv n■pn^«'ntl' only a little more than 

'*'■' l.-i.«ll. of the o"rpan. F.o.4l.-I_»«n....W«, 
')n tafririnl fiwlinn it it; sivn tJiiil tin- pniil liitik „, TTi^nr^. f.H»wi»n 
luf ibo nttcnL'' i> miulf up of iniLtfuIar tiHi^iw. anil siTKAwnf*!. .\».i«i- 
,1. «,..rir^ a»i pr^tc-iw ^-bH. of it. Wly .•;-;--■ «;--;: 
< ID i-nnlml. Um- in?ily U-lB^wn tn*m B»Noiair_«r"rri.nitti. 
- u a mere slit, while that of the cervix %e*i. (iarimwa. x I- 




40 



OBSTETRICS 



rii);iform in h1ia|)p with 



ill opening alx>ve and below — the internal 

am] llii> ('vtc-nidi os. 

On frnntiil B«:tion llu- ravil_\- ()f (lio Wxly "f tin* uti-ni.* pivscnti a 

triun^'ular ii))|)u«rnncc, whik- Ihat of the cervi\ rctaini; its fusiform chji|K.'. 

Afli-r oil itdlx taring, tiiv triiiiiKulnr tipiHiir- 
anpp Ijworues icsw marked, ami its tnarpn^ 
iMditiK- coiK-jivc inKli'ud n{ oiiivi-x. an in tlie 
virKinuI (■■■miilion. 

Cervix Uteri. — Tlip cervii is the portion 
of iho hIctus which He* liflow the intprnal 
o«. Aiitt-riorly ilw itppt-r iKHiiiitnrv ik iinli- 
cateil by Ihe point al wliicli tlii' [H'riloii:i'iiin 
it n'thxU-A from Ihv ultTii* "ii tn On- 
bladdor. 

It is divided, by Ihe attachment nf the 
vagina, into i^x•> luirls: lln- I'lipravjijiinid iiiiil 
infrnvn;;iiial iKjrti'mH of liu- cc-ivi\. Tht* 
foriiuT in ci^vcrOil on il* j)i)*lori«r SMrfa<w 

by peritoneum, while its lateral and anterior surfaees are in contact with 

Hk' ronniirive liH!<iie of lh<> hrond ligaint-ntM and Madiler. 

The infravatfinal portion of tlit! cervix, wliicli is usually det^igiiati-d aa 




I^o. 42. — SiKiwisfo JcsimMt or 
Vaoim* asd Ckbtix (Skrno). 




Flo. 43. — -ir-naiim akd AvrmmtxaK* or 



Fio. 44. — llTTHrt* Attn ArcKxnAiiKJi or Fotm- 




the p&rlio vaginaU*, projects 
inln the vnginnl fornix, audi 
at its tip |>ri-sout.-< a «rnall 
transverne openinj;. the t-x- 
trrnnl o.*, iMiiindiil in front 
and iH'hind by the so-called 
anterior and pnvlcrior lip« 
of IW fi'r\i-\. (*win^ to Itip 
fact thai llie po^lcrior fornix 
is deeper ihiin (ho iinter!')r, 
the ]HiHl(-rior li|i appi^ara 
loiijfer than l!ie anii-vior, 

Thf t'\tt-niid OK iiiflv vary 
grratly in appearance. In 
the virgin it i» a uniall. oval opening rei^nibling a tench's month, whence 
Die name, oa lincte. On Tujjmal eiaminution it gi\i.'» a .lenitHlion similar 



Fio. 4S. — l?rBBi'« *xn Ai'i'it"(i>AOiui or TwM*Tr-» 

Ol.n Ml.'l.TtPAHA. X f. 



LSTERSAL GENEUATIVK OltGANS 



41 





Pia.4C.— VwoMM. Exit ' 



47. — Paii'hi tlSTtn- 



nltUiim'<i "0 rivliDK 111* cnTtilii;;)- tit lln- I'tiil of iim-V turn'. ATlcr 
t-tiiltllitrtli llif iintit'i.' iHiiiriic* ifinviTli.-il idIh a irnnsvcivt- ^ilil, ^ihI hIk-u 
|Im> (vrriii; hiii> liet'n niarkcilly lorn diihiig liilxnir. it iiiiiy prrarnt .in irrpgii- 
Ur nndular or stellali.- appearant*. TIicbo citan;!<--« «iv vory elwinicti'rtslie, 
ami •rnii>ili> oim> Io aHwii 
■lib tiilcralili' o<'<niriii-v 
vhi-thr_>r a wmiisn has 
Utme rhildren or not 
(FiffB. 4fi ami 4T). 

ITir (^-rvit i» com- 
|>EV*I of miinti'livr tiv- 
«CN- in irlii<-h am many 
tionftriattHi tnasclc iilimi 
•iMl a f-i-rtaiti amniiiii of 
irlutir lLviiM>. n tart;<' |>arl 

•if ilK ili'l<'n>iliilitr iH-iri;; iliir Io |1m> pn-wmT of (lii- lalli-r, Tlii' wrrirn! 
nuul. a* lia* alrt?n'ly lii«n nnid, is fusiform in )i)»i|>c, aii<l prc«>onl^ a lonfji- 
ladiiuil riiigv upon iU antmor nnd pwtcrtor unrfacfv from wliidt nuincr- 
mt> nllufa run off tjansvcrsi'Iv, Rivinf; the mi?mbnui« a comigatal nppear- 
atrr — till" aritfir rilir filrritta or j'iiaf jialmai<r. 

In I)m- ikIiiII till- iir)K>r viln' in liniiusll to tlic i-<Tvic«l rannl ; Init in 
fhililboml it extends Ihrouffhont the niiirc cavity of the uterus, from which 
it bqgnK to tU>^p|>i-Hr u» ptilicrty is approaditM. In lime, afli-r re]>oitl'il 
rli~' ' it ^iiilitnily Ixvoiin^ niililfraltil, even in the conical canal, 
w1 l^ Ikt'oiup iilniost unttxtth {f<v l-'ipt. 4^ to 4S). 

I'ht' iniHHi*A nt llw (t-nit-nl <iinnl, «inl)ryoloKii-nlly »)icakin/, i* a iliri'ot 

tAiotini. ■ ■' •'"■ lining of t'"- •'"-'\iie cavity, but has become dilTcniiti- 

atccl fn>m it anil prM- 
Bcufiw a I'liarai'tfrislic 
ap(H-nrnncc. mi that 
^ectionii tUronjih the 
cunnl present a boncy- 
nimb-liki> wiTUftuns 
(Kit;, i^). Ttw mil- 
fni» in riitnpoM^l of a 
Mnglo laytT of rcry 
hi|ib and narrow 
cohininnr epilhcliniti, 
wliicli r<'!<li< iipiin a 
liiin Imfciiicnt niinn' 
brani*. f\» oral nti- 
BH' ■ilnatnl nonr IW hn>« of llio mininnar colli-, tho npfnT poriionn 
'-which prcM-nt a clear, nkorc or less trannparcnl npiu-nninr<- tliic to llie 
piiMiM^ nf muru«. It i« tuurilly «laliil (hat tliow w)I» arc abumlnntly 
■a]i|ttial witli rilia. 

Tl» wTTiral slanilR r.flcnti iloim from tlid mirfnci' of the muco^w inio 
til' '"i jin' of ibi- limni-hinp. riifi'inoiip Tnrirtv, auA nrc mi'rt'ly 

rv-i '- 'urfnit' f[>ilWI)um, iH^ini^ limil by cpttlirlinm of llto 




.14... t ...4 i *.«.. .. ^*, < *-...*.. A if. 



42 



OBSTETRICS 



wimii tlinrHctcr. KriotfirirMior wa.^ Ili<- first to Opmonstrate tliat it was mn* 
U]i of tnie '" IjoiikiT " nr mucous ci-lls. wlildi I'liriiisli the thick, U-nuciou 
wwri'tion of llic corvimi i-diihI. Thcrc! ]» nn «ubmuoo!i<a in tlie cervix, 
iiiiicti:'ii rcjiting riirt-'clJy 'ii\vm the uudi^rlyin^ ti(*u(.'. 

The nuifORH ol llic vti^iiml porlmii nf lint ti-rvix in liirvolly cnniiQiia 
Miilli lliiil of iho vagiim, and, Uka il, ninsi.-.|-t r>{ manv lavtrs of slratif 

epithelium. Nonunlly, Ihcn- aiv 
glaiidi' benoftth it, but occaaioQ&ll; 
thoHc from 1h« cervical cannl inn 
oxIi-ik) (Ioui) nhiiDSl to its tutrfaojl 
;iii<i, if their (liiftM are occ-Uuk-il. ma; 
Ihiiiiim? cotiviTlt-il iiilo ix'li-ntion cyaU 
wIiilIi Hhimnicr tliroii^h it ttn<) sM 
]ii'ar us rciiimUi! |ti'iiliihi'ran<«» lln- stz 
of small pons, Thi.'«(; are the so-i-alUi 
NalHilhiaii follirW m- uvuln .Viibullii 
Normally, the stratiliwi rpilhiili 
iim of thu Taji;iiial ]u>rli(jn aiitl tl 
cylindrical epilhcliiim of the cervicii 
cjiiiiil inii-t at ihi! i'\(i'rii«l os. Thi» 
howeviT, is the case only in early Itfl 
11* in iilile?' [H-rsiinx \)w. utriiUlii-il *^ 
iheliiiiii j.'mtl Daily extf'nds up the ccr 
vital niniit iirilil its lower thiril. am 
"(■ciLsifHially its liiwi?r half, in i.'iivi-rt-i 
hy it (l-'rietlliiiidor). This chaiigf i 
movo »-M[i('cially iiinrbw! in niuKipat 
ous women, in whom (he lip* of th 
cervix arc not iiifri>'|ucntly marki't 
cvprli'd: nml occnslonnlly in efi»i>K 
this clmiitetiT, alntoyt the entire en 
vicnl cnmil nmy he lined hy <:trati6 
I'pithciiiim. 

In rare inslaiiees the junction 
the two varii'l !(■> of e|iithcliinii mA 
lie upon tho vaginal imrtion, oiilmicl 
the p-vlenml on, Thi« condition 
first de«eril)cil ly I'lsehel, who riesi 
nali-d il as riinijrniM rrlnipinn, aiv 
stuteil that he had oliserrcd it in in out of 28 uteri of yoimR persons whwj 
ho had cxainTiiw], SliU more rnrcly. the enlire vaginal portion mny ■ 
covcrwl hy rylindriral epithelium, which ni«y even extend down over m 
i7i<;inal walls. This annmnly wmk first de-icribeii hy Uiise in a case o 
inipiTf'inili' hymen. a»<ocint['d with hirinitlri-kii}po.i, in which the eiil; 
vagina aiul (he inner .iinfmv of the hymen were eovereil hy a single la; 
of columnar, ciliated epithelium. 

Corpus Tlteri.^ — nn- «id! of the ntcrim' liodr r* made np of three 1 
ers: seioii!i, miipeular, and mncon^. The serous layer is formed hy 













Flo. 40. — CkuvteA). CuMtn. 



XBO. 



LNTERSAL flEXKRATIVE ORGANS 



43 



awnm ••'wcrui^ tlw- utiTus, !■■ wliiclt iL is (irmly ailhercut except at 
I thp mnrgiii^, wlii-iv it U (ktUx-tetl lo liw 
linuiil li]t;iiiTit'n(.>. 

EadometriuB. — Tite lanermofl >ir mu- 

[cmw ln,TCT. vtiii-)i mtvcs as a liniDf; for 

lihe nlerinc <?iivity, is c^ninnnly kmiun a* 

'Dm- cnddifxtntim. 11 is a thin, pinkisti. 

I ndTt>tv iiienihruiii', wliidi on ilosi^- vAJUn- 

is sivo to t>e {icrforalnl by bl>;e 

of miniilis ojH'riing* — llm moiitliH 

gUmU. (Ill nccoiiDt of ttie 

t^ai ti> wiiii'Ii it i> itiilij**);! 

the ficjnuil life of u-Dioan, tlic 

at-lriuni van** miirkiiily in l)ii<-k> 

atxl laay uim^ure aiirwhc-n> from 

to i or ;) iiiillitii«tn'« Mitliniit Iwiny 

BMvwirily aluiorniul. It (■oiu'i^ilH of a 

KrIJur rpilWIiuni. ^amN. nt»l inli'r- 

(lindular tiimiu*, in whii-ii arv found 

nMToae Uood-v<.'«f<i-l« and lympliutiv 

A* tlw laiilnuiL-lriiiin dom not pifBtu^ ii *'ii1iitiii<r'|pa, it ist iittadiul ilim^tly 
y> llv BDdortyitig intu<:ular layer in Bii«h a iDsnnor tlmt it« outer bouudar/ 




lit, BItllU'tflll 8l(A|-K «>■ I'iBMINK 

CAvrrr akuC'kkviimi-Caxai. x I. 




^H inmti invtmlaritifs in nntlini' c»rre«p<jn<linK with the intentieeii betvcen 
^^ llr mtt>cl<- tftinillii'. Thi*^ urniii^>tn>-nl h of oonniik-ralilp iiu]>')rtimrt! in 
MiniMirtMw «ttl) tlie o|M'rH(iou of curetta^ej for, oa DiiTcliua and Werth 



Flo. ftl.— NmutAi. RNnnurmtm. x l^l- 



44 



0B8rrKTRI(£ 



lijivD uliown, it i* from tho [)ortioii« indudcfl bctwcCTi the mii»Hp bandlc 
that IhL- cii<I(>imMriiHii i.-> r»-j;iiK-raU'ii iifli^r Uio iinx^LHltiiv. 

Th*! jitirfiitL- i-]iitl)i'liuiti <if tin' ulcriiip mucosa ii- ei)riiiKi«'(i "f n *inf,'Ii' 
layer uf ki^li ooluuiuar ctliuli'il ('t-l].->, which uri! chuscly [lat^kcxl togethi/r^ 




itueou 



Fw. AS. — Ekdowktmipm or Ncttlt Buhn nntoi. x ISO. 

llie oval nudt-'i an? eiltistcd in fiw. lower jwrtions of the oelU, b«t ac 
so iHTtr tlii'ir Imsi^ ii^ in ilii' trrvix, lU-iKnith Hit" 0)>itWI!uui in a thin bn* 
iiieni inutiiliraiiL- with Darrow, i'piii(ll<'-)i)inpi?il niiili-i. 

Th« pxi^ti'iifc ot alia wns fir»t th'niniislraUt! by Nylamier in ttip so» 
liul tlH-y Itavt' sinoe Iwcn found in nearly all aiiimals, Althnugh Wyrtfl 
utatcd that they wert- uot present Ju the iicw-born child> the rwcDt 



tnucoa 



mu-'-ii; 




Tt.H, it,i.i.\.t^.< y. 

Vta. SX — Sekiu: ExtHmmtiL'u. x 17. 

TOarche* of McyiT show that they are dejiion-itrable at variable porio 
being flnmetiiiicx pmscnl ut birth, hut wimetinKM not aptioarinf; Hntil mitO 
later. Tliey persist throuRhout ihc entire piTiod of iwxiial activity, an^ 
M<-ei>rding to Parviaineu, (liKup|>vtir eight or leu ywrt aftt.-r the ntenoiMiUfic. 



INTERSAI. GENERATIVE ORUANB 



45 



i 



F I^|i tn 1893, it M'Os ^Tii<>rany tnii^lit that tlif current pimliin'd itv llu-tii 
npu liinrUJ from Ittliiw ii|inuril — iwiuelv, frmii tin.- cervix towanU llii; 
[XuDilw; Itiil llofniviiT cDntlusivirly lUiinm^iratixl tliat it U iu Ihc ujt|H>- 
Ljte iIinvtiiiQ, aDil hin reiiean-lKi) haw finite bccii eontirined by ManOI. 
pt may thcivfoni be rotuidiivd lu a dvfinitrljr i^tablUhud fact that tha 
■ri]lai7 cumtnl iu IhiIIi the tuliea uud lh*> utoruH U in Dmi -qiiiit! ilir<-<-lii)n, 
aad tfitetuls iloN-tivranl from tliv liiiibnut<^<d I'tiil ol th« tubes to the extcr- 
akl in. 

In n-ry exceptional instatices, t]>c uterine ravit>- may be lined by iitrati- 
fiod epithelinm, as in iIk chwm TL-portt'^ by Zctli^r and V. I-'ricdtiuulcr. 
Swfa n iiiiidiiiiin nnilily t-vptain* tlie ]KK<iuldc iiccurrenue (if l!at-celled «ar- 
cnoDia «f tbe Uidy ut thi_' utenie. 

rnijixrliiix diiwii fmin ihu Kiirfm-v of Ibn f iidomcl riiiin an largv iitiin- 

l»n of uniall tubular ;;lamif*— tlie ulrrine glands. The^e nimit be rejjarded 

■r mure iiivajniu>ti<>i» of tin- «iirfa<v tr|iilbt-huiii and rtiwinblv Die I'liigvn' 

nf ■ ;cltive. Uumjih mviu-itiiially il)ey hraiuh Hli);luly at their d()e|>i'r e\- 

tn^Hitir*. TtM-y i.-xli-nd thrmigh the vnttnr thiukni>H of Ihc cndunR-triuni 

to Uiff miMriilur lavi-r, which tiii-y DciUHionally penetrate fi>r a vbort tlifi- 

,' tnre. 'IIm-v |>r€>H'nt the »imc hutolnpuil i^lnKtuiv as tlte niirfaee epi- 

ihdtum. and an- lined by a ainffli- layer nf hijih, t-oluinnar, cilialix) epilbe- 

luB, wbirtt reAtc upon a thiti l>a!Kiiient membrane. 'Vhev mmt^Iu Hmall 

^^ ^Mntitnv ut a thin, alkidiiie nwrt-liiin, which senw to kwp Ok uterine 

^H avity mot«L 

^H In stndying micrfHcipie M-rtioii". it niiut he remnnltered that tlic j;Iand« 
^^Lns nnt always cut vertit-ally, and that tln-ir appi-iirutiei' will vary a^t-ord- 
^^I^Kln tbo dinx-tiitn n{ t)ie Kvtion. Thn». lliev not infrcijuently ap|nwr a^ 
VHIHttt rir "Val u()cniiip>, and whcii hyix^lr'ipbii'd iimy pnwiil. ii inrkM'n-w- 
Iflcr ap|>«r«ne«. 

In th<' child tin- HteriiK' f;landK are mere »hal)iiw dejirtvsion*. wbiib. 

•rmnlioi: tn Kiindrat and Kn},'i'l tiioo, do not n|ip(-ar until iIh' third year; 

*>bI iIm' rrrM-ifrhtv of Meyor. whieb art' tonfirmed by my own "tudie*. show 

th»l tlivy an' n»t hifniiuently pn^enl at hirlb. At the iwnopnuHe the at- 

cntkitnetrinm un<lerKoe« atrophic cbangee; it?; ppithelium becomm 

i< K">dually di<ap|><-iir. and itH iiitergUndular tiMiie tako< 

■ mo .1' appearance (rtx? Fi;;. 53). 

Thtf pirrtxin of Ibe iiMlomi-triuni lyinjt ln'twcen the inirface epithelium 

> rlyin;; muwie, which ix not nenipied by ^land.", is filK-d by an 

T tiutvf or stroma of an embryonic type. I'nder the mien)- 

ijp». 51 ami Hi 1 it Is wen t" tn- made tip i>f cIom-Iv jmckt-d ova! and 

pod dihH. amuml which there is very liiiie pnilopbi^ru. Wh-.ti 

Hamtw on- uprend apart by irdema, it i* readily i*een that the celln pn?- 

" At! ap|K'aranef. with hranehinjt pnilnpln.-iinic' proees.-ft' whieh 

im' with another. Theto eell.t are niori* cIoHelv packed around 

Ap gland o and blnniI-vcft<eU tlian dsewtiere. OccaAionally larger or 

nnaII*T (iillertion* of round cell* may lie eoen Iwtwccn tliem, though it is 

■mcertajn whether or not these are to 1m> n^rdod a* fi/mphnid nodtitea. 

Thf ■ Hire of ilie lulcrplandular ti^^w? has {;i\*en riw to a great 

deal III ' ti, concerning which thi; atil)iortii<>s are not yet fully 




46 



OBSTKTRICS 



Bgre^, llinoi lociko iiprm h ns notliiii;; tiut embryonic ti^uc, while Si 
MiK^ ill il u n'.Mfii1>liiiKr l" IviiifiiKiiil tiT>Kui.-, iiikI Artliur W. .loliiintunu 
holil.H ilml it U of an luli-miii] Ujie. iia the ciIIiit hand, lrfo[K)!d, Chain- 
jjiwiuiuTir, Poirivr, and iiihurs t-oniiidLT that il rt'iiix-x-nls ii lyniphutie sur- 
face. According to ix^o^iold, the " utcriuc muca«a should be considered as ■ 




J^'^A*.' 









rid* 






>,'»- 






.■--.■\.»,^»«. 



Tui. .VI. — L'TtMJM; (il-AMi ANll Jil'HDVt. X A2l,. 



s[)rf(nl-mit lviiii>h-;;land ( Lymiihdrilwnfliichc), whith does not cnntnin tmo 
l_nn[ih vesiit'ls, hut (.■mfii^t!' wf ^jiatv-s limil by uiidnilK-Iiuiii." Thorn is a 
cmttiln iimount of evidence in support of all t>( these viemt, but I am 
inelincd tu aj-'rei' with Miimt in con^iilLTing it ib< iiK'rcly an euibryon 
tvpi.' "f I'oiinwlivt" tiMue. 

When prepiiratioiiii from t\w (.■iidoniclrium arc Ircatrd hy approprtaH 
Uictli'ids, an nbiinduiil I'l'liimlitm can In- lU-nion?'! ratii) tliniii^hoiit iLs 
tire cxti-nt, which forms the scaffoliling upon vfhich il is constnirted. 

'nir i'nd<nn"'(rtiini (■"intiiiii.* itiiiiiv IiIihiiUvi'-vi'Ii'. Tin- Hrli-rit-s piir»ui' 
spini! iiiurr*-- ami bivak up into a capillary ni-twiirk jiHl l»n''.itli the mirfat-e 
fpitiii'lium. from vrliich thi.- hhxHl i« rvturni*d hy a fi-w coiiiparatirdy tar J 

Vl'-tM'l-. ^ 

Musculature of the Ut«ru>^Hyonietnuin. — I'hi; major part of the 
nliTiis tji luiidi^ up of liiiitill(-s of ivm-ntriatiil miiM'lc, wliicli »n- iiiiili'd 
hy a ^ii>nt<^r «r h'ssi-r amount of connective tissiii?, in whii'h arc fotind nianv 
vloetic libn.* (I'iek). On ^wtton the iitirnnr wall pr^■s(•nlJl u thitrk, felt^lil 
stnicliiri^. in which definite layers cannot Iw di.-tin^niished. 

A pivat deal of work has Ik-cii done upon tho arritngcmcnt of the mr 
culattirc Imlh nf Die pii'ijnant antt non-pn';:imnl uIitiis. Tariiii-r ar 
Kibi>inoul-lK~'8f^aip)es wcr' iitialilc to make out drfiriilc layers (if inusclu 
bnQdlve in lh« iion-pa-gniinl organ, while Bayer, KreitJier, Veit, and otbe 



INTERNAL OBNERATIVE ORGANS 



47 






iI»tmjrTii«lml M'wral, tint iliil mil iijjnv il'^ I" llii-ir arranRcmMit. All 
^init, tiowcVtT, lluit Uk ;;n'in(.T part of tikc nlorino wall i» iiiinlc ii|i of ii 
muK of muKclr wliicli u jH-rrurak-d in all ilirix-ticHiK by l>lood-ve«iscU, aud 
IB whJt^li il in iiii|>o(uiihl(> lo make out iiuv (loliniUi nrniRgi>iiu-nt <jr Hui 
hnndlK^— K^ftiJum nxfculare. 

Km-ipT rltiiliifl llic <)iir-<liiiii frtiiii a iVvdoji mental \y*in\ of vii-w, nnd 
ik-nKirL-lntitil that lli« iiiusclo lltin?:< &n dovdu|inl al'm}( tin- I'ouisc at the 
Unm]-v*9r«oU, but fuiktl to (Uetin{;uUli nnv <)ciiiiit« arranf^wcnt. Similar 
sluiii»> )iy nVrl)) iind (IniHlitv ^n hi ^lulw ibnt i\w iiiiisoiiliiliire of liu' 
(lElal and infanlik- iilcrus ])rp>ictilM a vtrv »iu))ile arrnii^cnu'nE. whicti 
W(>ini9> ttiilrli m'irf (inniklicaliit iiy [ihIhtIv is appr'niclii^i. During jj»-sta- 
liDO. on l\w oi\wx haixt. tlio ulenu uiidt!rg>M<!i marked hypertrDpIn-, v\wn 
tt bocnmtv (nxu'iUlr* In dii^in^^iixh rvrtain di»liiict laviTS whioli will \tc con- 
ttlcnil ill l)i4' rliLiplcr on ifti- ciiaii;;(^ im^idi'nt lo |in-^nai)('V. 

liSMneott of the Uteras. — KM<-ndin^ frtmi uitlier butf of t]iv utvnw 
tri- llir^v li)^tnL-niouN siriu'iurcH — \i\v linuid, round, am] ulero-itavral liga- 

lt« (ligauuiila luta. tt-Tttia. aiid ulvro-i-acralia). 
hTlu' bntail li;i;aiiit-ni», or Ur/iiinrnli Mn, am la-n u-ing-Iikv iitniotiinsi 

-h txtcnd from thf lalcral iitar-;iits «f iIk ulcruii' In llie polrio walU, 
uid MT*'' I" dividt' llnr [H'lvin i-u^ilv iiil" an aiili-rior and u |H»liTior 
MnpartnieaL Kach broiul lijr<)inent consiHts nf a fold of iteritouiBUin 
iMloaing vamuK r^tnH-ltinv witiiin il. und inTH.-iitu four murgiUK Tor v\- 
UBinaliitn — a sujH-rior, latt?ral. inferior, iintl nuHliaii. 'I'hi> Kiipcrior mar- 
pa, for itf. inntT two t)iird«, in occupifi^] liy the FaJlopiaii IiiIh.-, irhilf 
It* nulvr Ihini, rxti-nding fnini iIh- liniliriiil^il end of ihv tiibi; to llw 
pdric val), U kw*ira as the infumlUtulo-pelvir, lisitment-~ihe fUsjK-nsoty 
Qjnnimit "f Hh- n*«rj' ( Hemic) — and sorvra to tranKntit tin- ovHrian n-jtrf?!:'. 
TV [■irlinn iif iIm^ limad lit-iiiiicjit tn-noalli Iho FiilIoi>iaQ tube U railed 
tW mrmaitfHnj-. end iiHiBifU ni two liiwrs ot [K-ritoniciini whicii an- iiiiiti'd 
tf a nmail amount of l<Nin' ironntvlive tisiuo, in which U embc<lded Iho 
parentn'um or orjcan of Ito»onmullpr (eee V\g. 45). 

Tlu- |iar>ivarimn consists of a niiiiiI>i.T of niirmw vertical tuliulm, lined 
krlli i-iliattii e|>ilbelinni, whieti ennnivt l>_v their ii]<i>er endn with a Imigi' 
tfetinni liwt. which ('sti-nd* jii»l In-low the tnla- lo tlie lati^ral niarfftn of 
tk iitvnu. in whrntc muscular wall it endn Mindly nbnul the rcjpon of Ihu 
■UmMl ne, Thi« eanal i* Iho remnant of the WolDian duet, and in the 
f'li njitrtl as toirlner's dm-l. The [NioivarJiim (iirnT»|»md'' lo 

1)'' - iind if uKTially i-nn^idcred af ttu' remain" of lix- WoltluiD 

Wy. Wnlilvyer in 1H70. Imaever. lihownl Ihnt il repreMints only tlie 
CTinial [tortioD of ihi? latter, aix) di^ijinatiil it as I)h> c|KH)|>lM>ron, and t>ug- 
p^«l file tvrm paniophoron for iiii' eaudal porlioti. 

Tli' 'if>rn« U the anido^ite of the onran of litnildes, and neeord- 

iag to : "islive work of Kidiinder is siliiali-d mttr \\\r fn-e end of 

Ik) bntai) li>rnn)enl U-ttrern (he terminal tiranchoH of the ovarian artery 
jk4 U'fim' Iher tmlfx the ovarr. tl mnMKt* of a nmail niindHT of sli};li(l]r 
mn"4ut<-i) riilint"i. lined by iw>n-eiliated epithelium. The orjian tendfi to 
<(i leinif n-iir». nnd i" of intenvl only from tlie fa«l that 

it i _ ri*e to iDinaur formations. 



48 



OBSTETRICS 




in ^ 



f"!!!. fi5. — HfcdWm lllMIKflUI rTBHISK 

End or Hudah Ijoaukmt. x |> 



Ai il.i laKTiil iiiarKiii, the [HTitniKHl civiTing of the Itmuil ligiiinf 
u ri'HiiUii u|»"M (111! Kiiiv iif llic jii'lvis. Till- interior iiiarKio. whiili la 
ijiiit* iJiiek, is continuous with lUv Lonncclivf tis-ue of l\\v pt'lvic flimrj 
Tlirougb it pass tJie utcrioc vt-sst-U. It* Iowit [Hirtion — tlii> canltnal liRa- 

nient of Kocksi or the tif/amenlttm fmng- 
vcrmle r"//i (if Mnckriiniill— is cniii* 
lH>i*i'(i ijf dense «)nnective tissue vrhicbj 
is liniilj' uiiittid to the vtipriLvuffiriall 
]xirti(in (if tlie cervix. The median 
iiinrj;iii is conti<N.-t(-tl with tliv latcml 
tiiiirifiii "f liif uleriis, ami incloses tlie 
nUTJui- ve***'l*; ttiroiij;h it ci-rttiin mus- 
cular anil iijnnet'tivp-tissH« hands es- 
Iciid from Dk' ulcrux into tUi; i>rt>n 
liginnent. 

A vertical scvliiiii tl!n>u<;h Ihc liter 
ine t'Mil (if llif limad Mjinntenl is tri« 
siiffulnr in shaiH.', with the apex directodi 
)i[iwanl, while it.n \taf>i; is hnrnd and cnn< 
lairii^ (hi: uleriiie vcj^uicU; it is widulv 
c(>imiHrl<>d villi till? rimnective tissue 
covering tht- pelvic Hour and lying bo-^ 
hind the hlathh-r, which is il<vifcnn1i-d as Uie jtarametrium. A verticslfl 
Kvtioii thrniigh the middle fuirtiun of the broad ligament sIioV^ that ita 
U|i|i>T [iiirl i^ miide ii|i muiiily of three branches in which thv tulw, ovary, 
and riiuuil li|;aitienl are nilualeil, wiiile its lower portion iw not so tliici 
as ill the jirevions miction. For further particulars concerning the pclvif 
connective tissue the student ia refen'ed to the careful study of Jun^. 

llii- round Ugaufntt^, or Ugamnita terriia, extend on cither side frori 
the anterior ami Intend ]iortions of the uterus, jiiKt In-low the insi-rtioB 
of the lulies. Kuch Wvi in a foUl of thu broad ligament and runs in at 
upn'ikrd and outnaril dir(vti<in to the in^'iiinal cuniil, lliruugli which 
paEiH>i;, to terminate finally in the upper portion of the labium majua 
The ixiiinil 1 ijk'iiirieiit varies from 'A to h iiiillimetri^ in diniiR'tcr: it \* eom- 
poeed (if non-striated muscle, which is directly continuous with that of 
the uti-rttie wall, und n i:ertiiin amount of i.-i.innectivc ti»»uc. Id thu non^H 
pregnant condition it ajipi^ara as a lax cord, hut in preji^ncy it under-^ 
pK'jt eoiisidvruble byjierlropliy and WHinif tn act u* o stay for the uterus. 
It can Ite palpated during jiregiuim-y, and by \\a varying portion aids oni^ 
in diagnosing the location of the placenta. 

The ittefi-.siunil /t^umi'iit* — retrarUrrea Hti^ri (liUsi'likn) — Bn? two dtruc 
turc,* wliicli extend from the posterior and upper portion of the cer\ii,l 
Duciivio Ihe reitiini, and are in.ierled into the fnscin covering the K-cond 
and third (^acral vertehnp. Thev are likewise ^wmposed of nonneclivc ti.4t<i|i 
and iniiwle. and are covered by peritonaum. They form tho latera 
boundariea of Douglas's cul-de-nac, and are helio'ed to ]>Uy e. part if 
retajtiinjf the uterus in its normal }KMitiou by cxcrling traction upon tl^ 
cervix. 



INTERNAL GENERATIVE ORGANS 49 

Pontioii of the Utenu. — After many yoarn of discussion, anatomists 
tad gyiuMologists have agreed tiiat the iiormui position of the uterus, 
whether pregnant or not, is one of slight antellexiou. With the woman 
jituitliDg upright, the uterus occupies an almost horizontal position and 
ii somewhat bent upon its vesical surface, the fundus resting upon the 
pteterior surface of the bladder, while the cervix is directed backward to- 
wards the sacrum (see Fig. 20). The position of the organ varies mark- 
eJly according to the degree of distention of the hiadder and rectum, but 
when thctie are empty the uterus always tends to resume its normal position. 
The causes which bring alKiut its antetlexed position have not as yet 
Wn definitely determined. Xormally, as long as it is in situ, the organ 
i: antedexed, but when removed from the b<xly it immediately straightens 
out. Schauta would attribute the antcflexiun to llie action exerted by the 
Vt^si'ls when filled with blood, but his explanation does not apj<ear alto- 
^t-ther sati.-i factory. According to Xagel and most embrvologists, the ante- 
dexiiin exists from the earliest stagiw of developmcut, and is to be ac- 
I'luntt-d for by tlie fact that the entire body is developed along a curved 
line. The pressure of the intestines upon the uterus is also believed to play 
a part, a.-; tlio light corpus is readily movable ; while the comparatively large 
ctrris i,s held in a fixed position by the small [wivis. 

The uterine ligaments were formerly sup]>osed to play an im]>ortant part 
in maintaining the uterus in its characteristic jwsition. We have already 
indicated the functions of the round and utero-sacral ligaments. The upper 
pr>rtion of the broad ligament appears to have no influence uimn the jwsition 
of the uttTus, sinc-e Mackenrodt has demonstrated that it can be cut thniugh 
without causing any change in jxisition, wjiich only owurs when its deeper 
pirtion — the ligamentum trani^versalc colli — is divided. 

Blood-Teaseb of the Uterns. — The vascular supply of the uterus is de- 
rived from two sources: principally from tlie uterine, and to a lesser extent 
fmm the ovarian arteries. The uterine artery is the main branch of the 
hyiK.ga.'^tnc, which, after desoeniling for a sh()rt distance, enters the base 
'■' the broad ligament, cro>scs the ureter, and makes its way to the side 
•"■f the uterus. Just l>cfore reaching tlie supravaginal portion of ihe 
ti-rvix. it divides into a larger and a smaller branch, the latter — the I'ervico- 
va<;inal artery — supplying the hiwor jwrtion of the cervi.v anil the u]»per 
jBinion of the vagina. The main branch turns ahruptlv upwani and ex- 
t.-nd- as a very cimvoluted ve.-si'l alnn^ the margin of the uterus, giving 
•^•ff a branch of considerable size to the upper portion of the cervix, and 
numerous smaller ones, which penetrate the l>ody of the uterus. Just 
'■•■f'ire reaching the tube it divides into tliri-e terniinnl branche- — the 
fumlul. tubal, and ovarian — the last of which anastomosis with tin; ter- 
minal branch of the ovarian artery; the second, making its way through the 
Rii-Ofalpinx. supplies the tube, and the fiindal branch, is ilistributi'il to the 
npix-r portion of the uterus. 

TIk- ovarian or internal spermatic artery is a hraiieli of the iioriii and 

■-iit-r- the broad ligament through the infuiidibuln-pelvic ligatiient. 'In 

r>-a(hin;r the hilum of the ovary it lireaks up into a numlHT of r-ninll 

ltran<'hes which enter the organ, wliile it;- main stem traverses the euliri' 

5* 




Flu. 56. — ntorn Sih-i'i-t or Uniica [Krilvl. 



of iiie titrrii"' iirliTV- For fiirllicr pariiciilur-i conceiiiing tlie ra-sciilar 
(iDpply tliP student is rpferretl to the <riri]in-Ii(ii*ive tiiouo^'rupbs of Frouiid 
and Pnrabcuf. 



INTERNAL UKXERATIVE OHUANS 



51 



It is f!«»eT«i]y staled ihal lliere in very little cominimication lielwecn 
Ibe ti>M-lg on tlw two Mclwi of tlvc Htvriw, Imt llii^ n^i'iil fSpt-niiiMitji of 
Clftrk have )•(■«! livi.'lv ilfiixiOHiriittHl that Mich is not th* ciise. This ob- 
KTv-T found U»at when the uterine uncr>- on om* sidi; wii» iiijvctQd, the 
floid r«cn|Mi] fnim the o|>p<i>>i(^^ uterine artory before it b^ioD to flow from 
thi' TeioK. thns ini]ioatini! Iii« pre?-ence of nnmerous arterial anaHtomoMio in 
Ibc i>iihi>l»iiii; of I)h- litem*. 

The veins from the uicnH form an aiiumlant jilexna aimind «ach 
ateruiK Brhvy, aiHl unite to forot the uterine vein on (.-ithcr sidv. whidi 
then eoipticB into the hrfKigsHtrii; vran, whii-h mukc< ilx way into the in- 




Pw. 57. — LrMnuitLv or t'twn-* (lu4ly). 



' I'lid fmm Ihf ovary ami »]>j)cr jwirt of till' brnai! liga- 

a nuiiiU-r nf mns, which forni a large plexus within 

' the brosd lipimmtl — the pampiniform plexw^~ihiT 'khm-Ih tnm wliirli ler- 

iDUu1i> IB iIm- ovarian Ti-in. Tlie ri^hl ovarian win emptier into tlic vcnn 

irMTa. while llif left rinptit-g into llii' renal ii'in. 



OBSTETRItS 

Lynphatict. — The careful work ot T/wpnlJ, Poiricr. Brnh&s. ant] othera 
has given us a fairly (IcOniti,' iilra ff the i,Mii{)liaTi(- sj'^iem of the uieriu. 
The wnlometrium i* almmlantly suppiisd with lyniph i-paccs, but posaesses 
no true lymphatic v^svc^'le'. lnii]Riliali.'ly bcucath it iu iht- itiiiHcu)ari» u tw 
lymphatics may lie rnuD<l, whioli 1)ccointi beilc^r delink ai> Ihe peritoiueum 
is apptv)acho(l. and fnnn an abundant lympliatic plexus just beneath it, 
uhidi in <»{K:t'ially marked on the posterior or Jnle^liiial itnll of the uleriu. 




Fta. 68. — \i;nvot.i« flAXot-iA r»i- Pkmiv.im' I'-ttHiia (Fmnkenlmuwir). 
A, ploxui utcrlnui mn^iu; B, pltrxua hypijigiwirleu*: C, crrvical ganglion. 

The lymphatics fram the various portion)! of the iiterua are connected 

with seipral net* "f e'"nd» — lho«> i>r the cprviv Irrmrnating in the hyf 

gastric glands, which are siiuali-*! in ihi- i*|>ii(t» lictwci-ri thr external ilii 

and hyi>npfl*tiic tirlerivi. The lynnphntics from the body of the iiterni) 

'■re difiti'ibuted to two KWUps of >;lniid->. one set of vi'uscl* makin;; their 

[my to the hypogastric glanJs, wliile another set, after ioinin^ certain 



INTERNAL GENERATIVE ORGANS 



53 



^^B^MicK frrirn ihi- ntiirtuti n-gtun, ti^Miiinntf in lbi> lumbar };laii(I«, 
^^^^|h^ ftitiuiUil ID front of the aoria ut uImuI IIk- Uj\c\ i>{ Itiv lower 
Mtrftimi of Uk- kitliic» {ttx Fig. 57). 

InaerrftticB. — The nerve supply of Uw ntunis is derived partly from 
the ocrebro-fipinal, but priocipally fruiii Itic svinpathctiv ucrvou* xy^tcm. 
Tlio oerefanv^pinal KyHltJin i* n<pnii>'nUil tiy a few flbn» from the third 
ud fourth ucral ncrvcD. and llcrlixka liaii dcnioti^trati'd the prrvcnco 
nf mtvlulhited iHTve-Dbriw in llw uUritu; wall, uliich sliowcd frx-c vndings 
Mwwu tb(! n)UMrlc Hundley. IltiriT xn*! (Uiironj^ky have described gan- 
l^biiniL- n'iln in tlie niuitculariis, and the taltur has lM.vn nblv to follow iho- 
Iblnl ncn't'-tlbn'M into Ibi' i-pilhi'lial ii'IIm i>f \\»- i.-iid<>iiiftTiitni. 

The ;:r«it»T jMirtiifii of the nerve i^uppli', however, la derived from the 

■ymjiathrtic eynlrm. ond Itue bt-ni EtwtinI purlicutarly by Lw, Frntikcn- 

I t^nwa-, Ifeiu, and PifMrmslci. At-mrding to Um- authors limt. mentioned. 

[iugB [HTVtvtrunkH from Dh.' inter-iliac pk-.\ui> pn^ down <m either liidc of 

' tliL* Tirlinn. atid following Itiv wursL* of the iilero-Mioral lif^Hriienls, ter- 

;ailMtt> in tl»e ]arp> cerneal tfanglitin. This »triu'ture was tint diatrovered 

\\ff Ltv; it lim to Mx cmIv of und bt^iind llis cervix, and from it uumorous 

BtrMt make Ihwr way lo (he utt-ruit, as is readily *i'n in Fijt. .IH. Piiwem- 

lii in VMKi miidi- vileniiiTt.- im'i.':>tigaliiin:^ i))H>n tlHi ^ubjwt buM.'d upon ihc 

jnn'ful olitdy of -Vl «|Hi iriH>iis. tie i-oni-luilnl thai the i;t:rri<ial giinghon 

Ln' aiH] t'ranki-Dhiiiwer does not i-xift as such, hut tliflt a larg« plexus 

Iw found im ri(h«r *\Av of tin? wrvii^ whirh hff dvoigiutcd ii» the fuuila- 

ntfutal plexu!^ of the uterus. This id rompnm-d of lirsnelies from Hie scc- 

id, third, and f'lurlh i^icrul iiertcs, as well us otliiTs from tlie hypo- 

K>trie pU-\UA uiul the sytiipaihelic. Small but dellniti: ganglia iin^ pixstint 

thi^ counu. of the iKrvvs, but especially where the various brandies cross 

oj»o»h>*r. 

ETrlopment of the Uterni, — It i-i universally adtnitliil by emhryolo- 

Ihiil I'll)) tli>- tiil<<->^ iiikI the uterus are derived from the Mrdlerian 

Accordiu;; to Ilia, tlu; first .li^im of their developnii>nt can be nott^ 

-'n-D'! having a l«dy k-u^th of from 7 to 7.5 mill i mot n-s. when a 

iiif may Ih- noiieeil in tlH> »eliunie i-pitlw-lium on t)u- ouutr margin 

i-Ji Wnlthau hiiiiv. These (n^dually l»e«mie converted into tno epi- 

diii-l>, whidi coDvergi' and eventually inn'l tugethiT in Ibc middle 

p, ttfrminaling in the uro-g^enital i<inii«. 

The MililemD dnets reach the uro-ffenital sinus in embryos IiaTlnR 

hndy len^h "f 3.5 to 3.5 eentiim-tn-*. Their njipi-r ends fonn the Kal- 

ipum tulBss, whili' tlieir lower (lorlion^ fu-e together to form the nleru* 

nd vagina, lite fusion of the Miillerian ducta is usually Li)uipk>(ed ut 

ilvint tlif lliini month, Ihougli Die point at whieli tlie proeetiu is to occur 

' » iDdJcatcd at a mudi earlier period by the position of tlie round liga> 

nmtv I 

I i.itkrati:re j 

B4Tsa. 7A^ \ih\<4'A. unA pnih- MorptiolofW dcr OckuinnulUir. FVoumI'm OynUo- 
I tmfaMiU Kliiii;.. IHK'., ,Vri>-<Mi:> 

Mi^nvs I'eXtKT liiE Lv-iiiphui-ruM! der weitiliclieB Ovnilaliuii. .\rchiv 1- Aint. u- 
I in.v».^| .Vnnt. Ablital. 18D8. 57. 



locta. 



54 OBSTETIUCS 

CURX. Tt4i ('iiiiH.* HFiil Siloiitlniiiir (if I'Ccrini- HmiinrrtuiKC in Ciuim of Uyonia 

Uteri. Julius Hupkitu IluHiiiKil Butlviiii, 181)9. It -20, 
lH'VELi(«. 7mj Ki-iiiiliiiMi (Icr I'trCJUHU'hlcimfauut. Zdiachr. I. Citb, a. Oyn., 1BH4, 

X, 17S-18;. 
Ekakluas'. Tho Mucou* Membrane of the Ulvnui. Aiiirr. Jour. (.Mist, I87£, vi&, 

:«-M. 
FAKABCtir. iict vniHinsux wii|i;:tuuH dvs or^iuMu ^utu-urinuina. I^ria, tiXkV 
t'isoiEL. B<.'Ll^iiK(^ xur MorpholnKJe tier Portio vAKinalis ui«ri. Arcliiv f. Uyn.', 1880, 

xvi. Ift2-2CI2. 
F»ASKXNHSrBBH. Pii" Nori'cn dcr GelKirmiilri^r. Jeiui. IWi". 
FniKoiJixuBii. C. I'liys. lumt. I'litprsiicliutmeTi iiIht ikii fU-nin. Ltnpitig. 1870. 
Fiiir.iii.li.VDKK, r, .Vbnnnne Kpithclhildiintt iin kiiidlicJicn tTtcniM. Zpilnrhr. f. (tab. U. 

Gyii., 1898. xxxviii, S-16. 
(>Awiii)v>XY. Urlicr Vrrltrcitiuift und HndiKung dcr Nervcn in den wcililtrJicti (icni- 

talioii. Anhiv (. Cjii.. IW-I. xlvii, -27} iKi. 
Ueturr. t'cU-T dua luiai. Vwlmlu-ii der Xor%eu iu liem L'tvruM, etc MiuicJi. nicd. 

WofhniiM-hr., N'r. l. IWrJ. 
HtUiLitKA. Cjuulvd by JwFnel-Wuldoyur, Dan Itvektiii. Bciiiii. 1800. 704. 
Hi.*, Wc uiiiii(imijM.-hi- .Nomciuliiiur. U-ifixijt. IMfiS, 
llonlKiEit. i(!iir KciiiiliiisH ilcr noiniiuk-ii rU'ni!«(.'hl<.-iiiihHiil, Zi'ritiiillil. I. Hyti., 

I8SB, 7a+-7fl6. 
JofiN^roNK. Thi- Mt^nutnial < Ttcnri. lint. (!yn. Jmir., NovciiiIht. IfUHi. 

Till! r'uiK'tioii naii t'iilholu|j^ i>f Ihi: Itvtk'ulur TiBsue. Anivr. llyu. aiid Olut. Jtiitr., 

mXi. ix. 1A<1 I»i7. 
JvNu. Dh- Aiiaiomio uiid PhyHoluKiu dos Borkcnbindi-KewvbMi. in Muitin's Krank- 

hciR'ii dc* Ik'ckcnbindcKi'Wcbtii, IIHM), H9. 
K'K'KH. Dif iioruiult und imtli. l.uiw i\vn ru-piiH, i-t*. Boiiii. 1880, 
Khkitxkii. .\niitiiniii>ch» tinfiTHiichiiiiKCMi iiU-r dii^ MuHkiilitl.iir diT njrbt whvranirvivn 

LiL-bumiiitliT. IVKTsliuntL-r rriwl. Zvifwbrift. ItCl. 1 13, 
I.tK. On the CaiiKlin ntid Oihcr Ntrviiu.i Siriicluivs uf iJie ru-rus. I^nidoii, ISI2. 
Lboi'i)!.!). bit! l.yiii|)li|[L'riuutu dm uuriiiuk'ii, tiii-Ll wtiwiuigc-ruii, irturuH. Anliiv I. 

(Syn.. 1874. vi. I-S.V 
Stiiiiien (ilwr dip l'lenij«chltitnt)iiiit- Ik'rlin. 1878. 
l.t*H<iilU. I)ie .'Xiiuluitiic iUm Itvi-kuut- KuiUriilH^. 1873. 
HACKKViinorr. tlclxir liii? t'riiaehith dcrnonnnlcii und path. Ij^^m dec llMruH. 

f. Gyii,. 1805. tlviii, MX^L'l. 
M»XDi- i'clurr die Hic'hiunK di-r Fliminvrlicwegun); ini menacMiehcn l.'tcmn. Z«wi- 

lrall.1. f, flyii,, imiH, aJ:J-;KS- 
.Mkvkh. L'oU-t die (^lule UlvrtuHdili-iuiliuuL. Zvilodir. f. Geb. u. Uyii., 1898. xxxvui, 

231-240. 
MlNirr. HtuiiiuL Rrnliryulouy. 1802, .'I. 
Xaiiki.. Die tmblichcii Uucblccbuoripuic (tlurdclcben'K ilandfaueb dvr Anatmnio), 

Jen*. 1»SW, H7 !K). 
Paiivi.cm^n. Zur KaiutuiM der luiiittui VLTiiixlerungni dcr Gcbfinuut44.T. Rorlin, 

1H!)7. 
t'iCK. UelxT diis ekist iwlu' tii-ivi'li: in dcr iitirtnid(.'ii luid patli. vi^riiiidi-rlvD Odianniil' 

t4!r. Volkiniiiiu'ji SniTinilimE klin. Viiririi((p. X. !■'.. TWHi, N'r. '2K\. 
1*Iiibi:mhKi. Zur Aiiutoiiiie dea Pk'xiiB (uiidiitnviiUiiui uteri Ix^in Weilw. MonalAKtir. 

(. (Jeh. II, (iyn., 100,1, xvii. .*>2rt r.2(l. 
Pmhikii. Lyiiiphiili'iiK-- tiet otkhuc* ui'tiiliiiix de lu rcmmiv Paris. 1800. 
ItKi.V. Notes mir Ic plexut nervcux (nnduiiicntal de riil6nui Comptea TOndua de l» 

Soc. de fiioloKie, 188'J, Itil. 



n^v 



TUE I'AUXirUX TUBES 



55 



oxi^DtasAiaKBi. I'nfcU d'olMl^triqw-. Ptirt*, 1894, 30. 
HlBjUdrtw. Dm PiuxKipburua. MaHnitg. lOOR. 
B owam. Zui ('•tali-n KntwicKi-luiiK iln* im^tiiM'hliclivn T'lcnu^ FmUrlirift Eum 5(^ 

iifahs<^ JuMftiiii) iltTr (im^rlt. I. (ich. 11. (iyii. ill llcrlin. I8D1, 9-^. 
RuMMMl t.i m. tjuacdain de oviuiis ctulirj-unini vt fot-luuiu huinaiiunuii. I.ipidi», 

ItKt:. 
Bcux. 2»r EraNOMfrBpt- ZcJUchr. f. <m.-I>. u. (!jn)., IStt'J. vii. 23r-'J33. 
JoiArTA. I^hftiurh <kr ihwbiiiiiiU'II f Ipinkoloik', Wicn. IWXi, .*j-M. 
TiRKiiuL Tmit^t ik I'ait dun ■ccuurlii-nii?til^ Ptvris. 1BH8. T. I.. lOi). 
Ym. I'lcnumunkiiliitur. Miillrr'* l(»n<ll>iirh dcr fMbiirlihiilfi'. 1»88. i. 123-129. 
WtnK. U»tn>uchinicfii utirf dk' Kf)Ei-rimitii>ii di-r Sctilwiituiut iiiit'li AiiMU'linUiiriit 
iWr ru!nuk»rpcrtii>htc. .\trbiv f. C.yti., I8!».'i. sli.i, .■«», .170. 
ta I^re von don HIiilKvfiiMcn Art nurniulun iiml knuikun OvIiAriniitter, Jnui, 
MM. 
^Dmi <ind flRv8i>KW. ('nIerMKliuniKn I'lbor tUu Gntivick^luiix iind Mi>r|>hiilo|[ii; drr 

artwbUebLii rienutuiufciiUtur. .\frhiv t. <;.wi.. mw. Iv, .■«.V4J3. 
^luui. Itt-itMgR nir luimulcTii ii. [Nklh. ilwiala^^e dt-r iiicmtc^lii'lirn Cli^ruaiphlciin* 
hML Arrhiv (. Ilyn.. IB7W. xiii, l-.W. 

l^tloKiiiUKl iui rtcru*. Zi-iliirhr. f. (kh. a. fiyn., 18M, xi, 20-88. 



THE FALLOPIAN TUBES 

The Fxllopian or utvriiip liibiw are mow or Ie*s «<onvoliiU\] iiiii.->ciilHr 

whioii extMwl frtiiu llie ult>niM> mmiu to llic ovaritv. '|'ho_v ai'e 

frnti liy pentonipuin and pooECss a lumi-n liuoct \>y iiiucvuh mt-iuliraiio. 

n'pm'*-itl lilt" 

*^rriary ducCn rtf Itn- 

I BTarMn, KM it is thr<iii)!li 

Itbeva tluil Uw rtva caiii 

[•«-^w ti» Itn' iil«'riiw 

' I'V i tj-. T1m-> an- iiiort' 

*r Ibk cfliti<lrt«al in 

A«fw, luil vnrv fnini 

* to II ivnlitufln^ in 

ih. 

Pnr conrenienw in «)-^v~ ..^fc. ~^tf •* LiK.'^TI**. "Mr ' ♦! 

■l^-TiiHir-D. Mich tu)ic *^MjiK^^^%:^^>^!k^ ^W 
iM.T hr divi.lM] into ,S ^^^'^Wfc.Tig:.?tt'::^T ^- » ,j 
■""11 finrti) — till' nliT- 
[Nirlinn, ikilimiiK. 
Pulln. ami inrnn- 
'^''-iIuHi. The nler- 

■- ■ :■ - ■.,.■,.1. 
"1 r 

**" of iJM- ulproi), nml 
•^I'tuli fnini till- for- 
■**" Itu- tippiT nnple 
"' '' 'H' rsvilv 




Fw. M.— Tmui. UtvoM. X 290. 
Tu fiimrn is so >inall that it nilt admit onlv thi*' 



Tlif iilbmuA i» I)r> iiarmu' jiiirliiin of llif IuIh- iiiiiiii>ili;iti>ly 



56 



OBSTETRICS 



«'lj(>inin^ Ihc uterns. an<I frradiialH- piiKws intf) Hie wuler IntrrnI pnrtioT 
or iinijiiilhi. Tin- infiiniiihiilum. or limliriiilfii I'Xtrtdiilv, is IIh' funiiel-j 
s^hapcd ojwninK of ilii> intcral fiiiil of tiw tube, the margiits of whiclj 
{)rUM.'nl u dvntak- uppoartiiicv (mv Fig». ^S to 45). 



^ 



,_/>-L::^ 






L. 



aa_ 



FiK. eo. 



1^-. Ill, 








Fita. fll>-it£ -^cciui.sH TBBuuuu I'rciuxi;, IniiMic, jiHtt AMrLLLAU I'UKTiwn or' 

XIO. ' 



TBE FAlXOriAN TUBES 



57 



^ 



Tbi> tulw vnritft ronvidrnilily id Ihicknuse. tin? narmn'p^t portion of 
(In- fliitnus iiK-iiKuriii^ frmn 2 Ui -l millJini'lni*, iiiiil ilio wiO<vl [Hirhoii 
of the ampulla from ft to 7 or S millimptn-s in diamekT. 

With tlw cxivptioii ut it* uli-rinc portion, Uw IuIh'. throughout iU 
eatire leflfcth, in iiK'liided within the upper luar^n of U)o hroad liguinf^nt ; 
It is iTjnipli-li-lv I'urTmimhfl hv ]vrilinin-«in except Ht its loui-r |>ortion. cor- 
nwpiinilinir lo ihi^ iix-s<>^alpin\. The tinihrintLi) i-xtn-iiiiiv opnis fniOj 
into tbe abdominal cutity, ami om- of it* fimhriie — the firnhria ovarira — 
whtrh i» confitk'rahlv i«ii)i;er than Ih*" othi>r«, forma a wiiallow gutter uliich 
extatiLt alninst or <|uite to the ovary. 

Itrnvrally upeiikin);. t!a- niiwiihiliin- of the hihe i< urraiis^i] in !«■© 
layer* — an inn«r, rirx-ular, and nn «mt'-r, loii^itmhiiitl lavi-r. In ii!i iilLTine 
portion a third Uyer, tyins Iietwccn llw circular lawT and the mnc««a, and 
<viinp<Ktvl "f lonffiliuliunl filin-^. ina.v W dii>(ingniHli(it. In the Inri-ral piir- 
tinn »f th« tuU> llio two pi'tniary lovers bi<coinc le^i nmrkeil. and in the 
Di-ighlxmtiiiuMi iif tin- tnnhriiitid e,\livrni(y iin- replui^il hy »n inh-rlat^tng 
ih-lvork of muKi'lf tlhres. Ilin writer wa;< the firnt to laill nttenlion to the 
pTCBcfice of thf iniwr Innpludinal lartT in tlie ntirrino portion of thi» tubOi 
mnd hin nlisi-rviitionK hnvt- heen cunnrnxil hy Rallanlyn«, Maixll. (Irusdew, 
It«vUin;.diau^'u, unil i'ick. 

The lumen "f the luU- i» limil with a mnwu* mi-mhrnne wlio-*.' .jiiiiio- 
iiUB is RHDpoMxl of a sinsJe layer of high, columnar, ciliatw! eelt*. which 
i«n upon a thin lMUk>ni<'nt m<'ni1)riiNc (Kig, SB). TIhti* is no Mihmiu^oxa, 
Ik' •'pitlx'liuni \te\ag B«-[)arahil from tlie nndertying muscle hy a layer uf 
'"onn'In* tifwoe of rarying tliicknesii. 

'rill- mucosa in amn);)-!! in fold* whirli Iji^-ome more romplicwicd ati the 
iImI eixl is approached. The appearance of the lumen varies an.'ord- 




Tta. as.— I»MaiTr»iKAi. Fot-fM or Tviiai. Uivtim (oftrr Kap|iPr>. 



Kfl Ui i\» [KirtioD of the tidw cxaminm). in the uti>rine portion four 
4entio«U arc wi>n. wUirh {oj^iImt make a figure n-'iemlilin;; a )[iilli-<e 
taat. In the isthiiiic porlimi »f the (hIh* n tnon- eonipliezitiil ii}i|>i-iiran<« 
•u he notal; whik in the nmpalla the lumen i* a1n>o«t eouiplelely ocen- 
|rinl Itv Um- ari«in^«eent mueo^a. whieh upon careful culmination U Mi>n 
b !■■ mad*- up of four Terr eomplieul'-d tnt^like fntd*. 

FiH- 113 rfj>r>'*iit» a hm^iludinat -action throu>;h t}w luhe, and givis* a 
ITkHJ iit.-.i .>r tilt! increaaing complexity of its fnhU, 



5S 



OBSTETRICS 



Till' stiitcmonls of Hcnnip and Blaml-Sutlon tlint. (he tiiW 
g)an<l8 Iiavo since heca found to lit" erroneous, iniuimiich ai« the wtnie- 
tiircs, H'liicli lln"_v eaiisidiTi'ti ii> sneli. niv mi-ri'lv <li'|)rti»sii>ii« Ik'Iwwii 
fokia of the iiiuioHa. Tiie absence of ^^landr^ wtn rani.lt(«iv'cl_v ilemoii- 
etrated by Froniinvl, vrfao Aowed (hot thv glniidular a|>pearsTic^ dteup- 
Iiciiroi! M'ii<'n Ihi' lulu* wa.i iiiarkciily distindrtl, am! Ihal Ihn gr<aiU>r ]»iir1 
of iU liiiiH'U becaiiu! porfcclU" spioolli, wilh four arboriieceDl foldi- of 
niiteoifu iiriNin^ rroiii its Htdtv. It i* inU-rtsiiiri^ in imte Ihiit. Niti.inv not 
infitxiiicntly (iiTfornirt a similar ejtperiinent in caitcs of hy»lronalpinx. 

The current pi««l«eeii by the ciliu of the hihe is directed towards the 
iittTiis. an WHi* riiiirlii«ivety <l(>iiioiif.tralii! bv tin- i'\|H'riim-nis nf dinner, 
Jani, and Ivoile, wiio showed llial foreign IkmUcs injected into the ab- 
dmiiiiud i-divity of FiiiiiiiiilH iiiaili- lliclr way iiiln llie tiilie* and wcrv ^adu^ 
ally carrie<l liown into the utcnis anil thcnee into the va);ina. 

The liilitjK ure richly sii[i|ilii'd wilh IiIimmI-voto'i-U and lyinpliuticii. nw 
tin- latter n"t infreipi-iiily iHMonu* so dilaleil as to fill up almnstt laitirelj 
ecrljiin fold* of lli« nnuinn. 

Oopasionally, as Itielinrd Hrsi, poinlcil out, the tidie may poawj"* • w< 
Olid fiinbrioted cxtri'iniLy, wliidi is kiionii us an aeceswry wtiuin (Fij 




Pra. H. — Tt'BR 'Dint AecEwwRT Ornm. 

M). Again, not inff«|iienlly small tube-like Btriieture*. with miniature, 
limhriatt^d extnrmilitw, are found prrtjeetinp from tlie exterior of tlio tul>e.J 
A» a rule. 1111*0 are mere cutx-ilesiir. but oceasionally one i« met vfitli |m» 
sessin^i a lumen whieh connnunieates with that of the main tulie. Heiiixilii: 
and llerjiojf have lalily r<')>nrlcii a rtw of ovtni-iiteritie [m'^nniiey in uliiell 
tilt fertilised nnim liiid been anx*tc<l in sueh a stnieliire. 

Sitnilar format inn* are fri>*|uen(ly nhsi-i-vcd iijinii the anterior Aurfar 
of the mesosalpinx, but have no mnneclinn with the tul«'. 'Hiey liavt 
IktU studied more |inrtii-iiliirly by Kiwsiiuinn, who dcsipnalfi them 
ari-exmirii (ii/ic*. 'I'hey are proluibly derived fi-om abi'rrant. portinnx »f tbdl 
eii-lon)ic epithelium. 

In very exeeplionni iiiMlanii^ there may he two tuhnt on one sidej 
Itiib havini; reportetl two eases of his own, to};dher with Ave otlien «>1- 
IiiIihI frmii llii- literature. 

Diverfirtila may oeeasicuially extend from the lume_n of Ih* tulio foi 
n variable distance into it* muKeiiliir vaW, nml reach aliiiosl to its peritoneal' 
coverinii. Such stmetiires were first dt->eril>ed bv Idindau and liliein.i|i!iH 




THE FALLOPIAN TUBES 59 

iikI ni.v.'«If. The suggestion that thvv )iiij;ht jilay a part in the prnduction 
n( tubal pregnancy would seem plausJbk'. inasmuch as a fertilized ovum, 
which might eliance to make its way into such a divcrticuiiim. would be 
ambled at its tip and there develop, if suitable ponditious CAJstc-d. Similar 
I'lnu'liirts have also been described hy Uenrutin and (ioL'bel. 

la rare instanceti the main caual of the tube may brani^h, and two or 
WHi three lumina may be seen in sections. After extending for a certain 
diilanrc, more or le^ parallel to the main lumen, they usually rejoin it. 
hrbould always lie borne in mind that such ajijicaranccs arc usually due 
to the fact that two or more twists or Iwnds of the tulw have been includeil 
i" one section; although in several instances, by the use of the serial 
Mhoci, 1 have been able to demonstrate that more than one lumen really 
wt^itil. 

In the ni'w-liorn cbihl the tulnw are markedly convoluted, and pre- 
**■"! a c'irks<Tew-like ap|K'arauec, as shown in Kig. 4'^. This gradually dis- 
'CFt'ars wilii age. but wcasinnally tile fteta! condition persists and may 
r^y a not unirii[>iirtinii jiarl in the pRMimtion of sterility and tubal disease, 
*>was first |ioinied <mt liy Freund and Scbolwr. 

literati;re 

B*B. Ti-lwr DiiplidtiiH fiiliae Fullo|iii. .\rchiv f. Ciyu.. lOOfi. Uxviii, .131-401. 
"'Luavtvne uiid Wti.UAUH. The HiKt(il«Ky and Piithiilony of the Fslloiiian Tulies, 

Hrilioh .Ueiliral Jfiumal, Januar>- 17 untl 24, IWIl. 
rtcfjiu t'l'lier die Indicufioiien zur tipcrutiven Hctuinclluiii; der erknknktcn Tulien. 

Viilkniann'H Sammlung klin. VortraKc. IH88, Nr. 3'2:i. 
'*'>*«jiEL. BcitriiEi! ^(ir Histologic der Eilcilcr. Verb, der deiitsrhen (icsell. f. fiyn., 

'""ehEL. BfitraK ziir .4n3t«tnlc und Aetiolf>)rie dor (inivlililuN tiilJiiriii, ctr. Arrhiv f. 

<i>ii.. IWIS. Iv, ft.T«-7l.'l. 
'■"'■»*iiEw. Ziir HiHtoloKic (ler Fallopju'whcn Tulion. 7.[-iitralhl. f. <iyn., IS97, '^riT, 
"'^x?i(ni. t'elier die Klindicaiige der Eileitcr. Ar<-hiv f. (lyn.. 1H7». xiii. l.W. 
"cNhiitin ct Hekxoo. AnonialicH du mnul du Miillcr, n>mmc i^aiiw dCH gnwwKHpK, 

«c('>pi<|iH-H. H<5vue de KJ'"'. l***"*, ii, G.l;{-t'j4!). 
"'St. 1'eiH.T da« Vorkomnien voii TnlHtrkt'lliac'illfn iiii )te"i"idcTi (ifiiitak{>|iurat l>ti 

LunitenwhwiiidBUpht. elc. Virrhow's Archiv, cili, .5'J'J. 
"''»*mnNT«. t'fber arccsBoriiiche Tul>eu uiid Tulx'iioslk'ii. Zeitmlir. f. Ciclj. u, (!yri., 

m». Txij. 2.W-2fi8. 
I^^IiAi- und Rheimwteim. Bcitragc ziir path. Aiiatimiic d<'r TiMh'ii. Ari'biv f. <!yii,, 

ItBI. Jixxix. 273-290. 
I^***. H%p. Hfitrnge lur I*hre von der Waiiik'niii}; dcx EifB voiri 1 Ivariuin ziir Tnlie 

Archiv f. Ovti., 18!M. xIv, ■JQ.^-:r24. 
"andl. I'cher den (eincren Ban der Eildtcr, etc. .MiinalKschr. f, (iclj. ii. <i_vii., 18117 

v, En&uizunKH Heft, 130-140. 
^<X Ein neuerTypuBdes volumin'iBcn paroophorjlen AdcnomyoniH. .\rchiv t. ''i.vti., 

1997. hv. 117-206. 
PiVtwt. ITebtT den Eintritt des EifB aim di'tn Ovarium in die TiiIk', ct,'. .\rchiv f. 

.\nat. u- Ph.vit., Phymol. Abth., I8S0. 241. 
SersuscBACBKN Die Adenoinyonie und C'yHtadcniuiui ilcr I'Iitiih- mid Tuln'ti- 

vandunft- Beriin, 1806. 
BscEAXit. PaviUona muitipli^. Gaz. M6d. de Paris, .\i>. 20, 1S51. 



60 OBSTETRICS 

ScHOBEH. Ucber Erkrsnkunsen gewundener Tuben. D. I., Btrasabiirg, 1889. 
SuTTuN. Glunds of the Fallopiun Tube and their t'lmctioD. TraoB. Ix>niloD Obst 

Soc, 1888, XXX, 207-213. 
WiujAMs. Contributioiut to the Normal and Pathological Histology of the Fallo[Hai 

Tubea. Amer. Jour. Med, Sciences, October, 1891. 



THE OVARIES 

General Anatomy. — Tlie dvarii-s aro Iwu flattened, more or less almond- 
shaped organs, wliosc chief fimction is the developtiient and extruHion of 
ova. Tli«y vary considerably in wize, and during the childliearing period 
measure from 2.5 to 5 centimetres in length, 1.5 to 3 centimetres in 
breadth, and O.li to 1.5 ecu timet res in tliiekness (sec Fig. 45). After the 
menopause they diminish markedly in size, and in old women are often 
scarcely larger than peas. 

Normally, the ovaries are situated in the upper part of the pelvic 
cavity, one surface of each ovary resting in a slight depression in the 
upper jiortion of the inner surface of the obturator muscle — the fossa 
ovarica of Waldeyer. Witli the woman standing, the long a.xcs of the 
ovaries occupy an almost vertical position, which become horizontal when 
she is on her back. Tl»eir situation, however, is subject to marked varia- 
tions, and it is rare to find both ovaries at exactly the saihe level. 

Each ovary prcs<.nts for examination two surfaces, two margins, and 
two poles. The surface which is in contact with the ovarian fossa is called 
the lateral, and tlie one direclcd towards the uterus is known as the median 
surface. The margin which is attiichcd to the mesovarium is more or less 
straight, and is designated as the hihttii, while the free margin is markedly 
convex and is diR'cleJ backward and inward towards the rectum. The ex- 
tremitii's of tlic ovary aro termed the upi»er and tower, or tubal and uterine 
[Kilcs res [Hie timely. 

The ovary U nitaclicd to the liroad ligament by the mexovari-um, which 
forms Ihe posterior leaf of tliat structure. The oraruin ligamenl extends 
from the iaieral and posterior i>nrtioii of tlic uterus, just liencath the 
liilial insertion, lo the uterine or lower pole of the ovary. It is usually 
several ci'nti metres long and 'i to 4 inilliiiictres in diameter. It is covered 
by jwritona'um, and is made up of muscle and connective-tissue fibre.', 
which are continuous with those of tlio uterus. The infutidibulo-pelvic or 
siixpenwrt/ ligaincnl of the ovary exicnds from its upper or tubal pole to 
the p<'lvic wait. It represents the portion of the upper margin of the 
liniad ligament which is not occupied by the tul)e, and through it the 
ovarian vessels gain access tn the broad ligament. 

For the most part the ovary projects freely into the abdominal cavity, 
and is not covered by jicritonienui except near ils hilum, where a narrow 
band nuiy he oliservwl wliich is continuous wilh the j)eritona;uln cov- 
ering the mesosalpinx. It follows, therefore, that over its lower portion 
only can be noli-d the glisli'iiing up|iearanee characteristic of peritonieum, 
while the greater part of its surface is of a dull white colour and looks 



THE OVAKiES 



61 



Thu Jwtlru^tion »a.>< <iiHiiiToivt! by Farre, Iiut it* iiiijioruinci' wa» 
I (uipliAf iziil tiv Walik-VLT (I'i;:- <1), vrlto litiuwdl llinl iIk' ovarv abovi} 

IIk (•'nlnttiuil titii! Vin* (■i>v(,'n*ii dv I'ulxitilal ■■|iillioliuiii. 

lu UKUif ot tlw lower animals IIk: uvarv i1(h» duI projetil freely ioto 

ll» d^Mitinal uvitv. but i« niorc or \v*f Liitiijili.-U-ly iiK-t<i»ttl in a pch- 

MmI ttc.'. into whlelt ngx-iiA (be fltnbrJati-d end uf tbc IuIh.'. In Tbe 

mf, <k^ und cat itirrv ie niorc or b-ss friT ("uiiimiink-atioii bi-twvvti tbu 

Iifimuid []m; jx-rilDiuuil cavity. 

Thi- r.Tlvrior tif tbe uvary rurie?! in ap[i(.-ara]]cv acroixlin^ to tbe age of 

thtuhliitilinil. In yiitiiig womiii tbt- organ {irvx-rilH u iiriiuutb, dull trbitu 

tatfarv, tiiniii^i whicb glisten u nuinl)er of Mnnll, clear vn^k'leH — tbc 

I'iMllnii fnllicbw. An tbe winiiiiii x""** 'iMtT it tjikiw on a iii«rc «or. 

npirA a[>|ieamiH-c', vbieh in the ajjed may Itecoine tu marked ah to be 

..—,-. ,.|. „f (|„. iiiiiYidiitiniw of llw! bruin. 

."Heral ntriieturv of l)u! ovary can bvnt In; MndW in eroAS^MC- 

iMi>,iilit'ii lb« i>r<;an i> m-i-ii to U- muib- tip of two portions; tlie corlvx and 

(nlitlla, (ir iMiua [Ktrt^nibymatiiMa and 

Mk iwK-nlfva. Tbc cortex ur outer 

Imrtaric* iu tbtckniSd according t"> tlie 

V*'Oir in<lividuul, bm>iinn<; IhinmT 

*tA Mltauiiit;; yi-arrt. In Ibi- layer Ihe 

*• UmI (iniafian follirlu; are ^iluati'd. 

■I >• cnmiMH^l of Eipindlt.'->dta|>ed (^olln«c- 

ll•^lilMr «>ll». ibronffb wbirli are «aU 

■•n4|niiwinliiil and (•niatian bdlicbs in 

'•'wi* (Wp!^ of develop II lent, a'bioh bc- 

"«t IfM iiumi-Ttm'* ■>■ ibe woman grow* 

'*fc'- The moi't external portion of the 

•" I - a dull u'btti>b ap|>i-araiii'i', 

* :\-t\ Air llw iilbii'jinti, tboii^b 

* '• Mil nniilii):<>its wilb Ibe Himilarly 
'Jn.il -iniclure in tbe tcBtiele: on itjj 

A *ini{k- layiT of rutHiidal i>pi- 
'*'i'iiii~lbe niarian i^pitlwlium of Wal- 
irut, 

"<i or cvnlral (lortion of the 
•■- .- ...i,i|H>iiafl of liKxie (i)niiis'tii'(j 
'"■■ti vhieii is eiMitinDons witli Ibat of 
^ IT), It umlntiin Iniv Uitiii- 

*"' ■ .-v*»ipiol''. bolb arteries and 

"»t; mil. ocroniin^ t" Hi*. Ktillitlter, 
■"'■' ''■ • '^-''t, a (finf'iilerablc number of 
I'd uiUM'b'- tiling, vr)MM£ pn's- 
«1 lln- 1a-<l-nunH<il ol*^ei^er 'to 
i>ng IIm- enx'tib- ti>»ite». Tbo arriinjn-tncnt of tbe Mnnd-vi-iwdH 
™'«Tii •tudi'-d oxiiaiictively by Clark, to whosn admiralde nionn^^rnftll 
■•■ *<>\ I' r, fi r ;liiw<' inti-n^liii in Ibe i>nbjivl. 

" I j! '<iurhood of tbe bitiuiu one occasionally' abwrvcs small 




F)ii.iUl — (?«(»«•-• i: I TioN Am LiOruir, 

■BOWtMililUArll.t Fou.KJJJl. X I. 



62 OBSTETRICS 

collections of epithelial cells arranged in masses or strands, which an 
fharply marked off from tiie surrounding stroma. These are the medullar' 
cords (Markstriinge) of Iviillicker, who believed that they represented por 
tions of the Wolffian bo<ly which hud become included within the ovary 
The investigations of Coert, Winiwarter, and others show, however, tha 
KUeh is not the ease, hut that they represent the remains of the first prolifer 
ation of the gLTininal ejtilheliiim, and are anahigoiis to the Keminiferou 
tubules of the testicle. In fu-tal life the lower extremities of the mc<dul 
lary cords develop lumina which eventually eoniniunieate with the tubule 
of the epoophoron (rete ovarii) (Fig. C!)). In the female this is only i 
transient phenomenon, while it persists in the male and affords a satisfac 
tory explanation for the employment of the Wolffian ducts aa efferent chan 
ncis for the testicles. 

The medullary cords are rarely found in (lie ovaries of adults, but ar 
present in those of young children and erniirvos. On the other hand, the- 
are persistent and characteristic structures in many of the domestic aoi 
mals. Occasionally short tulies or duels lineil by a single layer of col 
umnar ciliated ejiithelium are found in the medulla of the ovary in tb 
neighbourhood of the hiluiu. Their significance is not clear, and it i 
not known whether they rei)reseiit remnants of the rote ovarii or of thi 
Wolffian bodies. 

The uer\es of llie ovary are derived in great [rart from the sympatheti' 
plexus which accompanies the ovarian arlery, while a few are derived fron 
the plexus surrounding the ovarian branch of the uterine artery. Thei 
finer anatomy, after they enter the ovary, has been studied by nuinerou 
investigators, among whom may be mentioned Von Horff, Oawronsky 
Mandl, Winterhalter, and Vallet. The consensus of these researches show 
that the ovary is very richly supplied with non-mod ullated nervc-fibret 
which for the nuist part accompany the blood-vessels, and are merely vas 
cular nerves; whereas a few form wreaths around the follicles and giv 
off many minute branches, which have been tracwl up to, but not through 
the meml>rana granulosa. 

Elizalicth Winterhalter has described a collection of ganglionic celh 
in the medulla of the ovary wliicli she designates as the ovarian ganglion 
She lielieves that these cells play an important part in the production o 
menstruation, although the majority of investigators do not share hei 
views. 

Acceuory OvarieB. — Wnldcyer, in 1S7(>, directi^l attention to the occa 
siimal pre.*('nce of accessory iiodics which are sornetimea found on thi 
hroad ligament in the neighlwurhood of the nmin ovary. These structure 
arc usually small, although in rare instances they may attain a consider 
able size. Occasionally they result from faulty development, but mon 
frequently are to he altrihuted to infiammatory changes occurring durinj 
fo'tal life, as a consequence of which small portions of the ovary havi 
been cut off from the body of the organ. The subject has been consid 
ered in detail by Eng>lroiii. Tliuinin, Seitz. and C'hiari, and eases havi 
been descrilieil in which there was found a typical third ovary cooncctet 
with the uterus by a separate tube. 



TBE OVARIES 



63 



» 
I 

» 



GE.. 



PO.,.. 



0.-^ 



— AW 



TnupluUtioD of Ovarie*.— Expuriim-ntal shidiw unil«rliiken hy Grt- 
ptrir*. Morn-, Kiiauor, aii>l oilipm Imw hIioh-ii tlin( the- ovHrk>» of animaU 
■nl »i"nii-ii nin_v lie I'XtiM-il from tliHr ori;riiiii! [xiHition utnl lnin<ipla»t(.-(l 
tuirth'-r |iiirlii>i)i> of llii- ImhIv, »ti<l lltat iti Ifioir new iiiliiali'iii Ihoy can 
nUMub vawiilar connection!* am) cuiitinui' tl)i;ir futicti^tnn] at-tirit;. Vreg- 
uatf has rvpcatnlly followed such ofM^ration^ in animaK nnj Mnrm 
dthi tiul It iiai' «n-ii (xvtimil in wrnn^ii. 

bternal Secretion. — fmni t)n> lime lli;tt Itrou-n-S^innnl jiuMiKlKi) hh 
•Igilir* <i}Hiii llii- ecicn-lion u( lliv tcsliclt«, it iuua btxu more or Ichh geuor' 
lUjr Mii'rM that th« ova- 
Ml liki-wt!« olatKinilc a 
Mwvtial anul'ijfiiux {iniil- 
wt, vhidi ptnrt an ini- 
fwtnl part in llu- fi-niali- 
■"■mBy. Indeed, the work 
*f immv, and Miiiwil «»<1 
Bfiipr rcndi'n it (trahable 
lUl thtt Mx'n-li'iii t* ili- 
wllj ooM^nuxl in niain- 
iMmx (hi- integrity of tlw 
''IxTKniuativi' or^an?"; in- 
•lowiiw they Ikiv«! >lH>vrii 
4il ilnphy of the nteruH 
Brinftiaa niiiiilly fiJIown 
Iktramal nf llio nrnri*^ 
**«»* this dm-* mit fx-- 
<■ •fcm the oviiri>r« aro 
"■wii from tltcir nor- 
■il luiilinu anil traiis- 
Huhd tn (ithur |H>rlion'' 
rf IW l«.lv They thi-re- 
'w^mclude that in mivU 
"^ Ur ahMmiv nf atm- 
f^ iniNt Im! Bitrihiitetl to 
"■a^aiti (if ihf inli-nuil »cen-tion nf th^ lriinH|)liinliHl ornrift*, tiinta nil 
•"^i' iT«iiM'iiriiw were K^ereil at the time "f ojH'ration. 

hanLp) m I'.'^^t, a* the ix^iilt of iii^-nioiiK ■•\]MTimentK and cliuieul 

^ *lale<l Uiat tln! iuteroa) eecrfiian was cJalmmted in the corpus 

■*••; (lirint^li hiH teaehini^ have not (itihiini-d {.i-ni-rnl iHi-eplann'. Upon 

*» iAtu- i* loiM-fi ihi- l)ieni{H'ulte apjiliealion nf lahlels (t>iii|to>4eil of ^i'*' 

"W"! tij-ij'' fi"(ii lilt' i^'niirv ovary or w»h')y from the eorpiiii luteiiin. 

SnelopmeBt of the Ovarjr. — An accurud- idrai of tiie Htruetun? of the 

^»J r%a \w ^inn! only DmtUKh tlie Rtiiily nf its dmelopment. To 

r wi- art' imlelilti] for miieh of our kitowhilfTf mnprrning t\w 

tliDi^!}) im{Hirtnnl pn-liniinary wortc hnil Ufn ilone hy Valentin 

iif PfinpT. 

'" '-?rt. Waldeyer pablitlied his inonoproph upon Hw fh'ary and Oinm 

-. uiwi V.i), orliirh wiik \m*ti\ in gmt pari npnn tlie emhn'ology 




t'i<i. (18— i*K<-n"i iiiwni'uii V/nt.mitii RnnT-Axn Rs- 
■ >l\MMil OfA-HV ANu Mt^M.»J:lt.'>i l>l:it (Waldfywr). 

X ino. 

•1.tf'.,abikiniiti>l wall ; l?./r., sfniinitl ppiihrlitiia : V.O., 
bt^iuiinie UQIIitHaii (hirt ; fi.^ t^^iunljiy; ovary; i*,0., 
tiritUMilUl irra; W. H., WullTliUk tioUy. 



64 OBSTETRICS 

lit llie cliicken. He founil tliat liv tlie fmirOi day of (levolo|)meiit the 
[■ii-loinic opitlidiuin f<)veriii}; tint inner Hurfai'e of tlie Wollliau IkmIv is dif- 
ferentiatwl fmiii the surround iiif; tissne, ils ci'lls Ixx-omiii^ larger and more 
(-nboidal in stia|H\ and uonic of lliom nsuuming a considt'ralile wize. Within 
a short time th(! cpilhdiuin prolifi'rat«M to Biich an exttmt as to form a 
dJKtinct clevulion, whioh indicnios the sitnation of the fiilnre ovan- 
{Fig. 6G). This ppitheliiiin Wiildpyor dtisignaicd i^s gmninal epilJieUiim, 
and tlie large, rlcar cells found within it as priniortliul ora. As the pro- 
liferaiiim continues, a niafs of cells is formnl consisting of large pri- 
nionlial ova and smaller ei>ithcliiil cells. By the upward growth of the 
eonne<'tive tissue and hi oik 1 -vessels from the WolUiun body, the epithelial 
masses heconie divided into smaller (Mirlions, the MO-callod ogg-nestn or 
I'fliiger'H lulies, wliieli in turn heeome broken np into smaller and smaller 
masses, until cvenliially isolated primonliat ova arc found which are snr- 
rounded by a single layer iif inorc or less flattened epitheliliiii. Theije 
veprcscut the primordial follicles, 

Wahleyer in IJ'Ol, however, stated that the proeess was not so simple 
IIS he had originally liel irvcd, and the work of Xagel, Wendder, Wini- 
warter, and Skrohansky clearly shows that in the liighcr animals, at lea^t, 
the prneesa of development is quite different. 

In either sex, the first trace of the sexnal glands is found in a thicken- 
ing of the epithelium on tite inner surface of the WollTian lx)dy. Tliese 
primitive sex cells rapidly proliforale and give rise to a distinct elevation. 
which is made up of closely packinl undilForentiated epithelial cells ami 
covered by a single layer of euhoidal cells arrangiHl perj>endicidar!y lo the 

surface of tlie mass. The lat- 
ter correspond lo the future 
V-v''*, ovarian epithelium and take 



■^r^i^^f 




lary portion can Im; distin- 
F,«. C7.-SEX Gi,AN,. OK P,.i K»«Kv,., 1.2 CM. Piiisheil at an early iH'rio.1. 
MiNo (Skrobaii-ky). Tlio epithelial cells simn Ih.'- 

come hn)k('n up into irregular 
masses hy the upgn)Wlli of ifiuneclivc tk^sne, hut have little or no eon- 
ncctiim with the surfai'c I'liitheliiini. The most di-cj>Iy lying cells do not 
hecouie diircn-iiliah.'d, Imt c\(i-iid liownwurd us the mwlullary conl.i. The 
nion.' sujicrlicial wlls, however, conliiiue lo proliferate, and soon slioM- 
signs of diffeii'ntialion, which prognoses from lielow upward. Many rc- 
fain tlii'ir originul ap|M'arance, whili' in others the nucleus Iwconies larger 
and clearer, and ils clirnmnlin iiri'iingeil in a difTereut manner. These 
latter cells are the oogonia. fr'nti which the ma are to !«■ develo|>iKl, 
After a certain iMTiml tlu' oogonin cease proliferating, and the result- 



THE OVARlI-ii 



65 



' rA\* biwnaie Inrtfor, anil Uieir Hiiviinalin nniWrgm*' n scriw ot mm- 
pintui r\i»tigvs, wliicli iTcntiially ItraiJ tu Itic Tonnaliun of Uifl n>tu'ulali>tl 
si>cl«Di <i( (!)<• primonlial ovum ur imovI*! of llir l!i>l onlrr (l''ig. Att). 
tif the ci>nliniu-<| },'riiu-||i of cnnnix-tive 
""Uf tlie muw*'"' "f CKx'vlcjt nml muiilTfr- 
[''Utialid »|iilht-Uiil rwlU bepoine still fur- iS^r ' *. 

^I&br lirokcn np. hi lluit i-Twituallv wwh 
I'liiihlM 111' a single layer of 
-, lliu* giving riw lo ■ jiriiiior- 
F**) fiUiiJe. 











-v 







.'"."a^n*; ^' **" ''"'i 



kA — l>M «A nr f*iii li>ia>n>, BniiwtKc Ukii- 

' 'I ■iKi.ii-M. I'n.ioKK** Tram ari-m 

V«B(iii'a i^«u>M iir licVKuir- 

.1-1 i,.v). 




t'ici. Oa.~Ill«aK&ll alK>«rts« KOMIU- 

TKIK Oir IJVAHV (Willl1l>r(i>r)t 

Ip unrrniiaul ^iHlhrliuiti ; 2, tpmii IuIh*; 
\ UHxIullary cuni; -i, ivut iirarU; 
A, i-imuptiutan. 



_'n>«l l)M-t*> i* no <:M>itliiil ili(ri:n-iuM> U'luritfi Ui« lUfrfn-iitialiil iikI 
t»mmti*Uf4 t»^l\» is nbovn Uy the fact that the ce\U of Ihc mcilulUTy 
• hiili lire lif Ihn lalttT ri)rii*lv. iiuiv 'Ifrrlnp into lv|)i<'iil ixK-vti's; 
I (be*. luri*i*Ti-r. i]«) iHil )tl\e r\m.' to iiritnonliul follii-los. Iiiit ilfi^'iu'rutt! in 
l^x, It wrtoM Ilian ii|it>i-nr Hint tin- |inni»nliiil hvh iir ixii-yli-* ili> nnl 
■lop from ttu> furfai-*- i-pitlH-liiiin, but ratltcr frou) lltu uutliiTcri'Dliatal 
■if Un' prtinitivv tviual gUuid«. 



OBSTETRICS 



This prwft-d haw Ijwii obserTwl in i-uhliilK, pifju. ami human lieii 
all rweiit invfHtijjnton.. F»r full information l!m stiidcnt is refii 
thv works of Wuldeyer, U'iniwarliT. mid Sknilianskv. 

'I'ht' ovnrv, Ihi-refcim. in iu mrlie^t kIji^w, ciiiisiicte of tiro la^ 
singlf layiT of giTiainftl epitlielJum covcriDg an iiniUTlyinj; l-oii^ 

ti^ue (Fig- it). 
man Ix-ings thi? fo] 
of oocytes ceaMs 
birth, hut in tnmo 
lower animals, esped 
the Iiat, the promw 
continue throu);hout 
At l>irth iho j 
part of the ovary o 
of tlio cortex, wli 
mnde up of closely 
priinnn!ial follicles, whitrh aro separated froui ono nnoOii-r liy v«i 
huntl^ of cfinmrtivi- tiivuf. allliouph occaiiionally small in^ups of ( 
may be in direct conla<-t (Kiji^t. Tt nml 7^). At this |K'n(Ml the I 
of th« ovary is covered by a single layer of cuttoidal epithelium 
ahaws no ninni* of proliri-rjillon. 

All aulliori til's apnv Ihst llic oocytes or primordial ora are dmva 
the germinal, or sexual epiclielium, hut there is still (vtnKidernblo (Us 




•** 



^:^'-^>fi^ 



Via. 70, — Smtiok Tiniocoji tiik Otakt or a Via 
Lnurto (XbcpI). 

O.B., KDmiiuil rpitliPliuni; X., itruniu tit Wiilffiiux Iwily. 




as to the origin "f the fpitheltHm snrroiindinp tlieni. Aecording 
Joyer and Ihe majority of otlier ohBcnvrH, the folHrular rpitMi^ 
derived from the cells of Ihe germinal epithelium, whidi has not bii 
vcrtud iuto oocvlen. Kolli<;ker, on the other hand, helieved that il 



THE OVARIES 



67 



~pjSni«nin» of llio Wnlflian Iimiicn, nrnl ttuil liu- im-.ln!Uirv 

I'di Uie ailitll (tViiry rip|ir»i'nli->l jiorliiiii* nf llic Wiiltlian IxkIv nhich 

'*yt utt RliliiH.Hl in lliii' uny. F<nilj», in l&'S, ataliil tlint llto Hn-rjillifl 

tWlloitar f^Mttielinm was ck-rivtid from (he TOUu«;livi- tU«ue of tlw ovary. 

|*nrflV-im-nl stndm of W«i«M«'r anil (Mark would «iin in omfirm this 

^"^ (l«ri Iw^w lii* <v.nrl unions U[>on his oh>!*-rvnl inn (luit \\w wflln 

""«Q»ru!)t the {inmnrtlinl follicles arc B(^iDdh'-^hn]>o^I am! difTor but 

''"''■ in ipiM-nrantf from Ok- u<ljjin-n1 slmma oi'lls; anil morp i-s[Kt'i«Hy 

^■"W Uw (act thai in ihe mrlicr sta;p^ of Hm" ovnrv many i>f ihe oocytce 

PPl* M i^rnmn'kil hy (i>jlhdiuni u( all, but art- in dirtft rcmtuct with Uw 

' ^'"^uiiilmg «>niM*<-tivo liiwiie. 

*»l<lmT\ virw. howpiiT, hafi oblain«(J almn«t DniviT*»l ncwptimro, 
*^ u {tUcvi! Iwyotxl all resiionalile <lutihl hy l)u< wnrk nf Winiu-arii.>r and 




'^'''Vrtr, »o tluit it would sopm adTisabk to di^mtw) Fnulic's tliwiry as 

'•nn* ii)'fAn<H9i tlv* rarfaw qtitlielium of thi* ovnry may be ciliated. 
■•l*** nnd afjain, as haii \nva poink-d out by Von Vclits and mywif. 
" I'liiim mnv tikpniM* Ih> found to jmshixs i;iliii. T})<>«^ 
, iit- of Ihwr rarity. »]vak slrongiy agniiHi tlw oonnwtiT*^ 
riffin fif Uw fnllicniar rella. 

opic StraetBK of Ovary. — Vmm t\» fir^t etairr-< of ifc< dwclop- 
nniil nit-t [|.<- rii>'ii.>|i.-iii4>- ihr nvurr i^ nndt-r^^xin); eon.Htiint ohan^^. 



68 OBSTETRICS 

According to Waldeyer, each ovary at birth contains at least 100,000 
oocytes, the majority of wliicli disappear before the age of puberty; bo 
that at tliat time only 30,000 to 40,000 remain. The changes concerned 
in their disappearance wiil be considered more fully when we consider the 
corpus luteum. 

Before taking up the consideration of the evolution of the mature 
follicle, it may be well to mention certain historical points in connection 
i^ith it. The Graafian follicle was first described in Hi72 by De Graaf, a 
physician of Delft, who not only observed the vesicles, but demonstrated 
the presence of ova in the tubes of rabbits. The human ovum waa first 
reiflgnised by Von Baer in 1827, its nucleus or germinal vesicle by 
Purkyne in 1830, and ib* nucleolus or germinal spot a few years later 
by ^\'agne^. 

In 1891, Boveri pointed out that the nomenclature usually employed 
in (Sinnection with the iii>ecific cells of the ovary was faulty. He con- 
tended that the teriiis ovum and egg are synonymous, and should there- 
fore be applied only to ceils which are ready for fertilization. Aa this is 
the case only after the eompietion of maturation and the casting off of 
the polar bodies, ht; suggested tliat otlier terms be employed prior to that 
period. Accordingly, he designnte<l tlic eells during Ihe stage of division 
as oogonia, from then until maturation begins as oocytes of the finit order, 
after the formation of the first jKilar body as oocytes of the second order, 
and aa ova or ovia only after the formation of the second polar body. 

In .the young child the greater portion of tlie ovary in composed of the 
cortex, which is filled with large numliers of closely packed primordial 
follicles, those nearest the central portion of the ovary showing (he most 
advanced stages of development. As was mentioned alwive, the majority 
are destroyed l>efore llie lime of pulicrty, and Stevens has given an ex- 
haustive account of the proccs.*. 

In yotmg women the cortex contains large numbers of primordial foUi — 
eles separalcil by thicker or thinner bands of connective tissue, which ise 
made up of cells with spindle-shaped or oval nuclei. Each primordiaU 
follicle consi.*ts of an oocyte and its surrounding epithelium. The oocyt*^ 
is a single cell, more or less round in shape, with a clear protoplasm aaX 
a t<)leralily hirge nucleus oc:cupying its central portion. The nncleoeE 
presents a marked retieidalcd network, and at one point a weli-define£ 
nucleolus and numerous accessory nucleoli, which are formed at the inter-' 
sections of the nuclear thread-work. 

According to Nagel, the oocyte romnins constant in size from birth unti j 
the transformation of the primordial into the typical Graafian follicle 
no matter at what period of life this change may occur. These oocyte-? 
measure from 48 to Oil microns, and their nuclei from 2!) to 32 micron - 
in diameter. The primordial ovum, or oocyte of the first order, is sur" 
rounded by a single biyer of small, spindle-shaped, epithelial cells, whicW 
are somewhat sharpiv ilitTcrcnliated from the still smaller spindle-shapes 
cells of the surrounding stroma (Fig. ~3). 

Occasionally n primordial ovum may contain two nuclei or germiiu^ 
vesicles, as has been shown by Niigcl, Klein, von Franqui, and others^ 



THE OVARIES 



69 



I 



\guB. occasionally two and soinctiR)«» tlirrc distinct ova niav t>e found 
la a •inglr priinordia] follu-k-. und it is frum Kucb xlruclurui lltiii nml- 
tiple [ifvgnaiii'iis Hoim-titiii-n di-vclnji. 

Wb«!n, undLT tin- inlluitict? of factor* witli which we arc «« yut nnac- 
faudtMl, Uu; ]>rinitinlJa] folliciv kfjios to develop, w« notice in tiw lin<l 
plaoe tliat it- i^pitbelium bororuc^ vontertul into a sia^ layer 0/ cnboidal 
(die (Fig. TS). Nuclear fijr- i,.. j, ^ -— «, 

imi MMM maku their iijn- r ii?ft]^^^*^?''P''^'/'"^ " ""^t^^ 
oui^ and tin- cells bt-jiu 1. I'iJ' '"'*^ '^*V", .. *i<^'fi 
fnihfrrati' ni|iidly. on that ill wW/i '^i^**'A^ , ^'i^ 

a rcrr short time the ornm wjili ^ , 




no. n. — OvAMV or Yormi Wool*)*, mioitikii Pnt- 
M-iHiiiAi. ■'•M.i.K'LKn '»^ t.«rr l<inic ahii Kou.K-i.R 



■ iili iiliMTifil betwwD 

Lhr-m. Tiiw |iriK-«-w mn\ia- 
uv* until a ntnuidi-ralile ]M>r- 
<jnn of tht> folliclr ix flllol 
«vtlh fluid, which in forineil 

tU iiy ttif dfgi-ni-ration nf 1)m- follinilar n<\l» and partly by tronModii- 
tjoa from purToiin<)in}|; vcmwU. 

t.'nioci<)enl with the drvelnpmcnt of the Huid, the eo-callcd lienor 
f«llinili. the ovum Ixv^nit'K pti»lHtl lo one Kido of the folliclu, where it w 

)n\ liy U Ill8i«i4 nf Cclln — 

Tw pfi-lii/rruJ' or cmHutas 
upiuni* — whili: llif nwt of the 
itthelium is amui);ed io a aura- 











Fw 



74. — nuTBtnrfwo FoU-irUL 

xini. 



Kia, 7*. — DrmorDWi Foujn.R. 
X2la 



l«r of ta.ti-nt around the interior of tlte rullicle, and » known an Iho 
VfA^mna tjranuUva (Kip. 7«). 

Wliilf thrw .-liBuic^ are taking plftw, the ovinii ilself lK<can>eTi lurgcr. 
Wfatrtant rdunge* lalie )itacr in \\a nucleiu pre]Mralory to the formation 



70 



OKSTKTRICS 



of llic lirsl Hftlnr hmly, ,V'>Ik yiuniilf§ or lictilnpla^in nn; (li-posilwl in 



jto|ilu 



and 



lliiti. IraiiHXirt'Kl slruclnn'— |in- yiiiiii ix-lluciila 



|«'i 



appitaiN »)>riut <U ]ii-ri|)liiTT. Al itii- .■•iiino time, the etroiiift imiiinlLai<--l'l 
iiiirruiin'lin}£ tin- ^rowin.i; fnlliile litroumcs vafcular. and itf vvilf f\Mt 
miirki-'l cvidfncM of jirolift'rnti^n. 'Hit' nn'iiihriinn gruiuilot^ is it'parat 
from tlio Klronia Liv a thla basement nioniltraiiti coiieietiag uf a eiiijjk- Inj 
Tn. Tml f MG 




Tut. 7S. — Nkaw-t MAnrnit Fhi.umjt, x 310. 
1)., diwu* ptnliciFni*; M.O., mnnbrann crnnulam; T,fx., tunioa nxUniB: T.i'nl., Miiiea lata 

af fliitlciioi!. wpinilti'-sIiajMil. c-onni'plivc-tissiic cells. Jucl bi'lwren llie tx 
iiH-ni niiinfiram* and Hu' omernuwt layr of th« meiidjriinn ^ninuWu ll»? 
not iTifrpi|iiiiillv sii>]'rar« a iJiin, transpnn-iit Inwr, which was firot lit 
N-rilMul li)' f>rii)io ami Slavjitiisky. ThU. no lr-K< than tlio xnna jwlluddi 
U a ^pccie^ of pwiiialc frorn the graiudosa ci'lls, 

Uatnre Graafian Follicle. — Kroin l>irlli until i\\e rotation of se\ 
lifi', (iviinfiaii (rilliil<-^ arc fiuictanily being flpvp|o|>fil. Before IHa ngf.- 
pulnTtv thcv flTO ffnitid only in llio dwjicr porlion;* of llip cnrlejc. i 
An not rracli llii- siivfmi? iif Oift ovary; Iali*r. ItouitviT, llify di'VfI(i|i in 
superficial porlioiia of the rorlcx and make iheir way to tlie surfaeo, whd 
Ihey a]>p<<nr nx trannparcnl vci^icli-s. varyinfi from 3 or 3 to 10 or 15 mil 
metres in diameter. M llie folliele nppmaehes tlio nuiTnii* rtf t^0 nrary n 
wallK become thiiim-r and niort^ nliuiidtiiilly i-tipplied with t'eswis, excel 



TUE OVAiii^ 



71 



in ib niont pnimiiit-fit gtnijcclinf; gH)hM>n, ultich )i|i[icjir]i ulntii»t Mi>udtcM( 

l« desiftmiLud tw tlio Migma, tlic ■f\ia{ where nipturt' is lo occur. 

I*riic mature tinuifijiii fnllielc <.'onxi»lt^ of u t"niK-tl ivi-tissiw «>vcriilg 

r^dw- Ut'i-a folliculi; nil <'|iiilH>li>l Imin)^ — Dk- mtiiilmnii );raiiitii>.Mi: tlie 

I Ileum, aiiil ihi- ijituor foUieuli. The tkvca folliculi is n'u<Iily divided iuto 

Iwii U5«rre: an ouli-r, tho tunicm vxUtiui. mid un inner, the tunica iiili-nin. 

tunit-a L'xti'ma ooiwsts of U»e onlinary ovarian fjrnina, which U ar- 

niiiccnlmiiliy about IIk- follicle, wliik' tin.* toiiiH-clivu-tissui; evils 

kf U«- lutiica iiilornn haM- umtt-rgone innrkei) chaugojt. 

Alirimt 81^ eooa a» tiic (triDionlial r<^liL-lD shows signs of dcvolopmvnt, 

■Britvr llfiun^ ai>)H-ar in the wtroitm imnioiUaU-ly surnumditt}; it. mid a 

liderahk ninltiplicatioii of cells orrurs. The^' boeonie considt-rably 

fr than Uw ^.urriiutidiiij; (imii(vtivc-tix«iK' tvUs, «»■} a* llti- fttlliili' in- 

lu hiee aAsmiip a ;:ra)iiiliir ainieanintv, which i» duo to the prest-nw- 

■f a 5«t|lit«*i>'ti pi){iii(!nL. Tht^w celU »tv di^igiuitiTl nK lutein cells mid. aK 

vtll W leen latur, play an )iii)Hirtant part in the formation of tltc corpus 

In trnwl hanlt'nwl Mptviiiicns tliv colonrin" matter has Imii di»- 

oul, am) i)iv ii'll;! ap|H'ar not iiidikv (lio-o of tin- nuprarviial caji- 

wllk* {ma: TJ., Pig. 77). At the sanm tiinu ihimr » u nwrkvd iiitTtiOMi i» 




*i^i^^':o 



», V ^r-- 






s 



^r 



■<-^''^-'w.. 



T.I. 



TE. 



■ -^ *tr '^ 
- . . ;■' v-^ 

iiu. 77. — r»*ATUf?, lUBuutiu W'au. of U*ivitr. t'oiJ.Hi.K (hgthly lunciiilkiil}. 
ll.tl., uiamtrtaiu sniauJiMi; TJ., (UBica intonut; T.H., tuitMTs r\t.>m«. 

*!»•■ VMiiiIarity of IIil* llinn. aiid numerous lyin)ih«tic sjiiuvs make tliwr 
*1'|*«rMii-<'. 

Tt- * lining "f llic follicle, or memhmna ijntituf'^a. (■ouxifl-i of 

*Mnil" I r» of ^mall {loly^nal or cuhoidal culls, with roiiml. darkly 

•ItiBing nnrh-i. which arv arranifiil in tuv/er layvra the l8T:gtT tlw fnllic'Iv. 
AtiHw point the T . ' ii. nuioloiia te much thicker tlian cIsewlKTe, and 



72 OBSTETRICS 

forni:^ a more or less pyramidul mound id which the ovum is included. 
This is the discus proUi/cnis or oophorus, and is usually situated at the por- 
tion of the follicle farthest removed from the surface of the ovary {see 
Fig. ?(i) . The foUiele is filled with a clear, albuminous fluid, the liquor fol- 
liculi, which is partly the product of the degenerated follicular epithelium 
and partly a transudate from surrounding vessels. As the follicle approaches 
its liighest development, marked alterations appear in the follicular epi- 
thelium, which by appropriate methods can be demonstrated as due to 
fatty degenerative changes. 

The ovum becomes much larger as it approaches maturity, and, ac- 
cording to Nagel, measures from 150 to 250 microns (^ millimetre) in 
diameter, as compared with 48 to (iil microns in its primordial condition. 

If the nearly mature ovum be examined in the liquor folliculi or in nor- 
mal salt polution, the following structures, acconling to Kagel, may be dis- 
tinguished in and uliout it: (a) & corona radiatu: {b) a zona pellucida; 
((■) a jMTiviteltine ppace; ((/) a small, clear zone of protoplasm; (c) a 
broad, finely granulated zone of protoplasm; (/) a central, deuUiplasmic 
zone; and {i/} the germinal vesicle with its germinal spot. 

The corona nulUila consists of a number of layers of follicular epithe- 
lium which adhere to the ovum, and was ao designated by Bischoff, by 
wliinri it was IJrst described. Inside of the corona radiata comes a narrow, 
transparent zone — the zona pellucida — wliieli is a product of the granulosa 
cells, and docs not belong to the ovum itself. Separating the ovum from 
the zona pellucida is a clear, narrow space, the perivitelline space, within 
which the ovum is freely movable, so tliat no matter what position it may 
assume its geruiinal vesicle will always jmint upward. Inside of the peri- 
vitelline sjjaee is the ovum proper, which differs markedly from the pri- 
monlial oocyte, not only by its incrcasi-d size, but more especially by the 
presence of a yolk or deiiloplasm which fills the greater part of ita interior. 
The dculopldfin occupies the central portion of the ovum, and is made up 
of large numbers of irregidarly shaped, highly refractive granules. As it 
develops it pushes the genuinal vesicle to one side, so that the latter always 
assumes an eccentric position in the ovum. 

Outside of the deutoplasm eouies a narrow zone of finely granular 
protoplasm, which owes its pcruliar appetirance to the presence of very 
small vol k-gra null's; e.\tcriial to tiiis, again, is a still narrower zone of 
clear protoplasui. 

The geriiiitml vesicle, presents a distinct rclieular, nuclear network, the 
intersections of which iipjieiir as very darkly staining points. The nucleolus 
or gcrniitxil spot is much larger than in the primordial ovum, and accord- 
ing to Aucrbucb presents tyjiical amu.'l>oid movements. 

An ovum presenting the al>ove characteristics is generally described as 
mature, but is not capable of fertilization and further development until 
it has undergone certain changes, which are manifested by the formation 
and casting off of the polar Imdies. 

fJraalian follicles, ns we have already jiointcd out, develop throughout 
childhood, and oci'asionally attain a eimsiderable sizi-: but they rarely 
rupture at this time on account of their position in Ihc depths of the anrj 



THE OVARIKS 



73 



ai thr intervi!ntioD al a thick )ayi>r nf cortex betvi>po them and the sur- 
ttu. In atlnlU. im llic nthcT liaiid. llu> ^i^clopinK follidc tnsk<» ib< 
nrtothe surfa^t-, ami wtii'ii it Iiah altflim-(! lU Ui^'hi^t iicvolu))iii*'at rup- 
tiwiml cxtniilcK iUt ovum iuto thi; porttoaea] cavity or tlic tul>c, wiu-re 
U w Ik Ii-rliliMi], 

FwwiHj it W8» belieTct) that riiplurti of the fatlirle was hrou);ht ahotlt 
I7 tk iiwn'nMiH ImKion ri'Ktiltint: fmm Uk rapid rnrtiialimi uf i\w li<iu(ir 
Mllnli, which, at^xinlin^ u> Na^ol, van markedly accentuated br the 
|na>un* FKirf-d by lh« lutein wll» <k'Vfl oping about itjf poriphiTV. Clark, 
hmrnr. has HhowD that nipliira of the rolltcle iii a omplex process, 
mi » Awe primarily tu circulatory clian|!i». As the period of oviilution 
mmdi», the oTary ti«-oi:ii'H i'ii;;rir]^il with hliMxl, and the intrii-ovartau 
tam Idng markt'tlly itM-roaf<:<l, the g^rowin); ovum lit forc(\l to the suf- 
'w: il the rtmc time Ibw (■imilalioii in the m<x»l di*tcfnli'il portion of the 
•illrf tl» fnlUcle is interfen-d with, wtw-nce nvulbt necrosis at tho point 
^"ilffc'l ait the iilig^a. which mi-ntiinlly givo way. 

Vajnt Lateun. — Tht- corjmH lulfutu i^ a sinifliin- whit-h is funnel iit 
Ifattiteufa rupturvd follivle. When the muture follicle ruptun's, Dk oTum, 




^ C.F. 

^K TflL— l^ianoar or Uvuit, ■nowimi « Cllniu'nt I.irnrii or PntaKufcr, wnn Cwna 

^^^Bc^ M w i il d i*; C.F., cnqiw MinniRi; F., <inuJi»» (ollwlm; UC. littein nU*. 

HipMr fnliicitii, ami a ninwidiTahle portion of the d(^{ffn«riit4Hl innmhrana 
^VnauloM make their w«ape, an<l th« walU of the empty follicle ollapi^c 

l« « abort tim*-, h"W<-ver, its cavity beeoniM fillwl with Wood, which is 
it partJj fmm tbc ToaeU si tlM point of rupture, but principally 

"M Umw nf ihe tmuca inlema of the tlim. 



74 



Till- cf»r|iii» luU-um, ilu'iefori', !u ii» earlie«t fltflgcfl i 
lurL-d follide tillwi with IiKhiU, uuUiiL- of nliich is a narrow ydlo 
fontivd by Uie lutein colls of tlic tlicca, which, howov«r, proliftraUil 
and iiivailf liie hlooil-liUiHl follicle, forming a fci'tooDcd lajL-r an 
ct'ntial ijloml-ilot (Fig. IS). This Invcr i» jtvllowijih in colour, 
iho ItTtii •■ nir|nis lutciiiii," Am Ui« ^Iructiirt; Ijccotiieit oI<itr, the 
rinp liecouK's thicker anil thicker, until at lust it uliuoHt ontirely 
interior of tlw follido, Ow ivniral blood-clot remaining being M 
muall. 

At its j^reatoit doTelopmeiit the corpus luteiim is alwa^'s lar| 
Iho oH^iniil fciliii-lc. and mil infrei|Ui-nti_v oerupios a considenihle 
of lli« ovary. Boinetimee na much as oi](;-thir<l of the entire organ^ 

MicroM'opic Kecliun? ihmiigli a u'i-11-dfvdc>[ii-d ('xuinplu alinv 
centre is owupiiii liy a coniprcsticd blood-clot, iinmedialely 0Tit)>ide ( 
is n thill layer of m-wly fortned toniHvtive tissue. The greutvr 
tbc Htructure, hiiwei'er, is occupied by tiie featoooed ytiUow ring, 




Fta. 79. — Sxcttmt TimofiMi Vnjxnir i.jiTMt or Cnneva UerwvJt, Hiiowiain 

liiiKk' up of largo, polygonal, epithelioid eclle, with small, round, xc 
faintly wtjiining iiuck-i. TIh^mi? are the lultin clh, wliow protopl 
taken on n granular appi-aranee due to the presence of a poctiHa 
pijiiiit'iit which ]* Miliilili- in clilorornrm, (di-ohol, and ether. The 
lutein ecUs is traverrx'd by Ilumci■oll^ raijiate, tolerably thick, cmil 
tiMiiK' pnrtitioiiH, to vhieh it owes its festooned appearance. Th 
riehly supplied with blond -vcwi'Ik and lyiripbatics (P'ig. 79), 

As the eavily of ihe follicle is I'ncnmcbi'd upon by Ibfl growing 
eell(-, I lie Mood-clot lieeome? nioro and more eompre<.ied. and 
Loojjut (.^teuiJ into it and ^oon (-au.su its organ ixu lion. At iLu same 



THE OVAItlES 



Und (nnnriiL i* mnn\«A liy iRHcocylas wlii^^li <^nii be rann<! in Iho iiur- 
MBi' willt tlii'ir iMiili(-i illlnl with jwrtii-Ies of it. Otviis ion ally 

Inii'T I ,. 1 -a Di.i take jiliirt- into tlif ru[>lurwl follicle, and a wrpHW 
htnm u loTtuvd witlioat a central Ulood-cliil. 'DiJ* U ttiu i»«c]>tinii in 




» 



Flo. MX — Ompvn F*iiiiiii*ni. X TS. 



^mn fitinifs, liul ihc nili> in many of Uw lawiu- aniniiili>, nc in the rabbit 

AJut tUr cBTily iif lln- fttllirlv liiw )i.'<'ntni* oMili-ratifl by llw ingrowtll 
•fifct lolein cflls anil connective U.iHtio, di-Rpmriitivi- c)iiiii;i:iv .^mn make 
Iktr if.inmiirr ill llw fonnrr. iinmo of wliidi iinilcrp> livatin ami othors 
'•Hf <!i^^i*jstiriD. lu ytiiiniu: wonipn, in wlioni Ibc circiilatton w iwlivv, 
lb (ttyptii'mlnl liitrin ci'lla arc rapi<))y ahmrlici], no that in a filiort time the 
'"'pw lull ■ Ties r^'planii by (m-wIv fortni""! roniJivtivi- tiB»ni' wiiich 

""""("oii- 111 ap)>ciirancc to tl»? tmrToiinilin;: ovarian ulroma. But 

s nmrr ii|vanc«i) Iif**, wlM-n tli*' ovarian cimilatinn lia* U-come impain>rl, 
™frti"o pnp.-i nn Irss rapitlly; and not infrrt|u«!ntly Itio ilf ifimcrBl ion 
'ibal. ((, ((„, inlfni-iiin<: mnnpctirfl tiK^ue ami bbwid-voiicl!: nntil the 
'-*Ji' iimclnn- w ronvcrUil inin an almost honiojicnoous uia*.* of hyaltn 
'* "hidi only a U'v ooniwclivc-ti^-uc ccIIb anti dpgcneratcd hlood-vewels 
'^ hf wen ( Fig. MO). Thme «lr«clur»— the tto-mlW corpom fihrma or 
****»fiB— pn««iit on fre-h ticclion a dull wliitc appoaniiHi-, snmcwltat 
•^^iir iif old mir lisum'. Tlicy arc. IioU'<t<t. ^ndnntlv invndcil bv tin* 
""ttsBding stroma, and Ii«v>mp broken up into Mnatler and smalb-r hya- 
'^ iiLiku.1. vliirh arc eventually abMirltii. the silo of llic oripnal fot- 
imlicjitnl only liy an arna nf uliiiliily thi<>henn! mnncoiive txteae. 
'•Ti Uui L'itPnlation i« titv dcfcctivp. ab«orption takes placp niucli more 
■*lr. •#! ihal it i» not uncommon to fiml the ovaries of womi>n near tW 
•*>paBM- almoKt filld by rorporn fibroKH nf varvinj; hiibc. Not infriTiUcntly 
t^mll hvidm 1io<iii» rosnllinp from Hm> breakin;; np of llw-* stnirlurwi 
**■«■ pwuliar and bizarrp forms, and vcri' oftt-n pivmiit ii nirvMl aiul 
lid ajtpiwruieo migjjiisUve of a d(>gi>ni>raliil arlory (Fi^. HI ). Similar 



TO 



OBaTETRtCS 




re of] 



I.ATKB SrActe or CoRn;ii Fidrositu, 



|struc'turc« are moiiictiiii^ left after the obliteration of non-rnptt 
liclfis. 

Practically all luithoriticM are ngrew! a* to the life-historj- of th« 
lut«um, ami the only point which still remains imcclllcd deals w 
oriffitt of th-: lutein nils, Tlic mrlirr (iljscrv<.T.* wuisiili^ri'ii that the i 

were analogous to j 
f^atiiKutioD of a bli 
wiiit'li WAX follovn^ 
fornintion of di 
tiwiif, lull at pnvti 
view possesses onl3FJ 
toricul interact. 

The majority oi 

tigiiti>r» bc'liwt 

lutein eelU are 

tiTV-liiwtiv origin at 

rtsent tlu- wlln of n 

interna. This v^ 

first nilvancwJ by v^ 

and has bci'ii onf 

the work of Ktitlich 

Btigi'l. BcnckisiT,^ 

lark, Waldeyer, Uiishasen. and many otherfl. A few authors, on 

hand, folluuing the cvaiitplL- of BisrhotT, consider lliat they ori^i 

ppitholini fvMf and nix- di-Hvt-tl fnun iIiom- of Ihc nR'mbruna 

Thi)! explanation has been advocate<l more particidarlr by Sol 

ha.* lalcly nsi^iviil adililionul I'lippcirl frimi t.hi- work of Krt'ii an 

while Ijoeh believes that they are partly of connective tissue a. 

(if ■■|>ithelial origin. Full dctnil* of Ihi^ dlM-tiiuion are eimtair 

papers of Clarli, Solmtta. and Ihm. J shall content mji^lf wi 

the cviilent-i- in fiivour of the f<3rri»T view. 

The con nei'live- tissue origin of the lutein eeJIs in based upon t 
first, the ccllx of the hiniea intirna "I" the tlieea begin to undergo, 
changes an soon as the follicle eoiuriiences to develop; ami MHYfin 
mcinbrana granulosa prej^ents extensive degenerative changes, snm 
ally east ofl* in greiit. purl at thi- lini<! of rupture. | 

In the earlv Htages of folllenlar development, the cells of Ih 
inlermi inxoiue Iurg<-r and assume an epithelioid ap]K'ar«nee, Nncl 
ures soon appear and rapid proliferation nuues. At the same till) 
prolopUim ln'conies more Knuuilar, and pigment is deposited withii 
so that they i-losi-ly re-M-nibli- the lulrin cHln. Tliat they first ap 
I the tlieea would argue ajjainnt their derivation from the memhranj| 
^^(»a, hut even mnn; no the fact that tiiey are *eparati'd from it by q 
^^Btarner of tinehangeil eoniH>ctive tissue, the upper layer of whi* 
^niio bnsrment membrane of the folliele (wv Figs. 77 lo 79). 
^V '''he malurc follicle. Dim. is surrounded by actively proli 
lutein cells, while it-^^ membrana t;rnnnlrw» nhowN sign* of fatly di 
^_ tion. Tn niuiiy instancv^, before rupture, a narrow yellow ring 



h 



I 



THE OVARIES 77 

/ouud surrounding the periphery of tlie follicle, from which it is separated 
by a thin layer of connective tiusue. As soon as the follit-le ruptures the 
lultin Ltlls proliferate more rapidly, and with the vmboIs included between 
fbem, speedily invade the follicular cavity. 

Obxervations based upon the study of several hundred human corpora 
lutc« have coDviDcctl me that the connective- tissue origin of the lutein 
cells ia established beyond all reasonable doubt. Strong support in favour 
of this view is also to be obtained from the changes which are observed in 
follicles which develop in the deeper portions of the ovary, and degenerate 
witboat rupture. This process has been studied by a numl>cr of observers, 
notably Slavjansky, Schottlander, Clark, and others, and is usually desig- 
Mted as follicular alrenia. Under such circumstances, precisely the same 
thanpw are observed as in the formation of the corpus lutrum, except 
Ihat lia'tnorrha};o is absent and that the process is less marked. In many 
'"stances tlie entire niemlirana granulosa is separnted from the walls of the 
lollicie and lies free in its cavity, presenting marked signs of fatty de- 
pn«ralion, while the cells of the theea are actively proliferating and are 
l^ing converted into lulein-likc cells. 

The function of the corjwra lutea is to bring about the obliteration of 
'lie spaces left hy the ruptured follicles without the formation of cica- 
"ifial tis.*ue; for if they liealol by the latter process it is evident that in 
< vtrj- sltort time the entire ovary would l>c converted into u mass cou- 
fli^ting of nothing hut scar tissue, the very nature ot which would eiTwtu- 
»ily prevent further ovulation. It has been estimated by Chirk that if 
wc-h follicle healed in this manner, and if ovulation could continue under 
*ii<.-h (-nnditions. a fibroma would eventually be produciil 5,000 times us 
lii"^*? as the original ovarv. 

Kraenkel. in 1903, advanced the theory that the chief function of the 
'■"r|iiis luleiim is to elalH>rato a secretion which regulates the hlood supply 
"f I he uleni* and thus controls the process of menstniiilion, as well jis the 
'i^iTnation of the dccidua and Ibo implantation of the ovum. His theory 
*aj» supporltrd hy numerous experiments upon rabbits, and Bomo upon 
**>rncn. In the latter be found that the next succeeding menslruiil period 
'■il*ii to occur when the corpus hiteum had been destroyed by means of ii 
f^^itm-. which might readily l>e done without danger during the course 
"• a fimple operation, such as suspension of the uterus,. Shortly iirterwani 
.* fiA a second paper upon the subject Itefiire the Viennii Obslctriciil 
■ H'ii.ty, but faileil to impress the audience with his views. Skrol>iiusky, 
"^ Ihp other hand, holds that the corpus hiteum of pregnancy has iin ojipo- 
*'**-' function in that its secretion inhiliits ovulation during pregnancy; 
'**t confirmatory evidence in favour of either view has not been adduced. 

It is nsua! to distinguish between true and fahp eorixini lulen^naniely. 
I^^** following impregnation and menstruafion respectively. This distinc- 
*'>n bf based entirely upon their relative size, and not upon any inherent 
'"atomica! difference, as they both present exactly tbo same sirueturc. the 
'ireer size of the so-calle<l true corpus lutouni being simply due to the in- 
Pfwstd va.scular supply incident to jin'gnaney. 

\ot infrequently the corpus luleum of pregiiuiiey contains in its centre 



82 OBSTETRICS 

timetrcs. He arrived at this conclusion l>y soaking in water all the napkins 
used l>y the womun, and delerniiuing tlie amount of hitmoglobin in the 
tolutiou. 

Anatomical Changs in Henstmation. — The statements concerning the 

extent of tlie clianges occurring in the undonietriuni during mcnstruatioa 
are very contradic-tory. Sir John Williams Iwlicvcs that the entire mucosa 
is cast off at each menstrual period, while Mimriekc and numerous other 
olhtervers state that there is little or no destruction of tissue. Between 
these extremes, we find a numlicr of authors slating ttiat a greater or lesser 
portion undergoes disintegration. Generally speaking, the older author- 
ities jield that the entire mucosa, or at least a considcrahle part of it, was 
cast off. Their adoption of this view is ]>rolial>Iy ex])lained by the fact 
that their eonelusions were drawn fri>tn the study of uteri in which post- 
niortem changes had taken place, since Ue Sinely was the only observer 
among t]n)se Vhose work was liased upon autopsy s|>ceiincnd, who stated 
that there was Imt little destruction of tissue. 

In 1882 Moerieke cx]ircssed the opinion that menstruation was accom- 
panied by little or no destruction of tissue, basing his statements updn 
the examination of 45 specimens of the menstruating endometrium which 
he obtained by curettage. His views were soon conlirmed by other ob- 
servers, among whom may be mentioned l)e Sinety, Liihlein, Weitphalen, 
Strassmann, (.Jebliuitl, and Findley. Meerdevoort and Mandl consider that 
the extent to wiiich the tissue is destroyed varies witliin wide limits, the loss 
being almost impereeptible in some individuals and fpiite marked in othen; 
while Kahlden and Christ believe that the destruction is always consid- 
erable. 

My onTi experience, based upon the examination of sevenil uteri re- 
moved during the menstrual period and numerous speeimcna obtained by 
curettage, is such that I hai'c no hesitation in adopting the views of 
Moerieke and his supporters. " ~ ' 

Plate III, wliic-h represents a section through the endometrium of a 
uterus removed on the third day of menstruation, shows very distinctly 
that but little destruction of tissue has occurred. The entire mucosa is 
markedly thickened, and its sujierficial portion is infiltrated with blood. 
The surface eiiillielium is intact, but in places it has heen separated from 
the underlying tissue by small colleefions of blood — the so-called subepi- 
thelial hwuiatoniata of (lebhard. The uterine glands are markedly hyper- 
trophied, as is shown by f'eir twisted and corkscrew-like course: this hyper- 
trophy is associated with a considerable inerea.^ in the intergtandular 
tissue, the cells of which, howcvei-, do not ap|iear to have undergone changes 
in shape. There is marked engorgement of the blood-vessels, and just be- 
neath the surface opithcliuni may lie seen capillaries which are distended 
almost to the point of bursting, while considerable quantities of blood have 
escaped from the vessels and lie free in the tissues. From these and similar 
observations, then, it would .seem evident that menstruation is not attended 
by any gr(«t loss of tissue, but cimsists I'sseniiallv in marke<l hvpertrophv of 
the mucosa, engorgement of its sujierficial vessels and the consecpient .escape 
of blood, partly following rupture, but in great measure by diapedesis. 



MENSTKUATION AND OVULATION 



83 



I 



A/Urr tin* mcn^lrual flow hm txaMni, u cvrluiu atnount of (It^cnrrnli'Ki 
I«k«w plMT in tlw MipfrRdal lavcre of tlie mticiMa, wliH-b, houcrcr, is toon 
prpain?d, ODtlenr fi;;unfti a|>|>cttnnt; in llw wlU of Ihc vpitlieliuiii ami iuti;rg 
flKEiiluUr tisMjc, which ht-gin tn niiiltipiv and re|)lnci- Uk- dc-gciicrtlwl 
ceils, Mt Hull ri-:i'ui-r4ti'iii i.-. ru|iii]iy (-fTwUil. 

Af infill truBtiou tictuni cvt-rj' twentv-t^i^ht liny*. it U apparent thai tlie 
lomi'triDni i» Muhji-cti-d to an aluMMt coutinuntis c)innfrc, the |>rnt.-c«« 
birinf; (JctcriUxl by liCOpoM and others »a tin; tni-n.'lnail cpett. This 
4-fiii-ri' u pf-rKitl (if «ixln;n d«yj«, (Svl- of which arc niwlcil for iht- jircltmi- 
siry -welling, four for the hh-il-ws proper. hikI SfVtrri for tlic period of 
n'gt'nfraliiiti, M) tlinl tlif cndnnKlrium rcniainH (|iiii.¥cvnt only alioitt twitlrv 
dmya in oich inonllL Miirshiill hn.* ^)n>wn lluil Htiniliir hixlologival chiuiKcfl 
iwf ttr in U)f nitlin^ pi-riod of the ferret, and that tlie same cyele im folhiwcd. 
F(ir furilier jiiirticulurs tiinii-rniitg Ihc uii.-ilomii'iii di-laiU iihscrvud in nien- 
ktmation. tin- cxhaiihtivi- arlii'te of (iehliard htinuld Ix' r>>n><nllM). 

B«Iation between Henstrnation and OTvlation. — Hy ovidnlion we iin- 
>tatid the rupture of a inntiire (iraaHan folliile and tl»e estruMon of thv 
am. TIm- rrlaliitn l)el«wu nH-n>itriuition and nvuhili"n tui?i jii«tii ri".- to 
i;mtt deal of wtDtniversy, and while many inlem-tiny farln have lit*n 
«d*hil 111 our infunuatinn, it uiuxt he coitcoded tluit (Ih eubjcct is utill far 
'tota iH'inj; satinfaclorily nmV-n'liXMl. 

The fact that young (rirU do not UKuaUy conceive until after the ap- 

nim- III thi' iiit-nw-j., uml Ihe exlreinc rurity of iinprcjEiuitinn iifli-r ihetr 

tion, rpnilert^l it naiuriil fi>r the earlier otivniTii to i^upi^k-e ihat lou- 

LfttMiD ninhl nut nceiir vitlmut UM'n«tniHtion, and that the meiiMnial flow 

■n-prv>«entt*l llie female weinen. Thi.t view. howe>-i>r, was jwon abandoned, 

and the dischar}rc was reKanled as a prncorf> of purification. 

It wa* iiiit until tin- doelrine of [H'ri'ulii-ul nviilalton hiid Iiei'ii o<tah- 
iibed by the work of Uendrin, N^ier, Biwhoff, Foutbet, uud others, that 
'finrb* id(wi cnnld Iw forninlnletl oonwrnin); the relation lielwt><>n orula- 
i"ri and nienwtruation. P'roiii that time on. howerer, it wa* j.'enerully l>e- 
i.-v.ij that menial ruati oil wo* brou^'bt almut by the ripniiiig of the (iraaliau 
'»[lii:li«: thai the l»o ]>n>cn«ie!i oi-eurred atmo-l, if not ipiite, siiiiultane- 
Ir, and tlint nienxlruation ehotUd be i-un«i<lcrvd as analogous with the 

nr rut of animal*. 

TTiiff doithne eutminated in 1885 wiih (he appenroncv of Pflufrwr'si 

rtiele ufiti the fli;,>iiili<-an<-^- dim] mi>4> i>f niii)-<truation, in which he t-talcd 

lat the flow rt-kidled from a reflex stiiuulalion, which oweil il» origin 

I the pr>vKuru exerted hr the growing follicle u]K>n ttie nerTcti of the 

oran'. Tliis theory obtained almost immediate acceptance, ami fot yeant 

wa.- ' ^iminnnl Mief; upon it wan Ihi^oiI our metluMl of raliulatin-; 

thr ' i date of confinemejil. the rule bt-ing to dale llie Ix-giiiinng of 

preiroanrT frtim the la«t mi!ii»truul periwl. 

rflfip^'* iheopf. however, wast Mititewhat »<haken by the work of Leo- 
fmM. Prochownict. and L*e Sin6ty, wliow careful htmliejt of the wndition 
1 ' tnoved al ojH-riitii>n pniveil coiM'luHivi'lt' that the tn*n processes 

1. . -i^wirily ^nit-hrcmouft, but might occur ipiite ittth-jx-udenlly of 

ooc Uhither, ai)<l aecordingly orulalion i-ould not be considered the unvary- 



84 OBSTETRICS 

ing caus€ of nionstruation. Clinical experience also lent further probabil- 
ity to this view, Bince it has shown that ovulation and subsequent preg- 
nancy might take place without menstruation, as was demonstrated by the 
instances of conception occurring before the first menstrual period and 
after the menopause, as well as during lactation, when the menstrual flow 
is usually absent. Moreover, a few cases were recorded ib which preg- 
nancies had occurred in such rapid succession that menstruation did not 
occur for years. Ahlfeld has reported the case of a woman who gave birth 
to numerous children, but did not menstruate until her thirty-second year ; 
and one of Leviot's patients did not menstruate for fourteen years, and yet 
during that time became pregnant no less than four tinjos. 

Sigismuud, Liiwcnhardt, Liiwenthal, and Aveling nest advocated the 
theory that ovulation preceded menstruation, and that the latter was due 
to the failure of conception. Aveling designated the process as nidation 
and denidation, and considered that a menstrual decidua was formed each 
monlli for the rem'ption of the fertilizi-d ovum, and that if conception did 
not occur it degenerated and was cast off with the menstrual flow. The 
gist of these theories was tersely expressed by Powers in the dictiun, 
" Women menstruate liecause they do not conceive." This view was also 
adopted by Ilis and most embryologists as true, for a certain niiinl^er of 
cases at least. Tliey found on esaniining ova which were nominally of the 
same age, as entimatod from the last menstrual period, that some presented 
a stage of development several weeks in advance of the others ; they held, 
therefore, that this difference could be explained only by supposing that 
the former resulted from conceptiftn soon after the last menstrual period, 
tind the latter from conception just before the first perioil missed. This 
view is also confirmed by the reproductive history of the orthodox Jewesses, 
who arc noted for their fertility. Acconiing to their laws women are con- 
sidered unclean during the entire menstrual period and the seven days fol- 
lowing it, so that in them conception probably occurs just before the first 
missed menstrual period. 

In IS'Jt, Leopold and MironofF made an extended study of the condi- 
tion of ovaries rcmnvcd at ojjcration from 4'^ women whose menstrual his- 
tory had been carefully noted. In 30 cases they found that menstruation 
and ovulation were synchronous; in 11 menstruation occurred without any 
trace of ovulation ; while in 1 case ovulation occurred in the middle 
of the intorFiieiistrual perio*!. 

Strassnmnn, in ISOU, nmrc or less rehabilitate*! the original Pfliiger 
theory, by sliowing that rut can 1h3 produced by injecting gelatine into 
(he ovaries of animals. His views have received a ccrtiain sort of confirma- 
tion from the discovery by Klizabctli Winterhalter of a sympathetic gan- 
glion in the ovary. 

Fraenkel, in HHI.'i, stated that menstruation was due to the elabora- 
tion of an internal secretion by the corpus luteuni, which regulated the 
blood sujiply of the uterus. }le enn-^idercd that observations u|>on women, 
who bnd been subjected to laparotomy for some condition not connected 
with the ovaries, proved the correctness of his contention: since destruction 
of the last corpus luteum usually prevented the occurrence of the nest 



MIGRATION OF THE OVUM 85 

iMfi'^niHl pcTiixl. At the prt-st'iit time Ihia must bo rogarcled as nn intur- 
ttim^ clicon', which in still in iioitl of corrulHirutioii. 

From the vviik'nee before U3, we must conclude that ovulation and 
■eni'tniaiion usually occur about the wirao time, but that one not infre- 
qoratly itntodates the other by a few days, while in oxccptional cases they 
BiicMvuri|nitc indGjK-ndently ; but in any event that the latter is absolutely 
dtpeoiiral u[)on the presence of the ovaries. 

Min' Putnam <lacol>i in 1876 advanced the so-caltod menstrua I -wave 
tktorr. which lias been accepted by Stevenson, Webster, Ott, Van de Velde, 
ud uihcr^. According to this idea, the metabolic processes in women 
ptMut a distinct rhythm, and gradually increase in intensity up to the 
lime uf the menstrual flow, when they cuddenly drop and reach their 
lAVf^t |K>int: after this they gradually rise again and attain their uiaxi- 
BiHni iiiU-n.-ity just k'fnrc the next menstrual period, thus indicaliug that 
ibeirilirt' jih^tss is under some central control, and that neillier nicn- 
ftnutiiin iii.r ovulation is directly dependent upon one another, but upon 
fmr cHHTiil and as yet unknown cause. 

TU- rr'sults following various ojMirutinns u|ion the genital tract twul lo 
tW lliai iiienstruatiiin is de|R'ndont u]>on the pnsence of the ovaries, but 
l!aimuhili"U may take place wilhout the presence of the uterus; as it is 
gwoTally ndmittiil ihiit the complete removal of lK)lh ovaries, which nccts- 
uriiy sloji-i ovulation, is always as.sociated with cessation of the menses. 
I'd iht- Dtlier hand. Ilie tolal removal of the uterus, while assoeiuled with 
"Niiiiin iif ilic nicnstnial flow, exerts no effect upm ovulation, as is mani- 
fr-li'i t'V the regular occurrence of the oo-calUil menstrual molimiun. 

X iiiiuiIht of ohser^crs have allempte<l to show that menslruation may 
"mr iinli'|i.-ndenily of ovulation, basing their contention upui the occa- 
imul mntnmam^- of menstruation after the removal of the ovaries. 'I'liis 
fniiufii.n. however, is fallacious, as in such cases eilber the ovaries had not 
l^'i n.m]ilcti'ly n'movi-d, or an accessory ovary was present. The now 
*<ll-<^laiilisli(i| fact that a very small |iortion of ovary will sulhcc for ovu- 
I»iiin llll^ Ikvu demonstrated by the occurrence, in rare instances, of prcg- 
lUDiv" afliT the removal of Ixilh ovaries by eompelent operators, cases 
w «l)i(h have lHt<'lv been re|Nirtcd bv (lonlon, SIere<lith, and others. 

■■*u<ii olisiTvations conclusively demonstrate the fallacy of the view ad- 
WkmI l.y Tail, Johnstone, and Savage, that nicnstrnaliim is regulated by 
il'^-'Mfllbil menstrual nerve, and that its f)ersistonce after operation was 
•iiie in Ih" fact that this non'o had not iH'cn ineliide<l within the ligutiin', 

"niinarily, the Fallopian tulies take no part in the m<'nslrua! fuTu-liou, 
UrJ in none of mv sjiecimena were there any traces of a blntHlv ihiid in 
tlwm. Occasionally, however, the tubal muc-osa may share in the pmcess, 
I'lw- ln-i-n !-liown by the exjierience of Thompson, who reportni a ea.se in 
rtifh a jivo^alpinx had ruptured through the abdominal wall, leaving a 
6-tii]<ii|s ojH-ning which did not heal, and through which a slight amount 
of Mi^hIv fluid exude<] at each men.strnal period. 

Kigntioil «f the Onin. — The mechanism by which the oviiiii gains 
acce-f to the tul)e after escaping from the riiiilureil follicle is a ipie-tion of 
eilrenie interest, and one which has given rise to a great deal of discussion. 



86 OBSTKTKICS 

Ttic priKTfWs is ryadily undcretooj in those animals in which the ovai 
are more or k-ss complotoiy inclosed in a peritoneal sac into which the t 
o]R'nfi ; but in women, and in animals id which the ovary projects freely i 
the peritoneal cavity, the question presents greater difficulties and 
not as yet received a thorouglily satisfactory solution. 

As we have already shown, the fimbriated extremity of the tube lies 
the neiglibourhood of the ovary, but is not necessarily in direct coni 
with it, the only organic connection betv.een the two structures be 
furnistied by the fimbria ovarica, which is attached to the upper or tu 
pole of liic ovary, 

Niinierous theories have been advanced to explain the manner in wh 
the ovum enters the tulje. Eouget believed that the latter became 
g(ir}.i-<I with bliHxl at the nienstrunl pericHl, and that as a result of its 
CDiiiiiig erectile, the fimbriie applied themselves to the portion of the ov 
ill which the ri]ie follicle was situated — so tluit after its rupture, the ov 
was imiiitiiintely taken up by the fimbriated extremity of tlie tube. 1 
view, however, bns been abandoned, as it is ditlicuU to suppose that 
tube iiiuld iristindively pick out the exact [wrtion of the ovary to wh 
it shiiuld apply itsi^'lf. Kchrer believed that the ovum was ejected fr 
the follicle ut the time of rupture, with sullicient force to ho thro 
directly into the fimbriated end of the tube. This, the so-called ojaci 
tion (li<i>ry, for a time enjoyi-d considerable vogue, but haa likewise b 
abnndoneil. 

At pRWut it is generally believed that the cilia upon the fimbriated « 
of the tube give rise to a current in the capillary layer of fluid wh 
lies iK'lvveen the various pelvic organs, so that the ovum, on escap 
from the fullicle, is taken up by the current and wafted towards one 
Ihc olher tube, whence it is carried to the uterus. The correctness of t 
view haw Imh-u substantiated by the experimental work of Pinner, Jani, i 
].,<Mle. 'I'he former injectwl cinnabar and the latter the ova of ascari 
into Ibe jieriloneiil cavity of animals, and found that they made their \ 
(o the ]»clvis, wliere they were taken up by the tubes, through which tl 
were cnrriiil to the uterus, and eventunlly appcantt in the vagina. This 
IM'rimeiital evidem-e is rc-enfoni'd by the fact that in certain amphibia 
large tracts of the periloua'um become covered by the ciliated epitheli 
shortly IwfoR' the time of ovulation. It is more than likely, however, t 
a considerable proiwrtion of the ova which escaj>c from the ruptured i 
licle fail to gain access to the tubes, but remain in the peritoneal ca^ 
where they perish, 

]n 1SJ4. BischolT dinvled attention to the fact lliat not infre«pieE 
in animals possessing bicornnatc uteri one finds that the corpora luti-a 
in one ovary, while the embrvos are develoiK-d in ibe uterine horn on 
OpiMisite side. He sup|<os(xl in such Ciises llmt the ferlilizeil ova had co 
from the ovary in which the corpora lutea were found, and had made tl 
way into the wrnu of the op|nisite side instead of into the one coi 
s|>onding to the ovary fnun which they came. This pr>K-ess ho dosigna 
as iiiiiinili'in of llir nviiiii. 

