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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≪
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.
Bowam. 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^ Mwiil di*; 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. iMHiiicnl»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.
0
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
0 ^ "
»'■
*
»* *
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 irinfcit. 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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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,
•** fcuwarily 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 TiiMOin^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
fcjpKfi [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"* dMUpJ 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
^ "yiiBl 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
pttff 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 lu^^
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 0 -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 fatlntf^'
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« 0
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«i\e ; for in^lanoe, in |)alieiils &iifrerii!jj from aeute diseaHCH and licart
it the indieation for deliven' is ur^ient, and it U impoMiblc to briim
ii I fnot. tl>c child iniut be vxlrsrttil of. it lies. For thU pnrpoK tlie
^***l*-i finfftT of one haod is hooked into the anioHor gmiii. and Miniag
■***^nwani trartiou made, ^upplcmcnle'l. if nwc-*wn,-. by the use of lire
*^*^*«sr huid which grasptt the wrist Thh procedure is continucwl until the
'***«■ trrior buttock hn* iilmo«t reavhnl the pelric floor, when the index fin-
's*^*" nf tlie other hand is
ki^ into lli« posterior
»i n and tncltiin mwlt!
^""■tJi both Itand^. As soon
*^ tJie latter li«Him>^ ar<t«.
*■ "l«^, di-Jiverv ean u.-uallv
*■** naddy elferted. bul. m\-
*"*»*^«tuilcly. in a w>a»idfn».
*■■*« natnber of cases one
*^ nnaMe to briiii: tin* bnwh
'"•'«' ttnough lo olft'r ibi» a<l-
*»*rit«|{e. For I his rea^ou,
^k»«0 lbi> brriYb i» bi){h up,
'** cntraetion *lnmld not he
' Huli'M iiiiperu-
i^iudtil by Ihe eon-
lixton nf the motlHT nr
chiltl ; iithtT^be it is far
tt»?r to wait until it has
lower before inter-
Ai maa an tbit buttocks
*** liort). firxt one leg and
"••**» the "IbiT i> dnivn out
***•' •■itrai't ion arcomplinhed
** 'Wcriliwl above. A> wHs
*^\ brfore:. traction must alwaitt be euppl*m«nled by pressure upon the
■'rom ■l.nve:. This pTi"ratitio»aryiiiea.-ure whouM nercr W n«gl«-ted.
-V mn fr>v]aeully U- jwrompli'-ltwl by its ttii\ vihvn it would he
'•■ if traction by Ihe finper"- wirt- nloin* reliw! upon. Indeed, it 19
^''- jt.iil oDf ha* attrmpled a diflVnlt frank brwch cxtmclioD that one
■ how little forro «ui lie ejertM by \hv Bngew.
A Foot is Fkask Hnvrj-n Pti^r.nTAnmt.
|K..
432
obstetuks
t'rognotis. — The pro^osis for both molher and child b less Tavi
ai>l« in fniiik brv«ch itiau in foot prcMtitolion:'. Id Uw former Itic
cioascd uianipuUtioD affords ^roatcr opportunity for infection; while
altctiipt lo nm-h lln- jxwifirior groin ofti-n glvw rU*: to doep le«r* bel
(hi! child has reached the perinwum. A^ain, in view of the longer t
mjuired (o elTwt di-livery, ilio child la expcwd lo more dtSfvr. and
addition to the accidents incident to extraction by the feet, fractun
(lie femur nmy follnvr ih« nltt-in|)t to bring down a foot, c^pcci«lly v
«lrong (raclion is innde ajum the ];Toin.
Use of Fom-px. — In vii-w of l\w didioidt^r which »oinotimf» uilcnds
exlrsciion of the frank bri-cch when high up. I.usk, Budin, Reynolds,
other aulhorities have rcconiini^mlnl the employment of foreepi>. the bl.
being applied oblitjiielv, one over the i^acnim and (he other over the th
[7p to the present time I have had no Mpi'rienee with this procedure,
ing been able to effect delivery in all my ca!;es by traction exerted wi
finger in the groin. When this fails the application of forceps ia ecrw
jtistifiuble. although when the breech i« high up it «liould not be sltuni;
except under pressing indications.