The [lossibility of such an oivurrwncc in women was iir?[ carcfi 



MICItATIOX OF THE OVUM 



I 
I 

I 



'tr^ Ku6«miiul. wiin flntt^l thai it tni^rhl be brouglit about in two 
mt-r bv iIh^ ovum intking » i-Jnftiit Uin>ug)i Dw ]»Wic. niTity and 
iLti t^iiittt; aonpsg lo tlti' i>|i]>n«ito talw, or pasiiiiij; down out? tiilx!. (rav- 
mog ihu DtfntH: I'avilv, iilnl llu-ii tnnkin^ il.* vay ii)> tbi- o|i]Misiti* IiiIk'. 
Ik fanuer l>e deai^naleil as exumal, ihe hitter as internal, tni^ration 

Srirmal migration of the Oram is not inrrF<r|uenl)y obwrrM, vherenit 
Am i> rooiiidcrablc- «)i>vu»sioD an to the possibility of the orcurrene« of 
EMomI mifirnlinn. Wi.* nrv iiiuililo lo nKnTliiiii li»w rns|tK-ri(ly i'\l<'rni)l 
■ipitina takeii pliux* in normal uterine pn^naneiN, lhou);h it is probably 
kkimranf rare. On ttw other haml, ito occum-nc« tiat Item rvjicatedly 
JapMutralciI in n*t^ of liit^iniunlt' nteri, and tboAC pn-sfntinj; a nidi- 
^Itnr btim; ami not inrrci|ti(iilly in nonniil iiU-ri, when one lulx- ia 
■rUljr diMiiMHl and (be nrlu-r mun- or U-r'ti norniiil. u^ in <-a^> or hydro- 
•tpBt and inrtammalorjf lesions of one tni* associated with ocriuHion of 
ill fauliriainil I'xiri'inity. In *iieli aw* when the wirpii* luteiim is found 
••ll* mlr iif like dir^'a-^il hilie, it is inferred that the ovtini tfiiineil aocexa 
I* tl« Bli-riiit Ihroii'ih Ihe nonnal nr only slightly diRiised liiln- of the 
^|mle »ide. Moreover, tlic xanic e^eni has not infref|ui>ntly lienn olMcrved 
■ nin-ntcriiM> prrpiancr. 

Eibrrnnl mi^miiHQ of tlie m-um lia.* ))M>n prrKluoiil o\j>eri men tally in 
flpil' by I>>o|Kild, who exeiM.'d onv ovary and the npim^ite tube, and 
^pl ia a nuuibiT of »ut'h niM-s that the animal.'' 1h*i.miitii- pn-jpinni after 
w«f«talion. A wrr convincing easfi hai» Un^n repiirtiil by Kt.-lly, who 
NiMinl (he diiwaM'd left nvary and ri)*)it tube from a pntient. teavin;; t\w 
nmnl fitfht ovary and k-fl tulH> Miind. Piftet^n motilli^ Inter the woman 
Tifl at term, and seventeen month" after delivery the remaining 
n-inov"l for a ruptuitHl extra- iilerim- pn-gnanev. 

I hm examined speeimenti from numerous cases of extra-uterine preg- 
■»T.»hioh apfwrenlly olTen^I incoiilroverldde evideiiw «f external mj;^- 
'••> *i the (iviiui, Ihe eorpus luleum lieing found in Ihe ovary of one side 
*l Ikr pn-piiiiii-y in ihr op|»>»ilc lube. The same condition wan Ijeouli- 
'^j a«iiplilitil in a epeeinivn which i)r. 11. ('. (\k* x-nt an- for examina- 
^ Ib tlitu caMi the right tul>c had twice been tlw scat of extra-uterine 
Nflttm'y. Tlie llr*t prejrnani'y, whieh dal«! frfim «evi>ml vi-st^ iM-forp. 
**• "iliftilnil in the islhmir p^irlinn of the tulx-. tlie fo-l»H havini; l)«*eoiMc 
"•"fl.ij mill a lilbo|Kflion whieh eomph-lily blm-lied the lumen. V.x- 
'"^i 1" this, ami oofupying the lateral portion of tlie tidw, was a frftddy 
"Vwl four monlli*' pn^naiiev. Tlie right ovary wa« i«mall, atrophic, 
••on«»tl by adhe.*ionn, while the left eontainetl Ihe corpus" luleum of 
^'m»n. Il was apparent in ihii rase Ihal the oviim mii-il have lieen 
'"tiiuitl, "lifin after liavini; the left ovary, by a njK>rniiiti>«>oTi whieh liad 
■•A^itt »ny Hp the left IuIk-; after whieh it had lioen earrieii to tlw right 
''*«d ha>l |wu»tii dfvtt-n il until arTtr>le<l by the lithoiNF>dinn, when it 
""mini fiirlher deiHopnienl. 

l*«li»f«rtiirT midemv bus n..t yet U-eii nddneitl in favour of Ihe oeeur- 
■^'iif imtrmal mifiniUfn of the ovum, and il i* hardly pa**ih!e thai *uelt 
)^ »n ewir U- brought in tin- fulunr, though il* tlteoreliral possibility 



88 OBSTETRICS 

cannot be denied. Schaeffer and Veit have conclasively demonetn 
that the Bpecimens which were formerly relied upon to establish ita 
eurrence are open to other and simpier explanations. 

Place of Keeting: of the Omm and SpermatosoB.— During coitus 
semen is deposited in the vagina, and the question arises. How do 
spermatozoa contained in it make their way into the uterus, and when 
where do they come in contact with the ovum ? 

The number of spermatozoa contained in a single ejaculation is mai 
lous, and has been estimated by Lode at 22G,257,»00, Various oxpl 
tions of the method by which they gain access to the uterine cavity I 
been advanced, the most widely known being the aspiration tlieory of 1 
mann. Wornieh, and Beck, and the mucus-plug theory of Kristeller, 
first-mentionfJ observers held that the external muscles of the ut 
contract foreiiity during coitus and compress the uterine cavity, into w 
the spormaloxoa are nspiraled when relaxation occurs. Kristeller heli 
that at tlie height of the orgasm the thick tenacious mucus, which is usi 
found in the cervix, is forced down for a short distance into the vaj 
where it Ir'coiiics covered with spermatozoa, after which it returns t< 
original position and carries them with it. 

It cannot l>e denied tJiat spermatozoa may gain access to the ute 
cavity in either of tliese ways in a certain numlier of eases; but in 
majority of instances it is probable that they may make their way thi 
by their own activity. Moreover, the observations of Ijiiw indicate 
the mucous secretion of the uterus possesses a positive attraction for tl 
as can Ih; vorifitil under the mieroseo|)e. That this view is correct is dei 
stratcd by the instances of pregnancy following imperfect coitus, and 
ticularlv those which have been observed in women with unrupt 
hymens. Furlhcrmore, it has been shiwn by Ilenle that spermat 
can move at quite a rapid rate, being able to travel a distance of 1 o 
mcln' in three minutes. 

It was formerly taught that iiriiirvgnalion normally occurred in 
uterine cavity, ami it was IxOievinl by Tait. Wvder, and other obsei 
that conjugrtdon was favoured by the direction of Ibe currents prod 
by the cilia of ihc uterus and the tulies, the former being directed 1 
Mow "upward, and tlie latter from a!>ove downward, so that the 
met in the up]>er jwrt of the uterine cavity. Thus, the ciliarv' eui 
would favour the cnlrance of s]H'rmat"v!oa inio the uterus, while rcr 
ing imiHissilile their entry into the (uIm-s, except in diseased condit 
Rut in view of Ihc oliservatioiis of Hnfiucicr, Mandl. and others, w 
show that the ciliary current is dini'tiM from oliovc downward, in 
uterus as well as in the IuIh's. it is ajipiin-ut ihat tbi-; tlKHiry must bo a 
done<l, and it must 1»' aiimilli'il that llu> sjH-ruiato^iiii liave to make heat 
against the curn-nt from the time they enter tlie iutcrnal os. 

It is probable that spt'rmatozoa can n^trly ahv;iy- K' found in the t 
of marricil wnmen, into wliioh tbey make tbeir Wiiv bv their own moti 
T.iviuff s(H'ruiato/iwi have Ixvn obsf'rvi'il iu the iiiK's of unmen hv B 
Ilirschfeld and Hiibrss^'n, and it is a well-known f^i.t ihat they rviain 1 
aiiivily in ihc tuU-s of ihe bat for many monihs. Years ago Bis* 



I 



PLACE OF MEETING OF THE OVUM AND SPERMATOZOA 89 

sbowed that they could be foiuul on the surface of the ovarieis of animals 
for a certain length of time after copulatiuu, aud tiie occurrence of ovarian 
pi'e^^iunc)' demonstrates that the same may occur in women. 

From the evidence available, it appears to be tolerably satisfactorily 
dfsxioiutrated that in women who copulate at frequent intervals the tube 
mu^t be regarded as a speeieg of receptacvlum seminis, in which spermato- 
B>a, ire always present and waiting far the ovum, and that fertilization 
usually occurs in the tubes and only rarely in the uterus. 



UTERATURB 

A**«_FKu>, T.ehri)uch der G(>buri«huUe, 11. Aufl., I89B, 2. 

*•-■*■- I'eher ilus Vorkommen und die Bedeutiing der MenHtruation bei Hen Vfilkem der 

Allenwelt. Moiiatwrhr. f. (teburtakiinde. IftW. vi. 161-179. 
**"^1J.VG. <H>rt. Jour, of {{rent Britain and Ireland. July, 1B74, 20fl. 
Bk«-x. How do the Sperniatoioa enter the lUerusT Ameriean Jour, of Obst., 1875, 

Mii. Sia-Wl. 
"***~"i'ri'. Die EntwirkelunK dea Kaninehcn-Rioi, 1B42. 

*■**« lilerstiire rai the Anatomy of Ovarien. 
BlKka-8-HiHHCHFBLn. Quoted \ty Zweilet, Lehrbuch der Cieburtahiilfc, II. Aufl., 1889, 

2a 
'■^MUT. I>BH Verhalten der Uleruaschleimhaut wslirend der Menntniation. D. I., 

Gimivn, 1892. 
C*»*s- Internal Mif^tion of the Ovum. Tranii. Amer. Oyn. Soc., 1893. xviii. 262-278, 
&" wiME.i. I.«bendige Hpennatoatoen in der TuIkj. Zentmlbl. f. (!yn., 1893, .593. 
Fas^BLET. .Anatomy of tbe Henatrualinf; Uterus. Amer. Jour. Olmt., \Wt2. xlv, 50»- 

m. 

f ■« *«LEL. Pie Funrtion dea CorpuH luteum. Arcbiv f. Oyn., 190:!. Ixviii. A'AH-hAH. 
<-K«K.iiiit. Die MenHtruation. Veit'ii Handbuch df r Cyn.. 1896. iii, 1-94. 
iKLiiiiHus, Traits phitnsophique de m^eciric pRiticjiic. Psiris, 1839. 
IWtauHM. Two PrpgiianricH following the Heiiioval of Both Tul>es aud ( )varii^H. TniiiB. 

^laeT. (Ij-n. Soc, 189(1. xxi. IO4-108. 
™A.utK. 8<*hwanKerw-haftflrGactionen der ftflalen OrKunen, etc. Zviltwhr. f. (!el). 

iL(iyn.. Ifl04, lui, 191-231. 
ftAUM. Quntod by Ahlfeld, Lehrbuch, 11. Aufl.. 189H. 1. 
■"■"Lt I^hrburh der Anatomie. 

la 

"■''■ Anatuniie menwhlicber Embryonen, 188(1. 
""•n«nc[i. See literature on Anatomy of I'lenis. 
^"'^•'EiLBH, I'elwr den Blutveriuiit liei der McnHtniation. Zeilwbr. f. pliymcil. 

Owmie, xiji, 54-5, 
*'^">i. The (Jiiention of Rent for Women diirinn MenBlriati<ni. Hiiyli'sidTi pri/« 

e^ay in 187fi, New York, 1877, 
**'. See Mteniture on Anatomy of I'terun. 

'""liwroNE. The Mcnutrual Or^n. BritiHh Gyn. Jour., XoiTrabpr. Iflftci. 
^^ti-hKN. I'etier dan Verbalten der UteniHschlcinibiiiit wiihreml nml iiuch ili-r Mrti- 
■tniation. He^aPs Fenlwhrift, Bciti'aEc rur tieb. u. Oyn.. .«liil(K;irt. IKK'.t. 
•"••ML IHe Zit^^nmeniiehungen des wpiblirhen ( IniiliilcunaU. IVitr'iiii' ziir vit- 
drirh. u. e\p. Geburtxkunde. Heft I. lHf'>4. 
**U.T. <>perati\-e Oyneeology, 1898, vol. ii. 189. 
*"<\«DT. Edinburfch Mediral Journal. 1HH2, wvii, H)8i. 
■^KUtTELLBB. BerUner kljn, Wftchennebr., IK71, N'r. 27, 2H, 



do 



OBSTETRICS 



KvsaUADu Von deiii M;iniwl. der Verkunuiif^mnt! iiml V«in]oppelun^ tier G«bAma 

Icr iiad di-T IJctitTwnndprtuijt df* Kit-j:. Wurilrtirn. IS5!*. 
LkoPdlii. Slildk-ti idior dit' Uli.-rtiwclilt'ini)uiiil, IVrlin, ItCH. 
))if rrberwundprmig dun Kicn. An-hiv f. < Ijii.. I8M0. .vii. J'2-11. 
riiUTHiii-huiijcvii Ubcr M«nNtiuAtinn U. OvuLilinn. Ardiiv I. <iyn., 1885, xxi, 34^ 

ids. 
I.K>>piii.i> 1111(1 MiiioN-ofT. Iti'ilmt! iMT Itfhre von d« M<aii>tnuktiim U. Oviiliilior^ 

Archiv I. C.yn.. 181)-1. xlv. 5(M(-,W8. 
LftnoT. Oviilftt.ion «uix nicniilriiation ponilunt uiin pMode do 14 aiin. Bull. «Ie U om^ 

irolwt, «t df K>!i-. I'liriH. 1 R03. aoj. 
I.ITJIMAVK. WftKncr'M nniidivc"irli:rtmch dc» rhymcilanir, lii. .in. 
Loi>R, Sw lilvrjtiirf on Armlotny of I'tiTii". 
LuHunx. Uas Vprhiiltpii (Ut I'lfniiwchlpiiiihiitit wiihrMid dcf Mi-nntnuition. tiyiid^ 

k'lloi^ T:vpriJnii[cn , lli-ft 2, Nr. IS. 
LiiWKN HAIN'T. Uk- iJi-roi-hiniiiK tirid rliu l%kui-r dt-r Sfhwnn^Tspbaft. Arohiv f. (iyi 

IW3. iii, ;t.Vi .101. 
LuwKVTHAi,. VAne uviuf Deutims tlM MpiiHLruutinniiroww. An-hjv f. (lyn.. If 

xxir. lfi!( 2fil. 
AIakm.. Tk'ilr.tn iiir FRimii ih» Vprhitllfna drr l'ti-niiuiiiii'i>i« vr.'ihrvnil <lw Mviixlr 

lioii. Aniiiv T. (l.ni,. ISBO, lii, 3.57-578. 
Sw lit.rmlurp tm .\nnl<)niy at Uli>riii. 
Hahshall. Thu fRsttrnui Cj-clc in ihw Common Perrot. Qiurlvri}' Jour. Mkr 

Si'icn <■?.■", .'•eptt-mbiT. 19<M. xlviii. 
MKEHiiKuviMmT. yiiotwl hv (IHihiini. 
Mkiikiiitii. l'n'i;iiiiii<-y utlvi ihv KuiiinvHl of B«th Oviirim lor Ihrmioid TUnKiur. 

Mix). J. lUfM, i. llVia. 
MiiKKii'KK. l)ip I'U-nwiif'lili'iniliiiill in ^Trueliiinlem-ii Altersin-riixluii Uiid iiir 2i.-il tier' 

M«-imtiiiHlioi>. Zi-ilm-hr. f. fioli. u. r.yn,, IssiJ, vii, M*-i;(r. 
N^ximKH. Si4^ liU'tulilrv nil .Vimtviny of IH'iirien. M 

Ow. (idwtj diT I'l-riodifitut d^r phy*i<>liipiW'lii-'n Ftinrlioncu im woililiphpn OrKanW 

IIiUB. V<irh. tkvi \. jnlornnt. miul. ('onKn-xwo. Rurlin. IKUl. IM- III. Alit. viii, 'J3. 
Pn.lfiJtn. I'tlwrdie ItiMlt-udiiij: u. I'raii'hp drr Mi^itBlniatiuii, Berlin. ItHiS. 
PiNNBH. Sw lilrnil.iirc on Aii.atouiy o( l'|rni«. 

]>i.ci«^ I>ufl Wi-itt in diT N'ulut^ uiu'l Volki^rktinde. IV. Au&.. 1895. Bd. I. 231-334. 
PwrniKT, Sit iilcrnlure on Aniitmny of Oviirics. 

I'lMicHowNiCK. I''iill von MctiHlniiilio [inwrnv. .Vpr^hiv (. fivn., IKHl. xvii, 3;!(l-38l. 
Itorotrr. ilcrhf-TchL'ti nur U-s uriniim ^rvc-lik-H do la fniimv. Jour. <ti> U I'liynolugifi, 

1S.-.K. i. .-l^ll. 
ijiATAdK. Tte hV-mnle Pelric Urciin-. 3d wl., Ni>w York, IfidO. 
Scharffkr. l'cl*r flio innerc ITdx-nmndprunp den fc'ien, Zeiiochr. f, (leli. ii. Clj 

Ism. svii. IS-I'J. 
SlalisHi-Ni), Iilrcn iilicr du« Wn«i diT Mwirtmatioii. Brrliiier k!in. Worhi-riwhr., 

I87I.81M. 8£'>, m 

on SiN^r. ItcrluTrchL'ii mir U inijqueu>ii:> iil^riiiv pviidtknt la inenKiruaUon, fiute^f 

iiiW. av Purl-. IHHl, No. T. 
HnuwiUANN. It(-ilrui:>' «iir I.<'lir(> von dor Dviilation, Mnnntnuttion tuid Conn^jtion. 

Archiv 1. (!yn.. mm. lii. I34^2S1. Jl 

T*IT. fk-o lilrfjilnio on Anatomy ol Plftflin. ^ 

Tmomi-hok. Ziir I'tiiirt' dcr 'hiU'nini-iiKlni«ii'«i. 7.«iTilnill>l, f, fiyn,, IS!iS. 1:;l'7. 
Van nFV»;i,i>K. {Ivaiiidfunriion. Wellrnlicwi.cim); u. Mpiislniulfiuirtion. Jcnn, I1I05. 
Vbt. nie t'miw der iniwtvn lIclxTrwandnninK 4lu Fjti*. Zdlwhr. f. Gph. u. (.lyii., 

ItflW. nxiv, ,127 3.W. 
WKtLiTKK. Till- Bioloiciiid RHHiiinf ^trnstrualion. Uontiral Med. Jouruid, April. 1807, 



I 

I. 



A 



MENSTRUATION AND OVULATION 91 

n'ERM<n. U^nr die Erectionsfuhigkcit dee unteren UteruHabBchnitteB, etc. Beitra^ 

lat Ob. u. Uyn., Beriiu, 1872, 297-307. 
W'STTPH-iLKN. Zur Phyaolog^ der Meoatruation. Archiv f. Gyn., 1B96, lU, 35-70. 
WiLUAMH. The NoTTOiU StructuTes of thu UU-riiic Muoosu. unii ita Periodit^ ChangeB. 

<>)wt. Jouniul of (ircat Hritain und Ircland, 1875. 
ft'iNTKHH.tLTER. SvG literature on Aiiutomy of UvaricH. 
Wtuel :ke literutun: on Anutuniy of UvariuH. 



CHAPTER IV 



MATURATION, FERTILIZATION, AND DEVELOPMENT OF THE OVUi 



Formation of tht Foetal Hembranei. — In the present work we shall nc 
attempt to trace the development of the ovum through all its stages, bi::. 
shall consider only those changes which are directly concerned in thr 
formation of the fictal membranes and the placenta. For detailed infoc 
mation concerning the general dcvelopmeut of the embryo, the student - 
referred to the standard works u]K>n embryology. 

Maturation of Ovum. — The ovum, as it occurs in the mature Graafian 
follicle, is not adapted for fertilization and further development until r 
has undergone certain changes more especially noticeable in its nucleu: 
which may bo regarded as signs of maturation. This consists in the fo« 
mation and extrusion of the polar bodies, which leads to the reductio- 
in the number of chrontosomcs to one half of that characteristic of thi 






np. 82. Vig. 83. Fig, 84. 

Fins. 82-84. — Formation of Polar Body (Sobott«). x 600. 

n., nuHciis; 1'., vildlinir mpmbranc; 1'., yolk ftramileB; P.. polar Hpindle; S., bead < 

ftperm jitoBOOn . 

somatic colls. The procc^^s has not as yet been proved for human beings 
but, as it has licon observed in nil the lower animals which have beei 
studunl. it is reasonable (o sup|io.*e that it also occurs in man. The change 
arc su|)posc.i to begin jii.-it before the rupture of the follicle, and to b 
completed while the ovum is in llio upper portion of the tube, thou|^ 
occasionally ihey miiv take place while it is still within the ovary. Thi 
process is most readily understood by Ihe study of ova having but fen 
largo ehromosonict;. .Vcrordingly, the egg of the ascaris megatfcephala 
which possessies four cliroiuosoincs, U usuallv chosen for its demonstration 
Sobotta has recently made an c>:bnustivi' studv of the process in fh( 
mouse, and it is frmu bis article Ihat most of our statements are taken 
92 



/ 



MATURATION OF THE OVUM 



93 



ITben the process of maturation is about to begin, the germinal vesicle 

approaches the surface of the ovum, or oocyte of the first order, and 

gppvAK to become Hmaller, while at the same time its membraDe disap- 

pe^TV. It gradually becomes kvs and le^s distinct, until finally its sitii- 

lijon i>^ indicated by a clear area surrounded by deutoplasm, which is 

lj.0vei>ed by many radiating lines. In a short time this area becomes 

jj.^j3=formed into a typical canocinotic or mitotic figure (Fig. 82), which 

jjdent*'^ the usual changes and soon becomes spindle-shape<i. The spin- 

jj^_ when it first appears, is situated tangentially to the surface of the 

.^-uin. but Iat«r turns and becomes perpendicular to it. The chromatin 

_( tb* spindle then becomes rearranged and a typical dyastcr is formed. 

Q^vi^ion rapidly ensues, and the new nucleus nearest the surface, with 

y^ti portion of protoplasm surrounding it, is cut off from the rest of the 

ovnm and comes to lie between it 
y"^"™"^ "n<l 'he vitelline membrane. In this 



V^, 





\ ' J 



i.^-i' ! 






> :^^: 







/ 






"•ox wmi Foim CHHOMOiumf.s, 

•" ^7 ^'H four chromoflcffnm b. formation 

r^'^'^^P; f, ■plitting of clirornoriiiiiii.'ri in 

•PMU; J^ wpwvtion ol dsuRhtir rliro- 

'"y ^Ba; r, eompletc ivparatioD itiUi twu 

"■ *(dt wilh (bur chnnnoaoroca. 



Fl(i. 86. — DiACHAM SHOWTSO TIIF. REDrC- 
TIOS IS TMR N'VUUKK UF ClIKOMOIHIMKH 

i\ ThiK Matihatios of THE Ovvii. 

aJr^. ()i>o\-ir of fiiMi orilc-r in vurious »laf;p« 
ftf <liviHinn; d. Oocyie of T*ocond orrlt-r; 
r, first pillar Iht-Iv; /, mature o^^lm; ii, 
F^ecimct fifilar boily; h. cells dcHvi-d from 
divisiou uf firvt polar body. 



M 



OBSTETRICS 



wny U formed the ooeyte of the t-econd order and the first pol, 
till.* priKi'iw IK u tv|iiral ci-U diviiiiriii, ilu* iiiirlt-ii.-' nf lictlh tlio ■»uin 
jwlar body will eimtaiii the typical luiiuhcr of chromosomes. 

Almost iiimicdiiitoly a new s[iijiilU^ iijiiKyir* in iho ovum «nd d« 
occurti wiiliout preliminary cleavage of the chrrtmosoines, so that two 
are formed, fnch of wliith ha" niily ime half the luinilKT of chnmiost 
ciiarai'teridtic of the njH'cies. One of the* is east oft aa the second i 
body, while the remaining; cell j^ the mature ornm, whose ducIl-us is 
dt-i<igiiate(l as the female pronueleus. 

As tlic lirst polar body is formefl by typieal eell division, it taui 
regarded as hontoloj^iu.-. wiih the ooeytc, from whioh it differs onl 
its KRialler size: and it may divide again, giving rise to two cells. 
Mwond [Hilar hoily i» iKiniologOitji with the mature ovum. It vontuin« 
half the number of chromosomes characteristic of the body cells, 
under Abnormal eonditton^ may likewiM' liomme fortilixiH); in uhieh et 
accordinj! to the theories of IJoiinct. Wilms, and Marehand. it may f 
a piirt in the priMluotinn of li-riitomaTii, ll would ihen-rore npp^'ar I 
in the process of maturation six cells may develop from the orif;inal 
fif the first onler: on the one humi. llio oocyte of the second order,! 
mature ovum and the second polar l)ody. and on the other, the first 
body and two wlU derived from it, homologous with the iiewmd polar 

{Fig. 8«>. 

Maturation is essentially a means of reducioj; the number of eh 
Komei, though its exact signifieanee is not riear. Following tlie t 
of Weissmann. it is senerally believed thai the ohjcet 
the ri'iliK'tioii is to ninko powiblc the inlrmluction o: 
paternal chromosomes into the ovum at the time of 
lilizntion, without inori'iining the number of ehntmo 
characteristic of ihe species, as must inevitably 
some iiuch mwhunism witc not provideif. In any 
the process must be rej;;ariied as a necessary prcli 
to the fer til izu lion and fiirthi-r deviloprneiU of llie 

As the researches of Klemming and Ihicsherj; a 
ently show thut thr stmiaiic i-i'lU of human bein^ 
Iweniy-fnur ehrniiiosomcs. ii must follow that they ai 
duced to twi'lvi' in \\w iimtnre nvinii and si-cond ])olar 

Fertilization.^ Hy feitilization is understood the V 
of a siH'rmaloznon and the mature ovum. Raeb *per^ 
xoon conBints of thii-e portions — the hnid, tail, and 
mediate portion. The head is soniewliai triangula 
shs])e and flnlli-mil from side to side: it contains a 
nite amount of chromatin, which is dcrircd froni 




Fra. 87. — HttHAH 

Sl-KHUATOIOA. 

h. head; <, inWr- 



mother wlis of the te.'ificle (Fig, 87). Interpolate^ 
tween the Ion;; tail and the hcnd if a »tnall evlini 
body, the iwlermcdiutc portion, to which is attached the tai!. The 
matoKoa are endowed with marked motility, deriviti from the rapid i 
tion of their tails, and. according to Ileulc, can traverse a distance 
centimetre in three minutea. 



MATURATION OF THE OVUM 



95 



Id Epermatogeneiis, changes arc ob^rved analogous to those occurring 
in tbe tuaturation of the ovum, and it has been clearly shown that each 
^rmatocyte of the first order divides into two cells, each of wliich in 
[iirn given rise to two others containing only one half the number of 
chromosomes characteristic of the species (Fig. 88). These latter are the 
ipenMtids, which later become the spermatozoa. Each spermatozoon, 
therefore, must be regarded as a distinct ceil, which is analogous with the 
nature ovum and the second polar iKMly. 

.\^ has already been pointed out, the spermatozoon and ovum usually 
come logether in the lateral portion of the tube, which may be regarded 
ui species of reoeptacnium semiuis. although in rare instances the meet- 
]tf miy take place on the surface of the ovary or even in the Graafian 
follicle, as is demonstrated by the 
w-urrfnci.' of ovarian pregnancy. 

" ,-L 




/■ 



.r 



/'X 



\, 




\ ' v^ \^ 

'S — DlAOaAH BHOWINC THE ReIU'C- 
'**'!' THE N[-MHEIt OT C)moHO«OMi;« 

~ WEDtATnoEN'EniB IN A Species with 

"** CHtOWnoVEB t» THE NucLCun. 

^ <»ii— luijte of firat ordet in various 
'■pi of ifiiiiiiin ; d, mpmaaXixytK of nco 
'■'Mte;«^4«Mtkb with two chnimo- 




Cl 






Pic. 89.— Diaqrak siiowino Fertilization 
ASD Segue NT ATioN or the Own. 

o. fi^rtilization: I, maJe pronucl^tm, % ffV 
nisle pronucleun; b-e, (ormalion of i(|im- 
dle with chmmOBomea derivBi from both 
ovum and t<|>e[inBtaHun ; d-f, cell division 
BhowiDfc perpetuatioD of chromoeoinea in 
body cells. 



96 OBSTETRICS 

In the lower animals in which the proceea of fertilization has bo 
studied, the ovum is found in the lateral end of the tube, surrounded by 
considerable number of spertnatozoa, a? many as 60 having been coontt 
about a single ovum. They rapidly penetrate the vitelline membrane, bi 
it appears that only one of them makes its way into the ovum, and \iu 
after its entry the superficial portion of the latter becomes impervioa 
to other spermatozoa. 

After the head has entered the ovum the tail rapidly disappears, aw 
in a short time nothing is left of the original spermatozoon but a smsl 
spindle-i^hapod mass, the male pronucleus (Fig. 84). This rapidly mak« 
its way to the centre of the ovum, where it meets and fuses with tbe 
female pronucleus to form the segmentation nucleus. 

As the mate and female pronuclei each contain only one half flu 
number of chromosomes characteristic of the species, their union lestSM 
the number to the normal type (Fig. 89), Thus, in ascaris, two of At 
chromosomes of the segmentation nucleus are of paternal and two of 
maternal origin, while in man twelve come from each cell. Moreover, B 
the chromosomes of both the mature ovum and the spermatozoon are the 
direct descendants of those concerned in the fertilization of the parCT' 
organisms, it is apparent that the process does not consist merely in tin 
union of so many paternal and maternal chromosomes, but has a mnc 
broader significance, in that it brings together nuclear substances derWt 
from the ancestors of both parents, and thus affords a basis for a coi 
prehensible theory of heredity. In the case of man, where the mat* 
ovum and spermatozoon each contain twelve chromosomes, it is appar* 
that many different combinations are possible, and Ziegler has calcul»■^ 
that any one of one hundred and sisty-nine possibilities may have to 
reckoned with. 

Ordinarily segmentation does not begin until after fertilization, but 
is well known that in many of the lower animals it is not neceaaa*" 
dependent upon the fusion of the male and female elements — parth^ 
genesis. It has been rejK'atcdly shown in recrnt years that segmentaC'i 
may be imnigurated without the presence of spermatozoa by subject^ 
the mature ovum to the action of various chemical agents, such as we 
solutions of acid.'Ji or alkalies — artificial parthenogenesis. In such c»J 
development appears to progress normally up to a certain point, but 
present there is no evidence available to indicate that thoroughly foros 
animals will result, 

Lefevre, 1!'0~, has shown in Thallascnia that the egg under such c*^ 
ditions casts off two polar bodies, as usual, but that the cells result! 
from segmentation possess only one half as many chromosomes aa wh 
fertilization occurs. Accordingly, it would appear that tbe process of t* 
tilization may be resolvnl into two parts: the fusion of the male aJ 
female chromosomes, and the inauguration of segmentation. In the higt 
animals it would soom that the two functions are inseparable, while e 
periments upon artificial parthenogenesis in some of the lower speci' 
clearly show that the tatter may occur absolutely independenti; of tl 
former. 



DEVKLOPMEXT OF THl 



* tinw il wad |)clk'i'Ml that the (x-ntTD-H>riio — ttto ^Ininture whirh 
111/ pn»Hl«» over the act of cell division — iliHippcarcd from tho 
^tiag tiie la»t phsws of maturation, ami accordingly Ltic iiiatuTv 
noM not lufin In M-gmrot ni>li) llic lucking Ktrudiiro lint) \xxd 
hr meaufi cif the male jiroiiiH-leu!i. 'V)\U, Iwiwever, cannot be 
u ■ univer>al rule, purlicularly in view of tbo fact tliat xuoh 
ihiti^ is lacking: in nrtiflciitl piirthcn(igi.>ni.«i». 
ilmiopment of the Ortun. — Soon after the appearance of the evg- 
■utioa Dudeon, car\x)ctiu!tic cluingc* tjiki- plucu within it ami give rise 






.!i;- 



f%. mil Fift vu n^. II3L 

ftam. W»-»2.— Tiivuon:* is tiir ftKUOKKrutiov X«'i-iJ:i-it (.SobolU). X 500. 
f',t pttlat biHty; t,ii., Miciii^vUitioii iiueldu. 

iTjiit-al niickrar i^pimllc, vrliich i^ iwnn cunwrtctl into a dvanter. In be 
ilj folbitinil b_v Ihf division of the ovum inln lm» ccllx ( Figfi. I'O aud 

(■jrh of lbc«c in turn diviil«i, pvin^t rise to four nAU, thou^'li 
:u'» tiivtvtigalions nn tlM- niouKc kIiow Ibnl one of tlw original ci-Jls 

itB earlier tiian the otiipr, w> lliat vrc next have Ihiw eelU. T\\U 
of oall diTtttiua or MgmtuitJitton govs on until tlie original ovum 



"#•/■' 




r^ IKK. nR. 91. 

fUat. Vt-W. — F'tMHlTIOM <>r Uft-UKHMT MaSI (gotlolU). 



XOOO. 



r«invtTtc<l inlfi ■ maw <if erf^J^ which is dnignatcd am tlw morula 
tHihtrt-f mtiai (Fig. !>&). 

iltiM Hxm Hpp-nn in the nnillK-rry mawt and forces tlie celU tn tlw 
ptwry, tbtu i^ii'in^ rise to a VMirular ftriK-tiin- iiiii«i*tiiig of a Kingle 
■lA celU which furrouud a cavity filled with fluid — the w^mentation 
1*) - ontirr ftrnclurc al thin time \t known as (he blaxiotitrmie 
Il in Un' nliliit und many other aniinaU is »tiil I'urrotiiidi'il 
■iiemlirane (Fig. 0(i), whereas in Ihc mouse the latter 
lliv fcnnalion of the niulbcrr}' tnaaa (Fig. lOV). 



9S 



OBSTETRICS 




.fcl 



Ftn. t>e. — KL-iHiuiiKitv]!' \'»>ii'i.i: nr IIahmt 
c, OBvitjc of ranolc; (<rf.. priiuKm- (ftixlmn; 

f., lllblllllillOU> l.-IlVI!lup(I. 



In a sliort tiiiiP « roUefiion of eells can be Dntod 
iuniT eurfua- of tl)e bluj^lodcrmic vvwivK", Thw in known mh iho t 
c^i-moiof, while tWHiii^!e.lavL-r(if wlk foniiinK the wall of tht vcsicli 

igufiilty N|H>kuu of Os ttif 
tive chorion (Kig, 96), 
vicwwl li_v (ninsiiiitU'd 11 
tnteriuil cell-maiM appea^ 
cr thttu the n«t of tlm 
of the bliuitoilerinic veeif 
iK'Ui-e is cullinl thf nuict 
brtjiinaliii. SL'ftiona 
through it at Uiie puii) 
that it is coiiipowd of^ 
Jaycrs of ct'll*, tliosc iK-al 
rsUnor \mag eetoiienw 
tti()!-c iienre*! tiiv ci^rai 
uivilv onliMlertna!. Onf 
oarlicttt liuumn ova titoi^ 
voRilition was d<»<Titt 
Iteii-hii-t in a rotiiiidcrHll 
fUijtK of (lt>volo[iiiivnt. ' 
ovul in »\x»\m. about tha 
ar }H-ji, atui jiartialljr com 
viUi (l-'ig. iiT). I 

Tlie formatinn of n blo.*tiMicrniic vtwidi; hiw not a* yot bocii 4 
in the human orinii, but as it has bwn demonstratiHJ in the ova 
various ^iMtitv of aniinaii* wliii.'li haw twcn 
avnilabli' for ' study. iWre h no doubt Ihal it 
iMTurs ill all iiiniiinuiU. Thi^i- (■ha(i)|nw un- »uj>- 
poM^I to laki- ]i\mv whilf the ovum is making 
\U way tlirnugh IIk- Ink's, which is ln>licvt!d to 
orcujiy « jHiriittl of from five to sl'Vch i\ayf. sine* 
Ihi- only human uvuiti thus fur foumi in Inmsit 
ihnnifih ihc Kall'i|iiaii uiln? wa.j di"i'ovt>red by 
llyrll in itw nkriiii' vml lin* <Imvs Bftvr tlic* is.'!>- 
r>alion iif the mt-nntriial iwriod, TbL' earliest 
htinian ovum appearing in the ulerini; cavity 
wn.' ih-.-crilied liy IVIfm, and, although ho i!on- 
siden- it to In^ only Ihrtv days old. eertninly 
pnwcnin a tolerably atliamfd siajit- of dciolop- | 

DKUt, Tlic studios of Hraf Spc« upon tlie guinea-pig show that thq 
dermic vt^i<-V is not formod unlil afli-r the ovum Ims iM-wme embq 
the uterine wall, and it i» prnlialiK- that the same holds good for ij 
I'VillowiiiK tile formation of blastodermic vt-siele and iu intori) 
nia.'^, th« further deV('lA|)mcn( of Ihe ovum varies groally acenrdinj 
intimacy of it* attachment to the uterine wall. If this is loose, ari 
\» an ahun<Ianoi- of spucc in the uU-rtii<i <-avily, irniKirlant rhaitgrs p| 
occur upon the surfaco of the vesicle, as in tlw rabbit 




Fill, or.— Hpmak 
r.D.. nntiryoalc art) 



DEVEIj;irMKNT UF TIIK OVITM 



99 



oil, if iIm* nviiin ii^ *<>rj ininiilv. and himd t)iti>nii*.> implsDtpd upon 
iiM mncnriA nimI tmrrovr!! intii iLt ilvfiltiK. iIk^ tUan;^'s art- )iirt.-ing, 
riirlii4-r ikTi?I.i|>nipnl Ukos plaw in lite Jnia-rior nt llw vwticlc — 
(lliv) ■■ invt:r>i>iri " (it tin- gi'nti luwr*. t" wliieli altcntion wa* par- 
' dir»-t«l tiy Selunka in 1884. At first ihin wan owiniiU-nxi po- 
ll certain nxli-ntK. but it it now known In omir in niaiiv ntlicr 
h. WH-ti n* iW pi)i, slieep, inonkoy, nntl in a)i pofxihility man. We 
■'v tiritlly ctjnFJHcr Ibc flianpre? opcurrinjf in tin" raliliit ami 
II Luki- up in mon» ili-lail tltn.'.t' nlisi-rvi-d in ccrtwin roil«?nti*, 
(aki!TB, anil man. 

|k> rellii •.■nmpnBtng llii* inliM-nal ct-ll-innioi prolifi'nili-. tlwv gire rise 
und or of«l arm at one point on Iho siirfaee of thi' l>ln>toilor- 
rmbrif- 




■e tliie ^tage of 
JMDt arr nwlilr 

f ' I itio loKpr 
illy rnl-- 
I (li«>. In liifiii 
nniiN- area, whm 
jlijr InUKmillnl 
' 6nt mnnil, but 
n) in «liap«-. n(i.. 
I ■ diirl: t-entiF' 

i;..l.. ;HTiph(TV. 

iiati^ rv- 
' he arm 

.'r«l firl- 

■ i. 
nir an^a 
L'litlr I'le- 



PS 



FlO. Hi— ^:MUKr'>^-l( Aiir\. I<>hi (Iloniwl>. X W. 

A.C.. M<ra Ufiw»; A.I'.. >■>« p'Miiriilk: ,U.^., miwiilfrmip 

ndiri; F.S.. priiiiilii-i- firrak. 



Mile vnrifli?, and now. fornix vrliat Ik known u Ihrt 

i/; it» i)iiri>n>nIinlion into llii- an-a opaoa anil tht- area 

w I- uiii> to (ho TarrinK niimtH^ of ceiU rompo^ing it. inaxmitch 

MJf amuiitt>l in M-vi-ml layr* in the fnnn<'r. wticn-A-i in Iht- laller 

'"■ uindi^ nut. A fi*w liours Lnt'T a darker Eon<! ap|>oarK at 

■ mlirvfinic ithidd and conn (■x<\x'<l» it in f^\w (Fig. i"i. .W..S.). 

I (be mttMl^rmir area, vU'uiU nn wcttnn is acen ta he ninle up of 

wapad and triangular <vlU. Kip. 99. ropivwnting a <ioction ihrvnigh 

irrnnif aim of n dog at lhi# (^tap-, «liow> dislitirliy tKiil il i^ made 

*-i — iviiu]t'nn and f'Diodt'rm, Ttw mcsndenitic anil rapidly 

...■■\ and mon fornix a i-onipli'l« layer in^iile titc b!&9tod«rnuc 

wn the ectmlcnn and ratodirin. 



102 



OBOTRTRICS 



Hhown at a nlill later (teriotl of dm-eUtpmuiI; tlip nio<tullary groove 
iiiurkvHl, uud ihi- niL-KixlLTin hiLs btvoinv Ihickwed to farm Itui M>g 
laviT. 

From the ectoderm arc develojied the central nervims gyftAtm and 
culiinnoiiu slrucliinT: frimi lh(- riicMKlrnii an- diTJvwl the aiuacular 
circiilatiirv ixirtioiis uf tht> IkkIv. ihe rcproduetivi- i>rgiiii» and ItH- 
nectire-tii^eue franu-work of tlic voriouH othi-r orjians; while the enliHli 

i~ fiiwv riM- ti> (111' dipslivi- tnurl and l\w. orfcutiK u'hU.>li ans more or 

iulimalt'lv cimii'vtivl with it. 
Development of Amnion and Chorion. — In the rliicken, rahhit. dng, 
iiiauv other luaiujiiaU Uif rhuriun mid itmnuin are not foTimi] until 




Som 



C;«-wy% 



Via. 1IH-— SiumaM ninotMai Don Emdiivo iinawi!iii Foiuiatuisi or .Vwniux (Biiniint). 

X 100. 
C.f tttfonii*; Ch., iu>t(wtiorrl; Ert-, irvXinU^iiu; Knt,. iTiilinltriTi; .1/,, mtwdrTin; •S^rn., i 

(ilriiri?: Sp/., j>|ilsu(-hii»|<lfMn-. 



puriclul la_«T of the ni<-Midi<rni hiw bccoriic wdl devclop«?d and. top 
with the eetodomi and entoderm, has Ikm-d ditferenltated into Hie soroHX 
pU'urr and Kplnnchnopleiin'. Then folds of K()miiti>|>l*tiirt' arise at the hca 
and lail l'nd^ and niden of Ihe emhrvo and. i;radual).v arehing over it. ma 
togi-lhcr and fuse, thus incln«ing it« durxal f^urfnco by two inenibr 




Fui. lOi. — HiHrnoi 'rnMii'ini Urin I^unnra mrowiwi F<>av*ir«ix oi- Ammox, wftm C'lKEATt 
nEV«i.urHi^KT iir SoiiATOi-r.riiiiK (nuniirtl. X 100. 

C, c>»Inni»i Ch., notncliord: Het., ivUhlvrni: Knl., i-iilncl.-ttii; M„ meaaiXmtm: Sam,. : 

Xie\m;Hfl.. •pl(uip|ino|ili-iin'. 



.Hxnil 



The oiitor of theiw. the chorion, in compofted of an outer layer of ocli 
(Wm and an inntr lavi-r nf mewidi'mi ; wliili- in (hr inm-r inemhninoj 
tmnitm, the ineMiderm i^ wilhont nnd tht- ectwtern) within, tov 
ftinhryo (Figs. KM lo KMI). 



DEVEL01'ME^-T OF AUMON AND CHORION 



103 



/■rrmuMi " nf Grrm iMg^rx. — lit iiinnv iiiiimmatH, afler Ihc itpjicar- 
i>f iW iuli'nuil «-)l-mii»<t, furtlH-r iliirlopinntt ilix-s not lake place 
Ibc surface of Um> Uliulailerniic vesicle, ad Itas ju.-<t \mxi\ (IvM-ribi'd, 




mitiwriea Ko«uAni>K nr Ahxion. 



k 



'a mW upnii (lie wall nf m i-avilv wliii'li (li-v<-lnpK in (lie interior of 
* miininl rvlt-mitftB. Iliifl piticc^ nn? (inil lU-scrilDil by Sclfiika and 
^ a <trrUi» nHiiiiU, Haoli an Itii- nioii.-o-, mi, uikI giiinHi-pi);, ami 
»* Wjifvul to ivprf<*nt an artwnl inversion of the gprm layers, iMer 
■*Ml^tinn, lM>W(-ViT, liiu nhowii llinL it io n miidi tnotv widely ^pn^d 
?*'•". Dill ixvurs in many 
^"*"f atiiiiinl". 

N f»M appear that 
■• Urii t|<it4 not oonwtly 
■"•ritr llir prrH-nw in nil 
*■•*••»». a» itivr^r»i<iD ihtr^ 
W <v»r m thi* «trict wn«- 
** IW wrd, linl ii: *iniii- 
•*"' ■ ' l'>pii>cn( 

"'" r.a ul >i 

H* miirr nr Iahs rPitioviil 
ftw ■)_ .-■•^•mal Mirraci* 
^t' rmic YesicU*. 

'*'■': II IHO.'I. j»idilii.liMl Hn I'stTi'nrMi dt-wriplion of the priv™>i in 

■■>:-<, tntm *hii'li miwl nf (Iti- Ktatrmnit^ niiMi'mini; ils early ttti^t* 

ilflw ftTtilhtation. the ftpginenlwl ovum can Ik- fwind in the utonnc 
•■^i A»a nn'nil« maw, and Fig*. 107 and HtS Amw it Ving transformed 





Tm. inr. - Omt fl» 

UoVBC Kecks n Haiv 
«r Focimr I)a» (So- 
botU). X VHk 
B.C., tvpnmtaliun tsvity. 



Fill. I(H. — Ri.AstobEKUir 
ViJ>u'i.K «P Itlovatu 
K\ii <iv Voi-'Hni Dat 
(HubutU). X -lAU. 

Jl.C. iMHiii cnl»tipii <mvUy 



104 



OBSTETKICS 




into a blnstodcrntic vesicle; while Fig. lOtt sIiowb a later stage, fl 

wcU-iIi-^'cIhihiI cavity aiul an inli,Tiin] (vll-ina>M. Tlie lallt^r pi-ulifl 

rupitUv, and a little later iho lawr of «l 
its inner surface becomes dilTerentiateil fr( 
neighbours and stains more inK-tn^'ly. T 
tlii^ first apjioaranco oT tho enUHlcmi, wh) 
tile other cells are to l>e regarded as ectod 
(Fip^. Mil and Ul). 

The intenin! cell-maiw then proliferata 
tdlj, and mxm gives ri»e to a more or Itil 
indricnl structure, ooinjwpii'd of closely f 
cell*, wliieli projects into the carity of tht 
cic. This U covcrwl hy a single lay«r < 
boidal entodermul eclU. while the ectod 
celU which form the greater paK of Ih^ 
of the v<.¥ielc Iokc IJietr cutioidal appearanq 
lM.f,'oriii' iiliini^i flalli-iinl (Fig. 112). (JraJ 

the entodeniLul rHI^ extend oiitniird iH'vund ihi' eylindrical struetun 

t<ventually come to lino the entire intertnr of ilie blastodermic vcsiele, 

llip}' form the cpillK-lial layer of the yolk-mtp. 

While thcsi? lUiiniris are tukiiix plai'f. (he ovum liciymies firmly nil 

to Iho merit*, and, after the dUajiiiesiranee of its epithelium, oou 

direct cotilarl With (lie ninncctive 

tissue of its mucosa ( Figs. 1 Vi and 

114). Ai llie same time. Ihe cell* 

at the outer |)«rti»n of Ilie eell-niasa 



FlC. 10!), III^VTOODIHIC 

Vmici.i: or Uui-ii:. rii-iii 
Dav (ScbolTo). X 4M. 
S.C., Mvnii>iit:ilHiti CBViljr, 





Fla. Iia — lluurmnmMio Vmiici.i: or 
Uocu:. Fin*r IUli- thxTM IIat 
(goboiin). X aaa. 

Ktt,, ttiUiiUina; A'ni,. wiiliHli>nii. 



D CM. I 

Km. II !. — Ki.iHioiiKRMic Vratci.K or Utt 
I'n.msir. CivrrT, Sr.cnKn IJAi..r an 
llAT (Hi.lK.ttn). X aWl. 1 

C.,p»t-ity of tmim: CM., nrll-iunw; Enf 
ilann; Kp., uterine Fpitlioliuin; lt.,t 



mnltiply rapidly, and give rise tn the ectopia ceiitn. whtcli, inrad 
adjacent niHlernal tissue, ojM'ns up it* blood-vessels so tliat Uic fa* 



2 




DEVE1X)PUE.NT OF AMNIOS A\D CUOKIOX 



ml ihi milUTiml IiIiithI iin- hrotight 
UMklv, a litiigitiHlinal Hplil up- 
jnn a tlio uink'rlyini! cvliniJrJLiil 
aaw n| nellik. ThU riifiiilly titwonii?)) 
WjRi, uul ffive'i ri>«e to a cavity 
lukil hf a RinKlv luytT uf «icU*Iit- 
wt (fill — il>e cmniotic cnritir { Fig. 
lU). 

Ita for no tnur nf Uio future 
nAnii is apfiarcnt, but &oon the 
HbatDOi* piiini iijion Itic vnlt of 
Uvprinitire oiuiiion Itogin to pm- 
ttW(, ani] girr riw Id ti t>-pical 
mbmnic ana, vhiob llien under- 
!»■ IW Mitir rwir of (rhaiijp^ a>t in 
'V- rthUt. etcppt iliat the mniato' 
I^Mtr Uk<i> iKi part in the fonna- 
ta a/ Hh! sninian. With the de- 



inlo (iimrt roiitact Ahnoc^t simul- 







< KmI.. nilalmii ; C, c»vtly 




('■a. 113. [liJknuiiEiiiitc VrjiK-I.EnpM<>i.iut 
IS IVirniNK r.tvirr. i^tcuvo IIa4.i> op 
fiXTii iUi (SulwlUi). X 31111. 

t/.C., Bti-ritm mrily; C, »»vii)r of ovum; 
CM., rM tmu--, KnI., i-iilulpmi: Sp. 
uurtiiv rplttiHiirin ; IK, drrlJua. 




CM. 



[■'lo. IH. — Hi.*!n"i>t:KMn:Vi*»i-ij;orMo<n»« 
t^ riKKixr. I'AVirv, FiicAT llii.rorSiti'- 
KWin IUt (S<-)xitla). x3l)0. 

/.>. ulcrliw tpitlwtiuin; C., rtvilr of arum: 
ffiif,, RalailHn; a.diMid**; CM..eM' 



106 



OBSTKTIUCa 



velc>|inii'iit 'if (lie riii'MiiVrm the fiiti»il(-i':Ti U'comi^ r^rpiimUil fi 

i'(-ti>iii-rin. uilli \\w ri"^iiltii)g f'lrmiitiim of llic yolk-sac. lii« allanioiH, ] 

llie I'Xlrii vriiiirviKiic i'ii-l<ni»-. 

The TOwan-hvs of liriif Spw have demonstrated the occurreno^ 

pr&cticatlv iil^tujcnl chnii^rt^ in the fniinea'pig, except in lh« fact ihat 

rivuiri )M.-['oiiiet< eiulK'thkil in the deplhi^ of the uterine niucx>sii .toiiiL' t 

Iwfore the i.Ifvi'h>}itiient of thi- iihistiiih-nnie Vtvit-lc. 

Van Beneden has shown that the developnieot of tlie amnion ant] i 

bryo occurs in a «iiin-whnl Kiinilar miihiicr in the bat. In this case, h 

ever, tlio intttrniil cclt-nuK's A 
iii>t fiive riiip to a cjlindr 
jirojeelion into tli« enviljf 
th(! litaKloilermic vesicle, 
formii a lenliotiliir enlnr)^ 
upon it« inner Hurfaee. 
the [Ie;:eneratii)n nf ih*- a 
in ilK centre a cavity appetl 
which if that of the aninii 
while the cmbrj'o is develop 
friini Ihi- ei-lU at iUt Wi>e(ri) 
lir., 117. and US). 

In monkevii the m 
»^ta^'« of dercilopni^t 
not hoon ohsi'rvoi!, litit 
earlv ora de«erihed by SeleD 
h'jivi- It" diMiht ts to (he mi) 
of ori};in of th« amnion a 
f-nihrvo. ITuw. Fig. tl 
which representa a sect 




B. i n 



Fta. lift,— 111.* sntDKHHic V'KMri.t oi' Moi.t«: in 
UmniMK CAvrrr, Kiaiini D*i (SoIhiHu). x 22."i, 

Am., nmaiiitic ravity; H., Uiivl: ('.. fuvjty of 
ovum; D,, ilccl<lii»; Hrf,, ticuiiliinu; KnL, ttohi- 
derm; B.f'.. tcio-|>lBrcnUi. 




Fiu. 110. — Bi.\"i>.>i»:nuic Vhhi 
ItAl- (Van llriKtlen). X 27) 

C, r^vUy of mvirlv; CU., in| 
i^V-nuu*; S., cnvoluplac layl 



thrnu^'h an imHv ovum of the gibbon, iihoirii a wcll-developec] cho 
and ccelomic cavity, while the small amnion and embryonic area Ita 
by a iMflicIo from the inner surface of the chorion. At thr point marl 
" X " in the drawinj; is a d(-)ii'ession upon the outer surface of the el 
rion, which in hII probability reprennls the point of invcreion. Lil 
wise. Kir. Ufl, showing a section throu^'h a semnopithecua o7um, prese 
a typicft! early placenta with wcll-developLd diorionic villi. Tlitre 



CM 







■■%•■ 

Fin 1 Ifl. — Otcm nt 'i^i.it^oniUKCV* Nwii(-l-« (Strtcnka). X 00. 
^ •■*■-■ Ck . rhnrfnn: />.. ilrriililn^ E A., embryonic *ivji; 13.. ulrrlau t),»ad; I.S,, io- 

: -tiliui. f^ ulniiurwnll; f., villus, 1' S„ yoik-uw. 

107 



large ctvlomic cavity, while a very sinaJI amnion is lOOsely attaoh^l t^ t\\^ 
iutcihr tif Ihr- clirirjoiuc iiiritiliruiiv. The uiiibryo U ropnwinliii tiy « 
miiiute LHnhryouic area and yn)k-!iAc, anil it ia <>Tiden( that it must h.nv« 
onginuttKl Mt mmiK ji'iiiit nn tiic inner surface of tlte vrnnion. 

The* eiirlicnt hiiiniin mum will) whit^li tic nr<T B(i|iiiiiiiUNl vati (Icscril^*^ 
by IVteffl in 1899, and although we are enliivly i^-norant concerning ils 

earlier (i|age», there i* vfr^^Tj 
riiison 1<> ftujipate that it V»e- 
came implanted iipnn ^Jltv 
uleriiie inuci^a, tih^nlieally nt 
descrik'd by Spce in *: Ic 
t l^^lE? Nrf^^^^"^ guine«-(iig. Ill this ewnt ■*: lif 

\' CM?1^S^^ft minnte ovmu woviM bori-«=»ii 

\\ju -f^-.^^^^^Jt*'/-, -; I tlinuifib thf uterine i")!!!!**.^!!- 

1*^«iJ '^^.caf Af*'^^. U'l'. and conic to lie in dtv 

-v/Ti III //*?!_ A^tMfi?^' inU-rgbindidnr liwun lieforo. it 

had reached the voiciil'V 
A»ffi "f develiipriient {P*^*- 
121 and ISO. 

I'<'liT>V specimen, wHi*^!! 
was f()und in the nterus i>f ■ 
u-nitian who eoinniittcil anioi*!^' 
three day!- after miiising I^*'' 
dienstnml jtt'riwl, nicii-tiif^ 
!.« X 0-8 X O.a niiiiimetn--^ '" 
it* various diam«tcr«, and T"^ 
BcntiHl a well-developed ctic»«"'" 
on «Tu1 » very i^innll anmi*"'' 
Plate IV rejirei^ent.H a seet'*'" 
tliniu)i,'h tin: [lurtion »t **"' 
pidua in which it was e*"**" 
biiidif!. and xhttwit )}inl f.t^'' 
ehorion is made up of (»^*"J 
liiviT- — a tbtn, iniior Inyvr f" ' 
connective tiK^ue which is pw" "^ 
in cellit and fornix Uie linin 
of ttic co'lomie cavity, and a 
iniler layer ixiiii|)iK>od nf maii_<- 
layers «f cpttheh'al cells. 'nK^>-^ 
latliT form a capsule of vary— 
iiig thieknt^w about the periph- 
ery of tbe ovum, and arv des- 
ijfnatiil us the truphiihlati, 
which in IMersV opinion rep- 
resents llio primitive ectodwrn of Ihc ovntn, Tlie majority of th*> ciA\* ar? 
distinctly epithelial in appwrunce and f»orisef« we!! -ma iked roundi^i or 
euboidal bmlic* and vi'sioular niidM. Scattered iK-twecn them arc maflaes 
lasiu which show no sign of division int^i^^vii 




Flfi. V20. - Surnott niROi'iiii Ynit.vo OruM ar Jlt- 
LMiiATEA, nnowiKo h'oiui*Tioi« or Aumiun 
(SclMikn). X 8. 

A.f luuinriii; a., uniiiotic |H*(tirl<^; /I,, hti^Hi-votfcl » 
C. chiiriiiii; C.V.. {■Imnmi.ni villi; i»., clMridiin; 
H.t Nnhrytt; /,, |)o^rxt nt uiveiwon of blaatodi^niiiti 
vnaolis Int^ itiU>niUou> npuoo; y.S., yolk-Mo. 





DEVELOPMENT OF -IMNION AND CHORION 



109 



tin irrej^ilarly eliHp^, durklv xtjiiiiin;; nuclei. Tlio tropIiiMni^t has 

tl llii- ■urrounilint; ilm<]iial lUiiuc nriI opencKl up numornun hlootl- 

p«, m tbat innnv com para tin-ly Urge blood spiMi-s lutw Uvn runnvd in 

from Uie uuil«lying coniuvtivi- tii^MW of lli« chorion. nuMu-n>ii» stmill 

prowifM-s |>n>jw) inio Iho tropltohlfl^l 
,-Z. /* c ami ri'imtM*!!! Ihi* (Wrliwt i-tagv* in 

' ' " Ihc fonnatiao of diorionic villi. 







HI .^'it'initA Pm** Ov™ Attacbed Flu. 133. — Ortrw «i' <U'im;a Pm Bimnov* 
p iTmisK Ui-'ixHUi Sktksitii P*r ixfl TiiRoiiiiii I'Tcitiit; Uivoii^a, Skit- 

^it\ X 375. i^.vnt !>«» <Si«e). X .I"'". 

VBoiUlimi raviijr; f^p,. iiu-rini' ir|nlli*> C, capillar}': /'.. ditiiluB; Kp., ulcrin* fjA- 

SU„ Dvum, JC., tutB ol (icUuciib. tJiulhiBi; O., (inuii. 

f i'i'i. ■ hiifhly i»a;tiitn<il Mnc-tioit oT thn *-in1>M*»ni<- purlimi of 
I rpecUDcn, ^hoiri. a minulo amniou id contaet with Uk- chorion. 



^% 




--ect 



mc9 







l— Po«noK o» Pethui'b Onm, llti:in.T MAOninicn, uRovfiieo R«u.t Staoe i« 

Dtt-EltirMEITT IHf K»in«Tl>. 

p C, eharlon; wf.. rctudciiB; inf., cnioiirmi: Mfi.. iiiraodunn; £.£., nabryoaic 
■lucid: r.fi.. yolk-SMiiSp.. [mrtiaaorcrilun. 

Wary Hiuhrvnir- area, anil a Ten' (■mall yollc-MC. Accnnlingly, 
Lijipnir tlinl tlwse strui-hm-* i-oiild not liovw developccl upon Uic 



110 



OBfm-rmics 



outer ^urfacu of the bln^^tudcrmic vvsidc, mid that the amtiioa could not 
be derived from folds of soinalopleure; (X)nsec[uenllv, lh« assiiinption 







Via. vn, — MiciinBt-oi-it- SEcii't-i. (nmwivci Strvt^^'Oxm' Ovitj EMiiKmicn-iM DeriDtiA aim 
StiHK<>i'ii>i:i> 111 ItFciiiLM fii;ri.£XA [Lnipold). 



ajipt-an! jii>'titicd ihnt mic ha* In dt-iil 



I 




FW. IZSL—Bl^R'e Hl^AK OVIM. I.UIIRVOMIC- Ama, 
0.4 Mll.l.lHinRK [.OKO. X 2*. 

A., amnion; Bt., Kbdominnl pnllrfi-; r., rlinriiin; e.f-.. 
chnriiiiiio rpidirliiim; e.m,, dioiloiilc ini««<lunn; 
v., cliuriuiiir villi; >'., jrclkfOio. 



with an " invnreirtn." just as 
llic IvjH's idnwly coniiidcTwI. 
TIk' only dirwl c'\'idonefl 
in fiivciir of fivic'b an '' inver- 
sion ■' was offeree! by Bwidw 
ill mm. who vt'ry hrit-fty de- 
scriln-il iiii I'Hrly htiinao otuhi 
in whicti Ihorc was a dirw't 
cflinmiiniciitinn tx'twt-on Ihc 
Mirfaci' of lh« chorion and 
tI»G anmiotic cavity, 
ITi* (Ii'scriplion. how- 
ever, ia so mongm th«t 
il is imjHiiiKiMo io base 
any definite rnnehisions upon 
it. From Ihc cvidpn«> at 
I>n>ienl available it it|<cnit 
peniiissibto to aK<iiini> that ir 
liiiinait iH-iiigH the <!horion 



DEVBLUPMENT OF AMNKIN AND CHORION 



111 




Flo. 12ft, — Skctiojc Titnoiinii Si-rir'H V'>i:s«is«' Otpm, unnwH 

ts Kii;. US. X :iJ. 
&, cbnHunir ttiranlimiii', rrl.nrtoilenn; vui. . mr-mlcnsi -. am., 

nllnntnaiii f/j., yalk-i 



npnMHts UiP nutcT val) of tbe MsAtoili^niur v<>^irlR, nml Ihal lUo umiiion 
tiifRlu|inl bj 3 |irou»« of " iurvnsiuii," whilL' Uiv embryo ih tlerirod Iroiu 
u cnibrTDitie anw 
rWh ^■pea^e a( some 
pMDi iiMxi ihv iniiur 
of Uu! taller. 
!l of Iht^ larly 
m itoefa luir« Im^n 
•(■JM in «i/u tiitice 

'i -)t:riiiii.'li leavi; 

iliiiibl OK In 

of implan- 

Oh' 'tvuiti, 

rintiy imlicale 

il |>'n>-|riiltT« Ibi: 

-|ii(beliiiRi 

•■J •«•" bi li^ in ll«' ilcptbH of the tldridua at n verr early period. 
8«di fndcnco is alFordwl by the ti|M>ciiiif!n.-< disioriliii) by M<-rtlen*, SjHf, 

Ibit^i-Doria, and Leo- 
pold in 1H!>7 nnd 1!)06 
(Kig. 134). 

.An ovuin from the 
(iocoiu) woek, described 
by (Jmf Spw. give* ux 
importnnt information 
mntvriiing llw iimnion, 
and, although it does 
not pnsM'nt tbe o«rli<*(. 
¥liigi?s in its formation, 
it ^TVfs to (ttniirm the 
vifvn just Btated. Tho 
entire ovum in thiti riue 
mfoiKum) ft X -t-^ mil- 
limi-trotj in ,diain«l«r, 
aitd jxwscniiixi a w<?ll- 
doveloped diorion. a 
|iortion of which i« 
»hovii in Fig. 185. 
I'liijtvlinp fn>rn one 
point of itf interior is 
a .imall vistjciilar ittnuv 
lure — the beginning 
eiribrvo. 

Tig. I9B reprewufct 
a Mvlioii ihroiigti the 
fvme oviiin, and .■'Imxta 
clmrlv the rcUtionx of 




tlir.-OM<i 



Ontrti. 
; /*., pOmiiWs atrmk; tt*.. vctodnnu; 



112 



OBSTETKICS 



An 



'y. 



r.-Mu 



l~ -««. 



-.t*» 



^U 



I..C. 



-ii^T flc 



Phi. 128. — Hvmjin Emiibyo 3 Mium- 
iiin'TtiH haxa (flmf 8p™), x 3a 

unle villi; B.*., Haiieh'titl : W.(r,. 
mfdiltUry sroovr-; .Vj.. ni-Urcn- 
(eric canal; /*.»., primit»T utrvak; 
r.i., ralk-«e. 



thfl three ([driii layers 
are well doMuiH-J. and 
with tlie >'\ot]ilif)n of 

tilt' CIltlKllTITl Crtiwist of 

*evi-ral iflvera of ciAW 

Figs. 'u» amt laa 
repreflent an older 
ovnm. with nn ftnki^'- 
(iiiic- nwfl -'^ millimetreA 
\nne. which wan nli-o 
th'NTiUii hy (Jraf S(hm>. 
and which he helicvitt 
lK'l<m)rrtl to thi' Ihinl 
week of pre^iijiiicv. 
Tin: nnhrj-o in ntlacht^l 
in Ihe inner surface of 
thi^ chorion hy the «b- 
ilotninal jiediole, and is 
made up in great part 
of the yolk-«ac. The 
emhryonic arva ig ovnl 
in sliapc, lind presents 



its various part«. The embi 
tuc-hcd to the inner surface of 
oitie nifiiiliriine liy n nKwoih-rm 
vfhieli rcj»rcBemg the earliest 
tiw abdominat pedicte (t]ic 
of tlie Uermana), which is tl 
Bor of ihc umbilical cord. Tl 
[HiHion of the OHii»r\-« is occup 
yolk-.'*ac, from one end of whii 
process, lined Iiy entoderm, w 
Iw consiilertJ an n nidirnentarj' 
pxtcnd* into the [MilicK'. <)c«i 
side of the pe<licte is a small CI 
hy I) ninijlf luyi'r of eptthellt 
corresponds to the amnion. O 
of ihi*, (tjrnin. i* a nn** of wIIj 
in several layers, which Tepri 
cmliryonic area, in which lh<'n' 
itivo streak. Fig. ISt represenl 
nin^ni/ii'd KiTltoti through tho i 
cmbnio of the earn* ovum, and i 



p#- 



£-. 



r o L H SAC 



Fw. 129. — Stenrin TniHition HnWAW Own 

Fm. rj8 (.Sprv). 

OiTiri; tifi-, nbilfiiiitiiiLl pt^-li^lr'; ^,. Si^nntiv * 
FntodcTin; n.r., neutrMrni- numJ; pt,. print 
>■,. chorionic villi. \**., vcwoU In wnll of^oU 



d 



STRUCTURK «F THE CHOKION 



uhI 



iH^nMiiillnrv groovo ami printilivc stn-iik. Tho Iwo arc not in iiw. 

i ri((hi. urigio; to Uh; fornii-r 
BGtwm-D (lie ivn i» a 



plane. I>ut IIh- luttiT in In-iit ulnioet 

oiiibryoiuv ar<.>a. 



/.^'A^^ 




I'ta. 130. — SlMTWiW Tnwnnti Hitk'h Oni . 
HvcH (Ksf» n»- Hmiim- Wl'l,l«,). 

An., nmnion; fri., irUHlmn: nu't., nmHh-nu; rnJ., niloiicnal' 
JIf ., nmtiillBry Rtnuvi'. 



o«x«pi(M till- inforiur end of Utc 
umQ cijNiniQ^, Out ncu* 
iMlcric L'anal, whicb 
k-noaa to mniKVt I lie 
vctixlerm wiUi the 
alodc^rai. Fi|{. 1^9 

itironicli tiit> Hanie 
'wkh, mil (ilMiw« a 
wfl-*l<'ti4iii>wl I'ltnrion 
■ilH typical villi. while 
lunoMin if n ^rnnll 
cloK^y appliiil over 
"*l»(tinning (■mltrro. 
^ hifthly ma^ilM^ 

^ym anil » tt-i-ll-il>-vr|i>FHil iu>iniito|>l<!tiiv ami .tiilanthiinirleure. By th« 
.'^'tliag lit llw fonner it is iwwlil.v nixlprstood \mw tin* body walls arc 
***imsl, and lijr that nt (he latter how IIm) priiniliv4- fpil hiiDini^ dilTer- 
^Imtnl front Uw ynlli-sac. 

Straetnre of the Chorion. — In it* wry iiiHii-^'l stii^i'-s the rhnrioii pvoli- 
'*/v (-nn^Lsts itf llif »iHgli- hm-r of HlfMifrmBl <f!t» formiri)!; iho wall of 
')«■ blm^mli-nniv feaicle, which noon becomes lined by a tnraodcnnic layer. 

S/tnn nflcr the imptuntation of lli^ mum in the 
uterii*, howpver, m» shown liy the ro^'arohcs of 
Hiilirivlit. Mfukoloin. ami IVU-r'. the ehorionic 
epitlu'liuin nipidtv pfolir<-nilcs an<t form.'! the 
manT-Uyered tmphoblast. In its csriiwt nWge* 
the ehorion is prnhubly a !inii>'»lH ineniliranoiH 
*ne witlumf villi; liH( in a short lime Duds of 
runnfftive iissac make thrir way int" the \rn- 
plmlilH!^ ami j-ive riw to niilimeniary villi (Kig*. 
1.11 nml Wi ami Plnte IV). 

Kijr. I3.T reproscntit n R-etion thronsh Iho 
ehorion from a two- to Ihrei'-wwks' ptV'j; nancy, 
T'l it ean Ik^ 'Ii«t)n;[oiiil>ed two pnrtion<t— Ihe 
ehorionic membrane and Ihe villi projeetinK 
trtim il. TFif eborinnir membrane eonxixtn of 
two Invert" — the inner of eonneelivi' linMie, the 
■Abrrnf ppitlu'lium- Its eonncrlive liMur is composed of ■ipindli'- and star- 
^pd i<»ll« iinlNildnl rn a mnraid inlrreelliilnr Milwtanw. and at thin period 
«•• M mntnin Mood-ves.*i>l». Iln epithelium is arranj^ in two lavem; 
■" imriT one iHtjoinintr tlie eonnective ti^ne, whieli i* wmpiMi! iif Kharply 
^afW rufuKiIiil or roiinilisti rells wttb rUiir protoplaum and lightly .*tain- 
*t wsimlnr nutlri, and nn outer layer made up of oa«nely granular 



' f •■• *" — t*KTr»- w Ruarr- 



1]4 



OBSTETRICS 




Flo. I33.>— Twn-WKBKs' IfiTUA.1 Utl'M (iiwupulti). 



proliipIaMti, wliioh Ahnvrfi no !>i>'iix of division itito ol-IIk, aS^^nmigll whic 
are sciilk'nxl irrvnu!tirly ^lnijii'ii, iljirklv .ilainiiij; mu'lfii. 

Kai'li villus iii-isf-i frrtiii lln- chorionic membrane an a single stem, fill 
jng origin to nuiiieiwiiH Ininctn.-- which rvfuh in a more or li'*» »rlH>ivJ*«!il 

Torin, the cnHuplexitv 
which incrcasvti willi n<l 
vaiK'ili^ *ge. The \i|{ 
coii>!i§t of a ntnni.'ciivi 
t))txuc ittroTna nni) uu r 
ilu'lial coverinjr. th** for- 
iii'T l)ciiigci>nliiiit»ii!t with 
anii analogouB in sinie- 
hirc to liic poMncclivi" 
tJi»ue of (he chorionic 
mi'nihrunc, w]iil« the L-[*i- 
tholiiim is conipoivd of 
tlic f^aine two luwrn. 
Projeelinji here and there from the snrfaec of the villi are e|>tlhcl>nl 
bud^. iiKuullv conKtf'tinj; of a ma^u of pmlopWin which i« not di\'idi-d iulit 
(lintinct cells, ami which, when seen in cross or tangential section, ivs«-mMc 
giiinl «r!I«, Tht^t Imd* iiKlicnle iiniliftTJition of the miter layer of tlie 
chorionic c|i)tlieliiHii, and r(-|ircscni llic lirst stage in the <)evt>Ujpment of 
new villous limnclies. Ih-re and there in the spaces botweoiL the villi, 
liirger and Ainalh-r masses of small, cit-nr celts with ve*iciilar nuclei an- 
Reen. They are iirinally dt^criliwl as ikritlunl ixlnnils. and weiw MipiHisnt 
to rcpresicn) «'clion* thronph decidual wpla, wliicli pnycct upward tuwnrds 
tlie chorionic memhrane. In reality, however, Uiey arc masMOi of trop): 
hliwt which have not W-n conwrtcd into villi. 

In early ova the cmhryo is cfjnniH'ted with the eon noe live- tissue luyw 
of the chorion hy a nic*oilerrnic pedicle, which vim (irst describe*! \iy Iliit 
as the tihil'itaiii'iJ jifiHrlf (KanchsticI). In it can I* olnservifl a vmall 
process of entodenn which represents an extension of Uie hind^t, ai 
which eorK^ikOiKls to the allantiiis of lower verHirat<». Throiij^h t 
ahdoniinal pi-ilicle the umbilical vessels of the emhrvo make their W*y io 
the iiilcrior of the clmrioti, which then In'Comiw vasi-ulariziil. 

For otir tirst definile information eoneeniinn tJie structure of tlw fiili 
derelf'ppii human rhuriim we hr? indclitcil lo Ijiii^huiu. who showed tli: 
it was made up of fonr layers: a gelatinous, a filirillar, a vascular, and n.xx' 
qiilhelial layer. The tn-hiiinniiii is the innermost Irtver and is c•1mpo%«>^«^ 
of star- and apimJIe-shaptil <i)nnceiive-ti!«mc cells emlietldcd in « mu<*>i4j 
■nicrcclhilar sithslnnce. External to this the ctdla become more fiisifovn^ 
in shajH- and relatively ahinidanl. itri that the meinhriine assninc* a moT-^e 
fd)ri!lar ap|H.>arance. Rcattereil through the portion just outside of ifai^ 
wcoiul layer ari- niiinenm'i vcwcl*. Imth nrtcric* imd vein<; while still nW'ra 
exU-ni»lly eom(«i Ihc epithelial covering, uhieh is composed of the t 
iayent alreiKly <K«cribc«l in the sorcnteen-days"-o3d chorion. 

I'rojeetinp fr>im the outer smfaei- of the chi>rionic uiem1>run<- arc v 
merous vdii, which at first are pretty i-<|ually distrihuti-d over its periphery'- 



Dl^^ 



/ 



STRl'CrUUK OK TMB CHORION 



115 



■A* {iRfiiaticT aJvant-cB. hoirover, Hm'J Uvonic mure abun<liiiil om^t llie 

fMrtno wliK'h is iu itmuci wiili iIk- (k-ckltia MTiiliiui, the dite of Uk' fuluixi 

^iHcnta. Tina portion of tlw diorioD ia deaigQatcd as tJif cJiorion fron- 

*»«(»«, whilv (lit n.-itiuin<liT, w)itL-h is in condurt witli llw duciduii reflexa, 

■ If'-naod ihe rkoriait titre, siitce lli« villi foveriiig it meutually undergo 

mnjilfih degeneration. 

■\ tertain nuniU'r nf villi rxtend tmm tti« cliorionic invinbram' lo the 
nntJerlying dvcidiM, aitaching tltc ovum to it, and heaee are di^signnlitl 

^'* fiutiminff rillL TIw majority of IW riiti, Iiowctit, >i|iring fniin the 
™'*rionic ni«nil>ranc as ariniratccnt structiiwn, wIiom- tnv eiidinp- do 
**»' nstch tbtt ilwtduu, and which invrutwe in wnijdcxitv ai* |iri.-gii«in-j' 

In mrijr pn-]iiian<-T Ihc villi an- i^ltort and pUniip and represent simply 
, lli<t niain etrms, which later giro off iimiitrniUK liraiidiOH ami a.->:iiiiiir an 




^*. IS, — BncnuK -miKit-aN TtrH-WK^iii' Hliiu( Ovt'n, luiowiNa <:uii<(io!(, Dtxunin amu 

lMimTIU.Ill:H )4fA(-KJI. 

^-^-.■alvr^ bluad-iTwH; C.il.,tbonome tnciDbrBiu*; ti.Atviilii*;'!., iiluriiu: gUnJ; IM.,. 
tiiln-iiDiioa ^tKBp; S,, aiiiejtiiaii. T,, tnifilanUaHl; V., vlUilii. 

"'wTw^nt BjijHnratKi-. Tim*. M-ctiona 1hmn)Hv a yoiinp chorion show only 
' '•-»■ larjfe villi, while those through an older one arc lillwl with a multi- 
iMp nf KtmUUT vdli. This ohanp? in «pp«>aniiMi' is Hue to Ihe incri^iing 
""Ore-renc*, and niay Iw coni[«ared to whni take^ plaec in a I'lunip of 
I"*, which st an mtIv period an reprewnti'd hy m nnmber of alnnwl 
■"•Med tmnlcj, hnt lattrr pve nff inniinnTHhle hranclMhi ami twigs, lltese 
■SweaeM hare b«n particularly euipha'^ized by Dc I^oo*, who haii shown 



116 



OBSTETRICS 



thnt with a litUe practira one can roughly cstiraaie the sf^ of the chortoo 
by i\* appt^'HrHiK-*- <ki »ix'ti<in. 

The (ilroma of the chorionic villi is made np of connectiTe tissue whi«h 
varies in ap|>t'antmt^ actonling Id the ugi' of Uic chorion. In tlw eiirliw 
staged the ccIIjj are braochini; in lihape, and are separated from one anolhal 
hy a large nmouiil of muvni^ inti^rcvllutur milulnm-e; l«l«r on thfj IxTomef 
more .■•pindli--shajit!d and more closely paekc<] tof^tlier, m> tliat the i^troin*! 
asfitmies a deiuvr appearancu (Fig)^. iM to 13(!). Aft«r the fir*t fo< 






FtO. 134.— l*t(l>IIII»IC VlU.a, VVi. VA-'. — CMIIKItlSlP Vtl^ FlI^ t.tfi.— <'llflll(l>MC Vt 

TniRi) Wr>k. X'£a. uu AT Focicni Month. i.iii at Kiktm UoimL 

X22S. X2I3l 

wooks blood-vc«H;ls appear in the stroma, and in the later months 
lircfinain'v thi^ artt-rifs pn'si-iit llni'V walls jxwwitj'ing the lypiml Ihr 
layers. The arteries and veins evlend to the lips of the villi, where Uic 
break uj) into copitlario*. but Uiere 'm no anaKtomoisi^ between the vaiv^iili 
.iiippir of llie viiriouA villi any nioi'e than lietweon lh<> liraneheK of diiTerdit 
trees in a forest. 

Tlip fpilliflium iTivi-ring llw villi viar iiii>nl)on<Hl liv Uulrymplc in ISl^ 
but lias fir?it deliiiitety described by [.anghans many years later, 't'he 
Itilter pointed out Ihat it waif madv up of two layL're similar to ihosv whieh 
have lK*n dtscribud in the seven toon -day s*-old chorion. The inm-r l«yi 
was dfsijinated as the cell-lar/rr (Zdlschicht), and is now f^-QL-rally known 
a.H LiinijUiin^'g ItXt/rr; while Ihe niiler layer is ii-inatly known iis the .<y« 
ci/tium. The term " snicytiuni " was introduced in 18113- '94 by Kotwmajinl 
and Merlleiis, nilhoiigh thu eliMracteriislics of the lisMue had U-cn n-cog- 
nisod years' before by KaHt.-ehenko, who d<-serihwl it a* pln-'mrnliitm. ^ 

Durttifi the lif-t linlf of prcijnancy the two are readily distinguisliMl.fl 
hut in tlie j-eroiid half l.aiijrhan.'i's layer bceomes more and more indistiitct, 
80 tliat at the end of prejjnani^y ihe ninjorify of the villi ar« eoH'red only b 
by a single layer of syneytiuiu. Figw. 134, isn, and l.liJ jfiv*- a goiwi »d<4^ 
of the suicesdive change.* in ihc vtroiiin and epithelium of the villi at 
diffirri-iit ages, f'arefnl eumiinnliim nf properly prepared specimens sJtowa 
tliat the outer margin of the syncytimn does not presont a iimnoth surTaoe, 
but is made up of a lavor of vertically arrangitl pwudopodia-IJIw. proti 
pUsmio process. These structureH are too coarse to ho conaidcred 0* cili 
and are detignatiil by ilan^lmnd. Bonnel, nofhaner. and others as Irrisdi 
like processes — " HorstcnbesatH." 

The origin of tho two layers of chorionic qiithplium has given rise 



lUnV 






STRUCTURE OF THE CHORION 



117 



• prti dt-al of liiwuMJoD, hut il lini Itw^n t^tabli^Itod hv the work of 
ifhiiiK Ivaistmrl)i.'nko. Minot, Wobxtor. lU'iikcIoin. Uis Itugp. and rctm 

llai Ihn are boUi of itetiil origin, and are tlcrivM] fmm th« ectoderm. 

Vtttn Ku demoiutratcd that ttivj both come from tho origidat tropho- 

bintu imering of itw ovum. He belii^vnt 

tbt llri^ va» ori^iiiHlly made Up of indi- 

niai (rlln, vrliii-li, tmwi'Vi-r, txi-jiitM! iiiii' 

•Mini mto sjucytium wlwre Ihey came iii 
|b Hffitirl *ith t]ic tnalenial blood. 
H^ TV' frrlal origin of Uw two Urers oi 
^■MWl rprlWIillm \ws aim i>«Vii cnn- 
^H^^^^ tiH> wnrli of lltilirecht for lliv 

•"WnK. Doral for dogs, KriiikH for 
|h bhht ttKi-u^ (if nniiiinl*, »ntl Opiu for 
B A( ini'M-n-l'iK- i^'- I"*! nibbil, and is at 
■ ftal llif pn^vniliii}; tii*w. 
L In 18*3. Ko-^mann adrancvd llie thc- 
H m; Hat the oytii^vtiuin wih dertvud fniui 
W lb' (^iMiitm of tilt? titi-HK. wlitlf) I^ng- 

^1 Uti-f ivpnM-nliil (Ik- nrigimil f'l'txl 

«*«bnB. lti» work was apparently con- 
^ btvil by SIiTlli^iM a yonr latter, who 
B <i*tnl niDcloifively tliat a oertaiD atnomit 
" J llninf rprltii'liiim wa* (omortnl tnt" 

*<iciiiira, ami thought hiin.-olf jiL^tilloi 

■ •wBrlndiiig that it gn-w up on-r t\f 

"Bitrtich Dp 1(1 tliat tiiii« wiTp oov«rcii 

^4al; i Finglc Inn^ of Langhans*» cpIIs 

* Ilrtil i^-tfKlcrni, atiil Ihii* gav<' thcrit 

"wwnnod or oiilt-r lawr, Tlw work of 

^'^nua atui M'-rtti^ft* wan very plau- 

"■*? wt forth and afrompaniwl by do- 

■"*• nn-lh-nt illtiafrnlioiK, and lh>'ir 

'■Wiuinim wpn- »ooii adopti-d tiy mans 

"•"wiiiw. ani'itiir wliniii wc may mcnlimi 

""Hani! aiitl Kolltnuiin. It wrouM mh-oi. 

"•'•w, ilial t]ii- vi(*w i-i untenable, iiui«- 

■••ili tln' work iif llnlirxvht. [[eiikclmo, 

•■' Vhij* lia* -hnwn that the orum irt 

•""^iJ"! hy the maiiy-laiTnii lr"j>(Mi- 

"•^ Wor» liiB fiirniatina nf the villi lie- 

II*. a«l that IIh' gyncytiiim reprewnls 
J. •')'• mmlifiniti'in of it. 
B ftilJ moro wtivinoing evidence acaiii^ it* ntoriiW! origin is al?ordt<l 
V 4 Ai nseot wrk upon ihi* implantalion of thw ovnm. Ait-oniing to thi», 

'•'•nun rserU a corroding infiitcncciipoii the wtraine epithelium vriUi 

•*»h it fiml 1 I wnlnot. and. in-notrating it. won nink* down into 

••ifcplli* of ■ ilia, with which the fa-tui ceUs come into inlimato 




f'w. 137.— Trail. HrciiB*, nuiinxii 
Co.vvDwios or ErrTRr.l.tt-M ixro 
Hvni:ttii-m. 

Nvmul n><il":l^"i» *» Ml, ■jmcytiuBi 
on right Md& 



lis 



OBSTETRICS 



conuwtitin (Fi(£«, 121 anil 122), Cons«iuenlly, it may be poeltivclj 
that ttu.' i^>-Dcylial inyi^r of the- cltoriou 'n not of iiin(>.^rnal urigin, nDdij 
»uch a vtuw is a rdio of the old and discarded tiworicts concvmiW 
itnplantntion of th« ovum. j 

On Itiv other hand, it niusi be adniittei] titat th« iiiuall areas of v^ 
cjiillu-liimi may occniiionftlly awuiuo a diiitinctly symrylial appearance^ 
not a fpw of my t.|xtiiiivti* I'lmtlnn llii? view ( l"ij(. 137). This ixritrn 
hovwiT, tiiHi<l Ik* rc-jtarded a;* (-M-eiitional, «Jid even when ]>or(ions fti 
converted, tatisraclory L-vi<k'iKx has not bi-en adduced to »how thul 
tisKue )[niH-.'< lip oviT Die villi and j^ivcst ri>« lo tliHr nyiicytial eorcl 
Tlif fonimtiou of syneytium is not uccv^arily characteristic of pre;^ 
nn<l mar occriir In other cuinliiiiiiis, us (ii'hhtird hii* wWwn tliut it I 
oecnsionally lie oh^rved in carriiioitia of the non-pregnant uterus. i 

Tlie thi-orv of Kn^^iiiann iitid Merttni" is ouly one of a large nil) 
vhich have liMn advanced in explanation of the orisin of tJie cJiofl 
ep'llK-liiiTii. Tlnw »hi> an- iiili:rc.->tcd in tin' Milijoct arc referred U) 
article of \V;jldi-yer, utto in ISVIO was ahk' to arrange in ten groupfl 
uuiiK-niiiN lliiTtiriis which hnd hiim ad^imrcd up to thai time. I 

Strnctnre of the Amnion.— In the very early staffori of prti^anq 
we have already I'houii, llic amnion i>^ a small *ac which arches orai 
domal Hurface of tlie eiiihryo, and later heiroiiies larger an<! eoniptl 
mirronnde it. At lirst the amnion is minute and occupies only a 4 
portion of the entire otuid'; but a* prugnaney advanem it increaKe* in 

until cventuallv it o 



in contact with lh< 
terinr of ihc ehonon] 
obliterates the fli 

r*iJJf. 'iJf '"J" L ^^fc_;_, embryonic portion a 

'\W !' ■jl ^^BP~^ "" ciilome. When the ( 

surface of ilie aid 
)ins applit.'d itself tq 
inner surface of the] 
I inn, the two meraln 
!'(conii' .ili«;litlv u 
■ ui, but are nover| 
intimately conntj 
for even at the 
prc^rnaney thin- 
readily :ie(<«irntp<) 
one another. 

From its earl 
Mages the amnion I 
»i*ts of two tavern 
outer layer of me«)derm anil an inniT Inyer, made np of llallenifl, at 
spindle-shaped ectodermal cells. The mesoderinie liiyer eventually he 
converted into niucoid-likv ti>u:iie. which does not contain blo«>d-v 
while the ectodermal portion chanfres into a single layer of small cull 
epithelial cells, which by thc-ir origin represent simply an extension 




nOL lis. — I'TTMra UMKO OT rhCnroiTA, COHTAINnO Hkvkh- 

■ro Etmrr-nAYB* Ovw (Lcopotd). X I. 



DBCTDUA 

nf UiP liDitiryo. Id soiucvKat moTv Uinn nne half of nil pinn^nlii* 

at limn. Email, mimditl anas may be otwervtid upon the aiuDioo, par- 

tioilarljr in tint itcighltonrlxxKl of th« atMcliinent nf the uiabiliml oord. 

I rpoo microscopical examination ibey an> found to be made up of «tnitiflu<] 

|e|>ilhc4rani. whicb bcarn a clost.' rfst-mbUiice to that of the ekia. 'Yhey are 

[tl'-^ii^iutml n* iimiiii'iiic i?antiidp», aikl wiil be L-uu»i<lcr(.-d moro fully iu tho 

iplL'f uu tiK- piilh'ilo^- (if tlie ovum. 

Sfxm aftiT its rnniiation, a certain amount of clear fluid collects within 
Itlw amniolie cavity — the amni»tic fluid — wbli-b imni-ati-?! in i|iiaiilily lu. 
-prcgiMUKT ntlvarices. The anmunt varies within wido limits, and according 





>')«. I3B. Fv. 1 40. 

•W ai, 140. — puoMAMit lu-raniATiKi; tli'Tt-miiAic I'iikohy or FunitATinK oit DKCwrA 

KKn.KJCv 

'■> ffhUng iiTi>raf!i>.s alioul 600 cubic wntinwln^ at tl«' end of pregnancy, 
(ItlwB^ it may be as much as 2^0 or as litltc as 265 cubic ccniimetnii. 
'^ ipwJlk gravity rangi^ fmm l.(Wi to I.Cl'Jtt, jmd il <«iiitaiiis a certain 
**<"ual uf iiHiumin, iirt.-a, krcatin. and variou.4 salt^. Tlie ori);in and 
'•iptiao of tht? aiiiniolie fluid will b« «>nj^i(iw<tl when we take up the 
f^J^*nk>ff of the feetus, 

Thnt far wv have li<H>n dewribing the fn'tal memhranei^ Before taking 

^ '' ■ nf the filacetitn, it will Ih' neeeMar^- to coiwidt-r tho cliaiigw 

ii<:^rinD inuouH memhrattt- undergoes to prepare it for the te- 

T**i<i» iif iJw fiTum. 

AMtidaa. — Tlte iWi^lua i» ll>o niucouK niomhrano of Ihn uterus which 

onderffono certain clianges under tho influence of prej^aiwy. to fit it 

■inn and nutritinn of the "vum. Il i* wi niimni from the 

1 ')fr aftpf lalxHir, Th«? older wrtlt^r* luiually di^tin^u itched 

tbe dei-idoa nf meDiitmaUnn and that nf pri!<niancy. but the em- 

1 of Ihf former term is no lonper jujitifiwl. since it lia* been shown 

rbnr» i* no jrrest Iobs of tissm' at the nw-nxtrual f>erio'l. 

iTsion of the mucous membrane of the uterus into dccidii 
:iij after Uie fertilixattoo of the ovum, though we are unable 




Ab 



120 OBSTETRICS 



\ 



(o Kliil(! oxiictly VI lien tlie process commences, inasmuch as a fairly weW- 
iiiarki'il (iwJiiuH was preseni iu all of the early pregnancies which have 
thus l'nr liii'ii ilfx-rilMKi, lieing wdl develo]KKl in the specimens describe*!. 
by IVUts jiiiil lAtiimld, wliich belonged to a three- and a seven- or eight,— 
days' pi'c;,'iiancy riw]>wlivuly. 

Very .shortly afUT conception, the smooth velvety endometrium t*^*- 
(•nmes rnarkeilly thiekiT and its surface is indented by furrows of consicl- 
erable dejitli, which give tliG entire membrane a mamelonated ap|)oaran.«i;e. 
I'lider IJie nuifriiifyiiig-jilass nuintTous smalt openings can be distinguisl"&.^^ 
which are tlie mouths of the uterine glands. The decidual formation. is 

limited to the Ijody of (lie uterus, and does not extend below the intor-»=B«l 
OS. tlmugh in rare instances, as in the cases reported hy von Franqne, ^,^<^a 
Weiss, and \'olk, isolHtci.1 decidual cells are found beneath the cervit?«I 
e]iithcliuui. 

For inir])oses nf description the deeidua is usually divided into scvc?J~^' 
|")rfioris; (hat lining the greater part of the cavity of the uterus beir^*^ 
desigTiiitcd as the iteriiliia irni ; that beneath the ovum as the decit/i^ '^ 
xiriiliiiii : while tlii' portion wliich surrounds the ovum and shuts it o ^"^ 
from the rest of llic uterine cavity 's known as the deeidua rcfiexa. 

The terms rr/li:iii and siTdlinii date from the time of William Hunter" ' 
who gave cxcelh'til drawings of the decidual membrane in his atlas. Un — "^ 
forlunatcly, (he author diet! jn^t after its appearance and before the com- 
pletion of the exjiliinatory text, which was prepared by John Hunter and 
Madhcw Haillic, wbo eonsideriil that the deeidua represented a fibrinous 
exudate from the lining meiubranc <>f the uterus, which formed a com- 
pleic cii>t of the u(erino cavity and completely covered the tubal openinp. 
They sup|Misiil, therefore, (hat when the ovum reached the uterine end ot 
tile lidie it.- fiirtlier passable was opposed by the deeidua vera, which it was 
obligrd to push lM.'fore it as it entered the uterus, 
wluTice ihe lerm reilexa : and that after the roflexa 
had liecn puslud forward, a new exudate was de- 
^' ' ^ ' ', • velopi'd lietiiud the ovuui, (o which the term sero- 

"■"' lina Mils a|i]ilti'd, 

''*^' ' ■ Tlii-^ rniiie|itioii Was universally acocptctl until 

IS Hi, ivlun WclH'r in (iermany. and Sharkey in 
lJi^'l;md, ileiiionsiralal that the deeidua was not 
:i[i c\ud;iii'. ina^lllllcll as it contained glandular 
>lriunui'- wliirh ihcv iden tilled with the uterine 
gland-, li )i;iviiig [hereforc liecome necessary to 
(•\pl;iiii iln iMiiiiaii.in I'f the n'llexa in a different 

iiiaiirur. ii wa- a— in 1 that the ovum, on reaeii- 

iii^' il;e iiiiTii-, fniiod it- entire cavity linwl by de- 

lidiia vera. M mIiu h ii heiami' ntlachcd at a [loint 

on ilii' anterior or po-i, rior wall somewhere in the 

nciglitiourlinod .4' ilic fundus; and thai tmmc<liatelv 

afliT ils allaelmii'iii {W- vera bc^iau to pri>!i('i rate and to form a wall 

arouTiil the ovum, wliiih gradually iTuii'a-id until it i<nnph'telv inclosed 

am! .-urri'iindiil it. Nol« iih>iaiiding the new ideui i-oucerning the for- 





.■' 


i •.. '■: 




\ -'-=-. 




Ml-. 1 IJ, 




]■!'.-. 111. II-'. 


I'li- 


t-H \\i- -i+"\\ im; 


!■..»- 


\i v"i"io\ hii Ih' 


rmv.^ 


lit n.h.x V ^I'o-Tf 


■ 1. 



idiiu. llir t>Tin>' nfli-xa iinil »<'rotinu arc »till TvUincil, 
new anatoinkal iKunemialiiri' »{ lIi.-> tliiy an- moa- properly 
thv dMdiia cfipsttlarU uiiil Imsalis n^poctivcly. 

Vara. — Tlu* tnioroBoopic iilfu<!lurc of llic i)mi]uji vi-ra was 
by Hp);ar and Maier, Imt it was not uutil llio vmk of 

anA Klin- 

:!ni;elitiaDil 



Bcturv WW 
lulvrstood. 

in 1870, 

t])at the 

«*a* eom- 
> |i»rlj«iu : coMpMt 
lytT siipLT- 

a uptingy 

layCT. tile 

ui-an-r to 

«atl nf 

iiiil fornt- 

tliickncjiti 
iw. Fur- 
was of ihc 

tho xrps- 

ki> iWi^iua 

of Inliour 

tin- June- 
lh(? twn 
howCTlUint "P*^' 

layt-r was 
rfn' nxiutl, 
{oiul rvlla, 
1itly»latti- 
r nuclei — 
tth; while 
layiT was 
the liiUlctl 



iilic uter- 



Biusdc 




Flo. 1*9.— Dkcidva Vbka. Fomru Moxni. X I*. 



idua vfpa 
rltHUy in 

nitfc UiM lirMt thitv or ffttir mnnlhi' of pn^iuincy, to that at 
hat time it lias attaitiot a thickness of aliout 1 oonlimctre. 

W'.l .Jmi* vvry ^Taphiciilly thv differeiKv l>ctwwii the noniinl 
aoil linciilna vera from n ineni^* four mouths ])rc):niiDl. After 
nnlb, Dwm;; In l!>e marked increase in the size of the uterus, 
Dally bmoiiire thinner, to that at l<rnn it it rarely more than 

thick, 
e uiicroKcopt- tho compact layer is «acD to be nude up of 



122 



OBSTCmilCS 



somewhat I'losdy packitl, large, rituDd, oval, or polygonal colIn. vh'iA ai 
di^tiiK't!) I'jiitlidioid in appi'iiniiRi-. and jkiwh-m n>uiHl. vi^iculnr nnclo 
which Klain Imt KlifEhtly with the ordinarr reaf^t^nte. When tlic tli«iue ha 
bcim dislviidiil bv tia'inorrbagv or axlctno. it i« tcca liuil. ntany of tt 
decitluid ct'lin prcM-nt n fltt>!)ali! n|i)it>nrHnoo, and are ])rovid«) wilh ton 
prDtoplatimic oiitj^rowlh^ wiiich unuetuniui^u with ^imilnr priMt»m> frot 
DvighlHiuriiij^ tt'Ua. Purticuhirly in tho i«rly monllia nf pri^nanoir, or 
6W8 «-attered brtwtvn the typical dwidiml cells a c«ni-idfrablc iiuiiibcr c 
«niull round lvIU, wIkim' bodiui^ iiru ulniunl mtinJy tilliHl hy tliu nndm 
Hitch cdh wen- formerly considered a^ lymphoid in clianiclcr, btit Uai 
chiind uriii l{ci»si-l)iiriH i-rKitcnd idnl tlii-v iin- fiiri'niiiiiiT:< of nt-w dit-idut 
(■elln. Ijar'in;^ llit-ir lonti'niion uprm llw fact that ihey freipieillly conUi 
Dittotic figniV);, uid thiit nil {gradations may l<e obKcrvinl Im'Iwwii (hem an 
typical deeidiial cells. In llie early iiioitlh!> of pn-cnanoy ih* ducts of tii 
uliTinu f;landfi may lie swii travcrsiop the coiiipait layer, hut Oity son 
dtAaplK'ar, mi Ihiil in the later nioiitliK nil Irmxr (if tlu-m is hnl. 

The spoii^- layer U made up of the distended and hyt>erplai-tie glaiMl 
«f the endonictriuiM, which arv )wpamli-d from one aiiiithcr hy a niiniinj 
amount of stroma. In many iiwtancfs the Riaiidiitar hy|>erplBt;ia in f 
niiiikcd ihal llw i^|iiiii^ layer ftUggi.'--<l!- an adenoma iti »pi)i,-it ranee. At fln 



* ■^-^^7? 



i%^iLiAejiu 




i 






^ " 









»'■ 






* 



»* * 



jM - • 



i 

i ' 



Flo. H4-— IhcnoDA Vcka, Fomni Moktii. x 420. 



the );land.'* are lined hy typical eylindricjil uterine epithelium, which, 
ci'cr. grjihially hwomc!' more ciiboidul in *haj>c and luidei^ocs fatty d' 
gcmralion. ;iiid is cast off in great part inin lliwr lumina. .\ cerlai 
amount of epitlidium. however. rt-iTiaiiiK intact throuf^hout pregnancy, an 
from it the eiulnmetriiim is regenerated after labour. In ntany tiuilinc) 
the stroma between the dilnted gland^i ha* undergone but little cliaof 
and cl"«'ly rft*cnibles that of the non-pregnant uterus. 



* 




DECIDVA VERA 



123 



I'luliT til** inSui-'iK^e nt pn?j:nanoy. Iho siirfaco opiLhi-liiini nm-ring Uic 
idua {.Twluallv Um-* IIk cvliiiilrk-iil >^ha|H> iiiitl iKH.'oniiv cuboKial or llat- 
H-tinu» tTin rtst'iiiblin^' (■ndoiliolium. Kliin fir>l *!irw:Iiil mii-ii- 
lli» i-oDilitiMii, imd 1k-)(1 thai it ku» a chiiracU-Tl^tic ciiicro^copic 
•nilaict' of )tru^:iuincy. Ail iiuImxiiii^i inveBli^lDm have confiriiKHl bis 

yif. I M reiin-MiitA n MTliim lltroitj;)! Iliu v»n)p»cl liiycT nT thv diiridua 
wi at the fourth month, while Kig, 145 shows a jjtand with its surround- 



4^ ^Va«._ 










V 



v.-^' 















[)■ fntm H nmi-firf-jriuiit utonK drjiwii umlrr the same nia^inca- 
ftii cimpariiiv thi'iii, it ix rpsdilv M*cn ihal the dividim ililTi-rs tmva 
fmgnAa\ friilxmi'lHum h.v u inxrht-d iiK-rt«iH; in stxe of the jttminn 
iud ft nijirkeil (I«erea^ in size of the irpithelidi colls. Kcltiok, in 11iOr>, 
^■M not thai lht> ticridns ii' |iiirticttlarly rich in lyinphatir spaees, aud 
(liBi It) [>iYi[ii-flv prvpantl s{)erim<!ns Um>,v occupy ul Ica^t »« ninvli 
)ulhi' hv|H'rlTnphic<l );lands. 

A* a n»ult «f Uw vfork of Hi-gar ami MniiT, Ijo«>|)o1iI. Mlnot. am) 
•fe», it i» now jn'ncrall.r atlmittc^l that tlic ikvidiial cells arc derived 
f»o tW *lr<>nin tvll- of the iiMlouHtriijin. which have iinderp>i»' markeil 
*'nvr in siw liiit nnly 'Itiiht ini-n^si- in ntinilier. Hukc directeii attcn- 
'"' •" ttH" Tr«inlilaiwv which Uiey l>ear tn sarcoma in-ll*. and slalitl lluit 
*lk lii^lual c«ll reprenentH the phrsiologicnl ivfKi of the mrokina oell." 
T' -in- tiriKtn of the dwidual cdt was cstaUlitihcd only 

'^' . nation, and lias been further n-^-n fnm-'l liy olwer- 

'"taB, Dindt- in ecrloin e«w^ nt f«rlv 1iil»al pn-;inancy, in which di-cidiial 
"1* nuv t^ oefu ili-vclnpinx in the nnallcr fold* itf ilu* luhal muc«#a. 
^i|wiiii«w show clt-aHy Ihat iWy are derived from Uic <»ixlinary oon- 



124 UBSTETHICS 

iin-iLvi-ii^ism' pi'lls ami roi^iilt fnnii tlip liypertropliy ot jire-oxiriting un i 
liUlur tliiiTi from lliuir jimlifcriilioii. Furthi-riiinre, Schiiiorl. Kiiio^liin 
Liiiili-iilluil. Itiiriiuinii. and ollu-rs have descTilxxl, in women <lytiig s<m 
iiftiT (■liiliit>iitli, small notluU-:!'. varviiig from t-iruulures jusl visilile to c 
iiiikisl i-vt' lo lioilii-:; 1 to S milliiiH'tTv^ in diaiiietLT, wbich arc M.Miier- 
"ViT ilif [wTi Ion II' II 111. cuvfrin)! iIk; i>o#terii>r surface of the ulcnis, Ikn-j 
Iii>*j. riil-ili-siir, ami ilu' aiiit'rior surface of the rectum, and oiva>ionii 
alxi oviT ilii' ovaries. Stlimorl considers that thiso structuns an- alwn 
fMUiiil ;ii fiill-liTiii [iri>;;ii(ini-v, and litis dcmonstratod that tlicy are mix 
nji "f ilnidiKil li-sui'. But. when-as tlicy develop beneath the [»eriIons'ii. 
ii is tviiliiii iliat tlu'v uiust lie derive<l from connect ivc-ti!=sue celU. 
Iiavi< -iDiliiil 1UO s|Kviini-ns wliiili ^Itoneil an uiinsually wide distributi 
"f diH'iihial I'lTiiuilion. In uno iii>tnuiV. in which the pregnant uterus w 
ilii- -i;!! <it' an a<l<'niiriiy<tri]a, lyplcal iltvidual formation was noted in tl 
iiueri-laiidiilar tissue nf the emtoinetrium-like areas far removed (mm tl 
.111 line i^niiy: while in a last' •>{ hyduiidiform mole, distinct decidual fot 
iii;iTiiMi Hii- ii"i.d imt only in the mucosa of the tul>e#. but alfo in tin 
e"iniei-iiii- tis^iu- jii-i U'lieaili thvir |vTit'>neal cnverinjr. 

Hi lure ilie ini.' naiiire nf iln' dei-idual c-lls was definitely proviil. 
varinii- il.Mirie- \wt\- aihaneiil a- t>> thiir origin: Honnig Mieving tlul 
lliey Mi'i'i- .]. r':\ei| frniii !eiiii«'Vies, Krinnmel anil Ovf-rliU-U from the ater- 
iiLe I iiitiii !;iii!i, iinil ilreiilaiii fn<m ihe ■■uilothelium of the blood -vcs.-*!*. 
Ai ilu IT.— Ti[ lime, i!;. M' \i.'ws are of iiiicn^t only fnuii an hislomti! 
-taii'i-iMeii;. 

DeciduB Beflexa. — K\e. !■! f..r liie ilrst few hours after it* cnirv" inl' 
;} '■ ;!;•;■;:-, ■'■.:>■ ••\ ■,:•!■. i- -'iii! .■:T frum ilu- r. -t of the uterine cavity l>y Ui 

■ :■■ A-.i: ■■ r". \, :.«';. ■■ f.irv - :i e^n-u'e -if d.-i-iilual lissiic around it. K'l 
;-- -': ■.■.- ,, - ■..-,..;,■;.-' ■■■■ejiiaii.y -u wliieh ih.- retie\a is qniie aiipan'H 
■-'■■ ; i - * -■ • ■ ' .'■ ■ :■.-!.;;. -' ■■-i _'T'ai;ev :n whieli il is well devi-lojHil. 

1 '■ ■ ■- ■ • .;'■. ■■,.■■;■> ,.■' IT' jiianey tlv dividna retlexa iWs n 

'" ■ ■ ■ ■ •■ , ■:■•■.. <. ■'■;;; a s.iiini ,-,f varvin^T si/e exist* 1 

■'••■■■ ■■ *. 'i" ■- ■- » "' -■■.•'wii ;:i Fill. 147. wliieh re|iresei 

■ ■■ - .-.-■-■ - -v .-Vs" ;iro_'i)ani uterus. At the foi;t 

■ ■ -■ ' ■■■■.:' _■ A>;_- •>v,!iii i-niin-'y tSils the uteri 

'■■■■'■■■■' "r ■"_-'; i;!M intimate e.mtact. * 

■■'"".- -■■:;!;Ti'<i iii!o,viii>ii-i up ti> i' 

■ " - ■■ ■ -■ . -w.i strnetiin'- fii-<- I'lL'elli 

~ ' ■ - "."■ - i--L!Ti;i.>;iys. Tllis view V 

' ■ ■ " ■" ■- ■ '■ '■'■"' ' e.lTl-l. .1, :nasiii1[e|i 

- ' :s ,■■.;:-■,!.■ ..f ill,, ptacen 

~ " - ■ -■ Tv,-"-rri.'tr>'- iliiek, a 
■-■■■■; ■^.- F--. -[T^-i.) 
'~ ■ ' ' '- ~" "■'''. ■'■iiVn-'ss ai alvmt '■ 

".'''' \- ' ' ' ' ' -' •"" ■'■■■'■• 't is made 
'.' ' .'. '■ ^' " ■ " -""-'i' "av. r .if llaii.i 

'■ . ' - ■-' o>!iTa. T WTlh 1 

_ . ~ ' . y "'"■' ■■"■;'•■ I'Uiu. 

• '•'■■ ■• ■'' w ^.'lands in 



DBCIDUA REn-EXA 



125 



brfouii-l, wiiwi' ilmr^, wIh-h iIh-v ni\- pn-wiil, iirc Mvn U> ii(icn only »i«»ii 

lla- (Hiti-r »iirfn«' of tin' nioiubraoe. 

I' (I to n fe* (■ttirs api it was univcr^Ily liflk-vcJ Uial tho rcfie.va 
puled from ihe jiroliferatioti (>f l)i<- v<Ta, whii-}i grcv tip around luid 

I'ldiuUj tatktfioi tl»o ovnm. fitaf Spw. however, pointed out that in 

P>ura*-{iig8 and in certain otlier animaU, the deciduit n-flcxa wiu not 



, DR. 







/ 
DS 



"* '*— flmJTTr.K-imi' FrntnuMTT Vrr-ni-n. X I. (,lnnl™n>n«l Miw^im Jiitiiia Hnji- 
kiii" rni»tT*iiy.l l-jalaryo ilniwa nrislivi-lj' !<"■ Inrtr. 

^ ^mbm i»Bi ■■. P 1 . drrxliiit •cnHina^ f).V.. 'Wi'liu t*Frai E., mAryoiO-L., urmrian 
bcuni'iil, tt-L., nHiiul lif^Biui-nt. 

'•""•J in iJiin way. but thai tltc ovum penctrateJ ihe snrfaco (^litholiiim 
•*• twTowrti down into ihp d('plK<: of Ihi- ¥<'ni, alintwt iimncdiaMr iiflrr 
'•* iBpUntjition, and Ibtw ramt* to !«■ swrroundwl hy tW* »tmiua cells. 
^'Wnliiif to this ricw the rcflvxa would Im rocn-Jy lht> |>orUuii of Ihe 



12S 



oBSTEmncs 



ilwidiia sera whitli wrtTs the oviim. \\m lU-rff U>en iiut«l, upon t 
n-lH-rtI gr<.iiut!.-<, that (wwiUv a more or K'w similar protcw taken pi 
ill huniaii IwUip*. IK- l)elie^-ed, bowL-vur, Uiat the ovum diJ not bocoi 

iiiiplantctl upon lb 
OR free Mirr»iv of tlia 

Yi-ia, Imt sauk ilowr 
into one of the <k- 
{ir<-^''i(>n.i bv vrliivli tbe 
lailiT h tiiarkiil. 

It was not. lio«r- 
cter, until I'^lita tle- 
Dcrilietl a epvcinw-n 
reprewiiting, a.* ht: 
la-liovwi, n thrcc-day*' 
pregnancy, in whicli 
lh« ovum was em- 
bedtled in tht- doi'idaa 
vera, that anything 
like pmitive proof in 
support of SpefiN 
viow's wax a«l<luc^l foi 
human beiii^. I'l«t« 
IV, taken fmm .a s«" 
tion throu);li Pi-li-p''* 
llinw-daj-n' pregnant 
uterufi, shows distiiK't' 
Iv that the ovum hiiK l>iti'rnu*i>il ilowii ticnt^lh lh<' Kurfaiv of tlie ■h'V'uluM veni 
anil is iying in the inUFt;laniiHlar elmuta. Sucli fircturcs eh-arly indiiiili 
that Ihc ix'lli-VB i!^ not furniixi hy the pmliferaiion of tho ilocidua vera as ii 
l^nerally *talitl. Iml simply rcprcu^-ntj^ the ponion of it which corors Uii 
ovum, and which undergoes pa^ive enlargement as the latter inereaa 
in sizo. t Iinve not had an ojipmlunity of exaininiii); the pregnant iilvfl 
in its earlioit jitajn:!. hut in wvcml very early cases of tuhal pregnancy 
have s»?.-ii iniuiitions which cmtlirm I'eiersV view*, while the ohwrvatiq 
of Spce. 11 lire) 111 ml. niul Ii(-<i|mi!(] plainr thriii i»c_>i)nd all doiihl. At 
to Btrahl, a fully fonnc<! (lii-iihia n-llcxa is to Iw found only in man 
iii<>n);cv«- 

Decidua Serotina. — The decidua inTotinn i« the i>ortion of i\w dwidtt 
which lii- iiiiiri'ilint'ly Im-iicrI)i thcovnni; from it tho mntcrna) )>ortio 
of the piiici-nta is )le\elopcd. Umadly speal;tnK, >! prewnts the smmc gw 
«rfti structure a« the decidiia vera, e.veepl thai it has hwn invaded I) 
fo-lal 1i».iie. m that iU «ii|»i?rficinl )H>rtioii> are compose*! of doeidnnl ccl 
and r<r(a] nctoiliTm. 

l"riet!lJin<ler nnd T-eopold staled in their oriipnal monoiji^Bpha that ^iai 
ci'Ils api»i'jm>ii in the M<rotiiin hImihI the middle of pre^nncr. Tlie* 
lltcy Ihoughl, made Iheir way into llic vessels and jrave rise u> thromhosi 
Their interpretation, however, i.; no lonper aeet-plcd. and it is now gfli 
emliv U'iievi'd that the majority of tlie so-callwl giant cella are not < 




Fm. nr. — 8iJ[-"K".K«' Phkisasct 

l'Tl.ni:aWini Kl.llVIUIinMlCf^lSVU, 

irt III cK-rtincD BY niK Orcii. x |. 
0.f:.,v\ifmai M-.O.I.. tMern»\ crt; O.V., 

OM; ■irciiluH n-llfun; f.'mb., riiil>ry.>; 



')i:illllU'> 

iTvatiqo 
LccofdB 
man fl 



A 



DBC'iDiiA aewmNl 



deoiilul iirigin. \m\ n'j)r<M-nt {NirliutiA of sTncvtiiiiii, vhicli have niadc 
lltuki waj- dovn into the dvciduu. J-'ig. iAS, nrpixv^-ntiitg a «i>ctioii throu}{h 
ihe dcciilUM tcrvtUia iu the Ini't [iiuntli Df prvgiiiincy. sliows (-U-urly lliat it» 
" "'t'ial fionioiu lire miiiiiiwd of » riii.\tun' of Ixiili fii>ul iind ruHLtfrniU 
finli*. (to tbf otber haiiil, eimtt-ml-H that a Urge part of the sero- 
tiiial ^nxnt tvll» arc malvmal in origju, hik) may Ik- derivvd Imm ccKincL-tivi- 
Ltwui'. a* wi-ll w lixliillii-Iial, nni>«Ii', «r gland wll«. 

In the deci'liia wrolifta largf Dumlterd o1 blooci-vcf^ls arc observed. 
T^ ■■ rn?< [nirviK' n (pirul (t>iir>*!, iind iiMially pt*iiHriito t!t« vntirti 

^' < - iif die uivnihraue ; while luauy of tlti: veinit b(<ti>mi' miirlvL-dly 







O., bIuiiI: v., w »I; F.*e.. f<jpt»l rrdvlirnn. 



., 75. 



"1 anil fnnn larpr sinuw*. In Fiji- M8 two umall vessels maj bo 

■liipli, afttT puMuinj; (heir courso through the miiicrficia! layer 

w^ntina, open into (hi* inlcrvillmw i>p»«t>H nf the placenta. Tl»e 

■tifiD nt IIme vaoeular ctiDix^tiona hciin-cn |Ih> tMxin and the 

>. tumvTia-, will Iw dvfiTKo] unlit re take up the study of the 



130 OBSTETRICS ^^^^^^^^H 

Via cjin proliablv host undcrslaiiil tht- sinictiirc of the placcnKng 
etmlying (-iTtiunt- Ihnmgli il ill tin.' finirih itKHitli i>f [>n-gnHiity, one oJ 
which is showu in Plate V. Here wa bm Ihal Ihe orgun i» miulc up it: 
gwiit part of chorionic; villi, wlio.io slromn piwiruts n »oiii«v)iat mucoid 
a])lHiiriLni-i% and coiitainK spiiulle- ami Mar-»iiaped conncetive-tisi-wc cell* 
k'twecn which vrt'll-clcvi-lopwl arteries, vcini^. and oiipillnri^'a inuy Iw ob- 
MTVt-d. At tliiH Ntagu The viikniH ejiitheliuin ii< iirrnngeil in tvo layers— 
Lflnghanx's layer and the syncytium — and from the latter many bndi 
protrude wliich. tvhcn mi-o in cmss or tangential wcUon, appiir aw gi|dj 
cells lying frw? in the inlorvillous spaces. ^ 

In llic npjKT purl of ihi,' pltilc iis the dceidim >-('nitina. witli w-liicli xora- 
of the Inrgi^r villi — the facteninp villi — are connected. At their ends caa 
tie noted a murkeil proliferation of I.arighnnKV layiT, whivh invadw tb" 
underlying di-cidtia, givinj; ri-e to rhe cell nodes or celt columns, and cor 
rpcijonil* to the trophohlu^lic formation of the early dry* of pn-giuincw 
Tlie ti-lU Miidiv nix> iiiiii|H>^i) nliiio>l t:\e)univcly of Lnnghnna's celle 
!«» the syncytium does not follow them down into* the depths of th; 
Becidua, T\w Hpneiu In-twiti-ii the chorionic memliruno and (he doeidita 
a« well as Iwlween the villi themselves, am designated as the inlfrvUhit 
«/!«(■'■», TlivM- an- filK-d with tnaliTim! MimhI and ihvir widl* are line* 
hy syncytium. Scattered through them are isolaled giant cells — tlie ev 
callod placental gianl cv-ll* — whtise origin wo liuve already oon»i<)cn>] 
Here and llierc are seen a fcu" large areas com|msM] of culmida) or polyg 
onal c-ell* with vcsientar linck-i. n'liich frL-<|iicntly prewnl markctl fign 
of degi>ni.Tiiti(>ii. Thcw? hi* the ■io-ealle<l di-Hiiual tAlanils, and arc lunall. 
supposed to regiresent factions through dcciduni septa, which project up 
ward from the mirfaec of the dceidua si-rotina lowarii* the Hiorioni 
memltratie. Itut. as has already Imxti pointed out. most of them ST 
Tiiji^si.'i' iif trojiiiolilusi. into which the chorionid i-oniiMtive li.-vut? haM 
grown, and which IherefoR" have not develojied into lypiefll villi. 

At the Junction Iietween Uie ceil nodci* and the decidual tiMstic, 
are noted which stain deeply with ouin. and nliich, on closer pxaminat 
are »eirn lo Ih- mailo up of fihrin, liom'vcouitH'd in variou:t directions b> 
small spaces — the so-caJkil raniiliied fihrin — winch prohahly nfull.t froc 
the de^.i-iKTiition of fieta! and decidual cells, litis i» known as Nita 
huch's fibrin lawr, from the author who first called attention to 11 
prc-«-nce in the diiidiia. lis exioli'nee has ln-eri confirmed, and its 4>hftl 
acteristics have Ix-en studied hy liiughanii. Itohr, TussenhroivW, ITloekc 
Slniganowii, and others, and it is gi-nerally e«)n.->idenHl lo mark the Imrde 
tine U^tweeu Ihe fu'tal and niBtcnud tissues. 

It would wi'ni that di-genorative changRt occur wherorer fa^tal 
mafenial ti.<-iios oime in contact, and the phenomenon suggests the 
sihilily that the fuiwtion of the dividitii mny not merely he lo nfFnrd 
Kuilahle structure for the implantation and untrition of the ovam, bn 
al«» to protect ill*! niali-rnet organism against inva.iioii hy fietal tiiwiifiS 
In the Kerlioiis on extra-uti'rine pregnancy and adhtTcnt phiccnta. varioof 
facts will he pres^-nli-d which afford a certain amount of jostificalion in 
favor of such a viuw. 



n ar 



I 



^ 



STKUCTUUE OF THE I'UCENTA 



131 



fntil itimparaliTi-lv nwntly the parlidpuimn of furUl tU«ue in the 
lui senitina hbh mit nxtiiciiiNil. »iul wlicii fu-tal cclU n-cre found 
iUi thi- rhorioiiic in (.in lira De llipy were c»iis«lfin'il m hcing of decidual 
ilL Accord i [4: 1} . Wiiwkk'r hiii! Dtlior observtrs Iwlieved tliat ili^ndiial 
IF uU'Ddn) from llie iimi^Ui^ of ihe d^'idiin wmtinji wit tlio irhole 
be obUt isurf«v of llw ilwrionk- rnvmbraue, so that the eiiliiv inter- 
iu Bpttce vae includtxl Iwlwcen decidual ur niutoniul tii;stie, Wtnckler 
Inited xi» fuperliciiil portion of the dooidua a* the hasal. nnd tlie 
fan m?«ring Uip ctioriouic iiK'nilimiiv n>i iht- climintf plate of the de- 
■. Wi- have already Khown that the tissue in (|iK--'<ti(>ii 1* mrnjuwi'd 
tntl iTtmlcnn, and tlw <»Doi-ptioii of dividaal plates Ejiould therefore 
Itudaiiei). 

Atoiw pnint (Piste T) n mntoTnal vc»iel U seen vhieh, after reaching^ 
nrfaee of the diVHlua, open.-' dinvtiy into lliv intervillous epMCca, ^ 
^rr«mt it in univrn^ally adtnittcd that tllC blood in these spneca IS 
iwivflt matcmnl iM origin. 

The fcptal Mood in the 'nsxU of thf> ohorionie villi at no lime ^ing 
*• tn Ih*' nuili-rnnl hloiwl in the inlen'illouii spawn, the two tieinf; 
lated from one suotht-r liy the double layer of chorionic epitlu'liiim, 
KtMHl of tliv stmina nf the villux and lliv \ef'fe\ trails (Plate VI). 
At the point marked " P " in lite plate V. a villn» v i>iv-n wtiow tip 

Kin the lumen of a uterine vein, and in inanv in8lam*!< the ends 
villi prtm- for n f<m^idfnd>li' diBtaiiiv into v<iisi-!». Wit has ■ 
nut that in nach ca.'WH |>ortion!) of villi may Ijeeome broken off, 
[tkits gain atxMWS to the general eireulalion. He designate!) IW proceea { 
jifortnlton, and ujnm it haii eonstriK'ttxl nn extensive theory oonecming 
Ijt of the fll>nnnnalitie« of pn-jrnaney, to which reference will later 
■ndi- 

tiractiire of Placenta in Latter Half of Pregnancy and at Full Term. — 
|rpl in tU inenHuwd txxe. the placenln in tlH> mh-oik) half of pre^ancy 
(rs Irot <di)j:hlly from lliat tif thf fourth nxtnlh. Micnvrfiipie wetions 
ki* pcrio.!. however, show certain points of dilfcrenw. Thc«t are well ' 
ttnln) in Fifir. HU, which n-present-i n srt'iion Ihmuj^h n .*oven-and-a- 
t-tnonths* placenta and thf adjacent uterine wall. Sludyin;; it from 
t» ipwar*). we *ei* Dinl it in eompo'^tHl of (he following Mlruetun^: 
pm, chorionic membrane, villi, intervillous blood spaces, and docidua 

rnw amnion eovrr* Ihe inner or fti^lal aurfaoe nf the placenta, and 
pi>t« nf a single layer of ciil>oida) epiltieliiini. Ih-Uiw wliirh ivhikw a 
f^ jnam m Imv Rhrillar eonneetive ti^Miie, eontnininj; no blood-vcsse)#. 
ttkirMalc membrane preecnl- cswutially tlf same Ktmeture a^ in tite 
l*r DOOtlu of prepianey. differinji «niy in thi- prewnce of a targe 
fnt nf canalized fibrin immediately ))enRath iti epithelium. 
fll» ffTT^t hulk of Ihe plntv'ntn in mnde up <if chorionic villi, which 
jftoA nmn- ahiiitdanl, bnt at llw name time considerably smaller than at 
HWth month. 'ITteir Btntma. which i* maile up of Hpindle-^hapod eelN. 
Ptor in BplM-atanre., is occopiiil in ftreat part by bhiml-vv**!-!.*, and differs 
JMIv tmai tfaH mucoid liiwuc of tl>e earlier months. The^c changm luive 



132 



OBSrrETRICS 



iv*'^ 



L«? 



r<i^ 



•0^V^ 















^^^K" 



R,. i». vi«=r^.v 



alrmily Iwen referrwi to,,, 
1— Dceiiiu. and are clearly shown in 

FigH. \:in niid' ISC. 
Tbe epitboJium coTprinj; tho 
rilli luiit kIiu) iiiulirrgotu- mitrktil 
chan^; Langhana's layer ham al- 
mwt completely diwinn^n-d and 
(iiilv a thin layer of si-ncytium re- 
mains, wlik-h give* Hw t" fi-wer 
hiids than previously. In many 
villi iminvdiatply under thi* i-pi 
Ibelinm, and occupying Uie for- 
mer pcMition of l.ang)iuns*6 layiT 
i>f Wills, a thickor or thiiini^r layer 
of canalized fibrin may be ob- 
KM^'txi. Thiii ft'iw Bnil d«*Ttl»«Hi 
by l^nghans, and i.t of t>onslaDl 
occurnjiiw in the latter half «r 

pregiiancy. Il apfiMirii In 
— <'harianfe indicate Ken lie deg^nvn- 

.[.Mwi. the Mme time, many of 
the arterits Av>v murVwl 
ohfliiges and pref>ent nil stage nf 
an obliterating endarteritis. Id 
wliirh, in jLircat part. Ih«> forma- 
tion -if Die tiwiie in qUCTtiun 
!'!uiiil<l lie allriliiitiHl, 

The superficial portions of IV 
<Widua at OiiK period are m- 
ered hy canalized fibrin. whiiK 
prfilwlly resiiltfi from rnap^iliilion 
necrosi* of the cotl nodi« at"* 
<^liimnfl. In tlie deeper ln>vn« 
numerous p^ant cellB are oWrviH- 
wliirh oeeaKionally extend intn tii« 
connecttve-lispne w^pta S.-I*w'* 
t!io mnMe fibres. Tbey arp o'' 
vnrious rfiajHW, and prohablt iv\' 
resent portions of nyneytinm v\w 
havo nanderwJ down into the A 
cidiin. 

From the free surfaei^ of fli"^ 

dftidua nnineroiis cIotii- 

— "■•"'"'•I' tiona of varvinir »liape« 

(iwcntirtne^ t' o r 

— Aiiihiiipn. 

F1". H9. — SKPTtrtw -rnxoiNiH Pjrtnw 
lw»m». X IS. 



\ 



STRUCTURE OF THE PLACENTA 133 

I HICK extend upwanl 'for a greater or U-ss diKtancc into the pla- 
ti. Th<'.v are composed of cuboidnl or polygonal celU, with round 
icolar iiui-lt-i, and only rarely contain btood-VL>«selii ; in many places 
r hare undergone degeneration and become converted into canalized 
in. They are u.-:ua]]y described as decidual M!ptB, but in ail proba- 
ty are derived from fietal ectoderm or trophoblast. 
rbe entire space between the chorionic membrane and the free surface 
he deeidua scrotina is designated as the placental space, into which the 
ionic villi dip, thereby sulidividing it into myriads of irregularly 
led cavities which communicate freely with one another — the inter- 
■os spaces. They are lined by the syncytium covering the chorionic 
il>rane and villi, except at those portions of the deeidua serotina which 
■ become convt-rtcd into canalized fibrin, and which are only partially 
red by it. The syncytium is thinner than in the earlier months of 
•nancy, and under high powers of the microscope its protoplasm pre- 
s a vacuolated ajipciirnnce, which, according to Marchand, is due to 
glycogen normally conluineil in it having lieen dissolved out by the 
Is used in hardening the plucenta. 

rhe intervillous spaces are at no time lined by endothelial cells, except 
very short ilistanees nn the surface of the deeidua serotinn, over which 
radnibelium nf maternul vessels may extend to a slight extent. It ia 
ImIiIp, however, that a great part of this tissue in reality represents 
iwH-niit symytium. Hence, it would appear that the intervillous spaces 
liwd entirely by fietal tissue, and that the maternal blood, which is 
iililing through them, lies outside of the body of the mother. The 
iMTifll Mood gains access to the placental space by branches of the 
Tine arttrii's, which pursue a convoluted course through the deeidua 
"tina and, after their walls have gradually become reduced to a single 
■r fif i-nibilhrlruiu. open upon the sides of the decidual septa. The 
■xi psf-ajioii from the intervillous spaces through more or less funnel- 
ijiftl ofienings n\inn the surface of the deeidua. which can he traced 
Miy into the large venous sinuses in it« depths. It is therefore appar- 
' llttt iherc is a distinct circulation through the intorcouimunicnting 
MTtilous spaces, though it is necessarily more sluggiwh Hum elsewliere 
Ihf liorly. 

TV nature of the infrrriUoiix spncm and the question as to whether 
"Tmnlaini-"! maternal blood have given rise to a great deal of discussion. 
itiT. Xoortwvk. and William and John Hunter, in the eighteeuth ci>n- 
fT. «pn'ssiil an athrmntivc opinion; and the Inst two investigators cou- 
Wipjy dfni'>n-:trat(il it by injection experiments. Similnr resnils were 
Itiwd bv F. H. Wi'her in 1^2. Rut this work was gradually lost 
^1' if. and all sort'' of theories were evolvi-d conceniiug their nature 
^"nitrnts. Bravton Hicks, Ercolani. and others IhIIcviiI that they did 
Ifnntain bloixl. but some substance derivi'il froiri Hie miicrius membrane 
'l** uterus which thev designated as tili'rinp niilk. 

('nrrer-t contTptions as to the nature of the placenta were finally estab- 
kJ t.y the work of Farre, Turner, Waldever. Xit!ibiii-b, Hohr, Bumm. 
ijxjd. and others, who showeil conclusively thai Hie tiitervilloiis spaces 



\M 



OBprTETKlCS 



L-otiluini'il iiiiitcmul IiIimmI, aiitl tliat vi^-vU fnii^ the mntbcr conltl tie Iratiil 
inlii llii-m. TliU WA-i ewpt-vialh well ik-inoii§ti^tiil Itv WaldevtT. wim. in 
five pri-i,iuiiil «nitivcrs, \iHf, iililo in itijwl tlwiii fnun llic inatvrual v.-.-wU. 
KiirUionimrtt, Un' r«-i'iit work of I'ptt'r*, LeojM>l<l, and olheni, has placMl 
the qaiftitinti iM^^Dtid all rt'itKOiiabk- tloiikU 

In vk-w iir ilii™> fiurtri, Ihcii. Ibo placentarnii^t he re-^HntiMl a^ a col- 
leetioti uf mauTtml l>loo«l, mcluilol Wlwi-ctf^hc cliorioiik nirmbruac aiid 
tbv iltvkkiii K^r>>tinii, inlo wbk'b Ibe vilb mp ani) bv whicb tbt-_v niv Mir- 
muiHleti. Sniui- itlca of llie i-niuplvxU.v of ite vascular arranjtGpiPUt may 
be gutmn] from Plnti; VII. which ri-iirosenU n cwrnMion |irt-|Hin(tk>n nt 
the fiptal porlion of a fuIl-tcTiii plaoiiita. which wan injectLii tbntu;;h 
tho iiiiibilicnl iirtwrics' ontl vcini' with i\'i] an<l liluc nrUoidiii. (AImi xr 
Plate VI.) 

\urtRultv tbcn- it: no cninmnnic-atioii U'ln'ttti the fu-till blotid cnntainni 
in tlie diorionic villi and tbe iniilernal bloni in tlti> int«rvil1oiut spiuv, 
itiii) it woiilil tip)K-ar that Ihc tran>'nii<vinii of cuhvtancv^ from one In tfic 
ulher xa aii-omplislut) parllv kv ommmifi nml [Mrtlv kv itw ilinvl oi-llular 
activity of the eyncytiutn. the proccM boinff aiuik>}pmo to that nhich tahr- 
[lUiV! in the lubnk'S uf the kidney and iinK-r or^ianH. The efTHc mati-ruk 
from the rtftuw arc carried hy the timbilical artcrk* to ibe capillaries of 
till' terminal villi, whence t.hev are Ininsmillcil In <he innb-rnul blorHl is 
the manner just dBSpribed. At the s«nie lime thv osypen and ibe niali'- 
riulit n<'i'rk-(l f'lr ibe niitrilinn ttf the fwtuH an- taki'ii np fnim the fonner 
and carried by the imikilical vein to the f<e1iiR, Thu-i, in a fff^Dera] wbv 
»i' may wy thai llie jibiwiitn n'preKciifct Ihe lun)!:H. xtonnieh. and c'xef\H«J 
ort';ii)^ i>f llie iiiilinrn rhiid. 

Placenta at Full Tern. — The placenta, an it in cast off fmm Die nteno 
nftiT the birlli nf the ehihl. \* m flnltiMicd. rnmidiich, or »val organ — IS l» 
18 ecntimrtrrs in diameter, and 2 lo 3 eentimetn» in Iwifrbt at it* thickort 
p«rl^fn>ni the niiirjrinB of which the fnonibraiK'K exlend, Onlinarily ib 
weight U aliout { of That of Ihe rnliiK. ^n lliat vihfn the latter U nonualty 
duveloped the plaeeiitn weighs from 500 to GOO fn^mniei:. 

It pressntH for examination two «irfDw* and a margin — thu Mirf«e 
in contact wiih the deeidiia serotina IieinR deeignatefl as tlie maternal "f 
otiler, and Ihal directi')! InwunlK Ihe cavity »f the ovum un the fti-lnl or 
inner surface. The former is roTcrcd by a tlun layer of deeidua anil 
pn«ontji a niffjA-d, torn appearance. Wtng <ltvided by doprcHftion^ "( 
vai'j'in); depth inio a numher of irn-frnlarly chaped areiu, the itn-callul 
colt/lrthitiK. which vary considerably in nnmlier, as many as twenty Uing 
Aomeiinies observHl. On oureftil examination of the decidual surfnce, 
niimcrou^ vessels may Iw awn which have l)oen lorn through nlien llie 
placenta wu» separated. Thus, Klein was nhlc to count 51 arteries awl 
53 veins in a iiin^le specimen. 

The ficlal or inner surface presents a glisteninjt appearance, owinjr t" 
ll»- fact that il i* envernl by amnion, which, however. i» only slightly ail- 
herent. When the latter is remove*], it leavpji a coarsely jtmnular surface, 
ii[M>n which Iho umkiliral <iird ii^ iisnnllv inwrl'>d wimcwhat ccci'ptricallT. 
though it may be juf>t at the centre of the organ and occasionally near its 








ID las 




136 

mari^in. 'Vhe various modes of iitwrtion will be coiuiJerwl when uei 
uji lli<^ «!>i]i>niiHlitii.'s of IIk- plu^tiitu. 

Tho vft«icU 0(1111 [Jiw in;; ilip uinliilirai c«ni spre-ad uul licnealh the 
iiton aiK) nipiilly tlirtdc. toit thu luaiti bniticiiti^ n'tiiain ujxiu the fuei 
aurfai'e nf ttio plHnmtn nnlil it^ niancin i» rtmoiued. In tiiany instiini 
II \aTffi ifi'ta, which i;- usually kiMwn a» (i» rirciilar sihiu, vxltrnd* ur 




Kii;. I.'>2, — F'lriAr. Mi\iiiii*m:« A<in T'TrHiwr. Will. x ".'., 

a,, lunniiMi: eJ., cuniicplitc tiHUd of uiniiinn Bnil churion; &r., nliuriixiir ■•|irtlipliii 
eanabKri librin; d., iWiiliis^ g,, KUml; m.. miwi'iilariii; v., vpin; I'., ktrnjibic liUv 

a cnnciikrulflo portion of tho ppriplHTj" of the placentn, hnt only in 
ruri' rasos «'iiTii|ili'ti'!y enoiivli-s ihi- oruiin. 

The firlal membranes roni^iit of the nmiiion, chorion, nnd n thin Iny 
of ihTiduii. The Htimion. Iho innoniiO"! of the membra ni-s. is n thi 
tranNpHrcnl, glistoninn atrncriire. which is rarely thicker thjin n ^hwt i 
wrilinf; pnptr. lis outer Mirfiici- is closely iippliin! to tho chorion, fro 
wliidi, liowi'vcr, it ciiii usHiiMv Im> .lepnriiti-d without ilillidilty. Th* eh 
rion is more oj)aque and lliicker (h»n the nmnion. though it rardy « 








I'l''. l>ki,^'KB'iTnEi.iL-H or LiiiiijMfAT^ < r'ini'. x I >f i. 



UMBIUCAL CORD 137 

millimetre in lliic-kncnt. Il rvpn^tiiU tliu chorion I»vp of the 
;tuiiUt:>. diitl iiihUt tlic m icTOM-opi' is M-t-n to jiii.vii^* u niimWr uf 
:tiiimlnl rilli. Clinfctiij; to itx outtT surfaw arc a few shreiU or tissue 
purliiin uf tlw (Itv 
nlua which in l'xkI iilT V I 

JtertlH- hiiih of the child. 
Fy. i:.S « luk.'ii fmni a 
•niiiin ihniD^h liie fiflal 
msiiiniOM ati<l tUi- iit«r- 
Oe Wll oul«ido of the 
fliouitul >iii', and jpvi<s 
1 ^mI mIl-s of tlu'ir com- 

IliOB. 

Vabtliosl Cord.— TIh> 

niiWi.iil (tinl. or funii^. 

• ni tik- navd of 

1 I'l Uh* fu'lul siir- 

lm«f tbc plai-enla. lis 

< 'lull white. mnUf Appoanitcp, mid throii;;!i it shimmer 

' U — (wo arlmt.-s ami a voin. ll varii-s fititn I to 'i.H 

"^iinrlivK in dianivti-r, nml uvvmgiw ulioiit TyS ccntinu'ltui in length; 

UJ. thouji^h in i'\lrirriic tnew it 

may vary froiu 0.S to 19S 
centiiTii-tixw. Till? aviTugc 

\eDifl\i of i.iKlO wnts.iiliioh 
wvn- nu<a>turc(l at Ihc Johtu 
Hopkins Hflopilnl. nnn 65 
Ct'ntimcln-K, thv shortest 
IwinK 12 anil the l(m)i;i!»l 
lOU ciMiliinflrc?!. 

Hie «>rii fniiiii-nlly 
prpst-ntfi a twieleJ appear- 
anoo, th« coiling ti»uully 
heinji fmm Irfl t<> right. 
A» Ihv ¥<■*«'!« nrc n^nnll; 
longer tlion the cord, thejr 
arv fm|ui>nl)y foMift npon 
themM'Ircs, thii>< j;iving Hko 
to idxIiiiiiiionM iipi>n the 
Borfueo which arc dcGig- 
mivd »» fnUe knol». 

The cord is covoiwl by 

wveral laver* of opitheli- 

am, which is n dirwt c<Mi- 

tiniiatinn of Ihc skin cor- 

Itw alalnmtrn of |Im> rmhrt-n: ilti intvrinr i« madi* np of a ninooid 

the so-ralle«I Whartonian jelly. 

^' iiiiw Ihmugh ihi- fuia! and placental cods of the cord 




UA. 



'■> lU-t BHurAl. Catu>, firtAl Knd. X -'if 
|''*< miiitnl trtrffx VS.. mnnani a( tunblUral 
MA-, r.r.. araUlMsl vrm. 



138 



OBSTETRICS 



nt tvnn prvscnt ii *rtfn''wUnt tliffi-n-nt ajijHiirniut'- lu Um" rnrnwr, 
■ III- vt'KM'U, om> UMiiillv !>(-f^ ivro ■<iiiall. darklv aUining nnso, wliicli ui 
hi;!h(>r muRtiilicalion apjit-ur u:^ »innll itacli' HavA Uy mlmiiliil or flittkii 

epithelial celU. One \* the iv-nioii 
of the sllantois, KiA tlw otber 1 
duct or «Ulk of tiiv umhilical tc 
d<>; nt tin* |ilaefnl»l end only 1 
latlw U proswit. 



^i* *'' ". ' _ ■. » I'-"^ of 






Fl«. IliS. ~ HCI^nOK TIIHOITUII t'HtllLICAI. 

Cdho, ■noniMQ Sr«LK or lJunii.H.-Ai. 
VinicxK. X 1 10, 




FwK ISO. — Bw-niix tnit"i-<iii Awhui 
Piuik:lk nr 2.2r>.M(LiJiiicnu: Ei 
<llu). X SU. 