The t'ill't. — In these caws il is tiome1itnc« convenient lo make
the fillet. Tliis nifty eonaist of several ihieknessej of sterile gauze b»n<
which ate pas^'d orer the anterior groin. Tlic fillet ia A wry eflic
tractor, but ils application offers considerable diilicully. I'nle^s the a
utor haK iit his disposal a N;H'cia1)v (.'oii^lriicli'il innTnimeiil, n f:itrlr
factory carrier may be improvii-ed from a rubber catheter, through v]
a piece of stont thread i« pa««rd. a loop being nlloved to protrude
the eye. A stylet is then introduced, and an appropriate curve h«
been given to the closed end nf the rtilhelcr. the bcnl extremity is. pa;
aroiind the anterior groin until the fingers in the vagina can sei^e the I
lo wliicii one cud of the fUlct is attached and Uicq cautiously draw,
into placei
Aside from the diflieulty cneounlered in applying it. llw only disad'
tage of the fillet is its liability to cut through the skin of the groin;
Ihi.i accident <-an be avoided by cnijiloying several thicknesses of gauu
taking care that they do not become twisted into a cord.
Tlic older unihors iidvocai<-d making traction upim the groin by in'«'
of a metallic hnok. This instrument should never bo employed upoa
ing ehildn-ii on aci'mint of its liability to eau.-<e fracture of the ftm
On (he other hand, when the child is dead and such an accident ie a mat
of indifference, the hook nffurds a moi>i convenient niean.t of making tnet
Venioa. — Version, or turning, is an operation through which Ihr pf*^
entation of the fa-tu* i* artificially nllered, one pole hinng *nb»titul*d T**
the other, or an oblique or transverse being converted into a longiludiiB'i
preHcntolion. ■
According as the head or breech is made the presenting pari, tlie opsW
lion is spoken of as rt'phalie or imilalie vrr<ion rtwpeciiwfly. It v al^
(hhiigiiali-d according to the mt'thoil by which it is ac<compli^l)ed. Th*
we siH-ak of txtTtial vnion whi-n llie manipulation* ftre made exeliwi
through the external abdominal wall; of inttmat version when ilte
EXTRAtTlU.V AND \ ERSION
433
^^■■ild h intrrMliK-itl into iIh' utoriiH' cavitv; an<\ of (omfiined Vfraion when
^^^^liiuiil riiaiii|>iiliiii-» llirou^'li t)M> nIxloTiiiitHi ua)! wIuIk (wo i>r imire riiigt^is
^^V^IIm' n|l« r iir>- miroduci'd iliro)i>;h the cinix.
^V Cephalic Venioii. — TliiitofH'raiioti wax pruoliwd from Itic iii<>7^l n-mole
antiquity, ind only gradually fell into disfavour after l)i« iDtroductiou of
ptMlaltL* vi>rKi(m by Pnr<^ ain) liU f(il)ou'i>rc Aflor llii> (liM-nvt-ry of Wigwidj
(m07) that the pwitioD of Itiv cliild coiilii c-shily tie altered by exterDu|
tnanipulatidiii, i'i-|)balic Tc»kin i-aiiio into nmro ^-m-nil iikv. mid *iac« the
Kblic-sliunii of ilubort aixl I'inard Imn become a well-r«co^iUcd proceduro
DerUun eonditioiu.