All., »Iliuitn»: .V.f!., ninlullBiy P«< 
I'.A., iioiliilinal iirlpry; Ct'^ uoibU 
voin. 



Ill most toxt-books, it is statetl 
Ihnr the cord i* derived from the 
nlluntoift. xiid is coreriil hv a Hhoaili <if amnion. The rp«MMi«i of 1 
iiuv.' i}i.linitch- Khown that such ii* not the oam- in mim, Imt ihiil llw- rii>tj 
in IliP I'arlic-it stnfti's of pn-jfimncy. in conncctod with the inner sorfi 
of thu chnrion hy a tolerably thick 
niHs of ti^iiiH-, only a >iinall parlion 





Via. 157. — SiimoN niRniiaii Yol-ho I'm- 
nil-iVAi. Vono (Miiiol). 

A., mltrry; All.. nUimt-in; t'^„ stalk of um- 
bitk«l VHirit<; V'., vniu 



Flo. lOft. — Stai.k or L'lnifLicAi. Vi 

BUMU IKn't<IMl(l If THE rHIIII.UTAl C 



t>l whifth is n(M>upie(l by thft ntlaniaitt. Thin Hi:; dwignatod as the nktonii 
pe«lrclu (RanchiitiH). and kViwi-iI IhnI it n>pnT«ent:< merely an extens 
of th« cniidai end of the embrvo. 



UMBILICAL VESICLE 



139 



Fij^ I5S rpprcKenU a station thnm^ch th« alxlominHl pciliclo nf oiu> nf 
Ike ttrljr nnl>r)r(ig>^ iiiu<Jio<l by IIU, nntl cU-arlv fhow^ tin nnaIo|f}- with the 
cnkTmc area. Thv ^n-at bulk of tbe :<tru<'tun- ih inadi- iifi uf mi-^iHlLTinic 
tiWR m which the umbilical TGiUicI» anil the allantoU arc ombudiled ; 
Ht dmal rarftwe i» corcred by n ttjitglc InviT of iTtoderm, showing at its 
ouUli' • iili;;ht dcpresfiion uliich n-'presents a ti>iilinualtoo of llic tiK'^Iul- 
lin^Kni-, irbilL- arching ovit It t« ihi- amnion. In itx {urtbi>r tlevolop- 
BcU tbt ivtiHlorina] portion, corre>|H>ii<linf; tt> Ihr KOfnutoptrun-. v\U-udii 
imurmi siul inuairl, t^tntuallT inclosing a sntall fiortion of thi- ciHotne 
{■■nyumilar to tbal in nliioh tbv alxiominiil watlit are formvil in tliv 
•il«J» itself. In Ihis cavity the stalk of the iinil>ilio»I vehicle or yolk-sac 
it irin fcit. tn Ihv iwinitiniv tW ainiiinn i* likcwi*^- cxlcmliiig aniunit 
At atin «lnicture, but is i>i>l in i-onlaot with it; and a^ thv fonner 
^"mm iiHiiT' and mort- di^tcndttl by the amniotic Huid. it becomot 
Inkn latl farther wjraralm! fmm tlie utHloininal |iMliclu, or a^i m- may 
••• «I1 it. Ih»- nmbtlicjil conl. EniHually the iimiiion if conni-ctcd only 
••111 the jioniun of the cord which is attacbcii to tho fii>tal nurfatx; of 
*t|4a«t«. 

Fij^ I5S rifprviti'ni-t a Ibirty-days' <'mbrvo dtM-rilicd by Hik, «nd piixw 
■ ■■jgQod idva nf U»' manner in whicli the istalk of the umbilical vesicle 
WNvn inrliid'i! niihio iho ronl. 

IhUka] Vesicle. — Tbc yolk-eac, or. as it Itecomee later, the umbilical 
wife, t* 1 rcry pmmincnl organ at llwf beginning of jtri-gnuucy, and is 
pRDI m all earlv ova. In its earliest !-'tage^ it occupies tht! entire in- 
tnt iif tlx- blaiiloilrnnic vraiclc. But, as the embrj-o dcveloi)*. it becomes 
"lili'rlj »mnlh-r. and, ns Wc have alrea<!y shomn, U taken up in great 
ft tn form the inlcKtinal canal, so that after the formation of the ab- 
teiiul trallx il protrude* fmm (he nnibitieus as a rounded suk with a 
*Maw stalk- An pregnancy adrancvs tlw sac bwomoe stnalter and its 
lA Inif^. 
TV ttructnrv persists througliout pnynHncy. and can nearly aliraya 
^ktimiil at full term, vhcn it i« repn^^-nli.'il by a luiiall oval i^uc, 3 (o 5 
tret ill diameter, which iBually lies on the fu-tal surface of the 
ihe chorion ami amnion, but occasionally in lh« mcm- 
I the pUivntal mari;in. It is connected with the uni- 
nrird t>y a fine pedicle, which, as has b<^n already shown, may be 
I MTlJons through the wnl at term. Srhultxe, in ISfil. was able to 
itf tin* umbilical resiele in 144> out of \M matare |t)aceniie 
Mrver has found that tW rwicle may atliiin considerable 
Hmw, it In-ing 10 to IT. millimetn-v in diameli-r in m-vcmI iatlanoorf. 
TV iDtni>alMlominal portion of i)h- dnrt of tlw umbilical vediele, which 
""tfnit from the umbilicus to tlte intestine, visually atrophies and di»- 
■ffow. Imt neraNionally it remains patent, forming what is known a* 
*ft«fi ditrriiaiSum, which may i>Iar an important pathological part in 

h I* uimah whoM nra pmj«tit ■ large amount nf yolk, the umbilical 
■Mb i» (lie main source of nutrition for the embryo: but in those of 
^^k Ut diicntfleance is not .-mi cltar, ^incc tin; proportion of yolk is ox- 




140 OBSTEH'RICa 

LCLilinglv Ismail. In name of the lower animabi it afForda a moaoR of vas. 
L-itlariziiig the chorion, M'hilt' in still othere it takes part in the formatioB 
of nn act'cssorv placenta, in addition to the main one which is vascuiarizei; 
from the alJtintoif. It mual, however, play an important part in th 
ttiUiomy of the cnihrvo. as it develops a considerahle circulation, and. a_ 
Selcnka hus t^hown, forms DumtTonx crypts froTn its entodermal lining 
As yet we are unuctjuuintt^tl witli its functions. 



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DEVELOPMENT OF THE OVUM 141 

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OvERLACU. Die paeudomcost. Mucou uteri. D. I., Milnchen, 1SS5. 
Peters. Ueber die Eiiibettuog des menschlichcn Eies. Wien, 1899. 
Pinto. Beitrag zur Kenntniss der an der Placentaratelle vorkommenden Zellelemente ' 

Beitragc utr G«b. u. Uyn., 1005, ix, 323-337. 
Reichert. Ueachreibiuig eiiu-r rrutuMitigen mensrhlichen Prucbt. Abhondluni^ d ■ 

ki^nigl. Akod. d. Wiiweniichuftcn, Berlin, 1873. 
Ruhr. Die Beiichungen der miitterlichen Gefiuae lu den intervillSacn Raumen der^ 

reUen Placunla, speciell zur Thrombose dcrselben ("weisser Infarct"). D. I., -^ 

Bern, 1B89. 
Rossi-DoRIA. Ueber die Einbettung des mcnBchlichen Eies. Archiv f. Gyn., 1005, 

Ixxvi, 433-50r>. 
RuoG. Ueber die menat^hliche Pkrciita. Zeitschr. f. Geh. u. Gyn., 1898, xxxix, 

550-588. 
Schick. Uelicr die Lyinph)(c-fiU«c d. Ulcruaschleimhant wohrend der Schwangerscbart. 

ArcUv f. Cyn.. mvi, ixxvii, 1^20. 
ScHMoHL. Uclwr (jTOHtwelliBc (dccidua-ilhiilichel Wucherungen aiif dcm Peritoneum u. 

den Ovurien boi iiitruutcriiier Schivan^rBchaft. Monataschr. f. Geb. u. Gyn., 

1897, V. 46. 
>JC!iiii.TZE. IW NabvlblfiHohcii ein FonsUmtea Gebilde in der Nachgeburt des aua^tra- 

gcncn KindcN, Ijeipzig, IWil, 
Sblenka. KcinibliLI ter ii. Priinit ivorgane der Muub. Studieii iiber Kntwickclungs- 

geachichte der Thiure, 1SH3, H. 1. 
Die Bl^itteniinkelining iin FA der Nagclhiero, ditto, 1884, H. 3. 
Studicii lilHir Kiitwirkeliiiigij»fl.'«:hirhlc der Thicre, WieBbaden, 1891, Heft 5: Mcn- 

sehen-Affen, WiusI widen. I8!t9, ii. 
Uluttumkuhr irn ICi der AfTen. Biol. Zentnilbl., 1898, xviii, 552-557- 
MeTiaclleti-.Vffeii , IftOO, iii, Liefening. 
5hai[ki^v. I'jnifli.th tninalation of Midler's Ilandbuch der Physiolt^e, according to 

S(-hroeder'H l^ehrlmch, XIII. Aufl., 1890. 
Sint iTTA. Die liofniclilmig uiid Furchung des Eies der Mans. Arebiv f. mikr. Aiuit., 

ISl)5, xlv, l5-9;t. 
Hit! iOrit\vi<'ki:li[iif; duH Klaa der Mans. Arch. f. niik. AnaL, 190.1. Ixi, 274-330. 
SrKK. IWtnin X. l^iit"jc'keli[rij;.sKi''<'"l"ich|.ederfrixhcrcn 8ladien dea Meerachwcinschens 

etc .Vrr'hiv. f. .\ii:it. ii, I'hy.s., Anut. Abth., 1883, 44-fiO. 
Neiie BcolKicht.iLHj;i''i iil>i'r sL'lir fnilie lOntwickclungHHtiifen des niciiKcblirlicn Eica 

.Archiv. f. .\.ii;i[. u. I'lijsii.l., Aiiat. .\l.th., 18!M), 1-30. 
B<.'ol)arhliiii.!;iii an i-iiiur nionschl. Kt'inisi'heilje init olTcner Medtdlarrinne. etc. 

An^hiv f. .\ii;il. II. I'liy.s., Aiiat. .\]>lh.. 181ll», 159-17(i. 
Die Iiiipl;iri(;itiiiri 1I0.4 M<;i.T.s<'liivfiii.si']iijri,'*i in die Uturuswand. Zeilachr. f. Morjihol, 

11. .\Ti(hro]).il., I!l()1, iii, l,ll) 182. 
Deitioii.ilialioii cincs jiiin;vs Stadimn ilur iiiciiwhiichen Eicinliettung. Verb. d. 

deiitsi'hcii ( !csi-llsHi. f. <;yii., liHHl. xi. 421-422. 
Sth,\hi,. l)it ]Oiiiliryi>iialhi]lltri diT S:iuj;(!r iind die Placenta. Hertwig'a Handbuch 

des T'lnlwiekdimnslKhrL'. I'.HHi, Bii. i, Tlicil II. 23.'.-3fi8. 
TuitNKU. Observaticiiis on tho Stmcture <if the lliimon Placenta. Jour. .Anat. and 

Physiol.. 187)5, vii. ]2II; i.lsn 1S77. xi. 
TrifWEMinoECK. Uiv IX^cidna iiteriiia lx.'i ekto]»is<'bpr Si-hwaiigersrhaft, etc. Virehow's 

Archiv, IHm, cxxxiii, 207-2130. 
Ui-fWKO-STHOciANOWA. Hi'ltriigi; 2iir I^'hre voin niilir. Kaii der Placenta. Monatascbr. 

f. Gob. n. (lyn., 189(i, iii. 2I>7. 
Van Hknkljkn. lierherrhes snr low ])retnii''res Blades dil developpenient der Mllrin. 

Anat. Anieiger. 181H1, xvi, :nr^;m. 
Vateii. Quoted from W'aldeyer. 



DEVELOPMENT OF THE OVUM 143 

Vols. D" Voricommen von Decidua in der Cervix. Arch. f. Gyn., 1903, Ixix, 681-687. 
WiLD«TM. Bemerbungen iiber den Bau der Henschen- uiid A ITen- Placenta. Archiv f. 

miki. Anst., 1890, xxsv, 1-S2. 
WuKK- Zuntie vom Bau und den Vcrrichtungen der Cleschlechtsorgane. Abh. der 

k^ achsiBcben Akademie, 1846. 
Webbteb. The Changes in the Uterine Mucosa during Pregnancy and in the Attached 

F<eU1 Stmcturea. Amer. Gyn. and Ot»t. Journal, 1897, x, 168-264 and 535-662. 
Humaii Placetitation. Chicago, 1901. 
TON Weih. Zur Kosuiftik der Placenta praevia centralis. Centralbl. f. Gyn., 1607, 

641-649. 
WiLUAHg. Decidual Formation throughout the Uterine Muscularis, TranH. Southern 

Surg, and Gyn. Aggn., 1905. xvii, 119-132. 
^'"(''Lat- Textur, Stnictur und Zellleben in den AiJnexen dea menwhlichen Eiea. 

Jott, IS70. 
Zuntn. Die Chmmosompn-thoorie der Vererbuiig, etc. Arrhiv f, liasaen u. Ge- 
«flrf»i»fie-l)iologie, 1900, iii, 797-S12. 



146 



OBSTETRICS 



plied uiUi nails; th« external gc-nitiilin are bcf^ioaing to show dcB 
nga» of ■'•ex. 

Ponrth Hontli. — ily the end of tlie fourth inontb tlie fiptua is from 
to 17 tvuiiiiR'tR-v long, and wt-ighs about ISO grammt*. An vxamin^ 
of thf e^ttvriial g<»)itnl orgviiK n-tlt now dvfinitcl)' rex'eal Itic m». M 

FifUt Hontli. — 'I'lte fu>tiia varies from IS to 37 oeati metres in tcq 
and u*i-igli» uliout S.S(> gratnmrs. Its «kiti Uas tioeooiu Iw traru^parvol 
down}' mvering is mvd ovor \\* i.-ntirir Imdv. while « mrlain amoiiaJ 
t>*pioal hair ha?; made its a{>|M?aranci^ on the head. j| 

Sixth Month. — At l\w inil of itic sixth month the fwliis variw tt 
9S to Ai it^nlimetrci in lt'n(;tli, and weighs at)oiit 634 j;ramiiieti. The « 
pn-M'nU a nmrkrdly wrinMiii iifipfiininco, and fat ix-'^ini- to be dfp<)»i 
l)eneath it; the head is still comimralivi'ly 
ijiiilc largo. A firtun horn at tliis period 
will attempt to hreathtf and move itit 
limbs, but alwa>'«i iK-riKlit-H within a short 
titne. 




F\s. int). 

tiai. 1I»-I7I. 



-I^ntiTi» ntotf Skookii MamH {Hit). 



Seventh Month. — The length daring thi* month varies from 35 t 
ccniiiiietris, and Ihc firtns attains a weight of over 1.200 grammrs, 
entire limly i* Vctv thin, the skin iii nitdl^ih and covered with t< 
caseosa. The piipillarr mcnihrane has just dLsafipeanii from Ihc i 
A ftvtn* horn at this jicriiH} movr-;* it« limbs quite energetically and i 
with a weak voire; but, as a rule, it rannol hf- raised, even with the q 
export care, although nn oconsional 6ueee*ifnl case is found in ttu* rc«M 

It is gem-ralh- U'lieTpd among tho hiilv Dial a ehild horn at the 
of the sl^venth month has a better chanoe of living then wlivn it 
into the world four wivks lati-r. This idea is a remnant of Ihi 
llippoerafir doctrine and is ahsohitely errf.neous, as Ihc more dvT«l 
the I'liild i)ii' i!"-nli-r are il.< dwinoc^ for life. 

Eighth Month. — At the end of the t-ighlh month the f<rtus has ai 
« length of i'i.5 eentinietroii. and a weight of about 1.900 grammes. 



THE FffiTUS IS THE VARIOUS MONTHS 



147 



nrtatx nf the skin 18 still red and wrinkled, and the child reBembles an 
old man in appearance. Children born at this period may live if properly 
ared for, though their chances are not very promising. 

Viitli XoBth.— At the end of the ninth mouth the fcctua is 46.75 ces- 
metres long, and weighs about 2,500 grammes. Owing to the presence 
' considerable fat, the body has become more rotund and tlie face has 
st its previous wrinkled appearance. Children bom at this time have 
Tery fair chance of life if properly cared for. 

Tenth Konth. — Full term is reached at the end of this month. The 
?tiis is now fully developed, and presents the appearances which we shall 
nsidcr in detail when we describe the new-horn child. 

According to Ahlfeld, the average weight and length of the fcctus in 
le last four months of its development are as follows: 



Wekk, 


Weight. 


LcDRlh. 


7th 


1,142 j^iiiiiies. 

1.635 

1,576 

1,868 

1,972 

2,107 

2,084 

2,424 

2.733 

2,806 

2,878 

3,016 

3,321 

3.168 


36.3 ceiitiinctres. 


»th 


40.4 " 


atk 


39.6 " 


■Kb 


42 " 


3lM 

Zti. 


■13.7 

43 4 " 


3U 

MU 


43.88 
46.07 
47 3 " 


3U 


48.3 " 


flu.. . 


48 3 " 


M 


491) " 


M 


50.0 " 


«k.. 


50 a 







These iigures poBsosg only an approximate value, and generally speak- 
!>¥ 'he length affords a more accurate criterion of the age of a child than 
t*»»'ighi. llaase has suggested a very simple method of determining the 
™' nf the emhrvo at its various periods of development. According to 
""». Ihe length in centimetres may be roughly appro.\i mated during the 
"M five months by squaring the number nf the month to which the preg- 
■"■o' ha:- advanced; in the second half of pregnancy, by multiplying the 
■Mill by 5, as is shown in the following table: 

Altbeendof the Rrst mouth 1X1, 

" " second month 2X2, 

" " " third month 3X3, 

" " fourthmonth 4X4, 

" " fifth month 5X5, 

" " aixthmonth 6X5, 

" " seventh month 7X5, 

" " eifchthraonth 8X5, 

" " " ninth month 9X5, 

*• " tenthmonth 10X5, 

ftt Child «t Pull Term.— The average child at full term is 50 to 51 
•Wimetres (20 to 21 inches) long, and weighs 3,250 grammes (7 pounds). 



1 (entimetre. 


4 rantimetrcB. 


9 


1 


16 


I 


25 


* 


30 


1 


35 


1 


40 


1 


45 


1 


50 


t 



148 OBSTETRICS 

The skin is einooth and polished in appearance, and shows no lanug«^ 
except occasionally alwut the shoulders. Over the entire Burface is BpresL* 
a whitish, greasy aiaterial, the remix caseosa, which is a mixture of e|:» ' 
thclial celk, lanugo hairs, and the secretion- of the sebaceous glands. TSr 
head is usually covered by darkish hairs 3 to 3 centimetres in length, 



the cartilages of the noac and ears are well developed. The fingers «» — 
toes possess well -developed nails, which project beyond their tips. In nn^^ 
children the testicles are usually found within the scrotum; in girls t.~M 
labia iiiajura are well developed and are in contact with one another, a^^ 
usually conceal the rest of the genitalia. The bones of the head are w^^ 
ossified, and are in close cimtact at the various sutures. 

At autopsy a centre of ossification, 0.5 centimetre in diameter, 
found in the lower epiphysis of the femur. This was first described ^^ 
Blecard, in ]82fi, as a diagnostic sign of maturity. It is not in fail ib ^^ _ 
however, as Ilartinann has shown that it was absent in 12 out of IC— -^ 
full-term children which he examined. Hahn, after studying a lar^^- 
imnilwr of premature and mature children by means of Rontgen ray. "^ 
states that the centre of ossification at the proximal epiphysis of the tibi* 
is always lacking in the former and present in the latter class ; whil *■ 
lla.ssehvander contends tliat ossification of the cuboid bone of the foo^^ 
affords conclusive evidence that the child has passed the ninth month o' ^ 
developiTient, ;is it is always lacking prior to that time. Holzbach, on th^ * 
other hand, holds that the most valuable sign of maturity is to be founti* 
in the relation betwei'n the fro n to-occipital circumference of the heaiE^ 
and that of the shoulder, as in only 1 out of the 31 premature childreW^ 
which he examined did the latter equal the former in size. No one of thesei^ 
ciinditions afl'ords indisputable proof of the maturity of a child, but:* 
wIr'U the nuijority of thciii are present the evidence becomes fairly con — 
viiu:ing. 

Soon after its hirth, and occasionally just after the head emerges frora^ 
the vulva, and hofore the expulsion of the entire body, the child make;^ 
inspiratory niov^uionls and bofrins to ery loudly. It moves its extremities 
freely, and al'tcr a short time passes urine and meconium. 

Negro babies at birth liifler somewhat in appearance from white chil- 
dren, but not so riiiirkediy as one would expect. Their skin presents a 
dusky, Muish-red liuc. but does not at all .suggest the darker colour which 
it will assume in the ciuirse of a few Heck.-. Where there is a considerable 
admixture of while blood, the dusky hue may be entirely absent, and the 
only evidenc<' nf negro ancestry will lie found in an increased pigmentation 
al)out till' exteriiiil genilalin. 

Weight of the New-bom. — Tlie average infant at birth weighs about 
?'.'l'iO graniiru's (7 pounds). l>oys being usually ICIO grammes (3 ounces) 
lii>iivier than girls. Jfiirked variations arc frequentlv observed, which are 
dependent upon the race and size of the parents, the number of children 
wliieh till' niothcr has linrne, her mode of life, and her nutrition and 
^'eneml condition during the later months of pregnancy. In 707 full- 
term while children born at the Johns Hopkins Hospital, T. F. Rig^ 
found that the average length was 49.04 centimetres, and the average 



WEIGHT OF THE FtETUS 149 



t weight 3,316.9 gramme (7.54 pounds), the smallest child weighing 2,180 
' fT»mn\ei (4 pounds II ounces) and the largest 4,553 graimncs (9 pounds 
12 ounccij). 

It appears that coloured children weigh consiilerably Icsi^ than white, a 

fact which, in large cities, at least, is indicative of the physical degenera- 

lion which characterizes the race. Four hundred and seventy full-term 

«»loun?d children nieasurwl by Higgs averaged 48.75 centimetres in length 

■nd 3.104.8 grammes in weight, a difTercnce of 211 grammes {7.2 ounces) 

in favour of the white race. 

Similar but less marked differences may be observed in the different 
coxintries and even in various portions of the same country. Thus Schroe- 
d«^r found that the children born in Bonn averaged 71 grammes (2i ounces) 
le=fj* in weight than those ohKcrved by Heokcr in Munich. 

IVrfoctly healthy full-term children may vary from 2,300 to 5,000 

g-rarnmw (5 to Hi'^ pounds) in weight. They rarely exceed the latter 

fip-uru. although it is not unusual to hear of children weighing 15, IG, and 

i-v^n ■'" pounds at birth. The majority of these cases, however, must be 

re^arJed as a|)ocr>phal, and careful inquiry will usually show that the 

w^itiht has liec?n only roughly estimated by lifting the child in the hand, 

sjiii not Iw.-^d upon accurate determination. Ilocker in l,09(i cases found 

nnly i children that weighe<l over 5,000 granunes, Winckcl 5 in 30,500 

deliveries, and Starcke IG in 34.000 deliveries in Leopold's clinic. Ac- 

t>oTtlinfr to Ludwig, out of 15,]G6 children Imrn in C'hrobak's clinic in 

Vienna, only 1 weighed 5,:i(t0 grammes (11^ pounds), and Varnicr states 

vhat in *evcB years, at the Baudelocijne Clinic in Paris, there were only 

*> chiltln-n that o.xceedc*! 5.000 grammes at hirth, the largest weighing 

•>-13<» jnanmics (13 pounds 3 ounces). Moreover, it is probable in many 

uuuncw. as pointed out by Winckel, that the excessive weight of sueh 

chiWroi should be attributed to the fact that pregnancy ha,s lasted some 

««*« longer than usual. 

Id over 6,000 children doliveRtl under my supervision, the largest 
'rifhtd .i.833 grammes, or 12 pounds 8 ounces; though several of my 
(rieBH* have met with babies which were considerably heavier. Dubois, 
i" 1**:, collected from the literature 28 ca'^-s in which the child weighed 
aWO p^tnmgg (12 pounds) or more at birth, and stated (hat the heaviest 
'^il'ln-n on record were reported by (Irtega, Hachi'l and Xeuiner, and 
Bwh. in^ weighed respectively 11,300 (24 pounds 3 ounc-rs). 11,250 
'-' pounds 2 ounces), and lO.lTiO grammes (23 pfiunds 12 ounce.*). 
"fKn'-i child was 70 centimetres (28 inches) long, and Be<'ch's 7fi cen- 
limelrrs (.10 inches), Ludwig. a few years ago, reported a ease in which 
'>^w obliged to perform Ctesarean section, after craniotomy and ampu- 
Utiofi of the extremities, in order to deliver a child weighing 7,700 grammes 
"' pounds 8 ounces). But in spite of these exceptional cases, one should 
^"nremplv eceptical in accepting reports concerning phenomenaliy heavy 
fkildren, unles:* one is convinced that the rc|>orter is a truthful person and 
^' twjrhed the child upon an accurate balance. 

On (he other hand, children are frequently met with under 3,250 
P»Hunes (7 pounds) in weight, and it is not unusual to see healthy full- 



I 



ISO 



oBsmmiics 



term 1)abie« weif>hinf^ from i.HXi (o 3,8(k> gniiiinir» {5 (n R pmititls). Ac 
wfighl bi'l'nr .1 iioiiikIh, in i\k etuv of aii infant Ixtrti al K-rra, shuuld 
wajn icad one (u j^ut^fK't-t f»nM.' tlisuuM: un tliu |wrl uf liiv niutlier ur f«etM-M 
■e ni-jihriti> ur KV]iliilU. 

(ienerally epesking, premature ditldren n-cigliing Xtxt than IfiCZ 
gniminn {'.I [KHiniU :! duikiv) liav<> |irnctii'ally no chance of life, tlious^ 
i}xcv|iIional ou^ci^ have tii-cn rcjiorUxi in nhich kucIi infant* liuri' iliu^i 
wdl. Pivring. in & nivnl iiri.icli', rcjiorti* ruining a premntuit- child tli^ 
v-cigheil only 1,130 grammes at birth, and mcntiom eases under the chai^ 
of Hitter, Rodman, and D'Oulrcpont iu which cliildrcn weigliing on j 
717, 719, anil 7.10 j-ramnies rp-p(?clivoly wctp BiicceMfiilly rcarfd. ICl 
A. U. Powell, of Ck-vt-lan<l. inrormii nic timt lie )ih* recently TAtnei an 
iofant which wciplicd onlv 7'>0 grammes ai hirlh. ^^ 

The *iize of thf fd-tiw increu#c» with iW ngu of the mother up tn tBS 
twenty -eigliih or ttiiHielh year, if pregnancies hare not followed in t» 
rapid eucocKiion ; tbf vhildren of f^ucM-ediiig pn-gnancic^ uMially follow 
same rule. 

The eixe of the fu-tu£ is aUo dc|iciidi-nt. to a conoidt-rablc extent, u|>i 
that of ihit panels cMjHK-ialiy the father; and in many inetaDces ita ha 
closely re«embk'» Itiat of the fullK-r'in t^hupc. 

The mkM ciHidiiion uf the mother and the comfort* by which she 
eurrouiidcd also c.xcrt a marked influence upon the child's weight, heat 
children lx>ing more lYimmon in the upper walkji of life. Thn^^, on locss 
ing over tlic records of mj private cases, which are almost oxclusivt^ 
among the well-to-do classes, I found tliut 13!! ht-althy fHll-lcrm ehildn:^! 
which I had weighed u|>on t!ie namt pair of scales, averaged 3,79J gramir^"^ 
(8 pounds 'i ounces) in weight, as con]|>ar<.Hl with I},!tl4!.9 and 3,1&^E 
grammes for the white and coloured children in hospital practice— ■ diM 
feroncc of 4T8 and fil'O grammes, respectively, Tlio heaviest child weigh - 
5,8.t3 gramm<« [Vi ihhidiIs S ounces), and the lightest 2,-WB gramii»^ 
(6 pounds 8 ounces). Eleven weighed 4.(!(iG grammes (10 pounds), a^M 
15 weighed S.iSG grammes (7 pounds) or lexM, leaving 107 betwcbu L^ 
two limits. fl 

Pimird and Bachimont. fmm n study of 4,415 ca*eK olwervcd in U— ■ 
Uaudclocfjuc Clinic, have lately arrived at more or less similar coDelu.'*ior" 
The}' fdinul that tlie ctiililn'ii of women who had lived in the hospital f-^^ 
ttu'ee months prior to confinement averaged 500 grammes (I ]H)und 
ounci^s) hcuvier than those of patieut« who had enlcrcd the hospital ju 
before or during labour. Thw consider that this difTerenee i« dm- to tl" 
better nourishment of the former class of patients, and to the atisenc^ 
of hard work and the oon!*e(pient tendency In premnture lnl)onr. Fuch* 
of Halle, obtained approsimatcly the same results. T. K. Itiggs, upo" 
analysing my cases at the Johns Hopkins Tlospilal, arrived at similar 
conclusion*, but found that there was a greater increase in weight in tbe 
coloured thun in the white ehitdrin. Ho was inclined to attribute the dif- 
ference to the fact thai the hospital fare was not much bettor than thai 
which the white wonu-u rcii-ivcd in their own homes, but was far supcrk 
to that to which the average coloured woman is accustomed. 




THE HEAD OF THK RETUS 



151 



p-nrr«ll_r Micvtil thnt the com (karn lively (HfTieitll labours n{ tlie 

(rtneo >>r (Ik- u[tjier i-la»u^ »t« duu to iIk' t-nenaliii^ iiilliifticfH of eivilixa- 

iD iUmI ltixiii>, irliile the easy lubours of the luloiirvil woiueQ an; eon.' 

^i an mnnid^tiiiitHifl uf it el«n?r nppmaoh Ui Nuliire. Thiwr eoiu-lusiocu 

• %t^ not jiu^tiliod h\- my experience, as I belie\-e that the wlourwi wnmen 

^en ill Wgc i-ili(* in- (iliyskal ili-gixu-ntt'w. CoiilnictMl |M'lvf'>i occur thrwi 

to (oiiT bows more rrcijueotly in them llian in while women, anJ were thia 

Bul MUBlvrluihiriciHl l>y llii* lowr «cig)it »f the folourxM] children, and 

{■ilinlarl^T bv tlie smaller »ize and ;;rimter conipresaibilitv of their hoaiU, 

Uwir wmild bo u mo»t diiia»troti» function, and would compiiratirety 

fno \aA lo a sniution of the race pratitein, I am iDc'lim>il to Wlit^ve, if 

tktiT thitdren were oi: Ur^v and Knd a^ hard hcadf^ as in the upper claEces, 

Ail 1 tbnnhl hv obliged lo pcrfom a Ciwarean rwction a week, inatcad 

•( Gm OT «ix a year, as at prfttent, A<:cordinf;ly, it appears perinisflibloj 

to iltrilnU' Uic mon^ ditlicull IuIhiuri nf thi> uii|ht cIakm^s to tlie lar^^ 

OR <■' thdr chiMrm. resulting fram abundant nutrition and a life of 

•M, ntlwr than lo Die i-ncrvating intliHiutv of civilizution. 

IWfidtil -the pdviH i^ iinrmal. it is unusual for children weighing Ic&t 
*n S/KHI gramnMv (10 pouruU) to oauw.* diHieult lalwtir dimply frora^ 
4w me. sinw Vaniier has ahowri that the diameters of the head do 
lat lum'iM- 111 thr «ini« ratio a* tht' weiiiht uf llw elilbl, 

Jbi find of the Child. — From an olwtetricol point of view the head 
dtkethild is it» most important part, as the I'-^scntial feature of labour 




rta 1T3.— Ciiit.n'* IlRAn «t Tr.m*. X t <Am«neaii Texb-Oook.) 



i> 1 !'""»>. iif adiiptntion bi'tmin it nml llic rarioux portions of the petris 
"Wii.-i b1,i,,|, ji [laijBcg, \d a<x-iiratt' knowledge of it* chamvteriatiet 
'•' ii tiMTrfon' nf <-apital impijrtan<-e. 

> - rtm|)aratiTe)y small )iart nf the head of Die child at term is 

T' I'T iImt tact', tlu; real Iwinj; rampused of Hms linn, hard skidl, 

11 



154 



OBfTTETHICS 



rniiu 
tinil 



lhr\ iilT'T III mmiir, fi.< tin- Imiies uf om- may tie mtt. cnmprc 
rcaitily displaced, vrliile ttio^p of aDolhcr ar« Hrmly aod densely 08<<ifiAl 
And odmittiii^' uf liiil lilUi- iiKililily, tlie TontK-r lH>iiig rvjidily inouldiil In 
tiie i^onitid canal, whilu ihc IoIIlt aro incapatitc «f i-L-duetioa in siz*. 

Hiyiiology of the Foetu*. — Our kntiwtcdgc wituriTiiiiig (he phy^tioiog}- 
of die fo-'tii^ ha." liem markedly enriched dnrinj; recent years ; jjevertheleM, 
wrhon comparfd with that of the ndult. it olT<.'n< many pniut* coiiccrnii^ 
whieh we are but sU^iiUy informed or profoundly ignorant. 

NatHtion of the F<etui. — Owing lo the ginull amount of yolk contaii 
in the htiriiitn nvinn, ihft growth of tlm fwtuH ii* alnioiil entirely de[)onthiht 
upon the amount of nutritive material which it ohtainj- from ils mother. 

Diiriuji; i\v- Hml fi-w moiuli-" of )>n-];nnney, IK Fehlinj; fli':<l poiiiteil out, 
tile emiiryo eon^ista almost enliiely of water, and it is during this period 
(hat it grows ntott rapidly. In the later moniliK of pregnancy, when mnrc 
solidA arc Iwinj; addinl. the inenase in size becomes gradnally slower. 
FohlingV conetm-ion* were coiilirmi-d hy .Miehel. wlio nmilyxH fa-tuM^ al 
variouH periixls of tlieir iit'vcl<j]itiienl. Some of his rejiults are shown 
the following table: 



WkUr. 



At 2i moinhn- 99.82 pur ren^. 

3d Ui Ml iiiuntli 89.115 " 

7ih iiioiii.h .; »1.73 

Al li-nii (iS.IG 



AJtfuuiikwuitA. 



4,39 |ier «nl. 

7.05 " . 
lOJM 
!3,9(i 



KUIk 






Tr»«i. 
1. 729 per twit, 
2.1K7 '• 
3.373 ■• 



VWiit 



Tnwc. 

.OSTgiwri 

11.75 "J 



It i« therefore apparent Ihal. ai^ ihc fu'tu« increases in a^, it contnl 
rclativelv lesfl water and a markedly increased <{uantity of nlbuminoU 
materially. ^alt><. and fat«. ■ 

For tilt- llrst few dny# after (he iin plan tal ion of the ovum upon 41 
otenne raueoi^ it« nutrition is probably entirely derived from the wrun 
which aeconipanicH llie ii-demuton.-> (.■■mdilion of the hitter. From the end 
of the firfet week it is surroundetl hy dwidiia. and Iwtween it nnd tlH 
chorion tiR* deveiopi'd liu- iniervillnii-* hliuHl sjimih.* which Bn> filled witli 
maternal Itlood. At tins perioti the chorionic villi arc devoid of ve^jtelsL 
iind the iinly way in which nutritive ninli-rial can lie taken up from tlw 
maternal Wood, by which they are stirrountled, is by osmostE. 

Id the Ihird w)?ek nf ])regiiu«cy the omphnlo-iiicwmcric romw^s make 
their appearance iijwn the curface of the umbilical vesicle, and whatcvcf 
nutritive materials tlie latli-r mny coiilain arc convi-ywl to the embryo by 
Ihem. IJurinu the fourth week branches of the umbilical vessels apfx-ar 
in the chorionic villi, and from Ihii time on thi* greater pari of tlie nutri- 
tion of the foitus U receive<l from the maternal blood, which in the ejiHicr 
weeks of prT-;;nRncy surrounds the entire ovum, but mon becomes limited 
to the plaeenlal site. 

The Fatal Circulation. — Owing to the fact that the materials needed 
for the nutrition of the ffetu.t are brought In it by the umhilieal vein, the 
fcetal circulation differs niatcrially from t}uit of tlic adult (Plate VLIIl 




PLATE VIIL 



n 




jlW 



S 




FtXTAL CIKCCLATION. 



I0« 



PHYSIOUXn' OF THE PtETUS 



155 






H TlvUood b pnrillcd nml laden with nutritiu- mnurinl in ihc placonu, 
H '*>d is titca curried to the fu-tu^ through the umbiliciil veiu, which, after 
~ /■"fcOtiii^ tin- ahilomiiuil vthII, ilitiilt-^ inin two liriiiu-hi's. Of ihi^w; lli« 
w 'w/fcr uttiiva with tht- |xirtal Vfiii, the blood from uhicli cireulaU^ through 

■ w firer and tlK-ti jniun ucnv* lo thv inferior vvaa cuvii through tho 

■ ^"pttic Tein. The other, the tarj^r hranch, which U desijjnated as the 
P rfunng -ntinvii^, fiD])ti<-j( dirw:tl_v into the teiia cava. The coiitfut« of 

'* TpxiA cav4 a)>ove the he|>alii- vein, therefore, ron^isi of a mixture of 

vieni-I blood from ihv {ihKi-uta and venous blood rctuniing from iho 

f^fr c^p^ctfemilks of the fwtuR. IIiia in carried into the right auricle, and 

"■ing t^i the intervention of tV* Eiu<taehian valvo in dircotttl through the 

■"Mw^M* <««Ie into tlie left auriele, wlw-noi- it juni.^C!' into tin- li-ft venlride, 

wliieli f airrrv it into the iiorta. The grcnlcr part of ihiti blood makes its 

*'! izav^o llu^ VRMela whieh xuppl.v ttie head mid net-k, while only n i^niall 

("*tt»r» of it jmssee by way of the arch of the aorla to nourish the lower 

» of the Wly. 

Hood KhieJi is returned from the head and upper eslremities by 

tin* Mtptrior veiia rara ii? (loureil into the right atirieti:, and eni**- 

currcnt from tlic inferior vena cava passes into tlip right ventricle, 

tt IS forced into the pulmonary arteneif. But im long a^ the luiigx 

iniM-tiiin, only a whbII iKTlion of this Wood Kaiit-t acit-iw to them, 

Bv f'r mtirr part of it jua^^in;; through the dm-tu^ arteriotitis to the arch 

V ">* •&orU, and b>ing Ihen earnt-ii to ilie rest of iIh' IkmIv of the embryo, 

B T*^ hloot) wliieh has gained aeeew; to the aorta directly from the left 

bil aL^km from (he right ve»lri<'Ic, through tho dHclu* arti-rio^u*. i» pro- 

P""™ «Jnwn tl»e aorta aud given off to the various organs aecording to 

P""' "^^nt; but (he hulk of tl enl'-rs the internal iline and hy|Kiga.*trie 

■'™^^^— the latter after pa.<'>tng the umhilicita being deitiguated as Uie 

■f*™'*^':^! artehos — and through tliein gnin;! acri*» lo the placenta. 

1 J^**«i tile fon-going de.*cription it ts api>arent that the blood cireulating 

Bfl^ Xii-lus is at no time Ktrietly arterial or etrietly vcnoitt!. but that the 

^^'^^ of the infi-rior vena iwva i* far purer than (hat of the aorta. 

^^**^ distinctive features of the fo'tal circulation are connected with 
^' '^**«tui" wiioiu* and srtcrio^i^, the foranten ovale, the hi^wgaitrie 
P*^*""^ and the umbilical conl. After birth tli^-m.- structurrK utidrrgo 
HH^**! changes. A* *aon an the child i^ l)om and Wginii to hreathe, the 
^^B^laiy eireulntion heeomoi c»lablls)ie<j. As a result, a much gnnter 
^^1^*^ nl Mood M pnnipn] by tlto rtglit v«nlrirle into the pulmonary 
HVW**^ while a lesAened amount piasses through the ductus arteriosus. 

■ Mon«c»*Pf. a. «H)n o* ihe cirrululiou in the f^nl ir^ nljolinhcl, the umhilieal 
I ^ '• func-tion]c«s. and a diminished (juantity of bloo<l is returned 
m V' ,,.!i auriclr- hy the inferior vena eova. This change leads to a 
I 4wtnilinu in Uie tension in.the right auricle, while that in the left side 

■ ■( tW iicari i* mcniiiwil, bringing atxiut tli« closure of the valve-like fora- 

I \» ili^ cin-ulation through Ihe umbilical artn-i*** rttsf* aluiont inime- 

I ."niMi after lh«.' pulmonary eirculation is establiithecl, Ihe function of th« 
I 'ii'«ttiM> arterim is rmdfreil uselew. and Iheir distal endu rapidly un- 



156 OBSTETRICS 

dergo atrophy and obliteration, which is usually complete three or ft 
dayii after birth. The ductus veuosus aud umbilical vein also beco 
occluded during the first week, whereas the closure uf the ductus arteria 
is more gradual, and frequently its opening does not bceoiiiG impcrrii 
until several wt-cks after birth. Permanent cloeuro of the foramen ov 
does n<»t occur for some time, and not rarely months elapse before it 
completed. Occasionally it remains more or less patent, and circulati 
disturbancfs of greater or less gravity result from its persistence. 

TransmiMion of Subataiices through the Flaceata. — As was shown wl 
considering the structure of the placenta, there is no direct comniunicat 
between the vessels of the chorionic villi and the intervillous blood spat 
In the (irst half of pregnancy firtal and maternal blood are separa 
from one another by the syncytium, I^nphans's layer of cells, a thiol 
or thinner leaflet of the stroma of the villus, and the walls of the ftE 
capillaries, while in the secimd half lionglians's layer gradually t" 
appears. 

The inde|K'n(lence of the two circulations is readily demonstrated 
e.xaiiiining the contents of the fietal vessels and the intervillous spat 
In the former large nuiril)ers of nucleated red corjmscles are found, wh 
are never present iu the latter. In order that sub-stances may pass fr< 
the mother to the fietus, or in the reverse direction, it is necessary : 
them to traverse the layers of tissue which we have just mentioned, 
would np]ieiir that gases and substances in solution pass by osmosis direc 
fr()Mi the riiak'riml blood to the vessels of the chorionic villi, and rice ver 
lint thill foriiK'd substances must undergo certain changes in the cliorioi 
(.'pillu'liuni before they can \h:; Irunsdiilted. 

The traiismissLon of gaseous substances has been definitely demi 
stralcd IhiIIi \>y I'liniciil observation and ex|xirimenla! work. Comparis 
of the Ihlimil in the uuibilical vein and arteries, respectively, shows tl 
the former is lighter in eulour, indicating that it is richer in o.xygen th 
the hitler. This fact liiis also been demonstrated experimentally by Zw 
fcl, will) sluiwed thai the Jilood in tlic umbilical vein, when examined 
iiieiins of the s|ii>(lr'os(i>|H'. ciin1iiiiLi.il oxyha'moglobin. Again, Cohnsti 
and '/Aiiity. have dcmoLisUitled that the blood of the umbilical vein in 1 
sheep is richer in oxy^icn and )nH>n'r in ciirlmn dioxide than that contair 
ill llic uinliilical aitericn. ZMriTcl has also shown that chloroform adm 
istereil to llie riiotlier is ra|iidly fraiisuiilled to the fivtlis. 

T'li' iuiTcase in the size •>! Ilie fieliis affords conclusive evidence tl 
materials in solution nnist pass from ttie uiaternn! to fho foetal circulati< 
and this has Ih'cu ileiiioiislrafod exjieriiiieTitallv for a nuiubor of substanc 
The first work of this cbaraeler ve owe in Maver, who in 1817 proved I 
jiassage of cvaiiide i>( potassiinu. Since (hen conclusive evidence of su 
transmission has been adiluecd for ioilide and fernicvanide of potassiu 
sali<'vlic acid, corrosive sulilinintc, nietliyleni' blue, :dcohol, and many oti 
siilistiimrs. 

Kriinig anil Fiilli in If'Ol invcsligated the molecular concentration 
the ftetal and maternal IiIihhI bv determining their fleecing ])oints. Tl^ 
found that both fluids froze at the same teiuperutui-e, a fact which im 



( 



PHYSIOLOGY OF THE FtETUS 157 



Ktex (hat they possess the same osmotic pressure, and that osmosis can 
tn-cur «ju&]ly readily in either direction. 

The evidence concerning the passage of formed substances through the 
piaccnta is conflicting, but until recently it was generally believed that 
"uch does not occur, unless the riiaterial has first undergone marked 
changes under the influence of the chorionic epithelium, or the placenta 
pF'esents lesions. The work of Bonnet, Hofbauer, Wallgren, AscoU, and 
others clearly i^bows the various substancea, such as iron, fat, albunioses, 
• titl other albuminous substances, arc taken up by the syncytium, and 
^■^"entiially passed on to the fcetal circulation. This was positively demon- 
strated by the experiments of Hofbauer, who, after feeding pregnant 
**»itnals with fat stained with Sudan red, found the characteristically 
"stjiint,! fat in the intervillous spaces, then in the syncytium, later in the 
*'t>"<»iiia iif the villi, and eventually in the foetal blood, and occasionally 
^■*'«-*n in thf various organ.f. Moreover, by the Ui'c of appropriate biochem- 
■*^»1 methods, he was able to follow the absorption of iron in the same 
**»a.nn(T, and in his monograph upon the biology of the plawnta pictures 
*■*«-- inin particles in the syncytium and villous stroma. 

In the case of fat and haemoglobin it would appear that the substances 

•'^ taken up unchanged by the chorionic epithelium, whereas Ascoli bc- 

«>«:v^ that the albuminous materials must undergo certain changes before 

•"sorption. Moreover, the demonstration by Licpniann of the presence 

*-■* Various ferments in the fu;tal portion of the human placenta enables 

*^D»-' to comprehend in what manner some of these changes are cITwled. 

■^* i* Ihcn-fore apparent that the syncytium must possess a vital selective 

™*"ti«)n. and that the function of the placenta is not limited to mere 

^''--orption by osmosi.«. This is particularly shown by its action towards 

_*^'*"rt*in to.xin^ and antitoxins, as Polano, Scbmidlechnor, and others have 

f>n>vi-n that those of diphtheria and tetanus are readily transmitted, while 

"'wny others arc not. 

^ The <iUfstion as to whether the placenta acts as nn clficient filter against 

■**ctcria has given rise to a great deal of discussion, but at pn-sent the 

**'»n«Dsns of opinion is that such transmission occurs lint rarely, and 

*''*ii«lly only in connection with .some distinct kvion of the organ. The 

'KX-urrrnn' of intra-uterinc small-pox was urged by John Hunter and many 

^uliMijuent oliH'n-ers as proof in support of the aHirmative view. Formerly 

It Mtui not infrc<|uent for niothers who sufferiil from sumll-pox during 

VTt^jrnancv to give liirth to children liearing marks of the disease, and one 

'•f the most celt 'bra tc<l cases of this character was that of Maiiriceau. the 

**'l!-linown obstetrician of the soventwnth centurv, who was l>oru pock- 

•narkdl. The significance of this occurrence, however, is by no means 

*Wr, inasmuch as we are not as yet acqnaintwl with the malrrirs morbi 

■"•Wfrnieil. 

Luliarsch has shoH-n that the organisms of anthrax, pneumonia, typhoid 
'•*", rflfl|>sing fever, and the various infections due to pyogenic orgniiisnis, 
"•T 1* transmitted now and again, but regards such an occitinme as 
*i(*ptionaI. This is particularly well shown in tul>erculosis, and out of 
I "f Urge numlwr of tuberculous women who are delivered every year, 



158 



OB.^rtn'HKs 



llauser in 18'J8 wa» nl>l« to t-oUcst only 18 who hare pven birth fo chiltiii 
or |>liiwi>ta> which gAve evidence of the disieaae. Birch- Hin»ciif eld, Sehnidd 
Ijchiuann. an<t uthirv linvi- ile^cribod tiiliti-culo^ie of the fcrtal portion i 
till' fiUcv-nlii, itiiil iH^iiiHiiiiiid lii.-u-n <>r coiigt'iiital LubiTc'ulii^i>. \hxi i» imM 
of llie plairuiff from tiitiL-ri-iiloiis wuiiii-u which 1 have examined liavej 
W-n ahle to liiid the sii);hu--^l Imw nf tuU-rcuItMiK in tlte f'Hiii jioflid 
even when ttie decidua was affected bv the disease. n 

The saim.' apjilii'* to lyplioid fner, ihuitgh il wuiild npjH-ur lliut 1 
this diM-aw i\n' iraiLsmiHsion of dr^cisinB oecurs more freiiuontiy thi 
in tiil>eri^^iili>»iK. S|K'i<T. in IMlIt, fouiitl the ^ijKXTilie hacilli in tlH> "rg^ 
of a ttvUU' whose inotlier was sulTeriu^ wltli Ijphoid fever, ant) coil' 
II Htinilnr cn^ra from tliu literaturu. F. W. Lviieli n-porled n row of 
MiTie chnnii'li-r which was (jluervts) in my seiTi<'(% hut in aitother fal 
Ctifv we eouM t-tiltivnie tlic WeilU from the blood in tlie iutvrviltoiii: i^poi 
but nut fmin the fn-lti-i. Ilirkit am) Fn'iicU nolul iuch a tranitini.H 
in lU out of .'to rases. 

In other iilliflion.-* il would nppcnr tliHt IniRi'miwiou never wciin f 
mother to {a-tm. Tbos. In malaria there is no evidenee that the e\ 
pHnivitci! enn {wks from the miiteriiid Ui the fu-liil IiIihkI. 

'Ilie traosniissioii of materials from tlie fietus to the mother has 
bwn fxptTimenlallv demonntriili'd for uiiiniuls. I^w* Savorj- nml fl' 
sorow showed, bv injeotioj; stryehnini? inlo embryos still within the utei^ 
Ihnl the tin>llii.'r ilitil witliiii « *bnrl luiie from slryi-linini.- jwiisoiitni'. Sii^ 
tar msiills werx? also oblained by TreyiT uilh hyilnu^vainc acid, aud 
Nieloii.v with alcohol. 

The Natnre and Punetioni of the Amniotic Flnid.—ln addition lo 
malerials rei-eivcil frojn ihi- plai'i-nln. il i- tiiTnTiillv believed that tlie fail 
obtainK a grwil purt of the fluid nwfSfury for il« lii-nlopmeiit from I 
CDutaimd in Ihe amniotic iiae. K)>iL'j.'ellH?r};, Alilfuld, Zweifel and <> 
have demom^tniteiJ that considerable ijufinttlioi of it are tiwullowol. i 
much as ibey found lanugo hairs, i-[jiili>rriiic lellw. etc., in the stotiiaeh 
iiil>-*liii(':i nf the fa'tus. Ahlfeld U'lieves Ibtit the umniotie fluid ifi s 
loweil in such Inr^e iguiinlitti-s ihut even Ili>- Ktiiall atnounl of albn 
u'hich it contains aids in ttie nutrition of the f(i-tu«: but Ihis poim 
veri' douhlfni. 

Accordinj; (o lloiipe-Sevler, Ihe amni'itie fluid if dear, alkaline 
nsclioii, ha>inj; ii siMTific (inivily of l.mui lo l.ddS, nml (iin^isling 
98.48 [ler rent water, (I. Ill jx-r CL-nt albuminoid nmlerinl. n..'i5(! per 
mduble tnorfranic »all#. (I.S [ler cent cxtractiv**, ami U.l'2-l [H>r cent ir: 
ble or^nie sails. 

Tnlil vcri' recenlly it was jjenornlly ndmittc<l ihnt it represents I 
great part a triin»iiibilton fmni the uwtcrnid ve.^wls. as Is a[>|iaren 
demonKtrated by the fact that the injwiion «f such snbKtnnces an po 
siuin io<lidc or sodium indrf,i;)nuli)bnte into ihe maternal ein-iilnlion 
promptly foUowiul by their a[i|icflrnui'i' in the amniotic fluid, while 
tram- of lliem can Im' fntind in the To^ImI ki'lm-vs. Miiny iiiitlmritien a1 
consider that a portion of it in licrivi'il fnuu Ihe urinary socrelion nf 
fa-tiis, and Diidcrlein hiu eoncluiiivelv ^hown liial in the eiUf llm (. 




THE AMNIOTIC FLUID 



ISO 



■ tidnm functkni during tlio lutU-r pari of {iro^niincv. a; in Uiis sniinal 
H lI** unitorr e\4.'ivtiuiiB an- ]HitiriMl inln thu alliinloK- vi7<iclf nixl <l(i not ' 
H atn^ villi Umi u>Dliiit« of tlip HDinioD. Itut in Iht- Ididiuii ra-liiN. whidi 
H iats Ml pntwcw a vuikiilnr ulliuitoiH, it ih cvtilt-til Hint, if (lie kii)iii>.v.t 

■ ^»Ttt, Um urino inuf-t lie jNUiscd iDio tlw amniotic cavity, and thi« prob- 
H km hu wil M'l U-i-ti l]•■fillil■^)_v «>lvi.-il. The (juiiilion tia» b<iMi utii'wi-ntl 
H <■ the tfliniiatiTi' by Scbrotxlt-r, Na;;L'l. acii! other)*, tboir conoUHioiu being 

■ fcwed in)[nitt purl ui»ini ihn roniuilinii nt rvU-iition tvifl* in omlirvw which 

■ immilHl Eiiitie aboontmlity in tlio low«r portion of the urinary tract. 

■ fhiinieai BDiihvi* of the amniotic llitid, I)ow<-t<.t, kIiow^ tbat it contain.* 

■ Terr amill quautitte^ nf tiiva, and indi<-»(i>:) thai the fu'tal urine, if secreted 
P •* ill, ■IiITti' niHrki^lly fmin that of c.\tra -uteri lie life. 

"Thf eiperinicnbi of SidiaUfr. in IKlH', rt-ndi-nil it oxtri-mi'Iy ilnnhtful 

_ **"*!» thf ffptal kidnej-s function ut all. This obscncr availed himK'lf 

■*'' Uii' vtJMtmiwn fwL't lluit tlu- ad mi iu.<t ration of phloridzin givis Hmi 

, * Inniit-nt iliaU'le^, wliii-h rtwult^ fiiini tlit- action of llio time upon 

^^ fna\ rpilhcliiiiii. am) imt fri)ni cltniigi's pniiliiit.'d in the hlixid. Ho 

*~^wt that after the drup Imd l)oeii injected into the mother its pres- 

^"•* MiolJ n-adily W demoii.it rated in the liMUiv of the fwtuc. while the 

r*^*'Mir Huid rarely ratitainrd traces of aujiar, which Hhnuld Itave been 

!v^*»iil in Inrgi- ijtuinlily )uid tin- fo-liil kidncvx fniK-tionod. On Ihc other 

-»^**1, Zanjre me later, upon riiKiing that tlte frcv;:rnj; jxiinl of the amniotic 

i* IcHs than that of IIh- m.>ruia of tlw mother's blood, held that the 

(ituld not lie a transudate, and mh the (oHal urine iikewi.'e potMessna 

Mrer frt-ezin^ point, oomluded that at least a portion of the amniotic 

ninni !«• d«Tivi-<l fn>tii the f«-l«l nrim?. 

ataoo. in t'JOl, eiudieil tile ()u»lion from a bioelteniical |>oint of 
r, ud, a* hr found on tlic one luind thai tlu^ amniotic Ilui<l and fo'lat 
tia Bill contain rertain anti-tHxIieii found in the tnatenial blood, and 
t\v nth-r linnd tlmi (he nmniolic ftiiid and mab>rnal htmxl lack a^ 
I whidi is preseD! in the fn-tal urine, therefore <-on('lu<l(Hl thatj 

• ^Ir-rin-d ndllicr from the maleniul bloo»l nnr tlie fn-tal uriiM;, 

•1 rTin«H|ui'nlly must come frmn some other itouree. Iteasoning; I>jr os- 
1, he itmi'lodi'd that l)w only oilier origin possible must Ix; a direct 
lory action of lh<- anini»tic ■■pitheiioin. 
Stnre tlie obsrr%'alinn>' of I'oiano. itondi. and Mandl iiidieale that care- 
tuM'iliiiiirM] Kiaminwiion, purl iculiirt y in ruse* nf hydniinnitiw. »howK 
^^^uaiEw in tbi! amniotic epitlK-Iium which are stmnKty indicative of secriv 
'vitv. it ran W n«>iiioc<l llial in all pnibabililr lln^ amiiiottc llnid 
"1 from till- nialernid blood scnnn. which has ticen altered bv sonic 
tyerilir activitv 'm (in- part of the amniotic epillielium. 

Ikiildihon to supfdyinp water to tlie tissw's. the ainniolic ilutti pla}-ii 
■A Wfnrtant part by surmiindtng (he ftetus uilh a niedinin of constant 
"■^BrtiiTi*, which tnt-K lo prevent los^t of Im-hi while at the Mime lime 
"Mian a protection a;;ain«t sudden *ihocl!i' from uitliout. It also sub- 
""tk an iin|Hir1iint function hy preventing: llie formation of »dbi-!*ionx 
^**m ttic ftrlui) and the walls of the amniotic sar. which, when tfacy 
'^v, *(biD givf ri*v to iivriou.i duformitien to \k couiiderul later. 





160 OBSTETRICS 

BetpiTfttory and Difreitive Fanotioiu. — It would appear that the ta 
in uUro requires a relatively small quantity of oxygen to support life. 
there is but little tissue waste. Again, the fact that it is surrounded 
amniotic fluid makes it necessary for the ftctus to produce but li 
warmth, as only a small amount of energy is expended during its restrit 
movements. Its need of oxygen, however, is demonstrated by the ra 
occurrence of death, with symptoms of asphyxia, whenever the circulal 
of the umbilical cord is interfered with even for a short time. 

It has been demonstrated that the ftctus actually produces warn 
ns Wiirster showed that its temperature exceeded that of the iatcrioi 
the uterus by 0.5° C. or 0.9° F. Champion, in 1903, arrived at a sim 
conclusion, and put the difference at 1° F. 

A'cry little is known concerning the functions of the intestinal ti 
of (he ftvlus, though it lias been demonstrated that the stomach cont4 
jicpsin and rcnnin after the fifth month, their presence indicating a ccrl 
iiiuount of {glandular activity. The large amount of blood which circuit 
throiJj;h the liver would go to show that this organ serves some impoH 
purpose, and the formation of bile is conclusively demonstrated by 
preseTice of biliary materials in the meconium. 

While the fictus remains in the uterus its movements are restrif 
williin narrow limits, though such undoubtedly occur, being felt by 
TiinthtT as "life" from the middle of pregnancy, and at a little h 
period by llic physician when he places his hand upon the abdon 
Alilfcld demonstrated, by the use of the sphygmograph, that the fa: 
nmkcs Ycrv ra]'id superficial movements — at tlie rate of sixty to 
iriiTiiilc — which ho cousidcrcil represented an abortive type of respirati 
but his coTickisions have not beer, accepted by other observers. 

Sex of the New-bom Child. — Statistics show that more l>oys are b 
lliiiu gii'ls. till' proportion, a<'cording to the iigiires given by Rauber, be 
mtl 111 11)11. Ablfi'lil has pointiil out that this ratio is still further 
irc.iM'il in elilerly priiiiipiirie; for when the first child is born betw 
Ibc tliirtjctli and forlii'th yours, tlic pro[>orlion is 120-1.10 to 100, wl 
itii-roiiscs In i;iii~!lo to 100 lictwiK'n the fortieth and fiftieth years. 

A'arious tluoriis have been advanced from tinie to time in e\planal 
of (his fiii't, but uiinc iiT tliem are altogether satisfactory. Those who 
intiTe-;|ed in the subjeet are referred to the monograph of Rauber 
di'tailfil iufortualion. 

Iiilil Very reieiilly we were almost absolutely ignorant concerning 
caDsiilioii of se\, tliougb it was generally l)elieved that it did not bec« 
esliiiilisbi'd until smiie time after fertilization. Recent investigations, 
the cilhiT liaml, clearly show that this is not the case, but that it is dp 
rniueii either in the germ cells, or immediately after their union, so 1 
it has bit'omo ininiutuble by the lime segmeiilation of the ovum begin.- 

Iieubos-<ek and Morgan gave excellent reviews of the subject in 1! 
and the former pointed out in certain S[H!eies, at least, that the determi 
(ion oceurri-<i in Ihe ovum. He showed in Dinopliitus, a sea worm, f 
two varieties of ova could be distinguished, and (bat male and fen' 
individuals could Ih> ])rodiu:fd at will, according to the variety of ■ 



I 



SEX OF THE FOSTUS 161 

fclfcted for fcrtilizatinn. Moreover, he found that the relative number 

nf till* two kind:) of ova could be altered by changing the environment 

and f<N)d of the animals, eg that more mates or more females could be 

pmduccd, but at the same time each ovum retained its specificity. Some 

mpport la lent to such a view by observations upon human twin pregnancy, 

•£ it ia well known when the twins arc derived from the same ovum that 

tbcT are always of the same sex, whereas when each is derived from a 

separate ovum, the sex may or may not be the same. 

On the other hand, Wilson, Stevens, and others contend that in other 
species the determining factor must be attributed to the spermatozoon. 
Those investigators have carefully studied the arrangement of the chromo- 
somes in numerous insects, and in some species have discovered that they 
are differently arranged in the germ cells. Thus, in the oocytes the chromo- 
Bonit.-s are alway.'? in pairs of similar appearance, while in the spermato- 
cyte* three ty|K,'S may !« observed. In the first, one of the chromosomes 
is without a mate; in the second, the chromosomes in one pair differ in size, 
one being much larger than its mate; white in the third, no difference 
c*n be detected. Accordingly, when reduction occurs in the formation of 
the spermatozoa, two varieties of the latter will occur in each of the first 
two lypts, while in the last all will be identical. In the first type, one 
Tariety nf spermatozoa will contain one less chromosome than the other, 
while in the wx-ond type lx)th varieties will contain the typical numlior; 
bulont variely will possess an aberrant, a small chromosome, while the 
olliCTs all will t>e similar. According to Wilson's theory, sex will depend 
ap™ wtiich variety of spennatozoon effects fertilization, those with iden- 
tictl chmmowmes giving rise to females, and those lacking a chromosome, 
"r prrvTidt-d with a small one, giving rise to males. Whether the deter- 
tnimtinn is effcctwl solely by the spermatozoon or whether it merely brings 
to ihe oTiim certain substances which set in motion tendoneies which 
wnwlr exjsictl is not yet known. In the latter event, the determination 
"I*-! must eventually prove to Ih? a function of the ovum. 

In isiij, Sehenk startled the world by stating that si-x could be deter- 
miiiHl ai will, as it was entirely de[H'ndcnt u|H)n the condition of nutrition 
■^ 'li* riiniher, and could therefore Ik; influenco<! hy appropriate dietetic 
'f*ifnini. The considerations just mentioned, however, show that his 
f«neIusii,nB were visionary. 

LlTEHATtlRE 

■""tti,_ Bc^imtniinuen der OrTmne und dca Altera der Fruchl vor der Geburt. 
■Whivf. (jyn.. 1871, ii. 3.W-372. 
jj"'*lmrtpn aJlcrer t'>Ht|^HchwanKerten. Arrhiv f. (!j-n., 1872, iv, 5IO-,^20, 
'7' ^ Redcutuiift dcH FrurhtwaBHeni alx XahrunKiuiiittcl fiir die Frucht. B«- 
fifhleu, Arheiten, UipzJR, 1885, ii, 22. 
■*'"»-l«ire|tunKen des Fiitua, Uhrbuch der Cteb., 1898, II. Aufl., fi7. 
"""U. Pt,wirt HiweiM die placentare Sohoidewand. Hoppe-Se iter's Zcitsclir,. 

'^'V'lin'. De la pu^riculturc intrauterine uu coura dc ta grosseasc g^mcllain;. 
^Uede Paris, 1898. 






PHTSIOIiOGY OF PEBGNAWOT 

CHAI'TER VI 

CHANGES IN THE MATERNAL ORGANIUM RESULTING Fl 

PREGNANCY 



TTtemi. — Ttie maternal organism reacts to a greater or lesse: 
under the influence of pregnancy, but naturally the most ehara 
changes are observed in the generative tract, and especially in th€ 
which undergoes a very marked increase in size. Thus, it is convert 
a small, almost solid organ, G.5 centimetres long, into a thin-wall< 
cular sac, capable of containing the fatua, placenta, and a large ■ 
of amniotic fluid, and at the end of pregnancy is about 36 cen 
long, 25 centimetres wide, and 24 centimetres deep. Krause e 
that its capacity is increased 519 times. A corresponding inc 

weight is also c 
the uterus at fi 
weighing in the 
bourhood of 
grammes (2 j 
as compared v 
grammes (1 ou 
the virginal cont 
This enlarge 
due principally 
hypertrophy of 
isting muscle e( 
partly also to tlu 
tion of new ouet 
the earlier mo 
l)regnancy. Th 
developed muse! 
arc from 2 to 
wider and from 
times longer thi 
observed in tl 

prt'gnnnt uterus, irieiisuring 0.001) to O.OU X 0.2 to 0.53 millimeti 
rormur, iis cnmiiared with 0.011.5 X O.OS to 0.07 millinK'Ire in th 
According to the resi>arclips of Luschka and Ycit, tlie formation 
mu.«culnr (ibn's is limited to the first three or four months of pn 
164 




[li:. 17."). — MCHCI.K FlUKEH FHOM XoV-l-MEGNANT AND 
I'llhU.NAN'T I'TKRl'S (Sn|>]M>_v). 



CHANnrs rs the material owiamsm 



IBS 



Tilh the iiKTcax' in iJti' nunilicr ami >i7i- iiT tlio inuodi' ftliro« i* oahi- 
a niwiol ilfvt'lopnx-iil of ditstic li^uiv U'K^chia lia^ ^Itown tliut 
1am»M betwnrk aliuut Ow various miiK^lv bumlK-n. which h,v|HTtroi>hie> 
iti ■dvKDcing prcintancv. simI thus atUU Tiiatenallr to the «tron|^ of 
Itbo)^!'!'' wnlU. At tlvr Mnif time tlivro is n groat iucreoeo in tho f'vta 
Uood-vu^iieU, esf>e(;iall_v Hit- vi-ins, nrliich, in the m-igtilxiiirhooti of 
Ffltoenta] Mitt-, bectnm ronrcrtt'd into Isrgc sparcji, the so-called pla- 
atil uDoeeK. Mark<-0 h^'pertra]>h_v of thi- lymplmlii? and norrouit inipply 
of Ue tirnui also takee plac«, of the extent of «-hieh aoni« idea may be 
gkittil fmm tJw ^lati>in(!nt of FrnnkenliatiMyr liint the <x-n'i(nl ^an^lton 
inomMi in »irp fmm 2 X "5 to S X 4.5 f*niiinotrp-«. 

Iht'mg till* fimi few monthM, tlw Iiypcrtmpliy of the ut«nis nwnlbt from 
B^vnl •Tst«tnic chanffea indun^d by the pn^^nancy itself, and, according 
la tUban, i» bniii);ht about by tlw circulation of UTiuiii (^ulmtimccy" dcrivwl 
f^m thr plart'DLul t-pitlu'liiim. That it la not dini'lly due lo the pn'sisiK'i' 
^ ftf oTnin in tltv cavity ileolf is shown by the occurrence of prccifH-Iy 
Vamr ching» in eaws of exira-ulorine pTvunajicy, whi^n the orutn iit 
Wytuibd in the tiilic or ovary. ,\fter the third month, however, th« 
'■'nw in xizi! h mivhanioal to iii>riii> extnnt, and i* diie directly Ui the 
t^^mt i-u-rtnl by ihi; growing ovum. 

Ihtriaj; tlw (irsi few montlis "f pri'ynancy tho utcritie waIU an- coh- 
^''^'nUt thicker than in tlie uon-pregnant condition, hut as gestation 
**l*na!« they gradually b«c<ctiii« lliinner, *a tliat at tlie aui nt tli« 
Winunth Un._v are from 3 to 5 millimetres in tliickness. Thin mens- 
""■nt U rvtained thrutighout tlte «uc<feeding months, to that at term 
»"» Blan^ ti n>pr(^>entL'<l by a nitiiwiilar sac wliin* wails are ran'ly above 
*< ul arrer mort^ than 10 millimetre;) thick. Occasionally tlwr arc 
"■•d t« niuasiin? fy>nHiderab)y under 5 milliiiK-trc^. The enlargi^riietit of 
l*nmi» i« i><>i fvm met r it-Ill, but i* mo«it markt<d in the fundal region, 
lean readily bi- ap|)rM'iaiJLil by oljM-rvtng thi' relative {MHition:< id the 
I of thv tubes and ovarian ligan its. which in the early months 
■pignmcy an> almost on a levt'l with h\ fumliiK; wbcrent in the lator 
"'*'ll» iWir a(taehnient;» are found at poiol« slightly above tlie middle 



trib 



"Tfin. 



TV jiofition of the placenta also exerts a determining influence upon 
'» ntoii nt tlw hypertmpby, the portion of the ntems to which it 
•• madKd enlarging more rapidly tlian the others, as is elenrly shown 
^/" pMilion iif the uterine ends of the round ligaments, which are 
^J^ '■VMher wlnen thi> phuenla is in.Hi^rted uj>or the posterior, and 
""part trheo it U upon the anterior wall. 

^^|*Ug«Miit of the Hsule Fibrei.— Erer nince Hie time of Ve««Iiiw. 
''"'■"'^blo attention hm^ Ijtvn devotetl to the arrangement of the muscle 
'*'*• m tlie prvgnant uttTiiw. Among tin- niimemu'i invtsitigatorx wIioim." 
'^''''•iMudiM on this i-uhject dewrvc special mention are William Hunter 
*■ MltluMl; Madame Boivin. De^-ille, and llilie in Krance: Rocdcrer, 
warali, lli-ntr, FloffTuann, Bayer, I{ofmeirr, and othi-n* tn Gnrmanj. 
rawrtiinkti-Jv tlwir invfj>iiguttiin» have not led to uniform results. 

^"nHing In Lnschka and itenle, the musculature of llie jirt^ant 



IGO 



UUSTIO-UICS 



uttni)' ill airani^ in thn^ strati: sn rxtomal hoo<1-ittM> Injer. whicli 
over Itiu fiiiuiu.i and i>xli>u<U ioln Uu^ various lij^amcnU: ninl inti-mul 
voPsi»liiig iif ^pliim-ltT-liW' filing umiinil lli« on:: ' jm 




Flo. 176.— KXTWiJf*!. Ml -, t i.Aii I.AtKK nr 
PrccKA.vt I'Tcnm (II*lie). 



Flo. 177. — Ixn^HNiii. Mi-u.llj.m' 



internal os; while lyinR between the tw-o is a im*K nctwnrk nf 
fibrw^ pcrfunitol in nil diri ■ell oris liy blooii -vessels. 

Tho most important c-outributioL;;. Iii>w4-^it, we owe to Uelie, 
and Rug«. In the prefuce to liiii tiinRO||:rapii, H^tlia tclU ii=t 

liad (liiviteil twelve yeai' 
his invcstignlionH, ami Bi 
liaji been an jndefatl 
worker ii)k>u liu! si 
since I^^G. 

vVoiiinliiig fo Helii 
uterine niUiieulature oo 
of 3 iiinin lavcrs, i^ai 
wliieli is made up of M 
^iibKiiliary divisions, 
esternal laver is conj 
of 2 U>iigitudinal or 
form jwrtiona. l(otwp»>n ' 
lies a tmn*T,'erw Inver. Tlift inl/rnnl Inyer is euuipmci) of 3 Irian 
portions ninninff alonf; the inner surfaee of the anterior nml jhw 
wflllit of Ihe iilrnis if->i]Mvlivi'lv. tiiid i'lniKfli'd l>v an areliiform 
at the funduH. an ohieular jKirtion anmiid iwh tiilml ojiening. ai 
nnnnlar layer around tlm tnt>;rniil o«. The main portion of the 




Pin. I78.^Umiia9[ UuMruta I.avkr <»■ PitxiuiAKr 




CHANtJPM IS THK MATKUNAl, ORGANISM 167 

will i* fonncd by the middle layer, which consists of an interlacing net- 
•nrfc nf muKcle fibres, between which extend the blood-vLv^sels. Each 
Sbic mmprising thiit layer has a double curve, so that the interlacement 
of icr Iwo gives approximately the form of the figure "8." Aa a result 
of rui'li an arrangement it happeni; that when the fibres contract they 
CDiutrict the vessela and thus act as living ligatures. Bayer's work is 
atranely complicated, and those who desire particulars concerning it are 
rdmti to his monogrsphs upon the subject. 

Bige pcHDted out tliat many of the layers which had been described 
ly jtenmu observers do not e.xist as such in the pregnant uterus, the 
a^nniMB having resulted from the manner in which the dissections had 
kaimide; He showed that the muscle fibres composing the uterine wall, 
cfpRully in its lower portion, overia]) one another and are arranged more 
•M' loi like fhingtoi on a roof, one end of each fibre arising beneath the 
peritoneai covering of the utents, and extending obliquely downward and 
inwird, to be inserted into the dccidua, thus giving rise to a large number 
nfniucalar lamcUs. The various laniellse are connected with one another 
bvuhort mnscular processes, so that when the tissue is slightly spread apart 
it preaaits a sieve-tike appearance, which on closer examination is seen to 
l* due to the presence of innumerable rhomboidal spaces. Ruge attaches 
pnl importance to this arrangement of the muscle fibres, and believes 
iIbi it explains very satisfactorily the mechanism of the uterine contrac- 
iinn- md the manner in which the felt-like structure of the puerperal 
wwiLi is brought about. 

Cluget in Sise and Shape of the tTterni. — As the uterus increases in 
*'». italso undergoes important modifications in shape. For the first few 
■■^t* it.' original pyriform outlines are retained, but the l(ody and fundus 
**« i*-UHie a more globular form, which at the third or fourth month 
, bwrnw almost spherical. ,\fter this period, however, the organ increases 
■"^ rapidly in length than in width, and assumcri an oval form, which 
[*t'i-n until the end of pregnancy. 

TV in<'rea>e in the size of tJie uterus la limited almost entirely to 
It* Irtlv, ihe cer^'ix remaining practically unchanged until the onset of 
'""•nr. «n that throiigbout the coiirw' of pregnancy it ap[)ears as a mere 
^Ppnilijp- to the enlarged liody. Its most characteristic change consists 
'" • markt-ii softening, which is readily appreciated by the examining 
^i"^. and constitutes one of the physical signs of pregnancy. The 
"■urtii incri'a* in size which can k' noted is due in great part to in- 
■Tt*,il viMularity. and depends only to a small extent upon hypcr- 
iflfiliv nf its muscle fibres. As a result, (he secn'tion of the ci^rvical 
f'*"^ !*<«mps more copious and the cervical canal Ijecomes filled with 
* P'lB nf mucu«. The changes occurring in it in the latter part of 
P'^Ziuncv will l>e considered in detail when we take up the phvsiology 
'■( lilnnr. 

■V- thf liody of the uterus i>ecomes larger, the angle which it forms with 

thf i*njj liecomes smaller — in other words, ils physiological anteflexion 

1- iiumwed. Aa pregnane' ndvanci's the organ soon becomes too large 

tn if niotained in the pelvic cavitv, and hv the fourth month forms a 

18 



16S 



OBSTTETRICS 



tumour, the U|>{>er lM>nli-r of nliich nuu-tie^ to n point midway tieti 
(ijmjihyKJs [lubii- aiwl IIk- umbilit-ii^ As it Ih-ctiiih-^ still larg*T, it woi*^ 
in contact willi the iiiilt-rior ab<)omiiinl wall. <lii<|j lacing tlic inUxlini'- t 
till' Mvs of tl]i; alxlomtD. antl gruiluully riM-e u{> iinl4l it almot't impiRgc^ 
ti|ion the diaphrajrm. Ak tin* ul4--nin leaive^ tiu; pelrta for th« aMoniintf 
cavity, conHitk'rnbic tciLsion k cxitImI upon the broud Itgamt-nt*. vliicJ 
llii-Q )h-(Oiii<- iiiiiiv »r Ii-hh unfuklttd at ttit-ir uterine oikIa. 

The premium uttrnis po^^ewes a cuiuiidcrabk- d«gr«.' of mobility. Sine 
its upper [xirtion pmjvclii into and lied free in the alxlomiual cavity,. 




f 




^«*> 



^ 



FiR. )7<l. Kig. IJMl 

Fhm. 179. ItK). ^AMi: Kl-Uh^thui I-paiu ik Vkstical ANII 1{»HI>»KTAI. IVutTIQ 



its Inacr portion U held soniowlmt in oticok br Iho lax broad li^meitf 
it readily chau;;e» its position. With tlic woman in a staniUi;g pOKtum il 
]<Higiludinul AXM corTcajiouds closely with Ihnt of the superior Htratt, tt 
or^an resting in great part upon the anterior akloininal wall. In tin 
position (lie porliim projceting above the svniphvsis has somewhat mor 
breadth than height. With lli<- wonmn lyin^ on hvr liack, bowercr, 111 
uterus falls haekwani and re«lH upon t)ie vertebral column, it« Icflfd 
being now greater than its breadth. Fig*. 179 and IttO repn-sitit tlw son 




CHANOeS IN THR MATERXAI. ORQATflSM 



W*«M m IW njiriglit «li*l Ii'irizonliil [mxilioiix rt-siHt'tivt-lr, anil give a 
[iltt ot the c>iangc« in mntour o( the uterus and aiHlomeii, 
li Itr ularurt itmv* out of Ihi? |>i>|vir c^viiv, i( usiuilly li<\iimcj( slightly 
[W righl, Ko lliat it« loft niai^iii m iliivviiti more anteriorly 
u'liL ()ii'ii«ii>iiitllv IIk' lorxion riiiiy Ih^ in llitt iip]iiiKil<- ilint-lioii, 
IK* ^howiDi; ihat it occurs to Ihe right in SO per cent and to the left 
Bt |"t win of IIk- niM-*. The torsioii it due in gi\'4il purt to tlie 
nf the Krium, which usually ocoH|)ies the left side, and only 
ill; ihe right *idv, of Ihc pvlvi'^: though posfibly. in « cttrtnin 
itVr M imtmtKVA, the romlition rc|>resent5 mt^rely an exaitgeralion of 
' position of the nou-pn:^nant uterus, vhtch, m is well known, 
..i«*-s perfw^tiy ■yiiimeirkal. from niy own observations, I am 
iaiti to agrof vilh Wcbt'ler. that Ihv rrvfjueiiey with which lor^ion of 
' ytint Mrnra haii been ^niewltat exa^Tjirf-rateii. 

Vitb tlio adviDee of prpgnaney the iiteni!- losni th« firm, almost car- 
(vnuintftnei- w'hioh in oharaoterisiic of the mm-pn'gnant coiidi- 
I lod ImiMiMs eunverUxl into a sac having very thin, mtt wallK. wliieli 
■ iwDljreotnpresaible. Iliis i* well denioontratLtl hy the ease with whkh 
driucan be p4ilinit*il in i^me ca*«*. and by the fact that not iii/n-- 
*lh it a pn8sil>le at abdominal operatious |o olnuir^e sluillow dcprcsHionH 
I ">• lorfati' of the nterox^ which have resulted from the pressure of 
rtta iMntiBa opon it. Again, it is noteworthy with what readinCKs the 
|«lariBr nll)i yield In the moviinpntf nf the fwlal extremities. 

Tiki ud Otrariei. — .\* has already \>mii menlionef], Ow tiiix'^ and 

^•'*'*« nnditgo aiaricoil ehangcH in position with the a<ivance of prej;- 

. » thai in^md of cxt<-tiding outward almoitt at right angliw witli 

[lb ttrnu, tlieir long axes become nearly pAralld to the margins of tlie 

*"*. Ilf HpwinI impurtanee. moreover, i* tlit'ir incrcflw in v*i«eul«rity, 

Llllwlilhp large siM of the corpus tutcum of pn-jnancy ia in great part 

t«*pt in rarv iiwlanc^**, oTulnliou (■»*'«» during pregnane}'. *o that 

WWm do not ripen, and. accordingly, only the single large oorpus 

injpn^aikvy eaii bi- found upon the wurfaw «f one of tlie ovaries, 

■ 11 WO, afliir an eshaustive study, roncluded that typical ovulation 

'Wopnir, hut that many follicle* b«-gin to grow and, after rvaehing 

[•pW period of development, undergo atretic changes, with a marked 

it of lulvin n-IU in tlie thwv folliculi. 

|M anthorH l)dieve that the muscular fibroii of the tn\ti/^ undergo 

hypiTtrripliy under llw influenee of pregnaney. hut tliis has 

koen denied by Mandl, ami it mu^t l>e admitlol that, if it occur* 

' ii <rflrT flight in extent. It \» po«»ibli; for a decidua to develop in 

>^1Im while the pregnaiu-'V ts situated in the uterjA. Such nhitcrvation* 

ll- hy Wi4i«ter, Mnndl, and Veil, but are of extreme rarity, 

_ I "Uih an miniriene* in only one in.'<tan>ce. 

^Qtaa. — lti<-T>a'4>d TaM-alarity is the mafi marked change in the va- 

"• it i> dad the more cnpioui' f«cn-1i«n and iIh- oluiruett^risttc 

jtinn nf pro^maoeT. At tlw same time Uiere is coni'idi.'Ttt- 

•Imicnt* rompoii'ing Ihe Vaginal walK. ihi- lalti^r 

-iiig in li-ngth to suth an r-'xttnt that the lover 



170 OBSTETIUCS 

{Mirtion of the anterior wall prolapt^ce slightly through the thIt 
0[K!niii^. 

Thf pnpilUi! tif tlie vaginal mucoKa also undergo con-iidcrable hjiK 
trophy, tthi'nuo results an increased roughness of tlie membrane, whii 
in o(«uni()nal instances feels almost like a calf's tongue. Owing to t 
incruascd vasoulaiity, llio vaginal pecretion is considerahly augment* 
and in the majority of cases is reproriented by a tliick, white, crural 
sulislanct', snniewluit like cottage choose. Doderlein, who was the first 
diret-t attention tn its ciiaracteristie appearance, showed that the inater 
eonsistwi of (rpiihcliiil cells and a large numlwr of long, tolerably U 
bacilli. The same authority states that under normal cunditiom it di 
not contain Icncocytes or pathogenic micro-organisms. 

The iiieieasod vascularity attending pregnancy is not confined to I 
genitalia. Init extends to the various organs in their vicinity, and as 
consc(|iicnce thci'o is a slijiht relaxation of the varioua pelvic jointa, wh 
is aci'onipnnii'd by an increase in their motility, as was concluaivcly sbo 
by Hudin. 

Abdominal Walls.— With the enlargement of the uterus the skin cnv 
iiig the iiTitcrior aliilominni walls and the adjoining portions of the thi( 
is siihjei'fcd to considerable tension, which, according to Zeiler, results 
the rupture of tbe elastic fibres of the reticular stratum of the cutis, t 
the formation of (]i>[iressod areas which are known as the atruB of pr 
nnnnj. In ])riiiiip!ira! tbi'so present a pinkish or slightly bluish appearon 
as is well illustraicd in Fig. 181, whereas in multiparse two varieties ; 
observed, some resembling those of primiparous women, while others p 
suit a glistening silvery iijipcarancv, the former resulting from the pi 
ent i-nndition, ond llie hitler representing cicatrices from previi 
prffiiiiini'les. 

'i'lii; I'ormntion of siriii> is out characteristic of pregnancy, as it is la 
iiij:. Mii'inling \>' ^'\f'\v, in about H) ])it cent of the cases and is not 
fri'i|ii.'nily oliSfirvnl in non-|iri'giiant wurnen and occasionally in men, 
wloiii lliere hiis \>v\\ ;i rii)ii<l iiuii'asc in the size of the abdomen, eit 
IVnm llie ]ire-rnii' ol' ii tiiini'iir or ascites, or the rapid development of I 

Xi>t inrrcijiifnily tlir iiliilniiiinnl walls are unable to withstand the t 
fiuii lo wliicli Ibcv aiv sulijriii'il, and the recti muscles become sepam 
ill till' miildlc lino, giving rise lo a iJiiixtnx'is of gretitor or loss e.vtf 
\Vb( rv llic process is ex;ii.';:cr,itcil. n considerable [Mirtinn of the anttfi 
wall ol' llic uterus is covin'rl hv nothing beyond a thin laver of tis 
loii-i^tiii;.' only o[ skin, fascia, and i»'ritona'um. In rare instances 
.-I paralion is siillicicnily cNtensivc to iiilniit of a hernial protrusion of 
graviil uii'riis. 

'i'l nlargcd iircgiianr iilriiis occasionally presses upon the ven 

(nitilv-, which return the lilood from Hie lower e\trertiitios, the obstruct 
l"iii^' siiiiir'iiincs siiMicicnl |o raii.-r vai'icose veins or irdfmn. The latte 
iiio~i eiiiiiiiiotily oli-iTVnl iihntil I be imklcs luid fii't. but occasionally occ 
to ii nmrlicd di'i;n'c in tlic iici;;hbonrboo(l i.f Hic vulva, when the ll 
niajora may bceoiiii' imiiieiisrly clisloiidi'd. liiuliii sonic years ago m 
an I'xiLanslive sUidy as to llic fropieiicy and nwde of production of v 



CnANUI-B IN TlIK MATEllNAL ORGAX18M 



171 



iu prc^auc^, and to liis oiono^rapb tlie reader is referred for 
nnfofTDation. 

Bmiti. — fader the inlluetai! of jircgimiurj' marked ehnn^-ii uccur in 

' htutf, and in tite early weekti tlie woman not infre(|Uontlv complains 

It taut of ti'iinnuw und pmliins iu Ihwo ^t^o«l^ After tim wmttA 

I the tireaaU )H-giB Ui itu:n4i.-ie in x'iifi and iiiTt-f » sninevbat iiodukr 

iODDon pMJpHtion, whicb in tine to the hrportrophv of tho niniiiiitHr^ 

>iul Bx ibt-y U-cmnc Ktill Iiirgcr u dflifalc Irmvry of hinish veins 

L JBit benentb the bkin. 11»e most diaracterislie chungcs. how(r\-cr, 

by tltt- nipplut and Ui« liMue in Ibdr victuily. 1'lte uippira 




rto. IS). — Arikiucn or Fniuii-tKi at Tnui, nKowixn SnoM, 

MMiD liPToino considtrablr larper, more il(>eplv pigmcu)'''!, and 

ifnctilc, and afttT the tin'l fi-w iiionlba n ibin. rcllonicli tiiiid — 

-may he expresaed from them by ^^tle ma^c^aKe. At the Miin^ 

armla anrmutHlint; th^ nipple broODM^' considerably bmadpr and 

I nan d4)rply pipnvonn-d. tlw degree of pijrmentation varying aword- 

la Uu- tvtmplt'tmn of the individnnl. In blondes the arrala> and 

uBimii- a pinkish nppcnrunec. whik- in bruiwttoi llwy K\i)nii.* dark 

and nfa^inniiMy nlmnitt hiack. Senttered through the areola ara 

rmatl roumli^h cle^'ationn. the t>o-eM)led gland* of Itttnlgom'ty, 

Inm Hk h.vjn'ftrophy of the itebaceous ^aods. In a small 



m 



OBSTETRICS 



I 



iiiimlMT nf niMf itJiiiilnr >l nii'Lurm niiiku thoir jippearanco arounil 9 
|i(>ri|>liery o[ the arrola, and arc then di.'vigiiutnl a)< the tei-ondary nmt 
ir till.' iiirr<'u«<; ill Ihc- *>■£»': of tlic lin.ii.->1ii In- vi'ry niiirkiil, llic .ikni Dot ti 
rixsjiK-iillv pi'Q'it.'nt.-i ntriatioDit Hiuilar to llvtue ohmyrved od tlic nUlomttii 

Change in the Best of the Body.— Tliu ch«ii):i-!( rcKulting from pn{ 
nanc)' arc not limiU'il to iliu xi-'ifrulivfi trai-t, i>iit extend to otIiiT porlkii 
of tlic body as well, and in iiiuny «i*c:; llio ginwrnl crtinlition nf (lie jwtia 
diiTom markedly from what it waa In-fore coiiconlion. Many wonu'ii nuff 
niinuToug iiiconvcnie-nct-'S during tliii^ [K-riud, wbilc oUu'n m^oy 
liL'ttllh lliaii at any other time. 

Hc«rt. — Uuint; to ibo upward pressure upon the diaplimgin. the 
Ik'coiik^ (liKplanfl in nuch a way that iLi arra of diiliioM unde 
condidemhle in«:^l?s)^.' in size. lta>in^ hie opinion tipnti lhi>! Thi-I. 1^: 
in lS'i7 pixiitiiilgiilitl the doctriiii; ilittt ooniiklenihlc canliac liyiicrtrapl 
iraa a constant concomitant of pipj;niincy. liiB'vicws obtained raf 
avccpliiNce in Fnirico. hiil witc ir'ccivi'ii wilh i<oi?ptici!<m in Oennai 
licrliaidl, lyihlein, Kcllncr. and otht-rs stated thnt actual wcig*iing of J 
pn-jinimt hc«rl :<lii)wi>il ilmt lugicrtrophy (li<l not ntviir. 

It is apparent that the heart mu^t perform a jircater amount of 
during thif ptrrioil Dian at other times, u* is cItHirly dcmon^tntH 
yet wnpiiblifhed obwrvatious upon the blood pressure by my as«i» 
■). M. fSlcmon* and K. ('. (I'lid^horoiigb, su that a pnun the oceurreil 
of hypertrophy would not be surprising. Moreover, the rei^enrcjic^ 
HiryM'l would apjH'ur to indicate that it dm^s take platv, as he Ujji 
lliut the h<«rla of 7i) prr^ant and puerperal women weijtht^ ^'^V 
cent more Ihiiri those of non-pregjiunt iiulividiiiiU. The (jue:*ti"ii. ho«eti 
(■amiol hi; reganh^i as definitely settled, and oHers an altractiTc fleldj 
future work. 

Blood. — In fiirmiT times it was (ii'nerally believed that the elii 
incident to the placental cireiilati'm dimaiidif) an iiiercnw in tl>e amm 
of maternid hlortd, and all the earlier writers and nu)Ht of the te.«-boc 
stated that under the infliicnw of pri'jtnaiie)' an ini-rcaw-d hydnrmia* 
u diminution in htt-mo);lobin and red corpuscles took place, while tM 
same time- an abnormal utimmit of lihrin cfiuld he noli.'d. These ob^P 
tion* were Imswi upon antii|Uiilrtl moiboila of rehoarrh, and it wai< not iin 
IS86 tliiit I'VliNnsr- hy the aid of inodcrn iffiplianecs for examining I 
b!no<i, <'airir' to the eoiieluciori tliat it nnilerweot liltle if any change^ 

Since then a number of articles have appeared upon the subje 
most iin|>or{nnt lieing those of Wild in 18ttT, Zaniji-meister in VJO^ 
Payer in 1904. These iiivcslipfllions ehow that in the later mont 
prcgmincy the iiiiioinil, of ha-itioglohin and of red corpui'ck's is nom 
or even sliRhtly increased, while there is a detinitc increase in the nnni 
of white cells, which become markedly acrentuated during the fir«t (L 
of pucrperium. This leueocytosis is to be attributed to the changiw v 
eiateil with the healing of tlie wound nl the placi'ntnt «ile and th« inn 
tioH of the uterus, Similar eancluMions were reached by W. L. Thod 
in my *crviti'. , ■ 

The last ttiree observers also noticed a fall in ttie speciiic graritj 



eia I 



ant^ 



CBANtiES i.\ THE MATERNAL OBCASISM 



173 



llW UmL and Zangempt^tcr ckmonstratHl s diminished frccziof; poiat 
IttdtdNsvaM- in ilui alUiiiniii(iii-'< (iinh-tit. In vicu* uf rlio iionnul (|iinntity 
[of Or ml edis and Itainoglobiti. sucli a condition cannot projwrly be 
Iniy MnHOiA, 00 tiMt K««giuu«i«tvr propoHil to designate it a« bydio- 

I Bttb Zxnfnrnipiiitcr «>d I'arfir noted a decrease in the alkalinity of the 
lUnd daring pri'^nnncv. t)ut iLi exact H)gnifiain<« \* imt yet dt^r. 
I lop. — 0«'iiig to llie npwanl di?^ placement of t)io diaphragm in the 
|IbI trw nuutliH uf [>rt^uaue,v, it would .neent us though tliu c«)>neitj of 
lAr jgns* would Itv tlccrasnl. Ne>'erUiclos^ tbo re§pflrcticfi of Dohrn 
■HllNnrn that vwii in not t)u- caM', ^inix- tlie diniini!>liti) liin^iltt of The 
Hpid arilics is compen»tc<l for by an increatic in wi<]tb, except in 
■•ill {iriiiiijiartr in wlioin the eoi>ta] arlietihiltnus Have lit'conic o>.*iniil. 
, Uftr. — DnrinK preffnattcy llie liver is apiKircntly in a state of un>^tablu 
[ HfodAnsin. u*>\ i* iwulily affiviiil hy viiri"Hii nlU-rutioiis in nietaloti^m, 
rw dtoion^trateil by 1\k lei^ions aceom)Miiyin|^' eelanip?ia, vomitinj; nf 
IftV*?. and nt'ute vi-tlow olmpliy of the liver. Tlic>e ennititinnit will 
IWoQademl in detail in llie chapter on the toxa'mias of pref^oancy. 
I Umy Tnet. — TW kidiu-ys mnr- iikevri^ tinder a iimsiderably inenajt-il 
libu dDiinf; prej^iiaoey, and xli^ht dcgreee of nephriiis are so common 
IHM tbfjr am BK.<i{niMl by Hm- tfennann to the "kidney of pn'Kiianev " 
IfnnnitPm'haflftiierc). Such conditions are nearly always couiieeted 
pAli»TamiD» diKlarbancis of ntelabolii'm which will Im taken up un<lcr 
r*w»ii nf pn>jmaDcy; while the various alterations in the quality and 
imdUntiria of the urine in normal prrgnaiic}' will be conjiidercd be!mr 
[■falfa fw^tlini; of (ieneral MiMaliolt.im. 

\ Tbt nrrli^rs are sometimes eoniprewcd by the ]{rovinf; ntcrus, and 
l*fcr toA cuodilioiM a mild infcetioiu pnjiH^iu, which othcrwi«c mif(ht 
l''t|it« rue to Kymplonis. may cventualv in a pyelitis or py«lon<rplirofiis. 
I b Or mrty nf mills Iho Madder i* more or less compreiowd i>y the 
b**afE nt«riis. and cnnixijnenlly inereaiiiil frecpii'iK-y of micturition is 
n™9 I5"1i!. A" ihi* iileni-t riM-* wp into the alxlorninnl cavity it carries 
' blmltU'r, which in the later months of preignancy bcvnnips an 
I— nvnW in'li'ad of a pi-Uic orgiin, atul uh<'Q distended can be felt as 
P* httamt tumour c.xttndin); from t)ie symplmie pubis towards the 

I Iffttire Fvnetions. — In many instances tho early niootlu of prcg- 
['■■r bf oompltcated by minor disonlew of <lijp«ti(Mn. Fn?qiiently thew 
l'*> BM iadirp>-u(tejil aOwlioDB, but are to be regarded as manifcstatioos 
■ ■f milil iniamia. 

I I*«l Imut om- half of all cases the preignant woman sulTers from oon- 
I^F*t>«. In the later months this may be Tefcartlt-d as being parity dne 
l''«'j»»»urt Mcrlrti by the enlarj^ed uterus and partly to the lo!« of 
li<liRlt..f tt,i< ■tiiliiniinal walls nwiillinp from tlwir diotcntimi. 
Ihalea Olan^ — I^np-. in IS'MK rcporlrtl that ho had obterved a dcfi- 
^H>'|<mmphy of Hw tJjpuid gland in all but ~5 out of I.T) woiiien in 
^^l»l UirtT month* of preiniancy. Aft IS of the former presented albu- 
IWRrit, he oaturalljr thought that thenj might be some direct n-Ialion 



174 OBSTETRICS 

betwetni its production and the lack ot Iij-pertrophy of the pland. ¥il 
this in mind, he administered iodothyrin to a number of nlbuminur 
pregnant women, and in E«mc instances noted a rapid diBa|)pcaranto c 
the aliiunion. lie, however, expressed himself very conservatively cor 
cerning tlie mutter, but liia views were promptly taken up by Xichols* 
and otbiTs, and niude the bnsis for a theory concerning tJie mode c 
produftiim rimi treatment of eclampsia and toxffimia of pregnancy. 

lly (nvii experience shows that a moderate degree of hypertrophy o 
the tiiyroid is a usunl tniiccmiitant of normal pregnancy, B'hile the effw 
of its absi'uci^ will be coni-idcred in the chapter upon the toxsemiaa c 
pregnaniy. 

Laiiiinis jiml Mulon in 11)04 directed attention to an hypertrophy c 
the hyiHilbysis ccrcliri, but as yet positive etatcmenta cannot be mode I 
to its frcijiiL'ncy or significance. 

Skeleton and Teeth. — Rokitansky describeil the formation of irrt^ 
lariy shii]Hd |>lnc(|iies of poniiis, newly fornu-d lionc upon the intenu 
eurfncc of the cninial Umcs durinf; pregnancy. Those he designated f 
pui'r|iiTiil iistiiiplult^s, but neither he nor the subsc<]ucnt observers wh 
have Hiiilirnicd his findings are clear as to their significance. 

llaiuiu considiTs that tbi-y are most pronounced in those cases in whic 
there (icciii-s ;ni excessive formation of osteoid tissue in other parts of til 
body, whiih he is inclined to attribute to a slight grade of o.'teomalacii 
which he and (Iclpkc n'giird as physiologieal in all pregnancies, and as« 
ciiiti'd with the supfilv of calcium salts to the ftetus. Somewhat analogoi 
tn this jirr the changes oirurring in the teeth which are prone to deca 
ra|)ii!l_v, HI tiiiil the expression "for every child a tooth" has bceoii 
provi'rhiiil. 

Owiri^' Id tlic increased vascularity, the various pelvic joints becon- 
morc sitcculciit iukI permit greater mobility. Occasionally they becoa 
so rcliixed ihiil imortiution is sitIiiusIv interfere";! with. The treatment ■ 
this iil'iiurriialjty will be considered in the chapter u|Kin the pathology ■ 
prcgnani'v. 

Nervous System. — Viirinus disturbnnces of the nervous system occi 
during |ingnaiicv, bul as llicy are distinctly abnormal they will be col 
siilireil laliT. On the uIIkt liainl. uiild degret's of disturtied mental eqii 
lihrium ari> so l'ri'i|iiciitly nliM-f\i*d as t" be considered almo.st physiologicc 
lu this calegnry may be phuvil the bmgings and cravings for unusu 
or aliiicirniid articles of diei. Many women also ex|ierienco pronounct 
change-; in ilis[»isiliiin. and nut a frw multiparous patients n-cognise tl 
oecuni'iiec ol' )iregrianiy by iheir iip))eanince. Again, in those of noun 
palliie leiiihiieie-' llio menial c(|Nilibriuui may bo overthrown to a greati 
or less liegrir, llic ]iatif'Tit beenming excitable, morbid, or morose, and 
rare in^laiurs devcli)])ing a line psychosis. 

Skin, — Itefereiice has already lircn made to the formation of utriie ai 
to the ]ii:!nicntaliiiu of the ui])pl(' and areola. In other eases the lin 
alba becdines uiavkedly pigmi'Uliil, and occasionally irregularly shape 
yell^n^■i^h patches oT varying size appear on the face and neck, the eo 
dition being known us cloasma. Very little is known concerning t 



CHANGES IN THE MATERNAL ORGANISM 175 

utan of those conditions, but WycUgol has demons trated that pigment 
ii dvpwited in the papillary layer of the skin and rosponds to the usual 
toti for iron. He considers that it is derived from the hiPinoglobin of 
the miiemal blood-cells which have succumbed in the fight against the 

fitunl Xetaboliun. — Generally speaking, gestation is characterized by 
impmrod health. In some instances the improvement in nutrition is noted 
ihorllv after conception, but usually does not Ixx^omc manifest for several 
WMili*. For thid reason it is fre<juently possible to distinguish two peri- 
od* in pn^ancy. The earlier is clinracteriztHl l»y lassitude, mental de- 
F^^-i'm, and some loss of weight, while the latter is conspicuous for an 
[idlmi condition of body and mind. 

Analoftous conditions have been ohscrved in pregnant dogs, rabbits, 
•iri tHJimn-pins by Ilagemunn, Yer Eti'kc, and Jiigeroos. Tlieir metabolic 
rtmlifs liiive shown tbut katabolio processes are most prominent in the 
fif*I half nf pn'^rnancy, as U indicatt'd by the fact that more material is 
(Kwuii ilian iufri-stcd, wlicrcas the reverse condition olvfains in the second 
luU- During the latter period there is a marked tendency towarda storage 
i>f Ik' variims food stuffs. 

Aj M we are unuc<|uainted with the mctalmlic processes in the early 
nwiilh lit pregnancy in women, but a nunilter of o!»servations have been 
■■•lii; in itit' days imiiii'diately preceding delivery. Tlio latter clearly show 
^l T'lHien in the last weeks of pregnancy possess an unusual capacity 
f** rtorinj; up the essential elements of their diet, and render it probable 
Wlhrir m<-talH))ism is analogous to that ohserve^l in animals. In lUf>:i, 
litwDrr aiii'iiipii-d to study the metabolism of pregnancy by observing the 
ib«;;.-. ill wi'ight iif his iwtients, and during tlie last three months found 
U ivrajp' monthly increase of from 3J to 5J pi>unds. Tbi; gain was 
f^Tiional to the weight of the individual, and was rclativdy larger in 
^ultiliraviilii-. .Mon'over, he considered that the absence of such a gain 
ii»ii|;|ii was indicative of the death of the ftetus in vtero. ('oofirmatory 
■^■It* ircri' obtainird I)y Baumm, who found that tlic weekly increase in 
>* l«*t mxiilli and a half of pregnancy was approximately 1 per cent 
of tW WW weight. 

Thi^ t'iiin in weight is in great part due to the retention of water, 
">] id ist.'iit may W liest appreciatinl liy comparing tlie intake of fluids 
•''" ihi' mitput of urine. In thnv normal pregnancies, my associate, 
■^' M, Sli'iiidiis. found that the latter represisnteil from one half to three 
1"*^ of (he fluid taken by mouth, whereas in a patient with dead 
t»iBs |[ ani'iunted to S3 per cent, which is appro.\i mutely the normal 
""•■pfimint ratio. 

TH'fiaily output of urine is subject to so many variations, Iwing intlu- 
"**" W climatic, dietetic, and individual peculiarities, that it is dillicult 
*" ^> a normal standard. Ordinarily the daily quantity varies between 
'■""'' imt 1,5011 pp., though smaller or larger amounts of urine may Ije 
**™^H rithout necessarily indicating a pathological condition. 

■"rtl-id metabolism in the latter month', of pregnnncv liii-; \nn-n studidl 
L* Zicharjewsky, Schrader, and Ilahl, who have shown that ronsidcrublc 



176 



OBSTETRICS 



i|iiiintiticfl of nitro);«i arp retained whi>n the woman U nlloweil an adt*^ 
diet. Simitar obwrvalioii* Iiiivc Ix'i-ii mniii- in tny clinic liy Slvintiiin covei 
ii)j; tlic ]»fi fcvr wci-ki of pn-^iinn* y. ami the avera^ daily nitrogcnou 
exchange is given in the accnrnpanyiog table. _— 



Dailt Avkbaob 



Tt»«. 



Prtmiitnvida . . . 
Hiilii^vUIn . . 
Twin I'lTpinncy 



Flu ill 



I7S0CO. 
1800 rr. 
■23Si i-c. 



«( IVinir. 



iaO0CO. 
1007 PC. 



in FothI- 



10.77 (cniB. 
15.00 pan. 



in trnn». 



12.43 ffBw. 
1.1 'JK Kins. 



Niman 



0.53 |sns. 
'2.00 gniH. 



BidiuiBi 



+0.* 



i 



Such a Btongr of nitrogm n* *liown by Ihwe figun* wnulil iiidimt 
connidi-rable cttn.-ilruotioii of iirou'id tissue, and corresponds lo the growt 
"f the fii'Ins. placenta, ulmis. and the ninlfniiil firganism in p-nvral, M 

It IK geni;;rB]ly aii.iuin<Hl that Ihe n)(rogpnou.4 content of the urin^ 
incrvan^ during pregnancy on account of the fact that it contains tK 
wa.iti^ prodiict.'i of tmlh [he fieltil and mnicmal nictaMi.iTn. Kiicti a Ifeliei 
however, is erroneous, at leant in tlie lalter inoniliB of pregnancy, as tli 
iiitriigrii sloragi- lo which wt* linvi> jiist n-fiTrwl niiii>l ni'ei>s,*arily Id* accom 
panied by a decrease iu the urinary nitrogen. Tlus is clearly demonstrate 
hy llic ordinary urea 1<>st* mndft hy moanti of a Dorl-niiM urcomcli-r, wlw; 
the daily output of urea varies lR>twecn IC and 24 granimee, io^tteatl a 
iIk- higher figun'S usually given for non-pregnnnt women of the i*i\ 
weight. 

Along with the quantitative change in tlie I'limination of nitrogen 
aMkociated certain qualitative variations. Thus, tJie urea c»nt<-nt is nit 
lively low, and reprt-sent* only XO to 85 per cent of the total nitrogen 
insl4^d of S5 to 'JO per eenl ax in min-pn-^iiiint individuals. At the ram 
time there occuni a coincident rim? in the percentage of ammonia, whid 
is utill fiirilicr acci^ntiiali'd In twin pregnancy. On thi^ »ther hand, tl 
cases of intra-uterine death of the fortus. these constituents show a tend 
ency lo ri'tnni to Ihe noririnl noii-jircgniiiit n'hitinn*. The uric acid excM 
lion v-as found to lie practically oonniil in pregnancy by Zaeliarjew.tky au 
Roni. while the latter holds that the quantity of the punn bascit ik bi^ 
what diminijihod. " 

Ai-eloniiria was fnnnorly cnnsidcred a sign of ffrtal death, but raor 
recent work shows that it is of no clinical .lignilieumi-, Siolz oIm*tw)i 
it in inon- than om* third of a series of ST normal pregnancies, am) 
■lakseh. Knierson, and others believe that acetone i« a product of 
mclatMilism. 

Th*! rcHpiratory exchange wr» xiiidiw] in prvgnant rat* by Odd! 
Vicarelli. who found that the eonnuniplion of oxygen and the eliininatio' 
of cai'lHin dio\idf wa* eouisiderably increased. Magnus- Levy noted a 
iuereas^l consumption of oxygen in women »a pregnancy adrancvd, bv 
<'oni-iders that it is nu-ndy proportional to the increase in body iveigh: 
Jn a series of exjKTimcuts which 1 am now conducting 1, likewise, ol»«m 



tnd vol 
ddt S 



CHANGES IN THE MATERNAL ORGANISM 177 

n iDCKue in the use of oxygen and in the output of carbon dioxide, 
asodiUd iritb a relatively high respiratory quotient, but am not yet 
prepared to discuss the slgoilicance of such changes. 

In the taimal experiments of Ver Eecke, Hagemann, Jageroos, Har- 
Bwl: ind Klein, the mineral metabolism presients changes somewhat analo- 
pMU (o those observed in the nitrogenous elimination, and Schrader and 
Boni have shown in women that the elimination of the chlorides, sulphates, 
ud pbotphites is decreased. 

The limited excretion of these substances, as well as of the other 
■ateriili which enter into tissue formation, indicates that the maternal 
wgiiiimi preserves the strictest economy in its metabolic processes during 
fl>e wwid half of pregnancy. Its purpose, of course, is to facilitate the 
baiUiag up of the fwtus. but we are as yet entirely ignorant of the mech- 
aisa b; which such changes arc rendered possible. 



LITERATURE 

B*noi GewichtsvpranderunK der Schwanttcren, KrpiHwmleii imd Wiichnerinnen, 

Mf. D. I.. Miinfhen. 18H7. 
WTO. Zurphynial. u. path. Morpholope der (iebamiutter. Freimd'u f^j-niikologioche 

Bfflik, 1885. i. 369-662. 
"■■liR Bettrai^ zur Lehre vihd luitcren Uterin segment. Ilegnr'ei Beitraf^ Eiir Geb. 

•■'iyii.. 1W8, i, 167. 
"*'>*« Dccira. Traits pmtique dea makdies de I'ut^ruH, etc.. 2nie 4d., Bruxellea, 

int. 

*^ Quoted from Brit. Med. Jour., 1906, i. 1534-38. 

"*". I)et \-&rioefl chez la femme enrienW. Paris, 1880. 

**■*■ Ueher die narlienahnlirhen Streifen in der Haut, etc., bei Schwangeren u. 

^tbondeiieii. Monutmirhr. f, neburtskunde, 18.59. \iv, Wl~333. 
"•"ni BuU. de la hoc. anatomiiue, 1W4, quoted m eztenao by Cazeaux, Traits de 

>'>n<leiirrouchenientf>..1meM., 1850, 107-111. 
""■Uis. Du SrheidenRekret. etF. l.eipEif;, 1892. 

^*"- Zur Kenntnuw den EinlliiweH vim SrhwanKerwhafl, elc, aiif die vitale Capa- 
^ "Uldu I,unf;en. MunatNwhr. f. (ieburtskiinde, 1866. xxviii. 457. 
^*"*- I'eber Henhypertrophie Wi .Schwanj(eren und Wiirhneriniien. D. I., 

"•Am. 1991. 
*• Mcit Lea ^rhanitea maWriels dann leiirM rapportn avi:c Its phanes de la vie 

■»wUe. BniwIleR, 1900. 
"^"U. Itntrsg I. Studium dea schwangeren u. kreiaaenden I'terus. MaiiatnHohr. 

'• fH. u. GjTi. 1904, xs, 1-23. 
***■ I'efier BlutbesehalTenheit und Fnichtwaasemienge bt-i Rphwangeren, etc. 

*rtiiv r. Cj-n., 1886. itxviii, 4.')3. 
iKuu Hen und Schwangerachaft. Monatssohr. f. Geb. ii. Gyn., 1901 , xiv, 370-417. 
funuijniKK. Die Nenen der (Ichamiuller. Jena. 1867. 
™****. t'eberdieVerinderungcndeii Kiirperpewirhfes lx-iS<'hwajigeren. MonatHnrhr. 

£ I«burtakunde. 1862, xix, 1. 
'^■I'U. Die OMeomalarie im Ergolithale. Baael. 1891. 
'™Mw. De situ et magnitudine cordis gravidanini. Jcnu, 1862. 
BtOKus. Teher EiweiMoimsatz n'ahrcnd der .Hi.-hwangerii(.-tuiri. Ari'hiv f. Aiiut. 
t. njmoL jn>ra. AbtheiJ.. 1890, hi, 577. 



CHAPTER VII 

DIAGNOSIS OF PREGNANCY— DURATION OF PREGNANCY- 
ESTIMATION OF DATE OF CONFINEMENT 

OuDiNAUii.Y, tlie (liagnosirt of pregnancy offers little or no diflic 
and the patient is usually aware of the true comiitioa hirfore she con 
a physician. In a small minority of case*, however, the task is b; 
means easy, anil despite eveiy known melliod at our command we 
occasionally unaUle to decide with aljsotute certainty. 

Mistakes in diaf,'nosis are most frujiienlly niadc in the first few mot 
while the uterus is still a pelvic organ ; although it is by no means ini 
sible lo confound a pregnancy, even at full term, with a tumour of s 
other nature. Such errors are usually the result of Iiasty or impcr 
examiniition, but a false conclusion may sometimes l)e arrived at, ( 
after llie luost conscientious exploration of the patient. Some ides 
the fre(|ucncy of such mistakes may be realized when it is stated ' 
there is hardly a gynecologist of experience who has not opened 
abdomen in nuc or luore wcasions, with the cxp(*tation of removiD 
tumour of the uterus or its apjiendages, and been surprised to find hiui 
in the presence of a normal pregnancy. 

It is (irtcTi a malter of considerable importance that a diagnosis 
niaile in llie early uioiiths of pn'guaney; but, unfortunately, it is jus 
this peridd Hint our diagnostic ability is most restricted, as the absolu 
positive signs do not as a rule beeoiuc available until the fifth roo 
Hence it follows that in ciises in wliicli the existence of such a condi 
might alTecl ibe reputation or interests of the patient, an expressioi 
opinion should be deferred until Ibe diagnosis is beyond all doubt. 

Signs and Symptomg of Pregnancy.^The diagnosis is based upon 
presence of ceitiiin symptoms and signs. The former are chiefly sul 
tivo and are appreciated by the patieul; while the latter are made ou 
the physician after a careful pliysieal examination, in which the se 
of sight, hearing, mid touch are employed. 

The signs and symptoms are usually classified into three groups: ] 
tivc, probable, and presumptive. The jwxilirr nigrts cannot usuall_i 
detectcl until after the fourth month, and are three in number: (1) t 
ing and counting the fictal heart-beat: (2) perception of the active 
passive movements of the firtus; and (3) Ibe ability to map out its 
tines. The priibiililc xif/nx can be appreciated at a much earlier period, 
arc: (1) changes in the shape and consistency of the body of the nte 
(2) changes in the cervix; (3) the detection of intermittent uterine 
ISO 



PtWITIVE SIGNS OF PRBOSAXtrV 



m 



tnctMn; xnd (4> inrrea^ in (he mzk of Ow uIhIoidch and uteru#. Tho 
fntmmflin fvidfincet. with a few exceptions, are subjective, and mny bo 
nfahntul at Taniiig pvrM*: Thvy un-: (I) ccstifltioD of ttic meib«a; 
(2) dua^ in the lireaiiis; (:{) niorniug i>i(>knirH.H ; ( t) ((uickoiiiij;; (•'>) 
QHhntk's ^gn: (0) cU«turt>aRces in urination; (7) abnoniialitiGS in 
ppntauiinii ; (hi) aliDoniiiil omvingM; an*] (U) niciital dieturliancvs. 

?«itin Si^Bs of Pregnancy. — The Fatal Jlt^rt. — WhenoTcr we can 

hv nd L-nunl ttK- pnli^alKirii^ vf the fci-tal hi.-arl. the dia^noitiH of preg- 

[ uttj u asmmd bevonti peratkt^ntun^ ; uiifiirtiiiiiiifU-, thU Mign rannot 

[ wtMj Itr apprcvialiij until l)w lyghitvnth or tueutietb vrek, tliough 

I (KmnmIIv livi M)UU4li> ran W huani iit aii i^rlii-r pi;ri<Hl, am] on unu 

I mnita I was ahli- (o detect tlicio as early as the foarttviitli week. 

I 1V< fii-trti lu-iirl WAX fimt hi-jird Ity Miiy»r, of (icn<-va, in ISIht. in a 

I w tiitf. The sign was also diwovered indfix-'ncli-tilly by l^jumeaii tic 

I Kqindw in I8ai, li> whom w<; arc intlcbictl for niwt of our information 

I ipa thp suh^n^t ; ittilcL'd, so complete is Iiis monograph that subseqaent 

I <ni>uptiiini> have revMlixl but little with wbicb liv vims not familiar. 

I ll« Bade hid dirtcoverjf i|uite a<M: it ien tally, while atteiti]itin-^ to hear the 

"■hU aliteh he i^uiiihwiiI would Ix- niuik- by the fii-lu;' »p1u»hing In the 

I ^Mtrannii. On aur«euttating the aMonien of a pregnant woman through 

• *'ck(lnng. inrhidinj; the ftum-l. Itc hi-wnl a double mund, which varied 

■ In^iuy from M3 to 148 be«ti> to tlie minute, and clo»eiy rc*cmbl«l 

I 1^ titkisg of a watch under a pillow. Me c»ncUidL-d that it could Im 

RAv^ only by the fii*inl Wart, um the pul^- of the mother did not 

'"''i Td. For further details miieemin^ tl>e tiiintoTy and earlier work 

^ thr unlijcul, Hw! reader u referred to llic wvtrks of Ki^radcc, Kea- 

^, Ikpaul, bihI Monlgimierr. 

Alba alrca<ly bei-n r^aid. the f<etal heart-beat cannot usually be heard 

I Wd Uv ei^bto-nth ur twiaitieth wta-k of prcjcnaney, but from Uicn on 

I i^mIiI In* ch'trrted witlioiit diFTiculty. Ordinarily it variee in fraqncney 

I ■■*■ ltl> to l-fll UvU lu tbf minvili*. and ii> u doublt- Homiil, rbhu-ly reHem- 

**f Ibe tick of a watch under a pillow. In order to [war it tho abdomen 

•^ he banil. or at mn»t wiventl by a thin clolb, lu the earlier month.i 

t ^ •* l«si diriei'lnt liy mi-aiu of a !itethos<'o{ie, but at a later period tho 

I ~''*rt application of tln' ear ffivea flatiKfactory mullx. It k adrixahle fnr 

** •twkiil t>i pcrfm-t )iiniM>lf in the Intter mi-tlioii of auM'iillatinn, as he 

****'• liB4 bi." twrB with him, tut occfl-^ioiiidly mar l)c without hii^ «telh<>- 

l^pr 'Hk- fhnnid not W c<*n1i-nt wilh nu-rely hi^rin;z the fo-tal heart, 

r^l 'Iniilii always attempt (o count itii rale and com)>arc it with that of 

I ***■ wiiTruil pnlMt. .Sarwey i^tat"! in I'Jttl lliat it i» uoually [)o>»ihlc to 

™* the fotal lieart Miimda as early as the tuclfth or fourteenth week, 

*^ W statement ha* Uvn confirmed by B)iii>i»t and ollw-nt. In onler 

' '^* t", it i* r»wential that the bladder and rectum be empty and tho 

?"'^1 in perfectly nuiet surronndinps. while the »telluwe«ipe i» applitnl 

I*''^fT tlw Hvmph.viis ami the niera-> held in contact with the abdominal 

I •■Hi tjf oM hand of the ol»icner. In ninny iii*laiiwH the 'u>und» are 

I M tpjincisteil al once, xo tluil pnilonj|;i>d and inatlcnt lii^tenin^ is necfMsary. 

In tin early inontlts of pregnancy the heart should be Moiight jtitt over 



182 OBSTETRICS 

the symphysis pubis; but in tlic later months the situation at which i 
best heard varies according to the position an^ presentation of the fee 
details concerning which will be given when we consider the methode 
obstetrical csami nation. 

The rate of the fa-tal heart is subject to considerable variations, wt 
afford us a fairly reliable means of judging as to the well-being of 
child. As a general rule, its life should be considered in danger when 
heart-lionts fall below H'O nr exceed KJO. 

In wmiiou |)Ossessing virv thin alHlominal and uterine walls, the 
pulse nf the fu'tal heart may occasionally be appreciated by direct pa" 
tion, especially when the child is lyiug in the right mcnto-iliac posit 
Such observations have been reported by Fischel, Duval, and others. 

Frankenhauscr stated that there was a marked difference in the rapi< 
of the heart-beat in the two sexes, and believwl that a rate of 124 or 
indicatL-d a boy, and 144 or more a girl. Further investigation, howe 
has faileil to confirm his conclusions, as the diagnosis of sex can be n: 
by this means in only about 50 per cent of the cases. Indeed, there U 
nietlind by which the sex can be definitely determined before birth, ex 
in e few cases of breech presentation, in which the genitalia can be di; 
entiated by the examining finger. 

Otin-r Sounds which may be Heard an Auscultation. — In additioi 
hearing and counting tlie fa'tal heart, auscultation<of the abdomen of 
woman in the later months of prugnancy often reveals other sounds, 
most important of which arc the funic souflle, the uterine or place 
souffle, sounds due to movements of the foetus, fwtal heart murmurs, 
maternal pulse, and the gurgling of gas in the intestines of the mothe 

The funic gonffle is a sharp, whistling sound, synchronous with 
fii'tal pulse, which can be heard in about 15 per cent of all cases. I 
very inconstant in its nppearauoe, ns it may l)e recognised distinctly at 
examination mid be nl>scnt on s-uccccding occaKJons. It was first descr 
by Evory Kennedy, who sii|i|Kisud that it was duo to some intorfer- 
with the circulnticn of the lilnod tlmnigh the umbilical arteries, and 
sequent inve^li^'ations have served to confirm his conclusions. Occas 
ally, in very lliin women, the umbilical cord can be palpatetl between 
body of the child iind the uterine wall, and on making pressure npo. 
with the stellioseope a dislnnt siiullle can m.'casionally be elicited. Thi 
not. however, a sign of very great iiiijiortance, although, when heard 
is disftnctiv chnraclcrislic of jiregnancv. 

In rare instnncfs, abnormalities of the fivtal heart have Ixsen diagnf 
by au .soul tat ion during ]iregniiney. Siieli cases have been rc|iortcd 
I'oeliier, Cordoll, and others, and have lnvn confirmed at autopsy a 
birth. 

The uterine nouffh is n soft, blowing .■'ound. synchronous with the 
ternal pulse, and is usually most di.<tinclly heard upon auscultating 
lower portion of the uterus. It is due to the passage of blood thro 
the dilated uterine ve^-iels. This sound was first described bv Kegara 
who coniiidered that it was produced by (be circulation of Ihe blood thro 
the placenta, and he therefore designated it as (lie pliiccntal souffle. 



POSITIVE SIGNS OF PREGNAKCY 1S3 

tx-llned that it was of value in detiTiiiining tiio situation of tlint organ. 
Kiub^aeDt inv(hitigationj>, liuwuvcr, have t-hown ttiat such is not tlio case, 
and that the Eound originatL*^ a^ I have indicated, and should thorcfore be 
dertignited as the uterine souffle. As stated \>y Hotter and others, it may 
ocr«t$ioD>tlv be apprei-iuted by the palpating finger. This sign is not char- 
moterinie of prefrnancy, as it may Ikj present in any condition in which the 
blond sopply to the genitalia becomes markeiUy increased, and accordingly 
ii* pot iiifrc<jucnt ty heard in non-pn.'gnant women presenting tumours of 
tlie utmis or ovaries. 

Ceniin morrments of Die fwlus may iikewlsf' bo recognised on nuscul- 
tation. According to Ahlfcld, it is impossible lo hear the movements of 
tt** eilreniities, and he considers that the sounds which are usually so 
iiitcrpnUil are priKluced by spasmodic contractions of the diaphragm, and 
»r«iMlnjroiis t" singultus. 

Xol iofn^juently the maternal puhe can bo distinctly heard on auscul- 
**tinj; ihe abdomen, and in some instances the pulsation of the aorta is 
*<» li'ilcnt a to communicate a distinct throb to the car. Occasionally, in 
iK'nmiic somen, tlie pulse may become so rapid during examination as 
*o mask the fu'tal heart sounds. 

In adililion to the sounds just mentiom.-d, it is not unu.sual to hear 
^^''TUiii others priKUii-c-d by the passage of gases or lluids through the 
intft'tiiM's of the mother. 

^"pfiing out the Outlines of the Ftetun. — In the latter half of prcg- 
***iitTil is po.isiblo to distinguish the outlines of the fictus by palpation 
*™'<¥'' the abdominal walls, and this becomes easier the nearer term is 
■ppmichcd. When we desire lo map out the fa'tus we should go aliout 
**« eHmination in a methodical manner, and follow the rules for palpa- 
*i«a «hich will Ijc given later. 

A diagnoses of pregnancy should not lie made from this sign alone, 
wtilfsKone is able to feel distinctly the various portions of (lie frctus and 
*»»>iinp]i^h its hi-ad, breech, back, and extremities. Siib.seroiis myomata 
'wtiMoially I'imulute the head or small parts, or both, and their prascnce 
'^■"Wisitinally given rise fo wrious diagnostii- errors. 

^frtnrntu of the Fcctia. — The third positive sign of pregnancy i.s 
Pl^l*hpncver the physician is able to fee! the movements of the fa-tus. 
'j**»re active or passive, according as they are made sponlamimsly by 
"*iiHiin, or are imparted to it by llie examining hand. 

•Wtw ilic fifth month, active movementu may Iw felt on placing the 
*" ««■ the alxlomen. These vary from a faint flutter in the early 
'■^tlb to quite violent motions at a later period, which not infrwiucntly 
'"i'lle as .well. Occasionally, somewhat similar sensations may be 
fHnwd by contractions of the intestines or the muscles of the alxlominal 
""■ Ihongh these should not deceive an experienced observer. 

'»piMire morementg, obtained by hnUoHement. consist in the rehonnd 
«i IihjI extromity when displaced from its position by the examining 
'"''"• ■'hereby a sensation is affordwl similar to that produced when a 
f™" notion is given to a piece of ice in a glass of water, so that at first 
It ttnb ud then slowly comes back to the finger. This sign is available 
U 



184 



OBSTETRICS 



from t)io mirlv |mrt of llio rouftli inoDtli, and may Ix! obtaiocd thl 
either the vagina or the abdoinitial wulk. To ohtain vaginal Itallotb 
\ini jiaiioiil nhouhl Ih-.oii hi-r hack ; l)io |ihy>^imti ihon itit nxliK-cst two ii 
into the vaj^inii au<l earries them up to the anterior fornix, to whi 
impsrtii a suddoii motion with his linger-tip!', afterward retaining 
in tho sHino [KMilion. After a moment the evtreinity of the child 
oceupii.'e the lower i-egnieiit of tlie uti-rue, iL$uully thi; huid, drop« 
upon thorn again. 

Externa) ballottemenl ran be ohlained hy imparting a sudden n 
to the portion of the abdominal wall covering the utcru»; in u few tud 
the rehound of one of the e.vtri'mitiM of the ftttus ean be felt, Thi) 
is of very <'oniiidenilile value, and ean only be stmuluK'd liy n pMnnci 
tumour swiTiiminj: in awilir lliiid. When any one of Ihe ihree pn 
»igu« is oblaimil, the diagnosis of pa'gnaiicy i» iMtubUntK'ct bi^youd i 



^ 
1 





r* H 



Tig. ISO. tig. is-i. K.R. IH*. 

('•<»». 182-185. — SiioiriTra Rei-ativk Ahpomival KMLtiHiKwr.-fr *T TxiHu, Sixtu, , 
*tr» Tkmth Momtii or I'nrfliANCT. 

PlOlMible Signs of Frep>*noy. — Knlnr'iemeni of Ike Ahilnrntn 
the third month onwani the uierus can be felt through the 
wnlU tt» a tnmour, which gradually inereasei in »iz« up to the 



PROBABLE SIGNS OF PREGNANCY 



KS5 



pntamtty. lieaisnily spoaking. any enlargement of 1)i<- iiWomen liunns 

tbt Wlikltrarmi; irti'mI xhoujd he n^imli'd a*, prima faiit oviiJoncL- of tlii; 

lutoceor i»n>Kn«iK>'. Kik*. IHS, iS;J. 1«4, nnil JR.". giv.- n (rorxl idea of 

dwigw in the shape of tl>e nlidoincn ut the Tanous mooihii. 

*nK abdaminul i»ilargrincut is far less pn>noiiiic«i] in primipane thaji 

rniiltiparm, for tlie n^inn lliot in the lalU-r the abdominal walU ljar« 

*t ii i^frtl iMTl of their tonicirv anil are M>ini>ltm«-> «) llacciil that tlw.y 

F'lTil liiile or no itupfHin tu the utcni*. which then liwrnnr* marknlly 

ih^uctJ and ftgs forward and liownvrtiixl, giving ri^u to a pendulouit 

^titmn. Tliis diffpniiuw i» m apparent that it is not iinii^xinl for women 

sbr Inlirr part of a we- 

pn-gnnncv lo xiiApii-l 

IHmcc uf twine from 

'iutsisBnl st»* of the 

t«Tw>, as i.-oDi|>arcd with 

■t Kilnl in ihe ™rr»- 

•*n^ month of tlic 

pntiBUi imiriiaiti'.v. It 

l^iwuU also ti« iHimo in 

IbumI iImI Ihi- nlMl»mi-n 

i")"' -)ia|>e niaic* 

nil ,,,,,g ^f ^l^^, 

"•••in w in (he upright 
■o^iaonlal posilinn. Ijt-- 
taiMitK Unut promim-nl 
•t^i ilw is Iving di»rn. 
*^r\t>, 17!> and IW).) 

i'-it in Sif; Shape, 
— ' i-nrufrnr^ uf I'Ur' 
•-la H,.. fir-t thne 
* ' irr 111'- "Illy 

f': pUH araiiabte, 

•• 'b nirff^M «^ an 
"'"- ' ii/*T^* d/ dttv 

nn7 (/i^ fhiliihfarinff jteriod should ht regarded na ^rriteiMi/id'iTa 
'"^«'r nf pretfnaticff, untti such a poMtbilUif hat been coticltMvetg 

^i; tho fir«t fow weeks ihe incrcow in mixc t« limitnl almost cnlirRly 
i.rior diametor; Imt at a little later perKxl th* body of 
^' .-< ahniHi ^lohiilar in i^hapc, and at l)w tUtril month 

*"•-"*> Ihp size of sn orange. Piiring the first two (ninths the pre^ailt 
Blmh tUll [<r)ntiniii<s to be enlin'lT a pelvic or^n. whereas during the 
IfcirJ muh ji l„^ins to rise above tlie pvmphysi*. Al tlie name time 
"•" Will' twtwnMi the (■ody and wrvix hi-conn-* markedly accentuated— in 
"^^ •wd*. the phT»iologi<?al antt-flexion i> increased. 

Hoi* rfuracl''ri>'li<' than tlte changes in shape arc t1>n«« «(T<^cting Hf 

cfflwiflM fhi Iiimanual examination Ihe uterine liody oflcre a doughy 

, *r *k«k mrRntion. and in manv instances becomes so soft a* 1« be liacdly 




Fl<l. ISO.— Pi-Ntii I'll < AiiiH>Mt:.v i<i' A Ml Liii-nnoi* 
Woman BTm -VoBMAL I'ttVlll. 




186 



OBSTETRICS 



iliiitilif^uii-liable. Di«kin^on iitf^ {<ni»t<.-(l. out tluit (Ik-tv cliangv* 
Ddttt] At a very rarl,v pei-imi, aiul sUH^a llial ]w wan able to ilifTi 
liate a Kymnit-'trical clui^lic area in tin- body of the iiIitiim in the I 
pari nt the Uni woek of pregnancy, ubiili he coii£i<li5red aluoel pa 
nomonic. 

,\w'r>l'iig t(i R. viin Rraiin, it wrmid apjirar tlwt the earliKt ovid 
of im-ffiinni'V is aiTortk'd by the apiM^flraiicL- of n mnrv or Ivj* Innyilm' 
furrow iiiKHi cilbiT llic imliTior m paileHor ^urfaix- of the uterus. 
pKwnw In- ntlribiile> In chanKO)^ in consistt'DOT and the altcnuilion hcl' 
contntclioii and rolsxstion of 1)m- jjortioii of the organ in u'tiicli llie *A 
i» Kiluuli.-d. Von Brutin duinis Oial llii^ Mgii enables Mm to diagnotse 
Dxiiitcnre of pregnancy ns wirly iis llie first vfwk. 

At about Iho sixth work anotber sijni of considprabWr valm* — -the 
eallpd llegai^* *ign — licconii-s Bviiiliihlc. On ('iirrful Itiinnnual exaniina' 
w'ilb om- liiind upon the abdomen and two flnj^re of llif other h»tM) in 
vaj^na, or with a. finger io the rwtum and the thumb in the ragina, 




firm, hard cervix is felt, while above it n th<- «lastii: body of the uton 
and lii-rwiifii Hk- I"" i|uitt' a wft fonipivs'iblc- area, ()«caKiriniiny I 
chanp? in consiFti'nw of the lower segment of tlip utcni* is so niarkM II 
DO conneoiioR betwci>n lliv oen-ix ho<! body appears to ejrist, and in not 



PIHiItABLE SIGNS OF P»E(;NAXC\' 



187 



[fm luUoces Uiex)>eri(>ii(<e() oliwrvers have niistakeu tite (wrvix for Uw 
[utvTw, anal thi! soflcaicO bodv for n tumour of tla' uterine appciKlaKDs. 

Ttiiit "i^n, lin't ili-Mtriljecl t)y Reinl in 1881. vm Torilied later hy ffonn- 

[tmg ami others, ani] ilf> value is nou- universally admitU-d, and 1 comider 

(t the mwt valuiblv »jgii of cairly prvgiuincy. It ii' nut, liitw<'ver. atwo. 

cliaractt:ri!tlie, »it in ■ rccisit abdomiual section it was deRniteiy 

■t LD a noo-preKnant titcnis, wlioso cavity was empty, bat irho«c walls 

rtrr« lltii-):<-n«f) nnil N<>fien<fl in Nomi* m yet unknown manner. 11.4 pm- 

laplinn probalily depends upon the forcing of the part of ttie ovum occu- 

iTi*ir the ItwtT tit«rine *rf.'nii'ii( tnio (lie upjH'r purl <if tlu- SkmIv of the 

■n that tl»e empty and softened lower uttrine scfiincnl fun then he 





It^iianlt X J. 



Pio. 180. — RicmiKt; Uooi: 'ti I'miuucniilt 

or l)»MH'tl SlON. 



"•'■U rompnwM-d Ix'twM-n tlw finjtt'n'. Fig. I«i giw-s a pooil idea of 
(^wmaliikii 111 l>e ohtaini'd on hiniiiniial cxnniinniinn : iind l-'igs. IRS and 
t**(lKni the ronditiim of llic ult-nis uliiih ntukiii it po»iljk'. Thiii si;:n 
**f iRT mnnidenibtp value, and iU prescnee leavi.':* hut littlu doubt ai> 

toft../ „ 

f'- ,'intiing willi (lie »ocftud month of pirj^ancy, the eerrix 

"""Dw ««!iiderfll>ly softened. sihI in priniipiirouK unnn-n III*- 1»» eiilrrniim 
'*"* k tbf fin}:er a M-ntaliim Kimiliir lo llml obtained hy preewiuf; U)wn 
^ xk* yicldini; li|M inslexd of tlie ttariler eiirliliiice of the notir-. a* nl 
'™'' tunes. In «>ine ea^^s. hitwoTer, this sif;n does not lieeoine available, 
* ■ mtmn inflnminalory miMtilioni: of the uti-rus. m^ well n* in carci- 
"""u. Ihn nTvix tuay remain llrni and banl tiirougbout the entire duration 

'tttrmtUmt Cnntnirlionn of Ihr tJlenis. — From the fin<t wcoUb on. 

iif fwim five 1o ten minutes, the pn-vniint utertw iinderpjett 

alrni'lions, which in the early nmntlis can \>e apprccialixi by 

^tuinu] etamination. and later hy the hand upon the nMomen, when 

' ~ ' [lured iirfran in fell to liecoioe Unii anil hard, remaining w 

'itn.and tbi-n rrtnniinj! hi its orij:iriii! tfnidili'iii, Alli-ntion 

<^ W rallcK) In Ibia phenomenon hy Uraxtou llichs, and (he si;gn ha* 



188 OBSTETTRICS 

sincL' kfu known by his name. It is not, however, infallible, as similar 
contractions are Mometimes observed in hsmatometm, and occasionatly in 

cases of submucous myomata. 

Whenever one or several of tliese probable signs of pregnancy are 
dfteited the evidence becomes very strong. Nevertheless, if there is any 
[wssibility of wronging our patient we are not justified in making a posi- 
tive assertion, even though we may feel morally sure of our diagnosis. 

Preinmptive Slg:ns of Freg:iianc;. — The presumptive evidences of preg- 
nancy are afforded in great part by subjective symptoms, which are appre- 
ciated tiy the patient herself. 

CctstttioH of the Menses. — Most important is the cessation of the men- 
strual flow. In women exposed to the possibility of pregnancy, and whose 
menses have previously been regular, a sudden cessation is a most char- 
acteristic sign; and from it alone the majority of married women do not 
hesitate to diagnose their condition. But in patients presenting an irregu- 
lar menstrual histoiy this symptom does not possess the same diagnostic 
value, and we also know that certain diseases may give rise to amenorrliisa 
of many months' duration, in the course of which conception occasion- 
ally occurs. 

Not infrKiuently a single menstrual period may be missed by women 
who ffiir the powsiliility of pregnancy. On the other band, false state- 
nienls are often made, and a patient who has missed one or more periods 
nmy coiuplain of profiifc uterine ha'morrhiige, in the hope of inislcnding 
Ihe physician and indncing him to intrmluec a sound or even to curette the 
uterus, and tlicreliy jirovoke an abortion. 

In not a few instances menstruation may appear once after the com- 
mcni*eiui'nt of |ii'egnnncy. though the flow is usually less profuse than at 
other times. In maiiv of tlic:« cases it is probable that conception has 
occurr<'d slii>rtl_v before the period, although this rule by no means univer- 
sally luilds good. Only very rarely, however, does the menstrual flow 
appciir more than once, and ils regular recurrence should always arouse 
su-;|>i(iou lis to the existence of disease of the endometrium, carcinoma 
of llie ei'rvi\, or sniuo other pathological condition. 

due nec-asionidly he:ii-s of wcmien who menstruate regularly throughout 
jiregnnncv. but the iijiijoritv of tiiese accounts are apocryphal, or else the 
(■(niditiiin is assixininl with uterine disease. At the same time it must l)e 
admitted Hint very exceptionally authentic cases are obscrveil, and in a 
patient recently midiT my charge, the most careful examination revealed 
no niliei' source for the hieniorrluige. Such an occurrence, however, should 
iieviT W liilieu for gruntitl, and all other possihilitios must bo carefully 
excluded. 

('Iiii}i;/'.i ill Ihe lii-iiixix. — In \\w ciiajiler uiMin tlie Physiology ot Prog- 
iiiimv ri'fercnei' Im.-; nlreiidv been made to the changes which occur in the 
breasts. (ieTierally s|icaking, in jirimipiira' tlu'se are unite characteristic, 
lint are nf le-s value in intdti])iific. sini'c tile brcdsts of the latter not 
iufrcipn'oily eiiutain a small amount of milk or colostrum for months, and 
even for years, following the last labour. Oecasioniilly, changes in the 
breasts similar to those produceil by iiregnaney may be observe<I in women 



rRESUUPTIVE SIGNS UF PREXJNANCY 



189 



: «ilh nvariui «r uterine tumours. Nor is the posflibilUy o£ tlieir 
tNJivnau cxplu(kil in inJtaiWTes at npuriouH or iinajsinarj' pregnancy. 

•Tttfoi ami Vitnuliifj. — Tho cstatilisliment of pre-^nncv is not infix'- 
maaiHj lurkeii by diicturbiuicitv vl tliu di^t^iive )>y»iu-m, mon- pnrlimilarly 
numlstnl by nausea ami vomiting. This "niorNi'itj^ gickneaa.'' ta tbi) 
HMW inpUee, usually comc« on in t)iv c-urtier part of (ho day, and pair's 
tSiMtfev bourn, oititcm^b it oeea.tionally pi>r>iuit« b>nger or uiny ooeur 
■t MhtT times. It luaally appears about tbe end of the first month, and 
latu for tax nr eig:bt weeks, altliough itonie pati«nld imlTcr from it for a 
aueh itapT period. 

Tia* i- c*iri»i<bTable <Iiwre|iaii<'y of opinion a» to tbi^ frwiucnoy witb 

vUdl lltHe srinptoiiiii an> ob.ierved. .\erordini; to (!iles, tbey occur in 

akont two tliirj* of tlw cam.'st, but my iixperifnci- ii" tlial probably onft 

htll M pennant women suffer from them to a greater or lesser decree. 

Ib aanj it amount* to nothing more tliun an oLvastonal Ki-n:>ation of 

mums; when have considerable vomiiing, while in rare instances tlie 

onMa uiil romitin^ may be so persistent and coibtlant as to interfere 

•niooriy oitb nutrition. Oceatiionaliy. Himilnr symptoiiia n^ult from 

larnwthm or from the (ear of an illegitinialo pregnancy, nt vn-IE ax in 

nrUui met nt psetitloeiirsis. 

^^fidMimg. — About the eiubtcenth or twentieth week the woman be- 
mn)^ octtnnu* of »ligbt. tlullering movements in her alxloiiH-n. M'birli 
liially iBrrvase in intensity. These ar« usually due to movement* of 
LjUidr fimt appeaniiK-c i* diittfrnnlfx! ax " f)iirrkeninj; " or tin* 
<>0<-asionally fo-tal movemeiit.t may lie peri'eiveil as 
tenth wiTk. while, on th« oilier hand, in rare instaiK-iv iIm'%' 
^fiiBT Dol la ex]ivnenc(-d at all. 

^H Tki* Bpi offers only corroborative evidence of pre^ancy, and i» of 
^^■^ vbIoc usI*^ eonfirmiHl by tbe hand of the physieinn, as in many 
^^^^^^9aa *<aiiim similar sen^tions are experienced in itK absi'nee. 

Mii»nhi<itum of Ihr Mfunnn Mrmhranf of Vfri/itui anil Vulrti. — 1'nder 

*l»e tnflntikf of pregnaney the mar;nns of the \aginal opening and tbe 

*■■•■•' finmn of llw! anterior va^iiiud wail frt'>iumlly take nn a Momiwliat 

Afk hliiifi „f purplish, eonger-teil ap|>i'ariin<-e. Atleniiou was first called 

■o thia oiixbiiiKi by Jari]iHiiiier and Ktuge. hut particular str»t«s was 

bad Bp** lU Hignilirami- by Dr. Jame* R. (Iiadwiek. of Biwton. so lliai 

^^» thi* cninitry it is known as Chaiiiriff» niijit. Its prevnce supplier 

^HsltsabU- pTBitiniptive >^*idenrr. but is not condusive. im it may likewise 

!^%^ flli^nvd ig any condition leading to intense congestion of tlie pelvic 

Pig^mUlum tif thr fiiin and Ahdominal .*?friVr. — These manifestations. 

tidi hi\t airuady \ievn referfed to in the chapter upon tlie physiology 

ff^paofy, sTf usiuilly oWrvt^l in tbts <-ondition. but an- Ufit absolutely 

irarbriilir of it. ai' tliev are sometimes associated with lumonrs of other 




rriaary Outnrhiinm.-'Jtt the early n-eeks of [inynane?- the enlarging 
i>-r1ing pre^ture on the bladder, causes a desire for fni|in-nt 
Thi" i« nio't marlu-d in tk- fir>t few months, and gradually 



190 OBSTETRICS 

Iidsses off a» tlie uterus rises up into the abdomen, to reappear when th 
hi'ad descends into the pelvis a few weeks before term. 

Cravings — Menial and Emotional Changes. — Occasionally the appetit 
of the pregnant woman becomes very capricious, and she may evince a 
almost unconquerable desire for peculiar and sometimes revolting article 
of food. I recall one patient who eubsisted almost exclusively upo 
devilled crabs throughout the entire duration of pregnancy, 'and anothe 
who could ri'tain nothing for the first four months except broiled lobstc 
and Bas-i's ale. 

We have already referred to the mental and emotional changes wliic 
sometimes characlerize pregnancy, and occasionally we meet with wome 
who diagnose their condition mainly from the occurrence of changes i 
their own temperament with wliich they have become familiar in previou 
pregnancies. 

Synopsis of Sigm and Symptoms of Pregnancy. — For convenience o 
reference, we give a synopsis of the signs and symptoms of pregnane) 
dividing thom into three groups corresponding to three different periods 
The first belongs to llie first three months, the second to the fourth anc 
fifth months, and the third to the last five months of pregnancy. 

In the first [>eriod the symptoms are: (a) cessation of the menses 
(b) changes in the breasts; (c) morning sickness; (il) urinary disturbances 
The signs are r ( 1 ) eulargcment and softening of the body of the uterus aii' 
iuereasfd anicfle.vion; (!J) changes iu the consistency of the body of th 
uterus: (;i) Hegar's sign; (4) elianges in the cervix; (5) Chadwick's sign 
(li) the abdomen is not prominent, the navel is depressed; (7) auscultE 
tion is negative. 

Second period. Symptoms: (n) menses still absent; (b) more markp 
cliangcs in tlic lireasts; {«) disappearance or subsidence of gastric and ur 
narv disturbances; (il) ijiiickening. Signs: (1) the fundus is felt severa 
lingers alHivo the sympliy>is at the fourth month, and midway betwee 
the symphysis and iimhilicuM at the fifth month; (2) the cervix is sofi 
(^i) balliittemeiit is obtainahle; (4) intermittent uterine contractions as 
rei'ngiiisiible; (.'i) at the very end of the period the ftetal heart sounc 
ean be distinguished. 

'I'liird peririd. Syiujdoms: (a) menses still absent; (t) changes in tl" 
breasts more rtiiirkeil; (c) in llie last month fre(pient urination reappear 
often with neuralgii; )iiiins in the lower extremities. Signs: (1) progressiv 
eiilnrgenieiit of the abihimen -, ('i) umhilieiis smooth nnil later protruding 
(H) the betid heart can he beard; (4) the dilTerent parts of the child ca 
be piil|iate(l ; (."i) fietal mnvements are perceptible. 

In thi' lir.-t jieriml Ihe <liagui>sis ]^ usually very probable, but nevt 
nbsnliile: in the seemul, vitv rarely doubirut. and in the third alwolute. 

Differential Diagnosis of Pregnancy. — 'I'hc pregnant uterus is ofte 
mistaken for otliir (iiiiiours occupying the pi'Ivie or abdominal cavitie 
and iiVr rcr^n, tlmiigh. as a rule, the former mi.slake is more frequenti 
made, 'j'be early ]ieri'Hls of progiiancv mav Ix^ simulated by enlargemei 
of the nliTus due to interstitial or subniuciuis mvomata, sarcomata, htemi 
tomctni, and conditions resulting from indammntory disturbances. As 



SPUniOrS PREGNANCY 191 

inle, the uterus under thwm I'ircuniiitance:^ is harder and firmer than in 
prepiuH^, and does not prest^nt its characteristic elastic or boggy con- 
tiiwm. Jloreovirr, such conditioni^ are not, as a rule, attended by cessation 
of ibe raenses, except in hiematotnutra. If, however, there i& any possibility 
of 1 mistake, a delay of a fo«' weeks will usually clear up the diagnosis. 

The pregnant uterus is oceasinnalty mistaken for small ovarian or 
tabil cysts, though this error should rarely occur if the patient Iw care- 
(ollv eiamined himanually and the pelvic contents isolated, if necessary 
under an aDa>sthetic. As the tumour becomes larger and rises up into 
tlo abdomen, other points become available for dilTerential diagnosis, nota- 
Ut Ihe intermittent contractions of Braxton Hicks and the jKisitivo signs 
ti pngnancy. 

The diapnosi:? of pregnancy in a myomatous uterus often presents seri- 
wisdiflkiilties, and fur a time may ho im|Xissiblc. Hut a short delay will 
iht a more rapid increase in the size of the tumour than is consistont 
"I'll Ihe existence of an uncomplicated myoma, and variations in the eon- 
ntlfWr of different parts should also serve to direct one's attention to the 
pregnant condition. 

(Jcrasinnally, an ovarian rvstoma may l»c complicated by pregnancy. 
In Ihe early stages the diagnosis, as a rule, can lie easily made, as careful 
binannal e.^amina1ion should enable one to differentiate between the two 
tBBnnp; but in the lalcr months it may becouu- extremely dillieult and 
••TOfliiHw impos.-'ihk', owing to the increased distention of the abdomen. 
fifihennore, if the [Mi-'^ilive signs of pregnancy cannot be elicited, its 
"Veneris usually overlooked and a simple cystoma diagnosed; whereas, 
II Ihe heart sounds are heard, the cystoma mny escape recognition and the 
*M<**iTe aUlominal enlargement l>e altributcil to a liydramnios. 

In rare tnstane«.-s hypertrophy of (lie supravaginal portion of the cervix 
■•T wiously increase the diffjcultics of diagnosis, as the enlarged and 
"•rt eenix may be mistaken for the entire uterus, the soft and elastic 
"«.' '■eing either overlooked or regiirdeil as a tumour of the uterine 
'ppendajtes. Careful bimanual examination under anaesthesia should do 
"•y "ith the possibility of this error. 

'rrejrular development of the pregnant uterus, asswiatid with a saccu- 
WDnof its anterior or posterior wall, mny seriously complicate the diag- 
**". especially if the foetus be dead; as even after the most careful 
tttminaiinn the existence of pregnancy may remain unrccognisid and the 
"•""latinn lie mistaken for an ovarian cyst. This is especially apt to 
*"" "hen the pregnancy develops in Ihe posterior wall, as in such cases 
'* interior wall may remain practically unchanged, and when, under 
fSflhejia. one can fwl the fundus with both tubes extending from it, 
"8»lnio4 a pardonable error to conclude that the fluctuant tumour lying 
f***Tior to it is an ovarian cyst. 

"Pnioni Pregnancy. — Imaginary prcj:nancy, or /js'-uiWjmi's. is a con- 
."""' *ith which almost every praetilioinT, sooner or Inter, will meet. It 

Biiijly oliserved in patients nearing the menopause or in young women 
7*^ iniensely desire offspring. Such patients mny present nil the sub- 
Wite lymptoms of pregnancy, associated with a marked increase in the 



192 



OBSTETRICS 



tixc of Uiv abdnincn, whic^i in «iui> <>iLti«r In an abnormal iin<i rapid de 
tion of fat or to the existence of tympttnites and i><.-ca»ioDally of 
U'heu it M^ctirfi In Ihi- curiicr yvnTS of life ihv iuciim!!^ do not, us a 
di«i|i|>i-iir. Iiiit niii)' iin-si-iil (rrtniii iibnorniAliliui wliicli tiio [laUvul 
sidcrs nil! dm; to ht-r !iiip|»ist?il condition. 

Id inatty in^tanoi^-i ihi- noiiiua may imugiiie that slie dctrct« ttxtai 
niiint^ K-hicli are .-xtnietinioii m viuk^it ax lo make her fcarfu! that 

may bo viitiblo (o onlookprd 
ritviitly *.hK a |iatieiit who 
a;;ine<l hereelf in the last n|j 
of pregnancy, and who, ij 
talking to me, exclaimed al 
vi<iK'ilc<.r of (he m»v.-mt-iit«J 
on examination I found tha^ 
iitcni* wra* iinnna) in :ti»;,J 
tiiat her enlarRetl al>domcn.j 
dtiv tci a rapidly incrvfi>ina 
poeit of fat. 

Thu utipiKwcd ftetal II 
nionis usually result from 
triK'tinnn of llur intcstiiiq 
tlie museles of the alHloin 
wall, and oeoisinnally a 
markinl as to ileceive even 
ctan». Careful cxaminati 
the patient usually fnahle> 
to arrive nt a correct dia 
uiliioiit ifnat ditliealty. a* 
Miiall uliTiiH can be demons 
cd on hiraannal examina 
mudp, if necejs»«ry. under t 
Ihciiitt. 'Die ^rcalcKt diHicidty in lliefG ea»e« in to [HTAiiade the pa 
a* to llii' torrivtriiri- nf the I)iu>.'rlll^i». Bicliel)ois ha* pointed out 
invint; wiinicn fn-quciilly tiiilFer from tlie delusion that Uiey are pregl 
and jiersiint in xiicha belief for years. r 

DUtinction between First and SabBeqnent Fre^ancies.— (>ci-a*i(V 
i^is a rtuillcr uf pnnlicdl itiiporlaini.- tn ilecide whether n palierit is ■ 
nant for the first time or hjL-< pn-vi<iii«ly hnrni- chihiren, Ordinarily c 
hearing lcuve.< indelible traces behind it, which are readily apprecii 
hut very exeeplinnpliy aneh ifignu are lacking, as in a cn*c reportw 
Biidiii. (See Fij;- 3G.) Again, in verj- rare instaneoi*, all the .*igti* 
eaiing a previous labour may result from the prerions existence of a 
tumour whioli has hera removed thmugli tho vapinn. 

In a pregnant woman who lias never Iwirne childreji thft ahdo 
usually lrii»e ami firm, and the uterus is felt through it only a"ith 
culty. The eharaeterisiie pinkish hlnish striie ami the diKlinclive ch 
in the hn'ssls are readily obwrvi'il. The labia inajora are usually in 
api>06itinn, the frc^uulum is intact, and the hymen toro in se^'cral 



.■I" s .1 1 ■ . I I - ■ ■.[:!. rm:\r nri: iii 

I AT. ml: I'ATirM iH.niiMNn iii^noKtr ro nK 
IX yur. Laht Mninii tir I*iiK«NANi-r. 



DURATION OF PREGNANCY 



193 



prtw nfriiH is usually narrow utA marked bj* well-di>v«!opeii ru^. The 
^i-rn )» rariruol. but dm-;; nut luuallv sdmil Uii' tip of l\w liiigL-r until 
I 'Uft nr jin-);iiaiK'V; iind during the in.'>t four tt) iiix vrtwki »f 

r. . . ; tlm |irL>^Dliuj;; pari is found eDgagcd in Iho liupcrior strait, 
kiilv!« tatni' rlifiiirup<»rtion pxtots. 

[ la Biulliparnuii women, on tl)e oiIut hand, The atidominal walla arc 
^nuUr lai. flatihy. and fr<.-()ticnlly i>L-i)diili>u«. and the uIitiik is rt-'iidily 
pal|«itti thniujjU tlitm. In addition t>i llio ]>inkiHh Hiriw dtii.' tu tiie \tT&- 
.1 MnlitinD, the eitrin- cicatrice* of paai ]>r<.'gniiiK-)(i; uiay aim be notod. 
le bmut» are uxually not «k Grni »f in the fift prcgnnncy, an<) f m[U(.<ntly 
iip (similar to thotu? otn-ci^'cd on tho alxiomcn. The Tnlva U 

re nr lew g»{>in^, ihi? frenulum liii» ilisa|iii>jinii, and iho hynwn 

iv(tu«] by tht' canrH(«i/<* mfirtiforntfu. The external 09, even in (ho 
«n1| iMittlu iif |in4pumcy, ui^uuUy nhuus »igni^ uf iitLvrulion. and at a 
ittll>>Ut«r |M>ri<id n-ailily adniit« the lip of tlie Wn^s^, nhit^h can be carried 
vp tu Ibr intcrnnl n«. Furthcrnwn.'. ill ibi- uinjority of cai^e* the [iri'senl- 
(■(; pm tlfxs u»i eiipi;,-v in the iiii|U'ri<<r nlrnit unlil llie mwt of lahovir. 

BufDMit of the Life or Death of the Ftetur — Cicncrally ftK-akin)^. tlic 
'■nwthould \k CMUMidcrtil to Ik- allvt- unle^-^.n dctiiiiii; vvidi-iiiv U' thu coQ* 
•my caa be adduced. In the early iuonth§ of presnancy the dia;!nos)i» of 
'^drtlh nVvrt conMilvralili- tlitlti'tilly, and esn W iiinih' only after n.'|H'«IOil 
**)iniitirt)on<i hnvo 1 lemons Ira ltd that the uterus liajs remained stationary 
r a nnmlier of wivk*. 
i- .'..e later months of pregnaiKy, th* ditmppearance of f>vtai more- 
<"W*vually (iirrctA the attention of the patient to this pni-^iibillty. after 
'Wi ihH *ulTi-t> (mm til-dHlnwl M-n^ilion.->, suili ■» cliilitwss, tiinguor, n 
'HHiti(« tif weight in the alxloiiicn. and [iiTliapK a foul tante in the niuuth. 
•Jwfd im ■•>ti)[i)liiin hIiowh ihat the ulorux ilo« not corn's'iKim) in *iw! 
*>tnlai-«elimatcil duration of prefniancy. aw! ]>crhaps lias hccome emaller 
•■■ prptiounly: whih- at the suinc liuw n'tn>(in^**ivc cluingc* have oc- 
"""d in tlie hresHiH, which have be<N>nit.- Mift and flabby. The dia^tnsiii 
" 'h- (ttiiliii^in. IjowMcr. can be cMitiidcred absolute only after repeated 
"■oulioBti. when in addition ti> the m^a juHt menttonid one turn fnili;d 
L '"^r tV fci'lal heart or (wrceivc tho niorcmenlH of the child. 
I t.ifi inftirnialuin '\* otriiKioiiullv alT'ir'tiil when it i* posiihlc to 

B ""^(tw |,r palfration the maeerflted iJiull thmuKh \\w partially dilated 
■ ""•>; •lniMrTiT iilie can feel that the bonw of the head arc loo** and 
Y P'*Ki wnialtnn m if they were conlaincd in a flabby ha^;, the dtagnoiiiit 
'"''• ffl»ilo at nncc without ho-itation. 

"■ntiMi of Prepuaey. — .\m we have no meanji of AMHTtaining the 

'"" 4«r at which fertilization occurs, it is apparent that absolutely 

***^ »lnliTneiii« u« to the duration of pn'pnancr cannot be made; 

'""Ml. a' ha« already been pointeil out, eoncepiinn usually occur* either 

•*" if',.- fi., l|,.: :i p;>earance of the menj^es, or shortly before the fin't 

■■■■'! >i;i.fi ■- fiii-"'i. In rare instnixii' it may take place at any time 

the inler-nicfutrual period. These vii^w* hav^ htyn confirmed, not 

Ibe «liiily of Ihr ivinililitu) nf Iho ovarieA. hut also by tlie 

of einbriolf^inu, gg it id n<it unusual for young nnbrjiw, which 



196 



OBSTETRICS 



(tijdi tliat rather tlian fmm titv K^inning of thi? lasl period. Tl 
is slso subjvcl to voiiAideralik «!m>r, a!> ve liave no niL-auH of 
huw liiug the sperniatouitt may rantaiu in thu genital tract befo 

li<>U 4X*UM. _ 

III not u fuw iniitiinci^A, vjipecially in niir^in^ womon, concept 
U)(« ;>l4ic(^ during a period of aniL-norrha-a, siid tho putivut i^ 
prised by the enlargnnvnt of her ubdonit-n or l>y tlii* perovj>ti'>iJ 
movinncnlx; whili^ <i(-i>aKioniilly lht> Hv^t intimation that ithc in 
is given tiy the fact that her iiiillv. wiuch ha>i previously agreedj 
with the jnfuiil. suddenly tK-coiuw inili^-siiblt-. UndiT Kucb cir 
the umihI itiuthods of calculation are of no value, and we have 
upon other mean». which, unforliinnU'ly, an; cvlrvmely unKiilii<fa<: 
Kn-tiiivnt attempts have been made to estimate the date oAj 
ment, by adding twenty or twMily-inn! wwtks to ihr dale upon % 
patient 6r«l pvroeivMl fn^tal inaveinenta. I'hia iuet!i(Hl i^ founde* 

belief that qu 
i.4 fir^l exfH^rii 
(be cipbteent 
tioth wtwk III 
■ly. I'nforlui 
:iM<umpiinn 
ini«, as tile 
iioi infri^iii-nf 
4i1 a iiiucb carl 
1x1. and mnittii 
nnti) coniiideFal 
Tn other ci 
r :i]. iilaiion?" ai 
.ij.H'ii llieenlarg 
the alKionieJi 
height to wli 
funihi* of th< 
hni: riwn. ( 
fpi-aking, we ( 
ttio fundiK^at \i 
nionib is srvi 
ceis'-breadtlw a 
^viniihyMs pidii 
bfth month inii 
twton it and 
biliem:; at II 
month at iW 
the umliilieu^; at the wientb monlh tbre*' fingers'- breadths above 
hitieuH; at the eighlh month an etiual distance ahorv iu po^titio: 
ffvi-nllt montli; at the ninth month jUKt helow tbv xiphoid; w): 
tJie la^l moiilli. partiodnrly in primifiaroii'^ women, it sink-i downt 
assumes nlniocil thi' [MT^itinn it o<<c'tipi<'d nl the eighth month. 
ThJa method, howe\-er, gives only approjiimalc re*ullj«, as the 




F»ui. 181,— ReLATiTEHstuwTOrTiiii ruHDCs atimbTam* 
ov» WK*;ut or I>iimi.i«mct 




EgnUATION OF THE DATE OF CONnNEMENT 197 

of tbe umbilicus i^ subject to marked variations. Thus, according to 

SpkgiilbeTg, its situation varies from id to '^8 centimetres above the 

Mmpliysis, so that if this author's figures are eorrert, there may be a 

differtDcv of 6 inohes in its position. On this account it has l)ecn thought 

preferable bv some authors to estimate the distance of the funilui; from 

tbe sj-mphysis pubis with a tape measure, the average results obtained by 

Spi^elberg being as follovs: 

22d to2Sth week 24 to 24.5 centimetres. 

2Sthweek 20.7 ccntimetreB. 

30th " 28.4 

32d " 29.5to.10ren<imetreH. 

Htb " 31 centiniHtres. 

36th " 32 

3Stb " 33.Ioentimetrea. 

40th " 33.7 

Xbese mea^ureiiientR, however, are subject to considerable variations, 
u they are dtfiendent not only upon the size of tlie fo-tus contained 
vithiD the uterus, but also u|>on the degree of distention of the abdominal 
C4>nt*«it^, Xevertheless, in cai^es in which we possess no other data, they 
occasionally afford us information of very considerable value. 



LITERATURE 

J^^iJXtD. Beobachtungen iitier die Dautr der Sfhwangersrhsft. Monalswhr. f. 
'!*burt»k., 1869, \xxiv. 180-225. 
I^ nhnit'hmlitireD kindlichen Bewetrun|K>i. Ijchrbuch der (icbtirlxhiiiri', II. Aiifl., 
1»8.56. 
""OUT. Dei rapports entre I'embryon et le plurenta dans i'avortement. Thfse 

* Pwia. 1906. 
""^onu. Contribution k I'Hude de I'id^e du (trosaesMe, troulile piiyi'hupathique. 

lite de Xancy. 1903. 
^*-*v iL CiiKiiTTuFOi.ZTn. Uebcr die Daiier der menschlii'hen Schwangerwhaft. 

laiitjwhr. t. Geb. u. Gyn.. 190.^, xxi. IM-Ili9. 
*Wj«Bhm, Leber FriibdiaKnoae der (iraviditat. Zentralbl. f. Gyn., 1890, x.xiii, 



^ura 



Fnnines en courhea et noui^eaii-n^s. Paris. 1897, 1-4. 



"-•"•nx Value of the Bluish (-oloration of the Vaginal Kiitrnnrv as a Sipi of Preg- 

M«j. Tran*. Amer. Gyn. Sop.. I88fi. xi. ;t9fl. 
*'*'*^ Corgcenilal Anomaly of tlie Kii'tul Heart, ete.. in which a Syslolir Murmur 

*^ hnnt before Birth. Trann. Med. unil Chirui^. Farully uf .Maryland, 1884, 

^^•fl- Tnut« d'auwnilUtion obst^triralp. ParJH. 1847. 

^*'**'>*. The UiagnosiB of Prepianoy liotwpcii the Second and Sewnth Wctts hy 
^^^''WMiaJ Examination. Amcr. G>-n. and OImiI. Journal. 1892, ii. -'>44-55.^. 

**- Palpation of the Fecial Heart Inipiilne in Prvciianry. Johiix Hiipkins IIoh- 
P Pital Bulletin. 1897. ™i. p. 207. 
^^"•i- Veber cin binher nicht h^liarhtptcs Phunomrn Ix-i IVflesionslnRtTi. PraRer 
*i Wothennrhr.. 1881. Nr. 12. 13: 1882. Nr. 28. 

WtwterineD Tastborkfit den folulcn UcrzimpulHeH l>ei DeflexionHlagru. Zcn- 
••^.tGyiL, ix, 1885, 769-771. 



200 



OUSTETMRVl 



\ 



Kserciee ehoulO runMiiit uf wnlkitii; or ilriTinfi:, but the ordinary spa 
«)ioul<l In' iiiienlicted, though §ea-bathing in many imtancei i* very he 
ficial. U'liiii for various ri-iii«>iii' iiuliliHir i-jiert!iM> <-jiDniit be Inlceii, masH 
in ttiw haiuls of a skilful j>erson is to bi- rtitimiiiKnili'il. In the In 
months, loop jouriM;v» I'hould iiol \w umlcrlakt-n uuli^tt ali^olutely nei 
san-, find dririiig civ«r rough n>ads should Ijc avoid«l. 

Diet. — The dii't should be abundant aod uuuri«hing, itDd ordinal 
the patient should tx: allowed lo omtinm- Ix-r usual ou-'itoiTirt, but iJia 
be wam^ to absiain from vory hinhly Boationwi or indiins^tiblc artK 
of food. In slight di'gni.'!< of pclvio (;oiitra('lion, or in (Mlient^ vim h 
previounly gb'on birlh to ox(;i*w!Ti>ly heavy children, a restricted diet n 
be advisabk diirin;; ihv In^t two or tUim- month)', as I have ulre^dy >iho 
llul tin- Inr^-r xhi' of tht? children in the well-to-do clawes is in gt 
\tart atlributablu to the life of iiiso and tliu abiindantt- of food c-njo 
b; thi* nioilii-r«. I'l-oeliou'Dick |Miinti-d out, and hit) experieiiL'o hait b 
confirmed by Keeh and Noel Paton. that a dii-t poor in farlwhydratw i 
tliii<li i'V<-rlh II iiiurki-il iiitliion<^t in loHstHiing llu- weight of llit^ ohild with 
otherwi-'e .ifTti'iinj; it, and in uol a ft'W raMS thi'se prw-aulionary nic-A>i; 
inay obvijili- u dilluull ib-livcry, or evon iln away with Uii' uccOfwil) 
the indu<-tion of premature labour. These conclusions stand in mar 
contrast lo tbosi' iisuully held by lliP biity. who ('rron«ou#]y believe ^ 
aliKti-nlioii fnuri jiroti'id food i« the e-isenlial jioint. 

The BoweU. — Uiiring pre^rnum-y the k'nlari^id aterns i^metimm in 
fert^n wiih th<- noriital uilc-linal jx-rislaUis and ji;ivt9« ri^ii! to mure or 
marked mniitipntion. lender such circumstances care sliouM be lakco 1 
the bowels arc moved daily, which is hcs) arcomplii^bi-d hy the admil 
tration of i-a.-cjira nat^rada or pills containing; aloin, lH>llailonna. and Mrj 
nini?. The use of active cathartic* is inadviHiiblc. nnbwn their cmployjn 
tie tvptvially indicated in cerlnin morbid conditions. In some inilaJi' 
hovevor, the judicious adnnnihtration of an occaiiionul doMt of oIonHs 
followeil iiy miiik<-d bRni»lieial resultJ'. 

Clothing. — The phj-sician im fnijucntly asked concerning the cloth 
which is bi'st ada|itc4l to the pregnant slate, and CKjK'ciutly whether ««n 
tthouid be w«)rn or not, (Jeneraily speaking, the elothing should be lo 
and K» urrangi-d on lo Cx^tI as little pressure upon the waist as pO<»iti 
and in the later months of pn-jinancy, at least, the corset should cill«T 
entirely di*i»<'nwd with or rcphuiil by a loosely ruttiig <'or«'t-waisl. 
multiparous women, when the abdomen is markedly relaxed from prerin 
chil(UH<«ring. the wearing of an abdotiiinal support, either an ordiiu 
Scultetus handajte, or om? made of ilaslic material, adds mnterialty 
Hii'ir comfort. When varicose veins of the extremities are present, I 
legs should l>o luinda^il or encased in elastic stuckings. and whitn lai 
varicc* exist alwut the vulva the patient should be cautioned conoeral 
the possibility of their nipture. 

Sextiftl Intercoune.^ — In healthy persona sexual intcrcour*** in nrnd* 
tion usually doi^s no barm, as long a* Ihc nhdominal enlargement is 
too great to make it inconvenient for the patic-nL But where then- i 
teudeney to abortion it should be utriotly interdicted. It should alsa 



^ 



THE MANAfiESIENT OP NORMAL PREOSANCY 



201 




Flo. IB2.— WcHiin.K NirrUC ShiU-D. 



[pdHRR^j fnrbtililiu) in ttu- la^^t iitoDth of prt-jiiiuincy, (ih I kiiovr of al least 
KM- in wliicli u )wvfn' |iwrj>iTal iiifivlioii Iiils followed coitus during 
itn jKrtod. lu this iu-^uih^. Hh- |iHtit-iit, ntio liud not l>i->'U t-.xamiDat 
aittmily, bad a R''V(trv »tr(.-[>liMx>ccuH lufLfliou io the [mi>r|ii'riuiu, xm), 
ipo tnrchiiig for iUt cjiune, it uiw found tliitt Aw had iiad hjiuoI ioUr- 
oKTtf ja«t btfore the oiistl of the firiit Htnjie of UlK>iir. 

The Brcssts. — In tin* liiat (hixw mouths of pr<.>^iaDcy attentioa aliould 
laArTDud to the comlition of lh« hreasttt, and inorv purticularlj- to the 
^Uffirf, M by appropriate pmlitoinary 
ucnt mining mty lie rendt-ivd 
T. and the occurrence of liMureA 
ilii- I'onKoguviit danger of mani- 
(17 mfwrlioH in prwil pari prevent^l. 
^ir Ikix purpnw tlu- piitivnL during 
' Iwl two nionihfl, should bathe Ikt 
B|9hf night and morning; with a lo- 
Ua vliiili l±mU III make Ihtf .ikin 
"ftiTiit;; Ibifm iDi)rt> rc^islatit. A miIu- 
.iHnl (ulBlion of lairax or boric ocid 
laUfer cent alcoliol will an^er the 
fvinw vi'TT wril. WhtTC lUi.- nipplw 

■KqnUI it Li adti.-^lile to atti-itipt to lengthen tlieni by making a few 
lacauiii opnn ihcm »i|*hl and mnntin);; and when- they nrv but slightly 
fmiaent pnod rtsulU not infm|Ut'ntly follow the wearing of a wooden 
*>RiI( ihield (Fij;. 132) for a fevr hours of each day. I know of no 
teUH. I.ow.-nr. hy which dwply r*-triu'ttHl ni|>|>1i--v can Iw n»i<)c sorvfcctblc. 
Utiif. — Owini; lo llw fn-i|ucncv of reoal di!iturhan€M.>!< and the «eriona 
["Mf^'nnx vhirh not infm|U<-ntly rcuull from tlifm, the urine should 
Mr tvffultr ruiiiin«cl at n-fpilar inlt^pnl": once n month for thi; Gr«t 
I *^ moatbfl. and at least twice a month, and preferably every week, 
|™*( Ibe la»t tlirc* montlw n( pnvnancy. It i* ndviwddt- that the 
1 l**Aiiii hlwtuld not only arrange delinite jit-rioda at which lipeciineoii are 
but tliat h« should himM-lf make a nnt« of thct'c clatM. so that 
ri'ii-nl iK-comes carelesdi in the matter aixl ncjilcett ti> carry 
■ns, he can remind Iwr. Of C"ur«' it may be very plauxibly 
ioiCul dial tl)v patient inours tlie main ri^ from .-tuch neglect; but tl»e 
r^MKHo of a «io>;te deatli from celampi^ia will amply repay tltc con- 
'•""•TO )ihTi>irinn for mudi iM.*If-imp<w«'d laljour. 

TV mine »houM t* eiamined not only for the presence of albumin 

•■"iptT, but aUo microttcopicfllly. If albumin is dctivlol. or the patient 

Bit fTupt^niH tnilicatire of toxtcmia, t twenty-four-hour iipecinieD 

FOuuU (» .atid and fj/nl to a competent chemist for the determination 

il amouni of nilmgen and of the nitrogenous iiartitinn. Wh«rc 

; Ihle. at least the total animmt of urea should Iw estimated 

:iH hv m'^n* of (hr [iorrmni' urcoineler. {S*f (Tluipler 

h ailililion tn pving the patient ihe adrice almve mcnlinn*^]. the plmi- 
^0 •ioald al«> impr^'w upon her the importaiKe of informing him at 



ao6 



OBSTKTRICS 



ervd by the iinaidtxl «fforisof Nature; vhcrcsE if th? latter persist it caB 
be bom a{irjntnii(x)u.->h', )iut alwav.i n-ijuinw ttui hkI nf tJio olistetricia 
These atiiiornial pri?6etitatiqii§ irill be considered in a separatt! chapter, jj 
Cepimlic [nxv-<iitiiltoiw nn; dividw) into Mwral grouju, according to I 
relation which the head bears to the bodv of the child. Usnallv th« )w 




Fig. 103. rin- 1«4. I'is. IBA, Fi|C »«. 

Fkm. 103'196.— Snowixa Dirrr.nKxci: t.v AmrcitK ot Fotrc* u> Vmrex, Stse 

is Hhaqily iiexed. so that the chin is in contnct with the thorax, l^^ 
iheee circiinisIiiiKiw tlii' \t:nex U the pitwniing pari — vertex prr/fnt'ii 
More rarely Ihi' nerk may lie overpstamlwl, s« that tlie occiput and 
uome in contact and the fat-e '\t felt through the dirviit — face prtjttnlttl 
Again, Uit! head may awitimo an inlermediate position between tlie extremi 
of Hesion and. extension, beinp partially flexed in some cases, when tli 
large fonlanetU- ^n-fviw^—i-inripital prfsmMion: or partially e\t*nilrtl j 






Fig, 107. ««. laa. Fig. iw- rm. 

Kii»- I07-2HO. — 9na^Kxna V^lyrxMt^nvti i» AimrrMi or Fiirn'S ix Fkaxk Brmbch, 
Khkcii-ii. KmiT, akd Kkkr I*KIUIKVIjITION«. 



,3d0l J 



flth«r caseji, nt thai the brnw Ixvonies the prtst'iiting part— -frrov 
(ion. The lant two an- not usually ela^silied as distinet varielk-s, aa (1 
are uitiiuUy tnmsiint, aini tjeooiiie converted into vertes or face pr 
Kons »B latmur progrewe*. 



PRESENTATION AND PtWITIOX OF 'JHE FtETUS 207 

Mlien the cliild presents liy its [ji'lvir i-xtn'mity, tiio thighs are flcsed 
ud lh« legs may he exteadcil over Ihe anterior i<urfaoe of the body — frank 
bmtk pregenlalion ; again, the thittiis may Iw flexwl on the abdomen and 
tbf Itp upon the thighs — breech preacnlalion; or the feet may be the lowest 
fit— fool or footling presentation. ( ^ccai-ionally one leg may assume the 
p-i\m vhich in typieal of one of tlie a Ijovu- mentioned presentations, 
whili; the other foot or knee may present — incomplete fool or knee pres- 
mklibn. As the mechanism of labour, howeier, is essentially the same 
ia all modifications of pelvic presentations, the several varieties need not 
If afflsi'iered separately. 

FnitiaiL — By this term we designate the relation of some arbitrarily 
ehojHi portion of the child to the right or left side of the mother. Accord- 
iB^i, with each presentation we have one or other of two positions — right 
wIriL With Hs and in France, the occiput, chin, and sacrum are the 
wttmining points in vertex, face, and breech prescntationn respectively; 
■kile in (iennany the objective point is the child's back. 

Tiriety. — FnrtluTmorc. for the purpose of still more accurate de^erip- 
t™, w take into consideration the relationship of some given [mrtion of 
•l" [«switing part to diircrent portions of the mothers pelvis. Thus, in 
•*ti iKwiiion, the dftermining portion of tiie presenting part may be di- 
»l«i tn»arils the anterior, transverse, or posterior portion of either side 
'^ llii' pelvis, making in all six varieties for each jiresenlatitm. But as 
il* iraD-icfjc varieties arc not [lersistent, and rejiri'sent only a phase in 
t»nm|iani.-m of lalionr. they ni-ed not be taken into accoimt. 

'DBaelature. — t'n fortunately, a universal nomenclature' for designat- 
11^ ihi' various presentations and positions luis not as yet be<^n agreed 
"I"'!, auci the methials emplnywl vary in dilTen'nt countrii-s and even in 
"•Tvni part.-* of the same country, though <if late there has arisen a 
' P^I>T iiii'li-ncy towards nnifonnity. 

'n thf iiirlier works u|>on obstetrics, as in llocsslin's Hosengarten 
"■•'3). it was Ijclicved that the child might assume any imaginable posi- 
iMB n ulrro, and the numi>er of presentations and positions was limitcil 
'Blybrthe ingenuity of the writer. More accurate observation gradually 
'i" *»iy with the fanciful forms, hut even as late as ITT.t B;nidetoc(|uo 
^rtingai^hdl H4 different ((rescntalions. Slnie. \m ChiipcMe (IS'il) nia- 
I*™!!! »iinpltf]|i) the subject, and the classificatinn which she suggc-stwl 
■Itlfm but little from that eniploytil in France to-day, which has JR-en iM'st 
•scnbrf by FaralM'uf and Vamier. 

-iHnniinp to the French metiuid, vertex, face, and bn-celi pn'-<'nta- 
t.'ouiirf ijeiignatiil as occipito-iliac (O. f.), menlo-iliac {.M. 1.), and sacro- 
jJiar |.S. i.). \\ the International Meilical Congress which nut in Wash- 
iq^oD in InAT. an attempt was made to secure greater uniformity in 
jiniiK>nclalure. when it waM suggestin! that the denomination "iliac" be 
KS'tit^ and the various pn'sentations dcsiguativl as iHcipital, ihcuIhI. and 
airral respiftrvdy. The suggestion was ipiite generally adopiii! in this 
ounlrv. and Bar in 1903 advocated its universal adoption. 

Af the presenting part in anv pre-entalion mav Ik' either in liie left 
r right ixisition. we have left and right occipito. left and right uiento. 



21U OBSTETRICS 

l)L-(;aiiie nimc freqm;nt in the later uioiitliK. For many years it was tsuf 
that the presentation reniainLil constant throughout pregnancy, and 
was not until 18(il that Ilecker and others demonstrated that it was i 
unusual for chaugo^ of [losition to occur even In the later months. Final 
it is now universally admitted that the presentation does not beco 
definitely I'staljlished until the presenting part enters the pelvic can 
although it hecomes more and more stahlc the nearer full term 
approacheil. 

The theories put forward to account for the prevalence of head presen 
tions are divided into two groups, the one being based upon gravitati 
the other supposing a process of accommodation between the foetus and 
uterine cavity. 

The gravitation theory was especially advocated by Matthews Dun 
and G. Yeit, Ixtth of whom showed that a ftetus recently dead, when pla 
in a vessel containing a solution of salt having about the same spec 
gravity as itself (1.050-1. 055), floated with its head and right side do 
ward. This result tliey attributed to the greater specific gravity of 
head, together with the presence of the liver on the right side, Veit i 
showed that head presentations increase in frpijuency with the advance 
pregnancy, hut lluit breech presentations were noted much more freqnet 
when the child whs dead. This he attributnl to the fact that the spec 
gravity of the beud liecanie diminished after death. 

Furtherniore, it wiis pointed out that since the axis of the uterus, »i 
the woman in the upright position, forms an angle of about 35 degR 
with the horizon, provided the experiments of Duncan and Veit held goo 
the head would necessarily sink downward, and the convex back of t 
ftetua wouhl ndiipt itself to the concave anterior wall of the uterus; the 
since the left margin of the latter would usually be directed somewb 
forward, llie frcqiieucy of the left anterior presentations could be reed: 
expiaimil. 

Doitht has reii'iitiv been cast upon the conclusions of Duncan and V 
by SehiitK. who rniiiiitains that althoiigb their results were perfectly com 
wiien e\peririienting with a medium of the same specific gravity as t 
fu'tus, it hiis yd to he demonstnited that they hold good for the amnio 
fluid, which, it uitist he reuierniwred, possesses; a specific gravitv of betw 
I.OOH and l.'Hi!). or (■<msidefn!.iv less Hian that of the ftetus. Schatz s 
]iendiil 11 receiilly dend f<i'tiis from the pans of a balance in a solution 
suit of the same spi'cilie gravity as the amniotic fluid, and found that ■ 
breech hiid a greater teu<bn(y to sink down than the head. He theref 
('oncliidc<l tliat some Torre other thiin gravity must be invoked to rapl 
the friH|ueiicy of head presentations. 

We have been able to confirm Schatz's experiments, and found that 
head sank ilownward, as descrilied by Duncan and Veit. when the spec 
gravity of tlu' loediiim in which it was suspended was in the neighbourh 
of l.O.'iii. Hilt on grndnally lowering it, by the addition of more water, 
head slowly rose until the long axis of the child became horizontal, 
as the sjiecifii- gravity approached l.OOS-l.niO, the breech sank downwi 
thus pluming thai gravity doi's not account for the production of \. 



OBSTETRICAL PALPATION" 2U 

paaititiom ; for if it were thu most iiii|>orlHtit factor fi)n('oriK!<l, breech 
prwMiilions would prcdominati.' at tlic end cif [iit-jniain y. As this is not 
the our, s) mo other influenn) iiiui^t Iw invokf«l lo t'\|>h<iri the |irovaleiicc 
of hnd prv^-ntutioiis. Tliif is i-upplicHl liy tlii^ tlienrij of mxiimmiidation, 
■dnnml by Duboii^, ISiniptmn, uiid .Staiizoiii, acconliiig to whitOi tliey aru 
broo^tibout bv a process of accoiiniiodation iwtween tlie fti'tal ovoid and 
lh( interior of the uterine cavity, the shajie of the latter iH^ing siidi tliat 
ibe ftetDH Li most (foiii fnrtttblo and lil:> it more Hccitrately wlicn ]ireseniin); 
)iT tbe head. They held, therefore, that as soon as tlie fictus came to 
utapj any other ]x>sition, its cutaneous snrface became irritateil, whenc« 
iMiltftI reflex nioveiiients of the extremities, ;;ivinfr rise in turn to uterinu 
milBttions, which tended to restore the head preseiilation. i'inard is an 
t!itfii»ifc.iic advocate of thi.- thcor}'. 

ffchilz, in 1904, clearly showed that tlierc was a fjeneral tendency for 
lliflwlLiif the child to lie anteriorly, which increased iimliT the intUieneo 
"fpiviiy. This he demonstrated by lindinj: that the anterior varieties of 
"TtH |in-sen tat ions o<cnrre<l more frwjiicntly in the evening than in the 
tomiin;;. ill a series of women whom he e.xaminetl in the morninj; k'fore 
*fi-'%'. jiiil ajfain in the cveninf; after they had Ijiiin abonl all day. 

Tht frr>iuency of abnornial presentotions in the early months of piv;;- 
""'"■v. iml in all conditions in which the uterus is abnormally distendeil 
liy M MIV.SS of amniotic Hnid, tends to Hul)stantiate this thwiry: for in 
'iH.ln»wH the I)oi|y of the ehihl does not come in contact with the uterine 
*"!*■ will actordinjily the conditions necessary for the production of the 
•"w ninveinents, which give rise to accommodation, are entirely lacking, 
•W'trraviiy alone comes into play. 

-^a whauslive cimsiilcration of the various older theories can lie found 
in the (Mi„.]l,.„t iiiono;rruph of fohnstcin publishet] in IHIJS. 

Ittlisdiof Siagacning Position and Preicntation of Fatui.— The dia^'- 
tO'iK mv(\viih at our disjio.'al are fourfold : alnioiiiinal jnilpation, vaginal 
touch, (flmliincil c.xajrii nation, and auscnltulion. 

"■trtrical Palpation. — I'nder ordinary circumstances e.Meniai or ab- 
domiiul [jiiipfliion is the most reliable and valualile, and I should unhnsi- 
tltmjit uhdose it were I n-stricliil lo the employment of a sin^do method 
"' *i*niination. In traineil hands it enahles one to make a satisfactory 
■tUgiW'is without danger of infen'tion and with the least jKissible discom- 
I'Tttnthf [latient, and it is not going too far to say that its (topularization 
i«nBi Diip (,f i]„, jrroalest advances in nxwlcrn obstetrics. I'nder these 
'ifnun-tBuccs it iM'hooves the student to become thoroughly familiar with 
'wpnpi-r tec-hniitiie, and to avail himself of every opportunity to licwmie 
profifimt in the various manipulations. 

Althnngh cnide forms of aMominal palpation had no doubt beim prae- 
ti*") from the earli(s-t antifiuity. just as they an- still eniploycil by many 
fl'tlipshoriginal peoploK, its advantages were first pointed out i>y Rocih'rer, 
Wi^ind. and Hohl. as late as the latter part of the sevpnti-enth and the 
Orir part of the I'ightwnth century. It*; practical importance, however, 
«»i Dot generally recognised until 1S7S, when Pimird pnblishei) his work 
apno the Ruhject, after which the inethoil Ixtcame impuhiriiied in France, 



212 



OBSTETRICS 



bill wa* not eniploypd systMnati(?ally in (Jemiany ami this country 
Crede and lYeopold litiil R'pi-ttUtil_v iirgii! iU vuliic. 

In onior 1o (iljlain wilisfactory rc-ults, the examination «^hould be mt 
Hysteniatically by following tlit- (our niutiaiiivrt-* !^ugg«»ti.id by l>mp 
The pntivnt Hhnuld l>e ou a hard bed or sofa, with the abdomen \m 
at most covered with a thin chemise. During the first three manceu 
the I'xainiiiCT standi al the side of the bill which i* nii>«t coavenivn 
him, and faoes the patient, but reverses his position and faces her feei 
the last manu'UTrc. (.See I'latet; X, XI, Xll, and Xlll.J 

Firxt itanrnifre. — After as(;ertaining the outlines of tli« utcnu, 
fundus is gently jwlpatcd with the tips of the lingcre of the two hat 
ami the f<i'Ul jMiIe occupying it dilTi-ix-iitiiiHii. the brm-ch giving llie e 
sation of a large irregularly shapwl. nodular bidy, and the head tliat 
liaril. round obj«H-l, whidi is frtrly imivubic and bullotlablf. 

Second MarKtuvre. — Having determined which pole of tlie fcctos 
al Ihe funduji. the nxatiiiner ptocv the pulninr surfiK-c «f ]m hand« 
either side of the alnloinen and makes gt-ntie but deep pressure. On 
side he fwl* a hard rtvistant plane — llic back — aud on the ollw-r numrr^ 
nodulations — the small parts, !n women with thin abdominal walls < 
lege and arms ran reudily be dilTerentiatcd. but in fat persons only im£ 
Inr iiodulations can be felL In the latter ease, or wlu-n u emi^idcn, 
quautity of ainniolic fluid is present, the approi-ialion of the back ctn 
facilitated by making deep pro^i^urc! wilh one hand while palpating * 
the other. After determining upon which side the back is situated, 
next note whether it is directed antfriiirly. transversely, or poeteriot 
and lliirHiy arrive nt the jwsition and variety of the prewntaiion. 

Third Mancntvre. — The examiner grasps the lower portion of the 
dntnfoi, ju»t above the symphysis pubis, between tlie thumb and fingen 
one hand, and trios to decide what if iK'tween them. If the presool 
pari Ik- not cTigaf.itl. a movable birdy will be fi^ll, which i* tisuJiUy the hi 
The diiferenliation between it and ibe breech is made as at the fundi 
the former being appreciated n« a hard, roimd, bullotlablo body. If I 
presenting part be not engaged, this practically complelea the examinatir: 
a* wo now know the situation of the head, brwch, back, ami extrerait 
and all that remainit is lo deltrminc Ihe attitude of the licnd. If can 
pHlpation shows that thegreatest eephalie prnminenci' i* on lh« «amc 
a* the »inall pnrt.*. we kno>v (bat the head is flexed and that the verte 
the presenting part: but when the rcrerse is t}ie case, we know that 
bead i* cxtcndcfl aud tlwl we have a fare pre-u-ntalion. On the other hi 
if the presenting i>art In- wigagcd, this nisna!Hrre simply show.i that 
lower pole of the fiPlus i^) fixed in the pdvi*, and the details ooocei 
it are njicertained as follows: 

Fourth Mamru If. —The examiner faces the patienl'a feet, and 
the tips of the first three fingers of each hand make* deep pn-ssure in 
direetion of the axis of the superior strait. If the head present*, he 
that one hand is arrested sooner than the othor bj « lound hody- 
cephnlic promincncG; while the other hand descends deeper into the pe 
Is vertex presentations, the proinincoce it on the same side a£ the 




VAGIXAL TOUCH 



213 



f>iru,tiul in face pn^entatiADii on ihe »nnic skk- »i the luick. Again, tile 
tiqtrar of «sc witli uhich Iho prominvnct; in ffit intlit-nlea the extent to 
■III ' ri hii.1 (Kvurnil. In bivo-li |in-M'iiiii|ini», llio iiirrinnnlinri ob- 

Uii' line (uariu'uvrv is not i^o ^lefiiiitc as io head jircjentatious. 

io iranjr in^lam-t:^, wht'U the 1h-u<) )iii:< <]t.tKnKUil into the pc-lvU, tho 
^uterwr uhouldcr of the child can be readily ditTerentiated by the third 

' Tki* method nf examination is arailabli- lhmii;;lKmt the later in»ntli--( 

_of pTvgnBDt-y, and in llie nitcrvals hctwi^n llie painii at the time of labour. 
^jr iu iiM! ve caunul only detennino the prewntalion and ixMilion of the 
iiid. ba( also obtain important information as to the extent to vhich 
IW pn^-uitiig purl hu* drxi-nditi into t)u> pelvic. At tho Minie timu lh« 
I III the child ciu be rouj;hly estimated aod the Becood f(Ctut> mapped 
iti twin priYuitncy. 

Daring uterine contraclinns, on carefullj? palpating in t!w region of 

mlrmal aUlomina! ring, one ran ofl^u di^tinguit^h u rounded cord on 

Itithcr side — the ruunil ligiimcHis — from tfhieh iin)>ortanl tnfoniialton may 

4ilitaiiiiil. In the lirr-t plaecr. IIh- intensity of their contraction <;ive« 

Be wlva of the manner in which the uterun irt aeting ; and M-eondly, by 

Mating their courw. a« pointed out by Palm and Leopold, we are enabled 

M iJiaf-Biuc the .tiliialtiin of the plar«nta in alHuil HH {mt cnl of all eatxa. 

-^ tim il,e round lijfUciK'nt^ arc found convernin); towards the fundus of the' 

'I'-FW. Uw plai-rnla i* usually xilualtil uimn Ihe poi^lerior wall, wlwmis 

'<- I* upon the anterior wall wlten tl»ey are parallel or diverging. 

Iiunog laixiur, palfwlion al-^o give* a* valuable information eoucerniug 
!h^ infrr ulfrint tfgtnenl; when there exists ^me ol>>trit('1ion to the paa- 
**»> (if the child, the rontractictti ring may be felt as a transverse ridge 
'%i«iHliBg ocTowt (Im? Iiiwer portion of the uteru«. MorcoviT, in normal 
*•"•«, we can differentiate by palpation between the contracting body of 
"^^ nlerns and Ihe piuuive lower uterine tx^^metit; for during a pain thu 
E-Tmr <iT.-^-n|.-i a firm, hard sensation, while tlie latter appcani ela.stic and 
'■I**'-! riii'iuant. 

Tigiul EuniSAtion. — Dttriug pregnancy the n^oiltit arrived at by 

••K**! t'xaminalion. e*int"emii)g tlie presentation and jxisition of ti>e child, 

•** fc uw arily fomewhat iiieonclu*ive. Jt* <mh' i» obltgi-d to palpate the 

^•••ilinir pari through tl>e lower ulertiie ^ginenl. During labour, on 

i t^ other hand, alter more or Iciis complete dilatation of the cen'ix, im- 

I f">lW iafomiation may be obtained. In vertex pre*«nla(K>nit, the poai- 

I tk* ud variely an' dctermimil hv tin' differentiation of the variotta 

I "Mbim and fontanelle^; in face presentation;;, by the differt-utiation of 

I "» tirioui portions of the face; and in bre«h pnwentations, by the 

I I*'HIkiiii of the i>aerurn and iMrhial lulierojiitiefl. 

I l*Dder the ntnst favourable cireumstancce. the information to be de- 
^■^"1 (itim vaginal touch alone ix not mon- accurate than tliat obtained by 
^^Plivuna] palpation, am) in vertex presentations the fontanel!<.-¥ ore not 
^B|^*>|imUr miftaitKn for one anot)M-r, aitil (x-easionally fan- and brepcllj 
^^P'*sitHion» f-scape dilfereoliation. Moreover, in the latter part of labour, ' 
■ ''^thc fnrmalion of ■ tluid tumour beneath the tikin covering the pre- 



214 



OBSTETKIfS 



renting part — the mpat Mtccedaneum—^vlcct'ion of tlio various dit 
points »fl^ bcL-nmc* iinpoi<«iblt'. 

A mucli aiorv eerions objection. howiTpr, it* the itangev of puer 
inf<!c1ion, no mnlttT how curvfullv llu- obiiti-tm-mii umy havu alli.^npli.<] 
disinfect hU hsnda; for it is now ^lerally ndmittctl that abiioluie 




Fl<!. aOT— IJlAOKAM HHOWIXU McTHl'll 'If I^OCATUCO HaOITTAI. SCTIIKE O* VaOIS 

KXAUlKJtTION. 

ili»^iiifct-tioi> cniinoi ulwnyi' Ix^ ai'i'tHiiplUlwti, and even gmnting lluil 
Mae of rnhbcr );li)VC8 overc(>ini.-i- thi^ ilitliculty. the gloved finj^rs may st 
carry up iiilliogvuic micro-organ i»iiiJ> from tin- tnargiiiK of ibi* vulva in 
the vagina, and time infect the patient. Moroovm-, vaj;iQal «satniuaB 
n«coseitftt<!« i-xi>osiirc of the pulivnt, an<l »iilij'<«t* her to more or lesw »erij 
inconvenience. I 

Accordingly, it U advi-^ble to limit its t-mpbynu-nt aH much as possil 
and in normal caR-x lo do away with it altogether. For if i\w patient 1» 
normal pelvis, and we find by the fourth mana-uvre that the head is deej 
enga^rcd. all that w gain by vngitiitl oxaniinalion In information a» to 1 
dfgni' of dilatation of the rervi\. and This diM>s not iiinnt<*rhKUnvc t 
possible danger of infection. Accordingly, vaginal cxaniioatina bccon 
jil).iolutcly ntTcwsarv only in the ft-w caw)' in vhich palpiitior does not d 
sat if" factor)' results, or in tlio*c pn^tt-nljng some abnormality, or in vnj 
the course of labour is unduly ilelayeil. Pomonally. I conduct mon- til 
RO per cent of my private cases hy palpation alone. an<1 do not niah 
vaginal examinution until about to discharge the paticoit. 

In attempting to diagnose presenljilinn an<i position by raginaf 
amination. it is advirable to pur«ite a definite routine, which ia 
accomplished by thrw mantruvre^. 

FirM Manteutrrf. — After most careful hand dixinfeclion and appro; 
preparation of the patient. Iwm fin^n of «ther the riglil or left 



OBSTETRICAL AUSCULTATION 

u bat suits the examiner, are introduced iiito the vagina and carr 
9 to the presenting part. A few niomcntH suttico to determine whetl 
it i< t vertex, face, or breech. 

StrtMd Matueuvre. — If the vertex be presenting, tlie fingers are earrii 
Ep behind the symphysiti pubis, and are then ewept backward over tl 
ketd tovardri the sacrum. During this movement they necess-arily croi 
Jw figittal nutiire. When it is felt, its course is outlined, and wo knoi 
flat ihe i<mall fontanellc lien at one, and tlie large fontanelle at the othei 
m] of it. 

Third itaiueuiTf. — We then attempt to dt'temiiny tiie jmsition of the 
ro fontanelles. For this purpo^ic the fingers are paesL'd to tiie anterior 
tremity of the sagittal Buture, and the fontanelle there encountered ia 
re/nlly examined and identified; then, by a circular motion, the fingers 
! pawed around the side of the head until the other fontanelle is felt 
I differentiated. By this means the various sutures and fontanellea are 




^^— DltORAM BHOWINO METHOD OF DlFTERRNTIATINn mETWCCN THE FONTANELLEB. 

y located, and the pOfisibility of error is considerably lessened. In 
m breech prei*ntations it is still further minimized, as the various 
■re more readily distinguished. 

■Used Examination. — By combined examination we understand the 

letion of two fingers of one hand into the vagina, and the appli- 

of the other hand over the lower jxirtion of the alxlomen. This 

in rarelv emploved except when the presenting part is not engaged, 

ertema! hand is used to fix it so as to permit the internal fingers 

re it satisfaetorily. 

lltatioii. — Bv itself, auscultation iloes not give very important 

on as to the presentation and position of the child, but it not 

tly re-enforces the results obtained by palpation. Ordinarily the 

ids are transmitted through the ronvcx portion of the foetus. 

in intimate contact with tin- uterine Wiill Accordingly they 



216 



OBSTETRICS 



» 



iifi' lii^anl loud«?8t through ilic back iii vcrlr.v and brcwh, nnd throagli 
the thornx in [tux pix»ctilMli<>nH. Tin- n'giiin of lti« woman '^ abdomen 
in which the fu-tal heart i» heard most pliiinly variw acmnling to th«' 
prownltititiii inu] Ihc oxtv-nt lo whioli tlic [iriwcntiiig [>art has descendwi. 
In hfiiil prcsentatioaa the point of maximum intensity is m^uiitly midway 
bi'twi-cn Ihd umbilicus and the utiti.-rii>r sujwHur «i]>inL- of tlic iliuiit, while 
in liri?c'cli [iroicntatinuH it is iiaually about on a level with the umbilicus. 

Ausciitlation rri'<{ticntly gives us not 8 little supplementary aid in do 
tiTtniniii^ Ihc pii^iiiiiri iif llio child. Thii.*, in owipilr>-anterior presenta- 
tions the hi'art is usually best h(?ard a short distance fmm the middle line; 
iu llii- lrHiisvt,T.si' viirii'liwi it is heard mon- tutvniUy. and in th« pottt4n-ior 
varieties well back in the patioiil's flank. Occasionally, however, in riRht 
oi'ciiiito-pwli'rinr prciijitiiUoiis. the information piiincd fr'ini the [HMition 
of Uie fietal lieurl is irii^ieadin};. and may jrive rise to serious diajinnstie 
crrorfi: for if the flexion of the head be imperfect, the thorax may liwome 
conves, and the heart sniind» liein;^ transmitted through it would appar- 
ently indicale ii left unterior position. 

litickatuhe 

Ani.FEi.D. Irf'tirimch der CicKurtBliulfe, II. Anil., Luipeij;. 1S98. 

li.iK. Itiipiiort sur r(uiilipatii)ii de la iioinvncljilLire otinti^triailf.-. L'obnitiriqun, lOtO, 

v)i[. KKI 114, 
)l,\<iUKi.((Cg<iK, L'urt dm ikiri'ouclH-nii-nl& I'uris. 1789. 2uil- fd. 
VoHsirtKit. Die .^i-linloKic ilcr noniialcn KindrrU^. Monntwrhr. f. Obiirt«k., 1868, 

x\xi. HI-193. 
CuKt'l:. (Ji-nundL- iind kmnkr W>V'hnrrinin-ii. I.(-ipiif(, 188B. 80-81. 
CUKi't: mid I.ROI-III.I1. r>i(i Hvtiurfj-liullliHii:' ('iiIrn-tichni'K l-ripiix, ltl!)J. 
IXitiKHi.Ei.v. I.^-ilfiHli:Mi fur dt-u BcburtBhidflirlM-ii I 'poniltouBkiirii. Li-ipiiu;. 1803. 
Dtiiinm. .MiSmninr tur In caiim: dc^ prtutcnlaliniiN dc In Ifiv. ii&m, du I'Aoul. d(< MM., 

1K13. ii. 
I)t)x<.-jtN. The PoHilinn nf ihc Firtiiu. Iti-x^irrtwii in OhntclTim. EdinlmrKli, IKTiH, 

14-37: i>lsu I'MiiibiirKli Mt'd. uml Sure. J»ur.. 18o5. 
Faiuiiici'I' ct V.vKMKii. Inlniduclinti k I'Audc d'uiiijiic el ik lu pratlquv dm MNNnichr- 

iiicnlJ*. I'arin, tgiM. 
11k< KKii. Kliaik d>:r(ii-biiriH)iTiirc. I.<'lpj;ia, IKiil. i, 1". 

SliitiHllHrlinH utik ilcr (ii'liiiniiixlidl Miiiii-hi.'ri, Ari-liif t. (lyn.. IHHS, XX, STH-.WS. 
HotiL, IJic iRburlHliiiimi^hL- Explumtian. HalK IRH. ii, m-ItMl. 
iNTKiEV.tTiiiN.ti. M>:i>i(-.\i.ri>K(iHiciw^. U,|{[onuity in OhMlntricnl Nomr.iirtfltUM'. Aiiipri' 

inn Jour. ObBt.. ISRO. XV. lOM-lOMS. 
La Ctui-Bi.i.K, Midnme. Pr»li<|ii>- dcs iH'rouchemcnt*. Paris. IS21, i, 17-2S. 
I,BOPOLi>. l)io Uiajiiiiuiiu dpi! I'Lti'cntarintirH in dor Srtivnuigpnirliull mid wjihrfiid dor 

(icburr. j\rliritrri hum dur Dn-wlpixT Frriiieiiklimk. IWI.^, ii, IM-lfMl. 
I,Eopni.i> iind nuLi>i(iciiii, I'elvr dii- f':nl1ivhrti('tikfil il<'r SchnidFii-AtiwpnItiiiiEVD, etc., 

uiidijtH.>rdioitn>>>Hrmnt:ti<-)i<^\>rn^rThuiii(di.^rJiumon)i)Uiitcr«iichimKit)drj-<ip1]ur1«- 

hulfi-. Anhiv I. Cyn,, 1831, xl, 439-^73, 
Leopolu und Onn. Din I.ciliin2 iinrmnkr ricbiirlcn iiiir dutch Aurmtc Unlcnnichunic, 

Arehlv f, C^-n.. IBO.'i, xlix. .■«M-323. 
Lbopoui uiid pANTrtvB. Oil! Batcbnokimg dcr IniiprMi iind die Krflwtiiuylifhf Vbt- 

»-crthunic Hit ilii(t>rrcn t'ni«rsuchiin]i in dsr Goburl«hiil(e. Arcblv f. t!yii,. 1890, 

xxxviii. a.W-.Tee. 



OBSTETTRICAL NOMENCLATURE 217 

LiMOKMJ> und SfSrun. Die Ijeitung der regelmaasigeD Geburten nur durch ausBere 

Untcnucbung. Archiv t. Cyn., Iii94, xiv, 337-368. 
Mcu,SB, A. Veber die UreBchen der Ungleichbeit und Unklarbeit in der BeneiiDUDg 

tmd EintheUimg d«T Kiudeskgen. MoiukUaehr. f. Ueb. u. Uyn., 1900, xii, 161-181; 

266-291. 
Nabuxlz. Die I«ht« vom Mechanismua der Geburt, MainK, 183S, 10. 
P.&1-M. Ccfaer die Diagnoae des PUcentarsitzuB in der S(!hwangerBcha.ft, etc. ZuiUchr. f. 

Geb. u. Gyn., 1893, xxv, 317-350. 
PiXARD. L'nccommodation fcetale. Traits du palper abdominal. Paris, 1B76; 2me 

id.. 1880. 
RoBMitBiL Elementa srtia ohgtetriciiP. Goettinicac, 1766. 
ScAJCiONi. Lage und Holtung dcs Kindes in der Gebarmulter. Lehrbuch der Geb., 

II. Auil., n'icD, 1853, 89-93. 
ScvATZ. Leber den Srhwerpunkt der Frucht. Zentralbl. f. Gyn., I90U, Nr. 40, 1033- 

36. 
LHe I'rsicben der Kindenlagen. Archiv f. Gyn., 1004, \\\i, 541-651. 
S<'Hiii'Ei>£ii, Dlmhai'hen und Vbit. I^-hrburh der GeburuhiiKe, XIII. AuH.. 1899. 
iiiMFHov. Allilude and I'fwilionH of the FikIuh in ulero. Monthly Journal of Med. 

Srienrea. IlMH-49. ix. 423; 639; 863. 
Smelue. .\ Tn.'atiHc on (he Theory and Praetk-c of Midwifery, 8th ed., Ix)ndon, 1774. 
Vett. <•. IHc LagcnverhiillnLHi*: bci I'riih-und ZwillingBgeburlen. Scauzuni's Beitrago, 

IStiO. iv. 279-292. 
WiUANU. Die Ucburt des Mcnschen. Berlin, 1820, ii, 99. 



PHTSIOLOGY or liABOTTB 

CHAI'TKll X 
THE PHYSIOLOGY AND CLINICAL COURSE OF LABOUR 

By labour w» tmderstand the process which brings about the sepa 
tioQ of the mature or nearly mature product of conception from the 
terior of the uterus, and its cstrusion from the maternal organism, wheC 
the birth occurs spontaneously or requires external aid. 

CauK of the Onset of Labour. — From time immemorial inquiring mil 
have sought an explanation for the fact that labour usually ensues ab" 
two hundred and eighty days after the ap[H;arance of the last menstr 
period, but thus far no satisfactory universal cause has been diacovei 
The following are among the moat important theories wliich have b 
advanced as to its causation: 

1. The growing irritability of the uterus, associated with an increaat 
the frequency and strength of the intermittent contractions. 

2. Increasing distention of the uterus. 

3. Dilatation of the cervix by the presenting part, 

4. Increasing distention of the lower uterine segment, with pre* 
upon the neighbouring nervous structures. 

5. Changes in the dwidua — loosening, thinning, and thrombosis. 

6. Excess of carbon dioxide or lack of oxygen in the placental bli 
acting on a centre in the medulla. 

7. The circulation of frotal metabolic products acting upon a centn 
the medulla. 

8. Menstrual [icriodicity. 

9. Heredity and habit. 

10. Senility of the placenta. 

11. Physical and emotional causes. 

1. The increasing readiness nitii ivliich the uterus reacts io stimula' 
during the later monllis of prcfrnancy affords abundant evidence of 
growing irritabilitv. Tliu intennittent contractions, which occur at 
tervals throughout prcgmincy. I'ouic nn more frequently at this time, 
with so much greater intensity that it is ofttimes difficult, in the 
few weeks before delivery, to distinguish between them and actual lat 
pains. 

S. Since t!i<! tiitu' of Mauriceaii it lias lieen believed that the utei 

when distended up lo a ci'itaiii pniiit. must liegin to contract and attei 

to empty itself. Just as lia|ipciis in tlie case of any other hollow tia 

This prcsnriiplion is suppnrli'd by Hie frequency with which premat 

218 



4. hfUmann and Aniipffer advanced the tlieorj' that the onset of 
inr waj! the refult of the gradual formation of the lower uterine 
neat, with con:<0(juent pressure iiiwn tlie surroimding nerroua ganglia, 
sir work was done upon the bat and was quite convincing, so far as 
t uimal is concemod. But inasmuch as their conclusions are baaed 
a the as^^umjition that the lower uterine segment is formed from the 
(T portion of the cervix, it cannot Ik; accepted for human beings with- 
bwitation. 

5. Xaegete, Simpi^n, Hranzoni, and others beiievwl that the decidua in 
litter wiieks of pregnancy underwent fattv degeneration, whicli re- 

ied in the partial separation of the ovum and its practical conversion 
■ (foreign IkxIv. wliieh then gave rise to uterine contractions. More 
at investigations, however, liave shown that such changes occur rarely, 
It ill. 

It hail also been state<1 that the septa, bv which the glandular spaces 
tbe comfiact layer of the decidua are Iwundcd, become progressively 
sow in llie later months of pregnancy. .<o tliat in the la.'it few weeks 
M'ipfit move in cuts sufht-e to liring about more or less extensive separa- 
'of the ovum from the uterine wall. So doubt the sepia are consider- 
' thinner in the laier than in the earlier months of pregnancy, hut they 
lot torn ihrou^rb. as a rule, until nfler the e.\pulsron nf the fictus. 
f- Brown-Se«|iinrd, in 18.13. dcmonstratwl that an excess of carlnn 
ide in the hlood led to energetic uterine contractions, and his results 

^»epn confirmet] hy most suhsei]ucnt investigators (KcilTcr). In spite 
'!* fact, however, it is difficult tn explain why there should be a marked 
'wdJen increase' in the amount of carbon dioxide in the blood sufficient 
'* rift to labour at the appoinletl time. 

'■ttnreich and Kunlinowsky deny the corre<-tness of Brown -.Se(|uard's 
'Ueions. the former holding that carlnm dioxide has less ctTtS't u|)on 
[***Riiant than upon the non-pregnant uterus, while the latter contends 

*t dow not give rise to contractions at all. 




220 



OBSTETRICS 



needed materials fur lU miKU'iiniKt' oIIkt Llian lliow fumiiihed by the ^>~%s- 
c'ditA, and Oiat lu n reeult of insiittieiont nutrition cert»in cxcremenlilic^m 
aubftanee^i guitu-d ticc-usK to the niiilvrnal uirvulntioii, iind in fionic -^w-ij 
Kliiuiitiilt'd iln- iiIiTine (.■entrp. 

8. Mendu, Tjlcr-Smilli, Lowcnhardt, Btard, and others belike lA-3«i 
■ tlivri; is ail iiicroiMil ti'iuU'ticj' towanls uli'rini- (■f>nirHC'tioiiit nt Uw pwriciad* 
bt which the mouHtrual How itlmuld appear if the jmtient were nol pr^^^'St" 
hlaut. and llial i\K*v rt-^u-h their acmu at about tin- date of the tiiitb m^^^'"' 
HtTual period and give ri^t to labour. 

9. G<!yl and othrre ur« iDcliiicd to attribute the onset of labour at lu-^-^. 
QHual lime U> the fact that Nature, ofler ag<« of esp<!rimc*nt. hajt (ou^^ 
tile end of the tenth month to be the most -iuitable time. For wh^ -*? 

tlaltour (N'c'iint lit a latiT prriiHl it i» usiially vitv dilVicult and dvuIIk J~^ 

rdead children, while at an earlier jwriod puuy children are bom whi^ ** 
usually (wriiih tMjon Bfter birtb. 

10. l'"den and the writer have pointed out that tile frot^U^^t tn^nrrat^ ^^''* 
of infaril furmnlioM in tin' iilacenta at tinu niii>l hi- ri'tranlctl ah m!il<ii^ ^Dtx 

i 



of its senility, ami Ibai tbi(« rhanp:' U anal'>j!;oHs to the iililiti.'ralii>n ar: 
alrojiby of the chorion la-vc nt an curlier |KTii>d. Where these chuii^ 
are marked the nutrition of the fietus must be interfered mttb, and it 
possible that certain of \U mctalNilic pnHluctH may rc$»ult in sUmulstiL 
of th« uterine centre, 

II. It is also a well-known fact that excessive physical exercise, sudil^^**" 
j«n« or violenci', a.-> wi^l a* exiivmi' mental i*mi>titm, sncli a* grief j^w^d 
anger, may lead to the termination of prcRiiancy. 

While, then, there i» no lack of theories utmn the subject, at ttic sar^^'C 
time it is manifest that most of them are t-xtreniely unsat.i^faelo^y, a^n" 
tliat none are of universal application. It is probable, therefore, tbnl ^^ 
the mnjorily of enstw the onwH of labour is due to the combination a^ ■ 
number of the above-mentioned causes, and that only some slight stimuft ''l* 
or irritant is nndctl to set it in profrr<»K. On the other litind, it is poA^i* "I"^ 
that some law may be di.seovered in the future whieh will e.^plain t/tt" 
rh.Whm of the various sexual function in women— inenstruation, a^ v«il 
as the onset of lalioiir. 

Observations made in my clinic show that marked diangrs io metal'*'" 
liT-iri occur initiiiiliali'ly before and ill ihe time of iidionr, which in *" 
probability stand in some eaiiaal relation to it. Thus. Slemons has sb*^*'" 
that l.wpnty-fwur hours or !&*« bt-fore the onset of labour the ontpul **" 
nitrogen through nrine i^ considerably diminished, while at IW same t« ***^ 
a marki'il diuresis oeeurs. thus completely reversing the «>n<litioDs wJ» it**' 
existed throughout the bisl months of pregnancy. Accordingly, if -t^" 
nrinnry analysis could be made promptly enough it might afford A me*"^* 
of predicting the approaching onset of labour. 

In order to determine the relation which these cbanges bear to tr"^ 
eausAtion of lal>our. Slenions, at my suggestion, studieil the metaliol i"*" 
of two pregnant womtii in wbinn pregnancy was intvrrupt«I by llw ire*'"^' 
duetion of a bougie, and found that the changes a-ere nbsi-nt, or at l*?^'* 
nim^ leas marked, than when lalionr weiirred sponlam-onsly. 



wny ctiitinlnlm llw uUtus to coiitruction. 

(um, oht^rratiom vhith I have nnuli^ ujnm tlio n^giiralor}- ex> 

•bow that at the tmiv of labour tlto output of carbon dioxide is 

in (Hiv would t-\i>M>1 in vjfw of llie ii)rn'iu<ii^l inuHciilur i-i<'rl)on 

I to labour. Accordingly, as the latter mu^t ut-cewarily l>e atxxtni- 

ij an iiH'miMd prrtduction of c»rlx>n dioxidi.'. it miiKt follow tlwt 

kkio^ from tlie poDoral bodilr activity i» dimini^ihixl. .-jo ihat it 

Hp^UKtl tluit iiiUiur IK occoinpitiiiH by proftxiixl rhungc* vliich 

(he f^ntiral oxidative processes far Mow the usual limit. If this 

nuv, >t i« (iinrviviiblf tliat ihc alti-ration may l)o duo to tliu action 

same factors which caused the decreased nitro^n output and 

id diurrsi* whirli pnxwlc labour 

jly ail of lite tiieoriett to wliii^h refercn4H> ha« Itoen mad« rmjuire 

tTTi-nlion of the uvrruutt trVtitL-m for the ultiniate production of 

and the inve^tipitions of Franz »hoir that the pregnant uterus 

■m msceptible to stimulation than at other times. It is f;eiierally 

id that there rxUU in tlie uitiliilU a ri'nln^ for uli«riii<- 4Hin tract to tin, 

nn Iw Rtiniiilatetl hy atwniia and the preircnce of variolic tosio 

msi; and it wym* highly pmliahb- dial Ibt- fn-iimiicy of prtiualttro 

in eases of renal insufticienev and eclam|>«ia may he due to ihe 

*f nM'talu>lir poiwint! ujion lhi» ociilrc. Furthcniirtrt-. it «i-ini; likely 

Nttier (vnlre extMls in the tover [xirtinn of lhi> lumliar coril, whieh, 

IT. t* unhsidiary in i-bnraclvr. ina^nnnch n^ laUjur tnny eiLeue vitlt- 

Wterrention. an b denioR.->trat«l by Ihe fu4>t that nonnal bnt pain- 

llnvriiv harr orcum«d following the m^'viTuiuN.* of th<> onl above tho 

tWRling 1(1 Ki'iffer the nteru]= has a threefold nervous supply, which 
tiW prim'tpiilly fmm tlut sytn|iatiM>lii; ny.-<ti-tn, {Urtly from branches 
a laafaar eon), and partly from ilii intriiie>i« nervts. and that con- 
fr. I from tito ctimuluUon of all or uny one of IlKin. 

n* of tht! uli'ni* can be induci-d by the atimulalion of 
IV spinal nerve, and it is nridcnt, Iherefon-, that 




222 OBSTETRICS 

without difficulty. Similar obi-L-rvations have been made upon hum 
beings after injuries to the lower portion of the cord (Routh, Benicl 
Lusk, and others). 

Oser and Schlesinger, od the other hand, showed that pregnancy s 
labour might go on without interruption and end with normal labour af 
complete severance of the sympathetic fibres which supply the uter 
Moreover, Xchrer has demonstrated that the organ can continue to <x 
tract after its removal from the body, provided it be kept moist a 
sufficiently warm, Kurdinowsky has shown that the uterus of r^b 
may be entirely removed from the body and still go through the nsi 
phenomena of labour, provided it is maintained under suitable conditio 
and an artifieiai circulation kept up through its vessels by means 
Locke's fluid. Moreover, he has ingeniously utilized this fact for studyi 
the action of various agents upon the uterine muscle. In view of thi 
facts, therefore, it must be admitlul that the uterus contains an intrin 
nerve supply, more or less similar to tliat found in the heart and otl 
organs. 

Labour Fains. — With the onset of labour, the painless intcrmitt£ 
contractions Mhii'b jiave persistwl throughout pregnancy are replaced 
others of increasing intensity, giving rise to severe pain, and bringi: 
about the dilatation of the cervix and the expulsion of the child aJ 
placenta. 

The uterine contractions, just as those of ail other non-striated muscli 
are independent of the pill of the patient, and can neither be increas 
nor diminishtil in frequency by her volition. But at the same time th 
may he affectcil by Ihe emotions, and any sudden excitement may eith 
check them or cause them to become more violent. Thus, it is a matter 
common observation that the entrance of the obstetrician may be follow 
by a marked lull in the intensity and frequency of the pains. 

The eontraetious begin slowly, gradually reach an acme, and th 
gradually diminish in intensity, the active process being followed by 
pause of some length. The tracings of Schatz and Polailton show tl 
the period of inen'ase occupies the greater portion of the pain, and tl 
its acme is of very short duration. In the lower animals which posf 
bicomuate uteri, the contractions arc distinctly peristaltic in charact 
but the appearance nf the uterus at (Vsarean sections does not appear 
indicate that such is the rase in human beings, although Schatz belie 
that a certain anmunt of peristalsis may lie observed. It is important: 
bear in mind that labour pains are effective only during the period 
increase, and that the tightly contracted organ is worthless from a mech 
ical standpoint. 

These uterine contractions are nearly always accompanied by pain 
sensations, wlience the term "labour pains," although the amount of 9 
ferinp varies mnrkedly in different individuals. The pain usually beg 
in the sacra! region and then slowly passes to the abdomen and down ( 
thighs. In the early stages of labour it is due almost exclusively to p" 
sure upon the nerve endings l(etween the muscle fibres; but in the W 
stages it is augineutcd by the overstretching and dilatation of the « 



PHYSIOLOGY OF LABOUR PAINS 223 

fttU, uid becomes most marked when the head distends the vulva just 

Iwfore iLi birtli. Occasionally the suffering experienced during labour is 

WE)- lilight, and in rare instances the [jroeess may be almost entirely pain- 

f***, wen though tlie patient be perfectly conscious. A considerable 

■amber of such cases have been collected by Colicz and Wolff. Uaualiy, 

^"■erer, the pains are very severe, and occasionally almost insupportable. 

M tlie onset of labour the pains come on at intervals of from fifteen 

lo thirty minutes; as it advances they gradually become more frequent, 

*>d nentually occur every two or three minutes. Their average duration 

n about one minute — thirty to ninety seconds — though suffering is not 

ap^enced during the entire contraction, as the hand placed over the 

•bdomen may feel the uterus becoming hard for several seconds before 

the patient perceives the slightest pain. 

Tone exerted by Labotir Paini. — On this point there has been a good 
dflU of mi!*onception, and a marked tendency towards exaggeration ap- 
pears in the ^Tilings of not a few authors. Thus Sterne, in Tristram 
Shandy, estimated that the force exerted at each pain ' during labour 
amounted to 470 pounds, while Professor Haughton put it at 577 pounds. 
Voppel, Duncan, Uibemont, and others have attempted to approximate it 
by trjing to determine the force necesaarj- to cause the rupture of the 
nembnnes out.'ido of the body. This, they found, varied markedly, the 
Mtremes being 2,134 and 17.30! grammes. In 100 experiments Duncan 
pt»cwi the extremes at 4 and 37.58 pounds respectively, with an average 
>• 1*1 '3 pounds. 

Jnalin and other observers have attempted to solve the problem by 
'*lwlitiog the force exerted in forceps deliveries. Thus, on interpolating 
* livTumometer between the operator and the ends of the instrument, it 
"•^fouiiil that the tractile force rarely excef<led 80, though in some cases 
itrmhed 100 pound,*. A greater force than this cannot come into play, 
^^ It han been shown that one of 120 pounds is sunicicnt to tear the 
fliiW'* head from its body. 

Schitz approached the subject in a more accurate manner, and inserted 
"I" Ihe ntern* a rubber bag which was connected with a manometer. In 
■lii*¥iy he found that the intra-uterine pressure, in the intervals between 
j* fflntraeiion!', was represented by a column of mercury 20 millimetres 
_V"' 5 flf which were due to the tonicity of the uterine walls and 15 to 
I" cmiteiits. During the pains, however, the mercury rose considerably, 
"**!"¥ ■ height of from 80 to 250 millimetres, which corresponds to 
' ''"w of 8J to 27i pounds. He also showed that the force exerted 

■ yf nterus increases markedly when the foetus is partially expelled 
rnwi it, 

" iDQgh idea may also be gained bv estimating the expenditure of 

'y necessary to restrain the head as it emerges from the vulva. This 

y^J ttceeAn 50 pounds, although the obstetrician not infrequently finds 

■"powible to hold it back at the acme of a pain. This inability is in great 

""iie to the disadvantageous manner in which one is obliged to exert 

■•lajy, rather than to the actual force cxortwl by the uterine and 

contractions. 



224 



OllSTETKICS 



Fhyiicftl Changes during Uterine Contnctions. — Dnrin;; coot 
Ui(! uli-i'iis iiiuii'i'i^'H^ iiiurkiil rlmnp-^A in hIihjk'. With tin', jwtii'iit nti lir 
hack, the or^^ii in the thii-Lid state rcsis upon the vertchral column, an 
itJS lrnii»vi;r*i- tijtiiil.-' or exc^L'^tU il» vi;rti04il ilimiK'tcT. But wliui il va 
tracts the uterus leaven the vertebral cnluiun, becoinoi more erect, an 
pushes the anlvrior alxtominal null forward. At the aame time the w 
tical ini:n-fiM-« nl Ihv cx|K'ti«;' nf tho Imnwvorifc diometcr (Fig. 2'K'). f 

The (liktHliou oJ the oervi\ is usuallv hrou^rht about solely by tl 
action of thv iitcrini; muwlw, whereaii diiritig the G.xjtulfioii of the clii 
ibofe'ot the abiloniinni wnll atsui come inlo play. Durini: the Accond siaj 
Oil* palicnl hruic:' ht-r body agaiuxt some fistd olijwt. Ink™ n lUvji in*pir 
tiuii. cluges the glottia, and uiakea forcible atralDing niovetucutii witit tl 




i.^— <"oiirr>.nT. I'le-riiiE, mkib'i^o Sihi'k or Akuokkn HEn>B& ako mnui 

abdominal and respiratory iniisclvs. By iht^e luoans the intra-abdnod 
preesiiro is inarkeiily iiicrt^ist'd, and itt tranciniJtted directly to tlii! utfl 
Al ftr«l these inovimeiit'- are Toluntary. bill as Islwur Hdvaiiecs tlipy J 
beyond Ibe ennlrol of the will, and may occur even with llic patieui ua 
profound iinifvibesia. 

The abdominal niuwk*. therefore, play an important part in tlw ^if 
eton of lilt; diild, which in many instances makes no progress without Ihi 
aid. The fact that spontaneous labours occasionally fK-ciir in women "■ 
are parulyxcd fnmi the waist down shows thiit Ihcir action is not iu'ljj 
pensable in every case: but. on the other Imnd. the application of 
forceps is frequently rendered nece^ary by the inability of the abdoii 
masel(^4 to do Iheir work, or lo the unwillingness of Iho patient to 
the pain associated with their emplovment. 

The various lijiiiniciitary structures connected with the titerns aUo 
part in the contractions. Of these the most iniportanti are the round 
nients, which in nmtr.ictinp lend to draw the fundus of the uterus fo 
and to fix it in position. They can be readily palpaterl through i^ 



■"-!■' ■■■•"•■••■■"•"'»»■■■■■■■'•■ •— ■-■ ^I'l I ■■■! ■■■■■■■— 

It 18 also Htaivd that tlie temperature riwa a frartion of a 
io^ caoli fMiin. tlioiigh \tf ddvctioD r«|U)re« the i-niplonn«nt 
ai-i'unile llniniiiimt-'U'ni. liivpiralion b(H-riiiii>« slower duriii;!: ihu 
nitin- rapid in Uii- iiitiTTal bvtwcc^n llicm, ami in totally 
durinj{ itu! lupuhin; ]>airi--' ft llw hin^odiI sfUifc^ o( lulimir. My 
■lioiK upuD tlic roipiraton,' exchan^ Hhow that the ct)n»uiii|>tion of 
Ml'' 'xitput of rorlum dioxido an- iin;rntJM>ii iliiriiip liilMnir, but 
e\iifii oDH would Kup[>oM>. I liavo alivady swUii that tliU 
A} imUi-»\'f Hint tlw; gcntral oxiilaliri' profi»'<w of (hi' body arc 
to a mininiDin at thU tiiiir, and eon^uently tlint iIk? actual work 
i> wfmipli^'hnl with compunitivoly l<ss i?xpi-iidilurL- of ciH-T^gy 
i-a-v <}( ail iijual auwmnt of mii.'<ular pxorliim al itOier tii»«s. 
CoarK of Laboar. — Itefnro tukinj; up tli<.' c-onsidvratmn of Ihe 
)nitin*nM^l in tlH? t-xpulsion of tlie fii'ttis iirid t\u; nii'i'ha»iHin l>y wliH-h 
p»«t«mjpli*iKii. it is advir«l>lc for the etiMleiit to follovr or a spectator 
nf {tarluritinD in a print ijiurouii vroiuan. 

vi-rkn hcfnre iho onsi-t of labour the alidoiiit^n un(ti>rf,'ne>i a 
ingw in •hiiji"-. il» lottiT portion IjOCTHiiing imirr |ii-tidiil»u#; 
En IIm' m-iRhltourhood of tl»o costal marRin it looks decidedly flat- 
Tlu» duin^'v i» [wrci-ivi.'d l>y t\w woman Iwrwlf, wbo fcols tlmt her 
: W lioimie lower; aod occasionally it oocttrs im suddenly as to caiuie 
iiiii'; has givrn way inside her abdomen. 
; : , <<ri at this imtI'mI shows that llw^ fundus nf \hv adTiU 
from the position whi<-h it occupied at the ninth month, 
thai (if Ih*' eijihtli; while llii> third inuxKurre ;>hcin's thai thv 
I WB?< previously frcelv niovahle. has Ix-eoiiie fixed in the superior 
r!tnnjn-» art- niii^t murkiil in primtpiine, and fn-cjuenlly do 
r**Tar in niulti|«ne until the onset of labour. 
\f<r thb the patient exiieriBiH-es wnsiderable relief from the respira- 

Kianm rrnm whteh she may have Huiren<d ; hut at the saiti<: tim« 
may IrK-onte more rlitlicnil. and she niay suffer from scTere 
paiu in thif lower i.>xin-milii« and a more fre<(uent d<>Hire to 



226 OBSTETTRICS 

until the cervix is completely dilated. The second, or period of cxpiil 
extends from the complete dilatation of the cervix to the birth of 
child; while the third stage, or placental period, lasts from the birt 
the child to the extrusion of the placenta. 

First Stage.— -About the cud of the tenth lunar month the primipt 
patient begins to experience cramp-like pains in the lower portion of 
abdomen, wiiich she frwiuently mistakes for intestinal colic. At first I 
t«en.-<ationa Ttxur only at long intervals, but »x>n are felt more freque 
They are most marked in the lumbar region and gradually extend ton 
the abdomen and down the thighs. As the pains become more freq 
they likewise increase in severity, and in the latter part of the first i 
the patient may complain bitterly, and often seeks to ease hersel 
making pressure over the sacral region. 

The result of the pains in this stage of labour is to bring about 
dilatation of the cervix, and as it slowly yields to the pressure oi 
amniotic Huid contained in the membranes, slight lesions occur aboa 
margins, which are manifested by a small admixture of blood with 
vaginal discharge — the "show." During this period the patient is perf 
comfortable between the j)ains, and for a time can attend to her ordi 
avocations ; but as they become more severe, she assumes a sitting or 
ing posture, and frequently gives utterance to short, sharp, querulous ( 

After the pains have continued for from twelve to fifteen hours, : 
or less, there is a sudden gush of clear fluid from the vagina, which it 
majority of eases indicates that the cervix has become completely dil 
and that the membranes, having fulfilled their function as a bydrozj 
wedge, have rupture<l. Tlie amount of fluid which escapes varies accoi 
to the situation of the point of rupture and the position of the preset 
part. In vertex pre.sen tat ions, where the pelvis is normal, the cervi 
tamponed, so to speak, by the roimdotl head, and only the portion of lii 
amnii which lies in front of it escapes. On the other hand, if the I 
l)e not engaged, or tiiere bo some disproportion l>otween it and the pres 
ing part, the entire amount of amniotic fluid may escape. But eTei 
perfectly normal cases a small quantity gushes out with each pain. 

Not infrequently the meml)ranes may rupture before complete dil 
tioh of the cervix, and occasionally oven before the onset of labour. 
ccptionally, several days or even a week or longer may elapse bct^'een 
rupture of the membranes and the on.-jct of labour, so that in such i 
tine should be cautions in expressing an opinion as to when labour 
begin. SIcyer-Kuegg in 1904 collected from the literature 15 cases in » 
several months elapsed lietween this occurrence and the completio 
labour, though so long an interval is very unnaual. Under such cir 
stance's the ]»rcscnting part has to act as a dilating wedge, and aa il 
out the cervix less completely and accurately than the unruptured i 
brane.a, dilatation proce<'ds more slowly. These are instancea of wha 
commonly known as dn/ Jnhmirs. 

Seamil !^la<jc. — For ii slmrt time after rupture of the membranes 
is a lull in the lalxiiir piiiiis, after u'liich they recur with iacreasinf 
queucy unit vigour, iiud comjH'l the patient to take to her bed, irb 



CUXICAL OOUBdE OF LABOUR 



22; 



lUtohsMlf i-liif Bjvumra & cruuching or squatting poHlurc. During Utu 
Iprad till- Abdominal luuwies arc tirouglit iuto play. At tirst the patient, 
[r^fttfa uteriiH- pain, may eaii^f tJit-m to contract by an pITort, of Iht irill. 

J, hovt-rcr. tliic act bcvouin^ iuvolunlar}*, and she is usually unablft to 
|iBmi teariDf! down. At Ihi'^ oniwt of the pain she braci'»' lii-r fii>l agaiiut 

>nlid objn-t, lakes a drop inHpiraiion, and ItringH h<>r Hlxlominal an<l 
masrlu) into active play, her elTorta being nccampanied by a 
lAuMrmtir ^iniiii^ hhhhI. .\l {In- Kanic time bcr fucc b>'ti>mfs mark- 
IdTMOf^tcd. ami in tiio latrr stajr^s of tatiour foii?rf<i with sweat. As 
jlkpiu poM^v olF, tlio )r|ntti$ if opoiK-d and respiration nM»ttnbli«hod, ttii* 

' (jicaiiuieaa being rqieated ait M>on an another contraction comes on. 




Fir. 31Ut — itniTfi «r Hkar. itcAu* AmcAiiiNa at Vvi-va. 

It M ilanng tliif prriod that iIk- child divo-nd^ through the pelvLS. 
Aftvr apaUtiri' painii hare continued for about an hour tlii.* patient ox- 
a nuirtctvl dwirc to jro to *tool, wUirb indicates that the liead 
il itili> tin- iB-lvic mvity and is pn.i'sinv; u|M>n ll»' n-rtiini. In 
tiuu' tliL> |>elvic tloor mav bt- t^eea to bulge vitb each pain, and a 
' Ulcr ibp Fcalp of the fieliu may )m delertcd through tho slil-liko 
'•■- With i-fK'h wibwcqiivnt pain the pcrinarnm bulge* moTv awl 
**wi Tuka be«imej( more am) more dilated and distended by the 

^kJ. Iv-m^ (fraduallr ronvi'rtrd into an ovoid, and at la^t into an almoal 
liar upf-nine. With tlie liulinidenot^ of each oontraetion. it becomw 
titf aiul tlw brad nvedoA from it, to udvanee again with the next pain. 



228 



OBSTETRICS 



Ai lalx>ur progrewies the jK'rttia'iiiii becoiUM titill more dbtctul 
thinner, eepeciall}' in its Anterior portion; m liiat e\'entuall^' iu (n 
does not cxceeil a piece of [iiipcr in thickne^, and lool» as if it 
tupture with each pain. At tlif iiame lime tJie anus betwince mi 
ulivU-liwl and prntubtTUDl. and llit- anterior wall of tliH rwtuin 
through it. Uy this lime the perinajuiu baa become converted 



pr. 




Vta. 311. ItlRTH or IlKAD, VttTA rAllTIAU.V DWTKXOKJI. 



a^ 



gutter, R to 10 (?cntinietrej long, nt the pud of «-hich is thp rulvnl f^ 
which ]ook« ntnuwl diitvtly upuiinl and i* il i»ti-iid*>d liv iW hnid 
child, the occiput beinp prt-ssod firmly against the svmphysifl puhia 
diitcntion of llip vulva i* imist rimika! at il.t ptrrint'iil murgiii. an 
slight at iLt lalorai portions. 

The hond atlvHrnrw a little with ciirli pain and rcwdM in the ii 
bctwfoii thcni. Tht« i.i»itintii« wntil the parietal Ix>**e9 iKs-ome cngi 
thft vulra, when further rwawion becomes impossible, and with tl 
two or three painii it is rapidly cxjH'lioil hy a movement of extcnsi 
hii*e of the occiput rotating around llie lowor margin of the syt 
puhi.i as a fuh'runi. while the hregma. brow, and face «uccKW*ivc 
*bvfr tile fotiprhctte. In the majority of cases the perlnsnm \» un 
vithMand the strain to whieli it i* siibjcclt'd, and tears in ibi t 
portion, tlmiicli usually only |o a slight extent. 

Immedifttely after its hirth Ihe head falls backward, bo thul ^ 
comes atiuost iu contact with the anu». In a few momenta iho 



CLIMCAI. iX}VmK OF LABUUK 



229 



^^ towiU the one or otlier Ihigb, and cronlnallj- thf. entire livud 
^T^"^ 4 tnuifvenw punitioii. 'I'liw lit kiiuwu us L-.\ti>riiul rotation or 
ju|*''>'ioii, aod wrvc^ !■> bring Uiv bi'SMtTumml diniiii-IiT of iim cbilti into 
^**B nib ibe iuik-ni-jiust«ii>r diuiDi'UT of the pilvic oullet, 
t^ /' Au tinu! tlic jwriiwiitu i^ 4]tiitv tightly nlrnotcd around tti« neck of 
p "f^atii, wluMic fiMir in cont'c?q«eiioe bemint* marlii-dty cougedted. «> that 
. ^ */»«.' riiiitrd otmtt'Iririiui orii-ii hiw iin iilitKK't iiiit.-nnlr'illaltk- diwiri* to 
ttif /iiiad and to ejitravt the cliild hy Irartion u|ton it. Thin, houmur, 
^iljf xinnet.v>j^ry, for tiie noitt pain font* the anterior slioulder ilown 
''•o xvmphvi'i* ptdii^i, u'Imtv iI lnvomfti fise<l ; VfhiW tiw; posterior 
^BRTget over the aotortor margin of tl» periDiruiii, aflur which 




Fm. 312, — Sunn or IUud, Vvt-va ronnxTK-Y PnnncMtn. 

jVoiy nf t],|, child iK rapidly PX[¥'lird \ry a morommt of Ut^ra) eur?a- 
'ff-9>mwpnndinK to the axif of iho liirth cAnal. 

httOMlialely fnllnning I)h- chiM (-ninm n jnitli of amniotic fluid, whifih 
i^f^onbi tb«- piirtiim which did not esirape at the lime of rupture of thr 
' -/ttntm, and id more or les^ tinged with blood. 

In prmipuonB women th<> leemiH) iitajeo nf lalioiir ii>tial)y lii»tfi abou( 
If^bnn, and a murh ihnrtcr pi*rif><l in miiltiiinroiH women, in whom two 
IL, rtrprt pain^ not infn-ijiicntly sufli«> for the oom|>Ielion of the [R-riod 

/Af-' Stiti/f.—Vor a fi-w wintitc" after Ihc hiHh of Ihe child there ib 
l^ynati'ia of llw utirini- contrectionii, and the patient es[)cri4!iwes a 




OBSTETRitS 



marked sen^ vf relief. On glaiu-ing »t tiifi abdomen it U seen that d^^o 
uutriui ha.4 bemtiie niudi Hmaller and forms a imlid tumour whicli boru^Hay 
reaches the umbiiicuH. Afu-r u loiifivr or k)ioiii-r period the uterioe co^^kj. 
Iractioiu coniineDce once more and tlte woman lieginii u bear dowo; a ft^^s^ 

mom«nt£ latw th« fundus of the uioruB may be seen to rise up for sever ^ 

cvntiinctrcK, and a !<light ttmiefnction appears iiiimediat<^l)' almve tlwr »ycr ^xxi 
phvHis pubis. (See Figs. 303 and 304). This Indicatee that the plaeco^^E^-i 
hn» bw.'ornc tpparatc<l from lli« interior of thi- iiu-ni* and in now in the tow-%^»^ 
uterine !«g»n-nl or the upptT ]wrtion of the vaj^ina. From this poiiiti- ^\ • 
it IB expelled by the action of 1)k- abduiiiiiiul inu»clc«, thv time Tarri-^f^ 
according to the olticieney of thi>ir contraction. In mme woiiutn tltc fut 
placental period may be terminated i^puntani-otuly vritliin a few minu 
after tiie birth of die child, while in others the placenta may remain in > 





hui. ^i:).- - Hii:iii or llii.iii, mioiuxi Iituvtiii tn L.^u.-t^iuit. 



lower uterine spgiiient for hour* imless forced from it by proper raaiiipti. 
Iiitriin on the purl of the obstetrician. 

During tlie third i<lap' there is nearly alwa^w a slight amount of hum, 
orrhagp. which in normal cases amounts to 300 or 400 cubic ccntimetrp*. 
Not infri-tiwently thu patient may have a chill during this period, or im- 
mediately after its oomplelion. Thi.;. although it may appear somewhat 
aUrming, in itself }ias no significance, as it i* murcly a raso-motor pU,^ 
nomenon. 



DUKATIUN or LABOUK 



2»l 



IlmUpi of Laboar. — Thv duruti«n of lalxtur presents oonudcrable 

'^Aintsii varuiti'iiiA, itiul in usmiilh' alM>ut six hourn Inn^i-r in ]>rimiparK 

ID iii[|ltJ)>ara>. (leDernlljr epc«kiti^, llie urvragv fur Itiv formvr is 

't digliln-n tivur«, of wlijch sixteen are occupied by the fml, one and 

ijHftera to two b; the second, and a quarter to u half hour bv the 







»f lalM>ur: for llw lattvr it in nlionl ttt'i4vi* hoiin>. vIli'CU of 
nrcupi«d br tbt> first, and one by tli« wwiimI stage. 
i'ljr til *i. Vf\t, tin- in-(-rii);i' duralifin of lalmiir i" Iwiiity hour* 
■m* und iTi'lvL' for iiiiiIli|>i)nL>; accnrdin^ to Spiefrelber^. h^^O- 
IwiOvi- hiitm rt'-pivtivi'lv : wtiili' Varnii-r. frtwn tlii? reeord* of 
^l^l r^Mn, one half of which were primipanp, (<atimatea it at thirteen 
> Wf and f^-ven and n half houn' nsEpiTtivrlj ; tlto eMond stage 
KTeBly-fiv<) minutes in the fonuer, and tJiirty-Bve minutca in (h« 

tin tlover ronnn^ of Inliour in pnmi|>Hni- \* due to Ihv rc«tflanre 
It llii> Kufi parts. (Vorasinnally laliour may be extremely rapid. 
\jfn in primiparff tii* entire process is M>in«-timc« completed within 
hniir*; wbilf. on tin* otln-r hand, a duration of tweDly-four to 
it hoDrv or PTen hirgrer is not unuflua). 
i l^hnoT if DKitslly ninra prolongiil in vldt-riy lUan in ynnng pHmiparx 
if if, aTUt the thirtieth year, Atvonlinfr lo Ahlfcid, il avfragw i>er«n 
Utognr m the former, tlumjrh Varnicr ctatcs that the dittereoce is 
m 



232 



OBifTETRICS 



lery much lcs.t. Al tltn nmw time the laiter author points out that fi 
are much more fr«|ueiitly required in oldi-r primipanu. bcJog uppli 
'■15 por ci-nt aiuj l.lj pt-r uenl of ihe oaw!* napectivdy, ihus iodicatinf 
lafHiur would have lasted much lonper had it not l>eea terminBted by 
KtiiT moan?. It i« usually comidrrod that labour if likewiM; prol 
in oKlreme ynutli, hut the oliM^rviil ion» of fiache in 1*1 labours occurn 
pirls from tliirteen to sixteen years of age prove that such a Iw] 
crron«ou8. 

It i$ generally «tat<Hl t]tat tlie majority of womvii fall into iabt 
the early eveninp, and that delivor)- occurs moft frequently bctwc4 




11 Ri'HTiuK. 



houre of 8 and 4 a. u. Careful statistics, howirver. show that thb ) 
correct. Thua, if the ca-ses be divided into two frroujiot, cocording I 
livery occurs hetweon G a, m, and 6 p, ii. and 6 p. u. and C a. n. r^ 
ivdy. It will bu found that only about .i per c>nt niciri: thildren art 
in the tatter than in the former period. The ueueral belief that 
labo\ir$ occur at night is due to the fact tluit tho process uauallj 
more than twelve hours, and acoard)n|g;ty either its banning or end 
neowwinly fall butwi«n C p. m. and 6 a. m. 



TOE PHYSIOLOGY AND CLINICAL COURSE OF LABOUR 2Xi 



LITERATURE 

^KrKz.t>. Die Geburten altwer Erstgeschwangerten. Archiv f. Gyn., 1872, iv, 610- 

S20. 
^ta. The SpM of Gestation and the Pnuse of Birth. Jena. 1897. 
"■"l^K*. Vier Fille von Geburt«compliration durrh seltene Erkrankunjten der Mutter. 

Zrttjehr. (. Geb. u. Gyn., ISH. i, 24-72. 
*™*KiCH. Experiroente lur Frage narh den Ursachen des (!eburlnfintritt. Archiv 

'■ GjTi.. 1904. ba\. 135-179. 
^"'sr-StQtrAKD. Experimental Researrhea applied to Phyilolofry and Pathol(^(y, 
18S3,117. 
^*JXX. QuelquiM cannd^ratioHB m^ico-l^gales siir lea accouchements iiirnnsdents et 
-^■»«»« douleur. Th*ae de Paris, 1899. 
^^*"*>s', A Contribution to the Dynamics of lAlxiiir. ReHearehcs in Obttetrica, 

J>cijnbundl. 1868. 229-333. 
**-'^"- A Study of the Human Plaoenta. Jour. Path, and BafUTioloRy. 1**97, iv, 

*-'*'«- Sludien «ur Physiolope des Uterus. Zcitschr. f. Geb. u. Gvn., 1904, liii, 361- 



Lb grosMM et I 'accouchement chez lea primipares de 13, 14, 15. et 16 ana. 
-Vnnilas de gyn. et d'obet., 1904, N. S., I, 723-736. 
"*— leber die Uraacbe des Geburtaeintrittes. Arrhiv f. C.yn., IRfll, x\-ii, 1-18. 

'-*^*'- Mteioire but I'emploi de la force en obsUSIrifjue. Arch. g^. de niM., f^v. et 
»*»«.•-», 1867. i. 149; 313. 

'^^**.- Die Zu^mmentiehungen der glatten Genitalmuskulatur, etc. Beilrige zur 
"^'^■TJbeirh. und eip. Geburtakunde, 1867. Heft II, 41-,50. 
* * ■^- »«. Rccbercbes but la physiologie de rutSrus, BruxelleH, 1896. 
^-*" -^ >i:s-. Zur Klaning der Cervixfrage. Zeitschr. f. Gcli. ii. tivn.. 1891, xxii, 106- 

^ *• *■»«. Ueber die Uraajrhe des GeburtMtintrittcH, etc. D. I.. Dorpot, 1892. 
^^** ^r<iWBKT. Der Geburtsact am isolirten Uterus benbachtct. Archiv f. Gyn., 
*^0^, Luriu, 425-437. 

**'*»e Beitnge lur Phannakologie des Uterus. Archiv f. Gyn., 1906, Ixxviii, 
^3»^S78. 
l^l^ '»-ii. Studien ijber die Uterusschleimhaut, etc. Archiv f. Gj-n.. 1877. xi, 443-ftOO. 
'^^**'B4RnT. Die Berechnung und die Dauer der Schwangerschaft. Archiv f. Gyn., 
^*72. iii. 356-391. 
^^*^ The Science and Art of Midwifen-. Xew edition. I89,i. 126. 
•^'^nuu. Tnit£ des maladies dea femmca grosses, etc., 6m6 6i., 1721, 203. 
*^t Handbuch der gerichtlichcn Medicin, 1821. ii, 303. 
"'^vRcBGO. Eihautberstung ohnc Unterbrechung der Schwangerschaft. Zeit- 

•Ar.. (. Oeb. u. Gj-n.. 1904. Ii, 419-468. 
^i«ni. Versucbe eines Systems der Gcburtshiilfe, 1BI2. 97. 
*«* DnI Schlehincer. Exp. UnterBUchuiigen iiber Uterusbewcgungen. Strieker's 

ntd, Jahrbucber. Wien. 1872, 57. 
AuauKt. Recherches sur la physiologie dc I'ut^rus grai-ide. Paris, 1880. 
form. Veber die Renristenz der Eihaute. Monntsschr. f. Geburtsk., I8C3. xxii, 1-15. 
Iter, fieitng tur Lehre von der Innervation des I'lerus, Pfliiger's Archiv, 1680. 
V uiii.6S. 
' MOCIM. Puturitiao during Paraplegia. Trans. London Obst. Soc. 18*17. xxxi\, 191- 

axi. 

Urwche der Geburt. Lehrbuch der Geburlshiitfe, 11. Aufl., 18.'>3, 165-167. 



234 OBSTETRICS 

ScBATz. Beitrege lur physiologiBcheti Oeburtskunde. Archivf. Oyn., 1S72, iii. 5B-t44. 
Ueber die Formen der Wehenciirve und iiber die reristaitik des menBchlichen Utenu. 

Archiv f. Gj-D., 1886, xxvu, 284-292. 
Ueber die EntwickeluQg der Kraft dea Uterus im Verlaufe der Geburt. Verii. d. 

deutschen Gesell. /iir Oyn., 1895, vi, 531-542. 
Slxuons. Metabolism during Pregmmcy, Labor and the Puerperiiun. Johns Hop- 
kins Hospital Reports, 1904, xii, 111-144. 
Spikoelbero. Die Dauer der Geburt. LebrbuchderGeburtehiilfe, II. Aufl., 1891, 146. 
Tyler-Suitb. The Frineiples and Practice ol Obstetrics. London, 1849. 
Vaquez. De la teuton art^rieile pendant la grosscsse. BulL de la soc. d'obst. de Paris. 

1906, ix, 30-33. 
Varnier. Combien de temps dure i 'accouchement. L'Obst^trique joumaliftrv. 1900. 

174-181. 
Vbit. Beitrage zur gcburtshiilflichen Statistik. Monatsschr. f. Geburtdk., 1854, r, 

34+-381; 1855, vi, 101-132. 
Williams, J. Whitridge, The Frequency and Significance of Infarcts of the Placenta. 

Anier. Jour, of Olist.. 1900, xli. No. 6. 
Wolff. Ueber schnierzlose Geburtawehen. Archiv f. Gyn., 1906, Ixxvii, 402—418. 



CUAI'TKR XI 
TUK FOM'ES COffCUKSKD IN LABOVS 



Tk« Cenrix in the Later Fftrt ot fitgntuicy. — On vapnni oxainination 
to the InliT nwnlhs of [HVf^iuncv. Die ccrvi\ ii- fo»ii<l to Iw much softer 
■nil -Htincwlut linuiiii-r ituin in Dm- n<>h-|in';;nMiil <-'>nclition. At l)it> name 
uiiM* it ttfaallv gtwn ttie iuiprctisioo of Iwin^ coniiitlvrablv ehoiicnctl, vi-pa- 
rimily in il* anti-rinr portion. Tliin vniulilinii Ittl Almirtci.'jiii, Rowlfirer, 
ncirlr nil of the «arlior aulliuriti«e to helievp lliat from tiic fifth 
<talh onoranl thr u|>|kt [wrtinn nf Itic crrvix grii'ltiullr ixfjimtf oWiter- 
•i»^ sni! i^ulribulMl to the cnlarjii-mi-'nt of thi; uU'rine cavity, that which 
w«» Irft at ihc end of pntgnancy rcprcwnliug merely iU infi-rior wmJ. 
l^tnliz, in IS^ti, (leiiionHlratot) the iunorrt'ctnoMi of thiit ilnetrine, and 
that the Fhortenin;: was only appurcnt. and was brnn^ht al>ont by 
ifWIbmi dilatation of lh«> »-nii-al i-aiiul which nviillixl iu the approach 
if llie intrma) to tl»e external os. |Io Miovrd that the oen-ix rftainwl 
'itn intugrily nntil about two vpclui before the onset of labour, when tlic 
ouiaJ ilowlr bei-anit; ohlili'mu-it aittl nmw to funn |Mrt of Ih<> uterine 
ovity. Matthews Uum-an aeceploil tlien- vieWA, but pointed out that tln-y 
^if hrvn anttcipliil hy llu- anatoniieiil work of Verli^n He (iraaf. and 
lUrn-rht (l-'tt-'ADl- At tlw same 
he imnKliil njxin einiain moditiui- 
•. holding that tlx? i^ervioal eanal re- 
ii»ni pnu-tKally iinchangol until tlw 
.oatMt of lahour. Hi* Klatenientti wmhi 
rimi abundant donlinnnlion from Die 
ralion« of HoUt. Miillcr. I»tt, 
Taylnr, Luiibr nud iiuiuy oiIht invi-sti- 
f»tnrf- 

Ualler painted nat that the apparent 
•borlraing uf the crrrix «u dac to lh<- 
1 anteflexion of tlte utenu and tite 
on nf (he anU-rior fnniix of the 
itiM tiy till' pn?iPDting part, to whioh 

iinlil In- aildiii the iniinWd succtilenco of tlio entire ^nital trant. He 

r vtala) that the tingitT. at the end of pn^nam-y, could bo tutrodnoed into 

r<mfuU for a diftanre of 2.5 to 3 oentimetnw U'foro it was arr(>!4tiii hy tlw 

_iBiemal o». Hin e(in<!lu»ion« were verifipii by furllwr clinical observation, 

that it ia now generally admitted tJiat in the great niajorily of <'a»M the 

235 



Fio, 




236 



OBSrrKTRICS 




1 



Flo. 217.- 



[!ki<tix »t tiiE E.1D or rBKOMAinn- 



raiittl riMnuiniS pracjicallv iitialli-rc<] iiiilil the on»ct of labour, and tM^ .. 

laaj' (^vcii Ik- nliifhily l'>n>.'i-r llmn In cIil- iion-prej^uaDt conilition, l))ti» mdi 

eating Uint l\w terrix »hara 
Houiewhat ID tiu! gtiouml lijr[i 
trophy of the uterus. 

In Mceiit _vc«re the resul 
olitained by esaiiiinatJuii diirinji 
life have itfCM-ivod additiooal 
i-onfirniation from tlw Htndj ol 
froaii sections made tlirou^b 
the bodies of wnrm-ii drinj: lat. 
ill pnigEuinrv- Valuable cuiiL|jtj 
butions along th»<i- lines hM 
Umn made by Woldeyer, S<'lii31 
der. Braune and Zweifel, 1" 
nurd and Varaier, Leopold, i 
olhers. 

Lower trterine S«po«at. 
For a nhoTl liuw after ibe 1 
{xMirance of Itulli-r's work 
I8(i8. ilii- qucrtioii corner 
the behaviour of the c«rvij 
regaiiied a» practically aettl* 
but tbesG hoiH-s were rml 
^baTIe^1l in 1872 by the *t>i<. 
of Bratine upon frozcD sccti 
riindft through a woman who 1 
dii-d during tlie MX-oud stag*- ci 
lalMiur. UJb itpeeiinitl ifhoww 
distinctly that the iulerior of 
Ihe utt-nis was diviiU-d into tno 
parts by a projecting c!':'- 
ridjte. 10 to II wntii; 
iibnvc the maj^gine of ilie tii- 
lated exIiTnaJ o*, il» eitiiiitx>ii 
Iwing tnarkt-d by a largo I'i'^ 
and by the deflection of lii 
pi-ntonwum from Ihe anttri* 
Kiirfaee of the uterus ( Pig. ' 
The portion above it 
thick walls, while ilte nati ■ 
dor appeared n* a eimple, ihi^ 
«-aUed, muscular tube throiij^, 
which the head had lartiill 
[lasst^l. Hraune identified t!i-^ 
rrii^r or rJdftw with tlie intirrti»r 
,.,,,.. - it had (hx-n derived fnn» iW 

cervix; nor did he ihiiik it rem.irkahle that the «matl canal which W 



^ 



"FlO; UI8. — C'khvix ^^ tjik list) or Flatan/kXcr 




f"l'i. ai9. —Vnitiix AT TIIE h-.i. ,„ iHMHnm-r, 

KUOWntO PlUWMIVJkTIOH or CjLMAl, (lrf<0|l.)l(|>. 

xj. 
w, and eonelu<t>il thai i-verytliing U-ltiw 



THE IjOWKR irnCRINK SEGMENT 



ap to tlu- titae uf iab»ur dlwuld liave biiMi cuDvert«iI into a Btrucl 

iif mdi (lmu>D!iioii^. 

fiiadU ID lii» work upon ruplurv of Ihc iileriu. which sppcaKil ml 

3,|b>idUiiI uut thitt uhcD aikIi an a«>ci<lent occure, tliv point uf raptiin- 

ij always situated below BrauQeV ring — namely, in the htcer ater- ' 

u^tnt. The next yi-nr he Uwk up Ui« ouhject again, and congi^l- 

it iiMvni-eivabie thai Iho ivrviml iranal. whic-h tra» only 2.'> la 3.5 

letrea luDf! nt the iiiil o( prvgnancy. could bo converted in a few 

iotii tin: i-lructuri* dcwrik-d by Braiino. He Xhnntan concludisl 

if the upper boundan- of the latter really reprc«cnt«l (he internal os. 

lin prrpsntory nKKlilicattonn mtint luive taken plmt- during the Ialt4-r 

of pn^ancy in order to make nueh a remarkable change possible. He 

id that the tit^sue forming the oiitiT ]>orti<tii uf the cerrik was ^r«d- 

Ij fhiftnj during Ibe \vt few vnwkA of pregnancy, m that it becanw; 

ted with the mu^ulatiirv of the Io«vr portion of the body of the 

while llie ci-nteal inui-niix inembraitt? n^laint-d i\* original {lOMition. 

la hia view, then, tlie true internal na was Hilnated not at the 



>L 




nuLtfi 




- ) tHiU-.v Su-nnv ntHui'UH W<>>iii> ■•ii>'i i>t>ii>><i !^i- 
■aowiKa CbirnucnoK Rimi (t(niiiiu>). 



-I tilK lir I.AHUt'Ni 



|>-i t>Tniinatii>n of itu- wrvii-al mucoF«, but mnoh higher, and at a lerd 
— nr.i!:njr tii tliat "t Brauw'* ring, 

'■ i:i i:jli Baodl'H t^toipl ieateil explanation in do tongan* aoivpted, hiii 
Itnii' a plaiv in llu- lilenitiire of tlie subject. Nor kIiouUI 
-ijjlii iif that I'l him wi- nn- ii)d<-l>tid fur ntir elioieid uoii- 
i-onocrning ibe lower uterine <»eginent, inamiuch as he was tlie fir^t 
intuh idearly between the funetioii of lite upiicr cttntractile and 



23S 



OB^TETUKS 



Iiilfmol ini. 



Eiirriiil ■». 




InlFriul u*. 



Kxiemal e*. 



Pio. 331. — OiAatiAU iLLi-imtnTiMo Mais 

VlKWH AATO NaTVKK "r l,<in't-H liiKIIIMt 

SEuMBtr <Aii«Tii-)ui Ti-xullmikl. 



iictivo, mill till- lower pawtivi- ik'^iiicnii' of llio uterus, »i u-ull iln thti mint 
which they bear li> llip ocpurrence of rupture. 

'llie (liKcu»«iou dtflrt*^! by It«iiill lui* liii-n n»[)"iuili!i' for iiii imriK-r 
literntui'e. Two main viewn have l>oen iiitvan<t-<l coneiTtiinj; the nature 

origiu of thi! lowur iih-riiM; N^n« 
Acwinlind to the llrwl, it is ileri 
purtly from the cervis, Iho interig 
Oil Innng Kii)i|)<>»i'(l If) 1m< xiluiil 
or 4 centimetres above tlie exte 
while the Kwt of the ulriKrtua' 
fonntMl by the lower portion of 
biiily of till- iiU-rtis, At-eonliiij: 
the 8««ml view, the entire stmi-I 
frctm BruuiieV ring to Ihv t-stci 
oa, is derived from the wwix. ^M 
fiivt view hu)i rccvived the iniln 
iiieiit of such aulhoritics h.i S4-h: 
ilcr. Itiige, vol! I-'rumjue, Dittel, 
Veil, whih' the e»rrei'lni.i»> of 
fpcond e.\]>lAnation is upheld 
Randl, KiUtiHT, IJim-r, /wtiM. 
others. 'Ilmt the <|ue?tii>D in not 
^eltIl''l was >li'>wri hv ii di^cti^irioi 
fore tlie Iterlin Ob^tetrieal Soi-ict; 
l)(wml«T. 11105. wlicji ttiijt« vi^troiwly uiRiliUiiiict! Ihc conwtnees of 
former and Uiimm of Ihe latter view. 

At iirKi gluiicc il mi^ht apiH-ur stnin^^; that the (jue^tion liaa given 
to such diverftence of oiiinion, as it woiihi set-m n vm- Mtiiplc malti^ 
demoni-truto the ^tniclnru of the part* by micrownpieal cxsminnlion. 
the first view he cont-ct, the inner surface of tim pnrtii>ii which is 
ptiw'd to Ik- derived from the uterus )>hoiihl be liiiM by dceidtia, ami 
portion IhI'iw it, i'flrivA|H>nding to the cervical canal, by the cluiractcrM 
cervical mucosa. On the other haiul. if the second explanation it lo 
nwn'ptefi. the eIlti^(^ .ilructiiro below Brauiie'M ring^f/ip cnnlrttction ring, 
it is generally defiifriialcd — Khniihi be lini'd hv cei-vieal cpltlii-liuiii. 

t'nfnrlnnnli'ly, Ihw (p»-.*li"n is mil wi easily .*otvc<I. In the liret plM 
the formation of the contraction ring aiid the lower uterine iivgtncnl i* 
great part, ti clinical phenomenon; iind while it« eitufltion can u^a 
I(e difinilely made out by Ihe exatiiininj; fin^ref diirliij: lahonr. il U mA 
tlcarly miirked after the rL-nmva! of the ulenij- from the dead body. Aj3 
the majority of the »|Hviiiicns which have Ik'cu i-elicd upon to «ottle 
question were frozen before being subjwted to microscopical examinatii 
m that the (incr hi.itologinil dct«iU had bw-ome oblilontlcil. In spite 
these obstacles, however, the <iue<tion has gradually appnirtehiHl a ^nluti 
w) (hat the mnjorily of inve»ligHlor>i are inclini-d to owept the first v 
which is generally known hy Schr^Hidi^r's name. 

MorcoviT, A*eho(f in linir. i^tatcd that a great part of tho confns' 
is due to the fact that those taking part in tiic dinciiMion nf the qumliu 






TUG LUWER UXERINE SBGMtlNT 



239 



Mt agreed a* to what {y>ii»litutO)i the wnix. lli- linlil* Unit tlirv*; 
ilwiiiKt fniTtiom* L-iiu U- (li^>tlllgui><ll<.'ll in (lit- interior of the litems, na.iiely. 
(be ntmiu.' aud pcr\u-ul ravilit^rf, and Iji^twfL-n thi'iii n tiiirn>w purtion. tlnr 
i»Uimu», Ui which Veil dinx-tix) utliiitiuii in lUifii. TtuH h linn! Uy ul4-riiic, 
umI ikp (vrritvl nuiai b; wrviPtl miKiMa, It w Uiun-fnrv u]>ptirent that 
lh™«wbo lU.i'i^'nate its iijijx'r ojH^niii;' a.- th* inti'rnal m must I'ljiini Ihiil 
Ihr liiwiT ulfhiM- HfiiH'iit i* dtrivdl from tin- crrvis: while tUn»o who 
placr tlie iHtf^iud <ki> at the junt-tioD bi-twa>n the i^thiiitu and rerriral 
. caul an; liki^wiKV ciirrvt-l in ho^ditij; thut the iMMpiw portion of tho ntoru« 
^ irnxfi hnlh from jta tuxly anil cervix. To ohvinu- thin dilficidtr, 
A»d»ff propoHOH t" divignate the wppor and lower opniinRS of the isth- 
Mv, n«|wc'tiv(:-l V, ail !)»■ analomiciil and hiKtolii^ii'nl intiirnul nti. Tlic 
'"■InrlKiii tin;; corrifpoDds to tho romi«r, w!iile tite lnw«r aterioe rfji- 
■«t is dcrivfid from lh«- liwrnw Iving Vrfwivn it iiTid tho hi«totngtctil 

rW IX rrpn-wmts a vi-rln-nl mp«inl n-clion IhrfHiph Uit? utcrtis of a 
"■•n seven nioolib^ prcfrni*"!. wl"* died at the Johns llopltinK Hospital 




vr t4Hv>Mi St(>:k ur l.AHnt'ii. X ^. 
CM., BMitmcUua rliig; «il«., minraul «■. 



tIuiv ttthoiir. In thii' it is ek-ariy Mvn that the external o« 

-i. I>iit tiut tlM> n-rttral canal han ks^inne '<))lilerflti.vl and » 

art |n«t^ utfHiwr n'gincnl ha» Ixiiai forniiit. ('arcfid evaniioatioa 

''it the latlLT in liixil with a ti-|iical cervical inucouti inumUranc for 

■ Iff 3.S tij I iiiitinii-ln's fruin (Ik- mar!iini> of the external oit. 



240 



OBSTETRICS 



01. 



whi^rpaji aiinve this pinnl tlio titmae in diMtinctlj iiUriiKf in appeftrancc 
is covvn-<l \>y flixridim. 

Fijt,'. 'i'i'i reproeents part of a frozen section thrnti;;h a prespiant cadav— ^ 
shown in I'liitv 1, w*)iii.'Ii nut. kiinlly |>tuC(il wt my (li.-i{j<i:>al by Ilr^. •!. Holtn^ 
Smith and I,. K. Neale. The woman, wlio had a 6l)j;htF 
-^T gvnvridly (riuilrMcU'd rhacUitic [M-lvi*. dlrtl in lalxiur vri 
tlip niftiiibranes protruding from the rulva. llie chii 
prewntcd by the brot-cli, ivhicrh had not yet bocoine i-t 
gilgixl. Till? wn'ical eanal was ohlitarated and the oxic 
Ds) OS fully dilated, its margins being 1 inilliin<->ti« thic 
There was no Irai'i; of the internal n*. Seven cioniiraet 
above the external oa was a nvll-marked contraction rin^?. 
rnfodiimitely. the s[KTiinen was »« hudly mawnilinl IhMt 
ilie lining nieinltrane of the cenica! canal uhl lower uter- 
ine segment luid diKuppuircil. Micrwoopical cxanttnatinn 
reveatiKl only a few cervical glands in the neislilmurhtMl 
of the e\lenial o^. and gave no informiition »» to whctlur 
tl>e [jorlion liclow the eontraetion ring was lineil V>y di*- 
cidiia or cervical epithelium. 

Hofiiieier, in ISfiti, deinonntnilet) that the Mructnro nt 
the lower uterine segment is not homogeneous, and tliat 
the portion which corresfmiuis |o the cervix i* vnmpo>«d 
of dense connective tisene rich in el8J=tic fibres, wltilit U» 
ii|>[H>r piirf i» made up iif miiseiihir Innielln; wliicli puFKUe 
an almost parallel course, whereas as soon as the conlrae- 
lion ring ii< reuehe'l the uterine musculalure talius on its 
clmmi'leristic Hp]M>MrHiii'e. 

Changes in the TTtenii dnring; the First Stage of La- 
bour. — PiiJtsing fiXJiTi the*!- lu'in' nr It's* lii«ir«:lieal consid- 
erations to tlie eondition of the uterus at the ons<-i of 
liibmir. we find that the organ is made up of tw<> (Mirts: a 
tar^e. thin-walleil, niuceular sac — die hodv — to ihe lower 
end of which tliu small ctirvix is attaelieil. Th« waU of 
the foniiiT rnn'ly excwHl.* 5 millimetres in thioknt^^A. It 
is lined by ilecidun and the fa'tui niembnuics, insiile «*f 
wliicli are the aiiuitolie fluid and the fdtus. Th« w-rvix in 
softened and very suceuh'Ut, It pre^^ents a more nr IcM 
MvxTiE )''innH fuHiforin canal, 3 to 4 eentimetres long. vliioJi Ik bouniled 
DKNBt"""™* ™ ' ** '** upper and lower ends by the internal and external 
TVHK IN U-nnH "" rc^lMft ivdy ; it* wull.i rarely exnvd I.ii cwnlimetreit in 
(H..f.iM.j.ir). thickness. The condition of the estemal ob vane--< eow- 

/", ppnioQcai cov- sidcriihly. according a* the piitient i* a primiparous or 
mux of uipn«; mnHipjiro,,, woman. In the fonner it is nnite tizhtir 
«.£.,«« ixiMrDutn. cloHcd aiiil barely admits the tip of the little nn^nr; 
while in the liitl<rr it Is widely gaping, .-to that (Kir index 
finger can be readily passed into it. and can frequently be earrittl «p |o 
the interniil iw. 

During labour, under the influence of tHc uterine oontractions. th* 






¥■'} 



Fia. 223. — Sbctiok 
Tiiuoeiiii LowKii 

Utkiiixk Skij- 

KiiiiunixiiAi. An- 

UANaM<KVT or 



PLATE IX. 




*IIH A IL\U UUNITIS' PHWINANT I'lKHITS hTlOM WOMAN I>VING 
IN TlIK HRflT STaOK OF I^HtitR. x *. 



DILATATION (IF THE CEKVIX 



2il 



ttv ililTerpJiliatei] tntn two (lUltiu-t ]>nrtinnK, which are sepa- 
(inc aiHitlHT hy the miitmc-tion riii);. 'llii? upper ia the active 
portion and bccotms titicker hm latxiur A<i('an<>OH, whilv the lover 



M 






>.' 



> 



IVZM. 



rw, 326. 



es. — IiiuiKAiu Of IliKin ITa-nal at Ksd or PncnxANcY ami miiikii Biieom 
OK or L^BoiH, iuiui>i!iti FiiMUATioK Or KiHTit Cakai, (Schmcdpr). 

L-rdv |>iu»ivi> pnrt, bccoiiiiDK conv^rtecl into a muscular tube for 
lisa^on of tti<- fu'lii^ (Fig. 285). 

(Iw (iniift of laliour paiiiH the fluid (•onlciiU of llie uterus are 
lo prwj'urr. As t)if lowtT uterine «^ritcnt and the ccnrix will 
coDatituie a [Miint of Ictut renistance, tlie fluid ])rc!'eure, which is 



AT*nD9i o* CBnnx. fVxxirt-^iiAi'Kn Ow.rTK>Aii(iH or InrMuiAi. Os ucn 
CuncAi. Cahal (l^ijKild). 

njuallv in alt ilirrctions hy Itic amniotic fluid, contwqnently 
to nn ittun-aM.tl ti-n^ion and distention of tbme portions of t)>o 
)n aUloniinal palpaliao. b«?for« the rupture of the membraiu^. 
[can readily be diffcreiitiatt^i, the upper one of which is firm and 
' a eoutnction, while the lover affords a aemiilucluaot iieDiMtioDu 



242 



OtfcrnTRicB 



The former reprc«aita the t^ontractile portion of tiie uterus, tho Uj 

(lasaive Inw^r uterine M'^nciit ami crrvit. ^ 

Again, siiit-v llit- wrvis is [iprforaled bv its canal, the fluid pi 

exerted hy ilif bag of walore tends to cnuw; it* oLi! iteration 



Fta. 337, — niMi*rii>h oi ti.uvu mmixn advanheb thasi ix Fio, 32(t (I 



\« 



(Hiiituiion. w)ii<')i iH iiii1<-<! I>y l)i(! (ruciion cwrtM upon il* niarj;in« 
contructiiig fibres of the lower portion of the uleruB. WIwui co 
(liUfjition has liwn virisiiil, ihc margini' of the uxU-rnal o« lie 10 
ceniiinetres below tlie contraction rinj(, and no traiH- of tlie intern«l 
ba found. At the same tinif Ihe bladder is gradually drawn up ii 
of Hiv lower utniuv xcgincnt until it l)(M.-on)(« ii1niu«t entirely an I 
inaJ or^n. 

The dilatation of Ihr rtrrtix nwy be regarded a-i eontiinlinj; of two i 
first, olilitenition of rbe i-anni : iind i^econd, dilatation of tlie 



Flo. 33((.— CKKVIejkL CaNAI. OOUrUrtKLT OUl.lTtKAlKU, BxnUtNAI. Os IlTT* 

The obliteration ocairs from ahovi- downu-arO, thi* bejrinninp 
caled by a fu»nt-i-^hu[)ed doprission al the regiwi of the intcnul 



THE FORCKS CUNCERNED I.N LABOUR 



243 




gradvtWy mcn«M» in i>xii;nt and (W)il)i until the eiitin^ ciliwI has disap- 

pemnd. when the uteriiK cavity U iK'purutL'd from the va^iiin moielj- by 

tfae ciUinuil o6. "ITiifl U clearly hIu>wd in Fig*, S2tf. 327, and 228, an<l 

al«a in Fig*. 2SS, U:(ii. 331, uud 'i-ii. which repr<*enl rvcbiwtructiotih 

fznom th« fmz«n Mxrtinnx nf 

I rwik-r, \\ in ter, Ssjcin- 

, aih] Tilx>ni-, all nf which 

made thrduj;h wonKD 

die] daring the fint 

tf^ of Ul»ur. 

AftiT tbi- cervical caiuil 
bvcumi* ohIiternlKl, dila- 
t^»t»»ti of tile external w oc- 
c-wrs. Id matiy iiwlamxii iU 
™»«iTgin» become extremely 
KHxn, and ocnwtOTially giw 
ition aa if they would 
th« eXBoiiniiig fiiigiT, 
change in hrought 
■5«^ut alnioFt eutirvl}' bv the 
k^orr« i!jLcrli>d by ihe )»){ of watL-r», ur, whfD that has ruptured prematuivly, 
^^J' thn prewiurc of tl>c prcx-iiling part itx-lf. 

r" Tbi- tiiunte of eicntu dilTi-fs conHidemWy aixionJing lU Iht? wonuiti i* 

^> her Srat or a Eabecquciit prcgiuuicy. Jn the former caM! marked rv- 





tmuHk LuHii (SRlimdnt). X). 





IU lliuaMiTvia 'ir Ci.iju. n»- 
A^Bti : KrmsM, Ob UKOUUKiEii 



flU. 331. nil.A'Ill1l«N or (TEIIVIX, A14. sdt 

UntKK 3 UiLUMCrncn ofCasai. ohut^ 

nuTKD : EXTEBHAl. Os UmaUNOKU (SAX* 

iBRi-r). X J. 



u offervd by the external oe. and a confiiderable time must clapM 
cvoipli-tt? dilatation i» accompli")!*^); whil« in tlic latter, the m is 
«uid n-rr lilllt- force ts rei)uired for iti* complete dilatation attar 
'iaX cmnal )iad Lvmniv oblitcralol. 



244 



OBPTETHItB 




Pill. 233. — DiuiTATiDN or C't:iivii, Cakai.obi.it- 
t:iUT>:D; ICittIcrkai. Oa l,fi(*K.VTiH(.TKi:ix 1>I- 

UIKTIM. Vt^CKKTA Tn-tVIA (I'iboDp). X J. 



Changes in the Uterus during the Second Stage of Labour. — Dnru 
the first fitagc of labour llie eontractions of tho uUrtw liiive re^-ullvd 

it»t ilitTeivntiatJon into two put 
wliidi an.- »-purat(Hl from one a 
(ilhcT l>y llifi citntraotion ril 
Aliove is the active, contratrt 
|K>rtion. wiuL'h iKKmnin thid 
!!■< labour advancoM, and below 
ihiii-wiini'd, pa»iv«, lowtT u 
tiio ftcj^iient and cerrix ( 

Whilo Ihoi^ ohiing<u> arc 
t'ff(«ti'd. tliore ha« Iwcd no 
vanw; on llu? part of th*? ftp 
and a^ a rulo the proj^cntinj; 
0(«ii[»io.-< (he Miiio jiowition ( 
the onwrt of labour until 
pleto ililalHtion of the fx-r^ 
Willi tliL' conimencenii'iil of I 
wciHwl slapr, liowevw, iK^^ri' 
begins, and under norma) cowi 
tions continues slowly but steadily until delivery itt ac<;i>inplt$hc<l. Xai 
rnllv, llic difTiM't'iiiialUin iiiln »t.»iji.'i'-* i* ninre or less apl>itrary, an 
it ocfasionally liapfKiis ihut iIil' presuiiiiuj; part 
iH'pini? to dewonti during the latter part of the 
first sta^. 

Aflor it has brought about, t^timph'to dilatation 
of the cervix, lliu' liaj; of watt-rn ha-s siilicerved iw 
function, and nipluri; iisuiilly m>w occ-ur*. which 
iH itianife»lod by a .-uddcn runh of a greater nr 
Utwit i]uantity of a toltrnbly dear fluid from Ihc 
vagina. Ocawiimally llic nieitihranes give way 
eomo tinin before t-omjilete dilatation of Iho ctTvix 
has Ik^ji lirmijilit aliciul; wlifri'UB, on tho oilier 
hand, in rare ini;LaneL's ihey may retain their in- 
tegrity until tlie eoniplotinii of iHliniir, ho that 
the fa'ltis is horn surrounded by them, tho por- 
tion eovernij: ils lu-m! Iicinj; di'siKiiatcd a.n a rwu/. 

Wo have alreaily div-ctcd alletition tn the . 
changi'i* in xhapft uhiih Uii^ ulnruH prcHcnU dur- 
ing contraction. The.'* may be notiecd in ttio 
fir.ll, but riKiri' ospwiallv in the Srt'ond xtajie, 
when the or;;an inereai>e.'^ confiidcrubly in length, 
and 111 tin; Kaine lime dirniiitBhes in its tran.ivi>r*« 
and antero-poBterior diameters with each contraction. The increaw! 
IcngUi is due Hlmotft entirety to Iho Ktri'lrhinj; of the lower uterme s 
mcnt: but we are unable to make delinite statemeuts as to its «tt 
for at pre«!nl wc po>«»* no means of ascertaining how far the ret 



1 




Fio. 333.— DuoMAH 
I Ml Ani'i?i or I. VI 
L-irHIXB I*iuauit<BE, 
BKjkKK» tear RvrrtiM 



THE FUKCES CONCEH.VBD IS LABOUR 



245 



tinn of thr np{KT portion of the ulprus mav fcnv to cr)iintvrliiiliitu-e 
ttif >iin-t{-hiD); of iu iovn't !«gm«nl. In olixtructcci laltoiim, in whirl) 
iH^rkiil di^-propoTtton oxictti bctw^vn tht- sixe "f the prfscutin;; |Mrt ami 
tHtr |"J»"* i-iuuil, the lower uU'rim^ «-((nii.'iH ii Milijcitiid I" uxoistsivi- flrrtcli- 
iSMg, sail o«iae(|UciiUy the contraction ring simniueii a much higher levd, 
Ukd md infni|iii*utlv cnn Iw polgwiU-il ac n distinct transTcKe rid^ a 
.f>on dictattoc- below the umhiliini^ With llw fonnntion of l)w lowvr 
•cg'ncnt, Um? upper pi>rtiijn of the tiu-rus increases markedly in 

. ^.^i-s, and, aa labour prwcciU, covers « pnign'iwin-ly d<-vfx;a»in^ portiwn 

at tbv ehild. Thofi, when the hiwl ie upon the perinteuin lend Umn one 
tuilf "f till- fiflUH i.-< in lh<- ii|i[KT )>i<^incnt. 

FoTtec Concerned in Ixbour. — Art loti^ as the nieinhranoii arc unniplunx) 

— that u, iliiriiig the cjilin' first stnp- of IiilMHir. ind in the rave instances 

HI vIueIi thcj reuiam intact in tlie Hccond Mta^e 

— vfaatntT fun.* i* VJ«'rl<nI hy tiic conlrncliiiu 

wt'Tii* i» iran^mittnl to tlw ti<nior aiimii, and 

lit ii iiiIIm- tn-tiin. In acfinhincc with tlin laws 

nt Ouiil pri*r>iir»?. tlierpfore, it is applied willi 

•^ttal iDtiiMily ti> nil ptirlion)' of iIii,t child, an'i 

*m it ut that the lower nteriwe spRiiR'nt ami 

"Till n;iri-<enl the p»iiit of lejist n'sistjiiKr in 

1- -lini-. dll itn effrt'l would Ix." wa.Hted ; wherc- 

••. undiT the cirrutiii'lum'W, il gives rit« t" iIh- 

h»»tlwo of tlie lower uterine seRment ami the 

^l^bUa of the a-rvix, hut plats no juart in 

"■inj Ibi' ilfii-ni of Iho ehihi. Attention vra« 

*x* ijinviiil to ihiM pt>inl liy S<-hntx and IaIm^. 

ill <iiW-^ni'nL autl>oriti«6 hare oeeeptcO 

'■I '•llu-lu.-io^^. 

Ulir rapture nf the menihranw, a )n^?ater 

rtjtin uf the aniiiinlic ihitd racjipi-s, 

i-n preM-ntationn llie preseiitinK pan 

< lets u a fairly efKeient tampon and 

■'•* wlentinn of a considerable <iuantity 

iitiinis. where it fill* out the intei>li«» lietween ll»e f.Hnd and 

' ' 'iftitu: wall*. Ijth- tH'ljt'viil i1h> amount retaini-d wai- usually »urticicnt 

'" frrifni Ktual contact with the ifurfaix- of the r<elH*. and tluit lJn-ix!for« 

I'Mt vS tlM- lattn- was brou^t about by thiid pressure atone. Ilo 

•1 lb*t nailer snch circuinKtancep (Kijr. SSI) llie entire xurface of 

'Hw, «w^,l t|„- portion pr<jje<;tinK throii^-h the cervix, would be sub- 

," i! ^l iiiini |vn^iitiure_ which, a« it i» c«pial in all dirwtioiiK. would exi-rl 

'" ' '^' 'ipita tile fcPtni". McejH in a line pawiing tlirough the centre of 

" nnt tuhjected to it, thtw manifesting iti^elf as a downward 

. ■ snnj fllionl d«<-ent. 

iBffci- "''"""^ hand, IjiK* held that in all other prcaenta lions, as w«ll a* 

rf yyi *'''^**^ vcrlct. when the amniotic fluid lin* «lm«*l completely drained 

' ^^ (metitn omie into play whieii he regarded as distinctly patho- 

'& macb cases the contracting uterus wxtuld come in direct con- 




no. 234.- DlAUKAU MIDWIK1I 

Atnon or [icniA-imatKB 
Pni-JMeHK trtrit Ui'rnwr 
or 1HE Ur.HiiK.txui. 



24(i 



DBSTKTRItS 




tad wilh tlie surface of tbe fostu*. and lliu roiw L-xvrtvd by thi- fill 
woulil lie ditwtly trun^niituil to the prraenting part by w«y of tbe 4 
bral culiimii. 