r^Tfae object of Ihv opcrration is to eiib^lilute a series for a tesa favoar^
p preaeaiiation. A* it iltii-s not, houCTir, afford a iiiimiu for iintm'diatS
deli%-«Ty, iu ficM of uKcfuliicsH is comparatively limited, and its emp1o3niwiifl
till further restricted by varioiiii contra-iDdioalioni'. '
Jndicaliotu. — If a br<<fch or trnniiTcrse pre^etitation is diagnored io the
fev ve«k« of preKuaucy, its conversi^jn into a utIi-x should be attempted
external muua^uvn^, providml thcr? be no marki'd disproportion between
ibe size uf the child and Die jKiris. Cephalic version i* indioated by
'^akih uf thu incr(.-a:>cd fa-tal mortality attending sjmntanronc: delivery ioj
°*vvch preM^talions ; wbile if the ehili) tii^ irunsveTsi-ly a ebangc of presJ
'Station i» impcratircly demanded, inasmuch as a natural lal>our is out
*'f the (luestion, and if appropriate measures »n> not adoptnl llu- lives of
"'tit DiuiliiT and child will be lo^t.
tofvi-tiinatrly, after the aocompli'bmont of external ivphalic venion,
<liiUl tend-- lo return to its ori^nol position, unless th* new presentation
te rctaiiKHl until cngBp'mnil 'K-our*. ('"nw^cim-nlly. whenever this pro-
iji eiiiploviil durin;; prc;;nam'y, the wearing of a suitable iMnilage
iry. Moreover, the oprmlion pan K* accotnplii'b^'d only under the
conditions: (1) The presentiup part mu^t not be enRSfjed; (2)j
■lalnminiil wall mu.->t be KunV-ienlly ihin to admit of arnirale pttlpflJj
; |3) the ahd'iTuinal and uterine walls must not lie too irritable; (4) the
t mii<t <-(inliiin a siilTicii-nl quantity of li<iuor nninti to permit ihc
'■*y mmrement of the child. Gireo these essentials, eitemal ce]ihalic ver-
"**■! tbutilil always be alli-mpted, itinee it in ali^lutely IiarmW*. and if the
^"^r putititin i!> maintBiniil it may do anay with tlie oeci-s^ity for wrioua
''^■^mivp pnKwlurt-5 al tbe time of Iiil<our.
In the early Hiages of lalwnir, before llie tnembranes have rnptared, the
^*%ia inJirationa hold good, and at this lime may be extended In oblique
itatinna ■» well, lliou^ IIh->m^ usually ri]*ht themt^lves spontaneously
labour pTti|p«weft. On the other haml, exIiTiial eeplinlir version is not
icfltnl after (be cervix htis b^-come fully dilated and the membrane)^ have
T>Iiin^, rxeept in occasional ones of shoulder presentations: since it can
^Ifrded bnt rarely, and better rrsnllf are fibtain«l from podalic version
^^lo»«l hy imioMliaie ejitraclion. This is iwrliculariy true in ease* com-
^'*al*d by prolapse of tlw cord or placenta pneviu. Prions pelvic con-
^'^^tion i* a iWideil eontra-indiciilion. ^inei' although version may be readily
"^^naiph'fan), t)ie procedure is useless, as more tKrrioaii operative mctsnrea
Ic iMKCMary liefore delivery can be effected.
llb«,
will:
oiwrtTiucs
Methods. — Cephalic T<;r*ion nuiy bt- lirniiglit aiioiit qJiIm^ liy n-fi-n^E-^
matttpulations al<iiii\ m- liy tln> I'ombineil mi'llmii — with om- liatid on t ^•J
ii)Hliiim-ii and two or more linpi-r*, i>r i'»>-ii lln- whole iumii, io Ihe men ^
Uuriitg jtri-gimiuy llu- fmriiir i.t liw lUiU iiwth<jd ap)iiii-uhlf. and at t J
lime of Ukwt it sliouitl bg cinpluviil wli«ie»'fr fL-tLiilile. Tlio twhuii| i
ban bewi carefully i^z H
HTibud l>y I'iiiurd, ar
is ■oiiifwlial ui rollo\b
Tliv palicnTR uImIikw
having been banxl, ■
])r<;M!ntatioii and
lion of tlic child s
(■im-fnlly rimi>iK"d t"^
The fiptal poles are tft
M»»t(l villi «tthrr
and the one u-hkh
winh (i> prcxent in ^'v:xn
stroked lowanU Ihe
pvrior Ktruil. whili-
alher \» moved in
oppo>:ito diriTtmn.
tpr vprnion han livrn (?<»*i-
pk'lwl, the child tn* -^-^
1)0 lit'ld in itn ii<>ir j»«":»fl-
tion until enpaperw^*
oi'eu rs. 0u ring p f~*?"
nancy this is "a«c*»*i"
pliHlicd by apprnprin**''.'