JItKil rt-fent writers havv not iiwiliitwl lo a<i4.-ei>t I^htt'i* iiiUT|iret| 
but (>Ubau»L-ii hti> UiMy iliriK-teti ntteiitinu to the fact that tliu I 
force coiuts into play mcu ia iiorniul v<Tti'^ pnwiitntioD.*. He poj 
L out tliat only four froxen liectioDs, tbij 

n-omcD <iying in tbe fivirnl »t»fK of 1m| 
are available for the ftmiy of the quesdi 
n:imely. two of Bruunc and tliow of G 
and liflH)our — aitd ttiat in thn'e nf then 
fundus was iii dire>et contact with the hj 
of Lhtt t'liilil. Ill- ll«-n i-:<titnHt«-d that lit] 
!t'iO cubic ctntimelres of amniotic fluid 
rtijuirc'cl to lill out lh« iiitf.T^tiw* b»- 
tile surface of tbe ftplns and tlie uterine 
and staled that it wits out of th<- tjU' 
tiiat tbe child rniild Iw expi'llLiI sol 
Huid pri'iwun; udU»4 a grvatcr quttiitityi 
this were present. 

In WO rasvs h<t m^'Si^urod the atnoid 
amniiitie fluid e!<CH;iiu^' mIu-u the cbilq 
born, which praclicaliy n>pn'«e»ts the 
tity remaining in the iiteriu niivr rupti 
tbi; membranes, and found that in 80 pel 
uf tJie priniipnra' it did not exciW 3tH) 
rontimctre-i: while in tiO per i^^nt it wa 
ovw 201' citliic (■i-ntiriii'iri'.i. an amount by no nictms sufticicnt to (il 
the inlcwlices, let abac to bring about the separatum of the breech 
the fundiui, which is ah:«i)luteiy i;K3>i>nlin1 for th<! proper action of 
prc'*urc. lie therefore concluded tbat under such circumstances i 
prcworc must be e\erliil by tbit cimtnHlug ulenm upon the hm-ch. wli 
it 16 trantniitted through the vertebral column to ibe head. andj| 
thin i« rendered possible by ihe diminution in Iht transverse and nl 
posterior diameter of the uterus, which i-esults in an extension nf the 
and its cmiverKinn fcir the liinc licing into a comparatively rigid obj< 
In addition to these factors, the contraclions of the abdominal mt 
of the woman also play no mean part in vlTcoIing the cxtnisioo o 
child; indeed, aciiirding to Schroeder, they alone bring it al>out 
hauscn, on the other bund, while not denying their importance, doe 
consider tbat they are the sole facinrs conci-med. It is ap|tan*nt, 
ever, in most cases, that their action is absolutely essential for the 
of lh(! fndn*. for when it is entiROy absent, or only partially come 
play, labour is delayed, and a resort to forci-ps frequently become* nec« 

The descent of the child is also partly due to the fact tliat 
eonicA stmightened nut by the action of Ibe pains during th« f 
Etage. According to Schroedcr, its length from vertex to breech 
creattetl by 5.5 centiinetrea o* a result of thia extension; while Olil 



Kiu. 339. — DiAOHAM BiiOH'rmi Di- 
IlEtT ["KKKHtHK i:\):h'it.ii ut 
►'viimi-KAi-rtuCi'ufi.KitlvVitv 
vation or AMMiimv Pmiiu. 



THE JXJRCES WJNCEKXEU IN LABOUK 247 

"Uteiddis that the increasie is cinii^idtTably gri-atcr, and cBtimaten that it 

'«ri(s from 7.25 to 13 centimetres in 70 per cent of the cases. Part of 

"'is, it ii true, \s counterbalanced hy the greater length of the uterus, but 

'^t= nmunder is accounted for \>y flie desiTiit of the preseuting part. 

BTien the head has desceiidiil tlmiitfrh the pelvia and is resting on the 

/***'tjc floor, more than half of the entire lentrth of the child liiw beneath 

^*i contraction ring; moreover, as the upper portion of the uterus liecomes 

^'XSalfer and anialler, it necessarily exerts a diminished effect upon the 

^«ild, BO that in the majority of cases it becomes essential that the abdom- 

i**^ contractions should participate in the work. 

Immediately after the birth of the child a marked change occurs in 
tfc« pn^iition and size of the utcnis, and on palpation It can be distin- 
gTjiyhwJ as a lirm, rounded IxkIv which reaches to the umbilicus. At this 
tirue its contrai-U-d and retrBctp<l Iwxly is freely movable above the col- 
la* pjwd lower uterine segment, and can readily be displaced in any dcsiri-d 
i3 i auction. 

Changes in the Vagina and Pelvic Floor during Laboor. — The outlet 

(ȣ the pelvis Is closed hy a nunilwr of layers of tissue, which together con- 

etiiute what is known as the pelvic fliKir. Beginning from within outward 

ozic meets successively with the jieritona-utii, the subperitoneal connective 

tMtsae. the internal pelvic fascia, the levator ani and coccygeus muscles, 

tile external pi4vic and perineal fascia, and, included between the latter, 

tl\« superficial muiJoles of the perina'iini. external to which are the sub- 

("utinwus tissue and the cutaneous covering of the jierineal and vulvar 

regioiij. 

Of these structures the most important are the levator ani muscle and 

the fiffja covering its upper and lower surfaces, which for practical ob- 

*tetml pur|>oses may be considered as constituting the pelvic floor. This 

miwle clost's the lower end of the pelvic cavity as a diajihragm, and pre- 

•^ntstdincave upjier and a convex lower surfiicc. On cither side it consists 

**! 1 pubic and iliac portion; the former is a band 2 to 3.5 centinieti^s in 

••Jlh. which arises from the horizontal ramus of the pubis 3 to 4 centi- 

"Wres below its up{>er margin, and 1 to 1.5 centimetre from the symphysis 

Pabi*. Jts fibR-s pas.s backward and encircle the rectum, giving olf a few 

"Ti'^ which pass behind the vagina. The greater or iliac portion of the 

■iiwle aria's on either side from the white line, the tendinous arch of 

"■^pflvic fascia, and from the ischial spine, at a distance of about 5 cen- 

•"Wiw IjcIow the margin of the superior strait. Its libres do not possess 

^Miform arrangement, but, acconiing to the researches of Dickinson, the 

™l»wing portions can be distinguishiil : Passing from before backwanl, 

li^enii a narrow band which crosses the pubic [Kirtlon and descends to the 

iwlo-Tigiiial septum. The greater part of the muscle passes backward and 

HDJlei with that from the other side of the rectum, while the posterior 

ponems meet together in a tendinous rhaphc in front of the coccyx, the 

mart poBterior fibres being attached to the lione itself. The muscle fails 

totti out the posterior and lateral portions of the pelvic floor, which are 

ocrapied by the pyriformis and coccygeus muscles on either side. 

Tlie leratnr ani mnscle yaries from 3 to 5 luillimetres in thickness. 




Flo. ,.':!'r. - I II! I'm. TIC Fmoii bml.-i rn'iu aui>vz (KHljr). 




T«fc,1 



^^^^^^ 1 


_J^^^^^^M 


^^^^^K 
^^^^H 


—The rcLTKT FioOK vrrs ninti mlow <KoU^^^^H 



THE JURCKS CONCERNED I.V LABOUR 



249 



(iimi^ ila mar^iiiii. wliicli ciirirele the rvrtum aiul vagina, arc eomewhat 

pnudcer. On iimtrartion il nvrvos to ilmw liolli tlm rectum nnd vAjcina 

'"''Vanl tB<l iipvatd iu tti« direction cif the •irm))lu'HiR piibi§, iukI is to be 

•^B^rdrtl B* IIk- n-al clwwr of tlin vwgiiiii, cinci- Ok- cnn*! riclor (riiiiiii, «n« 

"*' the Riperllcial ina»'iM «f tlie porimpum, is too delicate in struciure to 

t^^ more than nn arcc*.-^n' fuiK-lwn. 
Tile niuorW foniiii)^ llw )M'lvtc floor wonid not be suinricnUv »tmaj: 
•ff^vrti KUppoH lo till' |x-lvir conlrntf wfrv tiny not R'-i-ii fDrci.-ii by the 
[*u^ jM-lTtc fascia. TIm- internal inlvt« fsM-ia, wUiHi fornix ilie upiwr 
•''^•■inj of the levator aoi. is atlaelH>d to tlte margin «»f the superior strait, 
"*rx^ It i^ joinnl bv th<> fiiwia lining lite iliac fus^-, ar> wfll a^ tin* trans* 
^■« Isjcta of llie alKloniinnl walU. It pasv^-s down over the pvrifortnH 

rami i)h* tij)|H-r lialf of tin- olilurntor ii)liTiiUK nius- 
^\ cle. and is firmly attacheil to the periosu'iiui cov- 

iSI^kV|^^^ «ring tilt lateral wull of the pelrw, tlie white line 
GS^pLM^^^ imlit^lin^ it» point of deflexion froiu the tatter, 
y^^^^-^^^^f wIk-iht il sprwids out over iIk- iipiwr surface of 
thv levator ani and cocKryjteus muscles. 

The inferior fascial con-rinp of the pelvie dio- 
phraxni i* diviiled into tiro parts hv a line drawn 
betwerii the ii^ehial Inljerositii-s. Its posterior por- 
tion riinwiulM of n itingle layer wliii'h, uking itjt 
origin from the luiero-tciatic 
ligament and llw iiu'hial tu> 
berortity, [HiiweH iip over the 
iniHT iiiirfncv of the ischial 

fTOt "' ^^ Ll^ Iwnt-s and the obturator in- 

•^>^ ' — '^^^'\^ tPrnuB niiwle!' to tlio white 

■ ^""'-^ss::^^'^^ yyittu. lavoBor line, in uhi»*e foriiialinn it 
p C^ ^ ^--^"^ THE H<iiHE<L FAiciA takes part. I-'rom this ten- 

D«L— th*..«A« .m.wi™ AnBA-xtitMKXTor P«i* dinous Btrwtnre it in rt-Awt- 
TK- um I't.uKKAL Fawia (Tnrtiii-r). ed at an acute angle over 

upon the infi'rior surface of 
': rr ani. \\w ^paee indndei] U-tweeii the latter and the lateral pelvic 

.' d>>«ignAteO aa tlie iBohio-reicial fotwa. The anutrior portion, or 
M .il [t- -ri iinifHT. fill* "111 the "piKV between the line joining the 
[ui-rii-iiii - u»d the piihie areh. 1 1 i« made up of three larers: 
[i) The d<*|i pi-rinwil TaMna which wn-ers the anterior porlion of Uw 
■fi^riiir ■tirfaee of the Icrnior ani mufcle and w continuous with the 
wim jityt devcrilied: (?) the middle perineal fa^ia which is A-purato<) 
the former by a rnirn^w *\<iKf: iti which arc Hituatnl the puilie vessels 
[jmI nerw; (•'<1 the »u)terfleial ]ierincal fa^-tn which, together with tlw 
m^^ jiKt (iLsra-ilioil, foni) a comparbnent in which tie the Kiijiorlicial 
|KTiDi' ' '■'*. tlw mmi nf tlie clitori*. tlie vaginal IiuIIm, and the vutvo- 




Th«- niiperfirial pcrirpal muwie* consist of the constrictor cunni. the 
'■-•'•--'""i. and tli»' I mhiiverxu;) |ienti4-i miucle*. Tlit*© Blmcturc* 
foniieil and powdss no oli^tetrieal eignificanee, except the 



250 



OB8TETHKS 



tsKt-nanK-xl mueclet), which ttro a[xrayii turn through in pcrihrnl Incer 
when the; tierve in gn>»t part In brin^ ahout gaping of tlw vouud, 

Vnlhra ClilBtlt 
Victiu 

Hp Contlhctor f mini 



'-\ 



I 

\ 




M. IriDlTMWn pcllM) 



CeMrim t«ni 



Fill. 238. — Pblvic I''i^ib iioTBii'rii nv PBDiKwttxii PnHf. HHowiMa SWBKnviu. : 

OF Pl:ni!i|.c[')i (ItiuiiBi), 

From a practical point of ricw. Hart haA (liT)d<>i) the pelvic fioc 
two segm«iiU — pubic and sacnJ — which are separated from one snot 




pKBOMitHi.T rHntMiiv »riij ZwcitH.) X i- 



THE FORCES CONCERNED IX L.<flOUR 



251 



t^ ntgina. Their condition remaJD-i jiracticjilly uiicliungt'H tlirniighnut ttw 
vatirv dunlion of [ircgD«ni\v. cxoupt that towards the end tbey liecome 
more Haxed, ow-inp In ihi* gniltvr ^iicciiIctki- sikI Fomc o-ttcma o( tile 
tiwDCK, winch un.' DiaDif<%tc(l by a olight iocrcaiM,' iu ihickncM ami a certain 
AOBOBt of dmoping. 

In tiiL- finst fltaRi- nt lalmur tdo hag of w«t*r* tnkw part iu (hu <ltlalnltnn 
"d dvimdoD of the up(>fr jwrtion of i1k> va(,'iDa, hut after its rupture 
II* dnngw OGrurring in l)ie pelvic floor are duv entimly to Dm; j>ns«arc 




341 



Hu-tH.--<. aHouiKi (.V>Ki>trt'>» iir Ti(K KiMia Cahai. i» Piwrr pAirv of 
IfUTo.iii KiAiiK iir I.AiirirK (Itniiuip). x )■ 



by ihf |iiTsi'Htiitj! pari. Ad thiii di'scfiMlf, tlw puhif «oginent be- 
sliichlly ilrnwii up ami forcnl againrit Die inferior and posterior 
ynclMKW »f iht nymphnii*. On the other hnml, tliu )>iwml Mgitu-nl tindcr- 
jiMir niAriu<d chan^e^, becoming pushed dnvnvard «nd forirard, and siib* 
jMr(> trvtohing. cventnaily Ix-ing courertwl Into a thin-wallcd, 

' —till- i^MTinail piillcr. Fig, 23fl givw a good idea of the 
wTurrinjC in tiu> pelrie floor, and demonstrates the iroportsnt jrart 
' < ' '^alor an! ami the altogether iniii^llieant function pf the 

id niusrli^. When the head drst*'ndi' the vnlva, its open- 

tndk? apmird and fonmn!. and the cour«' «f llw hirth canal along the 

Ktntr follow* tin' etirre tndiealtvl in Figs. ?22 and 241, 

Tebrter hu (lointed nut that the mo«:t marked change ennflists in the 

■ :i-» of till- li'^-ator nnt imisrie and ihe thinning "f the 

perina'iini, which bccoiiH« tn>n.*foriiietl from a w^gf^ 



252 



OBSTtn'RICS 



iiligped Riass of tissue 5 CGntimctret: in tliickncss to a thin, alinoei ttt 
parent mcmbruiiDU^ Ktructitre i tu I iiiillimvtrcy Uiick. At the Mnic ^ 
it i» puKlicil ilown fllnkitl 2.5 ci-tiliiiictn-K fniin iU nri^innl po^it.inn. 'I 
Wlicii itu' |mrinn-iiui is iJinti-iuled to the utmiwt, the aauii bertM 
markedly Oilatcd, and preamts an «))eniii<T which variui from S to i.5 i 
tinu'lro* in (imnn-tiT, lliniittrli which ihi' nntcVior wnl! of the rwrlwni is i 
to buljue. West pha 1(11 ha^ palloil atlcntinn to the fact that these chaC 
may !«■ iieci>tii|iiinii-il hv sllj^lit U'siniis in coitliiiiiily. Tiii;y were not« 
13 per cent of thu- 100 cawes stuihti) hy tliis author, and were «>m«t 
nufticii-iitly iiinrketl to bv aoooni]>ui]it^i by slight hjuniorrhttgo. 

P Lrri!R.\Ti:KK 

Akcikipf. Diw unltrc t-'tprimpginfin. Z<?il«chr. [. (.ieU u. Cyii.. 1906, Iviii. S 
ItAKDt., IVhcr Rii|iliir dcr firliiiniiiitlir. Wien, IBifi. 

L'l-ltt-r dun Wrluilli-n lies I'lerus ilnil CiTviv. di'. SlilllEurl. 1870. 
Baiiiiovii. Atlns nf the Aimlomj" of l^biiiir ICuhUiiii-d in (■■ruwo Stvtioni. 
E<liiil>uni:)i. IMH). 

liATKH. Zurphydol. uiiif palb. MorplKihiKii'dcrUelirinnuttcr, in Frvund'ii U}-ii. 

SttlttKarl, 1HK.1. 
Utrrus tiiid uiitijrwi T'twiimt-jmipnl. Arrhiv f, (]yn.. IW17, liv, 13-71. 
Braunk. I>it' Luge dts lltwus luid FOIub uni KnlIt^ iter Schw&np'niduLft. I*i 

IHW. 
tii(Ai.iNBiiiiil2u'FirEi^ (.■(•(rit-rdur(ihM'luiitt«iliiri>hdrn KOrjwrvinerHoduK'Jin'MiC 

t.4.-ipi:iR. I««l. 
^DMH II. ItLi-MHEini. Kin neu«r Gofrieniohiilit. et«. Zeitachr. f. Gcb. ii. O/n,, 
F Ivii, SS."! 271. 
Chiari. IVU-r die li)p«Kn>l>biw'lii-n Vi-rliiilfiiiitM Atm OwiitaleM «ln«' in 

vcrstorbctii'U I'riinipum. tt'icii, 188-5. 
Dincis-sov, SttidirJi of fhr t^cvnlor Ani MtiwJc. Amnr. Jotir. Oh«t., 1889, 

897-917. 
Dnmi- Hir^ T)chniiiiK«xon^ dca itphwanecmi und krcinwrtdfn UtcruM. I^ijuix. \ 
JJvscAH. (Ill (Ik! ■.(■iiKtIi of the Cvrvix I'lvn in Atlvuneed Prefciumcy. IteHarcH 

<>Uipirir». IJlitil-iirKh, IfifiS. ^43-273. 
VON FinHtiff.. ('(•Tvi\ >iii'i niiiiirfJi ITlerlnseKmont. Stiltlmrl. 1897. 

linltrsiicliiitn^-ii unci Kn'-niTunuvn iiir IVrvUfruBe. WiirEburj;, IHOft. 
II.inT. Tlic Slrm-iurHl .Vnulntiiy of ll"' Pi'lvii- ridor. FMmbiir([h, IR-Si), 
UurUBiRii. IhiH uiili-re L'tiTinnrKiiiciit ID uiiHt, uiid kliii. Itexiehutig, III Srhroil 

liet ji-hwrniKitre iind krci»im<lR I'tcnia. Hmin. ISSfi, 21-71. | 

RoLST. Bcilrutce mir CdmrtaliuHe ii. GynukoluK>e. 1H65. Hefl I, l.'iO-IfiD. 
KCvTXBn. Ilnii iintpru L'tprinHCKnicnt und die Deritlua cvrricsb'K. Jciu, 1882. 
I.AIM. Ziir Mei-hniiik dtrr Crbiirt. Marbiirii, 181)9; Dnrlin, 1872. 

IJie Tlieorii- ilsr Ccliurl. Honli, 1877, 
l.ANijHAN* mill Ml i.i-BU. Wciicivr nnat. Hfitrag »ur Fragn vum Vcrhallmi Jcrtl 

wiihri-riil drr Sc'liwancerwhHfl. Ari-hiv f. Gyii,, 187B, \lv, 184-189. 
l,K(ii'()ki>. ftpruit und Iviiicl. 1.fip!!ijt, 1897, 

I.rrrr. Ziir .\nnlnniji; ii. I'liyHiolfiicit' iIit Tthrvix iilcrL Krlangnni, IH7!i. 
I.USK. The Bcienw uiid Art (if Midwifpty. 82. iifw ■.■diliun, 18B.?. 
Maitiik.'kau. Traill^ den midiidirii d<--ii fcmnipn ^(raMKs, nfc. Bnw *d., IKI, I. i. 
MttLLKR. I'nleniiiictiiiiiiceri Ciber die VerktirminK der Vaifinalportiuti, iric, Sw 

Beitrn^V 1888, v, I91-:llfl. 
OuftlAtrsKK. KiTilr^ r.iiT I.ehiv vom Mei-hnnlMnili dor (Ii-burl. SlultlCiiH. I'M 



THE FORCES CONCERNED IN LABOUR 253 

taubtt VjaniER. Etudes d'&natoinie obst^tricalc normale et pathologique. Paris, 

iie2. 

BomnR. Elenienta artis obsletririse. Gottingae. 1766, 26. 

Bon. I'ebtr die Contnction des Uterus iD anat. u. klin. Beziehung. Zeitschr. f. Geb. 
lG^, 1S80, V, 141-118. 
UBtcni Ulerinaegnient u. cervikale Umandenmg. Zeitachr. f, Geb. u. Gj^., I90S, 
Wi,2M-313. 
BimsiL GefrierdurchBchnitt einer Kreissenden. Tubingen, 1888. 
Sain. Der GeburtsntechaniBmus der Kopfcndlsgen. Leipzig, 1866. 

Btitrigc nir phyiioIopBchen Geburtakunde, IB7I. 
SmotDBL Der achwangere und kreissende Uterus. Bonn, 1886. 

IMwh der Geburt«htitfe, 1899, XIII. Aufl., 173. 
Bmn. Consid^ratioDs sur quelqucB points relatirs ft I'art dcs accouchemente. Th^se 

■bStnubourg, 1826. 
XiUM. On the Cervix Uteri. Amer. Med. Times, 1862, June 21. 
TnniL Sulb plarentfL pntevia tavole omolograHche preparal« sopra il cadavere ronge- 

kto. Turin, 1894. 
Viuin. Le col et le se^nnent inffrieur fk la tin de la grossessc, etc. Paris, 1688. 
Vnf. Vnleres Uterinsegnient und Cervixfrage, Verb, der deutscben Oesell. f. Gyn., 

im. \-iii, 4W-149. 
ViLMTEB. Medianschnitt einer Hoohsehwajigcren l>ei 8l«issla>^ des Fiitus. Bonn, 

1M6. 
■IHTUL The Female Pelvic FIcwr. Researches in Female Pelvic .\naIomy. Edin- 

Widi. 1B92, 93-112. 
"w WwrnnLBs. Ueber das Verhalten des MBBtdarms wahrvnd der Oeburt. I>. I., 

StruabuTK, 1900. 
'iwnt Zwci Uedisnsehnitte diirch Cebarende. Berlin, 18S9. 
"Ura. Zweineue Gefrierschnittc Uubatvnder. Leipiig, 1B93. 



CUAPTEH Xll 
UBCHASISM OF LABOVB IS VERTEX PRESBfiTATIONS 



VnitTHx ]>nwi-nuitiuii# owiir in tmta fttt to 97 per cent of all 
ill them, as was first pointed nut hv Nac^-le, the Mf[itt«] siitun 
nlwiivi^ (ifciipHw t.hi- riyht oblUiui- (liniiu-tiT of tht- pt-ivis- In otlw^r mi 
• me usiinlly has lo deal witii » It-ft (K^ijtifi-iinii'ridr, or ii righl ix^^ 
posterior prc««Dltttii>u, That this iii m, and that ilie firHt'int-ntuHtMl J 
tmtalion in tlw> oijc nwnt fre(|UMitly obHtrv<^. pnielicully all lire 
iti** aiv asrewl; but ihat wide differences of opinion ftxist iw 
nlativc fni|iifii<'_v of ttii- '■(jvcrul other varieliw is t-lcarlv shown b 
following table: 



L.O.A. ..- 
L, O. P 
R. O. A. . 
R-O. P.... 



Duboix in 1.013 



71 per cent. 
.«3 " 
2.87 " 
2S.6 •■ 



I>jav4in»» 



52.6 nor cent. 
II 

.2 " 

3».a 



TV aHihw In IM 

2.6 *■ 
22.3 
H.8 « 



Mechanism of Left and Ri^ht Occipito-anterior Pi«sentations 
shall <tiii!>iilcr in llic first place tin" nn-ehHiiisni of lulviur in the Knterioi 
etiej- of verte.\ preMmiationn — namely, the left and right oeoipili)-^!)^ 




Km. 343l — I>i4aiuN nKiiri»a Oiild 
■M L. O. A. 




Pia. 243. — Duaaoi snowina 
Di It. O. A. 



Puignong. — Tim way in whioh the fojtufi U presenting isi nnwt t*Ii 
determined by ab<h>niiiiiil piilpiitirm. which «in he alilized not only <lu 
propnaney hut also at the tinu' of labour, proyidert it be pmctised 



"W-HIXISK OJF LABOUR IN OCClPlTO-.4.VrE«10R PRliSENTATIONS 25i5 

beiwcvn tlu! psins. lb at:cura<-v, lioui«vi;r, i> murkitll}' inijMiritl 
■ pitttiiu with very fnl uUlomJDal wullo, or in nhoiu the uterui> is unduly 
' ' br an eics«ive amouui of auiniolic fluid, or dvXonoed by $ut>- 



»v 



mwi 



I r\ 



i^. 




3M FaOStSf SefTIDH TIIBOtrcU WllMAK tT I'jiD OP I'llKOKANO', CkII.U tX R, O. 'I*. 

(Zwnf*!). 

binnU tir inlnimunil in.vomaU, whicb may occaaionally bv mistaken 
porUon* of the child. 

For pHrptMo "f (li«g»o»i* wv miploy tin* muncpuvm alrvttdy di-wriWl, 
wTtL the fntUfl iB the left oopijiito-anterior position obtain tlie follow- 
(Lita: 

Imt^ulnr Inwvh at lundUB. 
: llBOiaanl planr nl httA in the left and onlerior portian of ttrn 
ul'IrjiiieQ. K'illi ihv mall partiioii the rixht nilc 
II ihc bund be u»t citgaiinl. it U ttrlc nji a Fnwly movalik body ovM 
Uh •Upwiir Ktrnil : hut ir the head it fixed, tbo antcnur idMiuklcr 
tnay l» deteHMl. 
: Nqtatii'd if (iic head W nnt rnjtajgod; otlicrwW Ute oephalio pronti- 
tuumi IB Mt OQ Um9 liitbt xidu (Pbto X}. 

For the rifflil »w«rTpil»t-anterior pot^itioo we obtain the foIiowiBg: 

Imi[ular lirrvrh al fmidua. 
I t)i»n>*i(*t«: RnoMlaat pbui«< of txK-i; iii ihi- nithi uml milivior portioa o( the 
abdooMti. with tlic nnall (iotIii on tlie Mt nde. 
Yhtfd iiMium'i* A* in L i~i. A. 

I mmimttim: Ophalic iiraniinencv uu ttn- left diir, 

' — ' itie lirad linn Imuniu >-i^ciif[)4] \\». infnmiation ulilained by vaf^al 
' rm ifi (.-itrciiHtlT ntm^re: am) vwn nfirr vn^ra^tn^'Ul "fllisfaclnry 



256 



OBSTETRICS 



rcsulU cannot W obtatiHHl unlil tk^ n-vvix \» nufticimtlr dilated to 
llic tiii);iT In ili->iin>:>''''') 'k- various siituree ami fontanel Icii, 

In the k'ft antciior variilv. tliv satiitlul kuHir- "tviipits Jln- nj! 
oblique diunickT of t)io polviii. with ilw. Miiiall foittandlb in llu- ueighW 
hand of thv left iUo-pwtineal GinititjKrc and (lii! lar^ fontanetle dir 
tovrnrdti Die ri;;lit tuicro- iliac »vitc1i(>iidro$i$. In tlie ri^lit antcriur rarilj 
Ihf sn);iltjil :<utiin- iX'i'upicH iht- left obliigiitf dianit'lor, the .^inall fonUn^ 
Ivin;; ill the neighbourhoml of the ri^ht ilio-peetineal eminettcc, while I 
lar)«' fniitaiidk- look^i tuwaixlit llic left iitae ^yllcllon<i^^Mis, 

The dia^ot^tic Talu« nf vaginal examination is farther impaired by I 
fncl fitat tlic pRwencc of a rnarkeii aifntt furcfdnHctim may mnVf It 
possible to feel the sutures juid foiitanL'lles, not to i>peak of differeutiatj 
between them. 

In lli« left anterior piMittonf, tlii^ fii-tul ]ii:iirt *oiiiid» are u^uallv tmnl 
on the left Hide of the slHlonU'ii nloiig a line joining tii« umbilicuti and lt« 
left auti-rior siipirior njiiiie of llie liiuin; and In right ])OAitioiw at ■ torn- 
B[iondii%' point on the riiiht side, 

Mfchaiiistii. — Owing to the relnliToly i^iiiull siiw* and irregular ^hnpe "( 
the ))i'lvii! canal and the large diiiien^iouH of tlie mature fn^tal head, iti* 
apparent that anv [Kirlion of llic lutter. clniseTi ut random, eaniiiit tierta- 
wirily piiiw thiwifjli every plane of the foniier; lienw it follows tlist irmu 
pro«**. of ada|>tation or aeconimmlnlion of Niiilable jxirtiou'! of thi- iinii! 1" 
the rarioiiii (H'lvic plan*!* in iiiH-es.sary to insure the completion of chil^ 
birth. Thii^ is brought atiout by certain niovcnients of tlitt prvseottng [Mrif 
which Ijclong to what is Icnncd the mechuni^m of labour. 

For pnrpo>tw of in^tnielion, we ai\> obli;;e(I to describe the vari't* 
nioveraents as if they occurred separately and indejicndunUy of ow- an- 
other; wheRia* in renlity the nieohatiiMii of lalwiir consists of » coinlinBtHA 
of niorementu, 'several of whieh are jioinjj on at the same time, it bdngct- 
tremely rare for any individual <)nc to take pinet; tolHlIy irn*|KH-tiw of lie 
others, The.se movements are dividt?d into two classes, according a^ thry 
are absolutely ci^seittial to th« completion of labour, or as they nic 
farililale it« progruBt. To the lirsl gi'oup belong the cardinal movent 
— dfU'fnl. intfrnal rotalwH, and extftwon: to tlic second the ac 
roovenii'iUs— Aji'ih and rrlrmal riiloUnn. 

Kngngftiieui, — The meehanism by whieh the presentinu part entiir«| 
Nupvrior strait i^ desi;;natcd as eng;i<;cincut. ThJc is Uwt studied in 
who have Iwirne one or more ehildivn, for the following rcKson : la 
ane the head dcsceniis into tlie polric canal some weeks before tlw nl 
of lalfOiir, and when Ihcre is iii> disprnp'H'iion bctwoi^n the two, IIk 
dependent jiortion of the pi-esenting part li« just above a line jail 
the iiK-hial spint^: whereas in ninltiparou!; women this (requeatly docij 
occur until the eoinmenwment of labour pninn. 

In most multipar.i' at the end of prej^Tianey the head is fnwiy movrfi 
above the superinr »lra)t, or rests upon one or other iliac foesa, and ocmi 
pies a position midway between tlovion and 4>xteiision. Aceonltngly, irhn 
Ibe uteru!> begins to contriiet and to force it towards the pelvic o|>rninf 
the cephalic oircnmfereneu which firi't rftiche* it i* the one that paaai 



a-' 



'■ V 



OV LABOfH IS OCXIIPITO-ANTEHIOH PKK8ENTAT10N8 257 



^K extmnitus of the fronto-occipttal diameter, which normally 
t Il.S n^ntimirtrCM. Nan-, n* the oonjiiffiita vvra i» ouly 11 cpoti- 
D Icngtli, it i» iip|)iareiit tliat » nonnHl-^iufl \n-tiil (nimiol cii^iigc 
iagittal sutun? directed antoro-potitpriorly. li in true tliat ycnlex, 
llcK«iTDn. und Ki-tin-r linvv roccnlly rvvivcd the otd toachia^ an 
Mitiililv of :«uch »n occiirTencv*. nnd hare ret>nrli*d <!a*f» of innd^r* 
tncted |wlveH in which the hend en-iagcd in this manner, with the 





. I - ircFOILC 



FlM. ■^■... 



tjHii\itMS.\ I. 



l^ttAnrvrxz. 



Bludic situated either just bd>in<t tli« syinphyiiiji piibiii nr jnrt 
at tlM; jininiiintor)' cif th« Kacrimi; hut iriaxinuch a« iii all of titcsc 
' labour [iTOTod to be extremely difKcult. it if) eTidont tliat »uc\i 
M mit*t W i-iin"!! !<•[><) OS diiliiK-lly pathological. 
M aln>ady been said. tlH' head u.4uaily eniont tlie superior strait in 
I obU(|n« diamelent ( I'^JJ* centimetres), usually the right, witli ooe 
le lo^tEal suture dirtt-ted twwardgi the Ivft ili»-{H-ctini-At cmiiK-ncc, 
iCbar tun-ards the rifjht sacro-iliao HynchnndroiiiA, Thi^. i^ Virciiigbt 
Biro farlor*. In the lir^t place, the ftrtus, in the later monlha 
Iwrir, luually aMumi^ thin jiofitioti Kp<intanooti«ly ; and Hccondly, 
end of the left oblique diameter is encroached U|»on by the 

(hat. fnr pmdinl purjioMW. it i" shorter (haii tlin right. 

i!lanL<i> it uiay appear Btrange that the head doe* not engage in 

■ diami'tiT of the pelvis, which m«-asurv< 13.5 cenlitnelnw; 

recalls the normal autliites of the superior strait (Figs. 347 

> ia Mua that the proinoiil'try of thv i^oruni jut« forward in Mitch 



258 



OBSTETRICS 



a manner as to make it inijiossible for enf;ag«nent to dccut in this ' 
llur uvaihiblc tmii8v«r'i' ilinnR-lvr in i-oii»iiii.Tnbly »UorU'r iSmii thiK 
llie mechanism of en^>;<'>iicnt has given rise to a jtreat dfa] 
(-ii«j-ion. Nncf;i-]c bclicvixl ttiiit it took placu in cuvb a wuy thut the I 
suture asAuiiitnl un tt-cetilric position, being nearer the pratnonton' 





Kig. H7. tig. 248 

Pioa. 347, 24K. — DuaRAMH ■iioiwivi) wiif niK IIkao Doisa kvt IC-vtiAOC nt nm 
ItiiucTKn or THE SrpKHiiiii Hthjht. 



i 



Racnim than the symphysis, nnil that lhei'''T(' the witerior parieti 
of ibe ttL'tiii^ »iw firnt fHt «n vaginHt examination^ — .Vfl*jc/«"« oU 
Varnier. on the othtT hnni]. from the fltudy of the various frozen t 
at hii^ <lis[Ktsut, ii)iiclii<l<'il timt tlx* licail t'liiint'il the pi-lri>( in au 
opposite direction — namely, with its eaj^ttal stitnri' nearer the syn 
pubi^ Ml that Ibv posterior pai-ivlul Itone waK fimt felt on cxaiiiina 

Ni^llwr of thi'«« viewtt i« qiiit« correct when the pelvis in nonu 
the uterus not pendnloiw. The first prtvuppoM-K Ibiit Ibr axi* of the 
is to Ik- tumid «iiii<-ivbnt. in rru;ii of that of the superior sirail, a 
leecond, Ibat it lies |>osterior to it. It would seem that Varnier ove 
the faft that the cadavers, upon which his conchwioni' were- bajw 
frou-n in tbc horixinilnl |MiKitU>n, uiih the flaocid uteruA rt«iting; u| 
vertebral column: and while bis observations were perfectly correct 
tlnf i-ir(riinis[(incr-*. Iln'v do not apply to the liviii(r vroniiin. in vh 
uterus rises with each contraction, so that it.* long axis correspond 
or l(»«: clowly with that of the superior strait. Moreover, cafrful 
examination reveals the fact that the bciid nsually ■•ngajfCii in i^uirb 
Iter that its sa<;ittal sutiii-e lies either in the middle of the pelvis 
proache* the proiiKiiitory of tbc Micnim. hut only ulightly iiwl not 
moans to the extent that \'ae);rele had supjiosed. (>n the other lia 
condition of alTnire noted hy Varnicr obfainK only in l)io«' casw it 
oonsiderahle disproportion exists between tbe size of the ltea<) a 
pciviw. 

Denrent. — The first rf?qnitiil« for llic birlli of Ik' child w de^-cut 
occurs conlinnouHly. tlioii);h slowly, thnnigboiit labour, from tbe t) 
bend <'ngnfn» until lis cxjmUiim fivim tbe vnpinn. At the samti 
should l«- reinenibered that the greater part of this movcinent jfl 
to the second stafft" of bilMiur, wben il in Hiisiiciateil with the VHiriou 
menl:* In wbicb refei-ence will be made. Descent is brought nbaut i 
forces: (1) 1 ntra-wliri ne Unid prciwure; (2) diretrt pressure c 



iialUNtSH UF LABOUR IN OCCIPITO-AKTERICIR PRESENTATIONS 259 



lp«t thr fcrpurh ; {'.i) cx>nlraHinn nf llw alidoiiiiniil iiiii>^li>!< ; aitil (4) ex- 

lU Uk aDlmor surfaoe of ihe Mionnn ami tUr- [KiMtTior KUrfacv of the 
R^^nm BiiaMutv Iti «m) 5 tfntiuu-lrw nsspgctively, it is apparent tliat 
ifilI{MrUof I body paesii)^ tliroiigh the peWu: cavil}' air to reach the 
nltm rtntit ut lh<' *njiH- timf. the onf? lyinK poitU-riorlv iiiu-it descend 
Mil anrt rafiitlly llian tlie aoterior [M>rti<>n. Ting minpensatory differ- 
Mt IB the rate i>f dcs'wnl of llie portions of iho priiMiMilin;!; part oocupying 
(ktnlerior aiul (Kwienor negiiK-Jit)' of llie pt-iris U known ttn jiynr/i'fiunt, 
ttdiiW«rk illn«ti»twl in fig. 249. 

Rerwu. — An wkhi a:" llic doc^ndiii;; head mwU with resiKtMiice, 

i^rihn it Im- from the margins of thi- Mi|HTi(ir struil or the cwrvij, the 

'•11"'? Ibi- prrlvU or thv 

.pmi' SiBir, flesioa re- 

[«ilt>. Bt thin w mfjuit 

'KU (hr l>ead ..fvtutes 

ital lit tran>viTM! a\U 

* fln a maaoer aa to 

[tfisfthf rliin iiilii more 

liteue contact with 

iWttmx, ilu'THiV «til>- 

*MMniK the AubiHripitO' 

I W^MIii- for i)n* froDto- 

•'•".' hanieter. 

- a purely m*- 
]ilM*noineDnn, 
I'' In iht^ man- 
I n a viiirh ihi> hi<ail ia 
■miticd with thi! VRf 
I MnJ iTituiun. whereby 
mn- 
,innc«i 
9, the ihort arm ex- 

fmui t))i' iHripital mndylm to tho iNX-ipilnl prtilu1>eran<«, and the 
fmm Iht' NIII11' (lotnt to tite diin (Fij;. 2^). It is tbereforo 
Dt I I rfrtiManw irt cnconntrrtii tin* lunj; anti of llw lerCT, 

. iiiary law:" of roifhunicn, muci UMiiid. whiK; thi; i^hort 
i. ami ihu* flexion ia brouf;lil altoitl. 
(Niiul of th>- hirth «in«l at which this movement occurs tariee 
IV. If de>ci-nt U'([ii»K lioforo the external <n i« fidly diluliil, ejipeciiilly 
[iL* tnaririni an' rp»i-Iant. Hcxinn mdv Iw coiiijiletHl Iwfore the hi-ad ti«a 
thf iilero.4. In pcnrmlly eontractetl pettcs. dcxton tab* plot* in an 
itnj nmnnT whlh; enfriiKenient in going mt; hut, m a rule, when 
■ irtion belwiH-n tltr pn'w'Utinjr l»art and the pelvic caiwl, 
. iilil Ihe n'siKtain^i- of the (>eWic fl-tor i< cnwiinteri'd. 
fTmlmtal Hotatinn. — By this vtv uiidc rotund a lurniii)f of the hcsd aliout 
ii Bxi" in i"Uoh n manner that tlw occiput (^adually niovw! from 
'I which it origLnally occupi«cl . tuwanU the Mvniphysia pubis. 




V*a. 3W. — l>iA4i>AH iLLdmuTTisn Anft-Ltniua (Alilfrid). 



260 



0B8TETHIC8 



In left po»itiai» the motion U from left to right, and in th« ivrene dii 
tion ill ri^ht ]>oBitionH (Figs. '2^4 and iTA). 




ElcL 2S0.^1'^oicK 8a;cTitiN, HKmita Htaoe or I.Annt'R, Oin.n l\ K. O. A., UmHSJiXtf 
CsBvrTtrncD fBmuiic). CMnptro with Fl|[. 2<4, 

Internal rotation i§ absolutely essential for t!ie coinjilctinR of Inbour^ 
except when tlic cliitd it; ubnormult}' Email, nnd in tlic anterior positioDE 





n«. aat. v\g. va. 

Vv». 3GI. 2i3. — DiAfliuu* kiioniHd KriivtTrHF KlrZ- 

l(IV, (Vjnteiibion Ol" t>0('IPIT<>.ntnKTAt. IHIO Sd»- 
ocariTcl-BmilUATIC DlAMtTTKH. 




Flo. 2S3. — IllAflRAU 

Ukad Levhk (Anrniaia Ti| 
Book). 



always occurs in the direction indioatrd. Iiidoed, no matter what 
orif^inal position of the Iwfld may be, the occiput Ofiiially rotates to 



KBCHAXISM OK LABOUR IS OOCIPITO-AKTERIOR PnESENTATIONS 261 



fnat, altboagb exceptionally, in occipito-pcMterior presentation!!, it may 
ifn lomnl* the Ixillovr nf thi> Mrnim. 1( should be ramrmWni] (hat 
inliTiul rotntioo iW« Dot oct-ur hy it^df, but U atwayti aisociat»l with 
(tu'lnxrat of tlw pn>M-nlin]> pari. 

Vin»)M ihM^rii-jt hare hevn advaiut»l in Iho atlcnipl tn <!xplain tlie 
[munfT in which internal rotation is brought about. aii<l a va«t titvratiire 
acrnniotalftl upon tin- Kiibject. Poriiiirlr it i>'n> g)>iiora]ly Mit-vtid 
it n§ n#Diit'ri>il ntTir-^urv hj Iho shapt? of the |X'lvic c^nal, it having 
I tatisht tliat tbf f^npi-rior strait ri'pnwnlcyl an dlipc whote long axis 
tTHni>Tcr«elT. niul the inferior vtrait ono wh0M> long axi« was antero- 
rinr: M» that for Ihe hmil to (UvocihI it vra^ ncrosciar)' that its mffittal 
Dfr In- dim-lnl tr»ii!>¥crrtel_v or i>blii)iit>ly to pus* Ihrongb (Ir- former, 
■J anti^ro-piwtt'nurty to p»»e Ihniugb the latter. A littlfi cons iderat ion. 





f** IM.— T)tM»ii>) "»"«»»« Amwuoa 

■brtunirt nuiu l_ (>, A. 



Pio. tun. — Ihuiuu loioiriKii AxmuoR 

KoTATIIiTr riM>H 11 O. A, 



r, w(li MhoM- lluit Ihi* iit not the vm«, for the inferior strait pn>enta 
*» ilnnHi i-imilar o|x-nin<;. its transTcrw diameter \»'in)i il and iU an- 
'«»1»i«terinr II-'> ci'n I tin »-!«*, wIk-o the tWTryx i* displaced bnekward 
^"im labour. Vami«r is tlH>refore j»stil!e<l in concluding titat the iihape 
■ iW pelvix ajunc doc* not iwH:wt«ril_v explain the prodnction of this 
■■••wl; and, inoreoTer, when wo recall the fact that tlie dinnielur of 
'•■■4, which pn«<» IhrtHiph it during expulsion, in not tl»c fronto- 
""ifiCL a* i* nouiill)' utated, but the .lulxKic-ipito-froiilid. vbicb nivas* 
*• W.5 wntimelrm (Fig, MG), it is evident that uulei^ Bome other 
"•f** mulRtwi il ncceMwry, the Iwuid coidd be bom without internal 
"■WiaQ. 

1^ fai-tiir in to W- fonnd in llw structtirw of the pclric floor, and 
^tciiUHi in the IcTfllor nni mu.'de. ' I'he latter \» [xirforated bv a nar- 
^ #iil, throDirb which the In-ad miut [mii-s. Thia opening, even when 
■Bt- ' i. still n-taia-» an oval niHlinc, iLi Irannv^nw diamiiter 

i)*!. i-on-^iderably lew than its antero-poitlerior. and fo [Itis 

At/*- iIh- hraii miiMt adapt itM'lf in onlcr lo lie Ixim. rurtbt-nnore. the 
•f wall* of the perineal fnitl>^ olTer a concave inclineil plaoe oiet 
kb tiie ronmlcd bead readily glides in its downward coarse. 



262 



ORSTKTRICS 




Itiis ex plana tian, althouf;!) t)atiBfa<:tory when tho occiput » origini 
KitiiuU-t) ill Ihi' uriliTior |Hirli(tn of thu [H-lvit:, untilt) not Dix-mearily smA 
Ui ajijily with i^jlial force to tlm^o cawes iu wliidi it n(!«'ii|»ti.4 n [xis'tti 
position. But tlic following uK^uunt of DuUoiif's vxpLTimcut clrarly 
iiii>ii»irat<-s ihiit i-vcn umier siuh cirriiiii^ianccti ihe [lolvio floor vxe 
()re<ioiii inn ting influtiicf iD ihi- production of this movement, " Jn a woi 
who ha<l <)iti) II »ltori tiiiii- prt-vioii-tly in chiliihed. Hit- iilnritii, vliKh 
reniaioi^ tlaicid and of latRB she. was openud up as far aa tlw cp-tV 
oritiit' xiu) lu'li) hy awi^iunti' in a »iiital>lft pociilion almvi; xhv i^tipt's* 
ait. The fu-'tii* of the woman na^ then placL-d in the soft and dilx 
loruit ill lliu right oocipito-jiosIiTior position. Smprnl pupiUmiilK* 
puiihiiig the fwiuH from above, readily caused it to enter the cavity of, 
pelvis. Mui-h gniik-r forci? wun ncedtil to innk*- ihft Itt'sil lmv<-l imx 
perioieuin and olenr ilie vulva, and it was not without a^^toniahnteni 
wo saw, in Ihrw !snc'(T'j->^ivt' adt-mjits, Ihnl when the hiwl hsd Irav.* 
the external ^-vniuil or^nn.4, the occiput had turned to Xivc right ant 
position, white tlie face was tiirnml to thv Ivti and In tlir rear. In a 
rotation had tHken |)hi<ru a» in natural lahnu;^ We repealiil tlie e\|>t>Hn 

u fourth tiuic. Inil us the I 
cJean-d the vulva the txviput 
tiiaiiiitl ptMtvriur. We tlieu too 
dea<l-bom foetus of the previ 
iiiji:!il. hilt of much lar;gpr bikc 
the prnvdiog, ami |iliiii^l it in 
MiniL' {Hifiition as the limit, and f 
in Hucceiaion wiiiii.w«^ tlw 
clvar the vulva after bavinjt f - 
cuted the movcniotit of rutnli* 
I'jion the tliiixi and folloa 
essay* di-livery was aocomphili 
without the occurrence of n>tali< 
Thu& the movement only cnu 
after the perinii-uin nn<l voUa 1 
lo*l the rf*i»tuiiw wtiich hat! itn 
it ncwwary, or at least had been the inciting cause o( it« aecompU 
ment." 

From Solaypfis de Itenhao (1771) to Oie prwent time, many autlit 
aiiionjE whom may be tiiciitioue)! ^k-anlIOI1i, Ilndge, and Kevnohts, hi 
sooifbt to explain the pnichii-lion of rotation by calling atlcnLion In 
ithain- of llif i».-\\ic cnnal. and pointing out that the inclination of it« 
— the indinvd plarien uf tlie priris — wned to direct t!ie occiput aitterki 
By others it was thought that the pnijwliiig ischial spinw aUo pltv 
similar part by iiitfr[Kisiiip an ob^tatk- to posti^riiir rotation. 

Schroudcr believed that the luovcmciit was inaugurated by the bodi 
the cJiiUl roiHling in such a way as to bring its hack more t« the front.' 
thai the hcail followed it. He wnsidcred that this was brought aUiit 
an attempt mi the part of iIil' wti-ru< to iisi'umc its normal lliitl<-mtl sh 
OS its coutenis wore I'sjioUi'd. He did not Iwlievt- tliat the sJioulilers « 



Flo, aoo. — IiuonAii Hiowisn Si'iimi-ii-iiiv- 
luiciiUATic, Sciioircirnu-niuViAi., ami <){> 
t1P^'(>-mI)^-rAt. ]>ia>iciki»i. 



yVK IN OOCIPITO-ANTERIOR PRESEVI7 

ktej until tlui bUacroinial diametCT vtw direftlv ( riin* verso, Wiit oonnid- 

liiat they rtninincd M>mcu*luit Iwhiod lliv occiput — 'M Aegnx* iiccord* 

tn Sclialx — Mid tlint tlu! i»ov<-ntraii nt (hn bod,v mi^rdy inaugurated 

of tlie head, which was Htill ftirUiiT aFccnltiatixl by accoMorjr caiuws. 



•*( 



■ WI.— K«i«j:> Wwniis ■(■■"t-on Wiiit*.x nt Lakivh utih ("hiui rtmi.T iiti.ivKm-.n, 
■■•ntwi nuT RxTKHWAL R<>T*nux or tiik Ueau i» kut I>>:i-cwiikkv vrun ItorATtiiK 
<" m BiKiuuutKt (ZoniM), 

''''liaiiHen in inOI arfia^] En far»iir nf tluH tlwory. but doe« not nvtn 
BiTB adduotl i*nv additioniit I'vidi-mv in jl« ;irf)>pi)rt. On IIk' oHut 
'*' Itiv fruxi-n teclinn nl Zvrc-ifi?!, throui;h n woman who had dii-d ju«t 



S.j?^' 



tKt'wr^f . 



L—I>uuMM SBovnra Deurmr or Hkjiii ik VmrcK PDnsKXTATKiw. 



' tiinli of tlw diilil'H Iw-iid. Aw<k* tliiit Iho laKer hml undcrj^ine 
■!i, while ilie shoutdcrs hml imt mlaied ho as (o 
. rinr diumiUur of ihv oulli-t, thus indicating ttiat 



2tt4 



OBSTElltlU* 



\ 



thev do not iDauguratu rotation of lIil- bead in Hits stage of the 
of labour. 

In !!»0« Sollboiin iimik' a ninct iniportaut coiitribiition. wliiohr 
fl tail tia tod, will i'omi>lftfly n-^nltiiirtiim? «ur i<lt-ii» i:um?i>miiig tbe 
prDciwt. Hi' )i<iI(1h tJmt internal rotation in tbc ininritable i-otiMsgui 
n ilcAnitc jihysical law. Atwnling to wliicli. nhv-nevsr » (^ylindrk) 
of »uit«blv size, wliicli con be Inmt to a diSerent extent in neveriil lo< 




F*a. 2S0. — OtAoiuM Miomxa I>suna<T or Ukao ix Vmrnnx VtaatxnTA} 

is forced Ihrougb a cmriHl cvlindrical canal, it must nwewarilj 
until Ihv piirlJ'in nliicli i* most Rwlily bnil nilii|it>' it-H-lf l« iJii' t^ 
of the canal. Ily studying newly bora children In; thvn denioDiitra 
in verU's; jiri'M^'iitutioiiK wucb bi-ndinji; occur» most rtuuliiy in tbcl 
region, and ti'mis to briiij: alioiil extension, while in faw pre^nll 
occurs in Ibv ojip'D'itc (liritlioM unil brings about flexion. Ac 
in the fonuiT rolntion iiiiL->t takv pinci! unlit the jxiHterior porliri 
nock adapts ili^clf ti> the "km-c" of the birth canal, while in 
tb* nnlcrior purl ion t>f tbe nivk inuitt Ixtowiv *n lulaiitvil, thus caj 
occiput or chin to rotate anteriorly, an the ease nmy he. 

By a RTic-s of ingenious cxiHTimcnts with nimlclx of the 
birth canal, ho has cihovrn that rotation always tKxrun in at-cMnli 
lhi« law, no mutter in what position t)ie presenting part nmy l)e il 
into the np|H-r jiart of the cnnnl. thereby also e.\plnining the 
of rotation iti posterior posilinn-t, OUhansm has admitted tlij 
nt^it of Sc'llhcim'fi reasoning, but maintains that the primaiy 
the back must atill he rockan4>d with af> a factor. 

Extetuion. — \V!ien, after internal rotation, the ^liarply 
nviehtTs the vulva, it umtcrgDcs aiKifber riioveruitit which in] 
c^R'ntial to it** hirlb — namely, it becomes extended hi tliat the 
occiput comt^ in direct rantaet with the inferior margin of the 
pabia. This mwcmwit i« brought alwut by two facton. In the 



JfOHAXLHSt (IF LAiMiCa IN OUUIPITO-ANTEKIOR PRESE.VTATIONS 2ft5 

MM lSt vulnJ outk't looks ui)wnnl iimt fomarJ, t-Mt'nrtiitn itiu.it i>i'i'iir )iv 

/ow liie bi-iul I-41I [iiw l)in)ii);li iu Kur if llw KliHrjtlv iU-spd head, on 

iiliinx tiw [Khic lloor, coiitiDiwd to be driven downn-ard iu tlie KUnt! 

— ' ti M Wivlufnn; — in llu; axi* iif llm SMfirrior sl.ruit — it would im- 

■ >u the end of the i-otwx and tlit- ]>iwtiTior jHtrlioii ut ifn- pcritufiim, 

i li If^ lis a Irrgij wTri- sulticiintly strong, nouM (.•vtiiliially lie forced 

ifiogh ibi' (H^riiM'iU lirv<iit-.-<. Rut witrn llii* li'iid {m'--«M-j( U|i')ii thiw »truc- 

■tt, Iwn rorcua come into plaj, the tir&t aetiog downward, eserti3d Uy the 

iSJtri^ and the MM-ond U|>wiird. fiiiipliitl Uy the na>ixtnnl polvic floor, the 

for*?e beiiig orn? directed forwanl and somewhat upward in the 

of thu vtthal "ix'iiiiij:. lWn-l>v fjivirig rim; to i-xU'iwion. JoMtph 

haa rL<centIy directed aitetitiou to the fact that the movement of 

docs mit occur mvrcljr at the artimilution butwcen Ihc occiput 

i atlaa, hut ia pren^M and inati|!iirat(>d hv an cxteni>ion of the entim 

n^ion. Itv holdf tlitit ciuh n nioveineut brin^ uhout a niarki'd 

in Ihe munniT in which ihe fnnv e.\t*rtiil br the uterus i.t tran^- 

I bi Ihe iwcipnt. aixl liktH'' it to tlie intcr;intitt4i>n of the crank shaft 

I *^*ivn Ihit etui of ttie piMon mw! ihe viUivi of an engine. 

'Ifter the ^ulion-ipilal iv^ion Uiw ronic in oonliwt with the infirior 
°'*'?in iif tlu! vyiiiphyciK puhi«, the Itcad U n» longer to W n'gatiUrd as a 




bi. 3GD.— OUMUN MMWIKO thiUTKMT OF HsitD IH VkktEX PuCSEXTAtVOH. 



■tl, hot fiintplf an a nm-^rnit.-d lc\Tr. the otvijtul hcii)); llu! fnl- 
rnm ndi llw arm extending from it to the diin, w> that any force exerted 
M^ iIk bend miut ncm-KKurily \rnd to farthiT cKtetixioii. A» (hiH lieeomist 
I^bU, the vnlva) »p--niti^ ^Tadiuilly <IilHt<« and (he tic^lp of the child 
lknMue» appan-nt thmujjh it. Now, if we mark iht- poini which rin>t 
>, and [nrcfidly examine Ihe child after it^ birth, we find in left 
iito-antmor prracntatione that it wa* the upper and portiTior niargin 
- iril tfinc Ouit liol nimif into view, while the revenc bolda 
>[ijto-anterior pioitioBs, 



•2m 



OBSTETRICS 



With incrcajring distention of the pcriiinrum and ragin&l opesio):. 
lar^-r and liti'i^cr [Mirlinn of iho occiput ^riKliiallv np|>i-iirs, urn) Um \m 
is bom by fiirtliLT oxtom^iati. the occiput, brrgiiia, forclicsil. lioeM?. mm 
nnd filiull)' till* cliin, su(ci=ttiivi-lj- jiawiii); <niT itic aiili;ri»r mtir^iii "( 
painieuin. Immediatdy afti^ its birth the head falls downward and 
chin come* in cnntai'l wilh ihc region »f ihf aniw. 

KitTniil Hvtaliun. — A fpw nioiiKnts after its hirtli tlie head ucdftj: 
another movcim-ut, ami. wliwi tilt- oi-oipiit ha* bct-n originally direr 
towards the li-ft, it rotalo-i lowardii the left tuber iiichii, and in tlic ui>|i 
site dirwiion when it has boen oriitinallr towards the riRht, Thi* 
known a.'* cxli'rnal rolafioh or n^titiitlon, mid \* >inipl.r IIkt indai <tt 
correspond inp rotation of tlic body of the child, whieh -icrves to brini: 'ti 
btitacrorii)Hl liiaint'tcr into rcliilion with tlii' uiiliTo-pfiMcrior dinmi'tcr 
the pelvic outlet. This movement Ib broufiht aliout by essentially the an 
factor* which produce the inl<Tnjil mlalion of the limd. 

litpnhinn. — Almost immeiliatety after the occurrenco of exti^nal rrt*- 
tion, the niit<'riiir .ihiinldcr fi|){ii-/ir< und<-r Ibc symphv^i?' piihi:^, and in * 
short time tho anterior portion of the p('rina>um iMK-nitios distended hf \\k 
postorior choidder, which if fir*t barn, bi-iiifj mpidly follovi\il hy Ihi^ "thfl. 
Finally, the body of the child is quickly extruded alonp a enrvod to 
oorit'*]K)ndinj; li> the a\is of thi- Ihwit piirt of the birth vmihI— that i*. 
with its upfjer side iiiarkiilly loneave atui its loner (-onvex, 

UechaniiRi of IUg;ht and Left Occipito-potterior Freseatfttioiu-— In 
I.liS" luisi:---. ()f laliour at ibe Johns Hogikins Hospital we ol)scrr*J JSJj 
oocipito-posterior presentations { 1G.8 per cent), the occiput boinn dip 
to the rijilu in B;Jll <ML*t*. iind to tb*- left in 1 1 (-ase". u pmjiortinn i>f at* 
1 to 3. From our figure- it would ap]>ear that these presentalione 
less frnjucntly thnn is usually stated. i\ n-sult prtdtahly duv to tW 
that many of our piitionlK wcn^ not examined until well »dvanf(d 
labour; so that in not a few the occiput, which was originally dim* 
, iMwterioriy. hnil nni]i>rj;"i!i- iiuierior mialion. 

i>ia(;nosi-i.^l'alpation in a right twcipito-postcrior presentation 
Ihr following 'latn: 

Find iniuiu-iivri-: Tlie ftinduii la occupini by the brwch. 

Second mai»i-ii%-rv: Tlic rcuotAnt pinnc of the lark ii felt well bark in thr. riKhl liuA. 
llu^ xiiiiilt |mrl>i Uiiiiu; ini the Ml xido .-oiij in fmtit itnil niudi DMI 
rcntiily [iiilpiiblc Ituui in unti-rlur pn-HriilatioDa. 

Third Ruuiiruvro; Ncxntivc if ihc hmit In ontciigcd; «tlicrini*p Ihn mnvsblc Imul m 
ilelc(*li.-il Blniii' the HU|H'rl<ir nlrail.. 

Fourth nianoiii^-rc: (Jejihiiiip prcniinciirc' on ihf k-fi «itlc (llnte XI). 



4 



WlK'novcr the buck of the child is felt on the right side of tlie niotlwf, 
the possibility of a right posterior position should nlway^t bo Iturnn in miwl, 
as it ocTUtv nearly or quite as frequenlly as the right anterior varii-ly. It 
sliould hImi be K-nicndHTcd, whenever the small parts are distinctly tdt 
in the anterior jwrtion of the alnWnen, that our liai: in all probability to 
deal with a tKistcrior [KiKition, more especially in the rare instunces in 
which the occijiut uccu]ti<h> Ihc hollow of the ii^icrum. In the Iiks frvvfiit>ti 



OF LABOUn IN OCCIFITO-POSTEKIUK PRESENTATIONS 267 



portrrior poeiti'^nK. palpafion jjitm similar rwullit. «\cupl llml tin; 
1^ a rdt in ibe li^tt flank itml (Ih^ »iiiull purU aud cephalic pmiiiiueiice 
[fimDil on dw Tight sidp of thfi HUlomen. 

Da vaginal l»ui-li in tUc right pij^tcrior position, tlie sagittal autun! 

tjma ibe rijdit nbliqiw ^tianieter, Uic? Mnall ronlaiii-Ilc i« felt opposite 

right eacnviliu<- Mnchonlrosis, the large fontanelle Ih'ih); ilinvtt^i 

Ibe left ilio-jM'olincttl onttneni-r. wUik- iii lh« left position the 

otilnins. In many rases, in the <«rly part nf latmur, owing to 

cl flcxiuit of lilt! hMi'l. Ihr largv fonlandic lies at a lower level 

iia anterior poeitioaa, and ia moro Teadilr felt. 

Pb aiiocultjition the hvart ix hcani in the right or left tiank of tlic 
. according aa one ha* to <lcal with a ri^ht or k'ft jimition. Btit it 





-UuiWAM ■nomxu Cwiut n 

L. a. r. 



FkO. 303.— DlAORXM ■■•DWIN'U CKir.D IN 

R. O. p. 



benxl that in the right prtHtfrior petition the heart fOHmls 

tnuumilted through the thorax of the child, and are best 

ifthfr in the middU) lini> ur slightly to tht* left of it. Thii in due lo 

irtial (iTcmion of the bead and the altered relation of the body of Uw 

d, whereby t)u> thorax ooine* in contaet with the anterior utcriiw wall. 

Ufkimvnn. — In tlie vant niajority of ooeipil<>-[io^t<?rior prewntationa 

tntdunism of lalxiur ik idciitieal with that obuened in the aiitvrior 

rfaa. fiecpt that the ocvijtut hao lo rotate from tho re^^ion of tlie aacro- 

I fyndiotMiroeis to tl»e symphi-f^iR pubi*. inalead of from Uw ilio-poc- 

■1 isnLnrtMrf-^throagli 135 ilegrmw InitteHd of IS di^reoi*. 

^ '-H|iicntly inlemal rotation doe^ not take place until the peri- 

ti) tiiilg^, and oeeaniotially doa-c not oivtir at all. nihuiIrik-'iiui 

ir Iwtng tlirn out nf thtr ipit^tion unli«^ tite ohild in very small. This 

innit uioally rcquireit ennnitlerahle time for lU eomp)i>tioit. mi that 

rnnlta a not ini'on.siderable prolongation of lalxnir. Varnier has 

iaf»*l the duralion of InlKiur iu lOn cnw-* of occiput posterior with 

n1 (iKO caww of oreiput anterior presentation, and found that it aver- 

Iknv hoars and ttixtnm miniittv to anf. hour and fifty minutes longer. 

> the patient wan a primiparoux or multiparou* woman. 

II i^-rn-ntaire nf <'i>m-« llu- i>ivi|iut, in^ttead of rotatiox anti*ri- 



268 



OBSTETRICS 



oriy, turns towartls the sacrum, si) that it eventually oceupiea its cone 
According to AVest this occiira in 3 per cent of the eases, while Vi 
and the writer have noted it in 3 per cent and 8.79 ])er c«nt respect 
In many instances it is difficult to explain why posterior rotation w 
but when the head Is imperfectly flexed, the large fontanelle oceui 





FlO. 263. DlAOHAM SHOWINO ANTERIOR 

Rotation thou L. O. P. 



FlO. 264. DlAQRAM BBOWIKO Aj 

Rotation fsou R, O, P. 



lower level than tlio small, whence it would appear that the portion ( 
head whicli remains lowest is the one which rotates anteriorly. 

After the occiput h«s rotated into the hollow of the sacrum, the 
may be bom in one of two ways. Ordinarily the head becomes mar 
flexed and lenjrfhened in its men to-occipital diameter ami eventuall 
region just anterior to the lai'ge fontanetle impinges upon the lower 





FlO. 2<1Ii. — DlAORAM HllnwiNa PoHTRRIOR 
RoTATd'N FBDU L. O. P. 



FiQ. 266. — DiAORAii HHOinrra Po 
Rotation nioii R. O. P. 



gin of tile symphysis pulii.s, affer which the occiput is slowly pushe 
the anterior margin of the |R'riiia'iim. Then by a movement of exi 
the occiput falls hackwaid, mid tJie brow, nose, mouth, and chin 
successively under llu; symphysis. After the birth of the head, e; 
rotation and expulsion of the body occur in the usual manner. 



tU-llAMliH OV LABOrU I.N OCCIPlTO-I'OSTKlllOll PERSENTATIONr* 2(W 

■limnliim t-i S»'n(fv, Wiinkt'!. We'iM. nnd Uiiller, Itie head is oeca- 
»>UiI,r Inro bj anolhcr mtvlmnifriu. triiicli codh» inlu pluy in tliiiM! cuimm 
■bkii ptrtial t.-jtluRitiou pi-rsiMt«. Undor iiuch fiircuinataocts the brow 




''-'— L*K.'»i. M>.iiiJiMP<u or pM.tviMr ■•» 1Ik*ii wrtit Ow-im is IIiuajov nr SjicwttM. 



'^ il tlur vnlvii, mill wliili- iIk' riH>l iif ttiv nn>4! impinp'^' U|ii>ii tlte 
f hvnE., Iiy a nioTciufDt of Be.vion tl>e brow, brvjima. and occiput snc- 
"**y ptts OTCT tlic perinaptim, until finally the face slip* out fmin tinder 
'JUiphniiy pubU. Till* iDecluuiii'iii ufiproucliat clowly to that observed 




prw4-nl»ti<in)). niid i* much nuin- ilit)k-iill Itian tbc one ju!it cun- 

mtl i» mon- lixhle to Itwl to leaiK of the iiiattTnal wift parlM. niux 

lit ibal lu tlic first iiwtaiicc titc vulva U distended bv tha eub- 



270 



OBOTBTRICS 



<iu-ij)iU»-fn>uta1 diaiuettT of the lirad, mid in t)ic i-i-oitd by Utc uoc)piL«)- 
froDlHl, whiirh tiieasurx! rtspoclively lli..'> and 11.7.5 H<nt iiiiiiln^i. 

i'rognosia, — It is g«n«rally bolii!\Gd that occlpito-posterior offer a mucii 
more j;l wilt)}- prngiiosi^ than ocTii>il:0-nnkTior pn'senlAtioitM. Tlu)> k protvfl- 
bl)- due lo thtf fact that Alauriceau, Smellie, and alt the <?ariy autfaoriti^ 
taught tJinl in such casv* lh<- iHripnl aUmH nUaUil int^i Iht- hollow of t^'* 
sacnini. It is true that Naejp?le shoirt;d thai i»o.-lerior mtatioQ was aim ^^ 
of vxc«>))tioii»l 0L'c-urn-n<v. and tliat in tlw vaat majority of caw« the occip ^^ 
rotated anteriorly. But in spite of htw teatJiinjuH, tlii^ older views utill ("^^^ 
vniU-d. Thus Cupuroii, in IWW. latijfhl that epfiutaiicouiT dchvory coo^^^ 
not lake place: and Tarniiir. wliih' niiiniilinj^ the correctmiis of Nac^-k- 
coDcliii^iouK, nc^'ertht.-)e^ taiit;ht that i\k prognosis wao always wrious, fn^^ 
erat when anterior rotation mrunvd, tiK- duration of lulmur wan tnartodlf^ 
invrcasiil and the maternal ajid ftelal mortality aupiu'titcd. 

A 111 to pit rati velv lar^i- cXfHrrti-mv with ihiii elai'H of citHe* ha:* Ivd mi£^ 
to discount Honivwhat tbiw j;looniy views, and to regard the oeeurrenw^* 
of [Hwl'Tior pn-M-nlationit with eipuinimity. Monwur, in view of ou 
uniformly Rood results, 1 do not consider it advisable to attempt to con—, 
vert litem into i>iIkt pnnitioro' during (ho courH; of hdmiir. excvpt when tl' 
foreejtii is to ije ap))lie<l. It in true ilml laixiiir is soiiiewhai prolon^~^i i 

tliem; du/^v. and iu;«(runivntal intcrfiti-m-o i» reiiuirw] more frvvpwnlly 

in 10 \»i cent of the cases, aicording to Vamier, as compared with S.G pew 
cent in anterior prwentationii. In !!81 camnt in which delivery oecurn£»^ 
ttpontsTit-ouHly or wan aided by fon-eps, we had no maternal mortality (li 
rcctly allributitbte to the posterior position, and only onv child was loflt'3 

Even when iho (Kvijnit rotati* inio (he hollow of tli# :iaerum, the pn>@^ 
nosis is not so very had, as in the majority of ra»e> spontaneous iWliit 
ocenrs, bcins noted l>y Vnrnier in W out ot 115 caw*. So doubt when th~f 
ocs^ipiit remain.- |Hwtfniir thcrt- is an inerea-ttl tendency lowar-is i>.rini^-T- 
teari«, which is particularly murke<l when the hc»d is born by the Ipfif frv 
<]uent mechanism. But lo my mind tlw- main oauM; of the dread in whii 
posterior jiresen tat ions are lield is tlie fact that they frei^uently eecajie 
iif;nition, and a<Tordin^-ly. when Tor any reason opitativc delivery Itcctnc 
necessary, the forceps is applied improperly — that te, as in oocipito-aaterir»''j 
pr(wn tut ions. 

When oeei pi to-posterior presentations have deseeoded into the pelvix, it 
is my practice to leave them to Nature as Ion;; a* p'wi'ible. and to intn- 
fere only when absolutely nwi-ssnry. But wlw-n i-onvinced that lh«; 
ioterwts of the mother and child will im subsincd by prompt deliv 
forceps should lie applie<l aeeonlin|r to Ihe din*liona whieli wUI be pv. 
in the appropriate chapter. On the other band, when the head id arr> 
al the su[n>rior strait in a posterior position, vcmion should W reso 
to as soon as 'uie is conviniwl that spontaneous advance will not 
provided, of course, that the operation is fwwible and is not coutra-indii' 
by di*pro[i(irli"n lH*l»<-en the sixe of the loiid and the pelvis. 

Changes in the Shape of the Head. — In vertex pre^ntationa the 
head iin<iergo'-s imixirliini ami elutracteristie changes in -'•linpr, 
result of the pressure to which it is subjected during labour. T 



CHANUI^ I.N THE SHAPE OF THE HEAD 



271 




Fig. 2fl». 



„ liteurs in which the mcmhranu har« ruptured before complete 
dibuiica «( tli« cervix, Uw portion of the head iinmediatdy over tJie m] 
** nlinMl from the p^Denil pn^Ritun! exLitiii); in the uterus, and a» a 
•^"Wifllliwicr a Bt-rous i-xudalf oc- 
f^m mier the scalp at thiH |Kiinl, 
I P'iiig rieo to a wfl ^vdling 
^hirfa ia known ad thi! cvj/iuf 
VIM, In iiio«t vufvs Ihi^i 
tliii'kih^KS or iiiily a few 
liltiinctres, but in prolongml la- 
■ftm, uuilKr Uk^ cirvtinMUiiK^-^ 
umI, It may iMicoiiie very o>i>- 
itili* ami clTn-iiinlly i>rt*M»t 
t-URiiniD); liiijtfr from di.-i- 
t] '>jtui»hin(i IIm* varinii* Kulunw 
•1 fnaUoeUefe. Hlore asnally 
npal i» funiKi] when ihc 
i* in Iho Iiiwir portion of 
birth canal, ami frN|urnlly 
iT aft^r tlitt rtvUlatic-t.- of a 
m1 laginnl ouUi-l if i^noimn- 
It on-uf!i upon the n»o.->t 
pnt-tinii of t)w head, 
rfon- iu 1 1- ft owripiln- 
pmitidOB is found over Uiu 
ITptT um) gNwIi-nnr cstrmnilv of 
n|;ht parietal bone, «i>d in 
kt [ifBtli'lUt KTiT thi- ci>rn>- 
: area of the left parietal 
Ilvnttt it fiillowM litnt tn 
I T it-es aftt-r labour w« 
>> diB^'iiiiM' Ow orig- 
ilioii liy the situation 
-..) ui ■m-nilau<rum. 
Hire important, bowcwr, are 
fi* |iivt)c rliangi-« which tl»R 
1m>I uDiWjfoes. Owioj; In the 
tttt Ihit llx! vanoiu Ixims of 
Ur Anil an.' not firmly united, 
twiwinrnt may occur at the vuri- 
nw ntunv. OrtliDarily the mar- 
pa* irf the Dccipilnl bnm\ anil 
marr nnty Uioiin of the frontal 
bune. tTf piub(<H under tliom- of 
ItlMT parietal Mw^; and in many 
T itof furieui! boti*' niay orer- 

iJm? other. lln' rul« twin^t that tlic one oceaj>ying the posterior posi- 
U nteriapped by the anterior. These changes are of marked sig- 




n«.a7o. 




rion. 30fr-37l.— nn>Ar>>r«KA<x-K of Otnrr Sco. 
cZDAMSf Mi Same tlEiP AT RiKTH, rmiz AN* 
Tb* Dat» BKMmiivEi.r Airm Ladolti. 



272 



OBSTrTKK'S 




niiicance, Mpwially in contracled iielvw, wlipn llie ability of the child ^^ ■% 
bfad to bcwmi? monlileci may make tlie diffcrfuce bflwrt-en a spoiiUm?^ ^i** 

iitw latiour anii a major ohsWtrieaB^ 
opt.' ration. 

\* n rwiill «f priv-^Ha' iIm) iKtwi a\>tn 
UHilerKocs a marked change in ^bape, 
whii'li ('f>ii;'i>la in a dimtniitinn of iU 
giiboocipito-fronta] and occi pi to-frontal 
(liumi'ti'rs. Ill ii|b<ir word:*, it lHH'<)m<.» 
lenKthciUHl from c-bin to occiput and 
cMtiiiprtiMiil in ntbcr ilin>ctiouK. Tlii» is 
clearly shown in Fijt. 2T2. 

In rKTipilo-iiiistt-rior prr-st-ntiitionf. 
vrbi'n the occiput Ima rotaUii into ihi; 
biitliiw of tlic cHcniin. IIk' frontal bont^ 
is nmrk«))y ovcHapped by the anterior 
inarfiina of the pari«Iiil bnnci, which h-ad:> lo u distinct doprcruion of that 
part fif llic head, and give* snmc idea of tlic force with ivhicb tin- ivpon 
of (hi' lar^'o fontaneile has bef;n presawl against the lower marj^iii of the 
nytnphy*!M. 




Fio. 273. — DiAUAAii BnofliiNo Cbienov* 
Rjinox or Heaii ix Vrhtkx Pkes* 

CMTAriOK (Ann'ricHQ Tl>Xt-tlrKlk). 



I.ITKHATrHK 



^*n7ROV. \Wmoir(- iiir riiii|Kiwiliilil|i di- raci'iiucht'rni-nt iialiin-l «-t lu n^rTuxlli^ (hi 

forei-pn dunii \vi porillooH occipilo-punt^ricimv^ liulleliji de I'Arad. du M<kU-<-uii;, 

1833, Nov. 3. 
DciicuB. Qiioloil by l^innni. 

QiKitiiii hy T.iint.. Thi" Si-iencc nnd Art of Midwifrry. NVw cdiiioii, Iffil.t. ITS. 
nuiH.B. Tht PrinriplvB hikI Pruftic*' (if Obstetrii-K. Pliiladrlpbin. ItMUi. 13<t I6l). 
JoNKs. S(Jmc Cnim-'Bot n<J»y in Ijiljoiir. with Special Ri?f(?fiencr tnllic Fiiiicttnti of lis 

Gyni<:(l Spiiio of the FcitHiil Jmir, Obal. and Oyn. Bril. Etnp.. 1906, x. 407 «3. 
Mackickau. Tmil^dm mnladiiv i]iw fvnittiM Kirunv. etc. 6ni(^ (A., Puriii, \Ti\. 
McK^nnoM. AnlcnhpoAlrriiir Poiiilinn of The Hnnd as a CaiMe of DUFicult IjttKnir. 

TniiiB, l^iiitdU OtiHl. S.H',, ItMK). .\h. IW-I.W. 
Mt'Li^Kit, A. fflbpT Hiiitcrhuupt«lii)£i-ii unct Srhpitc'Iliijirn. MonntMHrbr. f. Gob. u. nyn., 

IS»«, vii, 3H^' .-WJ and 534 .■,91. 
Nakukle. Dii- l^hn; voni Mfchniiiianm Aet (Jnbiirt. Mainx. ISSfl- 
OtxiitrfiRV. Boilnm tkit l*hrc vom Mcchanixnius iter fji-bwrt. Stuttpi't. 1901. 

Zur Jx!hrv vmu <><.■! in rtxrni-irhamM nun. Zriitmlbl. f. Uyn.. IIKM, 111,1-1119. 
P:\AHii. TtalW du pnlpnr alxlomuinl, 2ii«- *d., Pari*. ISM, 27 and 37- 1*. 
Rbvnolds, Mi-rlmniwii of I^ixiiir. Ain^r. Tcxl-Book of Ob»t*lrira. 1897, 394— ^tr.'. 
SCAXEosi. Lchrbm>h der CplwrlshiiK*. H. Aiif!.. ft'kii. 1853, 219. 
SntRoKDRit. l^hfbiirh der Gcbiiruhidfc, XIIT. Aiift.. ISOT, 187-I8H. 
Sellhkim, Oio Bi'zii^hiiiiin'ri ilts Ooburlskaimleia u. des GeburUobjt^klm Mir 4J«bur<*- 

mechaiiik. lj.'ipiig. I!MH1. 
SxNTXX. t^.tudo «tati«tique <t( ctiuiq\le «ur \v» piMtlions ovcipito-poaMrii^rcs. Paria, 

18r.'. 
BMEi.i.tK. A TrenliK on (he Theory and P^l(^tilK nf Midiriftiry. P.ijihili cdilUm, IaiIi- 

itwi. 1774. 
Sui^VHi^ UK ttKNHAC DiMwrtatio do jNirtii viribua nuit4>riiiii nlwoluUi. Pftria, 1771. 



HECOANISH OF LABOUR IN VERTEX PRESENTATIONS 273 

Tu-HSKM. De raecouchement dans lea occipito-posl^rieures. Semaine mM., Paris, 

laae. ix. i. 
TuxiKK. Ue I'attitude de b t£te au d^troit eup^rieur et du mechaninme de son eDgage- 
Bmt. AniuUes d'obat. et de gyn., 1897, xlviii. 442-M4. 
AteamiDodation de la t£te fcetale au bassin matcmel. Obot^trique joumali^re, Paris, 

1900. 131-149. 
1m ocdpito-poflt^rieureB. ObeWtriiiue joumali^re, 1900, 181-1S4. 
Vim. Zur Behandlung der VorderscheitelUgen. VolkmanD's Sammlung klin. 

Vortrige. N. F. 1892. Nr. 60. 
Tvr. Cianial PresentatioDH, etc. Glasgow, 1B57. 
VnruL. I.«hrbuch der Geburtsfaiiire, II. Aufl., 1893, 147-lM. 
XwBna^ Zwei neue Gelrierachnitte Gebarender. Leipiig, 1993. 



w 



CUAl'TKlt XIII 
MBCIIAS'ISM OP IAHOVH /,V face. muW. AS'D BftBSCtt 

l^nns^■:^T^Tt<)^■s 



Face Preientatioiw.— In faw pn'M'iitstious tho head in markotlly ex— - 
tended, so that the CKciput lh in ciintji<-t with iXw. Wrk. wtiili^ thi! tan^S^ 
lodbit <1»H*iiwiinl. I'iimnl. in nil niiuIvKiH or KS.OSO cai-cci of Ubotir. founiS^ 
3i'4 t>\ich presL'titatiori!', a j»orii?iitii^ of O.-l jier reDl — ihal i», I in Kvcfj«C 

The tmv. iito»t fn?i|iH>ntly iii-('U]>i(M IIk- n);)it '>lilii]iie dinmotcr of tlx^P 
polviK, sj timt lilt; fhiu is din-ctcd either t<)wanl6 the left ilio-pectiiM«l'-> 





no. 373. DlAOKAM HMUWINII P<UUTII>M OV 

CiNUI IN t.. M. A. 



Fio. 274. — DttuKAu nitnwiHa PoAinaoi of 
CJHiujt ttx R. M. A. 



cinincmce or the righi sacro-iliac eynchondrosis, Acpordingly, llie Mi^ 
nicnto-autorior and right niiiito-imstirior are lh« vufHTtuv u^unllj ub<^| 
nenrod. ~ 

It iB generally stated that face pru^eutalions do not cxiat dtiriog prep- 
nancy, hut owe their orijriu to extciifion of the head at tlie imperior etrail 
at the onset of lahoiir, altlioiiffh Ume. La Cliapolle. Naeji^'lc, S|)iegdWift, 
Kibemont-llfii(-iiipK«, Fieiix. «iui iilheri' have distcrilKHl instance* in which 
Uiey weri' dia^iiofn^d during iiregoancy. There are designated os primarf, 
in contradi»tinctiau to the niut.'h more friijucut secondary fsvo presenu- 
tionjt. 

Oiagntma. — In the left mcnto-antorior variety, paljration givea tlie fol- 
lowing data: 

27< 





t'lmt iiimnaiivrF. 



Kmpn-i uiJii-Lci'itrTTv 




PATION IN UiaOT MEXTO-ANTERIOR PRESEXTATION, 



MnmAXISH OF LABOUR IS FACE PRESENTATIONS 



275 



I'lM uMtuviv: Bn«<i-b ii) riindiw. 

twcradBUMUTni: tl«ri iii thr rinhl Bod pnxtcrior portion of the abdnincn, and di»- 

lIDrlly Ml (inly in il« uppt^r purtiun; miuiU parte hi t«(t tuul 

•Dlcrior purtiim of thr ubdomcn. 
lUdaMMnn: Markml rrphalio proniinr'nii; on rijijil aide. 
IWlhHDa«vi«: Msrkml («i>1uiIm' iMi>iiuni.-i»io uo riglit ode; &ngn« can he doimnoml 

dojilj' «i> left (rinic \I1), 

TV Trrtne lioUs good ia the ripht poeterwr tari*?lT. The character* 
u.Uc (ipi ill tlini tJn> a>[t)ialif pronitiui»« cyin W [iiiljniU^tl on tlit' same side 
a» Otf hmrk, the latter being iliitiuetlr felt onlj- in the neighbourhood of 

( N itginaJ touch tlie face U found in the hirth onnal, and the variety 
of |irwniiti<iti i* dia^noMi-d hy thv diffe run tia lion of tlii: various fi»tuTi«, 
tbtf mtlh and imew, malar honei and orhital ritlgus being tlie diatinclivi- 
fwitnU. la U»u lu/t anltfior vurii-lv, llir thin 0(cnpit« llw anterior and 
ihi- li"'* ilif jKwtiTior extremity of tJic right 
,J.lui» itkmetvT of tJie prlvii:, whilu in right 
pMtf^nr paiaitioiui Dw reverse olitaina. 

(fa aiuctdtatino the heart iu>tmd4 are heard 

tiie unihiliitiA on the e>ide of the aMo- 

nm which iIh- I'mall parts are felt; in 

mnl*, tliey are tran^uiitied ihmugh the 

TIh only otlMn* condition in trhich 

obwrration obtains ia in brow pn-^vi-nta- 

», sod in the rare oat^^A of occipitn-jMiiitcn'kr 

statJonit in which the liead i* partially 

Bdt^L 

Cnrnmlioa. — The chhmm of fait- jircwnta- 

are manifohl, and. roughly H|M'aliing. are 

by any fB<'Iftr u-niliiig Ui bring almHt 

itiua or to prevent flexion of the hmd. 

, markM wiliirgi-itwul of iIm* n«vk or 

tnx, coiU of eord al>nut the itwk, or sj»»Htic 

cttoB of ihr ccn-i<'ttl n»u«'l«, tnn.v aet 

!iu way. ;Vgain, it it* well known tlint 

■•phaltr- i-liildn-n it^nally pre*fnl by the 

a* tbe remit of tlie faulty dvTvlopment 

tte rratiial vaalt 

\1< i-iintHl nut that fai^ presi-ntation' 

inalty due to an elongal imi of ihi- 

[■ital pmliiin of till' iMHuI — itoiiekocfplialtis. 

is i» doubt that most children tliat an* born by tlie fact- har« 
iif tlm i^iariM-tcr. but (he fact that they asually nwumc their nor- 
mal >lia|ie a few davn after lalxiitr t'lKtwi' l>ey<«td nwstion that the defor- 
ni;i( I- Ihe fe«iill riilh*T than the cause of the pivKeutatioii. Zweifel 
i by Orx«rean section a doliehneephslio ehild, whieb tiad pre- 
v the limx'h U-fore operation, and considered that thin (■ase dem- 
-. 'f (he piMf-tbilily of llie cxiidence of u primarj' dolichfKi'phaius ; 




1 1... V.-.. — 1 iDow« or Hr-nt 

TIO.I. 




276 



OBSTETRICS 




Fla, 27rj. — LJoi.[i7iioci:rr[.iMr Hi:a(» ricou 
tlncKcii l*K>MK>it'Ani>K (Jcilmi;liaur>). 



but Frit^ch aud mo^l ohsunen c(>n1<>iit) Dint IIk^ pt%tiliur *ha\wi ol 
lu-ad remiltcii from jintoiure exerted u|mhi it by th* fundiui of the ui 

On Ok- ntk-r liiiiul. .Idling 
and ijttwncT iiave n-'Lvmlj ri>| 
t-flM» which Utuv l)t.-Iii.^vv i^ti 
the original theorj- of U 
and, (HI tht- wlmlc, it would 
limbnble l)i»l ^uch a eon 
may occuKioimlly hi-ar a am» 
Ution to face prettcntatioDA. 

Any factor which \nhi 
with cnga^^miuit nf die- bt-ui 
vmirs (he production of face 
enlationt), anil a<Hxinliu^'ly iirc 
Ihut tlii;y occtir itionu rrH{uenlly wli<>» the pelvis is cafltracti.tl or th« 
TtTV lartrc II is Ihi^rffon? an exoellonl praotioal rule to liear Ihi* 
f)(iK>iil)ilily ill mind wlu'mrviT ont; imi-ls with luck of citga^iucnt 
norma! pelvia. I'ptitjVan iwlievos that thi'ir production is favoiiriHl 
low iinplnnUititiii of tin- placcniu, wliidi he has uotod in two thin 
the faof jirfSL'Htations observed in I'inard'a clinic. 

To Miilllicw!" Dimiun lit-liings tin- credit nf having dtrcutnl atte 
to tlie most fri><|uem taiiso of face presentations — namely, an olili<iue 
lion of the utcriin, which 
pemiita the child's hack 
to sag towards the side in 
which the vi'rii'.v lit-*. Hi' 
pointed out that under / V 




Flo. 277. — I>I*{|RAH HnowiNO 
TW*T IS Kai-B P«lt»KN1*- 

nUKS ■»!« Opfipirr w rliK 
IjUko End or Ilcin Levkii. 



Fio, 278, — I>i*nRJtu iu.ifitTKATiK>i iMrowini-Tn 

UIIITR IH Fack PniWEXTATIUMH WHKM TUB i 

DinKcTi.T foHtrnoii. 



ifiH'li cireitmslancKi' llie altitude of the ftf-tux booom«t) distortwl a" 
normal, m that a slight obstacle to the descent of the [Kwturior | 




'II AhlfriJ). 

1^- C»ilu-Bnlfrior art' four tiiiie-> more frtHjUHit than rijilit nwipito- 

^'^***- {irtaK'ntMlinnn, llw *unir tvtn THn«lii« »f t«w pnwculativD occur 




3n.~Dium*M «Mi><riKu IiKi.ivr.nT or 0tijui w Pack I'uwiJrrATiox. 

*'"' *'>»''>-i i-qiml fm|acn<-r. Th«l miilliparity wnnid naturally fBVfttir 
"> nt ihifl condition iii vviiient, ninit- Ux alMlmniiiul wallfl allov 



278 



OBSTETRICS 



till.' ukriw^ to aiiiiiime aii oblique posilioii. Thiis ['iiiari] aiitl Wim'kel 
tiiat (iO [Krr n-iil of thi^ir cju*-* iKTurnil in imiltipuroiK, mid out** H 
cent in primiparoii!< woiueii. 




Fia. 38t. — t>MUKAM HMOWIMI DkI.IVKKV or FICAK IK pACK PataEXTATInK. 

iVffAimwm. — As toKW are UKiinlly derived from vertex prewnlatioi 
i-i apparent tliat iho former are but rarely obeen-ed in a fully d«rtfl 
^taU' Al l)ic xuporiiir wtniil, wlufn' ilic brow gunvrulljr digagtit;, vhil^ 
lac.e de^tnnd.i oniv after further extenaion. 




Pia. 2A3.— fiiKiR^H •>i({>viK(i nuivEHr or IIbad pc Pack Pim>i3tTATit»(. 

Ilie nHtchaniKm >» tlti'W pon.i( citttxist)! uf tlio rarjitwl iinot>i*im«^ 
di'sciiit. intoriml rotation and tiexion: and the iivrfgnunt tuopf^tm^n 
«\t<r«simi and i'\lernal nilnlion. liofcftit it brought abrtut by tlm 
factors a& in rerlvx pniwtiitatioDH, wtiile exleHxion rwnlta from tli« 



'VBCHANISM t)F LABOUR I.N FACE PHtSK-NTATlONS 



279 




Vm, 383. ^Skoii'Itio Ilnm>Kni»t 
iir FjK'K jtrr(.H IJki.ivkkt w 
t'Airn t*>wi:STATW>K. 



vtiifh llie linily of tito child liear^ tn iu lit^d, Dk.' Inth-r being con- 

I u il weK into a lvri>-artni.'(l k-vcr. the lonp^r arm of which exlendn 
tbr ovcripittil ««nii_vl«' to llie ncciitul; hi iliut wh4'n n^Li^tflnro ie uu- 

rtwl the Utter is puslicd upvranl, while the chin dewiviid* (Ki}{. 277). 

fartMJ rotaliim Uti* for iXs ndjo-t tlitf 

m iif Uif fagt* ill i^iirh n inaiiiiAr a;; to 
tix- rhin undur lliv syiiipln^ifi pubti'. 

oibet^iiie luitunil <leliv4>ry <-iiui)oi lie 

IJMbed. Onlr in tbie way mit the 

^petKl Ihr piwlerior «urfa(v of the 

TOs puhiH: whort'aii, if Ilic chin hi" 

fi pcwtcriorly, the sliorl titvk innKl 

d the Ulterior mirfaoe of tite Mscnim, 

Dtcainim li cpnliin<>tnK in Uii)^h, 

Ihif liirth nf t)M' head U niaiiifciiily 
>i)ih' unlatfi the ^lionldrr^ mn enter th>' 

Rt till- »>ami' li«i«, whii'h is ptxi^ihlL- 
vitb nnr nuall or iirvmaliin- chtldn-n 

2TRt- 
ficr anlcrinr roUlioD the i^iin wh) 

II apfmr at the rulva; Ihr nitilor i«iir> 
M Ibe diin liemm<!s stemmed atfairnt 

Vnphy^io. and thi* hmd i» (IHiv<>ri>d hy a nioveinont of flexion, the 
nw, lirow, lire^inn, and oix-ipnl a(i|x.'ariii({ in siiwt-ssion orcr IW «n- 
rmu)!in <.f tlie |icrinii'Uin (Kij^. 'jsn. asi. mid 2ft2|. Afler tht- hirth 
M Wm) thi! ovctpnt MijCii l>«rkii-»rd towaixls Itiv anu«. ant) in a few 

moinvnU tin- chin, hy a inovoiuent of 
externa) rotation, tiinis to the xide lo- 
wartU wliieh it wa» nri^nully din-rlwl, 
after which ihe i*hf>uIderB are l*om an 
in vertex pn^wntntioiu. 

In n uniall nundier of oa^it interDal 
rotation, inxti-ad of occTirring anterior- 
ly, may take pliiee lonardrt tite holloT 
<if the sacrum. I'nder euch circnm- 
i>tan<-«^. for Uh* rmiionit given nlMve, tlw 
birth of a normal-Hizeil ehitd iti iropo;- 
niWr. Itwil. in I1»ii5, has Ntiowii that 
t : " "'^* ° " \''Z^'^' «"*•'' » ''*^ '" «>inewhal too extreme, 
^r for. nftrr n-^K'wing ■■■> cm'i'^ of jHTxiKt- 

ratn-prwtrrinr pr^^iilntiniut re[M>rt4><1 in tine UtAmture, he fontid that 

Kicn delivered wilhonl chan;;e of pn^^-ntation. This, liowcrer, 
: Ir taken a* iiwlienting that Hrieli {Kwitiorix are not very «eri- 
ir fn Ibe entire series 1 l.B per cent of the mothers and 40.1! per 
rhildn-n {H-ri^hi-d in >pile of attempts at di-)ivory by vari- 




■r Head ts l\rr. pHmKK- 
(BninKn T«t-llook), 



iitAtioiiK Ihe fate hitiomfN dinlorlrtl imiit); lo tV- elTn'ion 
iW -kin. mhich wlwn marked t-ompk-tely oblitcratai tlie 



280 OBSTETRICS 

features and h very likely to caut^e confusion with a breech preeentatioi 
At the same time the mIluU undergoes considerable moulding, which i 
manifested b^ an incresKe in length of the inento-occipital diameter an 
a diminution in the vertical diameters of the head. 

Prognosis. — Until the latter part of the eighteenth century face pres 
entations were considered extremely unfavourable, and most authoritie 
advised their conversion into Koine other variety. But about that tim 
Deleurje, in France, and Zellcr and Boer, in Austria, pointed out tha 
most of them would end spontaneously if left alone, tiie latter autbc 
stating that lie had observed spontaneous labour in 79 out of 80 case- 
and had applied forceps in only a single instance. 

Owing to the excessive distention of the vulval outlet by the greate 
circumference of the head — the men to-occipital — deep tears of the pea 
na>un) are of frequent occurrence; and owing to the prolongation ■ 
labour the fa'tnl mortality is markedly increased, being usually estimat 
at about 14 jier cent, though Weiss lost only 4 out of 78 children (^ 
per cent). 

In dealing with face presentations it should always be borne in mL 
that internal rotation docs not occur until the pelvic floor is well distent^ 





Fio. 285. — Diagram tiiiDwiKa th*t when Fio. 288. — ^Dtaoiiam bhowino that *■*» 

THE Vehte.i w on Tirr. I,i.s-e joisisothe the Face ib on thb I<evel or thk Ik*' 

Ikchial Si'inkh, the okkati-^ht Diameter ial Spines, the Grbatbbt DiAMim o* 

OF Tilt Head mas PAasKU the Supehiur the Head is btili. Above the Scnuo' 

Strait. Stjuit. 

by the adiaucing face ; and fretpiently, when the chin is obliquely postmor; 
it does not take ])!Hce until the obstetrician has almost abandoned hope 9* 
its nccTirreiiee. Nor should it he forgotten that the face must occapj * 
lower h'vi'l than the vertex Ijofore one can feel assured that the greate^ 
circumferenci! of (he head has passed through the superior strait ThU 
can 1h' readily a]»pr(viaied from a study of Figs. 285 and 286, in which H 
is seen that the distance from the parietal boss to the vertex ia only 3 cmti' 
me(rcs, whereas a line drawn from the same point to the face will meunN 
7 centimetres. 

Trrnlwnt. — Tn tlic anterior varieties spontflneons delivery is the lA 
and even when the chin is obliquely posterior, anterior rototion nniQ] 



ll£i:UAMtUl OF LABOUR IN FACE PttESE.NTATIONS 



2S1 




lldiiii^'li t.ricn ntil iinlil a very Ut« [x^rioii. [n vit-w of ihi- inoTtotis 
alli!»iliii^ iu fiiilitn-, luul purtk-iiUrlj- when the fnw rolat«s into 
* of ttif Nicruni. in appropriiite 
■n Bliuiijit olioiild be tniuJf to ^ubeti- 
I ■ fffles |irvst>ntatJon. Wtu-n tin- fiice 
M ibvply LfiifBi^tl tliiH i-an Ix? rvnililv 
ipluhnl, tfitticr liv iiiioiiiii^ up Uiu 
or by making traction upon the 

till! dun is directct] tuilcriorl}', 

ipti nl tiinrvrsiiiri nrc iml nrtvi^ihle, as 

*Mtd niert'lv fiilwtitiiti^ »n iHripilo- 

iir p««iliou. which is but ttliffhlly more 

iliti- than tlm urig'iaaX tnw jint^eiitu* 

nut Ui Hpi-ak of tiw iiicrL>a>«(l JunKt^r 

Id »hH'h tlw wimisn miwt nrrcw- 

«uhjcct«l durin}! tlie luanivuvrL-. 

jtiely powtfTiiir [KMitionx, ^ oa the 

hand, uinren-ton h urKenlly indittalcil, 

ikNihi Int alu-iii[iUvl flk MHin at lliv cx)n- 

n i> recognised aixl the de^rei' uf dila- 

M«r the cnrfii pmiiiti, I'lidcr thcw 

mtUHo th« unfavourablo mciito-poif 

Rtmnrrrtrd into o favuuralde occipi- 
|br pn-JH-ntnlion. 
m iJrao tri time numennu methrtd.t 
' '•*» i<ii^gr»loI for thif purpot*, tlio oldoat and most effectual bcinj; 
MWui)-, ailrAc-atisI tiy lliiudt-hN'i|ui> ani! tvriTod Uy Thorn. ttVU.*, and 
»: AttHn]ptj> an' nimli' l<i puiih up Ihf chin by two fin^re^rs iutmducMl 
'■biTRpna; if l)ii.-> dm-s nol I'unii'd tho ptttiiail w aiiif--<tlH*tiM-(I, thv 
1» Wod intrmiucfil, and ihc head di(i]odfri<d, after which the vertex is 
■H and drawn ilown. At tlir iMimi- time tiw vxlernal hand of tliv 
Vatta the aA^.islant carrint the back in tlw opposite direction, so ati 
italc Mi-xinn. Vita* owlltiit n-sult)' hare liccn oblaincil by this 
and it* adoption in suitable caHex cannot be loo slrongty 

a iuittri^li-d thir tnctliocl of external ninntpulntion pirtnred in nio*t 
^oU, by which the vertex iit Kubtitituted for u presenting face. This, 
', i* nin-Jy avaiUhli-, inasmuch as lh<- pn-Hi-ritatioii d<KW not bocomu 
ilrteloped until after eng^j^ement has occurred. 

t fbt fam be too dcvply «ngaged in the pelvis In admit of tlie Bnudc- 
» Buuupufre. Ilie patient flhniild \» let alone and descent allowed to 
pU«r, m Oh- hope thai anterior rotation will occur when tin; fflc* 
» [' floor. If, however, this does not take place after a rea- 

:\vpf should tic applied in the manner to l>e dt^crihcd later, 
lit mad>^ to rotate the chin to an anterior poxition ; Bnally, if 
'\ resource lie* in craniotomy; although s^'mphyMOtomy 
■I bv Darts in nuch cssch. 



Pw. 3Sr.— UUdllAH UROB-IKO R»- 
UCnoN or riir«ll'BE IN CoK- 

Tmii'tN or k Face ijcto a Vcit> 
n:x PiiucviAnoN •* THoo-s'a 
Haiioivviir. 



I.- 



OBSTETRICg 



When the chin is ^itiiatcd dirw'lly poiiteriorly, and atferopts at 
version b«vv fiiilii], fxrfalic version ^lioutd be pcrfi>riinii ii* *aan tii 
cDRilition of ilie cervix will ix-rmil; liul if ihp face he m firmly oiigi 
that it cunii'it bt; piiitlieil up under anaesthesia, crauioloiny or piibiitti 
niu.-'t tie rcHorled to bb kooq a« the pati«iit'« condition ralU for d«li] 
The former has bf«ii rciR-Bti-d Iv pradiftwi, hut no Tar a* I know Monl^ 
is thw only noe who has perfonrn-d pubiotiimy under llie circuiastaud 

Brov Prwcntfction*.— Iti timw iironenlationii ilie head occnpic* a 
tion niidwHy l)i>iwicn flexion and extension; hence the porlion situate) 




fin. 280, — DiAciBAu hmoitixo Pa 

or CUIIJI in RkIIiT PutlTKMKHI 



Fid. 2(tfl.^I>iAaR*>f UNO wind riiaina» 
or Ciiiiji IV I.Krr Antkrkir Hkow 

PlIEBKNTAnilN. 



twecn the orbital ridjii.- an<l large fonlancllc pri>sttntit at the »upi-rior 
A« ncnrly cilery child whicJi is boni by the face has gone tlirou^h a 
liniinary stage of brow pre^ntation, (ho latter niu»t occur quilc as 
qucntly as that of the face, later underffoing spootaneoiiH conversion 
either a face or a verti's pn>»entation. It in gonert'ly stated that pereii 
brow prt-seii tat ions o«'ur oncu in every 1,500 to 8,000 cases, thougl^ 
Wei** oh«'r\'i-d one exaiti|ile in every I, (loo ciimi#. 

Ilie causes of this presentation, which have \nxa carefully ftaSii 
Aldftdd, an- jiractically idciiticul with IhiB^e (jiving riw to face piw 
tions, and dijwnd upon any factor which intcrfere-i with tloxion or 
mnUf* cutciLHiou of the head. In twin pregnancies not infrequently d 
both children may present in this manner, and Ahlfeld niaintainai tha 
anterior surfaces of the Iwo fietusiw coming in contact mutually dii 
tbe noniial tle\wl attitude, so tliat extension i& facilitaiiil. T'>nall 
brow is directed toward* one or other cxirtmiity of tbc right oblique 
liter of the superior strait, and awoniingly the left anlcHor and 
posterior varietii>8 are the ones mo»t fri^iuently encountered. 

Piiitinofv'. — The presentation can be recoji;nl»ed hy pnl{wilion and 
nal touch, ihoii^h the data ohtainahte from the first are not so cll 
teri.ilic ai* in the more iiiuimon prcM-ntfttioiij*. Ilie condition of i 
i^ found to he very similar to that observed in face presciital ion#. i 
that tlie cephalic prominence- 1* le»# marked on the cide of Ilie back, 



CHANISM OF ijVBOtltt IN BHOW PRE8EXTATION8 



283 



muuiki- iifTi-n^l tiv tint c-hin ran 1m* felt <>ii t\w »niiiv kiiIv bs the sniull 
On vit);tnal tniioh the rrotital anil the anterior (Mrtion of the Mi^ittal 
ini i-nnrnMli-riil iii one of Iho ubliijiiv diiinn'tiT*. ut one end of 
Utf Urgi! fonuiuelli' or th*- portion of the skull jii»t posterior to it 
U Mi ; while nl the olhtrr thi- orliitul ridgM, tJie root of thu noi^e, and 
lar be diitlinfnii-^heil. Ordinarilr it U not ))osiii!>l(> to patpatv tlw 
dlin, for when lh<v« are wilhin rcaeh we have to d<Mil with a facO 
itiim. 

Wianufli. — llw mi'chanism of labour in brow preRentationa differs 
ly with ihu Mze of ili« fiplibi. Ahlfeld and mo^t ohwrvers harfl 
that thu is mot^t froqtieiidv below th« normal : wheroos Weiss main- 
l^t Urg« diildn-ti nrv the rule. In tl)e former t-AM lh<> miinto of 
ru a rule h qufti? ea^y, while in the latter it U usually rery ditlicult. 
««M' of the diflM'uliy it appan'Mt •nUrn we i-oujiidCT that tho diairwrtir 
head which must eo]^)^ at tlie superior Hlrail h the meoto-occipital. 
_M)(cnMtit i* iherefiin' inipinsiWli^. unh'Ki' tho dnhl in of hidbII 
t UT uiarked moulding; has taken plaee, hy which the mento- 

Bikl diamt-tcr ha» hti^ume diniiiiishi-d and tlit* frunlo-occipitul incTUascd 

&fttr moulding and dctfcvnt Hnw occurred the brow usually rotatM 
fWflv. Bud tilt! for^'hwid, orbital ridj('% and root of tlie nose appear 
• iiUa. Une of llie iiupenor [iiaxillanF' bunci> then lM'eoni«« xti'mmi-d 
M iImi infi'rior mar^'in of the ftvi»p)i}^i>i, an<l the rest of tbt- head i^ 
ij a inoTcinent of cxtrt^'UK* flexion, the brow, bn-gma. and occiput ap- 
tg in inireeMiton over the anterior mar^fin <>f tlut perinirum. Afli^r 
itih of th«* oixiput, the month and ebin descfwl from brfiind the pubic 
la a mnirt.fnent of extension. In other wonU. we have a nieehani»in 
*hat limilar to that otisfr%'('d in the lees frequent mode of delivery 
nw of jmiiterior occiput prewn- 
, which have rolaltil into tlie 
<« of the sacrum. 

i* ha* alrvaily Uvn )H)int)N] oat. a 
AM oanont enter the hirth canal 
mt flmwid'-rablc moulding of llit- 
TMu mHn materially to the 
i of lalKiiir and ri^ultw in iIk' 
ofchtldrt^n willi characteristically 
Wd hnada. The caput i» found 
the rnrwh^ail and extendti from the 
ruli:e!< to the lutge fontanellt^ 
inanv fu*f* i* ito markeil at) to 

■' rwuiij hy vaj^oal touch al- 

idc. In DwMC cattm, as ix 
J "I, the forehead in very prominent and ^uare, tlie mcntft- 

^ r l»rin); diiniuiahed and the fronto-oivipital diameter 

— Tlio outlook in jXT-ii-ient fonuji of brow priwi-ntation id 
J fianii to be had, unless the ftrtuo Iw tmal). In the traniiient 




Fm. 29a — IMmiham aHoitiMa l\>itnov- 
KATinX or lil;4l> in Mmoh- rawcKTA- 
noH (Amokwi Text-Book). 



2S4 



OBSTFTTRICS 



VRrietift', of coiirw, it (Impends upon tlic presentation whicli ultflH 
resulte, and wlivlher tlic taw or verlex <nitj?r» the birlh canal. 1 

Batinniil tiii'LhiMt.t »f tn^iitiDcait. n^iniilar to lliosu iiidirnU^ in fa(« ^ 
entatiotis, mid mori' parlliularly Ktriitor iilliiiliiin U> awptii^ teohniqiic. It 
l«l lo n iimrkwl iiiiprovfineut in tlie pra^nosis, Tliu« Alilfi'ld, Frilo 
and Uwlin (lS73-'tlj) coltecti'd :I4 cu«« with i nmti'mnl and 
dvatlu, 4 of which went dircdl^* dtiv to tlto prcttentation. Weife, ol 
other hand, ha.i re<?ently rpportfd 'i9 <.'a)T(.« from Bruuu'# cUnic in Vi 
wilhoiil H dcHlh of firltiK or motliCT. 

Treatrnfint. — If the Urow he recognised at tho superior iitrait, the 
mvnt will vary at-cording a^ llic prrscnutinn proinimbi to be tranai 
persiftlt^nt. The fonner slmidd he left alone if the brow tiu anlvrior, 
will buenniP eoiittTlitl inio a iiifntn-aiitiTinr prcu'hlalion, anil the r' 
will pnilMilily be liorn s|)onlaneouiiIy, On the other han<I. if the prv» 
tatioo appears (o bt' pontiifteiit, and <-vfn in tntiMifnl vtutf vritli llic 
posterior, atleniptu at ronversion should l»e made before the head, 
undvr^ne iiny great dcKTco of moulding — that w, n« iv>on bi* tlw first 
of lalMMir ifl coiiiplelLHi. If ihe brow lie dirocteil posteriorly it is 
ally possible to t'Sibslitiilf an wcipilo-aritcHor pn**'ni«tion by piwhi 
the presenting part with the fiugern in the vafiina, while at the name ti 
attinipiti are made to flex tlio childV btnly with the i-xlernal linnd. If A 
triaiiipulations are not «ncet-s«ful, version »hould be jwrfomied, as n» 
mended in face prej^entations. If the brow b» directtxl lUiU-riorly. wb hi 
tlie choice lii-lween oonven ■ into a face pres^ttation by va;K:inal maoffl 
vres, or internal podalic verai ollowed by iramediate «xtrtction. Pa 
ally I am in favour of thu latter proa-dun*, whieh iihoidd alwaya be cmpi 
when attempts at manual ranversion fail. If the brow l)e well engagtd 
firmly IImhI, (-onvrr^ion kIicmiIU not )h* nlttmiptctl uiilejui n»ft !« 
push the presenting part up to the level of the superior strait, "the 
treatment Ik identival with that outlined above. But if thi^ caiui 
aecouiplishi^. the ease should \ie left to nature, and forcepe *])pliej 
iiuiicntcd liy the condition of the mother or child. It i^lwold be 
liered, however, that delivery under thwe ci renin stances is nearly 
HKtoeiateil with roiuiderabU' injur)* to l)i« maternal »ofl {narts, owing 
large circumferenee of the^'iital bead by which they are distiMided. 
lieh hiin iinide nn CBrno'l ^>ii for Ihi' pcrrnrmamc of (ivnipb\>"»lm 
persiiitcnt brow prennitations.'and has reported 7 operations with dq 
Ivrnal iind noty 'i fii'liil ilitnthK. 

Breech Presentationi.— A^ has already be^i pointed out, the 
lic'twwn Iho lower oxln'mitioc and liuttoekn of the child k nn( alwi 
same in sacro-iliac presentations, and we therefore dislinf;nish 1>^ 
frank bn^Tli, compldi- iiri'it'h, f(Hil. and knee pn?H.>nintionK. In all i 
varieties, however, the mechanism of labour is essentially the same, 
they ne»Hi not U- eonsidenii wpiiratfly. 

Usually the breech engages in such a manner that th** sacrum is di 
to llu! li'ft "ido of iho molIuT, and ne(«nlin^dy the left eaoro-anten' 
posterior are The jiositions most fre(|uently olwterved, having Ihx-u notj 
two-Uiird» of niY ca»ex. ■ 



1 i 



MGCIIANISM OK LABOL^R IN BREECH PRESE-VTATIONS 



2S5 



ift lOO.tHHi voMs) uf Ubonr. Pinanl oWrvei) .t,301 IikhtIi prn^nta- 
tat ■boot ;i.3:J |i«;r ivui. TIk-w Hlalixlkv indiKli- prciiiiiliin! n* wwll 
■ bD-tartu labours, bat it the latter alotii> are ooiisiikrod, we find one in 




|1^!n. — I>i*a>j|]a nitoK-iira Fomman or 
Cmu* ix L. & A. 



Fin- 392. — liuaiuu luiDiriKa Votanan 
a* Cttiut IK R. H. A. 



OkfMMt. — On palpation, thp firrt manctnTr? m'eaU a hani, r»tini1, 

jblUtdile l>Kly (Mvu|iyJng Mw fuiulii^ of lti«- uIitiik. uvX wlivri the nb- 

mll» sir vi-n- thin nni' cun ocu-o^ionallv obtain a charaPlt^Hntio 

aenaation DQcred by th*! Xxnaen the skull. By tlic twoond 




L~I'wixxM BamnH, I^rm P*«t ov pKKdMAiivr, Oiitn IK U a T, (WiOd-j-CT). 



286 



OBSTETRICS 



mautptivn.- t))L> buck i» found to occ-u]>v one Mile of the nbdniiifn 
»Biull [inrls ihi- oilier, {lOMlion aiii) vnriotv ln'in(i drtcrmincd bv the 
iion of tile former. On the tliirti uiuiKviivrt-, if vDsageiutuil has not « 
Ciirml. till- irrt-giiljir lirii*li w (ni.-\y niovabk- uhovi- tliu superior sU 
' while, if it Iins alreaily occurred, the fourth niarwMivrt' ithowit liuit Itii; 
is tilled by a wifi ihusk wliivh int«rfi-Tc» willi the ))cut'traUou of the fiti 
into its cavity (Plate XllI), _ 

On vH^iital i-xniiiinnlioti the diagnosis is made by reco;^iaing the eha 
aeterisiic |jorii<mH of tlic linwh. Cn-nt-raliy ifpt^king, one can fwl 
tuU-ra ificliii, tlio liuerum with iU spines and the anus, and wlien fur 
de.M<ent has oceuri-ol Ihe e\t(^rnnl gienitoHa may Ih^ dixliiiguishvd. In 
eni-e*', (!*[ii'cially where labour is prolonged, Ihe buttocks heroine mart 
BWollen, io Ihal (lifrtrpiitiiiiiiiii iHttwi'cu tljo 1sk\- niid brcoch may Ic 
dercd very dillicuU, as Ihe onus may he mistaken for llie mouth, ami ■ 
ischial tiibi^roxitiefl for thci malnr bontttt. ('are In emtnination, lioireij 
i^hould prevent this error, for when the 6n;!cr is introdueod into the . 
it experittnccK u inuKotilar rE^islantv, whttn>fl]> in tbv mouth the fir 
more uDyieldiii); jaws would be felt. Agaiu, on removinj; llie 6np?r, it 
not infmjiK'ntly foutid (« be Mtniiied u*itb mt-eoniuni. which could 
occur with a fniv prewnttition. The mo§t aecunite information, ho 
iit obtaimi! from Ihi- Karnitn and :l» xpiniht. for when IheM art fell 
diagnosiii of [mnition and variety i« cstablir-hed. 

In eompli-li? bnwh pn-sinlatioiis, the tt*l may bo felt alongside of I 
.buttocks, and in footling prcKentAtions one or both feet may hang On 
into the vnginH. In Ihe Utter vase, one enn rvudily determine nrhicli f^ 
is encountered by lM?aring in mind the relation of the great lo«. When I 
breteh bnw deseendcil iIcc|iit into the pelviit cavity, tlw genitalia maj ' 
felt, and if these an> not deformed by an effusion of i>erum, it h poffiiliitl 
diapno*e the se\ of the fd-tui'. Only under smh cirfuuixlaocvs can It } 
eertain as to this point before delivery. 

The firliil Ill-art Noundi' are bciin] through the Imu-k <>f tlie child. WHbU'' 
at the tfvi! of Ihe umbilicus or slightly alrnve it, 

jStio/fjy.— The aiusfst of hrewh pn'!>entalions are manifold. .Aio>nl' 
in^ to the ex|>eriinonts of Kchatz the foetui, when suispended in liqo 
amnii, nlway* sink* by it* bultockit, no that if gravity wrv the only 
iiinei-iniHl, hivi'ch presentations would lie the most frequent of aU. 
matter of fact, however, thi» i* by no ineaiii' thu wi)*.'- 

In the later months of pregnancy head piviscntations re^inlt fmil 
process of accommodation betyri-i-n the fu'liil ovoid and (ho utrrns; 
ingly, hri-ceh prciwn tut inns are prone to occur whcii the process ii in 
ferod with. In the earlier months tluw factor* do nol m> n-adily 
into ptsy. a"'l ljnxi;h pn'sentations arc acoonlingly much more conia 
than at term. They also occur very frequently in twin prcgnanciet 
in cuseti of liydramnioK, inii-''nuich lut the increased dl^tentinn of the nt 
int<rfi-re-* with accottimoiiation, when gravity cause;! tlw brcoch to d* 
According to I'inardV BlriliNtiis, Ti9 per cent of all brf-ei'h pn-i^-ntat 
occur in miiltipane, in whom the flaccidity nf the ut^^rinc and alidoniil 
u-alU plays u part in their ]>roductioo. l*heir occurrence is a]«o favours 



MEmANlSM OF LABOUR IN BREECH I'RESENTATIOXS 



287 



iln* jirtwruif iif an* iilj-t:arlc H'liK'li iijijMws tin' i'fij;ii{;«'iTii.'iil rif tin- Itiiid, 
■iz' in iiintracted pclvi-^, I'xnxivt.- »izv of the normal lionil, or h)'(lro{:f|:ilkiiluii. 
Hrrhiinitin. — I'niaw ihunt In- mhih- iliKprcijHirtioii IjctwcL-n Iht- sLto ol 
ihe chill) and tW pdvU, emgagrmeHt nnd tUwent t&uIi\\ occur in niw- of 
the oblHjuo dumiL-lciv of the pelvis. Uip dntcrior hip beinjt directal towards 
ilio-jKi-tim-iil fiiiiDotKi-, itiiil the p^KiiTinr liip tHwnnU (he opixHit? 
iliac KVDchotMlroMifi. Tlit' (oriiior uriimllr <)i>M-(>D<b< more ra]>itlly than 
tfav lathT. and wltvn it vncouiili-n Uu* rvxixtjincv of thi- pulvic floor, intvmai 




ffa. mt. — Piit<WAU i»i>wiNo DtHxenan or Imiksxai. KoiJtTioN ix IL 8. P. PiMtnoM. 

rwMitca nj-DKlly (xvum nnd lirii)^i> the nnlerior hi|i In lla- puliic tirvli, the 
^fcnH.-hanli-rio diurnvtor of tlio child coming into n-lution wilh the untcro- 
|pMto<-ir>r dinmr-lrr iif llir JM-Ivi*- niitlot. Kotalion u;<ualtv lake.-i pliioc frnui 
tbr ■lio-p^'inliDtud I'liiini-iuv to the putiiK thmu^'h nn arc of 45 dfgrecs; but 
. ....... li, wlii-n the loH-k i* anicrior. nnd giurticulnrlr when (be \)0*' 

tiity is prolafwixi, it may ntvur in the opposite direction, the 
: lup mtutin^ pu^t lliir KiK'nitn uml (hrunglt th« o]>[)Oiiite lialf of 

- - 1* — i, f-, tliniujfli nn arc of -i-i't di'gi'ci^. 

JLtt^T mtaliim, descent conlinntw until llw pi-nmriim i* dtHU-ndcd by 
■dv^ix'inj; tim-ch, while the anterior hip ap))eaiv at the vulva and ia 
amin>'t the pnltic arch. By a niovi-tiivnl of laUral fifxirm of the 
tl Mir hip i» (ht-n forred over ihe anterior margin of the perl- 

irr. 1 iraelN upward over the child. lhn» nlltiwinjit iln Itoily to 

.-D «Bl, whi-ft [lie unlvrior Iiip i* l>oni. The le^ and feet follow 
bn-t*-'' "wd in"y he l»orn spontaneously, although not infmiuently the 
rtf th« otn'trtrician is inquired. After the hirth of the breech a slight 
)I (if fjtrrnal roMvm oii'urH, and t)>e Itack UHtially turns eome- 
XD the fmat. ■$ the rei^ult of the stoulden beinjc hrou);ht into n-lalion 
at Ihe oblique dianietVTK of the pdvia. They then descend r«p- 
Bodergn intitnal rotation, the biHueromiol dinnieter now corre- 
Wtth tliL* uuti-ro-piNttetior diameter of the inferior gtrait. The 



2S8 



OBSTFTRKS 



«linuli)c'r» art' f<»ll<iw(«(l bv llic liciul. wliicli iiorniallv <li'»TCi.*nd« shnrply fl«*M 
upon llif Ihorax. IniinLHiiiitdv rollnviiiij^ thiir hiiUi i\w hen<l. wliich Um 
i]t<«cH.<ii<lcd in one of Uic oblique diainvU'rti, roUtnt in ttuch a umnncr it* In 





Fict. SOS. — HinTR np IIkaci iw BRRXon PniwisrTATTMt. 

bring the neck nntkr t]ie tiyinph;^ia piibU, after wliicli the head is Iwni in 
a position of (lesion, llio cliiii. inouOi. mw, fori'tu'inU bregma, and oi-ciput 
nppt^iiring in aucccttsion over the periiueiun (Kigs. 293 ami :ii9C). 




Tn a ■■'iiiall niimhiT of raM-i rotalion otriint in «iieh a munner tlinl 
back of tlic child w dirci-tcd towarr]« the vertebral poliimn. tnxtmid 



ME(;HANIKM UK LAKUUK IN BHEIiCH I'llEMENTATluNS 289 

tnw'anl,* ihf alKliitiicn of tin; niolliir. I'iiiUt such circwrnstuucus tlio face 
8|i|it'ars iiiiiliT lilt- s_viii|))iy>!is |itil)is. tlio (utx, lirow. iiitd liiiuilv the (Krijmt 
.-li|']iiii^r ciii»-ii iiiiilcr it, us tin' lieml is i<i)rii. ll is v[ tin- iiliimsl iniporluiui! 
Ill n'mi-mluT that if iiri'iiialurr triK-tioti Ih' i-riiiilimil the hi-ml may boctmnj 
I- \ [fill 111], wlit^ itti dflivury can imly 1m; UfcoiiipUshoil liy the njicratioii of 
I'Atriii-tiiin. 

I'rn'itKmi. — So far as thi; life iif the inotlier is niiKtiriipil, the prognosis 
■iilTri> lint sl)<rhtly in hnKt-h ami vitIcx prcsciitations, cxi-i-pt that with 
ill-; fonricr lalxmr in slower ami nmn' liahli- to \k conijilicatiil hy pcri- 
ii>-al tears, which froint-ntly cxtcml tlinniirh tlw s|iliin(-lcr ani muscle. 
Thv jirojrimsis for the child, on the olhi-r haml, is con>iilcralily worse than 
iu vertex proi^eu tat ions, the ftetal mortality U'inj: ^'cmTJilly estimated at 
al-iiit l'> ]KT ei'nt. This fi^'iire aj>|)lics to |irtniijiaroiis women, but a soine- 
• liiil I'.wer iM-nrntajre obtains when all classes of cases are taken into 
■ -••nsi'ii'ralion. It is not so hi^h in mnlliiiatiius women, for uwin^ to the 
;.'T>'at"T ri'laxation of the soft |iart.s the child is more readily cx|M"lliii 
-j"iniani'«iiL-i]y, nnd when extraction iH-eomes neei's>ary it is more easily 
acL-oiiijiii-heil. I'orak states that 1 child in \) snccumlii^ in the former class 
'<{ i-u-^--. and only ! in ;!ll in the latter. 

Till- s'lnjlin- jiro^iiKisis for'the child is due to si'vcnd factors. In the 
fir-l fda<f. after the breech is iKirn as far as the uiubiliens, the cord is 
iv\j«'-«->l lif a yrcater or lessiT de;:r(>' of com]jressi<in lielwi'en the head and 
ihv /M'ivif hriin. It is iisiially stati.il that not mon' than ei^'ht minutes 
Ciin •diii'M' lietwo-n the hirlli of the iirnbilieus and the lU'livery of the lu:ad, 
U thf child is to !«■ lK)rn alive, while us|ihyxiation may fn'casionally occur 
ai an i-arliiT jMTiod. 

Nut iiirriijni.-ntlv fo-tal death is liiie to |bc premature se]ianition of 
ih.- {>Iiii-i-iit)i. for if lilt' delivery is no! proniplly elfeeleil after Ihe head has 
rm—^-il into the lower pari of the birth eaiial, tbc partially em|iliiil uterus 
niav ri'iraci lo such an exleiit as to sejiarale the phu-enla from ils walls, 
■ ri>l lit"- put a ^top to the nteni-plaeeiilal eireulalion. 

In iiriniijiarons women, where iiiiisiderable n-sislauee is olTeri'd hy (he 
r*>l\i*' r^*tt [Nirts, s|Ninlaiu-fnis delivery of the head is ofleii niiavoidably 
«i— lit*'-*! and fictal diiilli residls, nidess the eliild he exlrai-d'd manually. 
In iill cBiH-w of hrccH'h pn-sentation, iheri'fore, lln> olisli-triiian slioidd Ih; 
Tin-|iiir"-"! to render pnunpt assistance if .Natun- shows herself unalile to 

Trmtmrnt. — In view of the serious foilal profjnosis altendinjr hreiTh 
|,r"-^'ii"iti'ins. the nhsletrieian should aim (o [iri'H'nt their oceurrenee as 
far 11- [•'issibli', and wliencver they are dia;rnosii| in llie later wei'ks of 
f.r»-;fna ru-y, an attempt should !«.' made to subsiihite a verle.x prisentation 
hv ni'-'anj' of fxlrrnnl I'lrMnn. This is readily aeconiplisheil in uHilfi]>ar;e 
with lat aMominnI walls, but is much mnri' dillieult in primipanc. After 
th«^ -utrititution lias l>cen olToctiil, the child shoidd be held in its new posi- 
tion I'V a properly fittinj; bandage until enjrafremeul of ihe bead oeeurs. 
for if thi.'= piwaufion l»e not taken it is not unusual for Ihe child lo n'veit 
^ iUt orijrinal position. It must, however, Iw coTifessed ibal sueb riieihoils 
only occasionally successful. Ilvlernal versiim Jiiay al-o he alleiiLpted 



290 OBSTETRICS 

in the firet stage of labour, provided tlie breech has not descended dcGpl>iV- ^ 
into the jwlvis ; Imt when it has once become fixed, all Buch efforts ar^ — -—Z 
unavailing, and it is best to leave the case to nature and be prepared t-^:^^^ 
interfere when necewsary- 

In many cases sjmntaneous delivery occurs, and the attitude of tl~_^^-,, 

obstetrician is merely one of expectancy ; nevertheless, he should alwa— ^^ 

hold himself in readineits to intervene at a moment's notice. For th — Tr^ig 
reason, an sO()n as the breoeh appears at the vulva, the patient should Ije 

brought to the edge of the bed in order that not a moment may be lo^t f n 

performing extraction should if become necessary. At the same time eve^^r^V- 
thing required for the resuscitation of the asphyxiated child should t»* 
ready for instant use. It is most im[>ortant to remember that labour -»•* 
materially facilitated by the arms retaining their normal crossed positmox* 
over the thorax, as well as by sharp flexion of the head. This is bef^ 
attainc<l by firm downward pressure upon the fundus, which should b^ 
maintainoil by Ihe nurse or an assistant, so that the obstetrician can keep 
his linnds clean for any emergency. 

Owing lo tiie fact tlint the breech forms a less efficient dilating wedge 
than the bead, care should Iw taken to prevent premature rupture of the 
membranes and the esca]ie of the amniotic fluid. For this reation among 
others, as few internal examinations as [Wissible should be made. Generally 
speaking, the frank breech forms a better dilating wedge than the complete 
breech, innsmuch as it allows a closer application to the margins of the 
partially dilated os. On the other hand, if interference becomes necessary. 
the complete breecli offers more satisfactory conditions for immediate de- 
livery, as a foot can reiidily be brought down and used as a tractor, so that 
the question arises whether it might not lie better in the former class of 
cases to make il n rule to bring down one or Inilh feet propbvlaclicallv. 
Usually Ibis is not advisable, unless some abnormality exists on the part 
of llic uiotliiT or child which renders it [irobable that prompt dcliverv mav 
Ih> called for. In such cases a foot shoiiM be brought down by Pinard's 
mario-uvre us soon as the membrnncs rupture. The ti'dinique of this 
mani])ulntioti, as well as the rules for e.xtraetion, will be considered in 
Chapter .WI. 

LITERATUIIF, 

Ahi.fklii. Dip Kntsti'huiig von Stirti- uml ('rcsirhlBlapcn, Ixipzip, 1873, 

BaI'iiklckiU'e. L'.irl tics acc-ouphfmyns, 178i), t. ii, .16— (0. 

JioKR. Wjflti'ii Kdrher iibcr riiitiirlii'hp (ifliiirlshiilfe. Wicn, 1834, !)fi. 

HrojN. Dt lii IHc (111 fd'luri iiii |>oiti(. dp vue Je ri>lMi(^tri(|iie. PuriH, IB7«, 

Davcs. Thp M:iiiiii!Piin;iit «! I'nif Prcwiita lions. Medical News, July II, IttTM. 

DEi.KTitVE. Tniili' d™ appoiichfiiipns. pIp, Piirin, 1770. 

I)l!N''AN. On (lie Production iif Pn ■sen till ion of the Face. MeehaniKin o( N&tuiul and 

Morbid Parlurition, Edinbiirch, 187.5, 218-231. 
FiBtix. ['lie rilwrviitinn ilp |jn''scnta(ion [irimitivc de lii face. Comptes rendua de k 

sue. <l'<ihs1., .Ic KVii. .■( dc i)!i-d.. VMHt. ii, 22,"j-2:tl. 
FluTsni. Klinik dcr K<''iiirl.-iliiilflirbi:n 0|MTalioimn, Hiillc, 18S4, 142. 
CltL'4S\Kn. Ziir .\pti()li>cic dcr flcKiclitaliifrP". Zvilarhr. f. (ieb. u. Gyn., 1897, xxxvjj, 

302. 



MECHANISM OF LABOUR 291 

SxctBL Ueber die ScfaBdelfonn bei GeBichtskgen. Berlin, 1869. 
^mmumBAjm. Ueber ffiUle Scbadelfonncn, etc. Archiv !. Gyn., 1896, 11, 33-48. 
Il.u^<xmLUt. Pratique dei accouchemens, 1821, t. i, 382. 
AComcMOEST. Sjmiphyaeatoiny in PeraiateDt Mento-poNterior PreBeiitation. Am. JiMir. 

out, 1904, 1, 343^347. 
'""■MsimiAif. Etude ilatiRtiq: e concemant Ic cas de presentation de la face ayaitt lieu 

1 la dinique Baudelooque. Th^ae dc Paris, 1904. 
l^XxtMo. Tnlti du palper abdominal, 2me 6d., Paris, 1889, 32-fiO. 
R>ami. Pennatent Mento-postcrior Positions. Am. Jour. Obst., 1005, li, 6l-5-6.1'>. 
W Ti iMOin^PwaAioxEB. Precis d'obBl4trique, 1R04, 425. 

"*'^ tw. Die Umwandlimg von Geaichtslagen zu Hinterhauptsla^n durrh alleinigen 
mmtna HandgrifT. Archiv f. Gya., 1873, v, 306-331. 
TdierdaiScbwerptmktderFnicht. Zentralbl. f.Cyn., 1900, xxiv, Nr. 40, 10.33-1036. 
^naiLSEKO-WiENEB. Lebrbuch der Geburtshiilfe, II. Aufl., 1891, 172. 
*^(W. 2ur maDueUen Umwandlung der GcsichtfllaKen in Hinterhauptelagen. Zeit- 
riir. f. Geb. u. Gyn., 1886, xiii, 166-220. 
Db St^UDft der manuellen Umwandlung in der Therapie der Geaichts- und Stim- 
kgea. Volkmann's Sammlunft klin. VortraKe. 1902, Nr. 339. 
ViuicB. De la ■yniph.VB6>tomie danslcs pr^ncntations pLTsistaiitcB du front. Coiiiptea 

raidus de la hoc. d'obat., de gyn. et de pw-d., 1902, iv, 18-34. 
Vim. Zut Behandlimg der UeaichtB- und f^timlagon. Volkinanii's Sammlung klin. 

Vortrage, X. F., -Vr. 74. 
WacXEi^ ZurLchn! von den (icsichtBlaKcn. Klinischu Htolnichtun^-n ziir Pathologic 
derGeburt. Rostock, 1H60, 59-6.5. 

Bemerkungen tiber einige O^niilitnilu aus der praktischcn KntbinduiigHkunst. 
Wim, 1797. 
twmtFWU Lehrbuoh der Geburtshiilfe, 111. Aull., 177. 




] 




PUYsiouxiY .\s!> m.\sm:emi:st of Tilt: Tiiinn htmie of t,u 

Situation of the PUcenta in Utero. — The (>l<)cr uii()M>n; bclirvMl th 
tlie placL'nia wm; usually itnjilanlitl at or in the iminediatc QcJ)^hboiirIt<« 
of tin? riiiiilii*. Tim riwi'iinhi-* of Si-IiixkiIit. Piiianl, AhlfHd, I^xipiK 
Ilolzapfol. and olhfrs, hnwevtr. have shonii that tliia is \>y no ineaiiM - 
rule, biit Ihiil llio must cmiTTiim silnation '» on tin- iintvrior or poirtiT- 
wall of llie utoiTi!!, orcasionallv on it.- lat<?rnl wall, and only id i^xoi^iliik: 
iiistaiUTs iipnii Ihc fuiniii>i. Fi},'. 2;i7. wliich rcprtwi-nU a vt^rtiral sect i 
liii'oiiKti ilic iitt-ni.i at Utiii, «ho»-s tho usual inodi^ of atlariiim-ni. .\ t 
mil" tilt' lower niarj^in i>f the plniviila lies sonn-what aboTO th© InitTi 
OS, for wliiii il iiTi|iiiijiC.* »|H)n or ovcrlajia the latter mw ha«o lo <lisil w. 
a palliolofricat conilition — plairnta pnrvin. 

Hcchanisni of Separation of the Placenta. — ritdiT uonual i^mhli 
the phuriita niiiains \\\vi\ to Ihe utcrmi.' wall until after the birth «f t- 
itiilil. ami iRvotiiw N*pnratiti fmni il only diirinj: (In- Itiiril *tafa' of \n\"K- 
Wliile the tlrst aiirl wixind Htagca are iinneediiig, tJit; uti^i-iae c»nlra(Ii'>- 
tiring nbout a ■'li^ht dccreas<! in art'a of Lhi; i>iirfaci} tu whicli it itt attarlie^ 
and in its atti inpl h\. acconiinfHlatjon llie plaii-nla iHi-omeji ^lifclitly {i\i'^ 
Hfion il"clf. il* niar-jrne beiiif; souK-what roundM and proniilieitt. At iS 
sainir tiriii-, liowcviT, it Is pn-»isi (innly ajEaiiiht thi? ut«rttnr vmll M' tP 
amniotic iluid, throu;;h which Die intra-uleriDc pre>wurp is tratiiiniilt'ii' 
ntlM^vrix- it i^ pnihablr thai pix-muture lu-paration would Ix! Ihv rule U^ 
not the exception. 

Aflrr lh(- ■■.\pnisiiiri nf tlic i-hiid. tl nnlraetinn and n'trnctiou nf 

nteruH lea<U to a coUNidcrahle thiekening of its wallH, with a irtrn'jtpoadiiM 
dtfri'iiHe in the siw? of it* nivity. "* wrll ns to a rapid Ii-iwninp in \Y 
6rea of lh«r plaeenlal dile, Mventually the (!iftpr«p«»rtion Ikvoiikm so (;re« 
OikI the jitni-r jvirtinn of tlie jrlnndidar hm-r "f tlie decidua h Ini" 
Ihroupli, and llu- plaii-iila and mi'mhrancw are scparateil from {\w wal 
of (he iileriiK and conic in lie fnt- in its c«vity, whence they are expell*! 
by further tuntrnotion!* into tin- lowt-r uti^rine se-ginent or Ui« uffpiT 
tioH of tin? vaj^ina. 

Aft<!r ilx I'xtni.-ion, the :nnli>rniil surfiui- of the placi'Titn dtill retiS" 
n (hin eoverini; of deeidoa, which ix'pn>ent-i the atrophic conipaet Uy« 
and the innermost |Mirlion of the Kfioniiy hivor of the dixrtdua fcrotinj 
whieli nnisl lie flrippnl off in onter to reach the chorionic villi. 

Mode of Extrusion of the Placenta. — \* early nx 1789 Bandelooqt 

had dwcrikd two vnty* in which the placenta could b« cstnided from (1 

302 



i 



% 




)DE OF EXTRfSlON OF THE PLACtlNTA 



393 



W 



TInM, MTparatiun from tin: u1(>riiie null cuuld coiiintence eilher at 
of th« |>l(uiiiia »>r at a point io iU pircunifcrenee. " In tho 

', the middle of the plat^nla U'in^; |ni*li(il ffirHttnl hv an elTurtioii 

of lii'Hxl lii-ni-iilli i1. llic organ bv- 
comm inrertwl upon ittrff iu fineh 
n innmiiT Hint it prpKi-iite by its 
fn-tal BUrfiuv, vhich in atvered by 
tliv nn-mliranc* iind vowls. . . . 
But w'iiiii till- pfiici'iilii iiiM^imis 
di'laclHil Ih'Iow, particularly if the 




*'■ — Immi«4iii mriirlxii Rn.«ni>K 
•• fWurt* fn ITterini Wau. im 

**"•■ Pur or PiuaHAwrr. x |. 




Fki. 3nK.~l>i«>iR4U kiinwivfl Rclatiok or 

PtlHT.VT* 111 I'tchitik W*ti. IN StAMHtn 
Htaiik nr I.AnouH (iWHtiKnl (mm (tchni*- 



■"■■p I«f((infl at a point in the neifiihliourhnni) nf the internal oe, the 
rhuiB ti> witirt-ly tliffemil. for the afterbirth bvcnnim rolled upon 
nf in tbf> fnrm of a cylinder, whiwe long axi« rorn-*i>on<i!i in tlmt of 
> "tmR, in fiifh n niannrr that it presents itg di-twh'iil iiiuterna) fur- 
■■^ tn ll» i!ia]iiiiiin)f finffcr, and ibi exit i* alwayn preretlcd by a small 
" of Haiil hlfywi'' 

iilitu w-cm to havr cinrib-it but litUit inlOTMt nnltl IftflS, vlien 

I the opinion thai tfte ptaivnta was iiAitallv c\[N'llr<l by llw 

. rilMij by ItuiidflnrfpK-. Tbtx Wlii-f riMiiHim''l practieaMv 

■ntil IHTI, when Matllieva Dumwn contended that tlw Mtmiid 



294 



OBSTETRJCS 



wan the ijioro fivquent and normal mcchatiitim. Tlic active din 
arouHcd by tliit^ KluU'nu'iil. nltliougli it U\l to no final etHUviticDt of 
<)tii'slii>n. li:i<l l.bo ('ffirl of (linn^tin^ tnnre (Mroviit uttt-ntion to the pj 
oloxj' of this t'iajia of lalwur. 

Th<^ two niettiotlt* aiv now ilu-sifcniiUil by l)it> nauK---< of Schiiltxe' 
Duncan respfcrively. in the formtT, neparstioa begine first «t the | 
trill pnrlion of tin' placciiln. bi*lwti'ii vrliich nod tin' utennu wull | 
or Iphh blood in ponred mil, irbich grndiially increnne* in amount ur 
ivlrij-pluci-nlul liii'maloina of iiiiD^idcrulik' the iti foniiisl, vhich invent 
brings aljoiit Ihe coinptolo »e|karation of the oi^an fmni itit aiie of at 
mcni. while the inembrnDm still remain adherent. The placenta 
]>n>8t>ntr> at \lic. internal r» by iitt fiptal ttiirfHcc and pas.'ti'j) thrniigli 
opening in the membranes, dragging them after it; it ia then exf 




(Pi-Hlttlomui). X }. 

from the vulva, itii firlul or nmniotic surface first, and lh« now inn 
iiK-mbi'ttneK following nfli-r. In lbi« iiiecbaniMii tlicri' If no t^cnpc of ti 
until after the extrusion of tho placenta ( Kigs. 300 and SOI). 

In l>iiiiMin"* inelhotl. tin lh« nthiT hnnd. the ptai-entii, aft«r its Be| 
tion from thi- uterine wall. Iiecom&i foldi>d upon itself and its Inwor 
prrKiTln Ht llu- iiiliTiwl OS. It ihcTi tnivvrsi')' lh« vagina and emerges 
the vulva by one margin, the nu-mliraiios Iteing sometinifc«. but by no 
flIwuyM. invt-rtttl. Wltcn <:-\pu1«ion ocvurf! in this manner, there is. 
but cnntinuoiis hamiorrhago from the birth of the child until the pi; 
i« delivered (Fig. .Wi). 