Iltliiiif pwK whiih are lield in phicc by a lianda;^ ; but at the time of lab*-'"'
Ihe IHTid limy hi* [jnuac*! down inUi ibc ^iijirrior rtrait and held firml.V" '"
position until it becomes fixed under the infiuenee of Hie uterine <««Mitr-«i^
living.
At the time of labour, if external inanipidationsi prove futik*. <ypti tf» I*
version may be aecompli»hL-d by the ombined or bipolar method of Hraf^^^
ilirkit as soon as Ihe eervix is sntHdently dilahhl to mlniil of two finj(«^'^
For carrviiiK nut thi»- proc'diirc Hickt* ftave the followin); direi^tirtiK:
" Inlioiliice the left band inlo lb« vii;einn tiii in podnhc wrsion. H ^^^
tho right hand on the outside of the abdomen in order tn make n«l i^*"
position of the fu'lus and Ihe direction of the head and feet. ShouM ^^^
shoulder, for in'lance, present, then pudi it wilb one or two finpT*
Ibe lop in tbi! diri-ilion of ibc feet. At the same time tir«-*<urv lis I
other hand should be exerted ii[«m the cephalic end of the child. Tl
will brinfT the child close to the os. Then lei the bead be received npr'^^
nil
k
I.
the tips of the inside linfiers, The head will then play like a luill brti
the bands, and can be placed at nlimwl imy pari ut will. . . . Ii is «
if the bn-eeh will not riw to (be fundiin readily and tlip lte«<| is fairly if'
Iho OS, to withdraw the hand fmni the vn^i'i^ <>"<1 w>ll) it pre-i-i up the!
breech from the exterior" (Fig, 4?i). While the credit for populariiins
KXTIULTION AND VIOTSIOS
435
(liin prnniliin' tinili>til>lii)k Monjr* In fli^-ks, il in iiilArtt«tiii)t to unto llial it
wJmiI Iwt-n ili-MTilMil Itv Manual) iiki- Wrighl, <if t'incinDali, many yearn liL-fun-
|Bki* aji|H-aniliiv ■•( MiokiV tlr^t jiiililit-alimi.
' llu-^'li, IVOuln.']ii>nl. miil ■■llii.'i^ ad \xica li.il alli'inptin;; ecphalu: vi-nioii
a/ltT wmjili'I"- liilalnlioii "I iW- wfrvi\, l)jr iiUnHluciiig om* luind into ihc-
uteniii ami Bcixin^ tbe brad, wliile the other i^ employed for external muiip-
ulatinQH. This in riR-ly if fior advi^iMe, as uod«r hiuIi cirrumritancefl it
I Jjt ftrvfi-rnlili* 1i> pt-rfiirni tnH'nud vcT«ion. wliicli in iw man dungiTous, and
^K thi- ■artii' tii(ii> iXTinils imiTiriliatc di''liti'ry if nitfHMirv.