With respect to the relative frequency witJi which thesw two mi 



296 



OnSTETRICS 



wan Ihe caw. MontiiTi-r, tlic sliili.i|in> bmii;;!)!. ruru'ikn] liv vnrtou* 
wniild scoin In ivudii' il)e niaitcr still more niici?riaiii. Tiius Xii-<;lt 
wruin^' iiiiiliT llic insjiirultiin of KWiliii^. folates tliiit \w. nliKi'rvvil DiMu'iii 
mi.TlmiU!<iii ill SS.G |wr ci'dI of Ills caHt'w, whereas in 79,76 jier centj 
AlilfoIdV cn»« timt of Scliiillac wns nott^ 

Holxjipfcl. in an o.^clli-Jit nmiinfiraiih, Im* givon di'taiU «ih1 a 
liu-riitiiix^ fliiiling with the t;tntU)i of thp i)uc>;tiai) hji to ISUH. ami, Af 
ri>e-iiU of vchf' inu-reiitirm cxporiinente anil otioervalinnA, conclmlea Uiat 




Fki. 302. — niaaRAJH ii.i.oimun^va ICxTiirHTnx nr Pi^i-f-kta kt ItitTnTjuc** Mr-mtKin 

[ilacenta nearly alwayti presCMitH at tho intprnal tm liy l)iiiicnii\ but lu 
the iiIltuk by Schtiltw'x HictliaiilKni. 

Allhniigh it is tiitlii^iilt to rcoDitcik- tJic cron trail ictory KtAtcmcnL* pf ^ 
varioiii; oliKL-irors. it would nppi'tir jtintiliaUlo ta cla^ both mccha 
[ifrftWly ndnnal, that (if nuiiian oreurrin;: inftsl. often wlii'n lliit )tla 
is xitiintnl in th{' lower portion of the iitfnis, tliat of Schult^o vhm J| 
iiitiiutt'il ill llie ii[i|H'r [iintinii. 

Clinical Picture of the Third Stsgc of Labour. — I mmcxlialt^ly foll< 
tlii> liinh or till- I'hiiil, ttu- rfiiiniiiil<-r iif lli(- umnintic fliiiil <?«rapit<, attv) 
whieh there is ii^tially a fUshI How of liloo'l, Tbp iilenis can now W ft"" 
a* a firm, Imn! iiih.«.», the fiitulu* Ivinj; a fi'w wtitimi'tn's hi>lnw the ii*"*' 
bilicuH. I-'or a short lime llu- [mticj^i esixrienwa no poin, hut after a to* 
niiniili-x iilerim: eimtrtteliom; bepin a>;Hin and nx-ur al n>'i))ar inln 
until the placenta Ix'Mimes scpaiati-d and ii espclleiJ inti> Iho lowtr 
inc M'^nieiit. 

At some tinip, varyinp bi'twoi-n five iiml Ihtriy minute* after the hir*' 
of the child, oarofnl pHlpation shows that the fundus of t)>e utt-rtf b* 
risen 3 to 7 cent iniH res nhnve its ortirinid itfwilion. wbik' ^itntiltnncoa^ 
a iltglil [irfiininenw has a|i[»earwl immediately abore the synipb\>iK pu 



a !*■'• 



300 



OBSTETRICS 






the end of two hourw, Ou the other h«ni], there on- ivrtjiinly v^ry 
«l>jcclion« to auv uiinei^sflarv prolongatina of llio tlnrH stiige of iabu- 
For the puticnt n ddny of «-\'rr«l himm luMwiiii llit? Ipirlh of the d 
niwl thi- coiiiiiklion of labour, means much additional dictwnfort and 
increased risk of iiifi-etion; while llii- husy phv^'ioiau van lit afford 
<>3i[i(-ndilHri; of valuable time, vnles-i hi? be conrinwd that hy such 
gonal sacrifice lit? cnii Ix-ller iiwiirc the wcll-lieiiig of lii* pativtit. 

lit normal casas therefore, attempts at expression should not lie n\ '-. 
until the placenta has been spoil tancout^ly cxpi-lled into lli« lower ute-i- 
«e^ra<?nt or upper portion of Hie vagina ; huL as soon ih thi» has t»l 
place t]iere is no reamn why the process should not be ha^iteUMl. In i 
ou'ii vliiiic th<! following' ))nii-iiliiii' Iim!' Ihk-ii adoplinl wilh iiKxvl sat 
faftorv re'^idts: Ae soon as the child is born Ihe hand is laid upon 
abiloiiicn, and if the ult'nix can \w Ml a* ft firm, hard, globular mn 
is left alone. <lu the nther hand, if it spixtara to be soft and flaccid, il 
grntly hniraded iiniil firm <i>nlra('li<ins are indutti). The (.-niuJitioii of 
uterus is then carefully watched, the hand being applied W it at freijiiP^i 
iiiliTviil,'!, but it ■-'■ kiii';idi-<I only whi-n iii'ci'.-isary. In the majoriiy J 
cases, after a lapse of ten or fiftcea minutes, it is notie^ti tlisl tM 
(nndu» ri«w up -1 to 7 ccnliinvtr(« above the pmition whicli it hat ji> 
o(>ci]})ied, but at the saiiie time remains Hrm and hard. 'Jliist chanj 
indicate* that the jilticinta hii.-* become weparatcd from the uterine 10 
and has been expelbil into ihe lower uterine si'xuienl or the upper |i«rti 
of tlic vagtiia. Ill doubtful caxcs, important information may Mmcti: 
lie nhtainitl by Iioldiiij; tlio cord lightly bi-tw<^n two fin^-rx and msli 
firm pressure U[ion the uterus with the other hand. If tlie placenta 
f^till udluri'iif. a ilislimt waw will In* felt in llie cord, which will 
absent if separntinn has already occuri'ed. Attention waa first diiw 
to the forinur point by Pinurd. SehnHiler, and Cohn. hut its impnrtai 
has not been penerally rwopnised. The placenta is now expelh-il by j^ 
ing the nlenw and mnJiing downward pri-*»iiri- in the axis of the supri 
strait, usinjj the uterus merely a§ a piston to sliovo tin- plnci-nta d'> 
ward and outward. When iJie IhIIit apjHurK at the vulva it ebould 
grasped by Ihe hand and the membranes gently twisted into a cord, 
tw to prevent Iheir being lorn o(T from the margins of the placonta, a 
which tliey are slowly i?i:traeltd. 

TIic modiliealion here reconimcndtii. which wo dceiguate ss "exp 
aioii from Ihe vagina," leaves the separation of the platviiUi from 
uterine wall aitsolulcly to Natures and simply expresses it after it 
lH«n siwnlam-ou.-ly exiM-IK'<l from the uterine mrity, and sliouM not 
confounded with the typical ('rede method, whose obje<!t is to ha^lcD b 
wparution of the organ and to cxprew it from the uterine earitj". J 
most cases the placenta can be ci[prei>iwd from the rnginn within balffl 
liogr after the birth of the child; but if tiie fundus does not riftsl 
spontane<msly by thi- end of that period, it i» my practice to resort to U 
^fpical Crcd6 method of expression. i 

Not infiv<)ucnt]y small portions of the membranes may l»e left behn 
in iiUro or iu the vagina. If the ends be outside tlie vulva, ihey sbnu 



UANAGEHKNT OF THE THHtD tnXQE OF LABOUR 



301 



C 



seited moA thu n^itinanU <l«lm?nil liy k*'"''*- traction; biit olhervisa it 
odiiMhk- tu \vtnv them alotiv nod to allow llu.'m to l>e cast olT wilh Itic 

sia. ratlH^r than t» iiilrodooc ihc fin^re into the vogiiu or utt-riu in 
attemi>t to rvinove tlicni. 

Iiuinniiatdy following the liirUi of the [ilurvjitji, tlic uIltus should be 
Ipated strain; normal]; it is found Grmly contractpd and rctmotcd, and 
if ii n'niaiu> h>, iIw-ti- i* w> daiigtT nf liJimiorrhagL-. But. on tlie otiier 
hand, if it shows any tomloncy towardi^ relaxation, it i<b<itilil k- kno-adt-d ; 
BDltl it coDtnM*ti<, and Uio hand kcj>t constantly u|>on it, so that b^ginninf; 
■dasalinn may tie (iHectcd and cnmhatAtl. i*hero is UKiially no dangi;r 
pf nlsiation ond cx)nH?'|Uciit hieniorrha^, provided no liigiis of it appear 
HnROg Uif fin"! b"Ur afli-r iIk' i-vlriuion of tin- placcntn. Aw<irdingly. 
lUw? condition of the uterus should !«.' carefully watched durinj; this period 
Vnf llit> phyKH-ian or numi*. Dut, even vIk-h this duly w delected lu thu 
Ilatl0. the physician slM)uId remain at the liouse of the ]>atient for one 
llwar, w n» to In- on baiwl in caw nn cincrui-ncy fhciubl nrisc. 
I OccavionaJly, tlic amount of blood IiKt tinuiiHliatt'ly following tho birtii 
I nT (be child may bo so grvat as to render imperative the prompt delivery of 
I Ar placenta, and under «ach circiintntanccit Credv*!( nii>lhn(l of exprissinn 
I 4tHil(] be cmplon-O at once. Under all other eondittons, however, vo 
I limM watch for Ifie rii^ng o\t of tlic fundiL-t Itcfore n^^arliug to any form 
I *l ejprcsisioa. 

I A> aoon n» Uh' plni.-cnlu and mcmbraoiv arc born tiM-y sbonld hv cans 
I hllj inspected for the pnrpo-* of ascertaining whether the structures liave 
I \m» npiled entire, or wbctber portions buvc lx.vn left khind in the 
I tlmu. If tiie^- an- [H'rfectly iniail, all id well; but if the niHlemal nur- 
I W iif the placenta shows defects which are not duo to mere tears of 
I '^ nJKuncc, but which ap{K-Ar l» indicjtte that a coniiidt^raMc part lioit 
I I*** bf t liehind, tlie band sliould be carefully redisinfocted, a sterile 
I ™*f gloti! pul on, and the nitaim-!.! |iortiou n-movtii manually, since if 
I iBwid to remain in tl>c uterus it nearlv alwa>-s Kives rise to biemor- 

I lo tire canes it may \>e found impossible at the end of half an hour to 
I **H Ihf pl&cenla by mnins of frt-ile'* melboil, and under ^Tlch circum- 
I "on*, nnlcBd the mndition of the patient U- seri<ius, or ihtrre tte frev 
I ■MnhgjET, the otulelncian should wail |tat)enlly and repeat his attempts 
I "npnsinn at iuK-naU. and nboubl not despair of eventual .iucm^w until 
I "kiA lao hours have elapsed. I'nder such circuntstaneeii, it is probable 
^■■H tbDormal adbcxions exi^t tx-lwix-n lliv placenta ami the ut^-rine walL^ 
^H^toquire a longer time than ifual for their i^oparation. In any ca«e,^ 
^Hmal mnoral of the orffan must never be undertaken unlcas abwlulety 
^^^^WTT, a« it i# a more wrions procedure than the application of forcep* 
I •rlllv prformanec of Tcniion. tn the former tiw hand, which is rarely 
^■UMly sterile, 'v jntmdui-ed )>otween the placenta and the uterine irall, j 
^Hl (YBni» in direcl contact wilh IIh? raw plnii-nlal silc. thn^iugh which 
i«B'««tt*ied noracroUH freshly tbmmlioscd veesels which afford a most M- 
IffiUntl cultnn' miflium for hnctt-ria; »hcr.-iw in Ihc hitler, tltc hands or 
birtmnentft atv introduiMl into tlic amniotic cavity, to that whatever 

r u J 



a02 OBSTETRICS 

micro-organisms may have been carried up by them are likely to be cast 
off with the afterbirth. 

For particulars coDceming the technique of manual removal of the 
placenta, the reader is referred to the section on obstetrical operations. 



LITERATURE 

Ahlpzld. Abwartende Methode oder Cred^'echer HandgrifT? Leipzig, IB8S. 

Ueber die ereten Vorgange bei dcr physiologjschen L6sung der Placenta. Zeitachr. f. 

Geb. u. Gyn., 1896, xxiiii. 418-442. 
Weitere Untcrsiichungen iiber die physiolog. Vorgange der Nachgeburtsperiode. 

ZeiMchr. f. Gcb. u. Gyn., 1897, xxxvi, 443-i66. 
Die Blutung bei der Geburt, etc. Zeitschr. f. Geb. u. Gyn., 1004, ti, 341-364. 
BAUDBLOcquE. De la dSivnuico naturelle. L'art dee accoucbemena, I7S9, t. i, 413- 

415. 
CoHM. Zur Phywologie und Dtatetik der Nachgeburteperiode. ZeJtschr. f. Geb. u. Gyn., 

1886, xii, 381^17. 
CnEi>^. Ueber die zwcekmaHgigBtc Methode der Entfemung der Nachgeburt. Ho- 

natSHchr. t. Geburlskunde, 1R61, xvii, 274-292. 
Ueber die KwcckmiiAsigKtt! Methode dcr Entfemuiig der Nachgeburt. ArrJiiv f. 

Gyn., 1881, xvii, 260-280. 
DuHRN. ZurBchandlungderNachgeburtsperiode. DeutHchemed. Wochenacfar., 1880, 

vi, 545-547, Nr. 41. 
Die Behandlung des Nachgeburtazeitrautnes. Jena, 1898. 
Duncan. Tlie Expulsion of the Placenta. (Read to the Edinburgh ObBtetrical Sodely, 

March 22, 1871.) Mechanism of Natural and Moii>id Parturition. Ekiinbuigh, 

1875, 246-256. 
Harvie. Practiral Directions Showing a Method of Preserving the Perina^um in Child- 
birth and Delivering the Placenta without Violence. London, 1767. 
HoLZAPFEL. Ueber den PlacentaraitE. Hegar's Beitrage rur Geb. u. Gyn., 18Q8, i, 

286-337. 
Ueber die Lftsung und Auastosaung der Nachgeburt. Hegar's Beitrage zur Geb. u 

(iyn., IB99, ii, 413-481, 
Jbllett. The Dublin Method of Effecting the Delivery of the Placenta. DubUn Jour. 

Med. Science, June, 1900, cix, 412-422. 
Leopold. Die Diagnose des Placcntarsitzes in der Sehwangerachaft und wahicnd der 

Gebiirt. Arbciten aua der koniglichen Frauenklinik in Dresden, 1895, ii, 151-166. 
OiflKAOREN-VEiT. Schrocder's Lehrbuch der Gcburiahiilfe, XIII. Aufl., 1899, 175. 
PiNARD. Dii palpcr pendant la d^livrance uonnale. Traits du palper abdominal, 2i[w 

(ki., PariB, 1884, 241-253. 
PiNARi) ct Vak-vieh. Etudes d'anatomie obst^tricale notmale et psthologiquG. I^uiB, 

1892. 
ScHKOEDKit, BfitWige zur Physiologic dcr Austreibungs- und Naijigeburtsperiode, 

Zeitwhr. f. ficb. n. Gyn., 18S5, xi, 421. 
ScMRuKDER iind Stkatz. Zur Phyeiologie dcr AuittreibungB- und NachgeburtopeiiodB. 

Der Bchnangere und kreissende Uterus, Berlin, 1886, 75-112. 
ScHDi.TZE, Wandlnfelii zur Hchwangersehaft und Geburtakunde. Leipiig, 1865. 
liel.HT den McekiriianiUH der sponlaricn .\uswheidung der Nachgeburt, etc. Deutadw 

iiicd. Wdclicnwhr.. 18H0, vi, Nr. .51. 2,52. 
ZiEiit.KH, Iti'ilrage zuiu Meclianianius der phyHJotogischen PlacentarUWrnne D. L. 

Halle, 1B95. 



CHAPTER XV 

CONDUCT OF NORMAL LABOUR 

The twrvirtw of the obstetrician should ho engaged some times before 
tilt expet-t^-d date of confinement, in order that the patient may be under 
ttiedii-al suiiervision for at least the last few months of pregnancy. 

The Importance of a careful preliminary ej-nmination, not later than 
fnur to six weeks before term, has aln-ady Inxin insisted upon. This can 
ke mnre (■i>nveniently carried out with the patient at home and in bed, 
»hen the obst<'trieian should take careful measurements of the pelvis, 
<fetfniiine the presentation and position of the child, and acquaint himself, 
*"( only with any abnormality which may exist in the generative tract, 
*ut aim with the general physical condition. At the time of this visit 
■'*'«> it is well to give the patient a list of such articles as may be needed 
■' the time of labour and during the puerperium, and which she is ex- 
pected to supply. The physician should also communicate with the nurse 
™ order to make sure that she understands the preparations which fall 
to Iwr share. Experience has taught me that the only way by which 
mistakes can be avoided ia to have all necessary directions written down 
* black and white, or preferably to use printed cards containing definite 
|tt<3 concise instructions for the patient and nurse. 

TKpuKtiona for Laboar on the Part of the Patient and finne. — At 

the time of the preliminary examination, the physician should inspect the 

toom which is to be used for the confinement and make necessary sug- 

^tions as to its arrangement. He should also inquire as to the number 

of Tvh-bafins which are available; for with the increasing perfection of 

limbing the onllnary wash-basin and pitcher are often replaced by per- 

aaaoil wash-stands, so that in the homes of the well-to-do it is sometimes 

dScnlt to find a sufficient number for disinfecting the hands and cleansing 

the patient. Five basins will be needed ; four for the use of the physician 

*ad one for the patient; and if so many are not already in the house, a 

•nfficient number, made of plain agate-ware and measuring 10 inches 

JKTMs the top. should be procured. 

The patient should also be instructed to provide herself with a bed- 
fan, a 2-quart fountain syringe for rectal enemata, 15 yards of non- 
•teriliicd gauze and 2 pounds of cotton batting, for making bed-pads, 
or 6 preparetl sanitary I>pd-pad8 and 3 pieces of rublier sheeting, one 
1X2 yards and the other J X I yard. The following articles should \m 
tJbtBJnei from the druggist at least one month 1>efore the expected date 

303 



304 OBSTETRICS 

of confinement, eo that tliey may be in readiness in case labour should 
occur unexpectedly: 



100 cubic centimetrea Squibb'a chloro- 
form, 
4 ounces potassium permanganate, 
8 " oxalic acid, 
4 " boric acid, 
2 ounce tube of green soap, 



1 ounce tube of vaseliue, 
100 bichloride tableU, 

8 ounces alcohol, 

2 drame ei^tol, 

1 nail-brush, 

2 pounds absorbent cotton. 



If one has a large obstetrical practice, it is advisable to have some 
reputable druggist arrange and kwp in stock a bos containing the above- 
mentioned articles, so that the patient can be told simply to buy an 
obstetrical outfit. 

1 give ImjIow the card which I have prepared for the nurse, containing 
directions for the pre]iaratioiis before and at the time of labour, as well 
aii for the care of the mother and baby afterward: 

DIHKCTIONS FOR OBSTETItIC.\L NURSE 

PHliPAltATIUN!; BI!FUUE LABOUR 

(n) See that patient has procured a " Confinement Outfit." and the 
other articles called for in " Directions for Patients," which include every- 
thing you or I shall need except baby clothes. 

(b) Prepare a eutficicnt number of sterile and vulval pads. 

(c) A week l)efore the expected date of confinem'ent prepare five pack- 
ages, two containing six towels or diapers each; one ctmtaining k^gings, 
one containing gauze sjwnges, and another containing cotton pledgets. 
Carefully sterilize and label them. 

AT TIME OF LABODB 

(a) If pains begin between 7 A. M. and 11 p. M., notify me as soon as 
possible, so that 1 triny know tliat labour has commenced and make my 
plans aecordingjy. But if labour liegins between 11 p. M. and 7 A. M., do 
not notify me until the pains are strong and frequent, or unless you 
think it necessary for me to see tJie jiatient at ouct^ 

(h) At the eomineneemcnt of labour prepare two large pitchers of 
lioiW water. KcH'p one hot and allow the other to cool, covering each 
vvilh a clean towel. 

(c) When luliour has definitely Bet in, give the patient a warm bath^ 
and a snap-snds enema. 

(d) Make up the bed on the left side. 

(f) Procure a piece of oilcloth or an old rug to protect the carpet 

(/) Don't give vaginal douches of any kind. 

(<j) Don't examine patient vaginally under any circumstances, 

(h) To prepare the patient for vaginal examination place her upon ^ 
Kelly pad, and cut the puhic hairs, if necessary. Then wash the genitalis 
thoroughly from above downward {towards the anus) with soap and warm 



ya) AS »>on sr laoonr ih over, cleanse tnc genitalia witn cotton pledgets 
****! water, anil then bathe with bichloride solution, after which apply a 
*teri\(, vulval pad ami place the patient u]K)n a sterilized bed pad. 

(b) Don't use an abdominal binder until after the tenth day, unless 
*»t,hpnriae directed. 

(c) C'hanpe vulval padR as often as necexsary, washing the genitalia 
**'^'' time with & l-J.O(H) hichlortde nolution. "^ 

(rf) Take temperntiire and pulse four times a day (8, 12, 4, and 8), 
**« oihiTwist* dircctinl, ami ni'urd u|Mm chart. 
^ (') Iton't cathcterize until the bladder is dislemltHl, and not until 

'' the {latient has failed to urinate in a sitting poj^itinn, 
j_ *f) (Jive J oz. of Rochelle saltfi the morning after labour, and repeat 

'^T hours if not efTectual. 
t^^^y Biihe nipples with saturated boracic solution before and after 
^Oa«ing. 

'"^ ^ateh carefully for cracked nipples, and report them to me at 

'j' Jliet: First twenty-four hours, milk, soup, coffee or cocoa and 

' ^^"^ "'' ^'^* tnnst, Second and third davs, as above, with the addition 

D0lte.-^j fir jMtnehetl eggs, raw or stewiil oyslers. and wine jelly. Fourth 

'■' "t )i (lavs, as altove, with the addition of chicken, swiH^lbrwuls, ]>ota- 

*'»"-*^ rice. And then gradually return to ordinary plain diet. 

CARE OF ciiii.n 

(•' Leave the baby alone until Ihe mother in enretl for. wrapping it 
Vb • *'~^r>llen cloth and putting it in a safe place. (S<A upon the mother's 
Vri* Upon chairs.) 

V>9 Wash the eyes with n l)oraeie acid solution, unk^s otherwise 

\^^ Rub the child thoroughly with vaseline or swet't oil, and then 
B"'^ a full liath. usinc eastile soan iind warm water. 



306 



01WTETRK"S 



A. it. to 10 or 11 p.u. Time one feeding so that it will cobhj 

After tlii> tiHtli, afli^r which the cluld may be Allowed to sleep for thn 

or four hours if it viil. a 

Ho not fivd hill oner bctwwii bedtime and 6 or 7 a. M. ^ 

As soon as the millc appears, write out a BPhedule for nursinfi; ar 
adhere to it, iiwaktiiiiig i\w child at euch f<*ding time if iiecc#i«iry. , 

Before each nuniitg infh out the chihl'a mouth with boradc aa 
sol II I ion. 

After the first three weeks f['\ve one or two bottle of millc s iny, u 
irinltiT how miuh milk thi- miilhi-r may hnve. 

{g) Wei^h the child twice a week and keep a rcconi of it. 



I 



FreparatiotiB on the Fart of tlie Physician. — \Vhen the phyaiciaD a 
pfcl* to I'u calkd to all ohsR-trical fttw, he i^hotild hold hiiinidf in resdinci 
to respond proiiipllv at any hour within two weeks of the expected dat 
of continvmcnl. If hi- ii; uhligcd to Icavo town slmut that time, h« ehoul 
notify the jualiont tind arran)i;e for a eoiii|X'tii>t suhslitnte to lake hiii plat 
if ncceseary. He i^hnuld also reinernt>er tli«t thi- projicr care of sueh tasi 
rieqnire.« a great d<-al of time, and fnijuenily no !*iiiall Bacrifiec of petHini 
comenieuce, and if hv is not willing to place himself at the disposal « 
his juitivnls, HK far ti* may he neeefliiary, he i^houUl rL'fu^ to attend llier 
I'ndue haste is one of the moi^l fm|neiit euiiiws of uoMliKfactorj resiil 
in thi.^ hrani'h oT mmlieine. 

'Die ])liy«ieiati should provide hiniwlf with an obstetrical outfit, whic 
should lie neiilly packed in an uppropriiile Ik»x or vglise ami he kept rcat 
for innneiliale use. It should contain not only the instruments which 1 
iniiy ntvd. Inil also thi? varioux drugs re<iuired for hund diKinfectton, ai 
lestliesia, and the usual emergencies, as well as a certain nuuilier of aleri 
|iiiix-l» and dri.^wing!S iu case the patient Imx failed to provide Iwrwlf wit 
such materials, and for sudden calls or consultatioas. The olMtetrio 
vslivc should eonlain a pelvimeter, u )>nir of nnil -clipper* and a nat 
cleaner, chloroform, permanganate of potash, oxalic acid, bichloride tal 
let*, green *oap, i^lerilixeil vaseline, a"<l a nnil-lirush, erg>i|"l or tlnid C! 
tract of ergot, tablets of sodium chloridR for preparing normal salt soluti 
and H hypodennio syringe with Uic usual tnbl«t«. There should also 
chlorofonn inhaler, a suit of white clothes, two packages containin] 
•lerile Inivels eiuh and one cai-h of sleriliwd alisnrheiil rullon and 
gauze sponges, as well as several sterilized roller bandages for packing th 
uterus, t>la*s tuUw containing sterile (yithetent, silk and silkworni- 
sntures, and bohhin for tying the cord arc also needed, »s welt as a 
holder, and a Kelly pi-rineal pad for opertitive caws. 

The following in-lnimint--« for repairing perineal and cervical lai 
tions ehould be sterilixetl and nrapiK-d in a package ready for in<taut 
A pair of si'iiuuirH, a ne«4lle- holder, 1 artery elamps, dissecting fo 
long dre.ssing forceps, bullet forceps, a three-hladwl or U Simon Hpccul 
and an assfirltm-nt of ncrtiles. The valise should also contain a tin 
■10 X 1^ X I" centimetres, provided with a lid and woo<hli handler, 
this Uie various instruments can lie packed when not in use, and at npen 



PREPARATIONS FOR LABOUR 



307 



lioa il HTves as a boiler and im a receptacle for tlicm after Hterilixation. A 
'•miiT axii^travlton, nr an onliiMirj SinipN>n frttv«^|iji, iJiouM In* carried, 
*«oniin); «>> iIh- plivHicinn lia^ liis^^riif nci'iintomod to the oni' "r i>tlK*r 
5*^nnait, as well ai- a 3-<iuarl rmiittiiin ityringi- with ii gitt»* nozzle for 
|'*tx-«.at«riii(>, aud a bollnw needle for HiiboiitaiK-ous injections of Kalt eolu- 




Fio. 3M, — OusiETn ■(*•>■. Bao. 



f^fU- The lattt-r rltoulil !« olvrilizod in adranra and wrapped in a sterile 
V>*H. *o M bt Iw ready for immediati' um;. 

Thit list do«« not indudv Ww iDfttnimont^ re()iiired for the dtixtnictive 
a^minnM, ax ibc^ are not unaaUy carried bv the ^nera] practitioner. 
^**nthiii]( nirnttutK-d in tliL* alHtrv list may bo packed ioto a boi 31 X 
H X S inriKa*. 

0*ldiut of the First Stage of lAboor. — The physician flioutd instrui^ 

™ W'f-nt a* In tin- U'>i tiK'Ibixl iif (-ommuniciiting with Iiiin witlioat 

lilt irenfirally speaking, should direct the nurse not to send for him 

" 1* UUnir comnii-no* at ni;ilil. iM-twi-^-n 1 1 i*. ji. and 7 a. u., iinlem itj 

■wwsari- ibat l»e slwuKl «« the patii-nt nt once. On the otlier' 

■1. vbra l)u? p«iiii> livgin )>ctwu-n 7 A.M. aiM II f, u., (he ph^vician 

le notifi«) immediately, ao that he may make bin plans accord- 

A> «M>n nil tbo nalurt- and w-vi-nty of llie paiiiK indirnlc that lilWiir 

^ wl in. tiie patient should receive a full batb ami a rectal enema. 

*kn the pliyxician arrive* he tihouM make a cAn^fiil external examina* 

aiap lint the protciitatiou an«l positioo of the child, and li.4ten to the 

I lioirt. In pnTnipiine. if (ho iwlvin !«• normal, and the child prcstrnl' 

: by the vertex, which is firmly enRajted, thrre is no neecj^^ity for making 



308 



OBSTETRICS 



i(l(i) that tHc bonrt soiinil* 



gOft.1 



»n iiitcniiil o.\timiiiutii>n. | 

ditinu, as all that can l>o gainwl therefrom is mfonnation cnticortiiii<;l 
lU-gtvtr iif <Ii]iiUi(i()n of tin- trrviir, Oii Ihrs [Miiiit mwr fiin iisiinlly tfir 
fairly atriirale iiiia from tlii^ behaviour of th« paliant and tho e\teii 
which the hviui htw (Ifwi-ndcd into the pelvis, which ran ukiiiiIIv be ill 
niin^d l>v exlornal iinlpalion. A^ain, ihi- ru|itiiri> of tlu> nit-nibraoea 
\hv OHKt-t of Ix-arinfii-down pains usuallv indicato thv beginning of 
mnxiih) HtH;;i', aflcT whiih, a» a rule, tliere in nmplo time in priiui] 
for thf nrrivul of the jthv^ician. 

In i^eneral. Ihcn, it niav Iw Mid Ituit in pHmipani'. if no utmnmu 
be Kii^]i(.Ttivl. an intvnial examination i)i nnnctcs^arv and xhoiild an 
niade iinli'K'^ the first Htaj^' ix undnl}' ))r«l<in):i'(l. On tin- othor banil 
rii'w of Uw fact that in niultiparniw women- the tirnt stage is frcqiia 
\fvy sli'>rt, and iIh" wiwid ni'cusionidlr tt'rniiiialiiig with n ft'w r^pnl 
painn, nnlc«« the phymeian is prepared to remain in the houw indelini 
it, niiiy he di-siralile to iii^corlain the rendition of the «>rvix hy vji] 
touch, as Itic patient should not be left after the external os is two tl 
dilati'd. 

Kretpient internal eiatninationa sliould be avoided for two na-wna 
minimixc Ihv po^ihilily nf tnfeclion and t<i suvt- the firelingx of Ihr pa 
&n far an pnssilih'. 

Hand SisiBfcction. — Itwent experimental work has (^npliisivHy ( 
onslrati-d thai it is im|)owih!e, in a lar};e proportion of eases, at any 
to rciidcT thi; ImndN aliKi>luli-ly gti-rilv. no mnlter whal ni<:-th(Hl of <) 
fk-ction may Ih' eniphiyed. Kven after the nnut rignrous directions 
been scrnpuloiiely followed, there still remains s not inconaidcrsble dm 
of infection, 

WitJl the view of still further minimizinj; these rL^kfl, the n*e of tuI 
p\n\f* has Ih'j'Ii inlriMlnoil. TIii-k*; mii be n-ndenil porfi-ctly sliTilii 
)>oi)ing, and when drawn over tho earofully disinfected hands afTord 
trreatcit "afely pos,<iljV. Sinec. Imwi-xcr. Ihoy arc liable to tear ooTM 
ally, tlie necessity for disinfectinj; the hands before putting them m 
apparent. But their employ rnciil, even in conjunction with all 
other pri'i'autions, does not eiilin-ly do away with the poctsihihty 
introdiirinj; hueleria into the ^rnila! tract, sini-c I have shawn 
jiatho^-nie orf^anisni^ art? pre.'i.nt \i(«m the inner surfait^ of the labia 
the margins of the hymen in al kiist (10 per cent of pregnant women, 
that the mere inirmhictiiai of a ttliTilixed f(lai« iipe<-ultim 'i eentimetra 
diameter, which is no larger than the two tingcra employed for exhia 
lion. ('urrii>( inii'ro-orji.'ani.<Tiis into Ihe raginn in at IituxI one half nt 
cnse^. MorcMivor. inaf'inneh as the delicate slructure of tJie part-* nen 
their thormi^di disinfrctinn out of Ihc i|nestion. and as the examii 
fingers necessarily cnmo in contact with them, it miuit he ailmiltnl 
mginal examinations during lalMiiir ran never l>o entirely detnid of 
ger, ami thi-v slumld tlici'cforc hi- iiviiidiil «• far av is consisbM.it with 
welfare of the patient. While thc^ consideration!! ^ihoitld not dcte 
from making an many examinalious an may be necessary in abnormal 
it shonlil alwavs lie l*orne in mind that the best resnlta are nbtaine 



HAND DISISFECTIOS 



309 



fcjp Kfi [Ktov'ililt' rmpl'iviiii-iu of the- viigiiiHl iDUch «■■<) tlic wifliMt poffiiblu 
HB&tinn of fxti^rnal ntctiimlfi of i-x a mi nation. 

' V lliH haiiiU i>f the plij-siciiin Imvo nwiitly cninc in contact wiUi in- 
[lirtiuiia uialerial at opiTaliofi <ir nulo(wy, labour F>hinili) lie ciindtwlihl by 
Wnmuil i-iamtnntioDj oloiie. vu):iiiiit v.viiminutiojii) liciiig made only in tlio 
bnsrncc of ximti abitnrinaiJiy, and tbcn only after nioAt cnreful diAinfcution 
ftuA die use of gloTcs, 

In til r»M*, ))cfore milking an iiiUrnal cxn mi nil I inn, |bf lianils ;>lintikl 

W ditinftcli^ ss carvfiilly a« for a luxjnr euifjical o])cTation. 1'ho lio^t 
I mHted for (liix )turp<>iri% intriHluntl liy Dr. HaUKxi tuimi^ yttm* ago, mid 
ld«Rm!in| by Dr. Kelly in IS9I, conKisfs of the followin;; sk-ps: 
' I. Cut Uiu fingi^r-nailii with di;i[>or4 or aci.-«t)ni to 1 millimtHrc in 

length. 

i- Scrub tlic baii<!» ami forcjirnw up to llic rllKtwji vigoniiii'ly willi 
I naiUtKh. preen soap, ami hot waler, for at IcMist five minutes by tbo 
l*^"**. and liinpT if Ihcy art- n«l minrrwnpically clfiin. payiiii; purlicitbir 
■■tltuiiiii y, tl,(. iiaiit ajid paliimr aiirfaio of the tlnjprrs. The watf-r must 
B"* dMUp J at ln»t onco. After clian^'in^' it. rvmovv dirl from bcucath 
IwfiBt^.tuiiU with nail-cleaner or knife am! renew the na-thinu. 
I ! itiiix- ttH- hsixlx in fri'»)i water ami then Mink lb<-ni in a hot eatu- 
I nUoi MJuiioii of poiassiuiu ]M.TiiiaU)|;analo until they take on a deep ma- 
l~pnT-W*nni colour. 

I L fHawilvf this off in n hoi saturated »iilutii>n of oxalic itvU. 
I ^- Timi gnak the liandr^ and f<>r«-ann« in a I'to-l.OOi) bichloride »>tii- 
I '^ for at h^axl thr<T iniiiui™ by the clmk. 

I <■ Tnuih notbinK until ready to examine the pAtienI, gninje direetly 
I ''W ihr Incliliinile to her. 
I ^nnlj Dtijeetiun whirh rain be made to thin method of hand dii>infce- 

■ t"> i* ilir h-njlth of time which il nipiin-s and the roti^hni^w of llw liaiids 
I •"* •(qiielinien followH it. The first objection cannot lie oveiiiime. a.i I 
[ -lii-ve that the band« can Im- llioronjtbly ili><inf<vl>i| in t<»« than 
L ' ^.uii» liy any inetitiHl. The seeonil can be otivialeil to a jirx'at ex- 
I '" ^ ■niiintio'! the hand* witlt gly<i!rin or mtiiu eioollient after tlic 

■ 'tmutimi hibi livn made. 

I . ^"ip'd nietli«)d of di>- in foci ion inlmdiicwl Uy Furlinnj;iTT, by which 
H*Mifrfij that the liamlit cnnid tie rendereil abiiolutely Hiertle in thmc 
H ^'•w. ha* been ^hown by later experimental work to Ur alwoltitdy iinrv- 
H*~- .Vnr hav<; the twcJnt mflthotU of disinfection by meant) of alrohol 
^HpuOulel the clainiH which liiire b<:'<-n made for Ibcm. inaKinnch aa 
^^pv hut obiiwn lliHt thry an- IhimhI ii|Hin a fallaiy. and that alcohol tW-* 
^HK»m a markedly frermieidal action, but fiintply produces conditions 
^^tt» •kin which for IIk^ lime Ix-ing n-nder it diflkutt to rcnioru tl»e 

■ tni^B (mm ilc nurfaw. 

I ^Ora nnmtier of yearo I have nom nibbiT ^Iovc.h of m<-<liutn lliickne»s 
B 4 Ihr nautai-t of all C8W« of lalHinr. and cannot endorw tlieir employ- 
|*W toft rtrflOjilr. I'mridcd they have been propt-rly boiled and drawn 
^^(Ik carcfiiDr dij-inffctcd handii with a suitable technique, they afTord 
HBbIw!!!! aluolule protection againiit infectiun by the physician's haiidii; 



310 



OBSTETiUCS 



bui. u.-> liiu alnwl}' bv<.-n {tiilii-attil. Ihcy otTi^r no gunranlty* af^aiiii^t in( 
tion b.v t'actcrta which may be carried up from the cxtvnml gcoilalia. 
Till' i>l)j<H't ion lliiil. I)ii-ir iiKC' inter firrtw willi lh<- hoiim' of lnii<-li i.< not \wAii, 
aa I know fi-oni my own tsperienw; that it can be oTcrcome bv ]»racticc, m 
thul the nioKt ik-li<.-uttr pro«tluri-« mujr he comlucUxl ju«t u« satiffurtorilj 
ail with the Iwre haiii), with the «ne eMcption of rupturing the ttn-in- 
brntiw. ('(niK(S|ucntly I iirg«ntly advise any one expecting to practiw ob- 
stetrics to becoiiit'acc'iistnnuHl lo llii-ir use ai the htiginnin^ of bin vareer. 
Prepanttioa of Patient for EzAmiiuitioD. — While tlio physician id dis- 
infecting liiji li(uiii.i. Iliit niipit! ehoiilii be making htr prfpamtiOEu for th* 
iiitt-nial cxaminniion. Tlie palient sbouhl lie on the right or left ajd< 
of thi> IhiI. aiTiinltng iw IIh' phviiician prt-fers to piamim* with ]w riglit 
or left hand. She shouhj then be wTerwl with a sheet, which is pulled tt| 
frmii ihe foot of the hts] ami its «ri<Is wrapped alxtut tlic legs in kucJi < 
manner as to leave tlie external genitalia fn-"e with the least pmwiMe ex- 
jKidiifP of the n-st of tlie person. The IxflclolfKw should not W thrown 
bfiek 80 as to leave liie liga of Ihtt patient expiMcd. Nor should tlw? plmi' 
cian be exixrUil to euintinv uniler any i-ovftring. Thv fulva and thv inmn 
surfaces of Iho Ihighs are ihen thoi-ouplily washed with soap and l»ot watft 
partioular attcntiim b^ing jinid lo the region* ubout Uic (unis and clilori* 




Flo. 307. — JJnuwixu ■■luii-UH METiii.>t> nr mviinixn P*TiKNt u'ith Smkrt tiBruuK 

A Vaiii!u*i. K-\ a win 11 run. 



1 



If llto pubic hair* an' very long they should be cut short witli itdunnl 
shaved. After a thorough cleansing the part* nhould Iw rinsiti with fm^ 
waU-r ami th«i ji[H)ng<-d with a l-to-3.000 biehtoride solution, iifter itli'tii 
they shoidd be covered with a lowel soaticii in Ihe (uinie eitlutioii. whidi 
rc-maiiiK in place until tlie physician U ready to commence his examinatioq 



VAGINAL KXAU1.NAT1UN 



311 



uhDj, a »terilv Utwrl »liuiiM be placi-d iiiMlcr the patiiiiit'e buttuct;:!, to m» 
l^niutt the citaiiiiiiing haml from mining: in oanliuit with the lied. 
jj Wkod of making a Vftginal Eziminatioii. — After Utorough di^iafoc- 
//^ thi! iliuinii uiil /on-fing^r of inn- hninl (lintfrMi lln* liiltlii wiiltily, so 

*> «la-tcti tbt' vsfpnal opmiof; and prevent the exanntiin^ fingtra fi-om 







I\XJII- 



linc in Mnuct vilh the inner surface of the labia and the iiiaricinii of 
^W* li*«on. wliilf the iimK-x iind mhthuI lltigfrx nt the othor hand nro 
mmhImI wid) ftifrilr rfli^line and intro{luoi?d into the vagina. 

lanakiii); Un-i-xamtnalion ii dirfinili' roiilint- should bt- followed: 1. The 
^*?«riion)d be intTodnced aloii); the anterior surfai-c of ihe va);inal wall, 
"i ii» •lupp and tine of Uw pubic awh and the height of the ej-mpbysis 
!, Tlw nereis Dhnuld tlicn lie exantined in order to ilelerniim! 
its ranal in olilitersU-d, the de^TM-- to which the vxtemal on is 
■ml Itiv i-UHrH4;l<>r of it* iiiiir)cini>. Next wi; nlwne whi-lh<-r th(> 
^"tm* are intoft or not, prcat care being taken to avoid ruptunus 
(•^o i( Off patk-nt ic in the firct "tape of labniir 3, Tlic prwuaiiing part 
>hi»lil '. : ■■ nnd. if the on he dilated, the pnwnliilion and position 

il thi- , , .,] Im- inadt' onl. It in also important lo delormim- it« ni- 

li> tile Hiiptrriiir ulrait and to lhi> line cnnntvting the iM'hial HpiDOf.. 
"Alia ba*inf; ticeided tlwM? points, the palmar eurfatv of the itngcri 
he (Itmlcrl prnttTrinrlv. and iht* p<frinii>uiii pal])iil>xl lietween thu two 
in tlu- vagina and the thumb ontcide. with siw-cinl n-ft-n-nee to its 
bioi-}, Ihiekm*!*. ami miiMamf. :». Tho mobility of ttw coccyx 
lid titea be tnt4xl, after which the Gngurc »lM>uld he paa»cd upward 



312 



offirrETRics 





over the noterior surface of ttic sucniiu and it^ vertical and lateral cu 
Itire iiuU-d. If tlio t>nw(tntin^ jmrt U nnt Kiw down, the thn^i lnw«-r mio 
vcftchriK arc readily palpalik- in norniai women, whereas the first » 
nvcinxl can W- Ml <mly in iimtnulwl [wlvi-s. ti. If tin* iintviitin^ part 
not dcE^ply eiifni^«ed, the diagonal c<'nj)ij;ut4^' stiould he uiea«un.<d. 

If tl li(-<niiit('i' lUHivMiry tn rt'jKMit the cAaniination, ('xBrtlr iho 
ri^roiis prejiaration is imperative, it boing iniportanl to remnnher 
xin^h- difinfc-ction of tlit^ haniU i» olVtcient oiil)' fur a (roiiiparatin!ly 
period. 

Aftirr c(>n)])lcttng Iht? exuiiiinnlion, the plij-slmn i.* usually expt'ctal 
express an opinion as to the prohahlo courec of events. If <>rcrytliiug 
normal, hi> ithonld amiirc the [Hitlvnt itiat all will be wdl, I>u1 Klinul^^ 
piard a;;nin»^t mstiin;; any very definite statement as tn the prohahle dun^^-"^ 
tion of luhoiir, an<l i-ontcnt hitn.>t>lf with Muyin^ thtiL iiihIit xnch circuir~^^ 
stances the avera^ lime U only a certain number of hours, «iid that hi 
suffering will prfthahly Ir" cndi.il within Ihtit periml. Th<^ ohsti-lrici 
who rentureii to make more preuisc- ataleniL'nti^ will 8pi'ii(lily Snd tliat h 
pixtlietiiinj' an- ofleii very ftinlty. even wiM-n tlic liejiil iw on llur p«-riim"ni 
If some ahuoiinalily Ix- prisent. it is not always wise to inform tlie pati«^^* 
of UiL* fact, hnt llic> physician ^hmihl be varufiil t» iiupud liis knowlnl^^ 
to some rtwponsihle niember of the family for his own protection, ia i»^*^ 
an cmerKeney Klioiild ariw. 

Ourins the first stage of laliour the patient luiually prefers to rnow^^ 
nhoul lier ri«>Tii, and freiiuenlly is num.- eimiforluhle when oocupyii^; 
sitting (waition. During this period, therefore, she sJionlii not be cii 
polled to hike to her liiil iinU-xs she feels *o inolinet), and when she A 
so flie >lu)uM lie cantionixl againnit attempting lo hiislen hilK>ur liy r< 
untarily bringinjr her alKloniinal mnsete^ inin piny, for they have little 
no etTiit upon Ihe ililntatton of Ihe (lervix, and the effort will only 
to exhaust her strenfflh. 

Conduct of the Second Sta^ of Labour. — The betrinning nf lln- seem 
stage of lidiixir ii ii-ualtv inilirateil )iy the rupture of the nieinhraiies 
Ihe onnel of lieiiring-down piiiuH, llmn^li tlu'M- iiigns are not abeolut 
ehnraeterisiic, as in a small number of I'asos niplure may oariir at an ca 
perioci, (ir the patient may tiHempt to hasten the enurse of laliour by 
making premature use of her ahihinunnl muscles. On the other haiul. lb-' 
mcnihrantvs Btmnlinics remain intnet until llicy protrude fnini the vulva, 
lu still rarer eases they do not rupture at all, the ehihl <n>miug 111(0 tl» 
world surrounded by llicm, or, as it is puimhirly termed, being bom wij 
a caul. 

In the latter part of the first stage the pains generally lM><><ime 
severe Ibal the patient in^lin(■tivl■ly sl■ek^ the rivunilient ixi.-^ilioii ; Itut if si 
ia still moving uliout tlie room or sitting up, she should go to lied imme- 
diately upon the rupture of the membranes and the iK-winning «f bearing* 
down pains. 

I'reparalion af thi- Bnl. — The hiil shonid be pn>panil as soon a.a the 
poiiiH b<-onine si.-vore, since in the case of a iiiultiparous woninn tlie kcco^ 
stage of labour is often exircniely short, and delivery occaxionalt; oocH 



tbr 

I 



CONDUCT OK THE SBCUND STAGE OF LABOUR 



313 



wtiil^ 11*0 [latk-nt U boin^ movul from a chuir or sufii lo the liwl. A high 
T.iii^lo iron Ih«1ku-iuI is pn-fcrnlili'. but in priviiti' priR'tiw one U'^iinllj' has 
%o be winlPDl with Uw oniinary iioiil>lt' Ufd. I'nder liiicU virfiiiiistaiioeB 
■ideuf 11 etioulil Iw pn.'parL'd for [hi- [mltciit; whi-ther the right or Ii^t 
t^peuLt upoo which hand thi- phyaii'ian exi)ei-ttt to luw tor taginni exain- 
. and llic cniHluct of lalioiir. A large pi<x^ of nibbt-r xhoetinf;, 1 X ^ 
nbiiulil lio |>lacnl i)Vi-r ll«> conire of liw iiiottn^ss, (iivfrin^ it* ontiro 
dth, ind liver thin a i^h^vt \» f^prtad. A M^oond pit-fc of rubber ehrating, 
Xl }ran], U pla<x'«l upon iIm> side of T.lii> lnil upon nh'wh tho patient in 
l». in snch a position that it will come direcllv undpr her buttock*. 
[Thcfstin- lull is ibi'n wvrrt^l hv a dniw-*hivl; ov^r iliix i* jilnwd u stmle 
tari^ npoD which the biittocke Wft. With this arrniipt'ment. the upper 
tlMini] tlic small piece of riild»T doth enii Im- ivmovi-d nl tlir ii)[oph;tii>n 
odiboar, ImvinfT the mattress protected by a large pioee of niblier ^heet- 
i>tui) tiip and4-r dni-l. Iti onlinuri,- (U-iiverii-* I hnvi- nbiuidoiM^I tlit- a*e 
•I liic niblHT olit^tetrical pad and reptsced it by t^terile, alit">rl)able 1>ed- 
pdi.0 ll*i' foniivr if vvry diHictilt In kwp clean, niid dwiii); hi the irn'jfU- 
Isitmof tti« vurface of the fied friiiuciilly defeats the pur|>ose for which 
D «v (irvi»(i], ill iliat the fluid which cojlcct-* in it cwapc* nv«r Iho ImsI 
■bI «iUr tlie patient. To avoid expoiture the h-gH should he encased in 
W tr|;giTi)p>. wliicli n-iudi to thi- thi^'hs and an> pinned lo Itio rolliil-tip 
'>|^i^n«iL In winter thc»« should l*c made of canton llaniKl and in 
"■■nonf thin muslin. 

Hnmiuiiliittt of tbf Patient. — After the patient has been put to bed, 
uqnoiiiio ariM-s whether or not a vaginal examination slioutd Iw made, 
Ml t)iii if (Hi'rmiiwd by the comlition of alTair^ in I'aeh ctae. If tho 
■id W l«comc engngci] In th*- fir^t stage of labour, it can be omitted; 
i*) t{ till' prmentinic part i» not en^aj^, nr any abnnrnialily is pn^wnt 
*^M'lnl. an inl'-rtial cxamiruilioii is alwnlutcly ntxH-ssary in order to 
■WTltia wlielher tl»o cord has jiroUji^ed, or if e\*erytliin^ is n» it slumlil ln'.. 
\i Ifif pnlient has apparently Uwii in the seoiiid stage of labour for 
MM* tiiDE witlumt rupjurc of the meoibninc«i, an pxamiuation is lulrlsahle 
JuBortrrln delenutDP the con<iition of tho cerrix; for, after it hue liecome 
J^m\MrU dilat'il, the menilirancs havi" jmt^ciI ili<>ir piirpnsi' and n'tiinl 
tlnn ha-tin the birth of the child, so that it may be adviiinblc to 
iBm Uvm artifiiially. (■'ornierlr this was usually readily atvotiiplisbci) 
ntfing thniugh them with tlie finger-nail, or pinching iIk-iu between 
Iva examininff fingers, hut cannot W done when niliher glo?oi arc 
, iO that it lieeomee nerensart- to rcu>rt to instrumental nKiins. For 
<tertli»il bullet forcr-ps is admirably T.iiib7!, but if it is not 
ibK a large nafcty pin. pn-vioniily sterilized by boiling, is a convenient 
9ttil». Tlif nu'Rilirnni^ shotitd nol ■»> rtiptnntl during the acme of 
• pmin. particularly when the heiul in t>ot di^pty engagnl, as occnfiioiiaUy 

tn ro-b "f «tntii"tic fluid iniiy W so gnnit as lo carrv the coni along 
tli it, and itKih bring al>out its prolapM'. Tlie l>rginner r-hoiild always 
mrt-fni In ditTiTcnlinlc Ix'twcen llie dislctndiil ii)(rn)bran<>s and a teuse 
iflt -ueceiianciim. 
AMifu vaginal examination:^ arc mad4> in th« second ulage of labour. 



OBSTETRICS 



titt' siinift ftringeiit prpcHutions as lo ili^Jnrfvtion nf Ihe )ian<lii iinil I | 
)<atieui'!i ({cnitHlia ^holll(l In? obtwrved. Wheu the IwaJ in ikvply I'ligus^ 
in lltv pvlvix. iiit«rtuil i-xaminiilioiu uru <iiiitv unmvc^sary, a« its dfiscv^^ 
cnn readily l>e traced bv the inoreaHin^ dilllcultv with whioJi ilw oi;p)(^^ 
jiromiDt-iicu i^ felt on I'niploymeiit of t)w fourth inaiitL-uTro. Moreo-v^ 
whi-n it ran tn> longer lie fi-lt from Blmvc, if Ihc leg* tuv widHv M-|)<uns.t: 
and the tipis of the fin^'erii applied to the perin^uiu, to the »ide at and 
ffunt of tlio uiiuH. and pr(««(.>d lirmljr inward and upwurd, the preHcn-tU 
[mrt can l>e felt an a firm, rounde<l I)ody. Generally ^peakinn:, thja o-i 
iKviivrc becoiiiw uvailnblv as tooa a» the h<iu<l hti» pushed bdow the Ic- 
nf tliL' iHcbinl npitu^-i. 

During the I'ntiro second Htaf^, aiu«u1tatioD sbouM bo pracU»<!' 
fn-fiuent inti'rvalu, parlit-ulnrly whon thi> head has reat^lwd the ]>elvic 
foi (iccasionaUy the cord is pres^ upon tightly, nnd the child may 
asphy\iiit<<d at l\u* ]nT'uti\ and lie lii»t, if not delivonti promptly. 

IMiveri/. — An t^oon as the head can be palpated tlin)n};fi tlifi perina«^ 
prt-jiiiiHliiitm :ih«tilil IfC iniide for delivery. A table should be placed 



K 



\ 



a cnnvcnient poattion at l}i« nidi* nf the bed, and upon it a Imfin nf j 
uatpr and another of l-to-2,000 bichloride solution, as well ax stij 
cotton plcfip't* or jmuzo Kftoriges, a c-ertain mim()er of iiterik 
the material for tyinir the eord. Tlie inittruments needed (or llw 
of th« porinKum tthould iIko W within 0«»y reach. 

Tlio patient uliouM then he ptaoei! in ptisilion upon the l«ed. 
eountn' it i* customary for her to li« upon her back with the le 



)KDUCT OV THE SEOUND STAGE OF LABOUR 



315 



Eaffluh] and many plaocs on tlie CAnlin«nt tl>c tutoritl \t(»\' 

rrrd. I l>rvriT thi- ("rmer, n» it HfTord^ Iw^lttT fncililu'w for 

DO of an aseptic tcehniqite. If tin- legRinga have not been 

>uM now be tlrairn up iiud piunod to tlie Dighlgovn, wliieli 



/ 



\ 



r 



m4 PiTTEKT P> Fnon-M FnnmoM mn Dhjvsbt, *!>« covhw» lir Smiui 
Dnmki.vaai, 

xl Up iKrncath tlio patent's back, m that it may not be *(ti\«A. 
I sbcitild it^aia b<! waubvd with MMp and water, an] bathul 
ride solotion. 

inK drown fre«blv Iwilm] gtnrcii oror hi# nn-fnllv disinfected 
he may inahe an immediate Ta>:ina) examination if imh'ciu 
Bhould jilatx^ a vti'rile t»wt-l bt-nvuth the palientV but- 
nver ber alabinten, and otherii over her legA, and pin them 
enver ereryOiinj; in the iK-igliboarhood of the genitalia 
liandF may cnnie in ivintacl, leaTing only tbt> rulva and 

im*t^ dnirn into the pelrts. small particlfis of i«cm are 
4tnl. and a>^ thev appmr at tbr> nniu t)u>y should be wiped 
piiwr of cotton, after whieh the partd i^liould be spungtHl off 

•■^ Miakol in bichloride Mdution. 
1 tbe Iwwl lK^n« to di^t^nd the vulra the patient's i-uffcrinfiB 
Bl kiCKawd, awl are frequently excnidatin^. At thif ntagc 
■ begin to uw chlonifnrm, partly to relieve the p«in, and 



ons-n-TTRins 



juirtlj- in aiil in prol«cling tlie pcnnu'um. If tlie nnnw be conipclfTil. il* 
iKiiiiitiiiitration hIkiuIiI Im? inlnisUtd to lier. Tbo patieut Itaviuf; been in- 
HtrtKrtwi III givt- iioiiw fiM wKiii «Jt r)iy fivl* ii ]>ain livginniiig, scvt-rnl \ln>p* 
of ohiorofarm are poiiretl upon an K^iimrcli inhaler, and she is told In 
inspire dwplv. Ttiis i* ri-jMilLtl with i-acli pain, the inhaler bcinf; removt-d 
immi--(ltat«ij afti^r iu o<!ft.->ation. In this nmnner, ufWr n Kliort timo tlw 
HFitsntion of pain bocoinra mnrkcKllv diminishMl, vrhile Die patient retaioH 
iiinHoioiisnew ami is gi-nc-iallv attle t» talk mtinnally. Rut whvn thi; liviii] 
lic^in* to eiiierpe fi-oni iIk- vulva, thi- chloroform elioiiM be push«l to 
c^>tiiji]i-tc itiui-stlic<in. (Itiriny wliicli itif liitiil U brirn. Thi^ ili^nx*. Imiw* 
i'Vlt. (should lat<t only for a few utonieiit^ 

l'rf>lertiott of tkt Pfrtnaiim. — M soon M tlw pcrinnMim ohoira sijjiw 
of btilj^iiif;. the pli)>ician slioulil make prcpamtioii«i fur its protection, ^ 
jibicitiji liIniM-lf in xiuh a (HiHition a^ to lie abh' (■fTi-elually to clMrk lliovj 
proprews of the h<'a<l if iieeeiiiiarj'. 

Jnjnrit? In ihe [H-rina'um are of very frcipH-nt nceurnmii^, and vannof--^ 
alwa}'8 be avoided oven under the most ekilful trcntmvnt. The gtateni«iitt..j 
Mf 1" their frf(|uem_v vary considerably, but all aiilb'>ritic!t nxn**. that i!i — 
oreur mueh oflener in primipsnius limn in miillipni-ou)' women. '11 i. — 
Hiliroi-di-r nliwiifd ihnii in .11.. I and !• jwr cent of Uih ca^s rxTspi-elirfij — 
ItaliUidiu in 'iMi> and 4.1!) per eent: and OUhauf«!n in :I1.1 and I.* V^^ 
Cfint. Th<f*c RfiureM wnubi aw-m to Ih* rather loo eonner^'alivt!, ox i»ligl»' 
tenrH implieatin^; the fotirelietle occur in aJHUit two thirds of all prinii(<iirii-. 
und in II) iM-r eiiii ot Hiiilli)iar«'. Oceacionally one nw^ets with pli_v.*iiuQ' 
wiio stale that they have dcliremi !ie\cral IhousatKl women with one nr 
two, or poKxibly willioul a Hinffle ]ierim-al tear. Siieh siati'iiM^ntit. bow«v«f, 
are alwavR erroneous, an<i merely indicate that the phvrtieian lias Dot Ui- 
iipwte<1 llwt purls Hfter InlHuir, and di^ijrnul"^ as lorn only ihoKc ease in 
wliii'h the vagina and reitiim have ln-en converted inio a cloaca, to iIk- 
existence of which hii^ atti-iilicm would iiiwiiriilly W ralli-il by the patient. 

In thv preatent nundn-r of cawi the fnureliette alone aulTerti, Imt nut 
nneoniitionly Ihe li-nr exl'iid* throti):h n grt-MliT or le-s«u.T i>»rtioii of the 
]i<-rinertl IkhIv and i^ usually associated with another cxlendin;r wmn- dr>- 
lance up one or Uitli vafiinni -■mhi. while in rare eH.t«i (In- entire |K>rinatim 
is torn tlivongh and tlie rectum opemil np. The first two vartetiiw ons 
frequently nnavnidnhtc. Jitit the eomnion Deriurrenee «f rom|ile|p tears is 
an indication of ijtnorance or negligenee, 

ttciieriillv speakiiiii, the eim'«i'.« of nipliin* arc fonrfold: disproportion 
between the head and the vulva. Ion rapid expnlsion, al>i)oriniilili<^~; in 
the mechanism of lul>onr. or ft narrow pul)i<' arch. Wlwrc llie head b 
evpftwively large or the vulva excessively small, the mechaniral condition* 
are such that birth cannot lake plwe wJthoul a certain amnnni of laora- 
lion. In not a few eawA the tearing is due not so niijeh to alnoliite dis- 
proportion between tlK> head and the tuIva as to llie lack of eliuiticity nf 
tlu,* porinn'iim, winch io parlicularly marked in Hdi^rly primiparv. T<n 
rapid expulsion, however, i* n much more frequen) cauM- of mplun-. «ni1 
when the beud is Nud<l<-uly and fon'ihiy extruded Dirougli Ilic iui{>erfeetly 
distended rulva. it§ mode of production is mamfesl. 



-A 



PROTKTION OF THK PERIS^l'M 



317 



H ^Krmu sbnonualitwa iii l)i« mn^luuiii'iii of lulwur favour rupture of 
^ t*!nBeatii> I'hv must frofueDt of iJit-w ia iiniKTfoet L'l^k-mtftu uf tho 
^_ tasML. *o tluit tbe vutia 1.4 disU'iidiii liv lliir wi'i[iitii-fn)nUil, inirti'ad uf 
^M Ibc^ioixipito-ttrcgiiuitic «r eulK»ccipit«-froiital circumfereDco, Id a cer- 
^r tain iiiDBl>er ut caMw tin- |iri'ML<jiliiig |mrl nmv In- ilinvtr«l t<>ti far bnckwarcl 
— fl oUiiT wnnlti, e.\toii»ion iloitf Dot <H.x:ur— ami iindtir the intliittiu-e of 
UK DtoriiU! (iiwlnwlw'nn liw pnwwntiiig part is foR-wl diRcilj- dniruwaril 
fm tbp periiMUl l>od_r, itultnd of lioini; f^iid<>d upward «nd foruanl 
IWinl» Ihn viiind <i[ifriing. Fn-<|iiiiitlj' a Hiinilnr cniiditioii is oliwrvwl 
^ «i<nivn ha(-in<; a fiiiiiiti-nliapi'd |»clvi!i. in wliirli ttu- jiuliii: anli i» loiij; 
»iid Btmiw, wlirn-tiv tin* Wjid in pn-ii-nU-d from engaging dirwtly iiiMicr 
IJar >nnpbvsiH pubis. A;^in, in rare inKianojs, an abooniial iiiHitialian 
«( titr |idviM, by nuixinjr tbr viilvid ogHrning to look mort" upward tban 
WBal, Biav bring al#>ul a similar ramlltion. In coit!<iilt>rin]|( the iiit>clian- 
mt uf Inl'xir wir dint-liil altriilion lo the fiK-tor* which prwlikpiist' lo 
pnnml niptur*?. whiii ihe li^nd in deli»tTeil in persistent owipilii-|(i«5iorior 
f<«(tinn4, or wlirn llw ohild pn^-ntM bv the brow, face, or breech. 

(liffinl, in IT.");!, wan the Bret to direct attention to the adviubilitv of 
>tttfii))(infr lo iirwwit pt'rint-id Wnr*. NunKToui dwic^s have siniv been 
••IigMlMl having tbe same object in view, but their very nuilriplJcity 
■iws tlial Ibej' an- not uniformly MitiKfoctor}'. In mo*! of lh« older 
BWhatt prRwitre wm applied directly to the periowmn, or various at- 
ttnpis vt>n^ mad« to relin'e ilie lenxion to wtiich it wui' Niibjwtnd, m 
dw iif phvfieian wa» said to enpporl the perineum. ;\n excellent mumi 
"/ Ihr mrly literature u])i>n the subject wilt be fotind in Goodell'* M-lwlarly 
utk-ir. puiilixliM in 18<1. 

la tlir tna'lhod whleb luw viood me in b«wt »teiid no attempt is made 

Mqiport the perinsum by pret<8ure, but tbe obstetrician sitiipty endeav- 

Ui faroor exteiwion of the biiid and pr(-\-ent it from Iteing sthidcnly 

Inl durint; the acn>c of a pain. Kor this jiurpofte, when tlw vertex 

lo diiitund 1)10 vulva, it should k- M-ixetl belwtrn the thumb and 

fiiiKCTs of one hand, and forcible prewure made againAt it during each 

At tlm Mimr time Ihe pnvsurc i^hould Iw dinTb<d in xiK'h a niiiiincr 

■fc» I'nng llie iwcipul. and later tlie na(ie of the neck, directly in.contaet 

inferior niiirgin of the cytnphvuiii, and thiw inereaw exIifiMon. 

. .'-^ly. ail roon a^ tlie head appears at llki> vulva the physician sltould 

V nwly In nvtiaiii ib> pr<)gn«)>. He should Imid his luiiid in xuch a 

mMBiMa an to !■> able lo bring it immediatelv into action, for in man; 

iiictxiu-n> Uie rrsijlance nt Ibe vulva is unexpet-toilly overcome, and a single 

. 'J may W nuiTicient lo push llie iiead suddenly through it with a r«ult- 

i.L r'^innil b^ar. After the iH-ud is so far bom tliat the- vulru it di«- 

T ■■■-. ),y the parietal Iniiwi. it may be advisable to attempt to express it 

.'.'pi ,'H*jt mrthini in an interval lietwwn the puirn:. For this purpO«C, 

ui- jxitr-nl having Isi-n instmcted to open her mouth and not to attempt 

to bear down, tike anxAtl>ef<ia i« deepened. At the same time two ringvrs 

sre applinl ju»l >H-)iind IIm- unu]>, and forward and upward preH.aure is 

mMif ufNto the lirow through llie periimnim. 

The stntlr-nt is vnmnl from attempting to protect the perituram b; 



DELIVBKY OP THE 8HOULDliK8 



319 



|uul Uic IiiImt uwrhii. The ngM-mtion if pnirt)N>Tl in tlu- l*oIief that the 
I <ulnl nfn-nin^, if KullM'ienllv ciiliirKnl l>v Dm inrlHionN, irill )H>t li^r Tar- 
llfi-T, w tluil m niiy ca/v (In' Urrralioii will oociir iii liio contiiiiintioii ttt 
"It iortrviiw, wimv' rti-iin-(-ut t^lgi-K will li»tit imm: riMilitv IImm tin- irtt'gu- 
W tpoDtancoiu leam. FerHODall}', 1 i«e no »ilvaiiu^ in tliu pnxmlure, 
'^f* utr experience i^ Itmt ordinan* p«nural tvurs will Ik-hI ulmiKt nniformlj 
B" pn>|irrly nuLtinxl nod <-itriHl for. 

^K f'ciVf o/ L'orif alioul the A'^tjC'. — IiDincNlistoly aflt-r tin- birth nf Ihe 
^^fi llw fitif^iT idMiuld Ih! )>n>w«l U> l!i« mt-k of lti« Hiild in onii-r m 
*^v»-ia.in whelbpr it is «n<-ird«d l»y one or more poiU of t)ie iiinbiliciil 
'*"^t Thi» cnin)dicuti'in m-cur* in ilHtiit cvm- faiirtli oaw. and the vw- 
•^•' «r«* Bi)n)(^(iiii(b )>n!:<:^l upon iiii ti^litlT that a-^phvxiaiion rwultn. 
'h n roil \te fvlt, it Mlioidd Ik- druwn down iK-twrtt'ii tin* finp>r«, 

and, if Ioohc eiKiii|;h. cilippcd uvcr die 
child's h«ad ; but if Uiv mrd Ih- too 
IikIiiIv «]i|>!it-<l ti) iwrmit of this pro- 
(iiluri-. «iid liii» hiiul tippi-Hrs <:nnm*l«i 
«ml BufTucoI, Uw- fonniT should In* 
ik^M^ und cut bftwwn two artery 
rlxiii|iti, and Uie cliild initiiolialcij' nx- 
tractvd. 




H^.lll- Tii»i-n'>»i»iuiitUitBOirr 



^•'•■■Tj of the Shvtttdm. — In the 
■ >t t%M» thv tihottldpn: ujtjH-ur Ht 
I jift afttT iht* ncriin\'niv of extvriuil 
, iiiul arr- Itorn triihoiit diRk-ulty. 4)rca- 
Ity, bimTLT, a tlfiuv occunt and ii)i>uediali; extraiy 
FlMi najr apfU'sr advisable. To accomplish thi« Ihv occiput 
' diiD «bould y» twixol by thr Iwu hand*, and downward triu> 

mwlr untd tii4- Mnt4!nnr Khoiddi-r appoar^ tindiT Uw puhic arch; nost. 
on upH-anl nniffiiK-nt, the [KiBlerior shonlder should be delivered, after 

till- ntbEf will oeually drop from beneath the tiytnphw!«. 

Thr t«i>ly almiMt alaavit follow.« tlte ahouMerti without difltculty, but 

"f prolonged <ielay its birth may l)e Imstmril by traelion upon the 

iml by himkinK Ihe fin;t*rs in th<- axilla*, since by tlM> latter pn»- 

:i^ aerfvf, nt the arm may be injariN) and traiwiiiit ur pomianent 

nvnll. Ind^. even the former method of extraction is not <Ic- 



i 



vn'id of itan^r. for occnsionully liit^ oblique trnctioo oni|>l<V 
fxc«s»iivt Klix^t chill); nf llic lirai-liinl pIvAii*, nith milwcuiu' 
Tt/ing Ihf VortL — 1 innieiliaU!! v after its birlh tin 
nia)c<:« uu iii'<[iirnt<>rjr movcmeDt and ttiea bv^iiu to cr\ 
<'in'uiii.->unre3 it shoald be plaoeil 
k>lwecn the patipiil's le^ in such 
11 iiiiiniH*r UK to liiivi^ Uii- c'X'd liu: 
and tlmu avoid traotiou upon it. 
If, hiiwi'viT, tlu- <'liilil iliM'N nil) Im>- 
>;in to tircathe iiniiiiiliJitcly, th<- 
«i>ni kUoiiIiI Ik; wiwl ami citt. lit-- 
twwQ two arlerv clamps, an<l pf- 
fnrt* ul rt'xiiiu.'itiilioti liiiiiiiii'IkviI 
at on«!. 




A^) 







Normally, tin' ooi; 
ligiklcil tinltt it ha 
Mite, In fiwiirin^' 
etcriliitoil bohbin ih{ 
itTitimcttt* froiu 111 
child and liublly tj 
ture ifi ptaciil 
show tlifl Bret, 
twocn the Iwn, 



the malcmal end mm-ly «'rves to avoid Mjilinj: llie 
wrapinf! from It; but in luin pRfriiumirt donhlr lipj 
whoii lii« two f«vUi«-ji ure ilerivwl from a KiiiftU- ovii^ 
exteDBivo antuftonioses in tlie pljRct^nlal cireidalion 
while "till in the uU-ni*. mar bleed to dwdli fn.mj 
the iOTii of lliv fir!«t. 

The nue-ttion nis to the proper time for tying 
to a great deal of di^etiiiAifln. Formerly it wa.- 
immedialrly after the hirth of Ihe diild ; hot B\t'\ 
centimetres more blood eseaped from the malerrJ 
«u-ty than after late lipation. Ihu.-. indicating Hf 
to the fcetus by early, and saved for it by latei 
demonttrutwl the same fact by weifthing the <J 



A.NiKn'HIiMlA 



321 



^pc*in afl(v Ibt- cnrJ hn*) ii?a>«d fo putimte, and vnm able tn i1cni»n.slnl(' u 
^P^KQ^mDilin;! iiH'ftuM- in wi-ight ill tlii^ lutk'r caxc. Budin Iwhcvt-tl that 
^^HI'tiuouDt of blood was drawn into the ciroulaiorj' 6,v»tfiii of l)i<- fwtus 
^^^'BinrwK- Uf-piriiltoii, whik- Spliiickinp held that it was driven into it «fi 
' nnll of %hf coDtprt!ssion of the plawnta bv the contracting titeru*. 
■P'»fmwr. 7,MTiM. mid Rihcmont havi- also shown that the initial loss of 
^r^'^f in the lir^t {w t\a\A after birth h uNtiallv \(»a after laif^ timn afttrr 

'*«"iv Iji^iion. 

I hsv« alwar.i pncti^ lato li^lion nf the <-iird and have ««n no 

'Ojvrimtf vffrcU following! it. and thvn-forc rDOommend its einployin^ot 

rift* */ifiii- t'liiortincv arim';- which lalln for mrlior inIt-rfiTfn<v- 
AiU-.r ligation of Iht ronl. tbv rhild should he wrappwl in a piece of 
fliknai^ or blanket pre]»ar4HJ for Itic purpoev, and laid in a »afe ptacf nnlil 
tiae plan-nta ■•> born uiid the inolhi-r hai< bfcn cleaned up and made com- 
iStWtable. 

^L J ■,,,-_\\V arv tndfbtwl to Sir .latnc!i Y. Simpson, the diMviveroT 

^M • I II, for the introduction of antf-HiheHta into ohsietriviil |irai-1i(.-e. 

^■« nnploTeil vtlivr for Ihiif purpiuv in Ibv jvitr ltJ47. and replacwil it by 
^klomform after the discovery of tlw latter drug. Kv<Ty one agrens as 
^b the itinrlciil l";fM-til» dcrivisi from an«->llMTia wbt-n operative prorwltin* 
^B>e to lie tiodi'-Ttaken. hut there is still considerable diffcrentv of opinion 
^b t'l the adtiwihilily of i|_< niutinr emplnymi-nl in normal lobriiir, 
H^ The most popular an«slhetica are ether and chlorofornt. and when 
^^fagiElrinil <i|ifnitioiii> are to (n^ perforim-d it rnaki^ vory little diffcrciH'e 
^f^ptk is cRiployiHl, as it is well known that the dangers incident to chloro- 
^Vwnn ATT niarkflly rediir^x) at Ibt- tiinv of lal>our. and Ihat only a very 
^ftlfw dnlbt have followed its use nnder such circumstances. Kxacily why 
^B ttw puturicnt wimian »l)onld enjoy ihiit inimunily is a qnoi'tton which has 
^V "' ' Kii'u definiielr M.'lile<l. bnl it is nevertheless a fact which has been 
H^ id )-'y<>nd |M-radvcnlure. 

^B (n tbf other hiiiid, chloroform is far preferable in nonnal latiour, for 
^M ^ r^ Vfv obstetrical anit::>t)K9>ia can W rapidly and safety produced ; 
^H ■mm ether, nwinjj; to its slower action, doeti not lend itself so readily 
^^■[IIA* mrthod of cniploynmit. A* the n>ult of my experience-. I believe 
^^^■1 dklinofortn, wIk-h properly admin intered, is practically devoid of 
^^^Bpt m furh can^. and i^K>utd be iimi;I olK-n^-vcr Ibcre ii time for it* 
^^^Viairtnlion. Of course it is cantra-ii>dicate<l when tlie patient baa 
^^^HPm* olijM-tionH lu Su iwe. as well u» in ihoM- cumv in wliich laliour 
^^^Htavt pninleHS. 

^^^^pb ehoi4?e of the time for itx administration, howei'er, i» of p«nl 
^^^Mlrlaan-. nor should tt be u>ed iK-fnre tlie latter part of tile second 
^^PIV'- vtien the head beconm vwihlc ut the viitva. or at tcn>ft until the peri- 
^m aHiiD favfrin- to bulp-. .\ few drojjs of chloroform should then be poured 
^B i|KD (hi- inbalfr. and with tlie ■■■•.'inning of a pain Ibe putienl should he 
^B Obtntlnl tn biviitbi- in i)h' fume* \ i)t»rously ; bnl as soon as the contraction 
^|.k» n%nti the inbaW >h«idd Ih' n-moved. lo Ih- it«il nftiiin when Uie patient 
^Latr* a miga lhat site fii-U tlu- flr!>t intlication that nnotlier is beginnin;^. 
^■riM (he (lii>tr-ntion of (he viilvu i» at iU maximum, obntetrtrat aiuestiieiia 



322 



OaiTETUItS 



J 



i» not sutViei«-iit lo Abolliih llic |iiiiii. nml it i* niv [irHi-lkt-, a>< uR^n^| 
ciuvrgw-, to rendiT my paticnl coiuplt'ttly UDconaciotiB for the tiiiMiicDt ■ 
iDereuin^' Uw dnno al tin- <jru^. ■ 

Bv tins pruct'diire tho wouian is ^aved an imniefuw wiiount nt uiiikmJ 
san' pain, and at tlie ^attKt liiiR- tlm ilnn^r nf |>crm<!fll laceration le ()im^| 
islied. For. if tlie iiufferiDn is ininimiii«!<l, ami doni.' nvny vtitli t'lHin'lv 
tie rritical niniTKtil, the |ititiciit wilt liv Ktiil iiitdi'ud «f to^iti<: m her tc:^ 
and there will not Im the same danger of the head Iwing suddwilv osfvll 
al the arnM* of » mn traction, wtiik- the phvMcian i« ciii)d(>yin<; hiii raefj,'^^ 
in persuading the patient to keep quiet, or may even Ih; forcing hrt \e^ 
apart Ml Ihwt. he may ahli- to pmlcrt the pvrina-uni. The amount 
fhloitifnini required for this purpone i;- very small, and rarely cxafiii 
or S draniK. 

Kor variouft reationtt. the adiiiinistintion of lOdorofonn cliould W d< 
r<!rriil a* long as [M)«tlile in the nc^-ond and iit-vpr re»>ortod to in the 6nr" 
stage, unlfw exceptional indii-alions eall fur its etnploymont. Iji-aving oi.^" 
of (.'oiixidi^ration il> jiimstlili- inllui-ciev upon the ffficicncy of the iiterir'ai 
con trat'l ions, it ii» only nttturtil thnt on soon a< the patient has experienc^w 
the soothing effects of Uie drug xhe is extremely loath to do without r- 
and, nncK having liegun, the phy^ieian may find himwlf toro-tl to eontiii'' 
its adminiHT ration for a c-onsiderahle length of time, iinlesa li« po»*OK*^ 
mon.' forliliide (han i> generally IIk' vhm: 

.'^gainst the employment of atuesthetici* in laliour it hax \w«a urg; — 
that tliey diminish the force of the uterine eontraetion*. This staterai^-^ 
is partially correct, for when administered for any great length of li^ 
they iindouliltilly lead to a shortening of the utorine coutravtions and 
a prolongation of the inten,-al In'tween them, aj was dearly denion>tra*- ' 
b; the experiments of DiJnltoff and Hens^n. On th« otlivr hand, wlr^fc^ 
exhihiled iinly at the prri|K'r time and in no exeo*tive amount, this «^ 
jwtion d'H's not hold giKnl. and in many instances small dnses appear ' 
Btimulati.' the uterine conlruelion<>, and hy diminishing the itenwition " 
pain I'liahhr the jiatient to hring her abdominal niusclos into full pl«? 
which she previously may have h<*n unwilling to do. and thus [ia»4^ 
the completion of lalMiur. 

Again, it has liwn taught that anawthesia preilijtpo*(» to relaxatioti M 
the uterus after the expulsion of the placenta, and thus increases tht 
danger of post-partiim hfcmorrhagfl. So far as my own cxj*erience (jo* 
nuoli stijneln- nie not likely to occur prorided the drug has been profX^J" 
administered. At the same lime it must Ih- admilteii that it* pfolori;""^ 
adniinislration certainly tendf towards uterine inertia, and is not wiih'til 
a deleterious infltience ufion the child. fl 

In (.'xceplionol eases chloroform, while diminishing the pain, ai^Ml^f 
to excite the patient. I'ndcr such conditions it :thou)d not U- ■•mptnye^l 
unless enniplete iinii-sllii.-iii i-« mfeswiry. It should never (><■ u.-^l in '^^^^ 
first :<tage of prol'mged liilM>iir>^ in l)i<: liiip<- iiT hastening Iht- dilalutinn i^M 
the cervix, as this object ix hetter atlained hy the proper administTtlMH 
of chloral or morphia. ^| 

Ordinarily the paticjil is ullowed to come from uwler Die inftotq^l 



I.IMIUU A.V*>1TH1%SIA 323 

"' tlir ana>silitlic us mhiii us the cliilil ii* Ixirn, as its wliiliitiim is not 
'•*^'«!«iry iu Ihi' third stage of labour, oxeept wliwi llie pluceiitu is to bo 
•Amoved manually nr an extensivu {K-riiiual lait'ration is to Im; repaired. 
Morewer, it should !h; re men i I >e red that after llie birth of the child the 
patient does not appear to enjoy tlie same iiuniunity aa wlien iu active 
Jabonr. 

Lumbar Antrvtlifnui. — Follow-in;: the rehabilitation by Bier of the nuli- 
■raehnoidal injection of cocaine for the pn)diielioii of ansGsthosia of the 
louvr portion of the Ixuly, ami ilw ]>opularizatioii by the work of Tullier, 
it -wu but natural that jt« etlieiemy should be tested upon the parturient 
Woman. 

The first publication enncerning iU employment at tlio time of lalMtur 
wms made in Auj;iist. 1!MK), i)y Kreis, who n'jMJrtcd the rwulU obtained in 
6 csKes in Kunim's clinic in BAIc. It would ap[)ear, however, that Doleris 
»»*: aorkinfir niniultancously u|)on tiie same lim-s. Since then a number 
of owners have n'porti.'d scries of cases treated in this manner with 
i«ir«ine or some of it« derivaiives, and their work was well summarized 
Hy Uiiller in l!i0.5. From their re[)orts, as well as from observations 
made in my clinic, there is no doubt that most striking resultii are obtaini-d 
in a certain prop«)rtion of cases. 

In favourable cases, the patient being in the second stage of lalKiur, 
the injection into the lumbar portion of the vcrlebrnl canal of li) to l.") 
niniins of a l-i>er-eent solution of cocaine ( ^^-i grain) is followed within 
1 few minutes by complete al)olition of painful s<>nsations. At the same 
lime, the patient continues to make visible expulsive cffort,s with great 
f*pilirity anil ofttirues with increiiscd fRi|Ucmy, so that if the effects of 
ibe drug do not wiar off too rapidly, the cliihl may l)e ex|>olled without 
|Wn»nd almost without the knowledge of the patient. Likewise, various 
"pwitivc prociiliircs. such as manual dilatation of th<^ cervix, version, or 
'Wp*. may Ik? |»ainles«ly performed. 

Snlwithstaniling these very wonderful rcMills. I do not hesitate to 
'^'i* itrnngly against the employment of the methoil in orflinary obslot- 
""•l prBclice, and therefore shall not enter into the dclaits of the technique 
'I Hitting the injec'tion. In the first place, the ri-sults are not always 
"ifomi, a certain number of patients aji|icuring to Ix' ab.solutelv refrac- 
"T to the inlliience of the drug when administered in doses consistent 
"■•h wfeiv. Again, its effects are sometiuies very transient and fade away 
J*' •'hen most milled. Jlore serinus, however, are the after-effects, the 
"'Jivity of [tatients suffering severelv froui heaibiche and nausea, and 
'•"[Wfltlv from an alarming but transient elevalion of tem[)eratHn.'. In 
^** "t their comjmrativcly short duration, these symptoms are usually 
"pried as a manifestation of intoxication rather than of infection. 

The m<i*t serious obje<'tion to the melhod is the fart that Ilahn, tu 
_'M|, n-^Hirted s dnilhs in l,T(l.S casf's in which its tih' hiis bn'ii riK-orded 
■ Ifce lifcrnlun' (l-"imi). Xn doulil, in scvitjiI inslaines the fatal issui' 
'*H not !■• fiiirly nttribuliil to llu' iuciIuhI. bill in si'vcral mbcrs lIc' 
M<^i: kIhiWi-iI Ic-'ions of the >piiial or cerrbral mciiingc- which could be 
kinlv to infection. 



324 



OBSTETRICS 



III view, tlini-ofon.', of its various KhorLcomin^ and (tan^Bri **o 
iviLsoii l» n.'ci>rii iiii-Mcl Oitr cTiijilo^'nii'-iit. nf npiiiul tuuuithi-xiu in oliKU'Uio 
\mn^ L'anviiK'iil that more uniform and tiUti«fac-torv results may bo obtains 
by thi^ pnijM r iiilinini:<truti<>i) of Hiloniforiii wtlh far ^n'Oler »afoty In Ui 
jmtiont. Moreover, were i^piitul auawthosia to coino into more extcnrlo 
uw!, under lln- ndviTso ii«i(iilifin!* frt-i|ufntlv I'm-funm-rcil in private pni 
tice, I fei'! rture liiat many women would ptTisli from nKiitngiti^. (lie rcsnl 
of the im[KTfi'ct ajiplioalion of tlie rulis of iu*ep)ig letrhuique. 

Scopalomine-moTphitiei An<r»ikfaia.. — Tliis method of (.■ombatiDf; th 
puin uf labour wuk introdiict'd hy Steinlitickcl in 1!>0'2. and Mjtm U\n\ i 
this country by (.'. M. (Jroene. The fornior reported Uiai the hypoderm 
injcclioii (if CtDiKJIt gnminie of i'('o|>Hli>min(- hy<lriilimmHti' anil n.til gramw 
of morphia (rave most satisfaetorj- reKults and practically annulled the p«ic 
of lulmtir, I'vcn permitting Ih*- application of fi>rit|w or dilatalton of l~ 
cervix. Numerous reports have since been made of its more or less s»t- 
factory i-mjiloytiicnt in I'liuill »fric« of ciiw?*. 

lu 190T Clauds reportt^ its administration in 1,000 cases in KrSn 
clinic in l-'rcntiurg. and i>tiiti.'d thai by n proper re^ilnLion of dn«agc II 
patient would pass into a semiconscious slate, which lie designated 
" I)HiiiiiR'rsi-hluf," In ihiit cuiulition tlir piilicnl ii|ijH-iir' \n apprci'iali' p^ 
at the lime, iiut has no recolli'i'iion of it later. For this purpfwe he adnu^ 
idlers (i.»l()l)3 iiranimc "f wnpHloiiiinc ami W.UI of morphia hjpodernii«T 
and repeats the scopatomine, but not the morphi*, once or t«'ic« latcc 
nivi'ssary. 'Y\\<! indication for iU r*'pctition is not afforded by the i». 
of any spci-iricd li-ngtii nf time, Imt rather by tlir mcniiil aindition of * 
patient, who should be kept in a state of relative amnesia. This is d<.-<: 
minimi by nhowing her some objix^t, which nhe should promplly forj 
having seen if suflicicntly under the influenoe of the drug, but anotl 
dose -■ihould Ih- adminintereil if she poiaetM any nicollection of it tkal 
or Ihirty-five niiuulcs later. ^ 

By thiN mt-an.'' tin- ^ri'ut majority of hi» pnlicut^ went through norti* 
labour, but had no recollection of it afterwanl, lie is naturally vi* 
entJiuaiaalte <^nceiiiinfi; bin re.tults. 1 hiivo had no ox[wricncG wiU> ^ 
method, but would advise caution in its employment until furtlter repof 
are available, for the reason that a lar^re uumlN-r of Ibr children in ^ 
series were very dwidy asphyxiated, and required vigorous re^tt-icitatioi 
Moreover, IVMaurans, in IfiOii, <.-olleeli-d from the litemturc SS fatal la* 
following (be u^e of tbiH agent, which clearly indiealefl tliat it U n"' 
devoid of danjj.'er. M 

ffi/finolifiii. — Numeroiia observers, among whom may l»o nirntiofll 
I^'iebstwn. {.'ocke. Malwjci'w, and otlK-r', have re|>orlcd instances in w^i'* 
bd)nur was painlessly eonilueted under the influence of hypiioti>nn, Pw* 
Bonally I have seen it employi-d kii('(1---*» fully in r>nly a single irutuKK 
An a rule, its licld i>f ii-efulness in ohstetrii-* \-t very liniitiil. for iSe 
reason llml the piitienl niuxt Ih> a I'liKi.i^ptibtc subject, and one who \is9 
already lieeii hypnotized on previous occasions. 

Th« l'»e of A'r^tjf.— Many anlboriliw! rwommend the admini.ttrntiu 
of a dram of fluid extract of ergot by the mouth immnliwtcly after tb 



RFPAIK OF THE I-ACERATEI) PEKIN-tliM 



325 



BpnUion of 1)m> idwviili), iik n jiropUjIuHHT nK>ii«uru Of^uitivt piigd-piirtum 

^wwnrrlia^. This w ufiialljr Hiin««siian-, a^ llie drug is cnllnl for only 

' n lliiH- r-OM'K ill which llii- nh-niH n-imiinK Knfl iinil flubhjr. iriKk'nil of 

I'lnnii^ a haul tumuiir h(>iu.>alh tlit; iiiiihiliciis. iVrHfitiully, I prefer to 

•IdibbU-r it hy[<o()tTniiaillj'. umi htitc foiiml the iTj.iilol prrpun-d by 

fi»t\t iml pnbme proferalile to the oHkinal lluid cxlract, iiuriinuch oa 

^U k Inai Itkriy )n [inMliic-t- an iiW^Crw ut llii.' point of injcr^linii, ImU-nil 

g^ii§('Jli-i] juxl UDilor and paintll«I to llit^ fikin, tlio ncc^ilo h plungeil 

Itw muMc-lv of llir thigh, uiul fruiii .ID to 40 miiiiniit atv iii- 

Ihe doee ttcioK re|wat«I if ne<?o^flary. 11 i^hould lif ri^mcmlwrei! 

Ilivtiuch inyxl'wu* uiiiinlly give rm' lo a flight but painful indiiraUon^ 

|*hitli (imistri for wrveral days, but only exceptionally evcntnadw in ahHceu 

ilinn. 

I most itutat once nrnre tliat lliU U ttm only time at wlitch ergot 

kkolil \v tinplnvfd in lolnur. as its administration before the completion 

(hinl dtage has led to untuld liarin. Formerly, rveii wHI-truinud 

M UMtl it in large ijiuintitifH during tlie second stage to stimulate 

eonlractioiut. t>ul at lln- pn^tnt tiino it i* m> umployi'd only by 

WiBt Ditdwirvs. 'YIk danger hoi in the fact that the premature use 

oflWilmg readily lead:i to li-tanic oonlrai-tinru of llu! titprii*, vrhicli in tlic 

pAKDrr of any marked dixproportion between the size of the child and 

I [»liu ue liktly to bring atioul rupture of the uteru^f and the diulh of tlie 

l^iliaiL UorvoTOT, it« adminietralion in the third stage of labour. b<.-fore 

l&ti^gjiHi of the plarenia, cannot b<' too strongly depn-cnteil, a* tJw 

I tMUing tftanic contraction tenth rather to produce a further retiaition 

I •"'•(pin. »i tliut iln miiniiid n-mnvjit frequently become* imperative. 

I bMact of the Third Sta^ of Labour. — Tiiiit subject ban already been 

I "Bnkmj in the preceding chapter. 

^Jt'frir of ihf lAirrratfd pfrinirnm. — Strictly Hpeaking. llli« .*ubject 
Hpd (w defem-d nolil tlw obeti'tric^ operations are dealt witlt : but 
^^^itml tvani are of Kiich frei|u«-nt o).T'urr(!tu<e, and a* tliey are Iwit 
^ "y iiBl in the intenal between llic birth of the child and the e.tpuUton 
HB^ flocrnta, the projn>r UMthod of procedure will be coniiiderud at 
^■liar. 

^^PW nmn-nirnrv in diwriplion. pvrini-al \imn art; diridiwl into tlirec 
^^BK Ihon' of i1h> llrrii, i^cond. and thini degrees. To the first bcloni; 
^B> flitch involvr "imply Ibc fou nlu-l (i- ami antitnor mar^n of the 
^^pniin, Ki^'inK rise to a ^matl. triangular wounded Kurfa<v which is 
^Hv ftiin> tJian \.Ti rt-ntimetrc dovp. 

^Bi tlie second, llie lact^ration extends through a greater or lower por- 
^^■Ufe perini-fll IkmIv, and not infniiticntly cxpoM's iIh' Hphincler ani 
^^^^VT'^ually it.-' mun^o doi>s not quite follow the itH^ltan line, but is 
^^bJ iJiliiiUfly downward and outwanl from tlu- |insterior margin of 
^Hidra. In many of these cases t)H>re are al^a le<iions of the ragiiu. 
^HptliT iinually invoke the »a(cui<^ on tin' »amir "idc a* the perineal t«ar, 
^H|i9)iM--ntly that on the other nidi- as well, so that a triangular portion 
W^M vaginal miicnm, wbieh n-pri'st-iiliE the inferior cxlreniity of the poit- 
Hir ootnnio, may become separatctl from the ntX of tlie canal. 



320 



oBSTirrmcs 



In tlic third tlcgn'c. Ific tear cxlciidB completely thmiij^li the 
\nx\y and tlio M|ihinr;li>r hui iniii^lf, iim) fur « mrtiiin ili«(«i)r« np Ik 
Icrior nail of tlip iithini, Itiu); ;;ivin;! riw to a rloHca. iiiln whirb 
vagioa auil rccliirii (ijivii. Thtfo an: duni^Dnttnl it* viuuyilvW, in I'd 




I'Vi. 314, — tiiirrnrii'iii. rijfi>,Mi iEAiu 




Ha. 31.'' 



(lititinotion to Uiose of Uie first and iiecond decrees — tlie inc»inp1et« te 
in which thv ri't-tum i" not invcilvifl. ]iiLi>ni]>lvti; tv4iiT um iiil-oiid 
very often, evep in the practice of the most competent obstetrician 
mattiT wliiit prwiaiitioiM m«_v In- lakvii to pwvont tlu-ni; hut tlie frr 
occurrence of the complete varieties indicates that the method emp 
for protecting tin- piTiiiuniin hii» been at fault in KjionlHiiiTiiih, or tba 
extraction hn-* iH'cn too forcible or ha*tv in ojjerstiTe deliveries. 

In tears of the liriil dogrc'c. the niucoiii^ mcnihnitie of the foun 
and the skill covi-riiiju; Uie upper )ii>rlion of |}ie )ierin.Tuiii and the 
cutaneous tissue are iniplicaled; in Ihow of the wcimd dtgree, tlie 
uurfai'c of tlic pcriim-iun, thu various pyrineal muscles, purliculark 
conotrictor valine and traDerersus perinei, are torn throufih. am) tbp <ri 
gaping Mound i» due in great )iarl to the nHraclion of tin* Iii^t-w 
muscles. When the tear extends up the vai^na. certain fibres of 
li'Vfttor nni muBcle are iiVcvriic involvod; while in liceriitions of (Iw 
(lejireo, the spliinotev nni muscle and the anterior Burface of the n 
lire implicated in addition to the KlruoturCK above naiiMtl. 

Ab has lieen said, the |ierincal t«ar conimences, as a rule, at the 
chettc and extends <ibli(|uelv downward and outward from it. But t 
very rare cas«i in which tlie vulval outlet looks loarkedly upwanl. i 



BEPAm OF THE LACGRATUU I'KUIN^UU 



321 



lilrh (No {Krinn'iim !>< oxtn^ini'lv n^ittunt aii'l t\v> mochaniani of fxpul- 

t4iill>, lilt' ImvrHlioii iiiu> ln<;:ili Ju lUc iviitriil jairLJon nT tlw pnri- 

nvam. nml lli>' Ik-uiI n|i|Hiir in iin oix-tiiti;; whiclt is furn>and«d nii all 

ikl«» \i\ rkiu. This i» kiitiwit uh a central ttar, atul \* nt extremdy infre- 

fe^BWI ocrarreooe. Ordinarily. «s the head is forced down Btill farther, the 

HjaCdtaitU riiwiinlx (he fdiirt'lu-ltc nr tovanln the aiiuii, or i-vi-ii in botli 

jH^Hinai, ami iUua ((iveo riM- to a d<<ep. incoioplDiD, or coiujili^tc Ia(«ratioi) 

» IW ram- mav 1*. 

I In ant a ft>a: casRi. where the va»inul opening t» rery reflistant, and 

I iln th* hi-ad hif n-inaiiM>d a long (itne upon the pelvic floor, wvn 

illkiiugh thiin- mav he im external wound or appreciahio leaion nf the 

*igiaa, ihvTv may iwvwrthrlcs* luiix; owurrwl a itiil>tiiiu'"ii" tair or wpuru- 

t»a «< certain flhrw of the levator 

<« na«el«. which will later (five ri« 

ktoub-d rt;la.\ation nf the vaninai 

■Itrt. Kot infni|iii'nllv the («n- 

*f«. although 11 nrecn^^i fieri at the 

t*- Itlw giv<!« rij«c to tucii aggra- 

'rtnl *Tiii|iti)ion aw to call for opera- 

•>m nan aflvT llw hirlh uf tht' child. 

■> ■ ■■ what the deRrcp, the 

1 '■!> 'Urr of prriitf/tl larrrit- 

' In «ilur« id urgently indieatod. 

^w* ''ight U-arfi through Uh- four- 

'^^ an- Ih-IIit rf|iaintl lluui left 

if not anitMl hv suture they 

'■strt-mvly juiinfiil. mid fur- 

n etcellent nidusfor infection 

••«»• llw aon* if hx in her <«re 

•* iif |Mli4>nt. In more extensive 

■u- p'juiir in nlwayo nee- 

. - Lite condition of the pa- 

wriounox tovontra-indicatA 

,1'tatire pmcednref. 

ii-KO ofir-nili'in)'. the palictit 

linmsht In t)>e e(l^> of tite 

. gitnopd in ihe Ulholnmv pmilinn. and the Kntures introduced while 

•*■«!«[ for th4- expulwion «f the placenta. Ilicy »hoald not be lied until 

in of the third iilup;. ii» the di.-tention of the vulra hy the 

■ uhjrci the rcpairrti wound to undue nirnin. Itv introdocing 

irinit thin jierind a gt*™! deal of time in ^avctl. and thi> temp- 

;. c;(|im>iiion of Ihi- pineentn in diminishwl. since tlie phr^iicinn 

I^Mpli-ntv In do while waiting for the ftindnii to riae up. 

Tbe wiibV lit repainnif thi> woiindwl ixTinvnm differ* ni-cording »» the 

Mtrnd* only through (Im- perineal IkkIt i)r is coiiiplicatfii hy laeera- 

'l©f the Tagina or iwlitm. In the firft caw. tin" wound shouh] W 

Ibjr d«TTJ MttureK of silku-orm put. which are intmdnwd at least 0.5 

from one margin mid carried well down under i(« _Jj(«', liotng 




t'M. sin.— (Vhcplete PKaniBAb Tm»M. 



328 



OBSTETRICS 



(lieii l>rou;;Iit nut llirnu;rli the sVin sntfiwc nn tliP oppneho niilo, !t" 
imp"rlHrit tjinl thr siitiin-s i.liiiiil<l In* iiiKfrliil iiml vnnT|;c al a <'on>-i<lpralili 
(lititaiti'r fntiii llio ■■il^.'i.'h of iht.- W'lniul, for. ■■tk'iii;; In tim iiiarkti) a^i'iiii 
whU'ii l'r(;i|Ui;!i]Uy follows tlieir iiilt'iHliii-liiiii, tlii'V urv mtv [iroiic In u-aj 

tliroujfh uulefis this )>r«!autioQ be taken 
Tiit-y shniild Im- filmt^ii iit inttTvnli' of ol<o«l 
1 (H>jitiiin'tn-\ and if aftniralo ii|i|)ni}tituno 
tioii JK nut hivitriHl in this nuy <(U|irrliciai 
sutures ehouki he emplovod l>t!l«'i»D thenr 
\^ige cnrvod miHlliv, which ran make t]a 
cutitv sw«^ at a sinjile tiinvL>i(M>nt, simul 
1)0 iiMil. B» tlifv rt-ndcr much hetlor wttIl 
than small nw(llt« whioh rci|iim' wvera 
bills. 'I'he suturc); should be tk-tl very loosvlv fnttu bt-Jow aptranl, 
cut off rfiort. 

As a suture matmal. isilkworm gut is prefprable to silver wire, sina 
it can 1k^ mort^ n-a<liU' hauillt<(l. Silk .-•iiturcj: nrt> nhjivl ioimblf, us ih' 
readily benime impregnated with the lochial secretion and are more likel 
Ui r«v«ur infwliiiii of Hit; wnimd. Ordinary, or ewn vhromieiwtl ait)n- 
is not satiBfactory for deep sutures, aif it is too rapidly abnorbod. owia 



Via. 317.— N«DLt rou lUv^uuKa 
Peiuneai. Tkahs. 



1 




Fm. 318. — Nkejhj: Hnuwit. 



to the fact that the o.vpoiwd portions are kept moist by tite lochia, 
very iKcfiil, liowov<-r. for i*upiTtlciiil sutures, whieh an> only ni^nii 
remain for a short time. 

When Ihe [«-iinGal tear is oninplicalivl hy laei-ratinn of the vagina, 
edges of the latter should he brought together by deep silkworm 
»uptTficial L-algut sutureti., jiutt as in Kmmet's Telax«i] outlet aporac. j 
after which the perineal wound should be repairttl in the usua] maik^n 

In compti'U- li'iirK, iilteiilion hKiiiM rrrsl lie nfiven to iIh^ wonvici 
rectum and it^ ruptured mucona unilct! by tine silk sutures, whic^i d 
knotte<] into tlit- netiini. the cmls iH-ing allowed lo protrude from th 
anus. When the rectum haa been repaired, the enda of tlie aphinctcr Btu 
should Vm i«i!nle(! and firmly sutured by etitjiut or fine silk suturw. ift*» 
which the vaginal and jierineal tears should he dealt with in llic manner 
indicfitiL'd above. 

The arter-lnrjilinenl of all dcfrri.-es of tears is eomi>ani lively wmple. ao** 
cnn§ist8 in keeping the wound trlc-an and covered by sterile drewinc*- 
Wlietii'ver (he hitter are changed, the womided surface should be " ' ' 
with a l-to-.'i.OOO bichloride solution for u few days, and later wit 
of boric acid. Tlie continuous use of antiseptic powders, such as iodofnnP 
or boric acid, is not indienltHl. as the wounds heal Mjually wdl withnnt 
tbcin. N^ifi.there any necessity for himlins the legs togcllier, nulciS the^ 



KGIUIR (IP TUB LACEHATEU TUtlN^UM 



329 



lent is wry unrulv miiI n-rux-* In kw|) stil!. CaLti«t<!rizatioti may also 

<l upt-iiwd with. ex<f[it ill cuftv of n'tt-'nlion, a* Hit' flow of urine over 

nj- woiiiiil ilix-s an luiriii, )>rf>viiU-d il i» followed l>y proper cleaniiing. 

i-n«*rully speaking, the externai outnres tihnuM In- rvntovt'd on ihc lenUi 

ky. anil Idc* vaftina) stil«)i<!i' a few days later, In team of the Snt and 

>ti«l ilc^ftrnv Oie Imwels should Iw moved daily, but in rouipMc lacera- 








Fw. 330.— Same, SrmuM Tikbl 



*»w8t it u adviiialtk to pnniiit an aclinn for the liint Two or llin-e dnyt, 
•itw which a large high enema of sweet oil ehoaUl be given, follovred by 
**Wd or raolor-oit by tin* iiioulh. 

TW nsnltH following these operations are muallr Tery aatiflfn^tory, 

•*J ilirti tin* |ian-« liftvi- Ibiii corriflly npproxinmlci, primari' union is 

••» lie. provided t\w suiutv* have lieen inirotlueid far t-nou]k'li fmiii tl»e 

"<n;uH of the wnund and not tted too tightly. This in a point to which 

|Hmi-J) ■lientioD ean Iiardly he juiid. for too oflen Itiere a a tendejiey to 

Bpt to make a neat-litnkiiig operation hy intTuducing the ^utnrev close 

agin* iif tlx! wound and tying tliem ttnugly. Ait a result of thi« 

itn) policy, however, owing to the usiema which usually follows. 

■V of ibo stiti-ht* cut tlirough and bocomfi uwIliw, >^ that union 

l"itL3rv iutentinn becomes impossible. On the other hand, when less 

■"'Atiim it> paid to iFie first appranii>cf of llitr wonnd, lh«- r^ultire* Wing 

fmlii-nl fnr from its margins awl tieil Mimewltat loosely, excellent re- 

iln ilm'^-rt always follow. 

Catiinuualely, operatioDs for complete tears arv by oo means so t-at'o^ 



330 OBSTETRICS 

factory, and as a general rule not more than two thirds of the cases heal 
by first intention. In the easea of complete or partial failure, a secondary 
operation is indicat*^ before the patient is discharged from treatment. 



LITERATURE 

Balawin. I'ebcr dtii MechmiiBinuB der D&mmrisae und der verschiedenen Dainin- 

Bchutzvcrfahren. Klinisrhf Vortrage, 1863, St. Petersburg, Heft 1, 95-127. 
BiEH. Vcrauchc uber Cocaintidrungdee Ruckemnorkes. Deutsche Zeitschr. f. Chirurgie, 

1899, li, 361. 
BuDiN. A quel moment doi^on op&^r la ligature du cordon ombilical? I.e ProRreij 

Medical, 1875, decembre; 1876, Janvier. (Obst^trique et Gyn^cologie, 1886, 

1-35.) 
DbMaurans. Comutunt on meure dana I'aneBtb^e gin^rale par ki acopalomine- 

morpbJnc. Sftnaine MM., 1905, xxv, 373-375. 
DoNHofF. Ueber die Einwirkung des Chloroforme auf den nomialeii Ueburta\'erlauf, 

etc. Archiv f. Gyn., 1892, xUi, 306-328. 
FiiaBniNQEK. Untersuchungen und Vorachrifteii iiber die Dcdnfertion der Hiiude des 

Aritea, nebst BenierkunKen iiber den bakteriologiBchen Character des Nagel- 

schmutzcs. Wiesbaden, 1386. 
Gauss. Geburtcn im kijnatlicbea DaminerBchlaf. Archiv f. Gyn., 1906, Ixxviii, 579- 

631. 
Die Teehnik des Skopalomin-morphium DammerHchlafca in der GeburtBhilfe. Zen- 

tralbl. f. Gyn., 1907. wxi, 33-38. 
GiFFARD. Cases in Midnifery. Ix>ndon. 1734, 396-398. 
UoouBLL. A Critical Inquiry into the Management of the Perinmni during labour. 

Anier. Jour. Med. Sciences, 1871, Ixi, 53-79. 
(!rke\'. Notes on Obstetrical Therapeutics. Medical News, 1903, Ixxxiii, 692-696. ' 
Hahn. Ucber xubarachnoidcale Cocaininjectionen nach Bier. Centralbl. f. d. Grenzge- 

bietc der Med. u. Chirurftie, 1901, iv, 304-317 und 340-3S4. 
Hensen. Ucber den Einlluss des Morphiums und des Aethers auf die Wehenthatigkeit 

dea rteruB. Archiv f. Gyn., 1898, Iv, 129-177. 
HoFMBiEEt. DcrZcitpunktdcr Abnabelung in seinetn Eintlussauf die eraten I^ebenstage 

des Kindcs. Zeitschr. f. Gel), u. Gyn., 1879, iv, 114-132. 
Kellv. Hand DtKinfcftion. Anier. Jour. Obst., 1891, xxiv, 1414-H19. 
Kreis. Ucijcr Medullamarkose bei Gebarenden. Zentntlbl. (. Gyn., 1900, xxiv, 

724-729. 
Kroniq. Versuche iiber Spiritusdesinfeetion der Hande. Zentrelbl- t. Gyn., 1894, 

xiii, 1346-I3.'j.'!. 
Matwjeew. HypnoKc in der Gehurtshilfe. j^entralbl. f. Gyn., 190.3, xxvii, 121-122. 
Mi'LLER. I'cber Lunibalaniisthesie in der Geburtshtilfe a. Gynekologie. Monatascltr. 

f. Crtb. u. Gyn., 1905, xxi. 169-185. 
OutuAUSEN. I'eber Damniu-rletzung und Daniinschuts. VoUunann's Sammlung klin. 

Vortriige, 1872, Nr. 44. 
RiBBMONT. Recherches Bur la tension du sang dans lea \'aisaeaux du fcetus et du nou- 

veau-n^, -Archives do focologie, odobrc, 1897. 
RlTiiEN. Ufltor (-in Dnnimsrhut zvprfithrcn. Monataschr. f. Geburt«k., 18.55, vi. ."121- 

:)47. 
S('nmit;i>E», l.i;hrbu<'h der (icliiirtuhiilfc, VII. Aufl., 681. 

ScHi iKiNu. Zvi Physiologic der Nochgeburtsperiode. Berliner klin. Wbcfaeuacfar., 
1877, ^iv,5, 18. 



REPAIR OK THE LACERATED PERINEUM 331 

SoDBON. On the Employment of the Inhalation of Sulphuric Ether in the Practiix of 

Midwifery. Monthly Jour, of Hed. Sciences, 1S47, vti, 728. 
AueMbeaia. Philadelphifi, 1S49, 248. 
SrKLicBt'cHKL. Vorlaufige Hittbeilung iiber die Anwendung SkopalomiD-morphium* 

Injektiooen in der Geburtsbiilfe. Zentralbl. f. Gyn,, 1902, .\xvi, 1304-1306. 
SduDenverminderuDg in der Geburtshilfe, etc. Leipzig u, Wien, 1903. 
TcPFTKB. L'anestMde meduUaiie en gynecologic. Revue de gyn. et de chir. abd., 

1900, iv, 6S3-693. 
WiLUAKB, J. WnmuDUE. The Cauie of the Conflicting Statements concerning the 

Bacterial Contents of the Vaginal Secretion of the Pregnant Woman, Amcr. Jour. 

Obst.. 1898. xxxviu, 807-817. 
ZwurEL. Wann soUen die Neugeborencn abgcnabcit wcrdeii? Zcntmlbl. f. (lyn., 

1878, 1-3. 



CilAl'TKU ^Vl 



TlIK FVKRPHHIUta 




Tllli jmerporium or ]iUL>r|it-riil stale com)irif«s the five or six 
fiillowing liilxiiir wtiicli iitl- nijiiintl for tlu> n-liirn of thi' ^itM'ruCivR 
lo \\6 unriual comlitiuu. Allhou^h tlie changfs ocourrm]; during 
[HTiod HIT (■'>ii.«iiirn'il ii> [ilivsiniojiirHl, tlii:_v iHiniiT vitv i'Iom'Iv u 
jmttiolojjiral, iiia?imi<:h at iiiider no ottier ci renin ^tani'cs docs j^uch 
Riid rapid i\t9^xv iiivlntioliHiii owiir without a departure rrnin a ooa 
of heal III. 

Anatomical Changes in the Faerpenura. — Invnlvtion of the Utrr 
IiiiiiKiliiili'Iv fiillnwiiiji; iln- «-x|mlfti<ni of ihe jilaoynta, the contracted 
rt'tracH'd body of the utcriii^i f"rm:= a har(l nmsciihir tumour, tito ajH 
which lira nlioul midwav between the umbilicus and eymphyais, u 

ly IB wntinii-tnn 
inches) above the 
ter. , During the I 
few days the uteru 
c-reaeiM «o rapidt 
»ize that hjr the 
day it ha^ du>c« 
onee more into 
aivity of the true 
vi», and can no lo 
1h? fi'lt above the i 
physin. ll r«a^hii 
normal siz« br the 
of fire or »m w 
Somt idea of th 
pidity with whipl 
proi'tw |p>08 on 
be gained hy nx-i 
the fact that the t 
ly delivered uttni? weighs about 1.000 grammes, one weiek later 
gramme*, at the end of tho second wfiek 37fi gramnKV, and at tfal 
of th* pucrpcTiuni only 110 praHimc*. 

This rapid deoreuRo in »ize ik due I'l what ix do«ignafed as tnrofi 

and i* brought about mainly by changes occurring in iho muscular 

On examining the uleruw of a womiin dying immediately after Inboui 

ig struck with its markedly anaemic appearance aa comparml with tt 

332 



FlO^ 321' rilO^L.% .^J.LE l'>.-h. :>Jii.>W 4Ni.< i 11-111 

ArTKR Dcivunr fWcbalpr). 



iiui>:auri:l.T 



AXATUUICAL CUANUl^ IS TUK PtiKRPKItirM 



333 



we fRi^niuit organ. I'liie is due. accnrding ti> WelMtcr, \n cninprw^ion 
f it* v<»m-1h Iiv Uh* (-uutnieliiig nnd rrlmctiug iiiu»:ular tibru^, simI 
i:>|:>rc!)%nl« Uie fint i^ta^ iif ibt involution. At tliu hhiiio time > con- 
a«lorsblv portion of tlic itMUc jui<.i.'8 is c.tpn.'sstxl From it by the same 
tk^a^tianinm. 

It wa* fomierlj- litlieveii that the muscle c:cll* iirnii'rwent fatly ite-g«n«r- 

it.i'*ri liuntig till- )>uvr;K-rtuiii, ami that large- nuiiikTK of tlH-m complclcly 

l%M«p|B<«raL The rv!«ari-lM~i of Silu^'or have itliown, hitHLH'iT, that only 

!%«■.- t?scvM> of pnilopliwni if ko nruiovcd, and ihiit the actual number of 

ixkdivMlual (vlls in not materiaily iliminiiihtN). In other wonU, thi>%' un- 

" ' -I atrophy, but are ii'*t dt'j^troj-cd. Siiiiger estimated that 

I " l(-ti)fiti in ilti- full-UTtii iiicniK va* V<>H.~ mit-roim, t* eoin- 

pwrvil tnlii i4A micmnK live veeU after labour. 

\* han Invn Mill In-fiiie, the Mpunitiou of llio plaernta and itK in«m- ' 
bniKtt ocvuM in tlie inner portion of the spongj" layer of tlie deoidua, 1 
ami •cmr-itngly the gn-ali-r jwrt of tlii< Inycr n-inHJn* in Wk uUtu* *ft«r 
liior t-Apul.-ion. It prewutB an irregular, jajj^red apjtearance. am) is mark- 
|«11t infiltraki) vith kl<HNl, i-»p«.vifllly nl the phuiiital i^ite. A* tlu; mnilt 
»t hTilin and fatty degeneration. lite greater portion of lliifi lissue is cast 
I off IB iIm> Inchiii, Irjiving iH-hiiid only thi^ fundi pf the gla»d:< of the vpong/j 
t^aoiil a minima) antouot of coimective tissue, from nhich the Dew oido- 1 
■Uiiaiii is ri-geiKMatetl. 

The procesA-s concerned in its regeneration have l>e«i carefully studied 

^ Friedlander, Kundrat nnd Eugclmann. I>yip<:d<l. Kronig. and porticu- 

^t liT Worni.ter. Tltit latter hiui yliouii tlial within two or l)irei> davM 

' Unirr the portion of decidua remaining in the uterus lieeome!< differ- 

•ttd into two lMyon>— one adjoining itie uh-riue cjivily licing nt't^mtic, 

•>il 4r otlicr adjoining the rauscularis being well pre*cnied. The fortii«r 

^CM uff in the Wliia, whih- tlu> hitler, which miiuiiis (hi? romli of tlie 

.nmailiM it nHu and t-oUNlitntes a niatri.v from which \\w new endo- 

i» regfiii-nittil. il* e|iithelitim resulting from ttw; pnitiferation 

' 1^ cdb of Ihr fundi of the glands of tlie decidua. and its strous 

^ tlw cnnnectivt! tissii* belwti>ij Diem. For the first t»'n days or two 

••As ilejpHKrotive prooen^cs predomiuate, but after tliat' mitotic tigures 

*(f*>r ftm) n-g<^<'Tstiiin i> rapid, thi: n<'w endonielriiiMi lieing fulli formed 

I* tbr end of iln- third werlt. except at the placental site, where tlw 

pou* it more gradual. 

JVI* IjeuHlrfi advunced the xiw that tlio syncytial tissue lying in tlw 

ns of Ihf deriilna and the iip(MT layen nf tlie miiM-ularia 

ifiiirlant ]wrt in ihe ptoceris. and that the grwiti.T pfjrtion 

«t Uw new epithelium is derived from iu Tlit* theory wast forniulaled 

■ - •■-!<■ wIh-ii it wa« lielievTCl that the syncytium was of maternal origin, 

■ ■ it luB Incu shown that it rfpn9H.-ntit f<j>tAl ectoderm, such A riew 

Me. 

'■ f'/mite l'«wW». — Immediately after tlw eompletion of 
• ■ third •Injtf "f Ulvnir, the plaei-ntal site is represented by an irregnlar, 
„ .;irl,ir. >liT:iti'| area nf alnut tlw size of thf pnim of llie hand, lUo 
^,uf ifi- - J., due to the presence of thrombosed vcwtel*. This area 



lirii 



334 



OII^'bTltlCS 



d«(;n:aM.ti rupitlly tti »m: mi |}iul a UK-Hfiirvo 3 or 4 cmtimctrc:* in 
eter at the end of the MHond w<*k, and ooIt 1 to ? centimetres at ll 
c'funfiletiiiH uf liw pui-riaTiiiin. olllmiipli il Klill nrmainit i-li-vaHil jt 
the general surface of the interior of the uterus and is tinged with W 
pigmvnl. Its ori)p»ul petition ninainM rK-o{pii>wb1« for tjititv a 
period, and oven six moDths after childbirth appears as a sligtitlj eli 
pigjmnl'x! stva. 

In t)ie laiit iiuinih of }in-^imnt'V »onio of the HiDu><eA at ttie pJ 
site undvr);o t!ironiU)»i8. but tht; pnce» becnuive more niarkvd in 
latter ]K)rti<tn nf Die second and particularly aftor lh« completion of 
liiird stnj^' of Inhinir, ulthoiifjh iniinv t^iiiuK^ never iM-ctimc thrombo*! 
Ijut art t>iiii]ily c'iiii|irt---i»fd hv ihi' (^inlrai-tin^ nlui-inc muscle. Tlie ihroii 
become organized by the prolif^niliou of the inlima of tho vessels, 
eventually are converted into typi<-al i^jnnwtivft tiwUG. 

As the non-pregnunt ulerue nxguires a much )e»s abundant blood 
|ily than tlie pri->.'niint or;fan, it i> iippnrcnl ihiir tho luininn of il.t variii 
arteries niui-t uiiderfjo a certain amount of constriction. This is broui 
al)0Ul by a aini jirriMtl'iry fnilarlfirilin, which i* not infrw|uentlv a--«>oci 
with hyalin changer in the tunica media, and was carefully studi 
Pankow in liHHi. Thwc clinngo* pewint for ycurT". and uiid«r tlw tnii 
scope offer n ready nicaue of difforeniiating between tho titcri of wi 
«ho hiive mid thoM) who have nut hunte chihlrcn. 



roil 

1 




I'm. 3ZiL — I'liojitii Wcmosi Jirnr Arrcn CoMPLrnow or Tiani> Stmh! at t,Aaatm.i 
IMD Cuu^i-HB or Ijiweb Urr.Hi.-cK Seoucvt axd Ckbtix (BcBclUtpr). 
CR., BiiilnUTlimi niifc O.K., iiKl«iriuL] ■•■; O.I.. inUmaJ on. 

Changes in tlm (Wvix, Vagina, onii Vatfinat OMfJei.— Immoliatcl; ■ 
the cnrnpl^^inIl i>r iIk- lliiril -lii£i'. the eervt.v i*. represented hy a 
iiiUNcular tnlit-, whon? Iioundarie^ tan In.- iiiadn out only witii dilTm 
Ihe margins of the external o« arc soft and llabby, aiid are usually mat 



CUMCAL Asrtxrru or tuk i*tJEUPi::iiii:u 



335 



Pbgr dKpnnioiu inducting tlw bCat of lacerations. IIa opeatn^ uontracte 

JHiivlT. For l}i« tirat few duvn iniitic<liiiti-lv following InSour it rmdil}' 

M)ntt« two fiiigrrs, but by the end of tlit.* tirut n(.«k it hai> l)e<?onie m 

auTow lu tu refuli^r dilTKrult 1)ia introduction of oiii- lingv-r. At l\w same 

time the lower uterine scpnent eoltapses, and what remains of the con- 

tnvtioa rilig romw in iimtwl with tlio upjwr portion of the eervical 

oanL A^ Webster han jioiDiixi out, tlwre is no doubt that the rUriii-iiif* 

*hir1i ii^ tiKiiiilly (wki^n for the inlrrnal o« oil difptal rxainination. rrally 

i^r^tttentd the lowt-r margin of the contraction ring (Fig. li'i'i). 'ITie 

in llii» portion of the nlrrun rendily i-xplain the production of 

IBarkml autcflexion which ocnaKionaliv i-haracteriKed thitf period. 

"IIh' rn^nii niiiiirot wmnr time to rt-coviT fmm tht- diKU'iition to nhich 

hv liren aubjectod. In the 6rtt part of the piier|»i'rium, it is repre- 

ilnl kr K larjiv. !>inoolli-wallfd paMugc, which ^xdimlly diiuiniKhcif in 

thiiiijcb it rarely retumH to it>i virginal condition. The rugv iic^in 

ir bUiiiI tin- third woi-k. The vaginal mith't i* «1m> markedly 

i. and usually bears flijins of more or Ie» extenxive laceration. 

Titt hyni'-n. iw i-iKrh, hn* dt>'il|)iH-anir!. and iU place i* takm by u numher 

tf mull tags of tiMUe. which, aa the proce* of cicatrizatioa goes on, 

WKrwDc (imrcrlod into the lamnniltr mgr{ifvrm*f, which ari- characicr- 

SFtac if the vaginal opening of parous women. The labia niajora and 

■>-iiHn hiyoHK! tlaliby and olniphio, an conipaml uiDi tlu-ir condition 

fcsf oit i*ildUirtlL 

i i'iangrx in thr i'frUnainini and Ahifotninal Wall, — While thr*"- clmngct* 
ItTQ titattff place in the nterux and tagina, tht- |H'lvic peritom»uiii and the 
I itrtirtiiT* nf the hmad ligaincnti^ are acfommiHlating thetnsi^lvc^ (o lh« 
I duKiiiit iTifidilion of afTairo. For tlw BthI few days after laljour the peri- 
I mnwin mmring the utenM ui arranged in fold^^, which luvin dii>appcNr. 
I Tlw hmad ligament is much iiwro lax tlwn in the non-pregnant condi- 

■ WiB. u4 nvjumv <'on>iiderable time to nvnver from ihi: «l«'U-hing and 
BBttniOg to which it ha^ been Huhjecleil. 

^^B Aiammlt of pn'longi-d di*ti'ntion diir In |hn pnvoDci? of thu vnlarg*^ 
^^PfMBt ntrrun, the abtloniina) walls rentain mft and Habliy for some time. 
^^**pl &r the pri'iU'iM'"" of »ilviTy dtrUe. tlM^y gnidnally rclum lo tlieir 

■ Btnial nioitition if the abdominal mUR'Ie:!! have retainetl their tonicity; 
^■P*Imd thia in marke<lly impainil itwy never n-gain their original con- 
^^f^- bBt remain lax and flabby. In not a few instances, particularly 
^^B"!*!! who have bomo a niimhur of childn-n in rapid KunWMtion, lii«re 
^^^P "" ■ martial separation or ilitutaxi* iif tUe rrcU mafflft. fo that a 
^^P**»>IJi- portion of llic oNhiininal wnlenl* i» coven^ simply hy |jen- 
^^P^'iit, thinn«d-out fat^ia. and skin. 

^^B Tit dungee oerurring in (he l>n-i»:l< are very charactcrinlic, and will 
^•"O'rifml in riiapter XVII. 

^■^'""iMJ AapccU of the Puerperitim.— /''«/-/v(r^/.n CkHl-SM infrt^ 
HH^"^' IKi- (wli'iit may liav.- a ^n"i>- or |trs« violent rigor <-omiiig ••it 
r^*"!.' Jfli-T the comptelion of tin- thin! ttagc of lalHiiir. Thi» i" purely 

■ •Krnui nr va»(Nmolor )iiwn»me»on, and is witlmnl ])rognoHtic «igni(i> 

■ B^ Is thu rajiect it utande iu inark<il contrui't to a rliill occurring 



336 



OBSTETRICS 



in/, 

■J 



* 



luter ill tlio piioqifriuii). whidi iiiiirl}' alvays iiidtcnkv Dip oiiwt o: 
uoute iiift'ctious procws or the recrmle6«enL-e of a iimlariiil attack. 

Ti-mfirnilnre. — (iciiiTuliy Kjicuking, tlif ti'tuiM,Tntiin' n.ut)uiii« praci 
rall.v normal tluiiop tlie puerpfriuin; lioic-e anv cwnniderahle rise abou 
Hlwiivf Ix; iiiiiKiiltinxl in- II I'i^n of inftH^'tion. until Limviiicuig trndpiKoj 
the contrary can be ndihiced. Not iiifr«iiiently the ti>ii))>eratiin- may 1 
(■nine fllghlly ik-vntt'il lnwiirds the i-nd or jii^t aftt-r tlit- cnniplctioU'^ 
a ililHciilt lalmur. riuli^i" siioh oiri'uinslancL's il ran-Iy jjm^* alwvo HM). 
1^8" C), iisuttlly fallK to uormal wittiin Iwcivc hours, and dow not 
Kgain. A higher tPiii{H<r«tiire during labour in all pmliahilily tndii 
infection of tlw liquor timiiii. 

Owing to the fiut thai Mlight ri«et of loinpiTaturt' oifur trvnn 
during the piivrpirium withimt appBri'iit cauw?, lOO.i" F. (38" 0.) t 
arbitrarily \>ecn di(>.->on a> the iippi^r u-rnpi^rtklun- limit for iltn noris 
)iurrpi.'ri\iiit, any rU^ alMtvi; it beiiiR re;^rd^ a« pathological. J 

It was fornji^rly lit-lii-vod Ihiil the (vlalili^hiiiiMil of tho larliMl Bccrcl 
ou tlif third or fmirtli day of the puprpfniini wau ualurallr attended 
a sli^dil rist' in tciiipcinturo. In<h-<'d. kii prcviik-nt wait thin idva Ouit 
prc-antiscptic times the so-callol milk fever was regarded aa a normal | 
Tioincnon. Itut at prownt wo nn lon)f(!r belicvo in tliR e^iintcncc of t 
a patholofiical oiititv. and wheitcvpr Ihe ttnifwraturc ex<*cds tlip noi 
limit at this tiim.', tin- timMt-iiTious oMclrician should f<-»r tin* hv^in 
of an infection and begin to look for the errors of technique whidi i 
have lixl to it. 

Pul»f. — During tl\e piierperiiini the pnlra is nsnally »niiiowhat kI<I 
than a) other time*, avemging lictwt'en tlO and Jil. fn nervous won 
h'lWi-vor, and in those who have had ditliciilt labimrsi or have xulTonil 
considerable loss of blood, a more rapid rali- than nonnal is not in 
qiiont. In a ('crtain luimiwr of eases, a day or two after the hirlh oP 
child, the pulse becoiiics MDirkiilly slower, and not infrequently falls to 
40, or I'ven fewer bealu to the minute, Kebling has reported a wwe in w 
the rate was only .il".. 

Ordinarily thi-i phenomenon lieeomes most marked on lh« iwconil 
third day. after which tlie pulse becomes quickvr and attains its n 
rate by the end of the first week or ten day*. The slow pulKe i* n*' 
regarded as a favourable progiu>*lie sign, whereas a rapid heart acti 
unless it ran he aceoiinti'd for by hieniorrhage or cardial' di^^^ajte-. nln 
be looked u|ion with suspicion. 

litis puerperal slowing of the pulse is usually rr^rded as n eliw 
terintie pbcmimeiioii. Heil. however, in 1898, stated that the Mief 
l«wd vifHin rmilly observation. He Hflirnu'd Umt if the ptils« bo 
fully counted in the same patient for some days before as well at 
lalmr, it will be found slightly quicker in the puerperium than tin 
pr^rnanei,'. He note<! the puerperal slow pulse in only 12 per cent 
his cn«C-*, Similar i nvej-t ignt Ions uiidiTtakiTi \w Vnrnier failed to conl 
lleil's conclusion-s. since they showed that tbe puerperal slow pul* « 
curred in 72 per cfnt of the ciu^cj'. My own observiilions slmw that th 
condition occurs more frequently than noted by Heil and lew fn>quenU 



CUNICAT, ASPECTS OF THE PUERPEIUUM 



337 



Mbjm by T«niii>r, oini* the «!« *m* HuhiKtmuil in 33 out of 71 cases {45 

f^r wJitJ olwiM-iwI in iiir clinic. 

I NiimtT'iun tlHtiritrs liiivi' Kvii nilvniii-iil fnun liiiio In tiiiiu in the 

l§U*.iuiil ti> oxiilulii lU niudc of |inHlurli<>n, l)Ut none iif tbeiii nm wliollv 

H|pii(ic lorv- It i» tKit im{>o<ij>iliIc (li«t lliv Koltitioii is quite eimple. anil 

^Bai till' ciHidition niny depend upon two factont: the nhsolulo iwl of 

llxe {Mliefil in heil, t<i{K<-thi^r villi tliv gniit diminiilion in iiork which lh<> 

W^arl u calK^ U|»n lo inrforni attt-r tlie t'li mi nation of i[«> iiti-ro-placi'nliil 

cirvBUtiniL Kchn-r utlriliuUil tin* winning in great part to the lowfring 

Itf Uw lilond pressnre followinf; deliverv ; Schrowler, to the iiudden diniinu- 

Kah vf ihf voM'uliir an-* itflcr llx- ulvnKplaccnlal cirrulation ie thmwn 

^^M of fanclion : l-'rit^h. to the horizontal po.'iition and rent in ))o<! ; Liih- 

^^^MjJ^rtitiiulalioii of (hi! va;:ii!< or i>t)ii*r n<-rv(iitH inlluciici.'K: and OUhniiscii, 

^^^^B ah'^rption of various products Mct free in tlio blood during tha 

ralMimi of tlic tiltrax. 

Vkangct in thf Hiooil. — It is iiHuatly »tAt<Ml that iherR ig> a sUglil dc- 

in tlw niiinWr of iwl corpuwl*™ and the amount of hfcinoglobin 

imdulKlr after (k'livcrv. Thiit '\a ui(ril>ntable to (he lo^^ of blixxl at 

tlMttiar, and i^ uatially c<>ni)R-n'atiil for nilbiii ihir (ir^l wn-k, after vtiidi 

tbe tsmal oondition ia restored. 

I QeflMiuiT hiw dirwtwl attention lo Hk- iitciirix'Mw of a inark<^ l<>ucoc>"- 

L lOBKccnrnnt; during and JHfit after labour. Ilv showiil tlmt the leucocytes 

^fcadiolK iwn--a*c in nuitilHT from iIm- "ii»fl of hdwur and riiiwli a mnxi- 

^nm ten or twelte houn> after its conctuDion, at which time they are nearly 

r tirin>M ibnndont as during pivgnaiKv. Daring attaimtl lltctr acme, they 

I Fwirtly fall to normal, risin;; ajjain Hliglitly on tlw tliinl or fourth day, 

I <^ the mlahltxhrncnt of tliu lacteal m.vR-tion, afttT which they remain 

F "J il* mrmal Wei. 

L ■Iflrr-piiiM. — >)n primiparons womm the ulcnu remains in a stale of 
I ^f^ nmtractioD and retraction dnrini; the puerperiuin, unle.'U it Itaa been 
I ■''JBSwl to uniiMual di«tenlioii. or MwhIh-IoU or other foreign Ijodic Imvc 
^. •■• iftaim-d in iu cavity, as a co»(*ei|uenoc of which active contractions 
^■p* in the effort to i'\|>cl t)H-ni. In multiparou* wonivn, on tite oDkt 
^■■ri, iW titerm has loiit part of its initial tonicity, so ttiat pcrnistt'nt con- 
r <^Ji.<in anil n'trartioii caniMt be maintained, and it tliiTcforv eontrscta 
III inler^aU. the contractions piving rii*c to fiainful Ncn^tion;*. 
■ nown as after-)Mlinf!, and which iMianiomilly arc *t> •even* «)■ lo 
I "^(iiTT ilw ailiuini^tnlion of a -Mtlative. In many patienlii lhe<w am 
I KVilirly nntirealile vhen thp child w pat to the breast, and may last 
I 'v rtiini davK. hilt ordinarily they lose their intensity and iHi^ime i^uile 
I ^tAlf a/tt-r the twenty-four honrs immediately following delivery, 
I ijriiia. — I luring the first jiarc <tf tin? pinTjierium thcri' oi-cum nor- 
I *''l.i ■ rariablc amount of vaginal di9chatx<^> — Hm' lochia. Fur lliv 6h>t 
I *»<1*T» aftiT dtrlivery it c<insiBt* in grnat part of blood — Uiehia mbm: 
*'W(iim*<ir four days it becomes potter— /or-A in s^roM; and aflor the tenth 
■ to a mnrkcil admixture with Ir-urorytet, it asaumcs a whitish 

H' ii'Wiiite colour — lorhin alba. It is alkaline in fraction, ami has 

'Pnliar Hatby odour, )>nggiatiiif[ fr<^h blootl. In normal caaes ita quan- 



S3S 



niiSTETRICS 



tity varitwi bi'lwLLii .i"U ami l.mtO fframmo*, Iieinjt lass prnfuM^ in IM 
vh» Mii-lck tlii'ir children. Foul-siiu riling ItK'liiii iiirli<-ml>; inTiKction n 
)iiilrDfH('tivr ItHck'ria. In iiianv iiu^laix-iv Ihc it^^l<li!ili i-nlniir i^ pn-ii'rn 
fiir M'vitrnl wttili.H. Iiul, wlicii i1 |i(-rni>l.-i for ii Iodj^it p<*ricii|, it imhcu 
imp^fwl iuvohitiou of tliv ul«ni« or the retention of portioii^ of | 
«rt<-r-ltirilt. Wltt-n exaniinuil unilcr the iiii«rnM>o[)(- diintig Die fmt I 
da}^, the lochia (.-ont^iitt of ml lilond-corpUircliH, liiicocytot, fatty epithc 
iTftiiH, mill i>lin,-ils of ili'^ciK'i'iiloI ilit'iiltinl lisHuc. 

Micro-'tifinnif^Fii* can alwin-s ljt> demonatrnlwl in the discharjn' jialhe 
kI till- vnlvu. I>ii( arc nol iil»iiy« pixviml wlii'ii it in oltluintil fn>m o\ 
jiortioiiH lit tlie ^'nerativi; tract. The invciiti^ationa of D<klerlem, Kriii 
])5d(^'rlL'in and Wtnteniitz, Litttv and myA-lf, ItHvo xhowii rital itoniially 
lochia ohtaiiiiHl <1ii-ei>tly from tho titt-rim' ravily do not amtain haficria i 
ing the firKt few days of the pucrporiiini, but which otvur willi incrciu 
freqiicui-y a* it ndviuiiv.*. Thty nn: not, tiowever, of thr pvoj^enic v«rioi 
except in case* of infection. Tho early work of Ketircr. Knrewski. and otl 
a)i)iearcd Xo indii-HUr Ihnl llic^ vn^iniU liK'iiia nearly always oontainitl [ 
gcnic hactena, fince small tjtiantilics of the di-char^e. when injocled uad 
lh<" i)«tii-nr» sliin. gnvr risi- lo alMct'** fnrinalioii. Tht' niorri nt^t-nt invfl 
f^tions of Kriiiii);, however, have denionslrali'd that lh<>e (v>uclueio(K 
crn>tuf>nii, niid Oial the vaginal tiH'hia, atlh(iu)f)i ridi in iiarmlcM' parax 
do not contain pj-openio orpanisms. with the execution of gonococci. un 
tin- iilvnis ic the w'al »t infrctii'iis [jrcHr^t*. Thp sanu- invi'wtij^ator I 
showed that the liacterial llnra of thi' vu;;iiia undergoes a marked chai 
during Ihe puerperiuni. During pregnancy luicilli pnHlvminate, but 
in great |)art i-epliiciil hy cwci during the puerperiuni. This ehai^d 
probably dne to the altered rcacttrin of Ihc sirn-lion. which i* mark 
acid befor*", and nlknlini- after laltonr. 

Oenrral Ftwlions. — The function of th« fkin ts markedly accentu: 
during the pucr[ieriutn, w U denmnHtrated by the profuse sweating «b 
frequently characteriKOS thiii )>vri(Ml. It if moat mnrkcil at tiiglit. an 
is mit iinn»iinl for the pnlient to awake from a iwund sleep to find 
night-gown lirenchcd with perspiration, 

The apjictitc i.* usually diminislit^l during tlie first few days after 
\>oriT, and Ihe patient experiencos very littlv d«»irv for nutritimu ft 
At the same tiriic. nwing to Ihc marked dia|)horesiri and Ihe (luantitj* 
fluid lo''t Ihrnugli the lochia! iliwhorge, ihir^l is coniiidcratily incna^a 

llie Imuvi'Is an- nearly nlwavs ciinstipali-d during llic (irnt (wrt of 
puerperiuin. This is due partly to ihc fact that the patient eat^ but lit 
^olid food, but principally to the marked relaxation of the alrdiMDil 
whIIs and their conit^ucnt inability to sid in <-vact)ating tlie intatil 
contents. 

Vrinf. — niere is n marked increase in tho urinary output during 
puerpwium. More iniporlniif. however, arc (he ehangi* in Ihe (•ompojit 
of the urine, which afford an index to the profound changp* in mctabo! 
which characlcrijic (hi« itcriod. AlnioT<t iMiitH-dinhdy following laltoiir 
total nitrogen increases to nrarly double Ihe amount i-xcn-titl itiiring pi 
nancy. w)»le tlie nnimnnin nitrogen chnw* a steady decre*w>. The nitra 



CUXECAI. -Wl'Wl'S OP .Till'; I'l-KUI'I'IltllM 339 

'ttiljiul •iiiitiiiiics 111 n liicii Icvi'l fur wviTiil iluvs iiml llirn ^nuliiiillv ftills, 
ri'ailiiii;; imrniHl til llii' t'liil nt Ifii days or [uu wii-ks. 

A \iifff jHirt iif lliis iiii-rc-HM' tiiii.-I 1m' iillriljiilnl In llii' i'.\cn>lirni nf 
lilrup-ii iiu-i<i<-iil In tin; iiivnliiliiiti nf lln' iili-rus, wliidi iw Ik'Hcv^hI to Ikj 
bR)U|ht ilnut bv a process of autolysis. Tins was clvarlj' shown by my 
*-*-istant, J. M. Slemons, on ooin|)tirin>; tin; nilro-junous tiirvo of a noniiul 
I'Ui-rprral woman witli tliat of a palieiit wliose iiUtiis IdiiI Inh-ii removal 
■' <';l^Mn-an sct-tioii. Tbc iliiriTi'ini' in tbc biHcr (■■)rrcs|Mtiiils closely to 
'tx- tnHitint of nitro;!(-n conlaiiiitl in the ampiilnliil uterus. 

Ju [liu majority of c;u.s«-s tliu c.xaiii I nation of sjiccimcns of urine, re- 
'Ooviil by catlit!t&rization iniiiu'dialfly aflt-r the completion of the third 
*t«^ nf laJKiur, shnwi* a flight aiiiniint of iillmiiiiii iiiul iiumorouH hyalin 
***tji, even tlioiigh Ixith may liavo Ix-eii uhsenr tliroiiffhoiit piv^'ii'icy. ^^ 
I.lMjfinf my own ca.-'i's wliieii were slixlieil with this iioint in view, albumin 
*** ntiuii in fi'i.'.t per cent ami rasts in lil,-li; per cent, iin<l similar results 
n«ve been obtained by Temesvary and others. This is a transient phe- 
••onienon rc-uliinf^ from Iht* systemic strain cans<Kl by labour, and usually 
"i^apjiearw within twenty-four hours, tbnugh in nlxiiit one third of the 
'^■s** Iraees of albumin persist for some days, hiit have no prognostic 
*ignifi(jincc. 

(kivsionally a .■^inall amount of su^ar may 1h- found in the urine on 
ilie second or tiiird day of the pueriieriuni. eoimideiitly with the eKtah- 
ii^niHit of the lacteal secretion. Careful investigation shows that the 
leaciioa is due to the presence of lactose, or milk-sugar, which is supposed 
to be alMor)M-d from the mamman,' glands, so that the condition has noth- 
ing to do with dialielps. Xey obsened it in TT per cent of his ca.ses, while 
HcCinn and Turner delected it in small quantities in every case which 
they euniine*!. In my own clinic it was pre.<ent in only a small propor- 
ti'm nf the cases — S.lt per a'nt. For a full discussion of the question the 
K»^wii refernnl to the diBs«;rtation of (Jusnar. 

Cnnvelaire and Scholten have rec<'nlly demonstrated that there is a 
•"•fted increase in the amount of acetone in the urine immediately after 
Wmnr. which disapfwars within the next thrw clays. The lasl-nametl in- 
'e*tijntnr notetl it in !>4 per cent of his cases, ami found that it was most 
tuBiuUnt after ditlieult and pmlongiil lalmurs. lie attributes its produc- 
'"•" to the excessive breaking Uji of cai'liobvd rates ri'sulling from the in- 
"*"! muscular activity incident to parturition. 

W infrer|UPnt!y there is a markinl tendency towards retention of the 
'fiW' (lurinj; the first few days of the puerperium, and the distended 
""'•'er i^n fre<|uently be di.«tinguislinl as a lliicluant luriinur above the 
"fcliilictis. Tlip retention may nsuit from numerous causes, but is par- 
'|"iUrlT apt to follow operative or ditlieult laUiurs; and under khcIi 
""^Manees may Im' attributable to contusions or other slight lesions 
^ ihf iirpilira. In other cases it is jiroliahly causeil hy the iliminisbed 
""n-ihaloininal pressure wbicli allows a greater (pianiily of urine to accii- 
"'I'l' in (be bladder Iban uniler nlber conditions, as wcOl as by Ibe 
^i<iity of the abdominal walls and the- conx'qucut ililliculty of bringing 
'*''i ioto plav during urination. In not a few eases it is due lo the fait 



340 



OBSTCTRICa 



Uint |Kift>iliIy al fljiy tiaie Uie patieul in unable to evacuglc tlii> Mnililrl 
Ihv nttimbcul poMlion. 

l.tiKi "I Wfi'jht. — In dilililimi la the hiwt «ir B Ui fij kiUn, vWuh na 
from lli« i-vHi-iiuiion or llit* toiiU-iiU of llii; utvru't. i( i> pcnuriilly »U 
thai llii-i* in & still further loss of body weig^lit duriDg iho puerperi 
nhicti acfordiug lo Gawncr tiiiiounU l" -l,5iHi graiimiw in llw firM n 
Hcil cstimalnii it at 2,0(H). and Kii'inmcr at only 900 ^(raniiniw. ThisJ 
imn-til porUradiclHiii is diu- to llic fail Ihal (JB^siu'r'" n^iill* wrn* »l>laB 
at a liun' wluji llie diist was jrrejuly re*iriott--d, btit at pii^fiit, wli«i 
IB more liberal, ihf b>« of Wixught is miicti K^w, anil iii many insla 
does nol o«ur at all if sufTicient food !«■ taken. In Doniial cases i 
nearly alwdyt; rij;nirn-il by the end of lliu piK-rpiTiimi. 

Care of the Patient daring the Puerperium. — Atlentiou immedU 

afirr /.iil'f'in-.^Ah'-r uin-fiilly r.xiiininjnj' llic [ilHCirnla itiltlUfliat'.'ly fl 
it« expulsion, to make aiire thai it is intact, the physician should de\i>t« 
att4-n(ion lo wulcbiiig the mndilinn of thti uti^riiK. At thii^ limv il »ll 
form a hard, round, i-esi^tant tumour, whose up[)er marjfin lies below 
uiiil>ilicii>. All long a* it rt-'^^'nihkK n frickft-ball iu (i>nsiKteiin' iht'l 
no danger of post-partum Iwiiiorrhage. Hul if it iiecomo.-' sofi and tU 
thvre a imuiinvnt danger of such au oi'currcucL', unl«t« proper mv*« 
are taken at once to guard against it. For tlii* iiur[«>se iho uterus sh 
he piilpak-d through the abdominal walls immi'dialcly after the coiloiu 
of the third stage, and if it is foinid to 1h? lirmly roiitraeteil, the a 
manteuvR' shouli] be rcj)fated at intenali- of a few minute;'. If. ho«1 
any trndeney lowanl* relnxnlinn i* delwttMi, the organ should be gra 
through the aMoiiiinal walls and vigorously kneaded until it remains 
ftixlently enntnicttil ; at (he same tiiiit? ergot should in: a<!iiiiiii»tered b 
dernuL-ally. 

In normal I'tiw*. even allhougli there nuiy b« no Iwideiicy low 
hieinorrhage, the uterus should be j)alpatcd at intervals for the firet 
nfler the e\piil>ion of the pluceiila; but if Knttsfnelory t-oiitraetioEil 
not oirur at on{». its liebaviour should 1h? carefully watched for al 
an hour iifu-v iIiitm- liave bn-n iniliii'i'cl, 'I'lut pby>ieian should never 
the patiuit inuiiediali'ly after the completion of labour, even if it hw 
porfec-Oy normal, hul chould remain within call for at len>it an hour, 
to Ih.- naiiy should any eoni plication arise. If the patient has a com\tt 
Iraint^l iiiirM*, ihe duty of ivnliliiiig the uli'ms imiv lie ilelegaliil to 
but Ihe physician should not leave llie house until he has nuide t 
a\ani ilia III III iiiid is sati-HfuuI that all reaitnunhle rlangi-r of hifiiiofi 
)ta» pii>«ed. 

Toilet iif thr Viilra. — Iiiimiil lately nfler Iho birth of (lie plaeenia, 
Koilcd linen having been ivnioveil from iK-neal)i the patient, the bntt 
and e.xteniid gcnilalia nre eleunsi-d with hot water and *o«p and hi 
ttilh a l-to-S.OOU bichloride solution. A .steriiiwd vulval pad, iiind 
eatt.on wrapped in gauze, is Iheu applied over the gi-uitalia and hcl 
placi' by a " t " bandage, biding replaced hy a clean one whenever r 
sary. The nuriilM-r of jiiids mpiired in the twenty-four hour* vnria 
enrding to the amount of lochial discharge, and affords a fairly ikc 



CAKE OF THE I'ATIKNT DUHlNa THE FUElU'EUUrM 



341 



^■V (•[ eiiliiii;iliii;; H^ t[iiaDlih'. Kach Utik! tlii< |>ii<iK an- Hidi!>;LM, and 
1^ wicti mnvi-iiiwit «f lln- IniMvU, ihi; gt'nitaliii i^luiiild Ix' iiuklitil wilU 
otton |)U^)retj! aosked in bichloride rtoluiion. (trdinarv d|>o»;ii>i rJimild 
wiw l» iiHid Tor lhi« piir)Hix«. Tin- parU should be wiwhijd (nun «lx>v<! 
I <Lf«ii«sjiL, bo aii to aroid con tanii nation from the rw-tuui. 
I Tl» mlval ]>iul iml nu\y hIimiHix {\k: lochia and pnnrriU conlamiiiH- 
I in nt the vulva fmra without. Iiul also makm it diltieull for tbt- patient 
I I* to«ch her giiiitalta, a praclicv rtTV fonimon among thv unudtivalcd 
I '''— snd ooi? that ocicasionally pive* rise to infcvti^m. 
I ' "■, — ^[nnv utitlmritics ri'vomnu-iid that a tightly Biting bindi^r of 
k nUeithed niuxliii, ivaohinf; from tho troehanlers to attovo Ihc umhilicUH, 
I *» iftbnl inimi-<tiatrl_v after dcliwrv, *incv tituv hold that it MiTtn a 
■nriWiil eOtvt upon Ih* involution of the nteruw. niakt^ tho |>atient more 
, unfnrulik-, and Iwid" In n'^'ton; hrr figure lo it* original L-oiulition. Pcr- 
I "iBlly. 1 am Dot in favour of its oniploynicnt. an<l do not believe Uiat it 
I •ni» ooy of the (igr|MiK-« for which it in ix-cimiimnlcd. On IIk- other 
^^i»i. I am of till? opinion that it oc-oaBionally jKivi* rUo to relfovor^ion 
^^bllK>llLiiiFn of lliu iiihirgi-d ami wft ulvruM, c»p<.%ially if it be appliuil 
^^bmUt ptnugly to exert compression. This ohjeclion. howeior, does not 
^Hlfood after (he organ has (U-Mx-ndasl into ihc pelvic cuvity — that i«, 
^Hp iW ttnih day. From thin lime on a u oil -lilting' bandap? can do no 
|Hii. Ukl wiruc palitiitf find that it ailds oomtidvrably to thnr comfort 

■ ^ npportin); tbe lax a1)>loniinal walls when the}' first begin to sit up. 
I ■Won ] find any widnwc of it» value iu r(*toring tlw figure, which 
^ ^ pulually n^lura without tLi uhc, prnvidts! the tonicity of list- alxlom- 
BW IhiiK-les Iht retain«<]; but when thia is seriouKly impaired I know 
^^VD^ that will hrioji aliotit tho desired result, although genth? ma»Aagc 
^Hm later mar do something towards it As tlw dangers to be npprv- 
^^KAiram the u^e of the bindttr are not iLTt-at, it in pcrha|w as welt to 
^^BrlU n» liy tbi»« patients w)io feel strongly that it nill aid in 
^Hfelf thi! ''K*"^> '"i* '^ i^ '"^ forbidden the physician will probably 
^^BMned in case a shapelGsH ligure follows 

W iftrr-jmiiu.—A* after •pain.'' usually occur in nuiltiparic, but only is 
I F*>i{>ni> when the uterus haii been subjected to undue di«lention. it ts 
^^iMiiIly ni5i«!*Ary to provide for their lieatmeni after ihe birth of the 
^Bai^i. On Ihe other hand, after the delivery of a niiiltiparou» patient, 
H^^cltiaMe to leave with the nurw several tablets of ^ grain of morphine 
B** Hi (rain of atropine, with instructions to adininisl«-r them by (he 

■ •'*•^^ itt inii-rvii!> of four or six hours, if the pains be severe. 

I *■■■' imi (jiii-l. — Ac soon as the patient ha» lieeii mafh- enniforlublc, 
[ ■lu>ul'l U' darki-hiil and she sJiould l>e encouraged lo slwp. 

L rivRi flliouhl be e.xcluded, and the nurm; should Inlhc and dn«s 

I m an ndpinlng aparlmenl. if there Ls one at her dis|>os«l. 'Dm 

^■ta: (Jiould lie kepi as rjuiet an possible for the first ten days, but 
^Hftml lo ninve frvely in loil iiml lo lie propped up (o eat her meals. 
Bering (bif (NTioil, ax a rult*. only Ihe immediate nieinlH-rs of tlie family 
■hU I>- admillnl to i-ee her. Moreovi-r, if lheM.> anr nuuuTous, strict in- 
^Hpion* phould Im) given Un; jmnv at lo the uutober of visitors eueii day. 



342 



onsTFrniifM 



Oift. — Fiirmwiv it wa« tlic custom to reetmt In u miiiiriium inS 
nr tlH! pucrperHl vroiiiun, iiiid ii>t ban alftttdy Ui^t Nitiil, thin liniitiitionj 
fur in fX|iliiiii rht! Ions of weight which wa* fK'<iuently obscnod dn 
Ihe BKt fi'u* davs. At pR'M.-nl. hu«'i>ver, « imire liberal ailnwaiiL-e i:f^ 
liiinnrv, iinil the |mti«ut i^t enc-ouTHg^d to titkv plvnty of plain Duurid 
food. 

If not niitin-nluil, i>he altould Ik; gircn a glass of millc or a cup 
[ioon after lalmur. Fur the (ir»t few dajw the iijijH'til*- is not vi 
but Hiiiall quantities of easily dieted food may be liikcD at fr 
interval!). 1 usually giv« iIr- ntinv tlw following dirccti»i»: For ih 
twi-nly-four bmiri. uait-r, milk, witfee. lea, or cocoa, and buttered or 
tottnt. On the wt-ond titid tliird day* tin- KHinc, with the uddilion of 
pie soups or iKiuJIlon, Iwilcd or |ioaohetl eggs, raw or atpwod oyste 
wine jt'lly- On tbe foiirlli and lifth day« a» abovi>, with the sdditr 
chicken. Iiakeil jMktatoei^. antl rice, after which the ordiuaiy diet oh 
be gradually ri-Kuiiu'd. 

Ti-mfirniturf. — Tfic temperature should be carcftilly watchwl d( 
Uie fir«t weeJ< of the puerperiiim, as fc^'vr is usually the first synl 
of the onset of an infcitiou!* priM-ess. If the patient be in charj 
a tntiued nurse, il should be tab-n four time« daily — at 8 \. M.. 1' 
i i: M.. and S i: m., ami nv-irdi-d upon n suitable oliarU Tlie pbya 
should Iw ininiediately nolitied if it riBcc above 100°. But whi'Q 
nurse i« ignorant, the tcrujjeraturfi itbouM Iw taken by Ihv physician 
self, morning and evening, for the first five days, 'ITiis, of coiir»*. a 
that iluririg that time he must, visit the patient Iwici- a day. oncf A 
for the foHowinji two or tliree days, and afterwani at Ic^h frequent il 
vals. Itnt when l)ie nitrse i^ coinpetirnt. a single visit a day will t 
uRhHw untowaril symptoms develop, as the physician can rely upon 
notifiit] prnniplly •>[ «riy rliiinjre. It i>« always better, however, whd 
|H)»iibli', tliat the patient should l»e seen within tlie fipt twdre b 
fnllowinp ilelivery. 

l/rin>ilii)n. — The patient shouhl he enciiurap-d to urlniile within 
first six hours. When she is unable to do so, the catheter should no 
employed until the bladder forms a marked tumour above the «'mpl 
and not eivn then until the piiticnt bos attempted to urinate in a ei 
[Hxition ; inasmuch as many women are unnbic to use a l»iil-[*an. I eon 
the change in fHisitinn much less dangerous than catbeteriiation. « 
latlr-r, no matter how onrefMlly pcrfonnH, ulways rarri<« with it . 
risk of infection and of a consequent cystitis. Moreover, in not a 
cases, the proccihirc, whi-n once cnmmenmi. nni«t he continued 
numlier of days, a condition of afTsirs which, leaving out of acronn 
dani^r of infi-etion, iHvomc-s very oncmii* to the physician, unlase II 
a connipfenl nur^e in charge. 

Wlwri. Iniw<'vcr, (-iillii-(criirnlinri Iwconic* aliHdiilidy nen-ssary. the 

(alia having lin-n iirpt exposal mid liailwl with a bichloride or Iwrid 

(ton, a glass catheter, which hn^ been steriliwil by boiling, ehcn 

introduced by cnrefnlly disinfivli-d fingers: or, letter still, it kIkh 

' grasped wilb u piece of friv^hly lioilcd ci'tlon. so as to pro'cnt its o 



UAItE OK TlUi I'ATIENT DUiUNU THE PUBRl'ERUrSl 



343 



In nnlail witli Ut« (iJt)i^rH at all. At t)i<- pruiitnt liuy, to ratlivlcruu a 
Kmuh amk-r a cliivt ur Uy t\w f^ase of loui-h in imI juKlitkUi-. 
I Bnvb. — In vi«w of ttu- i<lu);gi»UntMi of liw imvn-U io thv piii.'r|ieriutni 
l4wlil omitrtiv #haiikl be admiuiKt«rc4 on Ok moniing of the B«<;ond 
1%. mlew tfae; bare previousil^ Iwen (•vai.-UHlv<l >'|H>tilHiiv<>U)>ly. For this 
Ifnpae I gvmTally employ Imlf an ounce of Uoeholti* saltit in a hiimH 
|i|iutilir of water, half n Ixitlli.' of the I'lTerrtawrnl citnite of in«gnc»ia, or, 
I d tb {Mticnt will consent to take it, half an ounce of i-antoroil. 
I After the prrliniiniiry nthartiv, llw- Itowt-U nhoiild be niovwl onco 
IUt. If a KpoutaDmun action does not otx;iir, tho odiTiioJAl ration of 
■Atlniil «siru(i of ■■■Hcmra at iM-dtiine, ii> 20- t" l>ii-miiiiin iIokl'^, or 1 
■Vl^mas of the aromatie elixir, aLi-onlin){ to tin- miMvptibility of tlw 
nAial, » in(li(-4it<?cl. Hninvtimi<« a pill containing nioin, iH-iladonna, aud 
Iflijt&iiinr, (ir I or 3 teaDjmotifula of eonipound liquorice powder prove 
Inn Mlufacton-. 

I Vut of ihe Xipjtlex. — IVtail.'' i-on<t'rning the t-arv of the niiiplos will 
MpM in ChapttT XVII. but the pby*ieian should be careful to impres 
RlfvlSa nurw ihe necewily of obierving aaeptic pnwautioiu in dealing 
IvBhthoB: ami A\« ehouM bo ilircct^-d to rvport immediately the appcar- 
llMctif fliHurfti, Oil their propi-r trealtitent will usually |>ri»i-nt tnaiitmarf 
IslRtiiin aa<) the ronMiguf-nt danger of niuktili>^. 

I TiMr /ur Urtling Cp. — It !» a tiuitvlionoumi ctKium to allow Uic pitcr- 
l^nl «n«an to ait up on Ihe famth day. Tliit ntl«, howm'er, ehoiilil not 
IWtfnldly followed, ami overy patient should Im^ kepi in ImiI until the 
I mil of the uierufl has divappoared behind the sympliynis pubis. This 
I DtfMBlIy rKX'UD' by the tontb day, ■tocaj' ion ally a day or ivi earlier, but 
I *■? aftni not until fame riays later, (ienerallj tipeakin^, a two-wecfes' 
I M ■ tinl u» not excvwivc. 

I Kfctiw. in IS!>9, adrocatcd the practice of albminv' the patient to 
I*" t> m the tbinj or fourth day, and slatw that he ha* *<\ii no ill eonw- 
f 'low auch a procedure. His MicKc^lion was pnmiul;i:ati-d In-fore 

L ' :-,;4a Gynicrologicnl Contrn-w. but was not favourably fvceivc<l. It 
l|iiHa«iti]i)( to note that a similar agggcstion waa made by Charln^ Kliite, 
I* Ihadiatcr. »* early u I7T3. 

I it ii aUo adrUablf to give rigid direetionji »» to Itie length of time 
Bw^itifiit ahoitlil remain out of lK<d. I bare found it a convenient mlo 
l^pci that "ht? •dtonid nM up for one hour on the first day, two tioura 
^^p«imnd. atMl to increase the time by an liour each day until Aw ia 
^Bto he up all till- lime. She kIiouM Im) kept in her room until the 
PPblipa nf thi- third week, and allowed to move al*nut on the llnnr 
I* rtirb 4he wan contim-d daring Ihe fourth w«'k. Sl»e should not be 
bmBiJIiil to pi downiitain until the expiration of this pt-rioil. as it i» a 
ptt ff of experience that tbe average womiiti rxiinol U- pre^t-iitiil fr^m 
^^ing llw •irdiuary diili^^ of Ix-r bous>>bobl aftt-r nhe \uif om-e gone 
Hbair*: wbcmis ai> bmg xi h\w \f kt')>t on on<- ll«iir »\u- is UMjally 
fctmtili- III |Im> direelinn of biT pliyxician. 

Pl»*1 f '■ '■ — At tlie end of tlw Ihinl or ll»' iH-'/iniiing of the 
mrib wi- '*-:riMSU '^^ subjected to an inlemal esaminatiofl, 



■M4 



OUaTLTHlUS 



■ocl Uiv cotKliliori of iht iHTLna-iini, utcruii. nml a)>]M^n<laK(!s nnmfiilly ii 
Vtsti^atiil. Not inri'Li|iii-iitly ilit- utt^run will Ih^ fouitci <)tH|iliicd). vlwa \bim 
introduction of a projitTly titliut; pi.-i<»arv muv It'ad to a pi-oiii|ii oiin' ,' 
vrliert!aH if tri^ntini^nl Ih- ilcfinrt'il iiutil t^ytiiiiloniK it{){H-»r, ihu <^^U(litioii 
may not bo rdivvi'd m readily. In other caiws, various abnoriiialitieri maj' 
1h' noto^l, whipli nhoiild li(' Ircjiwd liofoif thf {iiiticiit is disdmrgwl, ani 
occaKionutly it may be nwcwsary to warn her or h(-r iiuelmnd that Ojhtu- 
ttvi* jimcwlurcs will lir ixjuiiinti in llic fiitiirc. If cvfrvthing is i>orfeetly 
nonn&l, it ie a great cwmfort to the patient to lie aiwurHl of tlw' fiwl; 
whcnfflit If KD.v ulinoriuality i» nob.i) and the attvntioD of iwinc ix^pnuinibl^ 
mvniW'r r>f the family \te dirooted to it, the physician may save liimM-lf 
from cennuiv if a '^uliM^ipii^ut v.xuniiniitioii he nivdv by i>oiue ouc uliic. 



LITEttATlIRE 

CoitrKi^iiiK. IV I'liiTti'inurii' trnnaitnin! du travail de rancotiphetnoiit. Aniudi's <lt 

Kyii. el (i'uJMt., ISftS. li. 353 307. 
DauBiu.xix. l*ntcmirhiiTij!<!n iibirr drui \'i>rkninii)i:n vcn SpulipilicrEii in dui I,.oc)upti dm 

tItcniK und Aet Vaioua. «ti^. An^b. f. Gyo., 1887. xx\i, 4I2~U7. 
Diui BrliHJi-nwkrcl. l-inpcig. ISB'i. 
DflDKniJMN iind WivnutMrx. Die llnktrrinloKJc dcx pucrperaliui Sniiraia, Uc^u^ 

R«'ilrui;i.- HUT OK u. U.vii.. IQO<>. iii. IIJI-IT-'i, 
FKiiu.Mi. riayniolopp iind I'ntlmlodip ile« Woi-bi-nln'lU. Sttiiti^n, IRSO. 
KniBi>i,lM>mi. Pliy»i(>l.-*nai. t'nlJTKiirhuiiKcti uher den I'li-nm. litfiptif-. 1870. 
FaiTdCH. Die piifriiemle I'lilsviTljiintmiiimii!. Anliiv f. liyn.. 1875, viii, :m3^flN). 
Oahlkrk. I'l-brr ilic Wrjiiidi'ninKi'ii lifa K-'iTjietyerviiehlH' \ie\ rVliwniii[i'mi, (.•trlwnnt- 

dcn 11. WfiphiHTiiiiiPii. tUuiiulwn'br. f. (.ivliurlskunilp. iWJ2. \v. 1-68. 
(ittH.NAR. Ik'ilTiiK<^ iiir t^actoKuric dcr WVicJuicriQni'n. I). I.. Hsiliv IWVi. 
Heii,. rutcmur bun icon I'lticr die KririwrKcsicbtinvrhiOtnttnc normalor WtSchDcrinncB. 

Arcli. I. Cyn,. 18BB. li. 18-33. 
Gicbl «» viiiti |)hyHi(iInKi>'''bii PulnvtrrkuiKNainiiiifc ini WtwhcnhcUn? Arcliiv f. fljn-. 

1808. liv. '.^5-380. 
IIoraAnsR. Kur I'hymoloKic dcji l^Icrp^^ill^l■l, Mnnnlwchr. f. <!eb. u. Ciyn.. W7. v, 

ErtEKii>uniE»ht>(l, ri'i-'i7. 
Kahkwkki. Kxp. I'nivrsurbiinf^n itber die ICinwirktui^i^n dor |niiT|wraU^ •^VLiv(« ^uf 

d*m ihiiirlwhcti ('rpinixniu*. Zi'ltM'lir. (. Ocb. ii. (lyn.. IKS2, vii. 331. 
Kkhheb. t'l-txT (lie Vi-rundFruaKi''ti di-r I^tl«-ur\'e iin Pim'p^uin, Ht-idcllipr|c. 1K96. 
Wirkungder Ijii'hii-n Miiflfhcndpjctli'wolic. MuIk-r'»Hiuidlmrhder(lcl>.. 1S8H. i. SU. 
Ki.UiMKn. ('otrraiK')iuii|j:Pii uU-r dc-n 8loffwcrbt»l dor Wut'LiiertiiiiMi uu<l dtc swnck* 

inRwigHtr DiAt donwibcn. Winckd*!! BcriRhlc und .^rhriitcn. 187lt. U, 153-ltN>, 
IvRiiMii. liKkU.'riuloid'^ di-H Ot'iiitaUaiialcB diT nt'Iiiniiiiiiiivii, krviiBii^ndvn tmd limits 

tn'Rilcn T-'mii. Iu>l|»i|[. Iti>i7, .*i4 r,4 iind HM> 201. 
ItoitniK TMiu Hnul. ViTluiltm ilt-r .'^I'hlciinluiul dcr CVrvix iliid deti UtmiK wiihn-iid tier 

,Sr;tiwiuigprnchaf( und icn Fnihn'fwhf^lx'Ii. Arch. t. fiyn., ItiOI. Uiil. 28-S8. 
KtiKbiUT iiml EMiUi.MA»,\. iriit«Tgiuchungini iibnr dtir I'lvrumFhleimlwut. Stri<-k»f'« 

■ nied. Jnhrb., IsT.'l, 
KtWvKn, l-it riuiT iffsundi^i Woi'hin-riii cine- prolmhirli! Botlralw dienlirh? Verli, 

dur dnutMrhrn {tRwlMi. (. Oj-n., 18!H), viij. A25 A.t5. 
T.jK>i>t>i.D. Studioii Obur diu I'liTUBBclik-iiiilumt. rto. Bwliii, I87R. {ArH>lv f. (tyn., 

x\ UDd xii.) 
Iatli. Bacteriology ot tbu Piiurperul I'lvnu. Am. Joiir. Ohet.. IWX\ lU, a)S~S17. 



THE PUERPEKIUM 345 

iMnnn. Teber lUs Verhaltcn den Hcriens hci Srhwanp^ren iinil Wiiohncrinnen. 

florlbw Zeit«-hr. f. fieb. u, Frauenkr., 1876, i. 4K2-.'iI(l. 
JlcCAxxiod Tdrneh. On the Occurrence of Suf^r in the Uritjc HiiriiiK thu I'uerperal 
Stale. Tnma. London Obst. Soc., 1892, xxxiv, 473-490. 
Kmt. Utha dM Vorkommen von Zucker im Hame der Schwanfteren, etc. Archiv f. 

Ce6.q.Gyii.. 1889, xxxv, 239-256. 
n^EADMM. Ueber die PulBverlanKHamiuiK ini Wochenliettc iind ihre I'nuche. 7jvn- 

UiBA. f. Gyn.. 1881, v, 40-53. 
pAMSai*. firaviditatit-Bi'leniBe tier Ulcniit- und ()vurialp;fanM\ Archiv f. 'l.vii., IWXl, 
bra. 271-282. 

LcriDaN. Uelier die aerotinal<;ii Kiesenzettpn, ct<-, Zeitwhr. f. (Mi. ii. <iyn., 
1897, Txxvi, 1-61. 
SiMiKB. Die Riickbildung der Muscukrin des puerperalen L'tcruH. lleitriigc zur path. 

Aaat. und klin. Med., von Wagner's Schiilern, I8H7, 134. 
SocH-rxK. I'eber puerperale Acetonuric. Heltrage zur (Jeb. u. (lyn., 1900, iii, 439-451. 
S(3t*oso£8. Lehrburh der GeburtHhulfe, XIII. AuJi.. 1889. 268. 
TKMBivAHr. Physiologic den Wuchenbett«B. Sanger-Hcrff FDcyktopadie der (ieb. u. 

Oyn., 1900. 498-502. 
TAKinxK. Du ratentigBcment du poula pendant lea miites dea coiisheii. Annates de 

gyn. et d'obst., 1899, Ii. 30-47. 
WsavrKR. The Anatomy of the Female Pelvis during the Pucrptrium. Kesearches in 

Frtnale Pdvic Anatomy, Edinburgh, 1892, 1-.55. 
Wmitx. a Treatise on the Management of Pregnant and Lying-in Women. London, 

1776. 
WoKMKEH. Die Regeneration der t'terusschlcimhaut nach der Geburt. Archiv f. 
Gyn.. 1903, biix, 449-579. 



348 



OByTETlUCS 



M 



taken tritli the care of the mrd, tLud wlien not a ain^lo c^w of pncrpr 
iliforlioti liMil Int^i in iUe wanl for vreelis M that im cmiim- iimld 1m- di 
covered for it, t-xccpt [nThaj"- mi infcftt-d Tiiigfr in the uiothtT "f o 
of lh« children. An iJii- uiiibilkai stump in Ibct^ (^ase> pre?«ated 
outward tiigt> of iiifvclion, IIk- comlitioiu n-(>ul<l liuvi- ivcupiil deUx 
had the rhildr'en not lievn -mlijected I» autopitj,'. Acoordinj^Iy, it may 
stated ai- a general ruk- thut. whi-nwcr Hiiidrt^'n die without any appr^^ftc 
abit' csiUM- within a !>-v w<i'ks aflcr tiirth. .inch an infi^rtioii ^hnuM 
fiUfipecliHl, and the i'X!iiiiiiiiilii>ti of tlie iiitra-ulMlominal pnrtioD af "till 
umbilicvd vivxeU will UMially xhnw that tlu-y are Tdletl wiUt purul «?>k« 
thronit)i. in which pyogenic niicro-nrRanisms can !« demonstrated, n.nii 
which hiiyr fs'ivvu rm- lilher t<) a pi'iiend iiifivtioii nr a pfrilonitix^ Fa 
view, thercfiH't'. of the not inconxid^Talilt- <laii);iT of inft^etioD from t^i in; 
wurcv. *lritl iiM^ptii' inTcaiitioiiM i^himhl In- obs^-rvcd in cariiii' for tht- cot-«J. 
llie reader is referred to I'loss's work for interesting dvtaiU concemixxfT 
itK iTenlnit'nt in variou.i (iMinlrii^ iind liy xlxiri^lnid ]V'0[t)i!ii. 

AfliT nmkiiis tht- moilier enriifortaVile the nurse :ilioiihJ derolc 
uttcnliiiti til ihf chiltl. It slimild lir*t lie anoinlii) with viistlim- or i)!i" 
oil, ajid l)ien placed in a warm bath and thoroughly washed witli l.'aft^i' 
»oap. Experioiu.'c lia« shown that the n-ruix comnmh \» mudi more mdl '^ 
renjoved when some oleaginous substance is first employed than by thi l u^^ 
of Map luid water ulnne. Afttrr the biith. the »titmp of lh« cord »)iaa] 
be thieklv sprinkled with {Miwdered bnrie aci<l and covered with a plA < 
«torilc uliwirln-ril cotton, which »hotdd be h<'l(i in placu hy narrow aittina^ 
strips. If the child Li doing well tliia dressing need not be dtaogei) fo^J 
some rliivK unless il licirumw moisl nr loiihil. On nrmoviiig it, the eor^^ 
will iisimlly be found lo have bi^conie completely st'iiaraUtl, othuroiie a 
similar ilre^sing should Ih? reupplieil. I have obtainod very eatisfactarT 
rtitults witll thi* iii<t1ho<l of tn-jitintmt, although in some case.-i il appifar* 
to prolons unduly the separation of the cord. Recently I have eraptoyei 
lliv alcidiol dn'Miiigs nnminieodw) by Btidlierg, and fonnd ihvni vctt 
satisfactory. For this pui])ose a small i>iece of sterile gaiue is soaked 
in 9S |ior cent alcibol, and wrapjRil amund Ili<> umbilical stump afttf 
the exeesa of alcohol bos l>een allowed to drain off. Such dreaaingii mart 
Im! ehnngcd at least once a day. 

After the eord hiiT> sloiiijheil off the };ranulatin;; umbilicuH slwnld in- 
trcntiil in the same munticr. and the cbihl nhould not rrcfive nimthtT 
fall hath until it hn.t completely healed. During this peritid it should 
be liuthed in the lap of the nnrse and not in a tuli. varg being takcu nut In 
contaminate the umlitlieal drcNtings. 

In the winter of IftOfl Dr. W. M. Diibney. one of my a.i.«iy|nnl>, 
performi'd u si-Hoj' ul experiment* in the hoiie of determining tlie lust 
metliod of dealing with the eord. He treated scrunt series n{ emsiB, 
respectively, with the following drctvings : borit acid, salicylic B«id, a 
mixture of salicylic acid and siiirch. and a UTapping of silver foil. Sn 
far a* he could see it made no difference whicli nielhod waa emploVM], 
provided the dressings were sttnle_ In still another scries of caite*. he 
applied an occl<i»ivc dressing of liquid vclloidin and absorbent eoltnn. bill 



THE XEWI.V 1«)RN CHILD 



M9 



£nutMi (hat under fncli HrcumstiinccK lli<- orj wajt kt^t nmliity mni-it. and 
RtM>n mui {lercciitibl]- del»j-(H]. 
T>iiriit): the pni'l ft-w jroMrc tliif (|iii-^tinii lini' given rW- in n ^'niit d(^ 
dl>cit»ioii. Ifickinmn, nt llui nic^^ting u{ |)i<- AniiTiciiu I i vnnvnlngico] 
in 1699, ri'ad a {Mpur entilk-d. Is the Stoughinj; I'rocc^ at the 
r* Xiivel coii)ii«ten( with AmjjwU iti C'liild-licil? uud uiiKuercd the 
■mbno in the negative. Aa the reenit of hin observaliona, lie recom- 
»l lluii ihi^ *^ft^t^ Ik- oimpIi>li-ly (■xriwsl whi-n- il join* Ihr idxt»m«ii, 
t«««-ls lt^at»l, and the n'ound cIosihI ttv suttin's. I'lKinibty thii« may 
rrvm* III U' iht! idiii) itii-tJind of tnuiliix'nt in hixpitul pnti-li(V. but it i" 
*|ia>tinn vhptlier it ie adviMbie to adopt it as yet in private practice, 
il b proLmblv that, oboidd the ehild die within a Tew ni-eks afli^ 
A procedure, the phy«i«ian would he severely eritieised br niem- 
«f ihi* faiiidv "liii have Im'oino acouiit»m»l in tb« titnv-)K>notirtsl 



In) Martin n-cnmnu-nded tluil thf c-ord Im^ h|^ib<d vluw to iIm al>- 
»mi* and cut through with a pair of tvd-liot wuimrs. ilut allhoujih hb 
tudml, Rt-tck, rf[>i>rltil very ftiT-lit-Ht nwdts rmm 1bi» inHhtMl of ti«ut- 
Bt. llartin hJni<^>lf ha^ i^inee abandoned it. I'orak and olWrs advocate 
^'HBpnwrtnn nf llw ainl by ponvrfiil forpcfw, ux in th<^ nxfiitly iittnHliured 
of an^otriptiV. Uut to my mind these procedures offer no advan- 
aver thine alivady in iimj; tlw important point in the tHmtmeiit 
not so much the method employed as the avnidatKe of infection 
moit rigid ailbentncir to the primipb'* of asi-jwlK. 
Cm of the Eyes. — In view of the frwiuenry with whii-li Iht; eye* of 
"• an«Iy bom child bpconK- infected when pai^siiij; through the birth 
iial nf women auffennj; from ;[onorrha-a, Crf*\i: intriniiu'cd the practim 
<f iaatillinv' into cnch eye immiiliotcly after birth ow drop of a I-pcr-cent 
J«'«tio!i of nitrate of silver, wliiih was afterwani washed out with t>all 
Iffilulinn. This procedure ha« led to a marl(«) decrca«> in tlw frequency 
'nf ifonorrhfi-at nphibniuira and Die m*pn of hlindntwi ly.^ultiug from it, 
MO>i 'IwitiUl )ie fnlloireil a? a matter of routine in hospital and funeral 
lirt-. In my private work, however, I employ a lioric-ai-id icolulion 
Mifad, except when there if any reason for bulicii'ing tltat Hk mother 
ffiiarrrrlMf-A, when Cred^V methm] i« fnllnweil. 
The prophylttclic value of silver nitrate wan etrikin^y deiiion<) (rated 
Mmb. whriM- ■tnliiticv xhoiriHl lliat iti< employment in biL->|iital praetire 
Inr^ Ibe frenuetwy of ophthalmia neonatorum from it to I per cent. 
iUr thu otatiiticv from many hn«pituls »h<>w only ■ very .«mall frocttoii 
1 per cmt. If, Iwwever, the di»eaac ^wuld appear in spite of the 
; " ' t) it should be promptly and vigoroanly tniiliil, ina)imue)i 
. ] it almost invariably leads to clouding of Itte cornea and 

t« oimplfte blindness. Cohii f*(im«tcd in ISJfi Itiat .1" jKir cent 
patientt in tlie blim) s«ylunit> of Germany, Austria, Holland, and 
fl«iul iiwrd their trouble to ophthalmia neonatorum, while twenty 
Ulrr ihewe fijtnr^ loid bi-eome nilucwi to 10 per tvnl 1 a result which 
_ that tho excellent resuIlM oltlaiiu'^l in ho-ipilal work are not yet 

'«Mpra*eh«d in feneral practice, and makea pertiiKOt tbe imiuirjr aa to 

9* 



350 



OBSTETRICS 




the aiJvieahilitv of Ipgislating with ti view to making the use of silver 
ootnpuUorv in nil c.am». 

Zwvitvl lia» rectntly advwatetl Mihstituling a l-pcrt-eot Mluttoa 
nilv«r awtfttu for tlitf iiitniUt, «ii<l n^iwrU that, in a M-riw of 5,222 fliildp 
BO treated, ophthalmia was olnicrved in only 0.23 of I per cent, and ti 
not a fiingli- cil-i- iiuIihI in 1iltiii)iiii». TIk* cmploynwnl of protargol. »;■ 
rol, ami variotin (Jtlu-r jui'imration.-* <\( ^iilvor lias ln*n biijij^sutI. 1 
Kperk'iicv hao xhown that tlii-y giro do butter, if nn gntni, results as sil'^gi 
nitratf. 

Stools and Urine. — Kor the first fow da>^ aflop hirtli the intei^tinal aoi 
tents arc ri'[in'sfiitici by n hniwrnijih iir hrownUli-gnrn. wift miitfrini — tf 
mt'cniiiiiiii. It is niadi' iiji of caiit-otr cpithdial wIIb from varioiL^ pnrtiou 
of the iiili'stitiid tnict, a fow epidermal ii-lls and lanugo hntna which ttaV' 
bwu i^watlnui-d with the umniniio Quid. ItK )»>euliar oolonr is due In llu 
pTesenco of l>il<; pigments. Duriug-prexnani-y and for u ftnr ]wut* aft«-i 
birth, the inlf'tinal omU'nt'i arv sterile, hut bnetcria soon gain aaxa t*f 
tliem and an' iiflt-rwiird |)n-Mtnt ihniujfhoiil life. 

After the thml or fourth day, with the e^tahliftliiiuiit of tin! mammal^ 
xecrelion, till- iiieeoniiim disMpj)i-ar<, and ilx jilaet! is Inkeii by ra\i», ■lilt?'! 
are light yellow in eoloiir. homo<reiieoiis in con^ii^teDce, aud pocise^ * 
chgraeteriiitie 'idi-iir. I''')r ihe first fi-i*- (liiy* tin- ^|iHil>i an- not form"!,!**' 
after a short time they take on the eharaeleri^tic cvlindrical fliapi". Tl:*^ 
IjowcIs, Ilk n nde, move twice daily, hnl » single Inrg^' dejection in siiflii-io*- * 

The thild usually urinates almost immediately after birth, and coc:*' 
tinuen to do m iil fixi]iienl intervnlK Tor the first few monllK of it* lif^ 
The iihysii'ian should irnpn'ss upon mother and nutwe th« neewsiti «^*' 
attempting to train the ehiid to regnlnr habits as to urination and dif*^ 
eation, and it i* xiirprisiing liow ttoon Ihew may l>c fortned if proper aW 
i« taken. Kor this purpiife the napkinit ulionld be chunged before mct* 
feeding, anil nfter tin- llrst few wei-ks th<! ehild should W held nvet * 
small ehaiiibcr at these times. It should also Iw cneoiirage*! to drf'<« *"' 
•t n-gular intervals. To ne^roinplish this, it hhould lie laid uiion the l*^ 
st the same hour each day with a napkin under its buttocks, and it* »*»• 
dflmon ithould he stroked along Ihe eonrse of the eohm. The physki*' 
should make it a rule to ins]»eet the stnoli; at each visit, nod injlruel tl'* 
nursi' ■■> stive a napkin in iinlieipation of his arrival, hk In thi^ wiiv irH' 
portant information may he gaineti eonceming Ihe digewtion of tl»e ctnl'*- 

loterns, — Xot infretincntly on the third or fourth day after birth tl*" 
skin and lonjnnctiva- of the ehiM take on a yellowish bne. wht<'h mn.' 
vary from a hardly visible diiteoloration to an intense janndioe. K'^hf"-' 
eoneliidwl that idenis weiirnil in 75 p<-r wnt of all children, ami a** * 
though this estimate is probably ton high, there is no doubt that ft i I 
very common. Acconling to Ilofmeier. the condition i* hipmatogenow * J 
origin, and in due lo the breaking-down of large numbers of red f-oqwwdM | 
Koon after birth. Ordinarily it p<ic>«c<^C!f no clinind signific-once, aAkJ 
passes oH in a few days without treatment. ^| 

Initial Low of Weicht.—Owing to Ihe fact that the child ren-ives lt^| 
or no nutriment, and at the same lime casts off eonsiderable <|UflnliU«&^| 



THE SKWl.V BOItX CHILD 



351 



[nsvlcms. nmi fWfal. ii ifrofirt-njiively Io«» veight f«r the Bret three or 
W4t,n><<r ii-'> IiTi?. ttif toliil tdiw iiiiiiillv MKgr<'>;a1iiiji; *.:'><i gramitu!« (tt 
!■««»). If Itii- Hiilil iii ii<>iiris!»i?<l iirftju-Hy, tlii^ is UHuallv n?f!aiDe(l by 
jlboiof tJic Ivnili (lay. nflt-r vrliiclt thi^ uinglit should iiicnvMi ittCMdily 
|<l fbe nti> of about :;& grainm«e ((i dnuiis) a dav for th« Brst few 

tlw iailial [oaj U DAiially niiwh Krailer irlii>n Itic rliili) 1.4 <!XOG!»iV€ty 
[wpr. a<vv1| &,^ in |inniialtirf inTHiiU nnil thiiNU wlu> rMviw an iiMulllcivtil 
liynt ft"*!. 

Aiatomx 0' the Breaiti and Lactation. — l-Jirh Unvft ix mailo up of 
\S 111 21 Iii)h^, nlik-li are arniup,xl more or leu radially, and sepa- 
tium oDi' ati- 



•<Vt It a 



vuryitig 
fat,' to 
Ik "ixo and 
'if tin- or^'sn 
t'fmt t'*"'^ duf. 
kil* rnoiiiittfl of 
ti4iuU«. which 
Uua aw madD up 
W'' niinili'Ti' i>f 
fe nil-*' laj-t are 
pMnl of a (^iiiglp 
«r ■■pitlitdiuiii, 
:li vliich is a 




'..-.+• 



bm. $i3, — l-tCTATiKO (*iir.\"r (Zpuv, Ltl>-4). 



with rapil)ari(¥. / 1 



IlinnijTit "if (immxlivc ti*»uc riclily (^iipplu-il with rapiDaritv. / Evctj 
itf pmriiled uilh a :<mall duct, whidi, muoiin^: ottu-rs, uiiitt« in (onn 
'^tleLuinT canal Utrvatii l4>lK^ These sok^IIihI larteriferotu duHs mako 
" " '!ie nifipk ftud «]>en MO|>anili>ly upon tl.* nurfaiv, veiiere tlw-y 

_ur»lml n* niinuU- imiatnl orillres. ( 

Tir acini represent the functioning jmrlion of the brMHU, iind it is 
1^ llirir epittit'liuni (liat the various con^tiluonu of Uk* milk afe formed. 
' (irl was finit dcnionstratnl hy Heidtinhain. 

"^ ' '■■■ aln-aily refi-rrol tn the chanfp^ (wyiirriiiK in Uic bre«HtA during 

and lti«ir condition rviniiin^ tniH-h ihr !>itiii<- tur iIh; Hrkt twu 

laltour. At tlii§ time tlicy do nni <^ntain intlk. nit a small 

..' inlimtrHm can be pxpmwiiil frnm the nippli!^. Thk in a thin, 

wh fluid. whK-li onvH its colour to |Im> prei^'on' of a pifntcnt which 

'IiiT and, n<-<'<iri1inK I0 Kiihnc. analo)fi>ii> (■■ Qii: i-olotmng 

' •! in the cells of lite corpus luteuni. ' 

iDnl under the microscoiie, Poio*lruni (1 Hvn to t0iui«t of 

^i..<h are aUKpciidcd nunierouH round tmdies, y.OOl to 0.033 

- in iliaiiK^tcr — IIh- fo-callKl rolonlntin rorpwjir/rsK- which rvpre- 

'^ithelial cells whii-h Iinvi- umlerxont' fmiv di"i;eiipnitio;i. Tlw 

iM a (ranr^ndato which con^ist^ in jfreat part of fcniiii albu- 

■i(a;:ulales on heatiu];- It tn gi^ncrally »tHlMl thtt ooWtruui 

OHin- fat. *ng»T, and >-a\ta, but le>iH protetd niaterial. than nnr- 

It poaaeeees hut sU^ilitly nulritiit- pntpcrtic!*. and U generally 



352 



OBSTETRICS 



lu-livvftl t'l ai't us n niilil ciilliaiiii-, Dniit itiiliti^ in riiMint; llto Imv 
the RiecotiiiiJii. 

ifiH\ — On t.hi> IliinI iir foiirtli fliiy nfli-r liilioiir iin<! (hi-iishhiuIIv on 
second, the breo^U tinddenlv t)(<coiiiL' lnr;;or, firtiior. utiil more piiin! 
This iRdic»tc» iho I'stiiliUi'hiiifiit of ihe liK'tcal javri-tion, iiimJ i>n pn.s» 
ft itinall amount of bluish-white fluid — the milk — will exude from the n 




:o ■-C 



j 




^ n 



Fio. 334.— HruAK CiniwiBtiM 
(ZriBi, DIM). 






Fte. S2fi.— HniAK Max (Zcim. UUA 



ptee. Coiucidt-nt with tlin>c cliaagv», l)iu putiviit i-jtpLTiiiKtiis more or ^ 
laivitudt.-. and may KufTer trnm headaelw. At the xniiic IJin« «1k* lius Ihn 
bin^ pains in tlie l>r(.ta«t!-. whk-h muy i.'xtcnd into th« asilla>, and the ]w 
bcTOuit;* iilightly ap(*leral«l. Them in rarelv any elevation of t»npa 
ture. It was formerly bclicvid thut the es^lablishm^^'nt of the milk 01 
was nsfoctnted with markeil contititutional <liiitur)>aiUH>«, wliivk were t 
garded as manifestations of thu t>o-caili!d milk fov-cr. As has already bn 
Kttid, a rijw in temperature fnmi Uiii< muxe is very exceptional, and in t 
vast majority of eases is indit-ative of iiif(>clioii. 

Mother'^ milk in niiually bhiinh- white in colour, Thou);U it Konaetiiil 
has a yellowish tinge. It is slightly alkaline in reaction, aitd lias a epoeil 
gravity of from 1.028 to I.o:)4. Vnder the mioro!ico]M> il appears ■ 
clear fluid in which are suspended larfTc numlicrs of small round bodi< 
O.OOS milltmi'Irc.t in dianii-tt^r — llic so-i-alled milk citrputritx. The¥ ci< 
siat of minute drops of fat surrounded by a membrane, Chomica] <* 
amination shown that they are ma,Av up of (he trijtlyccriik's of olat 
palmatin, and fltearin. 'ITie fluid portion of the milk is n traDaudtti 
and cnnsi^is of pmteid matcrlnl. milk sugar, salts, and water. ^!D 
therefore, represents an emuNion of fine fat droplets in n l1uid mi-iliDni 

The prok'id material in milk serum consists of casein or cftieino^^e 
which iii a diriTl nietnlmlic product of the mainmari' cpithelinm, u 
differs from serum albumin in that It does not ooa^'ulate on hcatin!;. T 
lat and laotoiie, or milk «ug«r. an- also products of tlie epitlielii^ eel 
The milk scrum contains a considerable amount of mineral matter, win 
according to the invest tgatton.f of Rotch, consists principally of cnlefel 



THE NEWLY BORN CBIU) 



:{r>3 



{ktplolf, 'iH.m ]>KT n-nl. potAwium (-Arbnnatv. S3. IT pt-r t-cnt. «ot)iuin 
cyariie, SI. 77 per cent, potawiium chloride, ViM ]>er cunt, pola^ium 
. Ripkie, ti.:t:j ]KT coiil, mugiifKiutn carbonuU-. 3.97 per tiutt, sod minute 
I 9KDlib« of Mvernl other dalUt, 

ThoTeragrcijtnpiMilirin of milk is as follows: Proteids, I to 3 percent; 

; lUc 3 lo 4 per cent : sugir, 6 tn 7 per rant ; unltn, 0.1 to 0.2 per cent, the 

I m Wtsf WHt4T. llillc also contains a not inc-on«i(lomblc number of htuy 

tm,t)uc\i, ai-iimlin^ to ll"- t^rfiirdMS of Kiistlin, are lierivftl from the 

'hnnMlmils of tlic lactifLTOiu (]u<?t« and the surface of the nipple^: it is 

[^KtfiOHlile »hill>er tlinv are prnwnt in th<! dcoiwr portionn of the tiieaAt 

Vatritiotif nwither's milk vHiicis markiyll)* in its composition, not only 

'aiHlttm\ indivtiluiiln, but al»o in l)i<- siiinc individual at varinuii timeit. 

ual 1o litid that the milk of one woman, which a;;rei?s per- 

I own child, will pmvi; indi]i;i3>tible wlit-ii given to tht' luiiilthjr 

tcbttl nf another woman. The rariation in (he composition of the milk 

tt tlv naw womnn mI dilTt-n-nt timiv im dc{icndi-»t upon variou" fiiotor*, 

P'U^llv tlie diet, the amouut of exeroi)ve. and the menial condition. 

[l^fWllilT of milk viirii-^ to « InrjK t-\tcnt with tlic nmouiit of fluid 

|»|CMal br the patient, and a diet rich in cow's ntilk coaducca to in- 

|cmmd aammary ai-tivily. 

ThliT are lar^e numlicni of prepaTBtion'' in ()»■ market which are 

MV ht •falttrt'i'i'iguf.i, alHt an- vaunliil >w incrcn»iHg the amount of 

|w&:Hiit whatetor virtue ihev may possoiw h due in great part to the 

BltT nf fluid taken wiih lh«m. EMrci*e in lli« opm air alw) in- 

I tbe milk floir, and it la frequently observed tluit a woman w)io has 

'■Hull i]Huntit3' ft long as shv is cnfifiiied to her room, will scxretc 

I ifcliiJunt i-upply as soon a.-^ she Wgina to take outdoor exerci*e, 

tfe lunlity of tlte milk i» likewise di'iu-ndt-nt in great part upon the 

lout the ainount of e-tercitie taken by tlie motlier. It iii a matter of 

nrc tiiot a diet rich in proteids in<-rca!^es the ratio of the fata, while 

aen'tM d>mini>hi>!i the amount of proieid maliTiid. Marked 

oDf in the quality ami <iuautity of tiic milk not infrequently result 

I wrvnn* and mental intluentv^i, and it it not unui>uftl for mme pro- 

nuiitiiin to lead to almost complete supprC-'sion of the lacteal seera- 

or til w c-hanjn' it" quality iu> (u niuIiT tl unfit for the use of tlie 

Certain dru^s alno exert a marked influence upon the milk flow, 

u well known that the use of bclladouua or atropine niarkixlly 

I it. Hany Kubslancra tnf^Mled by the mother may )« tranaunilted 

th« milk, am) thus o\ert tlicir ph>n>iologioal influenre upon (be 

Thi* i* iiiirti4:iilarly true of tlie Tarioua catliartiui an<l ali-nbolic 



The wrcnnrDrr of meii^trualion, or tJie onset of another pro^anojr 
tartatiim, not infri?i|uently exorta a very deletertouE effect upon 
[tr fif iIm' milk, in Mtme v*»e» reiMlering it neeeMMrr lo wean 
I.L' 

iTnTxinc. — Tlv i<l'-al fooal for Ihc u>-wly lH>n) cliibl t> the milk of its 
I -TnlcM lactation lie miitm-imlicuhsl liy nonte phyniral 'lefwt, 
. ian*it ilutv to insist that everv woman should at least at- 



354 OBSTETRICS 

tfiiipt to nurse lier child. In many instances where the supply of n 
at first appears insutticient, it becomes increased in amount if wan 
be persisted in. The act itself usually exerts a beneficial influence u 
the patient, as it is well known that the repeated irritation of the ni[» 
results in reflex stimulation of the uterus and hastens its involut 
Temesvary has proved by actual measurement that the puerperal uti 
becomes smaller much more rapidly in nursing women. This fact ah« 
1)6 urged upon women who are unwilling to nurse their children, ant 
not infrcfjuently hap|>en3 that, although they may have commenced it fi 
selfish motives, they will continue it as long as is necessary. 

Unless it be otherwise arranged, the physician who conducts the lab« 
should hold himself responsible for the well-being of the child during 1 
first few weeks of its life, and should remember that he has not oi 
the mother hut also the child to care for. He should accordingly g 
minute directions as to the way in which it should be fed, and sec tl 
they arc acouratcly carried out. 

Frei/unicy of Fci-dinij. — As the nutritive pro|wrties of colostrum i 
very liiniled, the child should be put to the breast only three times a c 
until the milk flow becomcH established, but after that time it shoi 
be fed at frwiiient and regular intervals. l><?finite hours should he set 
each fwHiiug, and if necessary the ehild should Ite awakened from a son 
sleep at stated tiiues to take its nourishment, -for only by this means i 
its habils be made regular. I do not consider that a nurse has fulfil 
her whole duly unless she leaves the patient with a child properly trail 
in the matter of taking its food. 

A definite hour should he arranged for the child's hath, which sho 
Iw taken as a starfing-point in arranfjing the sehcdute for feeding, Oi 
narily the most convenient time is between !) and 10 a. h. If the fort 
hour be chosen, the first feeding should be at 7 a. m., and the nest i 
mcdiiili'lv jTf(er the bath; while if the latter be chosen the child she 
Ik; i'l'd at li iind S a. m., and again shortly after ten. After the feed 
immedintfly following the bath tlie buby should be allowed to sleep 
long as it will, which will usually he about three hours, after which 
should he given nourishment at inlcrvals of two hours until bedtime, 
this arrangement it will receive eight or nine feedings during the twai 
four hours. The Inst should be tinieil for the usual bedtime of the parei 
and only one feeding should be given during the night — that is, betw 
11 1'. Ji. and li or 7 a. m. — and not infre<juently the ehild may be trai: 
to sleep the entire night without awakening. This, however, can only 
acconi]>lished hy hrding it at regular intervals during the day, ao as 
insure that it receives the proper amount of nutriment in the twenty-I 
houi-s. 

Just before each feeding the napkin shoidd be changed and the cl 
encouraged to urinate, but as soon as it is taken from the breast it abo 
be placed in Iwd and mil dislurbwl. It should not be allowed to si 
at lis ruother's liri'a^t, nor should it Ihi rocfce<l or fondled after feodi 
If these regulations !h' piTsistcil in, the child will usually go to it 
within a few minutes after being pnt to bed, and if it wakes befoK" 



THE XEftLV aoRN CHILD 



355 






iuct fecdinjt b cliu> it will muiain (juiet. Tht- ini|)OrUince of following 
pea«! dtrwtuMio cannot Iw ovvrcitiinnk'd, for it is only by rigid adhorciu.'tt 

■ rnvdi fleUilfi UiaC tlx? obild <;an bt- givt^n n>]|{ulnr luiliiu, aud tbe care of 

■ pmi-nt<.ii fmiii iNiTituing a I'Iruiii ajion all <^i)Dcltdc<1. 

I Atter ilw fourth or fifth week, om- or Iwu of ilie tircasi fi^linpt 

^k>tti(! bt n.-]>lucrd by a bottio, qo inatlL-r liovr much milk thv mother 

iBsy h»fe. Bv •-> iloin^ tbe tdatpry of miming i» gTeally mltivcd, and 

T a womHn ix indiiivd to rontinuu to nurse h?r child vhen sho would 

flbervlH; Wi'au tt. Wluni n tiiothiT is olilijuitl to n-turn homo iti^ry two 

tlirer boors to nurse her child, it is uppnn-nt that licr lime is so broken 

« Dpuo ax (() tx'mh-r il im|Mb«il)lf for her to obtain any real n'hixattoii: 

iW?rms if a single botlle be ioterpoUt«.<<l hdwceD any Ivo feedings a 

ftee Hpaiv irf four In »ix hoiin' will Im afTunhi). 

Duration of FtfittH)). — Dctinitc rules cannot he (riven ertn<vrning the 

pipuT b'n^lh f)f each fvniiiig, a* Ihii (M)iiil i* dv^K-Jidinl iipoti M-renl 

(Kltm — Uie ijuantily of milk, th* r««din*Hs with which it can lie oblainul 

Inin iW bn.'sct. nnd Ihu avidity with whi(-h the child nur^vw. (ivnerally 

•(•akin)!;, it U advisaltk- to allow the child to remain at the ItnMHt for tea . 

oiiiBlet at fir»l, aiid lu Ii-itgthrn or dwrt-aw the time aceordinj; to eirctim- 

•UiXM, tbni* or four minutes l>ein^ sufflciont for some children, while 

iltcaor twt-nty minutes will be rtvguit^'d by utheni. There is a universal 

'mlrat; lowanb overfuMing, so itiat at first it is letter to err in (giving 

•*" iiiili- than too ninth milk. Criing is iwtt alutiys a M-mplont of 

^tttp^i, jiut Miurh moD' frei|uenlly ■ndicati?^ tluit ihf lialiy is «ulTcring 

'■■^1 iai|i)^!stioD, resultiof! from an overloaded stomach. A child which 

ttnivin^ Ihe proper amount of nourixhuKnit should no! spit up its 

Uiould increase uleadily in weight, and should have normal yellow 

us jMSsaiK*. The 0(v«rrp»iv of rf)nir(rilution. nr the priwuace 

in the HtnoU, in a Hur«- sign Uiat it in licin): nursed too lonjt;. On 

Dtlwr lunil, loss of weight, associatcil with normal stools and tha 

:« of nfinrgitation. indk-alii' innnrtlcient feeding. 

Ibc child should Ik> weijjlicd daily, or at least twice a week, npoa a 

1; aurnrdlf pair of M-aliv, and its aiHiona in!k)H.vti-d daily by the |>hysi- 

Sa has atn^ady been said, it should regain its birth weight by the 

of iIh- 111)111 ilay. and from then on it shmild gain regularly 25 

i» a day, or. inwgldy speaking. 5 onno^s a wc«'k. After the first 

amtith" Ow im-nvM- i.i mon- gradual, the average ebild doubling its 

al the fifth and tn'hling it at the Rfteeiilh month. 

pracliniblf. if tlie child is doing well, an analy.-<iii of Ihe motticr't 
tbould be ma<le, ao that delinite infonnatiou may bo at hand as to 
jly of the fond upon which it thrives, in caM artificial feeding 
anv iiiin- ln-mme nceessary. 
Cart of tbe Breasts. — ilefore and after each f<Hi]ing thi- nipidtw xhould 
'• nin-fully wa-hol with a Imric-acid solution, so as to avoid the posei- 
WHi iif Iwt'tcna U'ing ground into them during tlw nursing. In many 
>»*. jflriifiilarly if prt'liininary prwautiorin bavi- not bnn taken to harden 
^"a. llw ntppb^ iHfiitne very ^ire during the lirst few days of nursing. 
IIkI Uttl<^ twu'ks or fissures appear upon Ihcm. Tlioe are extremely pain- 




(IBl*rKTttlC8 

ful to liii- iiititlier. iiml )ii Eoine ca»LV< rentier Ihc act of nursing .igoniici 
III addili<>n Ui tin; i^iilIiTing wtiidi Uie>' eau*e. Uie.v are alao « sourw 
(■on8i<ii'ralili- dan^rcr, as ii is through tliem that bacteria usually gf 
accetiit to the interior of the breatil. The nurse should therefore 1* 
structwl to he on the lookout for them, and to wum the phvEicion 
onoc of thoir appearanee, as prompt troalmont will nsunlly lead lo th 
speedy cunr. On tlw otlier hand, ncgleet of the«c premonitory signs 
not infrenuently followed Ijy a itiaiiiiiiAn- ah«M!SB, for ihit owurrence 
which the plivr^ician and nurw arc usiinlty more or le^ justly blamed. 

The faft that large uiiiii!)er» of ramcdicR are rocontm^ndcd for tlie ea— ^ 
of SHcli eonditiunrt is abundant e^'idencc (hat ihoy are not always readil*-^ 
iflie^'cd. They are lie^'t tioatod hy rtwt, and if the infant emild In- ki-pf^' 
from the breast for twenty-four hours tliey would heal witlwut furtlw, 
treatment. Ah thin h out of the i)U(Tr>tion, mine oilier nti-anii of .-o-euri 
rest niitst W adopted, and this is best allaint-d by the use of nipple shield 
tboiic of the ordinal^ Rntflisli type Iwing the most suitable. Many wniji' 
claim that Ilicy arc unabic lo uh" such a contrivance, but the diiticultr 
Usually due lo the fact lliat the holes in tlie rubber nipple are too »in. 
and if they are enlarged by passing a r«d-hot hairpin through tlwin 
rjiuinlity of milk sutlicient for the ehild can usually lie obtainet! wilho' 
much diflicutly. The application of compound tincture of benzoin to t 
tis.-'UA---< lends In make them heal more niptdly. and in llie inlcnals 
twcen the fciilings the nipples should Ix; covered by compresses soak 
with horie-aeiit solution. Particular attention should lie devoted In I 
caro of the shield, which should be carefully washed after each feedi 
and kept in a vessel eonlainiti^ a Miluraled solution of ImHc acid. 

In rare ea»es the nipples may be so deprewed Iielow the e^iirfan; 
the breast as to ri'uder nursing out of the qne^tion. Under such circa 
stances it ia nuetesa io attempt it, and steps should he promptly taki-n 
arnst the mammary serretion. 

The ehildV mouth should he KTiipulously cleansed liefure eaeli fnodi 
This is bcl accoinplislieil by wtishing il. out with a elmn piw-e of lini 
di|iped in borie-acid solution. The investigations of Kn«ise. irhivh hare 
shown that bacteria are present in th« biioeal cavity of H8 ]>er vmH 
of newly Uirn ehildren, and that streptocooei and staphyhx'occi are 
not infrc<{uent1y ohH-rvvd, emphasize tlie nuc(«si^ for c«re in this 
direction. 

When the child dies, or if for any reason the physician tfnAn 
lactation >« i-oiitra- indicated, steps should lie taken In ein>ek Inetation, 
as it is usually designated. " to dry up the breasts." Konnerly (his was 
ao<roin|i1isli<it hv n ledious and iMlxtHous procew, which consisted in tightly 
bandaging the breasts after having covered them with iK-lludonDa oiat* 
ment. Within a few hours tliey became v«ry engorged and painful, «al 
the e.\e<^" of milk ma* drawn off by means of a breast pump, after whid| 
the linndage was reapplied, and Ihe pniei.vs repeatt'd as freiiuentlr I 
np(M*sary for days nr weeks until the siTretion woa checked. The IffatinqB 
was frwiuently so painful that (he patient eompla!n«l llial i( was far wtia 
than the laliour itself. ■ 






THE -NEWLY BOHX CHILD 357 

SwiTuI ycATu iiRO, Dr. E. R. Lewis, of Westerly, H. I., tolil iiifi that 

r^iuiilly jtwxl ri-siiU« cniili] k* obtKim-d in fur \d'^ limo liv tlin ndministrn- 

titiri iif in grains of |Mit>b'><iiii)i aci'tati: rverv four lioiir;-. My i'\|H*riencL', 

Iwireicr, lias fhoHii that tin; drug is without vfTwt, and thiit Nature will 

Wke rare of the entire process if not iiggravate<l liv improper tR'atinent. 

Sinre January, 1905, my practiee has l>een to leave the hrensts abso- 

hriily alone. Within twenty-four hours after the last nursing, or on tJie 

lliin! liny if the ehilil hiW not iKH'n suekh-^l, the hroasls iHVome greatly 

'flKiirjH'.l, ami sonieliuie* i[uite luiinful. But if tliey art', not i'luclieil the 

"''■lliiig ::iKin i'iil)siiles, ami llie pain disappears within n few hours, after 

•^fireii the breasts gradutilly beemue smaller, and contain le>¥ ami less 

niiJt, .*! that the entire pniee-s is dver by the end of the thini diiy. If 

""• fmtient is nervous a plaeuho may In; ailiiiinisteriHl, or if the pain is 

•'•'•■re a single hy|H)dermie injiietion of morphia mav he re<[uin>(l, but 

'urtfier riHiliealion is not ne<;essary. It would aeeordingly appear that 

"»■ inetlifHls formerly in vogue, and partieularly the use of the breast 

pump, ili-fi-utcnl the very piir]('v<i! for which they were ernploved, and really 

wrvi-d i„ stimulate the secretion of milk and sulijeeted the patient to 

grrat <li;<nmfort. 

^'.v <-\pi<rienci' wilh the method just outlined, both in hos]dtal and 
pnvai(» [.mcttcf. has iK-en so satisfactory that I can strongly reciinimend 
it* ?en<irnl adoption. Those who are inlerestnl in details of the subject 
»r« '•■fi-rred to the article of my assistant, Henry .1. Storrs. which is 
ba"**' iijion IT! eases so treated at the Johns Hojikins Hospital. 

*rtillci4l Feeding. — When the supply of mother's milk is difeofive, 

nr *lien almonnalitios of the nipples or consiitiilionai diseasi's render 

jjur-iii;; inadvisable, arliticial feeding must be resorleil to. .NunuTous 

^v-calli-d infant fiiods are advertised for this purimse, but ui<)st of them 

ar»^ Terv defective, so that for practical purpiises inw'it niitk in s<ii[ie form 

i.i tin- nnly available sul»stitute for the mother's luilk. rnfortiniatciy, 

hi'Tiif^, it differs niarke<lly from the latter in coiupi)sition, anil under 

tlic inn-t favourable circumstances is only an iiu|HTfift substitute for it. 

It is u-ually slightly acid in reaction, and has a spcn-ific gravity of 1.02!) 

to J.H'fS. Its average com|>ositinn is: pmteids, 4 |>er cent; fats. 4 pi'r 

ffflt: sugar, 4.5 per cent; and salts, 11.7 jut cent. It is apparent, tliere- 

/V-re. that it contains le.ss fat and sugar, and uLore proteid luaterial and 

bjjt.- than mother's milk, and conseijuently cannot Ih' used in its rnitural 

{orni. but must first he niodKicd in some way. 

If the chilli is healthy, satisfactory n;suUs are frefjuentlv oblaini'il 
bv ililuiing cow's milk with various proportions of water and adding 
jinjrar. Such preparations contain aiipro.ximately the nornuil ariinuut of 
prot>'i'1 material and sugar, but are lacking in fat. In hot weather the 
mixttiT*- should Ite st<Tiliziil. but in cool weather this procciliire is ,un- 

^oilifi'd tnHlr, in which the various eonstifui'nls of cow's milk can Ite 
«Itpr»^ ■( *''"- "^ 'f""* theoretically, at h'ast, it closely iip|u-o.\imate-i 
0inth#rV milk in composition, proniiseil to supply us with an ideal arti- 
Srul tfinil. and in many res])('ets is the JH-st substitute for bi-east Fuilk, 



35S 



OBSTETRIfS 



Rut hi Die HUino time il difTc-K from it tti the fn<-t tlmt it»> pmtei)! ntaU 
rial i» far lew- ili|;i''lil>tf. ami. wIh-ii oui^ulnliKl bv lli« jtnflm juiii*, tnrni 
H tl)ick. iloii'H- (iiajtiiltini, iimlriL-iiii^- inifavouradlv wiUi tin- Dm- cur 
fiiniitil riniii liuDiaii uiilk. In ('iui>ltiviii|; i|. ihcrcforc, Hiusllcr i]uaiiLitiii 
of pnitekl muleria! tmii^l he yTwvrihed tliau arc norniallv prvAent 
lircAAT milk. 

The space at our disposal \a ton limitMl to permit ue to take np til 
inaiiv anil iwnjiliailM [inililein* I'dnti'H'Inl with artilJoial ftt«ilinR. Fdj 
e.\t«,'ini«i inforniation upon tliiw siibjctt tin- rt'adcr is refurn-d to tin 
varimw tniativM nprm Pn-diatrieji. There ant, ntTt-rthelew. liro pointH uj 
which I iiimt inMixt — namclr, the capacity of the ^tomuch nml the nc 
»ily for training thi.^ cliild to r<'giihir ImliiU, no imitli'r wlial inoiliotl 
fouling iti employed. Il Bh"iild lie pomemberrd that i.he slnmach of 
newly liorii child i« very sinall, ami llinl om- oiiiici? nil! lill il In rtrpliMic 
for the llrst few dayii after hirth. That anionnt of fluitj, therefore, shout 
not l)c exceeded for the fir^^t few days. afliT whirh il Kiioiild b"* iiicreHfiS 
very jrradiially. The instruction* as to [he frei|uency and manner of Uvi 
inp, which have already Invn ^iv«ii. apply tijually wi-ll whether tlie chiW 
if- fed from the hR-jtit nr ihe bottle, and too great etTi»i> caiutot bt: liu^ 
Upon their rigid obseniincc. 



I-rTKRATtTRE 

Amlkkui. I^hrliiii'h dcr (iiilmrtnhillfc, II. Aufl., 1807, 179. 

BupBBHo. Die BehaudluQg des Nalwlwhniimwtr^. j^iitmltil. f. Oyn.. 18SIS. t2fl 

12fl». 
CoHx. I'cln^r Verhn>ltunx itnd VerfaUtunK dcr AuRi^neltemnx dcr Nmijeeborcnm. 

Berlin , \sm. 
CiMtik. Vtiff VtrrhutiinK tier AiiKcnentxilndiintc lici ^'nll|[<^b4>T«llcn. Urrlln. ISM. 
Dickinson'. !■ u Slon^hia^ Prupe-u at the Child'a .Nsvvl C<ir«Ui('nl villi Avpitbi 

Childbed? .\miT. Joiir. Dbm., IHiBI. xl. H-fiiS. 
KKtiaa. B«ul)ii<i til linden hii 1IXM1 N<<iiKel>or»neri iibvr \'H>ii-l«irkraii1<uiiB?ii, etc. ArrMV 

t. «yn.. 1S9I. xli. J09-H9. 
TIaah, Die Mlkmknkkcn <li'r Dlr^norrlini-ji nponalnrimi. Foj'Iiu'linlt xii Ifomcr, Wk* 

UdfiL. tSftl. 
HorMaiKH. I>iR (iRlhmicht dcr Xeiit(cborcni-ri. Zeitwhr. f. firb. u. <iy]i., 1S82. viu, 

a87-:t.'.3. 
KxiiHiiH, Siuilien uStTdwi Irtorm neonal^rum. .Inlirlnidi fur I'iuliuirik, 187t. ii. 71. 
Kku.KR. Di>^ Nidx-Kiid'ktinTi, Ktr. Z«Titiu-hr. f, (!r-l>. ii. Hyn.. liKMi, Iviii. 4.^4 -47.^. 
Kvnni!, Die Utikterieiiliiira iter M<iiitlhilhle det> Ni-uiP^tiofvinm, Mo. BeUrH^c [. iieh. 

II. Oyn., IftOl. iv, i.«-Ma 
KosTi.iK. B<^iUuKe xur Fmri! dm KciiiiifflixItuB dor Fntiieiitiiilrh. Arehiv (. O^., 

1897, liii, l'ni-277. 
MAnTi.v. Dii^ \'i.>r«>rt;i[iig dca Xiktwlii der XeiiRcliontiicii. ZHiarhr. t, Civb. u. (lyib, 

iWOO, AJ. .Wa-.lltfi. 
Zur .NuliflKThiiiirvvrHorguiig bei Notigclioroncn. Monntiachr. I. Ueb. u. (ivn,, II 

«!. 76:i 7ea. 
Pt.o«a. Daii Wi?ib in dcr Nntur-und VAlkcMiunde. IV. Aufl., t8M, IVI. It, 18»-1 
PonAK. De rniiiphalnlriptiio. Aiuutles dn icyn. «■ d'oh«1.. iMM). liv. 1 12- 1 (3. 
KiHCK. Die Vsroorfwrig dc« N»l)el» der .Xtmgcborwnen. Moimiwchr. f. tieh. o. i 

1«00, xi, ftlH-O.!;!. 



THE NEftLY BORX CHILD 359 

StMnok Drying; Up the Itudaling Breant. Biilklin Jnhnx Ilopkinx HoHpital, ]flU7. 

xviii. 
Sf^iwtMAxx. Anat. ii. phyiiiol. Uiitonnichiiiigi'ii ulicT di'ii Bliitkr<;y»ur bcim NcuKe- 

bomieti. Afrhiv f. (Jyii., |fi!l4. nIv, :fli;)-145. 
Iter Vrrsrliluiw deti Ductus arturio«un. Hcgur'n Itcitrugc ziir (.k-l). ii. (iyii., IW2, vi, 

se-117. 

T^M^ifVAKT. The CofUMction between the Female BreastH and Oenilalia, Jnur. ( llwt. 

■nd Gyn. Brit. Emp., 1903, iii, 511-525. 
X^turmu Die Verhiitung der A\igenejtenin); XeiiKeboreiim. Z<'nlnill>l. f. (lyn., liMMJ, 

XXV, 1X1-1380. 



OITAPTER XV!T1 
MULTIPLE PRKflNANCY 

The uterus occasionally contains two or more embryos; thus, accord- 
ing to the number present we have a twin, triplet, quadruplet, ot- quintuplet 
pregnancy. 

According to De Bl^ourt and Xijhoff, the only credible instances of 
sextuplet pregnancy have been recorded by Vassallt and Vortisch, and CYen 
they have been subjected to considerable criticism. On the whole, it may 
be Baid that reports of the birth of more than six children at a single 
labour are to be regarded as apocryphal, although many such are to be 
found in the older literature, the most remarkable being the Rhine legend, 
according to which the Countess Hagenau was delivered of 365 eoibryoa 
at a single labour — manifestly an hydatidiform mole. 

Frequency. — Wappaeus found that more than one child was bom in 
1.17 per cent of 20,000,000 cases of labour which he analyzed. The sta- 
tistics of G. Veit, which were based upon 13,000,000 cases occurring in 
Prussia, showed that twins occurred once in 89, triplets once in 7,910, and 
quadrui>lets once in ISTl.r^r) labours. According to Mirabeau, triplets 
oecur more frequentiv — once in 15,500 eases, De Bl^court and Xijhoff, in 
1904, rcimrteil a case of quintuplets, and stated that they found in the 
literature what ap|ieared to be authentic histories of 28 additional cases. 

It would appear that multiple pregnancy is more common in cold thaa 
in warm climates. This statement i.* l>orne out by the statistics of Ber- 
tillon and Mirabeau, the latter stating that they occur onee in 41.8 tabonn 
in Russia, as comparcil with once in 113.6 labours in Spain. Gscbe 
found that Ihcy occurred most frc(]ucntly in Greece and least so in Pera, 
Iwing noted once in 50 labours in the former as eomparwl to once*iii 
ITO in flic hiltcr country. According to Duncan, twin pregnancy is noted 
most frc(|ucntly in multipara;, especially between the twenty-fifth and 
twenty-ninth years. 

It liiis been estimated that in (>4 per cent of the cases only one. and 
in .ttj ]HT cent hoili sexes are represented. Thus Pinnrd. in l.'iO obserra^ 
tinns, found that both ebildren were males in 46, females in 46. and <d 
diircrent si>.\es in .W cases. 

/Eli(itii<}ii, — f'ertnin individuals appear to be predisposed towards mnl 
tipJe pri'iinimcy, sinci' it is not unusual for the same woman to give bir 
to twins or Irijilels upon several occasions. Thus Peuch, upon aiuljl 
1,262 ciisi's of twin pri-giuincy, found (but 4fi of Ihe mothers had had ti 



1JL-I.T1I'I.E I'HEliNANCV 



mi 



twMx^ n LhriL-f, anil I upou i oattsions. [n wh[i« in!iURn!.'> itiiil(i{>li- jinjig- 

nancnr ban been ktwwn lo iKx;iir in nil Die fomuItM of a family lhrou(;tiout 

ml gcaoratioiifi. Miriibtrati tias |>oinie«l out tkni. aii Iiorwliurv ("jntlvnt-y 

..nij> iri|il«i jirt'^iiuin K-j- vmt ntxirdiHl in 13 out of the 75 catea col- 

InrteU bv hitu. lliif was particuiarly niarketl iu nne family, iu whieli 

' — '•It-t^, tutl u> itii-niioR twins, liad occurred one or more tioica in live 

^dive i^f^neratioiu. 

in rarv inftanix*, howcvor, lliis tendenty appears w cohk- tbroH|;h 

fHtJM-r, aim] n-ft-n-m-e in tniiUfiitly maik- 1" tliw mm<-whMt apficryplial 

uf tho Itnwian poafiant, Wasilef, who had 87 children l>y 2 wivea, 

flrvt Imtiiij; hm) I <)uadrnpli-t. 7 tripli-t, and in (win prvgnuovio* ; 

<I tlio itceoml 3 irijtloi and C twin prejinanciw. 

Ati-*>rilmjr t" Iblliri. I'nti'llani. niiil Ijirjicr. nuiltiplr pn-giiancy uhoiild 

b»" r»Tiriini<ii •■> a "in'i "f "tfj;i-ni'raii«n, and n?ptpsenlti an atavinrii; ri'vemion. 

Tbe first -nitmlinntil unllmrily )>tali« Ihat the ovarim of womon who have 

■«1 ■ nuniticr of )iiulti]>li- pn^^inatifiox (^iitain an exccwive nundwr of 

but thai in'livtdital ova with douliie uuckt are very nirrly noti-d. 

lYinliuv to iliiH view, Ihi' (umliliim is proliahly t\\w In llw iitaturatino 

■uiiatli of K-vfnil ova, im^littd of one, nx if ({cuorally tliv rule. 

Twin prettOtaac^ ma,r nealt cither from the fcrtiliuition of iwA ncpa- 

iW oTM or of u fingk* nviiin. tlw Rn<t giving riM to dotibte, KUd tlu> 

i<| t(i jMNjf/R opum Itfimi. In ttu> foniier 

p. tin? Ota may ooute from thu same ovary, 

«»o«.' fnim onch ovari'; while in rare iiutance) 

vth tDSV orijiinate in a .<iin;;le follie1«. 

T~ r Is it was fft-n^-raily hvlii-ii^l thai *infrK' 
wfDi, - wen- diTi^cil fmui ilw fertilization 

of an iiv-um which ptir^vuli-d In-o diotinct ger- 
— — .nl Yf^irlw. TIm! t'xir-tenee of iiuch ova i* 
-pittahle. Kraiiqu^. Hcrff. Klien. and olhert! 




Fni.339.— OvtMniTiiltoti- 

MJl OKmtXAI. VOICLK. 



tiu* 

el* oTum twiiw to U' dirvflo|»wl from wui-h 

omirt fiwf' ladf of ihf t*'! nm.-'t umler^ro 

uiatnnilinn and vn^^t off polar iKMtiiv, and 

rrr that «a(^h female pronudeiui $o reiiult- 

viiut tw ftTtilizt-d by a «-]<aratti j^pt'rmatozoon. it become* apparent 

■t rh" ptTit49(ii iH not mi ainiple as might appear at 6nt sight. 

1 in recent years the trend of authority indineK lo the view 

It '[ twin:- may Im- prmliiM-d in "wveral ways: by the fertiliza- 

af polar bodies, as believed by Bonn*t: by the premature «parati<H» 

I Mai'tomi^« from iHe «'gm'»ntin)r ovum; by the cleavage 

III' artii. or by double ;;a>^tndaxati<in of tin- blast odennio 

|r, iu (li-w of t)>t' n'markahle n-oult* obmimH) in experimental etn- 

j, SiiiflilU ljoIdi< Ihat there U strong evidenw in favour of one or 

of tbe Ult(T powibilitws. In thin event donbl« ovum twins are 



imsTEiRics 



cloecly related In the doublo montiterH, and nno may n-adily follow all 
(■radatiouH fnini tbi? fornn-r In llie Sianie^ twin^, awl from the lat"* 
tlirriugli the doultlc-liixluil, doiiblc-hiiidcd, or doubli'-k'i^p'd iiioin'I*''' 
downwiird i>i ilit< niiin.'>iei« Uv itK'lti:iii»i, and finally to the tcnttunu* ^ ^ 
Tktu, it mar wi>ll be held, Uiat dauble ovum twins on the one hand i*^^^* 
li^atoinnta nil lli<- nt.hrr. ri-pRiiWit rw-iK-ctivtrly the moot pcrfwrl and V^ 
TiioKt nuiiiiK-ntarv sia;;*^ of iho «ifiit* [imeew*. 

SftiiiUT MaU-* tliut in trijik-t jir*>pi«ncy tin.- cliildrcn iiri' umwHv 
rivt'd from tiro ova — on« from om- and iwn from iJic oUier — whilf 
rttre ratten, one of wfaicli he ban studied pereonally, all thnw dtildn«i ai*- 
dvrived from a sinffle ovum. In tbe qumtnplet pregnaui-y tlotcribnl 




Fra. 337. — PuMTKKT*. DatmLB-Ovnw Twnn, Vn-uoBcroini tKannnaN dp ('o«d. 

Df. m^coiirt. and NijhoH. thnw of the diildron wpre p>Min<-otiyI with' 
«ingk- plfloinU. nliiln i«cli of ibc other iwo bad M-)inrAie pliirt-nla^: th»^ 
indicatiii); lliat only ihrpc ova bad bwn fertilixetl, one i^iviiig ri* 
triplcti' ami llic ullicr Iwn to "iiijilf cbiMn'n. 

Of l.trj'-i iuritancet< of tvrin prtf-nam-T aiialyxod by Ahlfpld. ft'It wen 
diTivcd from Iwto ova and ISO fi-otn h xiiiglv ovum. In tliv forniw cmh 
the children may nr may not Iw i>f lh« *aiiw sex. while in ilw latter titi 
an* alvny^ of tht «am"-' wx. ami often cIo^pIv resomWe one Hnoilier. 

Rflalion tif Pltui-nlri onil Mrmlmtnf*. — The examination of the plarcnlt 
and ftftal mfmbrant'H after labour nsuallv enables one to lU-termiM) tht 
mode nf origin of Ibc Twins. When thoy an- dcrivcil from a sintrle ovum 
there Ik a sinf-le bir-;e pliiccnta fmni wbicb the iwo iimbdiial titnl* iiii 
off; bill when tbey an- (ii'Vi'lii|(ii| (r-mi Iwn nvn tlwn:' are iimiiilly lwi> 
rate platpntff. allhounh ocoafliouai ly, when I1i«fm» wen* origiuallv in>«i 
near one anotber, tlK-ir iijiitiguoue edgvs may fuse together, tliaa givi 



MULTIPLE rilEGX-VKttV 



363 




rMhiND «|ipiin^DlJ> din^cli' largo {)l«c(.'nl)i, in vrliicli. lM>m>vi-r, there i» no 
fflnnttioa bctWTOD tire circulation of (he two twins. 

In ilirabiivjvtim Iwiiij', ih> riiJittirr wln-thor iV- pliuwitic un* M-purato or 
fibnl b'frplhvr. llicre arc two chorioBH ati<l two anmiotifi, iiach child being 
•flielfifnl ill i\f. uwii nH'tiibrniiiv. Siiigliv 
"mm Iwins (mwwws only a singie chorion, 
^t, u 1 rulr, On tiiiiiiioiw, for thtr rvu^iii 
li^l llu! former rt-presonis the wall of 
tfce 'iriffinal lilai'Imli-rmic voiclc. while 
Ifc*" imnioa U imm- direi'tiv ooniiwtw! 
•itli ihf cnihrjTO itself. In rort- inclaiic* 
(• M^(te aniuion m fnuuil. Thin condi- 
gn, vliicli vaii iHitM in 41 cid«6 coU 
Lfc*rt*d frnm the iiK-niltin' hv IIoliEapfpl, 
li» n<ii priman-. bul mutts from pcrfom- 
[Hfn nf ibe pinrtition wall iwtween thrt 
nijriiul anmiotip cavities. 
TW ■rr(injr''rni-n1 <i{ tin- mi-riilirftnt-!' 
•■» \ff<n to Vianlel in the seventeenth 
wIhi i>liitnl tlint whiii iIh- i-liii- 
— .'i' iif Uic Manie sex iJiey were usu- 
I *^9' ntbiM-(l 111 n «in]!h; amnion ; whi^nwi 
"**• of difTeront sexes were separated 
•? M pir1ttij>n wall. He (■\(irc«i«.tl the 
'*''^ Uiat I*rovi(lt'we took this mranii 
"* manlinj* thL-ir moral )i in utero. 
"•nittf (I9Ul>. in a very inlcrwiting «r- 
*■'*■- h*f ean-fiillr i-ludicd the relation of 
'"*f.?lal tncnihrmtiv in tripli-l pnirnaney. 
I> 4insle-nviiin Iwiiui there is always 
* <*Ttun arwi of llm plaeonla in which 
«» a anai-toino^is between tlu- two 
**««lar -y^tnut. whieh i» never present 
t* IW fu!«ii plact-nta of douhltvoviim 
ttvu. Tlii> mndition lio^ biM.ii eihaui^t- 
nWrmidiwi by Sehatit. and oeeaTtionally 
fca'bi 1*1 wriftuti eonpier(uene«. Thus, if 
at n i!arlv {H-ri'itl (Ik lit'jirt of one <>m- 
I Arm if raoiiidcrnbly <tiiiO]!er than tliat 
|W the otbw. a gmdimlly inereAHin^ an-n 
lat tbf inmniunieaiinif portion of the pla- 
|C>!lita b- infif>i>|H)lin'(| hv llie former, nt 
il> iM-art iiNTmseM nipidiv in size. 
thi'I.- Itial (if iIm- lallttr riMrives U-bk awl 

■<l and eventually almphiew. Herein ia to be found tlM- explaitation 
'iir •ir*iitrriiily known as uiunliii. In --Hph ra«« almo^l the entin- pln- 
ilal iireulation in ntUix^l Ity Itie mirmol ■•iiihryo, while the deformed 
twin recvivis only euongh blood to iKiuri»h tta lower extrvmilics. 




FlO, 338. — thAOKAM unowtKii RU.A- 
noH or r^UI^KTA XSD Ukm- 
DKd.VKia IK rVll'HL» AN» S»aiUD> 
OWW TWIK pRKONANCr. 

m., lioubi^-ovum tiniu: A., daabtc-onini 

nt(iia;^_, (liiiikwtvBiQ twin*, ihhicIk^ 
itoii. iHii ainiuuiH. noil uiw (ilacDnla. 



3&4 



oBsTjrrHics 




Not infrequcally a difference in the stretijjth of the two hearts lead* 
to thv [irmlucliOR of hydramiiio<> in odo ovum. In xucli i%*o* it i» heH«viHl 

thai the stroD^er heart approprialvs an 
ever-iiicrfii»in|[ fhtire of llw; hlootl fmm 
the [ilaeenta and undergoes hypertrophv. 
which iu turn i* followed by n mnrki-d 
liypertrophy of the ki<ineys, which lead^ 
to incrcaiK'd tirinair M-cirhou and a rnii- 
Mi|iiinil cicei«> in ttie quantity of amniotic 
fluid. 

It) tht' rare instanoM in whicli Hingte- 
oriiin twins an indoiicd in a oomnion am- 
nion, thuir unittilioal rord« may Iiefomfi >o 
twisted about oui- auothi-r a» to interfere 
witli the i-inulnliou thrnu;|j!h theiu, and 
thu» lead to deatli and an eurly tt^rnxina- 
linn of prffTiuincy. Sonntag, in IU(r5, 
collected is »uch caseo from the literature. 
Onhnarily in twin pre^inaneit-K eneh 
ovum opcupies, rnughly «pi-akitis. one half 
of the utcnLi, tim long axis Ijeing din.-ct«-d 
rertically. OceasionaJly. however, they 
run IransvorM'ly, fxt tliat ont> fii>Inl gae 
comee to lie ulwve the otlier. I'nder such 
ciR'nmstanees ihe plnet-niH and mem- 
branes of the first child must be expetl« 
fmm the uterus Wfon.' the second cl 
can be horn, unless the latter can 
hf way fiast them. 

Site of ChUdren. — Generally KjK'iiking 
twins are «mall<^r and weigh \&* than rhi 
dren resujlinx from simple pn>^nanci( 
although tht-ir <-(>mIiim-d wvight is usuallj 
((reater than that of a single child. Tt 
smaller size may Im cM>iisidered normal, 
hut in some instances is partially to 
explained by the fact that the exee^ii 
disiention of Ihe uti^nis tends, more 
le)«, to premature Ifllmur, so that tli«> twii 
are often liorn several week* before mat 
ity. According to Ribemont-Deaui^ 
this occurs in 83 per cent of primij 
and 75 per cent of inultiparte. 

Tt i^ not imustial for twins to dilTer 
considerably in aiie and weight, espe- 
ei«tly when derivctl from a single hvuh 
Ahlfeld has reporled three cases in which the Iwins weighed. n»p^ftiv» 
i^'iO and MSO. 9,700 and l.fiSO, and 1,920 aud 790 gramoies. ~ 




Pk. 331. 

y'tam. .'ug-:!.'!). — DiAoRAiu Mcovtya 
PoBtnoN or TwiSB in I'teko, 



MULTIPLE PREONANCV 



365 



In doulilcH^Tuin twin pn-gnancj- il is not unuBTial for on<> child to tlie 
H an carlr period and be expellM] fmiii lh« u[t*rux booh uft«rward. while 
■ r nwv go on lo full development. More f rof)ii*-nth' . hon'i-vi-r. tho 
itoii is rcttiinMl until llnr wiii of prc^naneiF', and becomes llattened 
put uiil partially oinnunified, being oompresiied l)etwe(>n the uterine wall 
Ihr membranes of tl>c living i^iild--/irl«u papyrat^m or compreaen 
, Fi^ 333). 

rffrunditiim aiui :<upfrfirfalwn, — The ennii [deration of the differ- 
■he weigh! of twioj, and the pnsHihilily of iuk) Uiing olwrtcd 
't»ile llie oihcr diMi'lop* . - 

itil full Urrm, Irad^ up 
the i(ui*sti»n of fVf 
Fn-iindiitiiin ancl sii- 
fcruiion. By the 
»iT we uiMlprstsnd 
fuI'ItKiition of linn 
•*^«l villiin a iJtort jieri- 
•i •>( nnc anDlUiT. Iiut 
H «| tliv iwtiie coitOR ; 
^bona* in tin- hittiT 
l"«^«>ral mootlu mar in- 

Suji^fivuDdation is 

' •fll-rwopniwd occnr- 

'™<» to thr lower tni- 

" '■ iTid nndoubtedir 

ri hnmiin Wingn, 

.'fit it ia imposai- 

li'Ifrmini' It* fre- 

U IB probable 

la nuinv mw^ iIm- two ova are not fertili^eil al the same coitn^ b«t 

I mo l<e demon)'! rat 1^1 <inK- under execpliotml i-ir(«m«lunc"-». In a eat* 

Bt Uie Lan)>oii>)^re, in Paris, the woman bail had eonneelton with 

htle and a eoloured man rt^'pcctivrly within a "hurt period, and wa.t 

,def)v«n«l of twim^, one of which wna white and tlw other a mulatto. At 

•'ohon H'tpkins IloApital a coloured woman ^avo hirlh to twin*, one 

Iwm d«id uitd lh« oIIkt pcrfei-rlv heallhv. Distinct e%idene» of 

lU »Kn> present in the first child and itiii plaeenia, while Itie «iTond 

kliM-d ja-rfretk well Kimc month* after it* deliverr. On qnoationin;; 

fwtient il was ascertained that she liad had eonnwtion with ln-r hii*- 

lod ami anntlwr man within a jwriod of a few days, and that the former 

rmf ttmler treatment for syphilis at the time. 

Thr otrnrren«j of miperfn-tatton hait never j-et been dearly d«inoii- 

thmifth ita thKin^ticnl poecihility mu«t be admitted), (ii-nt^rully 

rili;r. the uterine cavily doc not Uvome completely oblileraled until 

idiu n'il<-tH Biwl vi-ra fii^e toffetlHM- at the end of the third month of 

cy, after whieh s>ii>erf(vtalion i» imi of the qt>e:<lion ; but prior 

■il Dure U no theo>retioal objection lo «uppo«ing thai. If ovu- 




V 



Fia. 382.^1 1 T.-f.-* I'APiRAfkf* ( Hibtoiom. Uf aignai). 



OBt?rETRICS 



Intiou liliould occur, on ovum ititgfit find its waj into the uterine cuvitr 
Faiid ttiere be fertilized. Still more favourable coadilions would be afforded 
bv a uUTU«i duplex. 

Till' Krcndi anthorilies ooniiider tliat each an event bait beea nnnclu- 
^ivelj dvmoii»trnliil, uml miLtiy of itiv Hr^umenlH wbirli Imvo l>pcn ad- 
vanced ill itt« favDiir are ^ivea by TarnJer. On tlie otlier haod, iiio»t 
KngliHli and ttertntii atitbor* Mti^ »onu-w)iat »c«|>l>c«l, and, wliilu adinit- 
liDg iu ihwirt-iical jjoesibUity. Micve lliat ihe majority of instaDn>!t jmt 
under lbi>^ wiUpiry hnvi- Iih-ii dm: vitbi-r t" tin* alxtrtinii iif one twin iir 
to marked iini^iiialitv of development. 

CaoeH octa^ionnlly on-ur whieli nppt-ur t<> \>vnr out live j»ae«ibility of 
»upi-rtirtaiion, but, u)H>n elooer ^tudj, fail to dn so. Tbutt, a jiliysiciau 
rewntly »i-nt me & (ijiccimfii wbicli In- th(iu];iit alTordml i-oHcliii'ive evideow 
in favour of suoh an ociurrrm^. It consisteil of tuo f<etuse*, whiili bad 
bi-cn expellt'd KjHmlaniviiiisly by a luiiltby niiilti|iHn>ii* wnmun who tliougbt 
heriu)lf four and one half months prei^ant. ()n»- fretus meajiured 18 «pd 
the odier i rfntiuiplR!' in length. The foniier «'a*i perficlly fresh, wlule 
tlie latter sbowt^ Higiis of atrophy and ha<l evidently i>ecn dead for lonniH 
time. «> that then- w«« but little doubt lb«t eneh bad ln-gun development 
at about tJiP name perio<I. Kven had both fietuiies been alive, ihe evidencft 
u-ould not have been unnoKailnhle. unle^tf lK>th plttci-nta> were found to bp ^ 
porf4>otly normal u|M>n examination: a» it is readily coneeivablv tlial soim'^^ 
lesion mi;;ht have k-eu pn'w-nt in the plucenta corn-!' ponding to the «mallcr>-^ 
ehild. which would iteriously interfere with it« growth, without, however-*., 
causing Us death. 

PiaifnfAit«.—li often ba|ipeiii> that the presence of twins in tlie ut»Tr,»-, 
is un.-'Urtiiwteil during pregnancy, and the first intimation which Uie pby^e^ _ 
(■tan has of the true condition i» iifforded by the unusually large iiir* - 
the titeruii after the expulsion of the ftrst child. Despite this fact, *■"- ,_ 

ever, it may \k- wiid that Mich nurprixw will rarely ixK-ur in lh*r praclrr ■ 

of tboiw who take the trouble lo make a thorough prvlimiiury i^__, 
amioation. 

Kxcessive size of the abdomen during pregnancy freijuentlv eauH's ctiw^ 
to suspect the prt»ien(i' of twimi, tbovigh hsuhIIv il will be found to (•p" 
due to moie other condition. Thus, owing to the marked relaxation «r 
the abdominal walls following the birth of the fiwt child, women prfjnitiK 
for a sei'ond time often think that they will give birth lo tains, altbou^, 
aw a matter of fact, their Utr* iin- giMierully witbont foundation. 

The dia^oslie means at our dir^posal arc palpation, auscultation, sn i 
touch. If a multiplicity of ^mall partj) \* mcountrred on pslpiatinn, i' 
po^ibilily "f a twin pregnancy should always be snspeeted and a furtbir 
examination made with I'^jK-cial r>-feri'nec' to Ihi* point. Tositive cvid«f>cv 
is alTorctc<i by Ihe palpalion of two heads, two hrwcbes. and two backs; or 
at least of one back an<l Tour fo-lal |K>te«. The dett^ictton of thnw firtal 
poh'ft in not crmclusive. for the reasou that in rare instances a iiuh|)ent0iUMl 
or intramural myoma may simulate ihe bead of a cllild and lime give 
ri«e to u-riovis diagnostic errors. 

AuiKHittutiou ocra»ioually gives moat valtmblv informatiou, and if au 



MULTIPLE PHEUXASCY 



367 



1 



i)i9t)n)ni>'*ii tun urcHK, i-niMi<]frAl>lT rviimri'd from oik' another, in 
ic^li 1 twtai lii-urt <!aD iie heard, lii'iii>< i^hould he su^jit-i-lcd ; hut a pout- 
t^ ihaj^Kifi thoiilil ii"l \» miuk- iiiihrw tlit-nr in u ililTvrCDCf ot at luawt 
1*> t>««Li i«;r miuiite ill the rale of ihe two hearts, tiie ^uuils being counted 
t'*>w aat tcaiit u iiitiiiil4- in I'Utli iMcittinii. 

Mst nrv in.-'Uini'«!i takiiuiI louHi may reveal importKTil finding, m il in 
«^-tiiDi^ [MiKfthlr III dioliii^nii'U a iiinci*raUil Kuid tliroii^h the iiiUct 
•TsiliniiiDi, or n |ir<'l)i[it«ii and puliii'Iiwi lonl mav lie fi-U ihn>ii){)i ihe 
r^' ix. whik' nitircullatiou gives pi^itiv« oviik-nct' of l!ic prcM-ncc of a 
li-v- u^ oliild. 

TTif pretence of more than two cliildrt-n can be prediclwi *illi certainly 
«»»»l V itndvr XKTx exci!|ititinal and fuvoiiraUe eii-inini'tanivn, although Kib-- 
rl•«kOt-L>e'i^^i<:n«« rejinrt^ tlw diagniwiM of tripl«-t» during; prrgniuic.y iild 
»*-* ^'-•lu linn at ion at iho tinw of InlHtitr. 

f^intrte of /^(/iwMr.— Wo hait- alrnidy referred to the abnormal size of 

.l»e uU-nix rfsiiltina from the |HT«eiii<c of twin^ whieh mav 1k' !«lill furtlKT 

'T#^at*d !■}■ hydrammos of one ovum. Thii^ may pivr ri>ip to c<>n»tdi>nkble 

aifort, iht- paiieni suffering markedly from dyspntm. prea^ure aymp- 

. uul mdema. 

Chnuinnally the extreme Htretchinjc of the utertu may lead to an 

ly diUtulion of the wrtix. 'rbiis. in one in*Iaiicp. I found tlii* cen-ical 

*»iii») (iimplcle)y ohUtciat*'! and i!w oh extermini dilated lo .■> renlimetres 

thiT«> vvrVn U-forc Ihe uiwi-t of lalxmr. Rtrfercmn; lifts already hw-n msilc 

t'^ the frti{ueiu-ii' of premature expnUion in these casee: and irhen labour 

•et» in. owio); to the orerdistention of the iitern», (he jminfl usually occur 

■t Itiiil! int'-rtvlK ami nn- lacktuji in inti-nnily, ho that tlte bJrlb of Iho 

'i'*! riidd is often markedly prolonptl. 'Die eord of thif^ child slwnld be 

'^n U-fiirn donlile liKatnri's, a^ failun' to VtfcMv tl* miitiTnul end may 

^i to tlie death of tin- fveond chUd from hsemorrlia;;? if the twins are 

*n*«! from a Hinj^e ovum. 

'•rtiiTHllv -|H';)kinc. the memhranen of the s<x<ond ehild appear at the 

!-i[ii''iliiii< [i iifli-r 1)n- first i> linrn and MMin riiptun-. Il« fxptilMDn 

■Mows the first within half an hour. J5 per eeiit of tlie ease* 

... Ny Klcinvriichler occurring within l]m pcri'Hl; whil« in the- rc- 

taunlfr a tonffer lime i-lapMxl — as much as Iveke honrH in 7 of hiii canes. 

^ < mlc it may hi- oaid (Iiat if Kiwiniam-iiiT.- dt4ivi*ry of lh<: h-coikI ehild 

fti't oofiir within half an honr interference 10 indicated, and the 

r •■[ifT fnrmt-rly in vojtue of waiiinit hours f«r it* Hponlaocau^ eipulMon 

caUHit lie repivJiMided too atrongly. 

HMRifnt in poc^ition of tho Hi^ml vhih) not infriipivntly occur during 

birth of the first. *o that at this time a reneweil exam- 

,r '~y <" o'diT lliat any alinoniialily miiy Ih- deli-ct'^l and 

rtu- pnffMT mHasnrfM taken. The rondition of Ihr fietal heart lihoidd aim 

-inrfnltv tralrhrd. nod delivcrr tmnniliatelv cIToeted if it lit^'omiii nh- 

id. 

/ ■ aoi (mill IwJiiii present liy iht- vi'Mhs, I|ii>o;:Ii not vi-ry rarfly 

.()■ ■ tiy lite lirMvh. In I.^IH eiw«K analyzed by Ijmtifaard, Uiu 

r»Thi«ing r»ndilk>nH werv iMXmi: 



M 368 


^^^^^F oiun'K'ruics 


'^^^^H 


^^ 


t^ttST l-KW. 


8£cu»i> rwiK. 




Pkh cent. ^^^^H 


^^^l 


Verlwi. 


\'«il!X, 




^^H 


^^^^^^^1 


VMt«)[, 


Bmrrh, 




21 10 ^^H 


^^^^^^^fe 


BreoL-h, 


Vertex. 




14. 3S ^^M 


^^^^^^M 


BnicFb, 


Brewh. 




10.70 ^^M 


^^^^^^^M 


VwtPX, 


Tnuun-crw, 




S.32 ^^M 


^^^^^^^M 


Bfi>och, 


Tmnm-tirw, 




^^H 


^^^^^^^H 


Tniiisvi-riie, 


Vvr\v\. 




0.87 ^^H 


^^^^^^^B 


Tmii ivutw, 


Brwc'h, 




0.T7 ^^M 


^^^^H 


Tniiii'vcpw, 


Trum-ctwi, 




^^H 


^^^ 


Total 


ioo.ua ^^H 


^^^ As n 


nilr the n1no<-ntu nf llio fimt ohilil rciiininx in intu until ^^B 


H^^ completion of lalKiur, tiut in rurc inmniKw 


it tiisy become {mrtly ur et^^B 


^^^ 




ptt-tolv M-[mnilii) idkI »^^s 


^^^^^ 


^-'^^*m^\ 


t\>» to hieiiiorrha;^'. ^^U 


^^^^H 


y^r^^^fc^ 


der Ihtve vircumnlnnif* ■ 


^H / 


^'k M 


eecontl child should be ■ 
fivere«] «1 0IK.1-. fl 


^^^ ft 


■^■1 


Owii)^ to previmiB i»^m 
distention, the uterus 


■ / 1 


^\ ^^^^1a 








\ tract au(! retract satiH^^^ 


.^^^^^^^\ 


/ liirily (luring the Tfi 


1 M. 1 


^^^^uT ^^^^1^ 


J stage of labour, eo thai ^^ 


^^H >. 


^^^Bk^^^^L ^H| 


ri<>nnMli(ie.4 iu the ]ilii<vii~ 


H \ 


v^H^^^^^^^H (/ 


period are not inltvr\at^^-' 


^^H^^^^^^^HR /^ 


If there it iiny l<'niii'tt-- * 


^^1 v\ 


^^V^^^^^^^ // 


townrd.i nn ejuv^iie Iif^ 


^^B \ 


^t^pTT^^ / 


of WoixJ. the ob^.tctritij*^* 


^B ' 


»h(>uM iiu media teK ex\mv^' 


\ ^f ' J / 


the placenta by t'redfc^^ 


1 


\_ mJ^^^^^^p^ r _y^ 


melhod. instead nf nailinrf^^ 
for the fundus to rise vy^: 
Occasionally the area i^^ 
placental attarhmeut nia;,^ 
be Ml \aTge lltat abnormal^ 
itif's in it« (lelaelimeot nin^l 
render necwsary iit* niau-^ 
nal reiniival. Thi« opert' 
lion, however, sliould wit 
be re^orli.'d to tuileAs ur- 
CESilly indicated. 

Th« danger of hKinor' 


^^ F-io. 833.- 


— DlAOKAlI BDOWIXU COI.I.|]tl(»l KBTWKIUI 


riisge doM not end with 




Heads ur Twdm. 


the expulsion of the pla- 
centa, n* llir iilcniii Miiiif- 


^F ttniftv rclHSi-s (hiring Uir Imiir iiiiiiu-diHtoIx 


fol]ott'in){. Aeconlinalv. tin- 


H phwJduD 


shoutd remain in the houw for some tim« after the oninpMion 


■ of labour 


and give his pereoiiul gupervifiion 


to thtt conditifHi of tlio uicfuBi 



UULTIPLK PRIOIJNANCY 



3fiS) 



npftn the Bist indicaliDii nt rfloxoUon. and re-enfowinjt it hy 
It*- hrpodf^rmk- iidmiiUfitrnltnii nf rr^^tt. Vitulcct in (liiii dintttMi )uut 
i^ttini-.-* }<■<! lo till' dtmth of Um* |iiitifii( rmm )MK|-|)iirtiitii lui-tiiorrhsgcr. 
Owiii]; lo llw; ifDuill sizw of liie childron. tlw-ir [iitiMtiitiof; parta may 
l>ot}i tlumpt to enter tlie sitpi-Hor Ktrail ul Ok- sanw time and ihu* mutu- 
ally iotm-fore with on* another. Iliis 
c-«»n»plirali"n ik knuu-ii ax collifirm, 
'*««»1 umy occur wlwo l»oth childrt'i' 
'*"•— *'nl liy llic vrrli'X. or vflii-n om- 
•rewontf by tlw Itead ami the otlwrr 
*y the brvfvh. In ihv 6r*t caw? ait 
>tu-ujpt «h>iuM In: mndi- !o juiiih uji 
I Um) pnseatinn part wliich Li leen 
j diatinrtit CRgngrd, iiml ih*-n to deliver 
Ihif other child rapidly. If this ia 
•»*»i rMih«ibk>. (he uliolo hand t^liould bo 
''Hrr>fiuc*d into live ulerud and the 
*niu]ifi„[, of aJTairs cnn-fally studied. 
liccMaionally it will he fonnd adviw- 
I "'<* tn apply forceps to the uppermoat 
•^"tlil oivi aiifmpt In draji it pa*! th<! 
"thi-r. In rare inxlaiicva craolotoai}' 
*P«n i>n« child may be indiiKtcd. 

Now and again during extractioD, 

**»«n tiic llr-it child pri-wnt* by the 

I '••^"^■h aitil lite #i>i<oud hy itw wrIt-\, 

I "**i Iwii bcuda may bet-omu locked 

f**^t aluve llie flu|)crior strait, that of (lie mvoiu) fiiting into the neck of 

*** Sr^t child mid making its dcliverj- imp<MO>iIiIe. I'nder niich circum- 

•^'UirwL, if tlM' lii-ad of llie s«^>iid t-liild cannot be dtHplactil. llii" fimt child 

*^vld be dn-flpilutcd. as it muKt ine%'itably pcri(<h during any attempt at 

'^traction ; aflvr this tlie hotly should he brought away and tlic iiecond 

*'MiA tlu'D deliTerod by forceps, 

Ifi rare iiiKtancr^ i]h> Hrst child may prtw-nt trHn«\YTM'ly and Ik; slnul- 

dlnl by tlie second in mucIi a manner that the legs of the tatier protrude 

Ihu ctTvix. Traclion ui>on tlM-m uiU «-rv« only to whI^ llw «hoiil- 

piwof the other child more tirmly into the pelvis and give ri« to insuper- 

I'k^iliflimltics. The pnip<T trwitmont can only be delfrmincfl after ino»t 

etatninati'in under ana-sthmia with the entire hand in tJie uleruii, 

'tttMH-oml child cannot Iw bom until llic dirlivery of ihc fir*l ha* lnwn 

Ttriad. The ii>i>ditii>n may call for Tpnion or decapitation, according to 

I eiigcncics of the individua) caKe. 




Fni. 834. — I>iAa>iAii iu.c<«TMTlNa Iakkw 
Toixn (Aiiwrimn Tnl-Book). 



LITEnATrHB 

/Un^MJi. t)<t>r.ntjilchuni[d(>r I>ii|iprlliiU|iiii|iifii mul (In- hnnvnUiKpn Zwiiltaffe. 
HIjiL. 187(1, i\. IDH 251. 



ArrMv 



370 OlWriCTRKS 

Hrktii.uin. Hiillcliii <le ki soe. cl'unthropohtgie lie PariH, 1R74. ix, 207-290. 

l>KBi:h:i'<>['it'r II. NiJiiori'. ]''niilliii);Ht:<'l»irli'[i. (InminKfii, ItMM. 

I>i-\t\\. < Ml Siiiii; Ijiivs (if I hi- I'riihii-tiiiii I'l TwinK. Jvliiilmr^li MiM, Jmir., Miin'h, 

I ««.'.. 
VON FuANQiiK. llowlirciliiiiif; I'iiiijaT wlluniT l'UiT[itofkMprii|itinil('. 'Acitafhr. f. l.<eb. 

u. (iyn., 1898, xxxix, 32G-;t4C. 
(iACUE. Im (ecotiditfi de la feiume dans 06 pays. Buenos Aireii, 1004. 
IIrujn. ])ii! I'rMuehe der Mulliparitat tier uniparen Tiere, I'lr. Miinchcii, ISD-'i. 
Hoi.ZAPrEi.. Zur Pathologic der Eihuute. Beitriigc x, Cicb. u. (iyn., IJKl;), riii, 1-32. 
Kleinw.'vchtkh. Die Lehre von den Zwillintcen. Pmg. 1H71. 
KuEN. L'elwr mehrciige Graufwhe Follikel beim Mensrhen. Miincfaener nuil. 

Abhandhnigen, 1898, IV. Ueihc, Heft 4. 
Lakueu. Lea sliniatiis olwt^tricau^c de la d^K^n^resocnrc. These de Paris. 1001. 
Leokhaiiii. I'eluT die Kindeslagen bti Zwilling^feburten. I>. I,, Berlin. IBM". 
MiRABEAi'. I't'licr Urillingsgelnirtcn. Mimchcner mcd. Abhandlungcn, 1BH4, IV. 

Reihe, Heft S. 
Patellaxi. Die iiiehrfachtMi Schwangerschafton, etc. Zeitschr, f. I'lcb. u, Gyn., 1H9G, 

XXXV, 37:M13. 
PiNARD. Quoted by Itibeniont-Doasaignes. 
PuELH, Des groBMeBses nuiltiplcH, ftp. Paris, 1873, 
KibemonT'Deiihaiunkr et I.EPAiiB. Pr£eiH d'Obst^triiiue, 1894, 864-897. (CiroxsemG 

gtoiclktiro.) 
Sanitek. UrillingBKcburton. Eitieiigc Drillinge. ZMtsrhr. f. <>eb. u. (iyn., 1901, xjvi, 

347-3ft5. 
ScHATz. Die rfefiisH\X'rbindungen der Placentakreislaufe eiiieiiKer ZwillinKe. ihr« 

EntwiekeluTig und ihre Folgen. Arehiv f. Ciyn., 1882-1000, Bde. xjx, xxiv, xxvii, 

xxix, XXX, liii, Iv. Iviii und Ix. 
SonoTTA. Xeuere Aiisrhuuimgun iiber die Ent8t«huiig der Doppel-(mii«)-bildiingHi, 

etc. Wiirzbiirgcr AbhaiidhmfKn. 1901, Bd. 1. Heft 4. 
SuNNTAti. VerHrhliiiguiig ii. Knoteuliildung dt-r NabciRchniirc. I). I. I^pii);, ISOS. 
Tarmbr ct ('hanthei'1[.. Des grosseHfies multiples. Trait£ de Part deis ar^Kmehcments, 

Paris, 188S, t. i, 543-.TC;!. 
Varsalli. Caeii di gnivid:inxa sewiiiilgtrmellarc. (inxelte niedira Italiano-I^niliardia. 

IB88, Xr. 38, 2ir.. 
Veit. (i. Bcitnige- /iir gebiirlshiilllieheii Statiatik. Monalswiir. f. Gehurtsk., ISSS, \i j> 

120-132. 
ViAHiiBi.. .AiiiiiorkTiiiEen von der wcibliehen Oeburt. Frankfurt, lH7(t. 21, 
WAPPAErrt. AWk- Bi'vulkeninKButjitisfik. Ijeipxif;. ISiifl, 



i 



OBSTETRIC 8UROERT 

CHACTKlt MX 
nrovcTios of abostiox and preuatvre labour— 

ACCOUCHEMENT FORCE 



^pumtiou for Olxletrical Operations. — Owing to llie incronsed ma- 
'I'wUlioD williin Hits }p>DiTalivc tirn-l inridcnl In an otiKlvtrini) <i|ii*nilinn, 

Ji' Uck (if dfoiilinn* i^ntaiU even m«rp ri*k than in the case of normal 
rj"*'. Afwmlinglv. \hf niHiiit'-rmnif of a rigjil iiM-plic ttx.-lini(|i]e i* alxwi- 
^^ imperatire. 
•«■ hondit of IIh' operator and his ow^i^itimtM cIhuiIiI be tltomu^ity 
^■f^d hj- pmlonj^^d wrubbing witli a nail-broHh, plenty of liot water 




S72 



OBSTETRKS 



a* (iMi^ribn] wlicn <<nmKlerinj; fh^ onniluct of a nonnal liilxmr. If tin 
hnii'U )iuvv ro(«iitlv come in conturt with »eptic matEriHl. '>r if the [Mlieii 
lie infni'tprf, rtr prf.-.«ni nvphililic iwions hImhiI IIh- vuIvh, Ihi- lis*- ot Itiii 
rultlKT glove* if alii^nliildy nwi-ssary. ulthnti^h | beheve that tlteir rout^ 
emptoyment i^ advisable in nil rusfa. 

A »ut1irivnt ijtiaiitity nf drc^xfin^. tou-pl;:, ^nze, absorbent cotton, 
ligatures, careriilly Blnriliwi) (wfcui-liiiml, shrtul'l lu> in reniiim^s**. All in 
KlniinvntH slmiilil lie mmltTiil wt^-rik- by boiliit]; immediately hofnre fl 




fm. aao.- SitowiNU P*ri> 



Ol-RRATinK. 



IIIJWISIJH CKEI-AllATUKt "til 



4 



opomtidii. A" an emollient, riweliiie, which ha« Iwen eterilizetl by 
in niiinll jan-, will servo t-vi'ry piirfMisc, 

The I'xU'rnui gcnitAlia are thoroujjhly cleansed with vtreen soap an 
hoi water, rinsed oil with sterile water, frt-ely irrigstH witli n l-tn-i!,0() 
bichloridi; wttition, amt finnlly roTered with a towel soaked in the mni 
wliii'Ii tthnuld remain in pla«' until the opcmlinH i* Ih^uu. If the puli. 
huirii are long and ahiimlanl (liev s^hoiilil be eut short witii Hcieeouj 
reinovnd cnliielv with a ranor. 



IKDUCnuN OF AiU>KTI(>N 



373 




'/ lite woman is uniitrct-tcd. it \n Dot i!(H«*«an !•> alti'inpt I" tlixinfect 

CX" >*ginn liy mcaiL-i of HiittM^plic irrifci'tioiv or otbiT manifiulutioiiH. But 

tf tbt tempera lure is elt-valfd. or the patient lias i»i>eji subjwu'J In re- 

WsIhI eudtinal ioDH or nlt^niptit at detivt-rv, a vaginal tlguch« ol a i-to- 

,(M> biuhJorido mlutioo may be giTen. | 

(i|>«t«irical ojieratioiiti, witi) X\w oXM-ptioii of Os^arcon section und nym- 

Itrawtomy, are usually underlaken with the |>iUi«nt in I!k- lithotomy 

«_ A* iiu- onitnary low Ix-de now in use are rery iiiconTenient for 

"fmnnsoee uf an operation, it U adviMiblo, an a rule, even in private 

tie«», to plaix tliu pativiit u[k>ii a narrow table: one that will anAVor 

^p" ^ •(uite fiatisfailorily is uMiinlly to U- fouitil in en-ry lEitclien. 

*" - imiispiiiuilile for all but llie f^implcst operative procedures, 

asda* w*i9xi UA die {Nilient in fully nnilor it* iDHuener her hiittoek^ xhoiild 

1« I'ffniijlit (o the wlgt- of the table and her legs hold in pla*-e by a leg- 

If a latile ia not available, tlie patient iihould )h- {iliK^ti eru»Nwi»c 

■•ilJi Imt bultwk* prntrudinj; over its edge. The nightRonn should 

I up above the hiprt to avoid soilin;;, and a.-> ndod hk Itw external 

^lAiuliaft havi* Ux-n pn-pan-d. Ilie pfllieDt*s tegs should be eiiraiwd in sterile 

B«liia^> made t<speeia)ly for this ptirgiosi*, and her alHkmien and buttocks 

«illi ctcrilfr towcl« in sneh a manner a» to leave only tlie genitalia 

iil<Md_ To avoHl ibe |>owibilily of enntaniinnlion fmm llu- n-<tu»i, it i» 

] hKmIjIc. |„ (i[>| t-niply tlw lower Iwwel by means of an enema, and then 

twwt tl>r anus with a folded Bteriiixeil lowel, which can Ih- held in placi" 

li -trip of iidlKwive plotter passed over the biittoeks, after which a 

prRpartwl ptertl« «hwt vltould eover «veryUiing except Uie iinrae- ' 

11'" ' 'M fif operatinn. 

MnttittB flf AboTlion.— By this term is undi-nttood the artilieial tor- 
""•'>''> of pK^aney Iteforw ihe fieius has attained viability — nam«ly, 
**" '" the twenty-eighth week. TIh' operation dates from ttie most nv 
Hijuity, and more or I«« awurate dirwtions for its )>erformanco 
Tid in the earliest writinp- upon nHtlicine. Tl was eo extcn- 
'■"I in Itonie tJiHi we find it re|)eatodly referred to by Plantus, 
■nd other seeular writcrB as a matter of ev«ry-day occurroncfl, 
spread of ITiristianily. howi-vcr, it oanie to lie i-onsidered a.* 
acppt when undertaken as a last n-sort in onler to save the 
(her; and we n<'W ilrnw a r'hurp di-->ltnetion lielwe<-n t-riminal 
abortion. For full historical details the reader is referred 
tn Ihr wnrks of Tji^in ond Rrenninji, Brouarrle) and Klein w2el)l«r. 

/WinriuHRii. — Thn^ ;^ou|if of eas(« may olTer an indiration for the 

frnfutn Tlitiii we umy think it our duty to indiH-e an aliorlion: (1) A" 

itit-nnft of »avin|; the life of the mother: (8) to do away with a 

jj which may thn^ilen her life if (ttntation eojitinuw; and (3) to 

>kl (wnain ilontfera which may supervene if prej^naocy is allowed to 

lo frill Irmi. 

: no ein-uniHtanees should the operation be undertaken anieae a 
tan-tai and Ihnniugh exnuiinatioii Iuih demouKlratnt thai l)>e patient in 
- - m^Ht •prions i-ondilMiii. Hit statemeuts are uititled lo but lillle 
t, sod the decision lo inlerrere sliould If lut»^ enlin^ly upon ob- 



— ^^ 



UB&TETHICS 

jectivf cymjitoiii? and cnndilions. Moreovpr, the alteration should never 
lie undertaken uilhout n eontiuitatioii with a rt-eoiid |ihyi<ii'iiiR. who assumes 
liis (^hiiiv ijf the ri'^poiij^ibililv. Thiu prwauiioD. iH'KJdee securing for tHc 
patient iKlililLoiuil Hilvt<r, will |iroi<s'1 the jihyHieinn from » poAtiible black- 
mailing on IliB part of unscrupulous |K'rM>nii. 

In the first ;;rou{i, llie iK^I-n^^iiifniMxl indication for ihc. operation u 
present when the vomiting of prrgnaiiei/ is uncontrollsble. In most cases 
this oi>n<lilion in ni-unilic in origin ami i-an \m eureii h_v niipn>pnat»r 
measures, particularly hy a modified retit eure and sugj^tion, thoui;b oeea- 
^ionally dietetic Ircjirmenl nnd rwtal fwiling may be luxemtry. More 
rarely, however, the vomiting ia a manifestation of a profound toxstnls, 
wliich upparnitly nhifVif no u-mh-noy towardn Kponlann>us care. In such 
cases if the urine presents the alterations which will be described in the 
ohapt^T r>n llic t()xa'inini> of pregnancy, tii» prompt induclioii of abortton 
is urpeotly clemaiided. 

Prior tn llu- rwntriMtion of ihv vnrving naturu of thi* condition, there 
was a natural hesitancy on the part of the pimician to interfcn? owinjt 
to llic fnct that in nm''t Hi*c* the vomitiup <r)L»rri spontan^-itUKly. or was 
relieved liy treatment. Kor this reason the operation uas frequently [losi- 
poncd until the condition of the patiinit had bticoine ho Krioui* that death 
was the inev^itable eonse(|Uciiee whether abortion was induced or not. So 
that we diistiiiptiish iRtwecn toxa-mic. nenroiic. and rctlc\ varictiei^ of 
vcuiiitin)!, such delay is not jiistifJable. For as noon as the ttymplom 
boeonie at all seriouti it is the duty of the physician to have the uri 
projwrly analyxed, and to induce abortion promptly if the toxemic variety- 
be ilrapiosticutei!, wherea" only *uggt»tivc and medicinal tn^tmoDt 
lie lui'diil in the iiciiroiii- or ri-fti-x varietie*. 

The induction of abortion i^ likewise urgently indicated irlt^i t:- — ^ f^ 
uterine eontentx have lK'w>me infect<Kl, a mndilinn which fr'>|uently f~~^^>/. 
lows attempts at rrimitiol abortion. Under such circuinstancc*!, if fl^K:})|t 
fields ha» not already '•iiceumlH^il it will alnioul certainly die. and the gr^— aa |. 
est ehanee of saving the woman's life lies in promptly emptying the ute -mr-xit 
and cleansing its cavity. 

Foniierly it was believed that abortion shouht l»e induced for inc^^'- 
ccration of the retroffcxi'd prnjii'iiit ulvnia. a» well a* in tlw rare case^c a/ 
hernia of that orpin, inaHniueh as death is the nsna! result if the pati*5nl 
b"' left to tier-clf. At prcent, however, bt^lter result* an- obtained in thr 
former condition by performing laparotwnr, freeing the uterus from «"■ 
hesions and replndnj; it in a normal position, after which pregnaJ"-'-* 
freipiently pursues an uninterrupted course. 

In the second group, marked renal insufficirnra or acute nephritis n*^^ 
neees-iilatc the operation. Bui inasmuch as such conditions usually m**" 
their appearance only when pregnane}' is well advanced, they will be co*^' 
»idcred when we take up the induction of preuiature laWur. 

iJiseafen of the orurn. K«ch as hydalidiforui mote and hydraroiiioA 
iKTHKioiiidly alTord an indication for the opernlJon. Whenever tlie fonnff 
condition is diagnosticated the uterus should )h- emptied at once, no mattf 
what be the period of jiregnancy. «it under such circumslanees the fcrtMg 







INUUCTlO.N OF ABORTION 



375 




Kthcr ilcotl ur vrry iiii|Kr{«(;tlir dm-elopcil, ami if Die di9(>a»t>() (.-honon be 
blow(n) to rcmuii iu the uterus, a i-horio-epilhvlioiiia inny develop. 
■ UtrriM kirm'/rrhinjf tii tiK' ear\y monthii of prcigtUiniTy ix ^eR(>rftlly a 
Bgn uf be^iDuiD^' ^{H>[]tuM.><lU> nbortioD, )iut if ihv l<K<e of blood raiitinui?* 
B[>r #otue tinii- and in no( followed by expulsion of Uie ovum, the uterus 
Buotilil be cmpliMJ lit o)i«?rHtiv<' mmiUk. l^ilvr in pn'^nsucy the most 
■-t»|actit cause of luemorrhage ie a faulty iRipiautation of the plHcentn, 
■Krtieularly plai-i-ntii junwia. ami uiidvr j-ufh circnnii'tanct* delirwy shouJd 
^e KffertiM as w»n hk possible, 'i'he rare cases of nii*.ifil ahorlion, in vhich 
lh« ovum in rt-1«itu!() fur irtfkn or mimth* after the dcnlli of the umbryo, 
■nd that Uh? Dterue should be ciiiptied an itoon tw seriouH ^ymptoiua 
"pear. 

The iiMJioatioDs ia the third (iroup an- afforded by markeiily rontrncted 

riv^it tir tumour furnial n>ii.v, and pulmouiiry tulK'rculoi<^if. Fnnuerly, the 

in>)iu?tmn of aljortion at an early period was eonsidertni justifiahln when 

t^* pdriK WUK no ootitraetni u« to preHtnt an abmlutv indicnlion for 

*-**«rean Nu-iion; hut at present, in vievr of the exrelh-nt resulU which 

*ltuDil Ihr latter openilion. this view hum been moditied. The same applies 

^'hen pregnancy is cmiipiicateil by Ihe piiwnw of utrrim- m^omata or 

I •"■.run cyHts. In tlw former class of eases, if llw symptoms arc urgent. 

I hvKu.,(ptamy lihouhl !«■ prnniptly perfoniiHl withoot regard to the exist- 

I ^ttoer>f pr^iTTianey: hut if the tumour pr^miises to aet merely as a mechan- 

I ■^l*b«taplc to IntHiur. prcjjnamy sh'iuld Iw allowed to go on to tt^rm, and 

I * '^^mo section tlten i>erforined. follonwl by removal of the uterus. 

I Oianan tumoun complicating pregnancy ithould be rcniovnl by Up«* 

ll^tcniT as soon a« the dia}n>osi<i ia mafle. In many such eases this can 

, ^ deatt without euu!>in): intrrniplion of the pre^'nani^y, and !>|H>ntan«ou« 

fc^tjtay will occur at term. 

p TV indnctinu of abortinii i? not indicated in maligHiMt jrou'ffc*, 
■"JwhiT thpy affnel the utcnia or adjacrat or);aas. In carcinoma of the 
''^Tiii the tr ; ■:: to Im- ptirsuiil dilTem aceonling to circumi'tarK«!i. If 
'*»eaui»- U- . immi>diali' byHterettomy it' indicated williout regard to 

'«*? pnr*ncc oi proonanoy : btit if IIk' di«yi»e hac prngiift«<ed loo far to offer 
, * pmi]a-cf nf pernmncnt cure after operation, ttestation should be allowed 
I Uh ofintisuc in the inter»ls of tin- child, which nhoiild bo delirered at 
I ***Tn by the procedure most appropriate to the particular ca«!. 
I <*»in(r to iho well-tnnuii fuct that pulmonary tiifKri'uloeii.-. usually pro- 

I ?»V*>M. (niich nwin- rapidly after child-Warin;;. it is advi«able that Inlxtr- 
I <^liiii* womm take eTer>- precaution lo avoid ihc (totwibility of conception. 
I 1' th» iwiTura. hoai'ver, it in the duty of the physician lo explain (o the 
■f)!' liable dcleterionn cffnl of the prejtnaney upon the course 

^Bl :. and lo Iw- prepared to induce abortion if desired. By 

^V 'bmi!, and placing the patient in projK'r surround ingii afterward, it 
^■k'"— •!■ happi-Di' that the diM«sc may Ix- arrested, wliereas olheru'iMi 
^W • hfvomea very gloomy. Ai Uie same tinte I do not feel that 

^B|^MraIion rbnuld i-' urt^i) upon the |uilien1. who «hould lie left fn-c 
P^^^Bv her own in>lincl« after lite situation has been clearly explained 
I (ober. 



376 



OBKTETKIOS 




MntkoiU of iHtiiicing Abfriiort. — (ivoorally ti(ieakin^, ftiR methods 
ducing abortion van- according lo the dnnitiuii nf prcj^naiH^. In tlie 
fiiiir niiiuth:f the oiieration van usually be completed at a single sit 
when necessary, whcruii» iK'twitii lhi« peniHl and tliu »ctviitIi »i»nlli | 
m«tliod# iin])li>ycd for the induction of premature labour are uiore apfl 

prialc In the Qnt pvriml, 
eerrix should be dilated i 
eicntJy to admit at least j 
finger. For thiif puqww G< 
ell's or Hegar's dihitom ' 

Kio. 337. -«<K.o«ij.*. IhLAtoB. be '"""tl vi-ry coDveniont. ' 

entire hand, anniutucl u-lth i 
ile vn*fline, 'i» then introdurcii Into the VH^ina and the index finfter i-ar 
up JDlo the ulerinc cavity ; while the other hand, placi^i ujnm ihi- aUtoa 
fornes the uU-ni^ downuard. With the lingor within the utent.i the | 
ecnla is eeparati-d from its attadinieut-s after whieh, aenmllng to I 
duration of jircgimney, tlie product of conception is rmnored entire ai 
brnkoD up into i^mnll pieces, which can be removed by meanif of an al 
lion or nviirii fortvps. 

To aiteiiipt to empty tile uterus hlindly by mcani; of a curette 
nvum forci'p* }» an iinwii4> procodurr. inasmuch an many cusoi are 
ported in which such operations have cauMwl perforation. Still a 
frcijiicntly larger iir »Tiinttcr por- ^,,^ 
lions of tlie placcola are left be- ^y^ 
hind in the uterus, giving rise by ^? 
Iht'ir pnwencf to si-riiius hieiiior- 
rliage and nccawionally to infec- 
lirni. Accordingly, one van never fee! sure Ihal the ojieralion i» cnin|i 
unlens one or more fingers have been introduced into the utcrua 
enrcfidlr palpated itn inUTiar. 

Occasionally, and particularly in vomen pregnant for the first 
the cervix may be ko R'^itiant as lo rencler i'api<l dilatation >iii 
I'ndor such circumstances, if haste is not imperative, a strip of sterile 
should be tightly packed into i\w een,-ieal canal aiiil the vagina tirnilj 
poneil Willi the .-■anie material. When the pack is removed at the 
twenty-four hours the entire ovnm will fnipiently follow it ; while in nl 
(Tis(» the WTvix will Im- sufrieicntly nofli-mtl to permit the inlnKliictioaj 
the finger, or at least of ito dilatation with a Huitaiile instrument. TW 
pi'iymrnt of a lauiinarla tent has been reeouimeiuUxl by irisny autltoH 
in place of the pack, but in my opinion JU ti*e ad<l>i mmewhat to the 
of infection. 

On till! othiT hand, when rapid dilatation is out of the question, 
it U de-tired to coniidt-te the prfK-eiw nt one Kitting, the utenix way 
readily and rapidly emptied after vaginal livsterotomy. In this op 
tion. the iiliidder i:< H'piiivtIiHl fnini llic inileriiit' nail nf lh<- ciTvix. and 
liilti-f ineiMil with s^'issnr* ii|i bi'vi)nd ibe inlenial os. The finger 
llu-ii lit- iiitniiliKt-il tiiti) ilie ulei'itic ctiviiv aiid [xvl oil aixl reinavv 
ovum. «f(er whieb the uterine and vaginal wounds are united liy tMl 




Flo. 338.— Ovum Fokcxts. 



IXDICTIOX OF PRI-:MATrRE LABOVR 



37; 



The iltiiiiU or llij- i>(H<i-Hliiin, whU-li I luiv<r viiifilitytti wilh k"«' ^itiffsi:- 
tiiin iipiHi stveral •ii-A'-ioiis. will W round uihIit tin- lit'^ulm;- nf vugiiml 

.\txirUun in muiL-tiuwM iiMltHn.1l liv pcrfo ruling tlic iiicriibmncii^ with a 
[»*«Jile Mtuuil wmI allowing tl»c liijuor anmii to drain oil. The desir«id rflsult, 
hiiwi-ver, dots inn alMavt^ follow ihv» msiiii-uvrc. ami it freqUL-iidy becomes 
'»w»oarr to supiilenicnt it by one of ilie proieilurvs jiLit di-*i-rilHi!. 

t'lytgniitiii. — 'I'lit pnt^gKin vuriw ara^onlinff to Ui« iiulioation for which 
.tin' (iprnitioa ih uinlertakGO, but with the pnlient in fairlv gtwd condiciitii 
|»*tidfB«-l»ry n.i>ulu< hIioiiM ttlwayw follow, pmvidiiJ a rigid u^-ptic ttvlinitjuv 
|i» )iti.^>n.<.l. 

I Indaotion of Premature Labonr. — Bj thix tcmi in- dceigriuto tlH> arii- 
ri(_>ia| tETiuination of pr^oancy after ih* diiid ha* reacheil ihtr [wriod of 
hiatiiliiy — that id. afUT Umj Iwcnty-ciglith wwk. The operation was per- 
P>riM«^^ tiv Uuillemeau, Maunn«u. Jii^tin^i Si«geinundin, and olhent in 
■■Mtcd ciWit for lia-tnnrrli«gi\ Imt. atnirding to Denman. it wai^ nol.gen- 
^^Bty advo(:aled uolil KAli, whtn a i-onft'rencv of pliy»i('i»n.-< was held in 
[^*»xl»in III <li'vi*e nicaiiK for doing away with the frightful mortality fnl- 
P'*''iip f'a^arean swtion for coniracK-d pelre*. 

I ' fndityifion.'. — 'Hh- indit-Klioii)^ for titc operation ari> twofold: to obriate 
f**^ ilangt-ni altondint; delivery at term ihn:)iij|;h n ittiilniolt-il pclvU, and 
P •«Te this tiff of the niollHT wlK-n wriou^ly thrt-ateiK-d by M»ntc difiesae 
F^'eti irhich »be may be AufTerin^, or on account of same palholo^ica) con< 
i*'**io exii^ting in tlic ovum. 

I In ronirnrtni prlrff prpiniiturv labour i* iiKlucvd with (1m> Wca that 
r^ tm[*rftvily devtloiwd child will be born more reailily than at term. 
p i*is vKiw if nndouljtt-dly oorrwl, aJid if tint welfare of llie inulhcr alone 
^V'K Goncemed the operation should be undertaken in all caaoa. On the 
I^^T hanil. iW intiTi^U of the rhdd atv enlitlol lo «nin- conxideratioQ, 
l'*'^ know that laliour will be easier the earlier the operation is |ierformed, 
I *** it mwt tw n-fiiemljcrt'd that Ihc HiiUl will be lejw VuMrt to survive it, 
I 'wH n^ if i^n, rtlive its chances of suecurabinp to complications after 
I "* larth will be proportionately greater. Inanmnch. then. a» t)w later tito 
I •l**nti>iti tlw* lifth-r llie outlook <n far a* the child \* mnri^rncl, the induc- 
I W'm iif prenialurt^ lalmur xhould not be attempted l)efore the thirly-fourlh, 
I **•! imfrrahly not before the thirty-si xtli, wwk of pregnancy, 
f ^•■- qiiwtton 1L1 U) the pmpriely of the operation has given rise to an 
p literature. At the Inlernnlinnal Medical rongn-** of IHIH), held 
I "' tltiilin. it was one of the chief siilijccti^ iindir discussion, tta that 
I '*'«a^iioB Pirvin, Macan. Culderini. Tlobrn. TjfojHild, Uihiein. and olhcm 
•Poke iipnn the nobject, and in the end it waa agreed. Sanger only dii«tent- 
■'"U the oprmtion wa* indintod in generally poulractwl pelres with a 
:.i!a vera rariing from 7.S to fl centimetre*, and in flat pf-irw wirh 
["Wjupita vrni of T centimetre* or more, and nhould be performed ao 
*• Ib pregnancy at* po«rible, preferably about the thirty-eixth wei-Jt. 

Tin- principal difficulty connorttd with the operation ix to chooite the 
|WnW time for its perform a oc*-. since ue are unahle to determiiw' nccii- 
Itlv th<- 'ixc of iW child'" hniil, Tlu' mulluxiii of Miiller, .^hlfeld. and 



'ri:. 



378 



OBSTKTHICS 



atlMj 



' 



ottiiT^. to »')iif-)i ri'ftTt'iioo will lie made Ju the chapter upon the treatme 
of comraelwl jielvefi, do tiol lead to very awiiratf rcsnld'. s« th«l nwiiig 
to the d>**in' of iici.-«l]ii)iijiiji llii' o[H'ralKiii until die laie-l jwwHiliif iiioitient, 
it is fri'i|ii<.>nt1,T iii>t undcrluki-u until thi- cIiIM'k hi-ad Itn;^ nttiiiiiol mu.'Ii 
proporlioii.s us to rtMidtr iU piuflap.' tlirou^h the pelvis difficult oi 
iiripOMiilile. 

'I'Ik' n-Ktiltx t>bttiin«l iiri' <-xtroin(0)* MitiAfiu^iy an far a» the raolli4*r it 
coDW-riiiil, iiii> iiiatt-rnal nu-nnlily lii'ing otdy 1.0:( per ci-iit in 'Mil opiTa- 
lioii* [H■rf^^rtlll•d liy Ahlfcld, Bur, U-uj>i>td, and Tinnnl. On iln> ot 
hand, the fa>tal mortality is relatively hi^li, raryinir from 4S to I? 
(«nt. acvii'din^ to the ittntisttc« from variuni lyiuji-in hot^pitaU. Ktc 
wathlt-i-. afler an I'xhaiiiitive study "f tlie finUjwt, oindinies that "S.3 \m 
cent of till- rhildrpn arc Imni alive. Imt tliHt many of them dir soon afti'l 
liirth, and only W.i \n'r ii-iit liiive tlic hoxfiilul in gimd (^>nditioii. A<> 
ourdiug to tlie»o figures, theii, the net mortality vould be 39.6 per centl 
hut w)u-n Mi> i'i»Hidt'r thai most (■aruful niiriiinf; and ti)i|irtipriut<> riH-<lin^ 
are afterward iH'trssary. it i- apvarrnl llint no in^'uncidernldo ]>ortion o! 
ihe i-liiidrt'ii di»itiiN<<r.Tl riniii ilic h'>s|iilal in gnod condition niti>t inc*vtln)ilj 
pcmh within the tiriit yeiir. and it is hanlly an exajtRcration to state thai 
M-areeiy tnio thin] of tlio^ Ixirn >iun-ivo that pt'^riod. It uroidd thvrofoni 
appear that the ultimate results, so far as the ehildreni^iv coDremctl, arc 
Ml piM>r iLi nol to comiiimd iht- upi-rulton t» favoiirahte iiiDKiili-nition. II 
must, however, lie admittwl that all authors do not share this view, 
Xorrin. IIctII. ami olhur^ coiiicnd that ihHr rc^tdtif arc fairly Mitiii^fatin 

In this cnnnoctinn, it ik iiii)>nrlant nol tn hiM! si^ht of the fnft thai 
70 to no ]x'r cent "f all labours ocrurrinj; in cniitrartetl |«etvos cma 
without arlillciiil aid, anil that it i» i-.vt n-nu -I y d>f)i<'idl in t.lu' di'^ret'gi 
contraction under consideration to foretell in a f;iven cdro whether ap 
taneoiiii delivery will oi<'nr or not, Pcrv>iially T have had a gro* Uvi 
iDortalily of only 13 per cent in a Keries of 2T8 oases of contracted pdl 
in which pnnmlurf liili'nir was nut induced, and Ihowt- figitn"*. when lal 
in conncL'tion with tho^i.' of otliers, are certainly not in favour of 
operation. Mon>over, if the rulei laid down in tiw rhaptrr on the 
ment of lal>nnr complicated hy contracted ]>elves Ite follovred. anil Cteeir 
wvtiou or |iiil>i'>lotny [iii'niplly pcrfiirnn'cl whi.>n indieau.>d, the fivlal nv 
talily stunitd la.- practically ni)thin<;. or at least not much «reater than 
nornml jiolvex 

At present I'inard considers the induction of labour no lonf;er jiLsti&il 
and ndvnciili-i allowinfr all ciijiw to ro on In term, wlwn symphyiecoti 
is perfornK'd if necessar>\ Bar. who has had a larpe experienoe with 
induction i>r pri-rnuturo labour, has likewise nhandnncd it. and recommi-J 
the perforniaiuT of Casarean section at lorin if !tpontaniy)uif delivitj' J** 
not occur, while Kronip advocates Cesarean .*ection or puhiotnmy atwjr'' 
ing I" llu- I'xigi'm-iev of the caw. So far as my own exiwriencp g"**^- ' 
nm heartily in accord with this Inst authority, and believe thni lliii< pr**- 
tic* would effect the saving of nearly all the chiidrtn: whereas by t\t 
indnotion of premature lalmnr a much sninller nuinlier will In" hniB 
into the world nlivc. manv of whinn nn- dooniml to certain death nr1 



li 
J 



INDUCTION OF PREMATl KE LABOUR 



370 



tg lilbctionii. In in,v nwn practioo [ have joduood labour for thw 
Itfoa in iidIv dqc lU^taiK-c. 

Um' |in»i-i)l liiiio. Itit-ii. it i^evin* U> inc tlial tin- »n]y riitioiinl iixlion- 
■r the inducUou of pa'Uiuturc lab'tur, co fer as coiiuL-nis t\w ■.■x>»tciit-r 
ptuiwrtiuD betw^Mi tiM> xixe of the bead und tV jielrw, in >ironli>il 
HMMKs in which the pdvin iii normal but the rhitd flliDonnally 
^^^ptfthvr to i-xttvi'iw d(-%'clopni<-iit or In an iiiitha- pn>lungnl imi 
FtwiK^'. If excwuive tltvotopriirni lie detecleil -«mo lime prc*ioii§lj- 
1 the operation ii- olvarlv indii-nttil. niiil tbi.^ «iinH- bnldK );o<k1 in the 
niul oiutft' iif prolonged |ire}^niicy, provided the child appears tn 
y developer). 

s nwwt unual indieatioD for the operation, however, !fl airorded br 
» vhich thrf«tcn the* tifo of ihv m"lh(?r. whiU- ut the kiiiik^ lime 
slatu a probability nf cure after (be tenninatioD of }{estatioii. Thiii 
•cuIhtIj- InH- in Ihowe tai«;« of Innrmia or acuU ni'plirilU coinplicat' 
BinMnry. whith show no teiideney to subside in »pite of appropriate 
iWiL Experirticc teaclHt' tbat nmli-r *uv\i ciniiinsfiinci-K. even if 
aury lie nllnvei] to continue, premniun? bilmur rmjucntty occurs 
liMioiuly, when a Inr^' pni{M>rli(in of llie childnm ait Imrii dead, or. 
*«. wry imperfectly dweloped. Moreover, one flhoiild also take into 
iwation the pow-ibilKy thai the renal <-ha»;:i'« nmy Ut-ome chronic, 
ilift^t. if ihrt-atenin^ i^yiopioins nupeneiie, labour .-honlil lie tnitiioed 
y period of pre^anrv vithout tiw conH>n'atiTe a regard for iho lif^ 

tliiU. 

b paliditA pr»*cnun|E loueinic syroptonis, the total amount of albumin 
^nt cootailH'd in the <wi-ntr-f»ur lioun'' lyine xhoiild Ix* dr-terniimil 

• nul whraiever lliore ia a stca^ly increase *n tlie anionnt of albumin 

• tamqiondtng dccresKO in t)>e amount of urun, in xpite of appro* 
l» tmtnient. labour should Iw induced in the hope of preventinj? the 

M tclampeia. If eclamfwia MipTVt^n«*. pn-^naticy xbutdd !»■ Icr- 
a» (toon ail jioiiiiible by weouehfinrnl foret. if the condition nf 

^1 permits-, but if (Itiit procwlwn- jinHninw to In- wrj' ilillicult deliv- 

Wd Iw effected by tdower and leea riolcnt nteanx. 

*nlue Icatonn otvufinaaUy demand the induction of prenmtnre Inbour, 

^•Wwld lie ri>-orttii to onlv in lase^ of broken compensation whidi 

W Tii'ld to appropriate treatment, 
p'^m the time nf 71'Oiitrepoui (IHSA), it ban been rvcnmniendml that 
VPaitian be undertaken in the intercste of the child in the rare caWi 
f'rrirfojtw in which the condition of the mother in m> iterioi» ait to 
P* it probahlp that sIm> will not lire until ti*rm. 

Ri^IaDsiDB interruption of pregnancy frvtiaentlv occnru during titc 
P* ft the acute infection*^ dii>ea»« — pneuinonia. typhoid ferer, etc. — 
pitKDch ai» rxperienrc ha* olioum that it materially increases Die rtska 
^Hotber. Die induction of pr>-)nalurf laliour is contra-indicated. 
^^Be ini'tance* a f;enera1 peripheral nrurilU inny *n i^anner the 
vffbe inotiter a-< to call for interference. I«pa;;e and Sainton (1901) 
pltd a mff iif alroholic oritHD in which the ioduction of labour was 
PM by mo«t happy result*. 



liSO 



OBSTKTRICS 



'I'lit- milder forniB of rhorfu conipliwiting pivgnanry aic twuollf 
ntnt'iinKk- lo ln.-)ilinviil, but when the tlUeano assiimos ii jirare ty]w 
ottendiHl Willi i^roat daii)^r, the muU-rniil niorlalitv. ucL-onliti}: In Fehlt' 
Iwiiig ^U pir iviit. Tlicn^fiiixr, if tlio {mtk-iii H)>|H.'HrM lo \x! in Mtri«ii!> litMff 
prGiiiaiuie ilelirery should be brought about, as expcrieucv liiu shown tli 
tla> umptjring of the iiteriiis !» usually followed bv iiittrki.il iiupruvtriuiuiL 

In patients sutferio^ frutu diabelet, ^tatioD soinelinies i^xerbi a 
iMclvrioue itiSucncc- upon lhi> courM> of tho disrasi'. Actwrdin;;!)-, i 
pitlittiitK <i>iidiTi<ii) bu-uniL'S niariuiiig, Inboiir kIiouUI bi- iii<lii<vil. In 
majority of caws, liowewr. tlwj so-calltd 'liabetw of prt-;fuan<?y is iim 
K luuliwuriii whidi in not likely to Im utU-iidt-d by mrriou* symptom*, 
patjeolu being apoDtaneously deiivenKi of healthy ehildr«n at term. 

A('it>rding lo Gracfc and other*, thf ocrunxnce of prt-giiaiwy in put 
sulTerin^ from pernicious anttmia or leukaemia add^ markedly to the gri 
of tlic condition, m that in oemstoual csm-n thv induction of prtrnui 
labour may lie indicated. 

In rurc iiiKlutices in patients etifforing from pyelitis, the prvgnant nl 
may m i-ompii-s!! the ureter m lo chuki: a damminji: Wck nf the piinUent 
ctiar^-. and thus pve rise to a pyelo-nrphritig. Under such i'iri'iiui«ta 
tlie induction of pn-malurt? iaUtur in indieatnl. In a nundier of 
under my care, interference was followed liy surprisingly xood rpsnltn, 
[Hilients rii^)Vcriug without rurllier treatment. 

Many authors recommend the induction of premature labour 
pre^aiicy is eonii>li<'iit.e<] by utfrinr or ovarian, tumourx, or by malig 
difieaae of tlie nterus or reetum which would offer an insuperuhle obd 
to the birth of n full-tenn child. At the prcwnt day, liowevcr. th« o 
tion i-an hardly lie considered juatifiable. What ha* already iKwn 
connection with tho inductiou of abortion u&dvr cimilar n»ndittoiLi. 
hnlds gotxl here. 

In ht/dramnios, when the abdomen ia 80 distcndifl «s to serii 
threaten the life of the jiatient. pregnancy i^hould l«? terniinatod wil 
too much regaril for thi- preservation of the child, as in many c*«« 
so |io'irlv (k'veloI)(^d aa lo have but little chance of livinK, ercn if 
at full term. 

In casfw of fit/iliitiitif'irm moh alarminj; symptoiiui n:<ually owe 
iK'forci the fo-tus in viable; but even shoiihl the Iwcnly-fighth wwf 
nafely passed the himiHliate tei'niinatioii of pregnancy it* iinjierali' 
dnnnndcd. 

Whenever placrnta prirria is jKwilively diajrnowd, the tiTiuinatiiM 
pregnancy is urgently indicated, as it is impossiblo to predict al 
morneFit iili-nne i'<intrncliouii may come on and give rise to profi 
even fatal ha>morrhage. 

Jn rare eajit^ of hahittial death of the fattu in the later montli 
pregnancy, when not due to i<yphilia or renal diiwai^, the inductio 
pniinitiin* lahtrur hae been rt^commended at > time slightly anterit 
that at whit'h f<etal death has o(Yurn?d in previous pR>giiancieft. 
hojxt that H living child may he obtuinitl. In such cases the npei 
may be undertakei) if the parents are extremely anxious for a linng 



INDUCTIOS <)F PHEMATL'HE I^BOUR 



381 



dllfangh in an iniUuuv nltDuld » paxitiw astjumncc uf euccoss be hold out 

/■/-rjiifnunji. — A« tar «.* Uw niotlitT U oonceniLiJ, tlio pro;rtioHi8 of tlic 
dacUoa of premature- labour is oxci-llcnl, pruvitM u rigorouK oMptic 
It iiliM-ni-(J ukI her physiival condition U not critical al tht< 
ill!' optTutiui). 
THt pnigii'wiH for llw; tliild 4k-|K-iMk. of cotirw, upon Ihc ilrgrw nf it* 
Ti4o|niuieiit, ax well m u|K>n the {Mllinlogjt'Hl comlitiun for whioh tin* 
■rnktioii ij<^ ni»liTtAkt'n. ticiii-nillv Kpc-ukiiig. in tliv aisc of i-liililmi bom 
n. "■ lliirtj-MHiiml Viwli lilt' (liaiii'i* of Hurviviiij; iin- verj- ^iiiall, 

' . H'hcii ni-plintii^ ur HviiniiinDio)^ atr»rdi> Kiv indii-atjon for iiitur- 

ilKUKiJe of Inducing I'rtmature Labour. — The simplest metlloil — that 
■if Solwrit! — (^)n.ii:>t» iu jntrronitin^ t)i>- iiii'inhraiKM vritb u nWrp iiixtru- 
*et>l ami allowing tlii' umniolic tlui<l to (Iniin off. The ivsulU, however, 
vr ODterUin, mi lh*l lii« pRHxxliin- i» appliciiliU- wily in ii rcry limiliHl 
■■"■nlvr oT ca«M. more specially in hydramnios and occasionally in pla- 
"W* {Kwiu. 

In IL- itielhod most oeually employed — that of Krauze — a boujtic la 

•"iwliiceil In-tHM-n IIm; nifniliniin;» niii] tin; titcriiie wall. In carrying out 

"•i* n'"te<lure tlte patient is placed in the dorsal or Simp's position, and 

wnMnial ^cnilAlin carefully di«inf«vted. The c«rm i» then Uronght 

itif* by meaus of a speculum, and a sterilized boiijeie passed IhrouKh 

lenlly i-arrktl high up inio the uterine cavity, betvrwn the mt-m- 

)ud the iiti-rine wall. In place of ihe Imu^io. I prefer a Ihick-walled, 

ntheter. 8 to 10 millimetres in diameter, which can be readilj 

by tmiling. It iihoiild be introduced by inctins of a copper "tylet, 

I a villidninn after the calhi-ler i* in plaw. 

W iHily iilijirlion In Krause's method is its tineertaintr. In many 

I li»e intnMiiit'tion of a sinjile ratht'lt-r i> followw! by uterine contrat*- 

' villiin u few hours, whidi lea*) to the expuUion of Om' ftetus uft(T 

'■mpT nr iiiwrler period. Not infre<|U(iitly, Itowevor, twentr-fonr hours 

in may elu[iw witltnut the appearance of pains. I'nder bucIi circiim- 

■ M.it>nd ejitlki-lt-r »)i4iulil In- iiilnHliuisl. to iHt fi)llow<il hy a third 

iry. after the lapse of a similar period. In rare inslances even 

Ihr dfsinvl nstill in ni>t oceompliHlied, and it iKViiTna* necessary to 

•""'milr pfi^tiancy in snme other manner. Unt for iIr* general prnctU 

lien luiKto b not e9>M<ntial. lliia in the Mif»i( and be«t metlmd of 



i-frtain and rapid n->:ulbs are obtained by the nrc of the ballonna 

["-tier de Rit)es. TlM«e am conical niliber hags with re-enforeed 

in w1k«u- iimall end extends a thick nibber tube providol with a 

'^(»«tli. TIm'v are made in M^veral sixes, tin* InrKcsl liavin;; a capacity 

I if 40Q to 500 cubic centimetres. The patient having been placed in the 

ImaJ nr Sinw'o punition, IhR «>rvix if l>ron|;rl)t into vi«n-. If its lumeti 

^ t.S ii>ntimetre in diameter the bug can be passed througti it without 

<&£tulli. Iiiit if smaller it should U- dilatdl up to that sib- by means of 

J (laodell or other suitable dilator. The bag, which hiu been »t«xiliztKl 

H 



382 



OBSTETRICS 



by boilinf, is then tiglitlr rolled into a cjlincler, Mutcd w'nh an approp 
utflj JhufRtl (urii'p*, Oiicklv snu-artTl with storilu vaaditic, inlrtHlunnl ii 
llic l«»vr iiU'iiiit' M'yiiaiil, and lln-ii |)uiii|H-d (till ot fWrik- juiK wIvHjj 
Within a few tioura it usually mo irritalca the uIctuh ah | 

to in<lu<f i^utritctionin vrhiclt «<kiii Wd to dilittalioa 
of the (-Ofvix iiml iIk^ <-\pi]|iiiori of the liii^. uftvr 
which the child can be exlratied or lalMur allowed 
Ki t'lid K[i(iniHiuf>u)>J_v. according to Itiw exigcu- ^^^^^^^^^^^^ 
«ies of tho oDsc Whore f^reater hattte in ^^^^^^^^^^^\ 
nwftwarv, till' dilttlutioii may be aL'cuk-r- 




Fia. 33t>. — DnAMnmRR iie Rirfj-'r IUu 

XI. 

atod by attttcliing a wci;^! to the I 
of the tnlii^ and nllavriiig it lu )ii 
over the foot of the lied. This niell 
ipres rery iuitii>fa(-lory rc-^ullit. though it i« cvidt-nl Uuil tlti* iaIrrKluU 
of the large bag into the Iowlt vteriiw segment must displace tln'TJ 
>«nting part, and ixviiKionally };ivc riw to nialpn-Mtnialioni^ 

Tarnier's txdlateur uUrin — a tbin-w»!lcd ruliber bag 3 or 4 centintel 
in diKiiic-lor — and Bariu-s's fjildli-liag!i are liani'il upon the nuntv princi] 
but their itinaller sijie renders them much less efticient irritants. 






Fid. 34(1. — (TiiAUPt-iiMi tiR liiiirji'it I 
uiciM iicAur r»R iNnuuiiTi-Tibii 



In placenta prsevia, more pnrtinilariy wliiii the ciM-fiT is but 
dilatL-d. tlio UKL- of u ^fterilo tuntpou may be attended by mnat ex<«ll« 
Milts. In swell cases, uniler the most rigid n-ic-jitii; procuulioni?. tlte 
u ntcriliwd l-inch roller gniizc Iwiidage is tightly packed into the 
eanal iiv rtitans of a ulerine di-es:*ing forccpn. afli-r which the rngiiM 
firmly and lightly paekcd with the same material. The jwick shonlrf ii 
be allowcil to rHiinin in [ikw for more than twelve hours, and oui 
removal at the expiration of that period the eervix will l»e found suRiciM 
dilatttl lo |MTmit of oiln-r maiiwuvrcs. I 

Numerous other method* for the indudion of prvmature lahonrM 
IxN-H siigg*-sted from time to time, among which may be mcntiotml tint* 
Cohen. Thi« f'onsi^t<'d in the in,icction of 210 to 3(10 cuhi^ ceutiiMtll 
of aquB picis between the nterioe wall and the menihrane.^ Othrr *ri 
hftT« snbKtitiited vArioiiM fluids. Thus, in I8U1, Pt'lxer suggested tlie 



AtX-OL'CHEMK>T FORCfi 

- i" caliK ccDtimvtmM of slvrilv glvcerine, which promptly gives rise tol 

'■-! tk- cotiirai-uoiw. ]t» criiploynti'ni. iKiwcrtr, iit tK>t to l)0 n.\N>itimi*n()cd. 

>■ ii u ■Mi'Sbioniillv follawvtl Ity »eriouii Hvmploin? of inloxicdtioii. iwma- 

^"■''.nuriu, iiibiiniiiiurtu, cU-viilion nf U-ni[K-rutiuc, i-jnitiwi*. and cxvasion- 

™/ tiy ilfalli. PfHoiH'Qxtiel was tli« fi»L t(> call altention to tbeae dangers, 

"x' his wkmini; liax bti-ii tv-voforvwl by similar i-xporinnces in ihr praiHicv 




Kid. MI.— Vaowai. AMD CCnvtcAi. Pack in PoairttMf. 

**t otbpT trriten*. Full <k>tnilR respocting the various inUcr metlHilH (tug* 
X^*ln] for thi' ii)i1iii'lioti lit prt-iiiatiirt' IiiImiiit w'II \k' foum) in the mono- 
'^^{ihi nf Kli'nnt'iti'htc^r. Kinix, atiil Williamson. 

AccoDchement Forci. — By tliix tvnn it nnik-ndontl tlii! forciblv dilaU- 
'"u iif tilt iQUct ur partially dilated cervix, follnved liy Tcrwion u>d 
'Abaction of the child. In p^l^-urttlM'ptic timcre the operation vss so 
■tiwnMJIy frtllrtin-'l liy infrftittn that it fell into th^nerveii disrepute; hut 
*1 the jirefwnt day it lias tieen rehabilitated, and when properly performed 
"Odrr mitahle ronditionfi h» hccn I)h> meaiiK nf nving ninny lireH. An 
'"wiWiI riimmr of ilw higtory of the operation will be found in the 
t«Ttation of Itiihi-mann. 

fliwratly «(ieakinji:. if the eervix he Rnn and hard and the canal not 
"lUtvtmled. acevuehrmfni forcr is apt to be rery dillicull and allcndfld 
"A coiuideratrlr ritlt \o the motlier, while occasionally it can be effeeted 



384 



OBfifTETRlCS 



only iiv II i-iuliiig opCTalion. On Ui« oilier baud, when the cervix U SDJ 
Hod the inti'mal os partially dilattxl, tlitf n))t!nilion !» midil)' p«rfonn| 
and it Mlnwd l>y iuihI Kuti^fuctory roiilU. As a geaaml rnlc, it i» loH 
dilTmilt in [iriiiii]]ar(>uri Uian in iitiilli{mr>iiis woiiivn. 

Indication*. — In this couiitry the nio-it usual indicalitni for ncmtidki 
ment forci is thr<;u(ciii.-(l or actual 4^']tiin])«iji. OccasioiuU}' it becomi 
iiocm.'iary in ennocali^d or accidental littmorrhage, or in otiinr oooditiw 
vliich tlircnt'.-n IIr' lift- of the mother or child, and alrio in the raiv> caa 
of acute ii'di-iiia of ilic liing!>, or hi'iikeu canliae cotii{)('ii.'>iitu>ii foiiifilieatil 
pregnancy, as well as in certain eawen of placenta pnpvi«. J 

Atimmil IHIaliili'/n. — If labour liu* ulrwuly Wgiin and the upper porm 
of thw cenieal eonul i« ohiiterateil, most excellent resulta are ohtaineil I 




Fto. 342. — PiAanAM<t irxvanuriHa 3Ijihl-4i. Dii^atavkim or CitnviK (Hanw),] 



the method of manual ditntation xug^vtrd hy P)iiland«r A. llnrris. 
if hilioiir hiL* not set in. and the cerns is hard and rigid, the nf 
may bo extremely dillienlt; and if the »lt<.rnipt at dilutalivn he (nt 
pereii^tfd in. it fi-e<}uently givea rise to deep tears thronjjh the cerrix.l 
ocoBAionaUy Ihroiiph the lower iiti-riTit- R'gmciit. wliivh may U-ad UlJ 
dvath of the palieni from hivniorrhajre or infivtion. 

Qeuerally speaking, if the index finger can (jo carriefl through thf] 
tcmfti OS diltitntion can Iw readily aw-omplistu'd hr fhi.< mcthoii. If^ 
over, if the cervical canal ia soft and yielding, ailhough too 
sdmit the finger, the first stage of dilatation may lie ofTwted l>y md 
of a uteol dilator and emnplcled by ITnrri*'* methorl. On the otiierl 
if the cervix be nndilnted and rigid, manuf^ dilatatloD itbould stC 
attempted, and a ending operalion "lioiild In* employed in its Hiead. 

At the time of operation, the patient should be profoundly ana 
and Iho aseptic technique miv-i ricorous. The danser of contatnin 
from the faveK can he mininiiwd hv iiiovine the howria freely h\ 
of a rectal enema, and then applying over Iho anas a sterile tovel, •tpi 



ATOUITHEJIENT FORC^ 



385 



» h^i) JD jilatv I'V iilriiw of iidhwin- ))1di>U'r until tin- comjilrtion of the 

Tarioiu nianipulalioDri. One hand, thoroii){hly anomlM with sterile vaae- 

/ini>, if ih^'H intnxliici^l iitio (Ih- raj^nu, and t)u> index lingirr carried up 

tbi; txTvivtl c-aual aiul niowtv fori'i-d Ihroii^^h tho iiiK-niul o*. aftvr which Ul<^ 

tip* of the index and «<wnd fingers are pa»ed inin thi> cervii-jj canal, 

Fnadtinllr dilating it ar wHI a* llie intrmal o». When t\w hue been ac- 

•xtinplithMl, (-omiiletion of ihe diliiiiiiion i* ii»ualU <'iim|>iiraiiv«lv edgy. 

TTie tfauoib i» pn«hi<d past the index gnper with much the same motion 

■* i» CTnpl")til in Koapping one'it fin^er>: Ui*ui, as dilAtaiion progrwuM*, 

pai«t twn, tlin-e, and finallT all four finpers, Thcec manwuvrea are clearly 

**»owTi in Fig. 34a. 

When the internal oh is otililerated, complete dilatation of the eervtx 
^n be cffvrtixl vrry rupidlr hv Harric'it mellKHl, and in appropriate caitca 
•ticm the Internal o.^ will admit only the tip of the index finjcer, satnfac- 
tr»«>' n-^iiilifi can nfually be obluinitl within half an hour. I employed thi* 
•»■ S3 timi'-. in tlie first j.O'tO ca.*fls delivered in the Johns Hopkins 

*» i--il, and found it verj- ellectivp. and am able to confirm all that 
■^Vfria hnn claiinei] fnr il. It Mhntit^l, however, bit rcmcmliered that it ia 
***>t diToid nf danj^-r. and evon in siiilaMe caHC« may lead to di'ep cervical 
**»r*. From wiv uwn i-xiM-ricnw. iU U)« i* conlra-indtiatiil in pliuH-nta 
P'"»'«Ta on atvount of tho increased liability to deep cervical tears, and 
*^«su lo rupturr of tlie uienw. 

WhenevpT Harris's method is employed, the operator should hear in 

'^^'iid ihnt llii- lirtbililr to ivniral imni i» giwatcr the mon? rapidly dila- 

^»ti.,n it I'iTvitiii, and lit- chmild ilierefnre be careful to avoiii undue hamt'. 

'"- caution is the more nwe>*ary. as there secins to be an irrwiMiblo 

^""ilt-Di-y in (mTC»lJiiiaie the time consumed in the procGuti, and from my 

7*^ Ft|ieni!iiii> I know that wluit may swm to Iw a long lime to the operator 

'•" 'ifb-n in r<-alilT onlv 11 f"*w minut(-«. For lIiU rea^iu it in always well to 

"■"'^a clock plaiw! l>efore tiw ojn-rator in order to check I'lich a tcndciK-y. ai^ 

hIhiuM Ju'I)[<; of |]h> exf(4l<i)iH- n( an olMti<lri<?i»n iindtT *wh otrcum- 

nt-vf^ tir the deliberation, ralher than the rapidity, with which he operates. 

Itvlfmr and Bonnair« hare de->4-nlH-d bimanual nielhnd* nf dilatation. 
*^'i'h they claim kivo most satisfactory re-nlts. I have not employed 
"**>». aitd tht-n-fort- cannot expnss a pn-rsoual opinion ax to their meritji. 
^ KHMval prinei[Jea it may lie assumwl that tliey afford tuimewhat greater 
^T*or1anitr for infit-tion from ihc riTtal c<>nti;nti^, hiikv the hands muct 
•*»»•.• mto more intimate contact with the anal region tlmn in Harris's 
tHialatitm ^y Vf*n* of Chtm/irlifr lin Hihfi^* Ballium. — WlK'never 
^*<« il not a fH'eal conHideration tliis is th« ideal method of acfOHclia- 
*^^i fitri-f. nn\ nhnulil lie employ"} wheni»ver pnfclibl^ Il in particularly 
""•'oited in rft-<- of plai^enla pra-via, and will be referred to morB fully 
""^t^ that bi-ad. The entire literatur* npon tho subject was well reviewed 
*^ hariBT in I!H»r.. 

tmtlrviumlal DiMalion. — Various iib't rumen In bare lM<en ilevtwd to 
^'- ' ' ' tind iviinpleti- dihitation of the cervical canal, but to my 

" i'<'m at\' as salisfa«torv as uianiial dilatation. 



386 



OBSTETRICS 



Lfnpold, iit l'M2, inlroiluced into Uernmn^v the uoc of Boiisi's powpr 
dilator, wliicli was fin^t i-mployod by it* inventor in 1889. This ii 
gibit^ of four heavy bladai, aiTiin^ed a^ coi:i;>oun<l levers atid opvnitvd.. 
a screw handle. Leopold was uioi^t puthiu-ia^ftic coneeraing it, and j 
yean Uter }m aM>i»tunt, Blirlich, reported 47 caew in which it had tf 
used in hiii clinic. Thi^ hearty endoraeniait led to iLt trial, in XHtH 
modilit-ation)^, in nil parts of the world; btit th« verdict conccmint; it 
not unanimous, as Bardele^ien, ZanjiiemoUtcr, Ix-win, and tnany others 
Uidt it is a most dangerous iaslnimeDt, and readily leads to deep 
cal learB. 

I have liad no experience with its uae; for, while there can 
doubt a^ to itH dilating {toniT, it Mixn* tn in4> ihni ilit sphere of us« 
Doss is very limited. If the oer*-ix in imdilated and rigid, its employn 
iiiunt In- dait^iTOUN : while, (in the other hand, when the nviHt«»rr of 
inttfnial os has already Ijecn overcome, equally satisfactory reculta i 
ho obliiiniil tiy other itu-lhodi'. Mori-over, if eervimi It-ars cnnnnt be 
tirely avoided in nitmual dihitiiiion. when the retiistamo* of the cervix 
be aii'tiraii'ly giuig<^l by tho operntiii^ liund. it niti.->t \n- apparent 
tJiey will occur far more frequently nlicn the dilating force is ap| 
by n)eani> of « powerful ^ilcel eonipound lever. 

It is iiittiresliii;; fo note that a similar iiij^lnimetit was devised in 
by Dr. H. S. Ijott. of Suleni. X. C, almo't simiillam-ously with, aud 
independently of BoHsi'a invention. 

Deep Cervical InrimoTis. — When rapid delivery is ui^itlr indicati 
caseR in which the rRrvii-nl eannl is obliterated but the external o« 
dilated. Uiihrssen recommended, in I8!I0. that multiple ineistons be 
through ihc viipniil ;iorlion of \\k eer^'ix, which lire united hy snt 
after the (roiii]>lction of labour. The technique of the operation is I 
parnlivi'ly .■'iiiipte, as the incisions «rv rciultty iiiade by means nf •n-i*^ 
but it has not lieen Renerally adopted, as there is no meaas of prevea 
the incisions leavinp «» the child is exinitleil, w that d«!p ccnica! t 
frequently n--sidt. which may give rise to pn>fu8G hieinorrbage ami pq 
most diHicult to repair. 

Vaginal (■a-sarean Seclian. — Thin operation, which is belttn- dMijcni 
as vaginal hysterotomy, was first descriU-d by Drihrssen in ISltG, bul i 
not oome into geniiral use for jioriic years later on account of the \tolkm 
nuuiner in which its inventor urged its claims. 

In niy opinion it affords the ideal method for rapidly leroiimi 
pregnancy in all cases in which the cervix is undilatcd and rigid, and 
far HUpi'riiir to hnital attempts at manual or instrumental dilalil 
Unfortunately, it require* ron.siderable surgical skill on the part *f 
operator, us well lis the aid of several traincil as-«ii'lant*. so tliat ib 
must be limited to hospital practice or that of trained apecialiata. 

After Ihc usual preparations for operation, a heavy traction snisn 
introduciii thr«)iigh cither .-ide of t!u- (vrvix. Tl>e latter is then drq 
down UK mttr as p()ssi!jle to the vulva, and a loni.'itudinal incision nit 
through the anterior vatjinal wall from a little alxive tliv urethra InJl 
antiTror lip uf the <vrvix (Kig. -WJ). The blwlder is then t>emifl 



AtlCUl'CHEMli-VT FOKCC 



387 



^he POUre anU-rior vurftide ul tin- iiliini* by mrniiK of a liiiKpr eov- 
rctl by a |>itxre of )tauzc. The Ht'H part of the m-jui ration in iloiii- Uy 
I ilooe, but later a lur^f^ rut[Hi.'tor, mucI) itx lliut of Fn'or with a bladv 
5 X l'<2 oenlintetres, lit uitroduoid into tlio wouod, after which 
b coni[)k't«^<d tuiflvr Ihi; giittlanci; vf Lliv «jc, the bladder beinj; 
tqi beliiiHl ihi; Mraelor, and the entire wall of the iitcruit, from 
Dr lip of the ccrrix to above tho eoiitrnction rin^ frt-ely expotied. 
nancy hw not advaniinl bcjond tho seventh or etghtli month, the 
wall of Uw cerrU and lower uterine «e^ineot U then incited for 




■ ""^'VtnitiAL 1'wutiEAH Sectiok. Bxraamia or C>nvix am> rmw^itr tMtiiKiriH, 

iwAttm nt Hhiiiit 10 ccntimeirm hr itiinriH of a pair of heavy scissors 

KB-*M|, Djiil aJter rcuvtvirif; the epeculum, Ihe hand if inlmdm-wl inio 

"(Tttt, niptnrt^- the metnhrani-i and tiini* tin- thilii. After its rxtrac- 

■«ml (he delivery of lh<' ptaeeDta tlio <ippeuliim it* afi"'" 'ntniiiiifil. rtiwl. 

■"•bog Ow tructioo KUtuRM tsiit. the entin- wound hecomcs risible as 

'■"MiTilar ofieninjf. It« cifSf^ are then iinitod from nbove downwanl 

miiTTiiplpt) ratinit Buttinw. which are inlnxliin-d under the guidiinne 

rn*. afliT which the vat;in>*l inrUiou is closed hy a oonliniioiifi 

;«itiire (Fiv'. M^\. 

If, howcnr. tho pregnancy in at term tlw extraction of the child i* 

ildatni h? makinic n pwtprior a^ well as an antcfHor incision. In this 

t)u- op>-rat)oa ia U-^-un by making a traD»ver«' inoi«ion in llic 



388 



OBSTE'rHlCS 



poslprior fornix at tlw lervical junction, and inwlinj; olt tlie |ii 
from tin- piwlvrior «ull of tin.- trni-v nmi Inwi-r utcriiiv M-^nii^ 
i^ llii-ii iiii-ii^d, ufttT which Ltie aiut-Tior wall ii tieatetl oe- iuLt 
jicribtxi. Tilt- rii-(-L-!^^lj* fur tliv double iitciittoii ii^ nwlil^- undc-TSt« 
nuu rvcuUii that ihe 9Ubocci)>ita-kr«giiuitic circutiifcrtJiK^e of ihi* tici 
an& 32 ceDtiiiietrcG. so thai if only an aiilt-rior incieioii i^ made, 
nuMisurv 15 t» 1« iciiliitH-litw iti ti-nglli to pi'iiiiil lliv pu!«ugi- of 
without lai'iiation of iI^ upper I'lid; whi-icai- if Uie iuciiikiiu am 
vach rMjuirvs to be only half so long. In Ihe latlvr cvvut, tl^ 
wound should in: cinntHl lir^L fl 

In competent haudi-. thi* operation permits th* delivcrr o" 
in li!U ttiinutt'H or ii-<-«, no luatlH- wliat Ihi- inndilion nf iW ccr 
the entire operation requires but tliirty to forty minutes for iLi 
tiotL It" advaiitngiM over ninnual or in."! ru mental dilnlntion an 
leaves a elear-eut wound, properly united Uv FUturts. in plaws of K 
lar, deep, eorvicnl laeerslion, which ma; Rittcnd into the Ion 




FN- Mr*. — Vaoisal C^esAiituN Srmos, Im i-kim ••■.- .^vrtitiuti I iKnlNi: W 

Sepa&jltiox II r Bumx^k. 



and which fntpicntly cniinol In- pr<>|KTly repHircd, If the itwii 
made in the mwHaii lino, the amount of hnpuiorrhajie i.« Burprisioc 
and if n snilnhli- large retraotor ia oiMployctl, every slop of tl 
ia readily visiUe. 



ACOOUCHEMEST FOllClS 



389 



1 couider tiiat Uie difiiculliM wLidi iir» M>mi;lim(w ('iK.<>uiiU;ri<il in iU 

■''fiHiiinnLr iin; tixuull}' ilue to two faclom: Unit, thai the spociiluni «ui- 

r^Vnl !• liH) ^iiiiill to Kivi- II Mtiiuhk- i-.v|m»iir(' of lli<r th-Ul "f "iii-nitinn; 

m-K^il, llinl t)ii' imixton tn <-i(ii('r l»i> uliort or nut in (lit- mi<l-liiit.- <if 

nt^'nis. Ill tliL- farUK-r cvviit. luirnilKPii •H.-uunt ut itH ii|i|i<'r i-iiil iiiiil 

iililn|ti<-lj' oulwani, giving l'i^« to profits liemorrhoge. Uiihrsseo 




- ***-— V*iii>j!. (^•wlll■.(>< Hr.cTi.is, l.iiis>; Ml Si Ti'nKi> in Akthmmim Imciwok, 
PtMiiiiiioit iKcmiiii.i AuitAiif 8t>n;>iKik 



,,rtP<"l "Ul tlmt IImtw wall' » twiifciif^ tn n-ldMili'iii of the uln-us after tlte 
L|x-niiiiin, aud udrinnl lliai the ntily he pociciM] wiUi ^uxe sa n pmphf- 
ftic uniiiwt rarli un an-idt-nt. I iM-lirw that lliU i* a wiw prutantion, 
B.J . ' r^ihioe iIh' piiok U-ron' bvin^: ihi- )iiitun^a in tlio anicrior wall. 

'J I ■ nf (lie o|HTa(ioii m-rc diM-UKMil iit the 1SH>5 im-dmg of the 

a^mnB (iynacoIoRrpal Congress, when Um poiiccmus of opinion was in 
fd¥Oiir, IliiDim fitatiii); tltiit Iw had pcrfomivil il in 5? inKtanroi. Ur 
fa«ouralil(r opiuioii is hn^«] on » t-nsee operai«l upon iu my sen-ici-. 
J] aeconnt of thi- oiwrotinri, toiiflhiT with n linl of all oij'c* rcpoiiod 
to ISOTi, will Iw found in Diihrtwen's article in Winckel's llandbueh der 
»tirt»hilre. 




ZwilmlW. t. Ct^TM^^ 




onaTCTitu-i* 



UTI-IllATflU': 
lilt Fiilli- vim Kltilvltiiiiic itvr IttLnnllk-tivii I'ruliguburl. 

ich dcT Oi-bitrtNhiilfr, 11. Aufl., ISOA. 4fl«. 
CoiilHbiitioii fl IWude ili'v inilionliorLB (If rMcrouc}ienmi( (ir^jiiutiintBrlilid^l, « 
l.-Ohrf^trKiur. 18113. iv. 471. 
evuiinilc JMillloloKii' (il>*ti'i(.riciilr. Piirin. ItMKl. 

iDKi.KiiKN. Siiutful)(:«i di>ti KiilliiiiiluiiKx-wrlahRnix mil trhncllf-r InulnuiicuU.- i 
XliillrmitiTidiirnrrit«'ruiij!. AivbJv f. (iyti., I<KM, Ixxjil, \S7-'£X. 
AiHIi. 1'ariiiiT el Diiditi. Traill dc I'srt dua tut'uuctu.'itii'DU. 1901, t. iv, 444. 
AunKt.. li'nvnrtL'oietil. Curia. 1901. 

lT«1:er di« Mpthodt-n dor kiin«llichcu Eravilrninf; <ln ■chirangerea u. I 
dcD rtuniH. Vwli. d. <li-ut»i-hen {kwll. t. (lyn.. IftOfi, xi, 54 -fiS. 

EH. I'io TVdfiiliiJig licr Hyviniiirrn: in det Go>iurtdititfi<. Arduv I. (lyn., Wt—" 
lxx\ii. 48.^-.i5tt. 
iKKiKi, ,•!«• Pnrvin. 

PBTIKR DB RinBii. Dc i'af«>Ufhwn<Tti( pn>voi(U#. Annnk-s dt (Q-n, el d'oW--' 
188». XXX. -101-138. 

IK. Piierp«nd IVriiicioiui .Aim-niiii. Tnin«. .\nipr, Cyn. Sm\. 1891, xviii. ITS, ^i* 
IMAN. All IiilroducMnti toti* Pnciimof MidwiftrT-. 7tb«l.. Ijondon, 1821. 3I& -^ 
iitx. Si!C I^rvin. 

EFdVT. Tti^liArhfiiniirn u. Hpcnrakilii^D. Oeiiiuiiimnie Zmtarhr. t. UcbuilA., 
1828. ii. .549. 

l*ri>pT ilcn WrHh drr ticfwn Owv(jt- un«l Sohiriden-tJiuniM FjiUKbuitU in 
I tier ( lei lurldhi life. Atehiv f. fSyii,. 1890. xxivii. W-00. 
vaRinjilo KuiiHTw-luiitt. Berlin, ISSfi. 

Kaisoraohniil. tt'lncLel'* llimdlmeb dcr Ocl'iirlsliiilft-. 1!>0.% 
.R. AdviinbigniiciftliL-Hiiiiuiiiud DilulAtimiof llu.'1'n.-iniiiiii luid Piirluri«ril DUrii*. 
T1SI18. Am. i'.yn. 8or,. UHlfl, xxxi, 10» 115, 

lutn. Zur luJiiiclleu Erweiiemiig ilea MutWrniundiii lutcb Bam. .\rriilv f. OyiL, 
lOW, Ixxiii, 43i)-.M3. 
Nu. Eiii Fill] voii Chorea cravidunini. Arehit- f. Ryn.. 1874, vt, I:17'139. 
lux. ProcM&i de pruvuL'uliuri ft dc lu t«rniiniii>nii'nrlili<-ir11p ni|i*(ie dr rHecourbit- 
liiVbt. Annnli-s d'ohxt. el de Ryii., HUH , li'. 4IHI 4riO. 

iXra. TpIkt den Ziinuiiiiiieiiluiiii; drr periiiciusva Aniemie mit ilcr OnividitiL 
r>. I., Unllc. IHHO. 

.i.BMicAti. I)e rticiiiviix iiccMielieriietil dtw (einilito^ Puri*. ISM. 
iiiH. A Method »f perforniint! Itagiid DJlutuUiin of tlic ( )■ I'teri, etc, Aaier. Jnur 
llwt.. 1894, x.\ix, :J7 411. 
pvr. .AniiLnllimebiuisbiilfe und ItittisKehurUlitilfe Jn ihn-m Vrrbidtnlfn cur kiiiiiit* 
liiihon E-'riihtcfiliiirt . Mi>ii»livt('>ir. f, (ieli, 11. Cyn.. MNili, \;tiv, 'rO-TJi. 

k'AiniTBK. Die kiiiistliehe L'nU'rl)rwhuii,it der SeLwHiiirerBcluid. III. Aiifl., 1902: 
IliR kntinl.liehe I'VOhKeburt. [trejilAii, IH.'in. 

n'ie weit soil iltiH TtiH-lil ded KiiideH uuf J.etieii Ix-i der (j«(iurt ft<^wjVlui wrrdn. 
. f. (icb. 11. r.yn., IfJOfi, xxul. 3(13-329. 
(BUBolilMtek). Beilnitc xur kiitioll. FriiliK«'l)iirt, n'eKen Ueekenoifti^. ArbFJUn 
am der k.-mial. rnnipnklinik in DrcHlen. ISflS. i. 93-123. 
H'DUu (SiThoedfll. ICrfBhnuiaeci liiier Uiinalliebe Prulif^t-lniimi. (.■iiigitleiWl irvscn 
Rcckeneniw. Anliiv f. Ojni., 1B01, hiv, I.II-IM. 
ur ■rhiiellen vollKtiUiiliin^n EmMlonuiK dca ilulterm mules niitloU dca r)Uatat<iniua 
TOn BoMi, He. Zpniralbl. f. (Jyn., 1002, xxvi. 4a9-i0fi. 




f 



ismicrios of abortion and prkmature labour 301 

l.KfAtiK et Sainton. Acoourhement provoqu^ pour iin ran dc nfvritc pi^riphfriqiie 
mlt^rtu tiUfUc. Comptes renduit de la aor. d'ohst., do ny"' clde p;i-d. de PariN, 1901, 
Hi. ».3-99. 
Lcviv («r«d Brenninu. Die FnirhtahtrGJbunic diirc-h (iifli^. ik'rlin, I8!)9. 
|jnri0. JJloodlesB Methods of ArtifiL-ial Dilatation of the Cervix Uteri at Full Term. 

SuriK. «jTi. and Obrt., 1906, iii, 756-76. 
I^^rr. I Kustnimental Dilatation of the Cervix in the Lost MnnthH of Pregnancy. Amer. 

Cyn., 1903, iU. 295-200. 
HjicWC^S-*- *3' Traits des maladien doa femmes groaaea, etr. 6mc fid., 1721, 161. 
pABvi."* *st. al. Artificiai Prenuiture Labour, its Indications and Methods. Verh. des 

X. Int4»nat. med. ConKTUsses, Berlin, 1891, Hd. iii, Ahtheilunft, viii, 107-149. 

pd,xiic Ueber Elinleitung der kunstlicben Friifageburt. Zeiitralbl. f. Uyn., 1S92 

xvi, 3A-36. 
prAiCN^^EHTiBL. UeberdieGefahrlichkejtderintisut. GlycerinuinHpritzung. Zentralbl. 

f. CSjm-. 18M. xviu. 37-J9. 
PixaW>. Ue raocoufbement provoqu^. Annales de gyn. et d'obst., 1891, xxxv, 1-16; 

81-1 1:2. 
lodkB.* ion de I'opiration C^sarienne consider^ en rapport avec cellc de la BymphysA- 
otonii^ et de raceouchement prfimaturfi artifjciel. Amiales de gyn. et d'obst., I S99, 
Iii, »I — 117. 
As0K)'O'?aE>Z!i. IKekODigl. preusnsche und Chur-Brandenb. Hof-Wehe-M utter. Berlin, 

1750. a 16. 
afgjjA*'*- The InductifHiof Premature Labour and Accouchement Forc# in the First 
5,0OO Z..aboursor tbeObBtetrical Department of the Johns Hopkins Hospital. Trans. 
jUH. CSyn. Soc., 1906, XKxi, 316-333. 
^^pic^OAxm Vomiting of Pregnancy. Trans, Am. Gyn. Soc., l!Mt5, xxx, 229-299. 
^jjtMBoM. The Induction of Premature Labour. Jour. Obat. and Uyn. Brit. EIrap., 
*'*'^flO-'i. -sriii, 252-271. 

fjfui^TKH. IFeber iiutrumentelle Dilatation des Cervix, etc. Zeiitrallii. f. (lyn., 
** igl»,)s,:«vii, 97-100 




The olnitetrical forceps is an instrumfnl (IpgiRnwl for the entractif 
umkrr (1'1'tiiiii t.i)ii<liIioiiii, n( tlio I'liild wl«-ii it prt-M'Ht-' h\ the ti«*jiil. 
coni^ii'lf of two bruDclics which cross oni? another, belli;; do^ij^^stej r 
sjxx-livdy right ninl li-fl, ucmrilirij!: In Ihv side »S ihc jidvis ti> uhivh vtx^' "^ 
correspotuU. ThCT are introtluced separately into tlie ttenital canal «»- 
an- 11 rlic dated after btinji pWi'd in iiositicm. Ravli branch L* maiii! i^ 
of four iKirlionri — llie handle, hlade, shank, and lock. 

The inj^lniiDcnU vary wnsidurublv in sine iiiid shn|K*. an will hr tet 
when etjrinin varit-lies of forceps are considered. The blades pwiicss 
double cunatiire — Ihc ccphnlic and the pe!vic^-the former being adapt 
lo Ihe wlmpe of tlie ehihi's head, the Uller to that of the birth canal. T 
blaJcH are more or li*i elltplicrnl in sli(i|(«!, tu|H;ring Uiwnnl* ihu iihMnk, taM 
are UKUally fenestrated sa an to allow of a tina hold upon (he head. Vev 

lain uutborilie^. Iwwivi-* -^*'' 
prefer Holid hhiile.-> in 1. 
belief that they can 
made 1ms tiuil;)-. 

The cephalic euPt" 
shnidd 1k' such a* la j»- 
mit the head to be gra^pci 
flrndv hut withnui «■«■>■ 





no. 3W. — 8rHnu>NlR FoncBn, CRPtiALic CenvK. 



r- 




eomprepsioM. 'Hie gr«^^ 



fxa. 3(7. — KiMF»nN'a KoRcrnpfc, I'l.i.vTi- C'lrnrr. 



1- 

est ditilaQco l«'luii-n t^ "^ 
two blades should not t- ^^' 
coed ?.5 rcniinielnv ^ 
iiiehiii) *-l»eD thej' a- 
articulated. The jwlric curve corresponds more or le»i Ui the axis' of t~ 
birth ronal. hut variwf con^idcrahly in diffen'nt inPtninienU. Whpo lC-^~* 
forceps is placed upon a plane surface, the tips of the blades fhonW 
(ihoul H.H eenlimetn-i; (;(J inelit-K) higher than the handl4^. Th« latt 
are connected with the hlado« by lb* slianlcx, which give the nqiiiE 
length to the instrnment. 







The two brancheii arlieiilate at the lock, which varies wideir in diffwc ^ 



instniments. The English type eonsisU of .i socket Hjwn each brancb. in 
which fit»i the «hnnk of the other Iialf of the instrument. This arning 
ment permits of ready articulation, hut d"«» not hoM the blades firmly 
^^^^^_ 392 ,^^^ ■ 



«• 



RllW-fJ-S 



'th^T. In Uw French lock a |)ivot is ticrewed into Ihti sliitnk of (lie latt 
t^A, whih tbi' righ( pn^svnU un opouiiig which mid be udjiutiKl to it, 
<'rev lieing iigb(ene<l nfler articiilstioii. Tlu> (ienaitn lock is n com- 
ton of 11m> two, till- ^lank of tlu.* left brniicli Ijenrin;! u pivot with a 
•^«J, Hal head, while Uie rijtlil U providtvl with » notch which cnrre- 

r^^ spondii to the pivrtt. When the imitruincnl i» 

^K prn|)i?rly urticululfNi the hnndh-M «^hoii1d full 

^^^m[ lo^tli(?r in liUfli a way as to he cnnvf-tiii'iit' 

_^^^9^^^k. I> gru^iKsi W (III' opiTiilor villi awe h«iitl. 





— Liiot or BnuuBM Ponctm. 



Fi«, MV. — Luck or l-'liiaccit Ktmcnni. 




Uitlorif. — C'rode (orcejis wew in ust' from an early [>eri«<l. Mrveral 
n-r-ietiuM haviu); hoi-n diM-ritifd hy Albucasis, who dit-d in 1112; but a* tlii'ir 
ai»*.T surface? were provided with tetth intended to penetrate the I>cad, it 
^a?vulvitt lluil they wen; inti'ndeil fur iim- only ii|i»n dn») ohililn-n. 

Bt true nhtiietriesl forceps was devised in tlie latter part of llie iiiji- 
iir the iK-giniiiiig of llw rewnUii-ntli octilury bj • menilxT of tho 
il«rIeo family. TV invention, however, was not nnnle publit; at 
liw time, but warf pretierved as a family irocret through four genersitionn. 
xl liid not liwtiiiic generally known until ihc «arly ymri of the eightwnth 
M«r(, I'nor to tliat lime version had Iwen the only method vhieh 
i>itt(d IIk* artiBciAl delivery of an tinmulilated ehild, and. accordingly, 
•^^Bii that opfralion wax mit of Ihe qm-slion and dilivery liif«m*- impitni- 
[""*. It could be aeeomplished onlv hv the deslruclion of the child, wlien 
■"•UtiTT wa* I'ffeclcd by mwin* of lumk* a»<I crotebeljt. Tliue. b^-foro the 
l«»«Dl)ftn of forrepa, the nae of instninienl.i was synonymous with the 
l'**th of the chilli, ant) frequently of llw; mollwr %\m, and tv^tded to bring 
f"*tflrioi into diHn'piile. 

VUlUm < 'liamberlen. th« founder of the family, was a French physician, 

''■*" 3i^| from Franci- a» a lltifEuenol n^fo^'w and I»n<led at Southampton 

1W9. He died in l.Wfi, leaving; a large family. Two of his miw, both 

*knni wen* named Peter, and desipnati'd «« iIm? elder and younger re- 

tlwiy. itlndini medicine and •etthtl in Ixmdon. They Koon bwume 

sful praciilionrr*. and devoied a large part of their attention to 

l»iff-tT. in which they became very proficient. They attempted to 

" I imlrurtion ftf midwive*, and in justiflealion of their preten* 

\ that rhev wuhl snawpfuIlT ili-livr putiitnt.-. wl»en all others 

UiImI. 

IV younger I'eter died in h^Sfi and the elder in Ifi31. Ilie latter 
children, but the former wiu survived by Bewral mm, one of 



^^ _ I w yount 



u'linm, hnra in KiOl, watt liki'wiAe named Poter. To dUtiDf;ui:<h him fTc:»^xii 
his fatlier and UDcl«, he is usually spoken of as Or, Peter, as the other t- 
(lid not |M>K<.t>»ti ilmt T.itl«. He ittn wei\ eihicautX, luivinfr siudiod nt Ca~ 
bridfie. llei<l<.>Ibcri;. and Padtm. and on his return To I^ndon vas elec-^_^ss 
ti Fi-liciw of t}it- ItAval ('otlo}ce of Physician^*. He hils ino«t MUuoMtful j^ 

the practice of his profession, and counti-d anioug his clients many of "•:^lie 
royal family and nobility. Uke hiit fattier and iinelc, lie attiMni^tcd to 

monopolize the control of the tnidwivcs. Lut his prot^insioiis wi-re set a^^ m, ije 
by thi- aiitlii)ritii>ft. lliew? iilti'm[>ts gave, hm; to a jiivnl ili-jd of din(ru>M x^jin 
and many pamphlets were written as to tlie nioralily of women in lal^^^^uj- 
King Htt<-ri<U-d l>y men. wliith he aiwurennl in a paper enlitlL'd '"A Voie«* ia 
itamah. or tlie Cry of Women and Children as echoed Korth in the 0<» sn. 
pn.vii<ins of Pi-1«r ('haniK-rlrn." He wan a man of <'<)nMtdenitiIc ability, ck^jui 
united at the same time some of the virtues of a relipiouH entliusiatit Avith 
niiiny uf the devioun i(ualili<-A nf a iiuaek. IIu diwl al ffoodliam. Mortin:~sir 
Uall. Esses, in lliM, the place remaining in the jMeeession of his fa»ia ih 
until wi'Jl into the xueew^liiig cwitury. Formerly lie wan oonsidored *-lr 
inventor of the forceps, hut, as we now know, this view wa.* ineorn?ct. 

He lefl u very Inrjn- family, and tliR* of his sons — Hu^h. Paul. a. ^"^ 
John — became physicians, and devoted special atl^tion to the practicf 
midwifcrj'. Of those Hugh <1630-]i(10) was the most important and 
Huential. Like hU father, he possesscil coD.4iderabIe ability, and al t 
same time took a priiclieal interest in politics. Some of his vievrs not lieC^^'* 
in favour, h*^ was forced to U^ave Kngland, and while in Paris in li>*3 e^^ 
tempted to sell the family secret to Mauriceau for 10.000 liTrefi. claimi^ 
that hv \U means he cnild ili'livor in a very few minutes the mfwt dilV>«&- 
cases. Mauriceau placed at his dinposal a rhaehitie dwarf whom ho had bi*' "7 
unable to deliver, and ('liiimU-rlen, after s*'Vitb1 limirs of «lreniinus eflni^'' " 
was likewise obliged to aeknowlalge his inability to do ■«. Kotuiilu'taii^ -^ 
iiijl lii» failiin--, however, he maintained friendly relations with Manricca— *7 
and on retiiminp home translated the latter's Iwok into Kngli3<b. In h^*™" 
pR-race he n.-fers Id ihe forwp" in the follnwmg words: "Sly fatln tf^' 
brothers, and myself (though none else in Kuropo a.* ! know) have l^^? 
tiodV bli'Wfiiig «nd "iir own imlu^try attained to and long praeli«d * 

way to deliver women in this case without prejudice to Ihein or tba— ^" 
iiifanUt," 

Some years later he went to Holland and solil liin #ecr«t In Ro(Hih«y«J-**^ 
(Shortly uftcrward the Mttlico-Pbannnceu Ileal College of Amsterdam "" '* 
jjiven the solo privilege of licencing physicians to practise in Holland. *" 

each of whom, under pledge of secrecy, was *o\i Chanibi-rlen's in^-pntj^^** 
for a large sum. This practice continued for a number of years, an ' 
Viseher and Vau der Poll pii rchaHil Die seerel and inude it public, wh^^** 
it was found that the device consisted of one hlade only of the foree^^^T*" 
Whether this wa* all that Cliumlierlcn sold In Kofinhiiyseu. or whotlicr 
Medico- Pharmaceutical College had swindled the purchasers of the seci 
is not known. 

Itiigh ('hamberlen left a considerable family, and one nf hix 
Hugh (IG(!4-1T28) — practised medicine. He was a hjgbly educated, 



n- 



At- 



M3RCEP8 



39a 




!i«l, anil phUaniltmgiiv phv»id»n, iiikI numbored anions liU dieuU 

nbera of tbp bo«t familie!; in England, lie was au inttmatv friend 

be Dukt* (tr Buckin^iuini. mid whi;n htr dk-d the Utter caused a etatuc 

i?rwt«l m iu\- tionotir m WwlminBter Abbey. During Ihe lut«r yo»n 

M life lu: alloneil the family «ear«t to l«ak out, and Uie instruineDt 

cuiit' into gnteral utv. 

(IT iiKire than odi> huudn-ij ymn it wait Iwljcvcd that tlte fon^cpH 

tho invvnliifti of Dr. I'eter Chanibcrleu, but in thcyuur IKI't Mre. 

ht-ll, lh(> hi>u«e- 

r of a rioh bn»vi-- 

Itn had jiurcba^^-d 

I'i't«r Oiamber- 

ciKintry Iu>um>, 

nd in th>.' mrret a 

ak cnntmning iiu- 

•Biiit lettejH and iu- 

imvnt*, aninn^ Ihc 

rr faeiofc four paira 

k forcvpf, togvtlicr 

h wveral levers and 

n». An u rt'idi-nl 

u the drawings, 

(nrri-p'' wirri' in 

wnl stages of de- p,„ 36a-4:«*Mmi«i.Wi, Korc-m*. 

Ofnunt, one pair 

aRhanllv a|i|>licati)t! 1» Die living vomnn. w-hilr (iw oIluT' Wfry u«>ful 
("tm-'nli'. Avehii;f. who lias oareflilir investifralHl the matter. ht-Irc^'w 
t Ifcc thnv paim of nvailalilr foneps wen* iimiI reji(irt-tivelv l»v t)>e Uiree 
*r\ BUt) tluit Id alt probabihlj the tiret irs!- dmiiMKl bv tlio ddvr Peter, 
«f Ihv original William. Prolnbilit:!' i» lent to thin view by tlic bet 
t Dr. Peter, on one oceaeion. at leant. «pokc of tV' invention of his 
Jr. 8atigfr niul Bu<liii, who havo al^ inve^tiguttd th« subject, iuelino 
Ibi* -ami' It'lief. 

Tbi* furcvpv eADM* into funeral emplovintsit in England during tito life- 
e of Hugh Cbainl-erlen. tlw vounger. 
nkwrntEF. who diinl in 1Tt!8, and wa* 
krf. The former, writing in 1733, say*: "The i^ecrct mentioned by 

Dr. Chaml>erJi?n wa^- the Ui* of 
the forceps, now vn-ll kuov'it 
by all thc! principal wen of tbo 
profeMrion. Iiolh in town HIk) 
ciiiintri'." 

In 173.1. Palfyn. « physi- 
cian of (ihcnt, rsbibitiil l>ororu 
Pan* AradinuT of Mvdieine a forceps which lie de«ifn>atvd an maiiu de 
II w»» crude in Hlia|H' and did not artieiilnte. In the diuniniiWtn follow- 
ito pK»(«talioD De la Molte stated lliat it would be impoeeible to apply 
1 the living wouan, and adiled tliat if by diaoce any onn .'^Ikould happen 



The instrument was noed by 
well known to ('hapman and 



^ I— fflf 

Fin. 3ft1. — pAl.rtn'H F'Mrre*. 



396 



OBSTETRICS 





Flo. SS3. — Short Ki»i< > i':f. 



to invont nu iQHtniment which cnuld 1>g so uacd, and kee\> 

own profit, lie ik'M-rvc'd to U* L'xpoN^ u|)ou a Imrrcii nx-k nnd 

viulf t»Iuckf(J out by vultnrefl. lililo knowiu^ thai at ihe time h< 

*in mf^tnitUL-nt hud Ixvn in llit- \tnt,- 

iivsiiloii nf llii: rhaiiilH-rleo faiiuly 

for nearly oni: liiiiidritl yvurs. 

Th« Ohwubcrlen fonvpn wa« a 
short. etraighC iu.-ti'iiincnt. which 
jiM^M-Hsi'd iiuly a (icphulic curvt-, mid 
ifi [M?i-|H.>tua(e<l In the t^horl or low 

fynt,']!* ot tii-duy- It wii» hmhI exdiwively. hut with lillln 
until the middle of the elKhlwiith cejitury. wheu Le\Tet, ii 
Smi'llii-, ill 1751, quilo iiidupL-ndeiiily of nnc BtmlhiT, mldi 

curvu jiiid incrciist'd t 
iho iuslruiiicni. Ia-vivI 
wa» tdii-^ci' and piwsesse 
(h'l'iiiwl polvii-- cun-p Iha 
Snicllic. and it is from 
inMniiiutitii ihiil thi^ l»i 
of the prywiit day is de 
the long Fn-[i(h fi)ricpi Iwing the lineal dc^<in<lant of the 
that of SimpKon of tliv liitlor. 

As sftrtn an the forceps liwariio puhlie proiH*rly it in» jsn 
vuriouK modi ficut ions, ko llml Middt^r, in his atlafi puhlUhed in 
atilc togivoillua- 
trations of near- 
ly 100 varieties. 
Some idea of the 
dwirc to niiidifv 
Btid improve the 
iu^itruincnl inay 
be ^ioed by 
glanoing at Wit- 

kowgki'ii OhHUtricul Arsi/iml, in wliidi are picliirpd serunil 
vepf. urhicli. nfu^r aII, oonatitute only a Hinall portion of tltM 
PouUet's inttTMtiiJg niouofrraph contniD^ an cx«llwit biKtorio 
lh« liCTi'loptnHit rtf (he inslniment. 

But, fODBiderin^ all the work done, it is )--\irpri«ing how lift! 

WHS rinid<' oviT tlie ii 
of I.evret and Sini 
lS*r, when Tamil 
i-nitnciati.'d the prf 
n\lf traction whit^ 
practically r*-vftltifl| 
ideas upon the au)>j< 



jsnl 




P)o. 3M. — Lovo FXbxoi Fobccw (I*vi 



i 

hot 

1 




tX>HCKl'S 



397 



■Tfaydrian it likoly In 1k> cmluirra^tH) liy tht- miiltituilc fmm wliicli he hud 
I Id i.-hiHtw'. Any jimperk »hafK-<:) iii!'truitu-iit will ^ivL' sutisfactury nviilts 
Ifnttidiil tl tx.- MHi) inu-lligi-iitly, hut for ^'ncral ]:tur|HiM-j the urilinary 
liim>(*i>iin foroepa is probably the best, thoujfli, if out' es|)cctf to do much 
Bhtutriml work, a Tanitcr asiMnicIioii fnrcvp* hocauH>j< tMeDtisI. Per* 
■Dnaily I hIuhv^. i>m)tl»y the I»tti-r, ii»in>; thi- Inii^tinii ixmU or nol, u('<i>r(]in9 
If t-irL'uiiihtauii^. *k I l>eticTc ii t>cili-r to l>tM!oiiio ihoroiiifhlv familiar with 
ptc- isi»lroiii<iil ihnii to have H-vi-ml for iim: iiii<lt'r ililTvrv'iil conililioiiN. 
I Xlu- forcvpa ^oulil be entirely of metal, bo tlwl il can Ijo readily stcril- 
^d tiy |i»iliU£. 

I ffinrii'm* iif Ihr. Furcffts. — Thin wilijt^cl iia- Wvn oninideRi:! in ilctail 
V ChiMipa^ny. TIk- forcvjK may In.' wvA a* u truvlor, mtalor, wniii>nr»,'«ir, 
PMtor, lever, or irrltiitor. 

■ Itx oKx-t iiiipnrliiiil ftiiietiou U traction exereii^ed for Uu.* {iiirptwe <>( 
"'■awiuju; llw ht-nd tJifou^li th« gi-niliil tract. In not, a few ca*i», how^iror, 
•krtieiiinrly in octiiiito-jiwlcrior presentations, it'i employment as a rota- 
P>^ in ndi-iidiil III iiKwl liap|>y re.-iiill.'. Il ohoiili) never In- iim-(| priiitarily 
■^ compre-^or. tliougli of oout^e it is impoesibte in make traetion without 
^^^■vtinji the head to a hU^'Ui d«^gr»« of ooinpr<Twion ; but when it ia de- 
P^^**i til hrint; about a diminution in itti eizo other ingtrumentfi are mor« 
'I*l*»oprjnic. 

Slanr anlhorn, eoperially in this country, advocate applyini; tlie forcepe 
*-'*"'^n(!b a pnrLJBlly obiiteraled r<Trt\, and BM^iKliiig dilatation W iTsetinn 
"l**^!! tW heait Snch a procedure, however, is unjustifiable, for when it 
H" nccewnry to deliver the ehiM nndvr ifuch eonditionn. the eervix 
Htretehed manually, and forceps not applied until diUlation is 

In rart* iRKlaOK^i, one blade of the forceps n>ay lie cinjdoyi'd t* a lever, 
no^i at priwent um in very Kldom made nf thif function. Fonncrly 
^t slR^« wa^ laid on the do-called dynamic action of the fonffio, by 
'i«h i* meant the Irritation of tlw uteruf which follows its introduttion. 
J^^f wtf Uw- employment of aoa'.'itheliefl, this function wa* of coRoiderahle 
■£kiTiaonr in •iperatiw nMii, hut at tlie prv«^nl day it pofisessee hut little 
iftirauee. 

imiicttHertu for tlte Ute of Foretpa, — Strictly epcakinj;. the lerniination 

lalmur by fureepM, provided tt can he aet^nipliiliei! wiOMHit ton ffreat 

. a IniUcaled in any condition which threatens the life of the mother 

On iIm; part of the motliiT, *uch mndiliont air eclampnia. lK>art 

isliended by broken eompi>nsalion. aeutr a><)euia of the lun(^•, luem' 

from pn-matiirc tcpiimtion of the p!a<-cula. intrapartum infection, 

"ihuii'lion. ttltenever lliere i« fiuestion of inlerfen*nn^ for th* la*t- 

J^tinl enndition. definite objective fx-mptoms ehonld Iw present, tiie enodi- 

i of ihf pulw la-inp of wpccial imp')rliincr: wlH?m«. on the other hand. 

tittle weiuht *b'iiibl be altaehed to the »latemenl.< of Ihe fiall'-nt 

\= retnrds the child, the operation may be called for by prolapw of the 

A roni, prt*maturr icparstinn of tin' pliU'i-iita. undue pressure cxerfiil 

I I- 1:fin!. anrl iwpeeiaily bt ehanner in the rhythm of it* heart-beat 

'■111; ■^-jxya ui mtgonium in verlcx presenlationi^. A fa-tal puW falling 







betow 100, or excc-udiii^ ItiO lo the ininiih-. iiiiliuiu« Uml the child U 
A&off-r aiid will parish if not promplly delivered. In vertex prewDUti 
thi! disflmrge iii Aiiiniotu- iliiiii lil)gt^) with mtMLiinium iudk-uU's intcrfvriJMr 
mth ihe plai^ental circulaiiou and imiierrpct nxv^enaticjn. mnnifeiitiDg it- 
by paralysis (if Iht- i-pliinctt'r ani. In broucli presentations, oa the ot"% 
hand, the pn-w.-jiti; nf mito ilium is wjLlmul sigaificuDce, Iwiiig due nwir- 
to pressure eierted upon the child's aUlntiK'o. 

lu practiw. iKntovcr. the mattmul iDdieatioDs for the uw of f'yK-^:^p^p^ 
may \»: c^'n^idcnilily cAti-iKiiH), iiihI in itifiiiv in.iTanciM thtt ofXTatioii rr^M ar 
b« Hdvifiahle in the case of women Miiffering from acute infcctiouB '^"~it-> ^ 
heart lc.»ioii*. and disrosw of tlic ri-epinitorj- Iract, who must Imt s)ivi-«j ^ 
far as possible from tlie exhaustion incident to an anaided Eecond stc^^ 
of hibimr. Owiwionidly also it may appear wi*o to relieve the Mrain vj^^-va 
a cicatrix resulting from a recent aklominal Huition. 

One of thi> most frequoDt indications for tlie operatioo is afTnnli'd '^J 
faulty wntraHion of lli« iilerin* or ntxloniinnl muscles, the forx*p» h« 
utilized merely to fe-enforce the insUllicicnt ris-a-tertfo. In occasionnl i 
stances, parliciiiuily in clili-Hy priniipam*, the rvsislanc*' ofTeiMt hi c 
pcrinffiiini and the va^'inai outlet may be so great as to oppose a fcrin— ' 
obstaoU* lo tlie pttssa^ of the diild, CTcai when the cxpuUive forces _ ^^^ 
nonnal. In uneomplicated cases it is a Rood practical rule to apply ^"™C "^^ 
if iiilvancr does not occur ntUr two hours of satiKfuclory second stup' P"'*'^Sl 
hill if the head is u|>on iho peiina-iim and no progress 1ms been made («^ . 
onp hour in spite of (jood pains, it is usually not advisable to nail niiii::^ ,. 
longer. At the sanip lime it mu«l Iw insistod ujion that tlic opt-nilion sboaC ^\,i. 
never be performed to save the physician's time, but only vhen distinciK-^ " • 
indicated by the condition of tho mother or child. — -j 

Till' fuUfjiciiii] i-iiniHliim.* must he fulfilU'i Irforf forrrfkt i-an he apfiir*-^' 
wilti sfifeiy: (1) The child must present correctly; (2) the nrrvis inustt^ 
fully dilated or dilutnlih;; (1) lh<- iiicnibranea must be ruptured: (4) tif 
head of the child niu^t be neither too large nor too <nial); «nd (5) tB"- 
pclvis must not be ciinlrufti'd. 

The child should present by the vertex or face, and an scourali- dia^se V 
noeis be made as to Ihc iwwilion and variety, forceps not being availal^-^" 
wlien the chin U dinwily posterior. The forcejM i» not upplicablr 
transverse or shoulder prr-scntHtioiis, nor is it intended to Iw applied 
the brccfh. It should not bo employed in brow ca^es until after coat 
sion into a vertex or face prwcnlalion hss been brought about. 

The cervi.t must alwny* hi' completely dilated before the applifdtion-i^V' 
forecp", otTiTing a diameter of from 9 to 10 centimetres. Of course \'~ "■ 
possible lo api>Iy the blades througli a canal measuring only -I or 5 re—^*"- 
mctrcs, but under such circiim stamps the cervical ring offers marked "* 
sistancH. and if the liend 1m» dragg<>d through it by brute force deep ti^'"' J 
may result, which may implieafc not only the cervix bnl alw tlie la^w*^ 
iilcrine K-gmcnf. Even if only ■;cTifli' frwrtion i* made, the practice h «* H 
to he recommindeil, iis it is dirTu-ult to know exactly when the cervix '»■ H 
become sufficiently wide to permit the passage of Ihc head, and the opcrtnT ^^ 
is prone lo iitUinpt delivcrj' before complete dilatation. AccordiirojJ^^^ 



t>«l 



b 



P0K0EI>8 



399 



upt delirerv Iwcomes impcralive when the cervix is only partially 
ited, its (.tjmplelf dilatation ehould be effected manually by Harris's 
hoi, after which delivery may be accomplished with forcepa if the head 
Lceply engaged. On the other hand, if it is only partially engaged, or is 
ting above the su|>crior strait, delivery is bcr^t effected after podalic 
nni, provided no i^erious disproportion is present. 
The membranes should always be ru|)turod before applying forcepa, as 

initnimcnt is intended to be applied dint-tly to the child's head. If 

membranes intervene, the grasp is not so firm, and, what is still more 
nrtant, traction upon them may bring about premature separation of 

placenta. 

Before applying forceps, particularly when engagement has not yet 
srred. the Aze of the head shonid be determined as accurately as pos- 
e, for if it lie unduly large, as in an excessively developed or hydro- 
balic child, it cannot pa.<s the superior strait. On the other hand, if 
e abnormally small, it cannot be properly grasped, since the blades will 

off when traction is made. Accordingly, the employment of forceps 
ontra-indicati-d when the fii'tus is premature or macerated. 
Generally speaking, contracted pelves present an absolute contra- 
ication to the application of fnrrejis: for if the contraction be marked 
ill be impossilile to drag the head through the pelvis, and if brute force 
gnploycd it will result in the death of the child and severe injuries to 

•oft parts of the mother, and occasionally cause her death. On the 
tr hand, when the contraction is but slight, and especially when the head 
irmly engaged in the upper part of the pelvic cavity, the tentative 
lication of forceps may be justifiable. Under such circumstances a 

tractions of moderate intensity should l>e made; if the head follows 
n the}- should be continued, but if not the forceps should be removed 

deliTcrr effected in some other manner. 
Preparations for Operalion.—Vt]i(tn the application of forceps becomes 
ieeary, either in llic infcresle of the niother or child, the physician 
aid so inform a responsible niemlier of the family. It is usually not 




gv^,?\^7\j^ 



RnBB'H I. t.ii- Holder. 




"iMble to <v)n-ull (he patient ujnin llie subjet't, as she is not in a con- 
lon to make iiii inlclligciit dei-isinn. 

If the operation pnunisfs t() be easy if may l>e performed upon the be<], 
I in all other cases, whenever possible, the patient should lie placed upon 
U4e of suitable height. Anwsthesia should always be employed, and 



400 



OBSTlCTlllCS 




Pio. 3fi7.— DiAnxAU ennwiNQ Pi)nrrr"N ii» Hbais 



whcncvt^T praclicsblc iu iidininii^tnilion fihnuli] be iiilru^tci] 
tent aisiittAtit, rather than In Ihc nui^e or »onie ni(-iii)>er ol 
since in the taltcr cilsl- a lar^o part of ttitr obstvtrrciau'K atUiitinn 
of neoe.^wiiy Ik- tlevoloii to wiitcliiiig iho jjtnsral condition inslead of 
CODceiitrsli'd upon the operation. 

When nn»«tiit-^in ir< niiii|i!i-1c, lli<r putiont'ii l>uUnrk.'i ohoald be hi 
(o tho L-dgv of tho lM>d or tnitlc. and her legs held in position by on I 

priuli- K-jc-liold^, wbj 
particulurly coiivviiivil 
(trivatc pnu-iice, as j| 
a bice one to dispensd 
uN'ii'tnnti' for hol<]iit] 
Icp-, After tho pubici 
hiivi' iHH-ti :<liav(>d, UiO| 
taIJa ehoidd be tboiij 
wa»h<M] witli ;»np oni 
water. butlK-d with a| 
and rhoroujkfhly »iiikH| 
1-w-lfWtO bicliloride ; 
tioo. DiiiDfection ot I 
f;Ina is not necessary i 
the jintiont i* infix-ti.^ i 
been sHbjeolcd to previq 
tempts ul dvliverr. Til 
and bodv sbotdd bu 4 
with uteriK- fowi-U in f-uch a iiianiur as to leave only the frenilalia e: 
Kpeeiul BttiTiliiiii bt-iujt givi-n in eoveriii); the anus so an to provent 
nation fmni itie fa'ces. (See FipB. 335 and a.Hlt.) 

If l)ie oiiili't lie Kinntl niicl rigid, it h advl^ble to dilate it 
of the liand licforo bejjinninf; tho operation. For this purporn; tlie 
anointwl witli sterile vaselim-. ore arrnnged in the form of a enn| 
witli a rntury rnotinu slowly introdueed thmnjjh the rulra until the, 
hand ean readily be carried up into the vagina. 1 

AppUfiCum of Furrrpn. — Foreeps operations ar« de!;ij;nated as Ion 
high, and floating, aecording to tlii» jHi^iition of the head. WIibd U 
»i>nting part rests ii|>on the perinwum. or lies below the line joinii 
ischial spines, we s))eal< of low farccjtn; when il jir^^^-nts nt nr jost 
the ischial i^pines, mid fun-f^x; when ilie heiu) Ita^ )>artiallv d&H 
into the pelvic eanal, biit its greatest eiren inference has not paw 
.superior strait, hujh f'lrrrjky; and when it i« freely movable above the 
brim the operation is termed forrrpx upon thf flmilini) hmd. 

The low foRCps operution usually offers but little diSiculty, aB 
be nndertaken tipon coinparativ<!ly itlight indieattonti. The mid opt 
is more diCieuIt. but not often excewively so. On the other hand. Ih 
operation if always dilV»'idt, and .ihould not be atlf^inptf^il nnl« 
ptrrulivi-ly ili'iFiimtic! by the cinidition of the mother nr nbild. F 
upon tliL' Hoating head U a most sitIouk prootilnre, and is very 
indieati'd. G<'nenilly epoalcing, the fact that the head is not <>ugag<9i 



■a e^ 

1 



RIHC'EPS 



401 



tl» 






Migii> diftirnportion U-imiti it nnd tlh' •ai|>omr etnit, m that UtP 
viiin Hlimilil tun Ih- tlii>u};hl u[ until Hi-riirnli- inf«ritiiiti<>ii ■* t» tltv 

si«> of both is 

iiTuilubW. Hove- 

over, in those 

caws ill which 

■ere in no wrintu (linpro- 

IHirtinii. and in w-liidi the 

ii|H'niliiin ap[K«R< ri-ii.->il>ti>, 

liolivery can iwiially be ac- 

cumpliMhtNt nmrf ituMy mil 

rapidly by verfiion. 

Tlio forcr-ps in wi ron- 
Btrurteil that iti> cepholir 
rurre in ))cst ndaptml to tltL* 
fiidm or the diild's head, 
th(t biparivtal diameter oor- 
rcs|K>ndin^ tn tlte lini> nf 
gTvjilivt dielancc lK>{n'(vn 
tlio hiades. The head in 
eraniicd in an id«ul munner 
irlien Itw lojif; ii*is of the 
liliiili-* coiTccpond'i to 
th<> ooci pi to- 111 en la I di* 
am«t4<r. tlic fencBtrs includ- 
ing thi' pandiil )iohh-« nnd 
the tijiti lyina over the i'tH.i?k'<, 
whiltt tlH- c'oiH'iiio mnrgiiu 
r.^.Ty.<v..Hr..->Yr Ap-utti. AMA« Occf^ ^f jhe blades look towai^ 

sillier the nwipiit or the 
iacc. With Hiich a grasp the 
fonviX'" olitiiin» u finn hold 
and cannot slip off. 
nnd tnu'ttoii CUD bo 
made in the most 
idvanla^eoiis mntinvr. 
f>fi the other hand, when 
the frirmpf i* applif-d 
obliquely with one bia»le 
0T)T tin* hrovr nnd the other 
orer the opposite mnKtoiil re- 
gion, the pra'p i§ ieas secure, 
and the bead ii* exp^wod to 
, — ,. „ „ „ more injurioua preKsoji*. If 

»»««. iii^rrtK. ""« blade IS amirntcly ap- 

pliii! over il»? faee and the 

nvBT Ihf fivifitil, tlic ini<trumnit cannot be locked, while if Hr* 

ii sli|i)ul down m as to li« only orer tlie forehcail, the ^raap is 



^^iT 



^^ 



^>~n«-t*i. I>luiimni. I*kltk: f^ia** mwAKiw 



402 



OBSTETRICS 



very iiiMtiiri'. ami each tnu-tioii It-mli' to <'\Ifti<l Dw IiwhI <*«,■ Figs, 
nnil ;iii:{). 

for thcH' iPii-iins, thai. Ilic fnnvjit I'lioulil Id- a|)pliif), wlicii ji-issi 
din^ctlj' to till- ."iiltst nf i\n- IhwI iilimg it.* occipHo-mfntiii nr juiio-prtru-UL 

amtUr. This is known as the cephalic 

(.-ontra-diMiiK-tiiin \n fhi* jtrhic applir:it 

Tin- fmriipr wn.* niwminemlLi] 

Smellie siti) Uiiiiih-Ioci|iio. bill 




l^o. aOL^KciRCEM Ai'i'Ui^ Oui.i>jiia.t nvKH Bhow axd Mjk*nni> Rkokin. 



Pra. 302. — ttiioO'iNOTiuT viietoxE BiJknr m Apn.ii:n(ivrmJoriri.TAa» Onnni 




Pid. 303. — Siiuu ma Kjcrrxumx up Kiud -otihv Omic RL.\ni: w Arpun> nvnit Rhivw i 
OniKn ovr.a Oistiput, expuisiko T«N"i>K\<rr or tui: iMrrBrMEXT m Rt.ip orf, j 

it iH more diflirult thnn 1)i<> lallcr, it Ml into i1i«uM>, anti wan not ggni-ratt..^ 
priictiKivI until Pinard, Farubcuf ani Varnier demonstrated the iiie^tin 



(-ORt'EPS 



■ms 



ilraatasff^ which it pnssttR^t ovpr the pdvio application. In Iho lattor the 

h-fl hlrnli- if iipplrii) lip lilt- ivfl mill tin- ri^lil lilmli- to the rifilit fidv nf Ihtr 

inotli4T'-> )<clvU, uo iiiHtter Klial Itio pnsi-titiilioti, <'.Hi?M)ii<-nllv lln- licjiii U 

fnwfM^ <>l>li<iucl5. uiilu# tin; I'flfjittal nuturc U directed aiiUTo-ixttilpriorly, 

All M>ciirntf i(l«M of thv vxn^-t powilton of tlio hvod k aMjlttlvl^ fiMestJa] 

(o the itiiihalic apftlicatino. With tli« liaid resiin;; upon the perin;puin this 

mn iiKualtv In- oblaimtl lir cxainiiiiiig with two llogiTs; Init irhrn it is 

''>){l»«-r up an alt^iolute i]iaKi>o"i!' wii I"? mailf only fcy I'l^t'in'j thi^ pimtfrU/r 

""'. which iiiniall)' nK^-?^it«t<.ii tlic Jntniduclioii of four liii)!crfi or the 

•vttirv? hand into the vagina. Thin, of cour^ nipiires profound ana'iitliesia, 

«n<I in tlii'rrfctre prnct ioahlc mily jukI i^'fon- intimluein*; llwi forcrpi?. Or- 

'luiarilv. ufliT locating tlic ear, iht- ejidmining h»]i) i» not ri'imived, but 

ftnaiuE in place to fcrev as a guide tor the introduction of the tirst blade, 

wUioh iliould be a]>plie(l over the [Mistt^rtor ear no matter whether it be th« 

'^K^t or lefL Thix rule admits of exception in two instances only — namely, 

•"••n ibe luaid is noting UjHin the |>erina-um. when iho UKtttuI suture ««!• 

"J'y e.iteatds an tcro- posteriorly, or wlwn it is movable nt ihe pelric brim. 

■"••uliv iliii^noKiji not infrHpieiitly ^ivejt ri*o to an improper application of 

'"''*^^'|>i. anil is one of the moet frequent factors in converting wliat should 

*n ejilmwly simple proci^ciun' into a nerioii* and dilTu-tilt operation. 

I'''itrrtfu Vrlirery with the ll^ad at the Vuttti. — With the lii«d in tlii« 

*>li<>n. Uii? oli*tarlc lo delivery it tixiiulty due to inKntlicicnt expulsive force 

"*" to al>nf>rnisl re-iistance on the part of the pcrina^um. I'mJer nuch eircuni- 

^^^Ocei itiv Mjpllal «utun' uituaily (>ci'upit^» the ontero-pofitenor diameter of 

Uie [iclrtc outlet, with the limatl 
-^ foniiinellf directrtl liiwanU cith^-r 
^ Ibe •ymphvi^ii' pubis or the eoncav- 
n ity of the .taemni. In eith«r event 




404 



ORSTKTRICS 




IxTnoDL-cnox or IUuut BtJtDii. 




■n.. .11.] T.iJW T'"ij.ii-.;i'»; Inwtkvhext IN 

I'l.tCK AND ARTICUI^TKn. 



tlic forceps, if ap(tli«)) to tlif 
sidtw of (hi! pi>lvii', will (i !"«''? 
Ilif Iu-ikI in an idi-al iiKin nci- 
Ai'cnnliii'ily. (Ill- k'(t Ulml*-- u 
Kilnidui'i'il III till- left ami tVw 
rijlht blaiif Id tbp right iiiilt- nt 
lli(! pelvift, Uie mode of proc«?«J v\n- 
laiiiff mmuwhut iw fn!li>u-«: Twii 
liners tif llio riyht hand «rr 
jias-td inio thf left kikI )m->mV. 
rior |)i>rti<in of tlie Tulvn. nnd 
carri^ up UiL' vagina lr> the 
ii,i;ii>n of the internal os, TTii- 
handlu of the li'ft hranvli i* (Iii-n 
M-i/rtl l«-lween ihe thumb itfi 
Iwo lingiTj; of lliw left liumJ— 
just aa in holding a pen — ai^^ 
liir lip of lh« hinilo i" j;w»''* 
passed into the vagina atoll); **"■ 
liti^-rs of tile right liniui ffiii*'' 
Mine aa a Rtiide. As it H intx^'- 
duced llie 'miiuUi- in held alin«>* 
vertically at lirst. bul »» tw 
lliidi- adiipl:! itti-lf to liip hi*-«'i 
it is <lepre^«Hl, m that it i-vinl^* 
ally Inlets n horixoiils) piwilioC- 
Tile guidini; finpers arc Uieo 
withiirann. and llio haiuUe ^ 
left to itjfllf or iN?l<i by an b««?1- 
unt. In IIk- itame muiin«r, t** 
liiigiTS of the left hand an- the* 
iiilriKliii-i-il through tlw Hjtbl 
and potterior portion of ^ 
vulva to »*-rve a* n pii<le fi* 
the ri{;ht blade, whieh is lii'lil i"^ 
liio right hand am! inirodiit*'* 
into liw niffiiui. The piiilinU 
fiiiKii'^ are now n>mi»fl a*'" 
alt that n>niain^ to lie done i* *" 
artienlftle the hraiiclic^. U^*-'' 
ally they lie in sncb a manim*"' 
that (hey cjin V; htrkiil irithr»*^' 
ditKeutty; but when this canti*^' 
ill' done, finit one and then ''*' 
other blade should Im> gent 1.'' 
movetl nntil they are brougft' 
into such a positioi) un in 1"' 
urtietilnti^l wrih case. 



OBKTl-rrRICS 




L'li urg(?nLl.v indicatnl, it elioiild bu vxlraclcd very elowljr, bo as It^ 
111' for jiroptT sltvtcliitig unci dilaliition of tlio pi'riiwuiii, whUrh U 
(|i,iioiis women tunuot lie salisfaclorily aecoiupliBbptl in Ies6 tin 
ru-^ii In iwi-iily miiiulvM. 

Many authors rem in mend raiuoving the Torciepij aa mod ae 
(Ii»tm<l«i by ihv lioml, aud «luwly <-i)>re»Hing it bj' pnwun; itpwi 

li^finr )>oruou 
pcrintpum. in ihc 
lief that by »o 60: 
the liability to perin 
rupture is dimini«b 
It w my prartim. tin 
ever, to l«i\e Uie f 
n'fw in pliHx- until 
hoad is complptolTlm 
since tu tliiit way ij 



.^^ 



v^' 



P-3.C 



Fi<t. 371. — Law Toncbix * 

1.1 PiMTKiai'ia; IIohihintal 
(KnmlH-iif iinil \*iitn>*Tr). 



pmwible to oxercine fnr ninnr (Mintml over it« t)dv8»cc>, the incrotttwd 
It-iiti'in of \\v vulva diU' ■■■ lh<^ tbirkncaii of the hle<lcH being no (liglj 
to hi- wilhoiit pnicliml itd porta ncc. 



^-^5^ 



tCt 



Flu. 3T3. — 1»K Fo| 
■•IT PiJlum.T 1 
im«n Tittcnnd 
sail Vaniin-V 



Wlu'n the "ccipiil i>- liirwifl p'isTi-riorly. Irat-lion should 
n boriwiiHal dircrtion iiiilil tbo fdirlnwl or root of Iht- n<i-<- 
till? j-'^mphvi'ii'. BftfT wltlib flii- hiiiid1<-w should lie slowly Hi'vjirj 
oc».'iput slowly emerppti over the anterior niar^io of the jxritiH-i 



FOKCKP8 



4417 



"iTifnWiiwiird iiintioii to llw in>'tniiiii.-ii(. iIk- foithcad, iiwc. utid 
II sud'&tf'ivi.'h- eintr^ from the vulva. Thi^i t^nlrai-iiun i» more 

tbiii wIhui tbo ot-ripitt is mituriur, and owing to the greater 
in of the Tulva, perineal tfare are more lUblt; to on-ur. 

Forcfpg iJpvration*. — Wben tlio head lies above the perinanim, 
ttal HUtqre tiif^ually <kx;ii[ik> un <:>bli<|uc or traDi-verw diniiieter (if 
w. canal. In sik-Ii vau^ iIk; fonctjij' Klumld Ir- applied to the sidiw 
ead. Tbu is beat accoinpliiiiied by introducing [wo at more fingers 

vagina suOicii-ntly deeply to feel tbe poeterior ear, OTer which, no 
vbethor it bi' the right or l«ft. thv firet blade should be applied. 
ift oeeipiio-anterior poKilionA, tbe entire right band intrcMlnoed into 
pMterior »e}^iciit of tlte (lelris ebould locate tbe posterior ear, and 
ime time serre asi a guide for lite Introduelion »f tbe left braneh of 
ojM, whic'b it held in tbe left band uiid applied ovur tbe pmti^rior 



\ 



A 



V 



\ 



JpWB PtwTEBMMI I^IL or ("iniir Bl.lkDE. 

M- puido hand i- llien wilhdniwn, when tbe handle of tbe fortrp* 
by an H^iiitant or left to iLsclf, u« it will usually retain its 
hnut dilTiL'iilty. 

of tbe left hand are then tntniduced into tlie right and 
it of the fienHal cnnal. nn alti-mpl tieing made to rcacb the 
wliidi lim in (be neighhourbood of tlte right ilio-pcctineat 
Tbe rijrht hranrli of the forei'jti. held in the right band, u 
iTKlnr*^] nlonc the left hand an a guide. After its introduction It 
inin- fn apply il on-r Ihe nnlmor ear of Ihi- child. TbU- x* ocfoni- 
liv i^rnttv mtaltn^ it niilfrtoHy until it comi-s to lie dinvtly oppo- 
hlailf wbti-b WB" firi-t introduced. The two bmnehes hein^ now 
■ -H- Iilnib' of tlte foftviK iHvtipii'ii (he pnnterinr ami ihc ollfcr the 
. .:.. iiiity of the left ohikpie diameter (see Figs. 37'1 to 377). 



■ios 



OBSTPntlt'S 



If tli»? lifwi is in (III- k'R Imiw- 

x'ersc position, llie foweps ia intrti- 

(Incnl in u t'iniilur nidniicr. tht.- tirst 

lilnde liciiig )i]i)iii«?i,l iivcr tin? jMiiftfl- 

rior car. and the second being ro- 

tatt>d niilfj-iorly tinlil it. cnmus ro lie 

oppoiiite tiio first. In this case one 

iilniiv liw in rmiit of tlH-Nicriiiii anil 

tiu! other ix^hiiid tlie nviiipliysis. 
In Dm rij;lit positions, the blades 

ure introduced in a similar inann«!r 

but in opposite directions, for in this 

ease tlie right is the ]K>!ilerioi- ear. 

over vrhidi tlic ftrst bladv must bo 

appliod (i>eo Fi^ 378 to 380). 

ttTiMt'/^rr ihv original j«i»ilioTi of 

Uie head may i*. ilcliverv is i-ffwleil 

by making lrii<-1ion obliiiucly down- 
ward umil the net?i|iiit appears at The 

vulva, lb« n»l of tbw op^^ration being 

oompleled in the manner already de- 

wrilwd. Wtu-n llie iK/riput i* nlili(|in'- 

It anterior it Rradtially rotates spon- 

tanMiiii<ly lo ibi- Kyinphy>ii<. pubis a* 

traetion is made. ,But when it ia di- 

riTli'd trinii'viTwIr. it i» Bonie times 

necessary u> impart a rotar>- motion to the foitope while makin]; ti 

iu order U> bring it 1u Um front. The dinvtioii in whiHi thiK i« In tw 

vnricp, of eoiirse, accord 

( ^ the {Misition of the Oiripnt 

' T. lion from the left side tl 

'y'' the middio lin« liv<D|;^ noj 

when th« oceiput iB dj 

towarfl^ lh« left, ami I 

revenrc direction when i^ 

reih'd towaiiis tbe right I 

ilu' pelvis (set- Figs, 




Fio, 373. — MiB Fnacxrs. tsmovDC 
8EroKi> Bladc 





fiOK. 318, 377, — Mio Fohckw, iMBmoiiaNT Avi-tJi:c> is I.. O. 



POKCEPS 



409 



in nuiking traction. iH^fori,' llu- hfiul appears at the vntta. niK? 
iiia\' Ik- eiii|tlovtil an-oittiik); l« (he amount ot foncf rti^uircd- 
-■*. whfii iIk' Simpson 



or both 
In Uiv 



■■ uxil, OIK- liuu'l gra"!!!* 
luniUtsi of Ihc in.ilrumeot, 
tliH finirvTH of tlic other 
'buokeil over llii? triinsvi-rw 
tthni at their iipjKT cud^. 
uiuit Ik' iakva tuit to cm- 
>y ton iiiQcb force. To aroul 
iimir Ihc npiT«lor "WuM 
I nr sit with hU aniii' lli-xetl 
thi' elbowr* livid doiv^r 
the tltorax, as it is not 
•'rTniMJlile lo make nw of Hw) 
t. am) Htill lata tn 
■ t &gaiit<^t the K>do 
the tnd (Fig. 381). 



•fevX 



I) 



I 



K 



Hk. ifTS. Fig. an. 

Vtot. tlH, Sn. — Mid Ftxirxm, JxitnTHnrr Aprusn i» R. O. T. 

Afffu'it'ftn ii( f'orifiKt in Otiliqurlii Pn*t*ri»r Pimitions. — Prompt do- 
frtx|[it'iitlv U'coim's DCKt^wnry whvu Ok fnial\ foDtaoeltc is directed 

towards nnv or otlicr 
sacro-iliac Bynchondio- 
nu — namclj, in R. O. 
P. and L. 0. P. pre*, 
entationit. ttlwii in- ' 
terference ia nijuirwl 
in i-ilhcr of ihcfc, thf 
head U!(ually Iks nt or 
In-low till- li'%'cl of the 
iiri'liial !iipiiM», ami it 
nMiaWy imppffoctly 
flexpd. 

In many cases, when , 
the hand i^ intraduced' 
to locate the posterior ' 
car, tlie occiput will ro- 
tati? i^ponlonpoucly from 




t*i. 3Mt —Mil- K<>«(-Kn>, R<>T*t).>\ »u R. O. A. 



a iKMtoniir to u trau*- 



410 



OBSTETRICS 



vene poaition, and dclir^rj- bv forcepa is then reiulily accatDplislwd, J 
alrriidv doserilxii. If. Iiowx-vcr, rolutioii dot's not occur, llie Iwwi vluuldj 
KeUitl, with four fiiip-n' "vcr il* (Hwtvrior himI the lliumti over its anti 




\ 




Fl«. 3S1.— f*i.i 



M v\'vMi *'t \1>M ■,. 



&Ud Foiiaetii • I 



ear, nrid im nllntipt niitilc tn rolato Ih^ (Kviput to a transv«rw> 

ThU can frequently be accompIiHhixl with ^rent oam, an<l occaHmnallT fn* 



f^ 





IV SS3. Fiit- 38*. 

Pi(W. 382, 3S3. — DiAUHAHA nHOwticfl RoTATinx or OrcitTT 10 &unm Axn ftoW* 

I'lmi* MHI-KPTIVD.T. 

rotnticMi t<> iin aiitcnnr (loaitjnn cnn be limu<;ht about. 'I'iw fomet^ ^ ' 
applied ae described abore. 



FORCEPS 



411 



. number of cases, however, niantuil rolntiou cannot be effect- 
Mfps muxt ihi'n be sppUnl with tbe occiipul ftill tlinxrtiii ob- 
r. I'ltikT \Uv*K viTviiimitntHiyf, if lliv iiiHtriiiiit-nl 1m! ujiplicil 

||h> U^ail, or I'Vi'H olili<|ticly. un<l an alt^^iiipl !iiail« to Hfivt 
tkinj; irai'Uoii in tin- ii^iiiil iniiriiit-r, grval ililiiciiltv is es- 
verjf powurful traction lei-oniw De««rii>arj-, wlii<:)i, rnjvcrtliu- 
ild to briug iitoxit the dwsirwl nwult It U this experience 
n rifie to tbe p;ri'it( ilrond in wbioli tlK^- pixyvntutioni: arc 

anil a i" a wry piml prarticiil rule whenever uiivJKjn-etHl 
perii'iu-etl in alelivt-rin); niinl in appan^iilU* u sini|ilo nnl^ 
ID, tn think of the posxibilitv of n mistake in diajcnoHifi and 
;tK> iintieiil. In 
tv of such caw)' 

tani-llK will Ih' , -4 . n 

I to<rards one ' \ 

■•iliai: «ynclion- 



?nr di'livi-ry tn 
muMt rotate ao 
JMgittal iiuturt* 
e with the an- 
tismtrtur of the 
I This can U- 
ly rotating the 
ios of Ibe for- 





■iiwtNii txTKBkloN or roiic-Em whkv ANTKaioa ItirTATioM nt *rm<i-TKD 
B. O. 1*. PiMntos, wtmon bkaffltiku tiie Ishiwomknt. 



DO(!h an arc of 45 de)!T^c« to the liollow of the snomm, or 
136 (If^TOrut t" the >>Tui))hvitii> jjubi*. The lat(«r i« preffmblc. 
hat delivery in llie former position is more diflicult and also 
pvi; riw tn dii-p jHTiiieAl twir» (I^jr»- 38S iind :W-T). 
fly, whi^ it in dtvireil to rotate tlw occiput forward, the 
in) In the M(\i-^ of the head in the nsual manner, with the 
e directed forward, becomes inverted by the time rotation 
r> that th*' pelric cnrro looks posteriorfy. sin] an nttcnipt«d 
iht' inHtrnment in <hi< poxition i.< liable (o <-au4e jwrioua 
tabmuU mft parttt (Fi|^ 384 and 385). In order to aroid 



412 



OBSTETRICS 



this, it is )>e6t to rcmorc and rcnp- 
\}i}' tike iDstruiiK^nt. If mw. wUIias 
to avoid this duuble application, 
the head tnsy bu Ki-izvd obliqtivir 
with one blade ovftr Iht; aiiit^rinr 
brow nnd the other over tlie pos- 
terior iiiai>toi(l region; but thtit 
procwiure is much more dillicult 
for the operator iim! fiir nmii? duii- 
KertniJ* for tho ohild. 

The double applicatiitn of f'tr- 
eeps in thU daxx nf cawh wm 
rciiiomiuetiditil liy Scammii itisiiy 





Fie- 38& 1 e M7- 

Fin*, am, 387. — tk'AMlOKi'M HAWIBirVRK, KUWT Arn.lCATIOM 09 FbMSI 

years ajro. and io my hamls has 
frivcii MK-h vvccllout r'*iiIU thai 
1 employ it to thi; exclusion of 
all othar method*. As tlic right 
occipito fKMit4>rior oRotim fur 
more frpqiRiilly than the left 
vtirioiy. T shiUl lU-siritic in <li'- 
tail the procedure indicated in 
Uie fontKT. 

In the flrst step of the opera- 
lion. IW- blad''« lire applied t^) 
the sides of the head with Ihe 
pelvic curie looking towanU the 
We of the ohihl, whereas in the 
.■K'cuiid ninnipiiliition il hHiliK 
towards the occiput. For the 





Fig. 888. Tig. 3Sil. 

Fmm. 388, 880. — KcA^noKi'a Uakikvvhk, hiiowiho RwtATiOK to Tiu.'n* 



FOKCEFS 



413 



Kfinl application (Figs. 386 and 387) the right hand iii pamni into Uie 
'tft posterior iiefiiiiirat nt ihe )(cn)tftl trat-t, aixl Uiv |io«terior (right) v*t 
laght for. Otfr it the left 
bii« " Hpplktl. Tliii' ii' 
tuftil in {HRiiUdii hv *a a? 
iMCajit. while the operator'- 
tft. hand is pUMud tntn tli<- 
■jBxt «ul<.' nf lh<- vaj^ina an>l 
^M- il i* iiitr»<hK'>'<l tlo 
^■mt Made, which is then 
^LftSftl aiitrriurly until it 



^^^^ H». 300, t:r: 'M\. 

^V^ Dill, 3nl.^-<kwUlti>KI^ IfAKiitirvMit, ■iHivrxo RirrATioK iw AMntKinB PowniMt 

^K FoRCEm Ikvkhteu. 

Hkme* t» lie opposite the bla<ie tint iotmduc^. The forceps U then Im-lcDd, 

BU bUilus Dov oc^ipying the left and the nigittal >FUtun) (lie right »b- 

h'lUi' iliatntrfer of tiic. pelrta. 

Ihvnnnl traetiuii ipi llieii 

■■•li) until lli« lii'ail irn 

r>IW»<ipon tlw pelrk tloiir 

*Imi a rotorr iii<>linii i^ 

iBptrtid to til* forreiis (.. 

"tuA the iKcipiK i* j-lowls 

niUiA to a rijtht tranHvery^-, 

*MUtrr on Ui an nUi(|ui-l\ 

■■'"i'l: fMiitioD («w Fijr- 





» 




i^n 




rnH. 39% 3B3. — ScANniHi*it Maxoii'thi;. !twir\i\.. A. 



■ <• or Kokrciwi, 



TV foix'epa havin); become in^-erted mu»t he taken off. and reapplied 
to the uiual iiiunii«r tu llie head, which now ocmpieti a Hghl anterior 



414 



OBSrETltiCS 




i 



poHilion, tt'liun ddivwy i« nyiilily nw-fimplijiliwl. Some diKicu 
ill Win^iiij: nl»nt ))ro[RT arlii-DlatJon. sinrt- llio ImmHe i.( Ihi 
Ijin^ alii»i- the right iviiiii'il Ir- liHkitl, but tlur* laii Ix* rcai 
|}j- rotating; tin- former araui:'! tin- hiltor wi «k to liring llic I'w 
pimitioii (HI' Fij;. ^t'.M). In left iMwilkins the hladesare uppliet 
manner. Imt in ihe re\'erae (iirection. 

By Ihii iiK'thod i hnv« ubtuiiKtl mast tmtisfaotory results, 
nhle t'l <iL'liver many women with osiw; nfter the iKual niotliixl 
ImUiil. mv ■■xpericnci' lum Iwcii •« sHti»fiUTlorv tliiit 1 liavi- i'lm 
rtciip) ti>- 1 » interior jirt-Mnlation!!. ami now re^jaril them with 

fwliii^' that. 
he readily a 
fi*trtl wfhei 
To avoii 
ty <)f ttiii.tiiiit 
in mind wh 
and «'tii«i 
hranch of 
is a good pn 
fr)r a in>j;iii 
having madug 
i!ia(jn<>-->is of 
of Ihf lii.'ad, 
lh(- fiiri'i'ps 
fhem l>ffore 
llur piitii'nt, 
lie readily 
liow thty (■' 
plied, and w 
is to go OT 
rior ear. 

Higk f 
]\H!i iiln-iidy 
llie higli a 
(lillit^ull [hti: 
low fori?epi 
iitiil shouh) 
tiilji-n iinh'wi urgent iiidic-iitinns are prcKonl. If the heaii he 
the forcejw should lie applied li.* in lh« mid or low (ijH'rulion, 
owing to Die more c)e\'atf<) position of tlic litntd. the blades n 
dueed for a greater di^laiioe into tlie genital iraot. 

On the other hand, if the entin* head Ues above U«J snpei 
only a umall segno-nt of il if cngagnl, ihv use of forct-pe glwn 
if possible, as »nch a condition usuaUy indicnte* con^idcrab 
tion iH'lwovn lh« hiL'ad and the pelvis. If, however, the open 
to lie oalle<! for, the fiiriTji* ^hoidd In- appHwl oliliqwHr. o\ 
thu mastoid and the other over tlie oppo-iie brow. To ray 
the only condition in whieli the intervMln ol Ihe mother and 




hfl 



I'm. 294.— SfANWiNl"* Sl*.\o:Pviii:, ■i<ou-ik» l>irricl-i.TT 
1.1 Anricvt^rinu Iii.ahiji in &i;<;uki> Ari-LicAtiuN or 



FORCEPS 



415 



ill}' aQ]>lrinji: lli<- font'[Li ilinirtty b> the aid^ of the hcoA ; Uut 
D'itr llnTM' I'irc-irni.-lam-i^ \iwrv »r^' m-'vitiiI con Ira- in< lies (ions. In llip Rret 
V. as the pclviH U UHtiall}' cniitrucU^l. Uk- kii^^KkI >^iitutx^ will g<-nrriillir 
tnuaterMly, anil am>wnliu(;l,v ttie bladra tj( Uie foroepa, if applied to ths 




K — TVtuiMOt imnwiNn lirmrr or Cei-iiaiJ(^ Apruci-naiN nr FonrKm witEV ItK^lt 
Ki 8in]iii-m ttTntn: lUuir*, Ijke im-i<'«tix<i IltHM-noK or Aiti'ai. a^ii Doi-rxD 

lof till' ImiuI. 0-ill <ircii|i_v tin- cxlrvmitiir* of III'- <v)n ju;^ta v<th, and thuii 

[ftiTllier jntita-ie tJi* d i » pro jnn' lion. But iiiitn- iinjMiHanl nlill '» the 

^M llut, i>inrr till: Kliajx- nf the birth cunal makvn it iiRpoK«iMi.> for tlw 

llnntfn to miirnrin to iw axU, (lie poaterior hia<Ii! Iiridcff ov<;r llie anterior 

[**a(>ritj fit t)u! i>a<-nin] and tlitu; pn.i-i?nt« lliv hmd from (■nli-ring tho 

nriiy. iind ho defeats the Tenr purpoHc for which the operation 

)■• unil'Tlakt'D. 

'irU-tntrliiin Forr^px. — With the onliaarv lung forcepw, th«? htjjth and 

'*****nallf evtm thr mid npvnitinn i* i-odiparativoty diflieiill, Klroiig trso- 

'"• Winjj DM?i-:«arv to ertwt delivm-. Thin is liiw to ilw fat-t that, nwiag 

' '■'Wffcapp of the liirlh caiiiil and of (he fi>r(fp'. it i* impoiuiiltli?' to pM-rl 

' •'Wioii dirM'tly to the aiis of the superior strait, 'Ilie latter, as we know, 

'*^U, if coDtintit«1 downward, piiK« thrnngh the lower |Mrtion of Ute ea- 

"■*; Iml, owinj; to th* prewnce of tlie perinaMiin, (he extremity of tlw 

**"■ and tho corcyx, it ie ini()os«il>Ic tn dcpnr'* (he hiindlf« of the forceps 

^^iflilit tn piTtnit of Irartiou in the dtsinil dirwiwn. A* a ixinHOiiuenire, 

^ * "^ (iitnidcraljtf part of the forro vxprtiil is wa^tt^nl in dra^^ing the 

**''vauft ttie firmphrsu inMtvd of Winging it dmrnwan!. ThuM, Tar* 

•^■tilft] iini ihat a fnrre of 40 pounds employed in an ordinary hijrh 

'"■"tion W"ulil he rtiiolv«l into two {nniv — <inc of M pounds and 



OBSTETRICS 



the other of 26 pounds — (he former hfflng in tiw axis of tlte superior nil 
and serviti)! to brtnj; uItouI dwiwnt, whereas the (ailiT winih! Ix' ilinr 
ujffiriKt th<' syiTiph\^itt piihU U)^ would not otdy ho «a«tuJ hut wotUd vz 
ally retard delivery. 




Flo. 300.— Tarkikx*« Diaumam, buoitiho DiirKrn) or {Ixihnarv Fmickpk 
ABC, line of Mtiml inutlon; .1 U B. Hne at daiinid tnetioa: ASF, lurar ««ctnl • 

This defect in the forceps has long been recogniMKl. SaxtorpI 
1778, KUggwti-d tliul ddiiren,- could In; grt-JilIy faoilitated hy atuchi-- 
lae to the ej?e of eaeh blade and inakiDg Iriiction upon thwMj. u mm 



-1\ 




Fni. 307. — pMirrt MAxoit.*vnE. 



with the handles. He also showed that a similar nsult might Iw »"*"'■'']; 
by mukiiig strung downward jireiuure with one hand in thv BeifthbouA*^" 













tl"^-''- -Vow 

^' V "Uehilln. 




*'.u":r "■ ^"-'w^ 






41 S 



OHWTKTKIfS 




fia. *02. — TARMi:it*ii KoiK-Bm. ■|'RA(-ir<ix Bot« im Pumte witti- 




perineal ciirvo. (irMvtili^l witli nliorl, ifctacUnblo tra^-tiou-roiis, one of whi^z— "V 
ix iriKcrlfjl jui^t beyond Iht- vye of t-ut-h liladf. WIkii i«>( in wnts tli«^'«=* 

are held in place fc w 
» pin upon the L3 
di-T (-urfaec of 4 
»hutik. frrtm wIij 
they can be rcaiL 
rn't-d, Hud nllac) 
Iiv their free er 
lo u trat^tioii atlit- 
nieni whit-Ii tenninateB in a handle-bar wliich ean he (gasped by one i* 

Ixilh hands («i- Fig*. J"'.' nii'l 4«:j). 

With thi& device, traetion can be maile almost in Ibe axis of the aiipe^r" """>! 
wlruit. ami, nwing lo ihc [iri-si'iiiv "f niimepm!' joint* in the tntclion atli^ — '^l' 
ment. the instniment can lie useil in any position. The handles of llx 

forcepd mfrclv w-ne I<> indiealo ibfl diroction in which trartion fhnuliL Ix 

made, the !orce bein^ applied to the haiidle-har, which h held horizonta 
no mattiT wlial Ok- iM>si:i.iii cf iln- bliiilc* may l>e, th« traction-rod* la™' ^"1 
kejit I centimetre beneath the handler ( I'iR. 4W). 

To my mind, this inKtmnii-nt i* *iiji('rinr to «11 other axrvlractinn 
cepa, and viith it moHt exeetlcut reiridts cau he obtained with a mining 

i-xfienditunr of t-m- 





and by it-* aid a di-— 
i-rv <yui (H'Wf i'>riall_ 
effected whioh wo -^"tW 
haw hwu impo«f«K:- Wi- 
with the ordinan' '"- 

stnininits. One of ''* 
best p<iinis it* the joint hetwwn Iho horii^onlol aiul vert» ^^ 
portion!' of Ihe Iniction at ta^-hniiMif , a* a result of whicJi •™ 
handle-har can be held h'iri/.on tally, even though thi' for***"/" 
is applied ul llu- i-iic!s of lIu? unler(>-[)nxti.Tior diameter *' 
the pelvis, I use this inKlninient in all eases, without *''' 
I racl ioii-r™ls in low and mid, and with ihcm io high '••'" 
cepi* operations, 
A ppliralion of Fonepn in t^acf {'rfxi-nhlian*. — In face pr«*i«nlalionr* *'"' 
appliiatioii •>{ fi>rci>p.-i occiisi finally bwimies newssary, htH KhmiUI lit* *'* 
templed only in the IrantvcrH.' an<l anterior varieties, the blades iK'i"*'' 
appli<Hl to Ihu »idi-» of tho ht^d alonj; the mento-oc-cipital tliainetef, V''^ 
the pelvic cun'ature directed towards the neck. Traction is made in ' 
downward din-ction nntil the chin appear* tind<T the symphyj'it': th<^ ''■* 
an upward movement the face is slowly extracted throiijjh the vuha. "** 
nose. Kyisi. hmvi, and ofeii>ul appcjiriiif; in succeitsion over the anterior i**'" 
gin of the [>erii)n>um. 

Forceps should n"l Ije applii il wlicn llie chin Is directed towanJs h**" 
hollow of the .'ncruin, as deliverv cutiimf !»■ ffTnleil in this position. '" 
rare instances, however, an e\|M'rl operator may enileavour lo luttt^ 
the chin to a Iraiisvvrsv mid lukr to an anterior pusitiun, though fix^ 



POWIKlti 



410 



nnpb aru rarely euecesi*ful, and are permissible only in exceptional 

Application of Forceps in Breech Presentations. — Occasionally the appli- 
«Hi of forceps is recommended in franii breech presentations, the blades 
tg applied over the trochanters. This is very rarely indicated, as deliv- 
can usuallr be effected more satisfactorily by the methods to be men- 
i«d ID the following chapter. 

from the time of Smellie, many authors have rocommendwl the ex- 
ttioti of the after-coming head in broerh pn-sontatinns by means of the 
cpa. In such cases the body of the child is carried up over the abdomen 




Fm. 4I>4.— 1>ia<iha« hkdwimi THirrioN with Tahnikr'h roHCKPtl. 
A B ill pntper uid X Y in inipnrppr inannpr (Rjbeniunt^L>pHH&i^nr:4). 

file mother, and the bladi-s are inl r<>diico<l under il and ap|)lie<l to the 
"•*»f the hea<l. .\sa matter of fact, it is never necessary to resort to the 
T^T* under such conditions, so its employment is not to l>e recommended, 
*** the more expert one beonmes in the use of Maiiriccau's method of 
**'rtion the less frequently will difficulty Ije exjiorienced in delivering tin- 
■w-toiiiing head. 

'^''jiMMM. — Jjow and mid forceps operations, vhen intelligently per- 
!*'''*Jiipon healthy women under prn[)er aseptic precautions, should not 
■wllowed by lualemal mortality, tlic ojteration beinjr undertaken to save 
*'**nitland f<f*al life. 

" i* generally held that jM-riiiciil leiirs occur more fr(H|iicntly in for- 
"^ti«a in spontaneous deliveries. This, however, should not Im; the 



420 



OBSTETRltS 



caw, pmvidt^il ilinl Iho head in extraclod siifiinonlly slowly. I'pfortuoatcVj, 
it would appiar tw tliough llii- av.-rap? Ofwralor, a» mhih W* llii; bt-ad ^"Ir 
[N-arn at ll»> vulva, i* seiwd willi an almost uncnittrollable dpsire In t-fT«f«l 
iU immediate d(.']ivery by briiKqtic truction, i[i»li>md of imitnling nature ^t-aul 
devoting from fifteen to twenty minutes to overcoming the nwisitanoe of 
the perineum and vulval oulJt^'l. l^-opold liu« statL-d that the forcepis m ~Chr 
blomliM of all olwii'tiical operntinnw, and this is undoiiliit^lly true if 
rhild ii^ rapitlly dra^<!i'd thn>U|:]i n partially dilated birlh canal hy t>s — miK 
force. On thi? other hand. If properly employed, it is a iiioan« of «i%- Snj; 
instead of dcetroying tli<; perinsum, iD&sniitch as t)i« exit of the head 
be Clint mlleil more effectively by means of the fonx-ps than by any r>t-3icr 
prnc'iliirc. 

AttiTiijit^ «t delivery thmtijih an iiniH'rfrtlly dilalinl wrvis are ti"« <*l 
dangerouj', and frLf]ucnlly rivc rise lo detp cervical tears, which may I **' 
to the death of tlip patient fioni hn'morrhago or infection, iloreo"^-'". 
tliL- application of fnrcpps rr(|nires an acenralc diagnwis as to the i**'*'- 
lion ami prvsentatiou of ilie diilfl, and when Ihirt is liu-king, a.-t In «?rtana 
Occipito-poBl(Tior and brow prenentalionfi. and the forwpa is ini'orr«>*^^')' 
ap]>li<-d, deliveiy can Ue t-tfeeti'd only hy bnite force, which Ciin hanlly f <il 
to vaate (-cnouH Ic^iomi for mother and child. Similar untoward rve***^^' 
often follow an alli^inpt to drag the bead foreibly through a mark<~*iJ> 
contracted pelvic brim. 

The fo'lal nionalily ih-iH-nds u|H>n the jifwiiion of fhv head ami *^ 
general didicully of the operation. It i^hoiild lie practically zero ju I*" 
and mid operations, esfC-i-pt in the rare ca.-<M in which a fi,inud-«hafe( 
pelvic i» ovcrtookeid. In a comparatively large experience, I can rec*ll J 
only Iwo eliildnn mho.*!' deatlii* cmild Im diiXTtly nilribuled to tltc ope*** I 
lion when properly pcrfi7rme<l. t)n the oilier hand, the high forceps opam- I 
tion in atlend<il hy a very siTimw fii-tul m'lrlniily, which bceomw ?«•*" fl 
the less deeply ihe head is engugeil. In 8Uch cases the head niav be tu^ I 
jn'Ii^l to injurious pn-ssiiri', wliich may li-nd to the nipltirc of inlr«"*r*** I 
vessels and the ^uh^cijiu'Ot death of the cliikL In rare instances aclii^ trt»'' ^B 
tiire of the »kiill may otrciir, and iM'casionally the upper part of the MC^ ^ ^| 
bone njay become separated froni its base, ^B 

Not infrnpii'Jitly thi- child may In- liorn with f<u:wl jjofaJjWM, *r t ■'^ I 
CDodition may develop shortly after birth. This U usually nntvl "la* . 
the head lias hcen rw-ixed obli<|iii'ly. ami if dm* to the pre^jmn* iiirrt>^ 
by the posterior blade of the forceps upon the neighbourhood of the itf* 
inustoid fiirnmen. Ihrongh which the nerve leaven Uie skull. Not eve ^^ 
facial paralysis, however, following delivery hy forcepa, should be attrilw*^^'^ > 
to the npiriition, a.-t <»eh a eonditinu i* ofcasionaliy encountered «fl« 
s|H)nlaneaua labour, and may be due to ituracranial cauitet) <]utte indepw^^ 
cnt of the n»c of in»trument». Full literature upon this subject will t^ 
found in Mae^'s article (1901). 






FORCEPS 421 



I.1TF.HATURK 

umi. The ChanibeiieuB and thu Midwifery ForcepH. I»ndoii, ISffJ. 

niAcqi'z. De la maui^re de se aervir du forceps, etc. I. 'art dea aecouchetnents. 

N'ouv. «d.. Paiia. 17^, t. ii, 300-343. 

i». L'iuvention dii forrepa & double courhure. Progr^ M£diral, 1870, tv, 779. 

a Cbamberlena. Iiequel d'entre eux imapiiu k- forcepH. < IhHtf-trique et (iyn^rolo^e, 

1886, 659-A68. 

MAN. All Vjitay on the Improvement <if Miilwiferv, rt<-. Jiondon, 173.1. 

nAOKT. he forrepa, etc. Paris, IH7I. 

■Ktions du fon-epM. Paris, 1891. 

UBDP et Vakkibr. Introduction k l'6tude <'linii)iie et h lu pratiitue dca accouche' 

nenta. Paris, 1891. 276-406. 

AMB. Cases in Midwifery. London, 1734. 

KANN. Veber eine neue Geburtaiange. Berne, 1S44. 

■BT. Not« Bur r^uilibre du forceps et du levter. Mtooires de I'acad. royale de 

Brlgique, 1860. 

tcr. Observatiunn sur tcs causes et les accidents de plusieurs accouchements labo- 

rieiii. Paris, 1747. 

t I)es panlysipH faciales spontan^es du nouveau-nf. L'Obat^triquc, 1901, vi, 

517-526. 

ILK8. Modification nouvelle du Torceps. Jour, de m£d. de Bnixelles, 1871, Hi, 

110-1.14. 

oil. HJHtoria literaria et critica forcipuni et vectiuin obstetriciorum, Lugil- Rat., 

1T94. 

TN. See Le^Tet, 

.±xr. Des divenies esp^ces du forceps. Paris, 188.1. 

tUL I>ie('huiiiberleni^ Archiv f. <iyn., 1887, xxxi, 119-144. 

ruitra. Theoria de diverso purtu, etc. Havniae and Lipxiae, 1772. 

num. Lehriiuch der (ieburtHhiiife, II. Aufl., 1853, 838-840. 

LLIK. A Treatise on the Theory and Practice of Midwiferj-. Ia>iii1iiii. IftTi'i. 

XttK Ilewription de deux nouveaux fon-epn. Paris, 1877. 

r»inr*Bi. l.'arM-nnl nlwletrical. Paris, Stciiiheil. 



:ha!tkr xxt 



BXTRAcriOli! AND VfUSlOX 



Extraction in Breech Presentations. — Tlit> deiiverr of tlte chilJ 






i-5 



■ XX 



tracltoii u-lit.>n Iho Rvt protrudi! fmin the vulva in brwcfa pnvcnuti" 
was probalilv Ihe earlieM obstclrical o|M!ratii>n. .j, 

Fmiii iIh- liiiif (>r Hippinnili-s up lo llir beginning of tlie sitlti*^ ^ 
cfnlury liL-ad jm-oiUations alone were cunsidi>i*d normal, awl lu-tice^l ^ j, 
nutlioritifs. » ith \\\v. t-xtrplion of t'clsus, ndvioed llie conversion of bret"^^ 
into vertex preseDtationH at auv ccmI, even though it n>nd««d Dcre^t*- 
■inputaiion of lliu limits. Afk-r lltv n-xiiKcilation of pmlalic Ten4oD ' 
.\nihroipe I'art- and .racijiies (Juitleiiieau. lufirf rational tic** prevailed. ~Ji 
llial in Iho tti-\ci!lwiitli iTHtnrv w find Maiiriroau advisiug ihe iiielh*^^^^^ 
of ej:ti'ai-1inn wlitoh is in general use at tbe present lime. 

As the t«>clini(jiic- of lliv operatioa vnrico aocordlDg as one has to 
with a I'utiiplole brt-ccli or font, or with a fi-ank breccli pn-'Cfltatifai. 
will \vi neee«ary to consider llie two conditions M^parately. In bolli. t 
O'iK'iilial prt-nipiiBitv for ilw jiiic<T'.«riil piTformaiKf of extraction lie* 
the wimpU'te diialalion of Ihe ecnis and the ab.-enee of anv serious i*-*^ 
t'lmnicsl ol)>.la(k'. It is triii- that in u wrtjiin niiiii)H.T of cnsix cilT«ii*^^ 
through an iitijicrfwlly dilated penix is possible, but tliis !■* usually eftsrt^^" 
only ut lliL- cii8t of rlfi'p ciTvicnl li-nnf. Slorf^tver. Ihe additional r»i*U»^'* 
ofTeriMi to ihe )iassaxe nf tbe bead will jfenerally lejid to iIb extension, tl'**' 
arms at the same tim« beromitig devated ot«r it, Ihercby so coinpli«li«^* 
and delaying diOivorv that the ebild is almost inranably lo*t. For tfc? ^"^ 
TOiisons premstiire cxirnelion i* indienlcd but rarely, and then only in iJ^* 
inlei(»ls of llie mother. 

hidicaiwtm fur Kflracdun. — ll \\af aln-ady hivn pointed out Ihil \9^ 
fn-tal morlality St. considerably p-ealer in breech lliau in Tt-rlex prwonr-^" 
lions, sinw in the former d<^lh frmn a<phy)iittliou is almost im-viiai^ 
if Ihe htfld In:? not delivered in le.v^ than fiijUi vtinutrs afier tin; acpffl ^ . 
atice of the umbilicus nt Ihe vulta. In these ca^«s the untoward nm^^ , 
may be duft to ««(• or oIIkt of several causes Tims, very often the coi^^' 
is euhjpcled to pressure between Ihe pelvic brira and the head, which m»J*'f^, 
be t»o severe as to iliis'k iDniiili-ti-ly Ihe cireidiitioR. Iji-jm frequently U*^^ 
rapid decrease in the -ixe of Ihe ulenin following the extrusion of ihe l»jdt 
of Ihe chihl rt^utls in prenialiin.- jteparation of ihe placenta before the hea4 
is bom, so that death becomes jne\'itsbte unless extraction is prompllj 
effected. 



EXTRACTION AND VERSKtX 



423 



•}\ |iKN<'nl«!ioiiH, 1 1 r< 'I turn til in.' :'ti'iulil In- mmlc f«r (-vlrm-lioil 
If liiilliH-kf ii|>jH-iir III ilii- viilvii. Ml iliHl till' ■•[•fnilkiii I'an Ihi 
iirlti) to if, iiftiT ilic iij>|H-iiriiti<i' rif ilii- ittiibtli(-ii>, llio cxlnii'ioii 
die ImhIv (Iik--? lint i'u|ii<lly fallow. Iii u ciTlaiu riumlH^f of 
ller whal llit- |N»>ition u( llii? lin-wli. i-xlrarlion mnv \ie mllcil 
(7vndili»u wliieh M-rioiisly thrvalpnti tin- lif« of the mother or 
m» in vortci: |)n-M<iiiaIi»iiK. When Kiii-nkiiig of ihc Intk-r, Iraw- 
nid Unit till' |>a>iKU>:<- of im-miijiiin indicaltnl that Ihe oliiW was 
vlu-n-tbt JQ UfiHt'li {iiint-uliilioiiK Kiit-li uit iM^curix-m-i* i^ willtout 
I, a« it U simply tin* R^tilt of tin- compiviwioii to which tho aMo- 
cliild )H iR'iiiJit i>ul)jivtiM). 
ion by One or Ilolh Frrl. — Itvfoiv boKiD"ing the operalion the 
luld be limu^lit Tij tlio itl^-t- nt tin: In-il iiud nuliji-cli-d to lliu u»iutl 
prpparatiuno. ('oiiiplote aii»iUhe»la is nwnwarr. except ill those 
:icl) tlie liody of tlm i-ltild )iud alrtsdy Imkii born and oidy the 
DB to bi- FXtracted. 

lie, ^niraclion i--< nil exln-inoly simplt; operation wlicn l(i« bnt-di 
oni sponttiK-otuly, wbin«a« it is !»>; eo wbco th« fvel arc Id 
and v«ry 



TV difficult 

are iitill 

iit«rni^ In 

nise, one 
i hv pa^iKCd 

(.■ervix and 
mndf to 

feet, the 
bit Bra*pfd 
nannvr I bat 

fingvT li«« 
Ml. Ttwy 
ongbt down 
nagina. and 

made un- 
prar at the 
, however, 
is I'XpiTi- 
;izmg both 

i! extracled 
r maiinirr. 
ail the feot 
n thp vnlva 
he wrappeil 



/ 



\ 



>iK«nlos, "nukcntiv tjriiN Fkict. 



Uimv\ HO itiat a firmer irra--p may be obtained; Bim* thi- Tomix 
dew them >*> ulippen- lb«l thM' are very rliflieull to hold. Trac- 
inade in a downwnni dirwtioii. and as the lege prolrade Ptill 
an- gta»|«!d hijrlipr np. first by iho mJv«* and later by the 



424 



OBSTETRICS 




JhtgliH. When tlte breech nppcim »t thft vwlrn, jrnction is matle ii 
L«ard direction tinlil il w <k-livemi. Tlio tliiiitili>i an- iIh-h npp]t»l ovci 

saiTiiiii iiii<l tlu! 
(JITS over itw liijui, 
iraciiaa in oontt 
in the eame ma 
until the llionu 
l(i>rn, wliPD Ihe i 
riiti^l lie rnxtl in i 
to effect ilij|iT«rj'. 
1 1 oi»l_v one 
has bwu seiffl.'d, 
iiiii) kIiouM Im I 
u|H>Q it until the 
lui'kit itpiM-nr at 
vulva, wltt-n tltD j 
lln]k'<?r o( tli« 
haii<t is introdrnfid 
itie posli-rinr gmin 
iiids in traction. 

Att Mion in 
operator be^'ins to 
upon Ums leg*, 
distant or tlie 
should *'\<Tt 
fiicwiurp iipi>n tl 




^■^ 



/mm^'^ 




\ ill. 4^Hj, — i>Mf,>-i;, i-j«i;i-44 ut'js. 'I^^tfioK UPON Tiimti'^ 



iiifi in ttii: axi« »| 
BUppri»rMrtui,wi 
o1»jret of pixwcrving the fli'xc(5 attitudi! of (In* h«ul nnd pn-wiitin, 
arras from becominji cxtcndi-d ahovc it. Itc-ides serving tho*e pur; 
oIn> aidt dint'llv in t)i<- i'\|jul'>ir.n of llii- cliild, iidiI thu« r<-ndeiv uvea 
a smaller amount of forci- tin tlic part of the operator. 

Downward traction shiuiUI Iw fontinuitl until lh« iw;upnlii> an' at 

parliallv outside of the vulva, and no atli.'mpt t^hould he made lo frK 

dfliviT tho arms tiniil this i.i cITtttiil, n.* failiiri- to oIh^itvo lhi« nde 

'qtientlv rendei's difhciilt what woiihl olhcrwii^e be a very liiniple proMi 

'In ordfr ((' frre and ilfHriT the artim, th« child yhoiild be weized will 

thumbfl over the scapulie and the fingers over Ihe si<l«a of the Ihorai, 

.fOlali'd until thi> biKniTDrntnl diaini'ler nceiipit^ an oh)i<)uc dianK>t<T ta 

'pelns (Fig. ^07). The posterior arm should he freed first, t^inoe ihrt 

inure availuhlu "paci! in Ihit p.i»|rrior and Inli-nil H-^n<-nlji of the p 

than elsewhere. To aeconiplish this, the feet should bo seized hy one! 

and carried tovrardii ihc groin of the mothi-r opposite Itw l^wterior « 

der. In nianv cases this manreuvre causes the latter to emerge avei 

perineal margin, tin- hand and arm etnyipiiig spiinlanenudlv. If \\iit 

not ooi'iir two fingers are introdueeJ iieneath the shoulder and pa:^»ed i 

the humeniK until this ellmw in naichtil (Fig. 408). Tltp fingere an 

applied in such a way as to serve as a splint to thu arm, wliioh in 



EXTHAUnoN AND VERSION 



425 



JuwuMinl over lh« ihonix and ticlivciud fnrni llic vul»a, To effod lite 

lirmr of Itie auivrior arm, the body b Beiaed as before and rotated so as 

^briRg till- tind«Iit-<'n^l iitiouMvr into tlic n4-i)H>lN>ur)Hi'Hl of thi; ncan^l 

-wialic notch. T\n- k'ifs are thni i^rri«l ufiward, no »s to liring the 

xiy to i\vi ii{i|>n»it(' jrroiu of liie mother, arid if ihc arm bo nol 1mm i<|XHk- 

LOiMtiiKlv It Li dijjvcri'd in th« tiaiiie nuinm-r a.4 ilio othor. 

If firie<i»airo from abovo haa not bit-n laaiie — and otcaKionallj in *]>itc ot 
-iJm; nnns may Ixwiimo e.\toniltil ovf^r the liiiid. Vtider aiurh cin^nm- 
t* iLiir (Iciivpry, allhou;;h iiioiv diHicnlt, eaii lie arcompliKlHtl by llin 
maiMi'uvrxM i*nliiiiinly emjilovci!. In <l'>in;; tlii.-<, pnrtiniiar can- niuKt bo 
^Jaktit to cam- liiv lingers up to the otbuw and ii<^? ihc-m an a ^'plint. for if 
^■be finp-r be nitirely hookod over Ihit arm and mron^ trarlion iiiaiitt, tlie 
^B>iimtTu<i or clavich* is eicpotiod to prMt danp-r of fracturp. OccasinnallyiJ 
^phf niaiiii-iivn* may lie r«ndei^l 4-a.->i<-r by puijiinj; the child a Mhort di.-iiaiice^ 
up tin? jp-nerativo Imct. 

tin (iilitT riiAes the arm la found aronnd the back of the neck, whon its 
3t>1i«crv beconiex utill tnorv diflictill. if it cannot be freed in the manner 
|ii»t (]n4-rilH>d, it must be 
!»rf?ili|y extnicti^ by hook- m 
'"S a tinpT o\iT it. L'nfor- 
tanatcly, frarlore of the ha- 
wema i« very minnion in 
"••"h fn^-ji. and the danpiK 
■'ti-nding tho pni-ciinre 
•'"•uld W [kiinlod out to 
•'tiip nNponfiblc mi'mlicr of 
"•' family; allli<>uf;h. ina^^ 
"""'h E<i the lift- of l\\'- fhild 
■*" In- Nivftl only in thia 
**)• ibe ritk it alwHru Jnitii- 

VflL-r the t^liouldt-TK liave 
*"'" Uim, (hr hmd n><ufllly 
**»>liW an oblique diam* 
'^'^ at the pdvia witli the 
™'i' ilint-rtil poslwrioriy, 
"••■a ila rxtnti'lion in liwt 
''^t^.d by MatiriefaH's 

^ttmirrr ( Fip". -I'Hl anal 

*'"!. For lhi» pur^MMe tW 

"»^- ' of on.- linnd i" 

^' into the mouih 

rttlw<ii.[ .,,..1 ir'i.licdovrr 



" Wt r«rtii Hpon Ihr 




I ,1 ! ^nUCTlOH. POMTVaiO* R»T*- 

THix or tiitni-i.iiKK. 
Hpon 

"'' "f lla* bn»d and ll"- fort-jinn. wiih i\w lrp< !>tnidilliri>; lln- tatter. 
' ■ imjKre of lite ollitr hand arc llicn l")fik«i over the nwk. and, grasping 
l^tlwuidnw, inalt« downward traction \iDliI the occiput appear* under tho 



426 



OBKTETKICS 



»yiii[itij.'>i>. The body of ihc child U now rai^Mhl up towanls tliL' iiwtlieK^ 
atidomt--ii, aud tliL- inoulh, note, brow, and i:vuDtiially Ihc ixxiipul, succk:^^ 
»ivvl}' i-itivr^t liter tin; |j<:rin»-uiii. 'I'racliuii Hhould Ik- i-Xfrunl only by I-^B: 
fiug<ern mi-r the shouldtTs, and not by the liugi-r in tlic moutli, since ~: 
many ca^'s Ihe latter elip^ from the «u]M'rior maxiUi and wmai to rcftl n|»' "' 
the inferior maxilhi «nd have of llic tonjiuv. as a CQnn\)Ucncu of which »e^Hi 
OU.1 iitjuri<-> niav In- i\ntw t" iIk" rliild if i-nrrgi'lii- IrmHion be einplHyoil- 

This mana-ovi'c was fir.-l [iiaitimti iiy MauruH.'au in the fipventpcnlh ok^?— • 
tury, bill for tonic ffason (ell into disfavour. Nearly a liiiiidn'd ycun l«r — 
Smcllie described a similar procedure, but rarely utade use of it, sa 1» 




PlO. 40H. 1^ 



ferred the employment of forceps. In the meantime other deviciM ccmc. 
into ui«e, until (>. Veit, in 18tt3. directed attention to Ihe iniKtiuable advt 
ta^e» which Iduuri<-cnu's mclhixl of cxlracltoti pot^jrei^.fvd orer all »tlu 
For lliiB rtfflMin in lieriuany the proceiluie is fnipiwitly oulUtI after V« 
or. when ;nfatcr accuracy is desired, is dosiRnalcd as llw iIaMriii-BU-SmeUi< 
Veil maiitt'iivre. Litxmann. however, is certainly right in )viinlin^ out 
impropriety of »uch a nomenclatnrc. nnd insisting that only the name 
the orifpnal inventor (Mauriccau) should he u*«il in dwcntiinp i(. Vumn^ 
OUS other tiietho<N of rxtraction have bi-en dcii-isod. Winckel l>eiiig ahle in 
1888 to coll«-l 81 different procrdures from the lilitralurv. alttunigh nom* 
has proved us senu'cable as that of Munricvau. 

In thtt va«l majority of caxas the back of tlie child vtimtuall; rotattv. 




\\ N 




■i,. ~* ■•- 



no. <ttt — lUtcw ExniAcnoic, )lAVW>cr.AV'» ItAiniivrwc, IVwabr Tiuimox. 

437 



428 



OBSTCTItlCS 



towards the frani. no matter what iti> original pwition; but vhe 
Dot tak« pl«w i^iii)DUiiiiiiu»l_r tlie movement niav be irmiigtinited by i 
stronger traction upon tbe leg, which would naturaDv rotate ant« 
If ihic (low not bring about the de^irwl miiill, and the back remaii 
terior after the birth of lh« oboiildvrs. extraction must be befnm u-; 
occiput posterior.. As a rule, rotation can iflill be eiloctei) by 




no. 411. — DeuvrHT iir Arm-l>>Mi)iu Hrau^ Um-jc Pokiumiuk (BubihO 



Uio finger in tlio tnoulb, aflrr uliicli the head can be rxtroctvd ipi 
ceauV niancctivre. When, however, thia ia iniiHweible, deliver^' m 
attempted, with tho head in it!* abnormal position, by the vniplortn 
» modified Prague manaurre, which is so called for the reaaon that 
^■antages were strongly urged and pracli«'d more particularly by K 
of llinl eily, altbougb it had boeu deiicribed by Pugb a century i 
Tho procedure is somewhat as follows: IVo fingers of ono hand j^u 
vhoidiU-r!<. while flic ntliiT band drawx up the feet over t)>e aUloii 
the mother. As a result the occiput of tltc child is bom first ai 
periujvtiti) is mvcvsarily iiulijeotcd U> greater liability of rupture. 

pTiignoii*. — The prognosis, so far as the mother is concerned, i 
favourable, vsvn when cunnidt-rabte disproportion cji*l« belwocn llM 
and the pelvis, since the pressure to which the maternal soft parts ai 
jcctrd last* but a few w<-f>nd*, inxti'ad of Iwing prolonged for hours, 
head preaentationw. Owing to tho necessary intra-vaginal manipuL 
IbcTB is a sliglitly incre-ii.*^il danger "f infwiion. and, more partit 
in the i<a.4e of a primipara with a rigid vaginal outlet, there i» gnat 
bility to laceration of the periiLRum than in head prevcntations. 



KXTriA(-riON AND VKItSION 



For Uie child, however, the outlook is not so favourable, and bemm^ 
jan errurne \iie UiglwT tlw eituutioD of the protmtuie part at tlte begit 
ot the openlion. The firial niorfaliiy is in great piirt clu« to Ihi 
era inherent to brwth prwcntalions, which are su>!uiimted bv im 
ittT liability to the oectirrcnce of traumattxni duriii); oxlnielinu. particu-f 
rly if U>ere in marked disproportion be4veeji tlio head sod the pelvis. 

Aj> lia» aln-ady Uvn iMtd, fractiin» of the hutncnis and clavicle cbjidoI' 
rMvs be avoidii], eien in the hands of expert operators. Oreasionally 
irtiiimala of Ihr xtrrno-ciciiln-miutitid mutcle are 11011x1 after the opcra- 
1, thiiuch tber-e an> usually of but Aifiht Hi^ifl<:ant'0 ami diHapjM-ar Hjion- 
itul; within a »hort time. Moru wrioiis rt-Ktiltif, Imwover, may follow 
^paralion of thf epiphifxes of llva acapnia or hutnoruA. In «xe«ptional 
/nntfynf 0/ the arm rctultn from pren'ure exerted Upon the braehiul 
tir the fingers in making traction, but iiinre fni|iit-ntly i:> due to an 

OTeTKtretcliini; of llie ncick in freeni); 
the anno or in effecting extratttion 
by the I*rajrue mana-nvre, A§ will b« 
ithowii in CWplrr XLIII. the amdi- 
tion usually un<ler;;oes t^pontaneouH 
care, altltougit in rare inntatkcot it 
persiata throughout life. 




430 



OBSTPTHICS 



furct^M iriirmluiH'j! uiuior it, the bladei^ being appli<Hl to tlie sv 
hwd. I'orsoimlly. I liavo ncvtT f(»uii(] it in'cwi'jmrv In iwort, i« ilii* 
(iwJhiv. nml liclii'vo llml it in but rarely pall«i for if the obstetrician,' 
made tiiiiiBcif Iboroiigblv fiUTiiliiir «itb Maiiriiiaiu's mainriivni | 

Extraction of Frank Breech FteaentationG.— When indicatioos tot 
livery arise after tlw brettb has (iitifen-leti inio the birth eanal, it» exj 
tioiJ i«ii iisiiiiliy hi- cITcrliil wilh- nut ilillicully by Itwj 

^the iiiilex linniT of one haii<} into ilu> iuitcrinr groin 

making' iraetion until the bultoeks ; appear at the vulva 

index finger of the other hand W Imng tht^ii in«;rl4!d 

thfi jKtittcrior groin in order to , W. funtiah additional t 




pin, 41:1, -KKTiL\cm>x tir Fdakk ItKEKfn, FimnuM ix Ghoim; 



On tliv ^thor hand, when the breedt is at the superior strait d»l 
is iiiiieyi more diJtieiill. In "iich (■«»!}« it i* sdviaUe to try lo d<Ton 
the wti|);e uitil Inin^' down one or both feet, which can lie readily a* 
pliiihed if attempted f'hnrlly after ruplurv of the iDcmbrsiies. but ha 
cxlrcmdv diffii'iili if a I'onsiderabie time ha* elnpiwd after the osca 
the li<|nor ainnii and the uterus ]ms l)eeome tightiv contracted ovc 
child. 

In many cases the employment of the followinfi; maDceuTne atigj 
by Pinard will often uid mnti-rially in brinirinp down tlie fool: Two m 
are earned up alon^' one leg to the knee and push it away from the n 
line. 'Yhis proeediire is n-ually fnllovrcd by cpontaneonK RoTion. an 
foot of the ohiM will he fill to impinge npun the l)aek of (he hand, 
it can |je readily ^mcd and brought down (Fig. Hi). 

In view of the fact that it i» often ren,- difficult lo seize and 



EXTItACrUiN AND VEH.SIO.V 



431 



K 



down a foot m iW laltor jiart of the eu(M>iHl f\ap; ot labour, Ahlfold aitd 

^Uu^n havf 6Ug^'»tvd tin- pr<}(>ri<-tjr of rupturing Die incnibrniMK w- sona 

*■■ Ibi? (vrvix i» full}' dilau-J, ami lirin^nii); down a foal pnt|i)ivliit'lkuilly, «o 

'•Wit a ci>aM!tiit.'Dl trat-lor tutiv In.' avuilHlik' iu vuec v\trai.'liua bccDiiii'ii iieoiM- 

"*'~y. This cun be rvHdily a«-<.-<iRi|)lii^tivd. but ik nnt adviwble as a routino 

/■>~«oImv. xiiHV tW frank breix'h formn a much Wlter dihilinj^ weil^ir than 

5'**^ iDcoiiipk-le brcirh prBSfOlalion. The prncptlure is jiiKti liable, bftwever. 

*** t )i(»c riiKiv in wbii'b it i" hij*Jdy pmluibli- ibiil rajiid dolivcn' will ln-ifimc 

■■■> f**!r«