^M f odalic TcnioD. — By thiii is imdersiootj the !«ixiire of one or both feet
^^r two or nmri- (injn'rK. and drawing thvm (lirmi^h the cwrrix. Dte n{icrution
^Bin); iL-iually followwl \\y f.i tract ion. I'oilnlir version wa* introrluocd and
^Barmly advinalai:! )iy I'aro. ami. iinlil IIk- inrfntiiii) of IIk- foro-p*. niTordiil
^Bm^ only nw^nii of arlitli-ially delivering nn mutilated cbildren. It is inter-
^^'uik; to note that (iuillcmmu. oih> of I'«rt-'» f^tudonlit. wa» cnahlnl by Uii*
tuwiM to jiare hid niai^ter's daiiebter fro<n dyin;; of hwmorrliftttc due In
■^l^f^i-ata |in-iiA. Ttw rnliic uf the iip«*rali<ni wii* recnfrniwd and innisliil
Pvi***n by UniiM- 1V>iir^<oi>, Manrieeau, and aniun^ many oiIhta by Ik- la
"•*ti*. who cmployt<d it very freqiteiit*
^^[ ^idi iniol tucdlenl r^ulta.
^H^ tnAtcHtum*. — I'odalic version i»
'^'•■l iratiil in two (jrenl (froujw of vjnn^
"*iaiiM'lT, in traDsTcrw or oblitjue
■■niutionM and in Im'aiI |>nvfntHlion<<
vhM-h it iii belieTcd that delivery
^**i Iw mon* Mfely and m<irL' rapidly
: after Tersion.
I . u ---^ity for Tcivion in itaat-
I ^orw and oIiImiw t>re>>e»U(ionH ia nbvi*
***>- lu abuoriiud bead prewntalions.
'■**« (III- faw. bniw, i)r iKvipul is ]ni»-
■r and inovalde abow llie superior
iJt. deliniry can frrqncntly be more
dil)' iUMxifnplif)i''d after n-mioii
by any oth<-r ineann. Fodalie
if ui'nally Ihe operation of
*itr in prolapw of the eslremilii's
■'— 'ilieal eord, and in many cases
■ Ilia previa. Moreover, when
■ I f- iwmic deformity de-
f I ; '(iw ver\ much faeili-
■fliir version. Generally npcnlc-
till- riporation \* indionled in all
n»9Birin(f prompt delivery when
Iwd i« ll'intins nt tbe miperior slmit or i* but .ilighlly en^ngeil, pro-
there is do grral diRproportion betireen its fine and Ibat of the pelvi<.
micli i-iminwtances it ia ttsually « mueli (wfcr proeednrc than t\v
[(tnilion of hiph forccp*.
Pto. 4ta.— HRnna or four tn tmmMAL
PniuLic Vaunow (T«mi«).
436 ^^^^^P OBSTETRICS
thus of it* wi<ii-»l HvM* nf Msvrultiiwi it after tlw <]ilRtnliriii "I *^
«ervU ill luvoHcMniful (orri, Mpeciall; iu eclatupHUi aiui liKmorrht* ^^,
when vorsion and uttnurtioii )'»p)>ljr Ihc n-ailicsl and iiionI. it'iixirat' *
liietiuxl uf iliOivt-ry.
Marked difrrt-oi of pelvic dt-fonnity eontra-indicftk' llic ©[Wrslion.
ia true iliat vursiuu can !>f aoii>nipUHheil, but afterHanl ii ■-■< frGi|ueii
iinp<>M<il>]v Ui cilnip) an iinniulilHli-d (.-hild. It ulnuili) n«nvr Ijv
tfiiiplfcl u-hen tW child is xulleri
TA'iii'N. llkcN Ak-tkiiioh, HriiimK or
LoncH I''<iuT.
Pio. *18, — Vkiuijos: TliANiivKiiiu Piil=***-
The most favoiiralilc linn- fi)r the pcrfdniiamn uf ihe opvration i> ^^"'''
inediately afti^r Ihf riijitiire of Ihf membrane!;, before the amniotic i~^^''
hail druim-il i-lf. iiml whili- lh<' child i* lymdilv movahlf in «iiy diiwli-^ ■"'"
(k^Qoialiy i'p(.'iikiii;(, {KHiuiic vt-rsiou should not he altt'mpled throu^i
imperfectly dilslvd ct-rvix. exwpl i» certain case* of |ila(vnla pnt-via.
In many oa>>e3 the patient is not seen until long oflcr niplnre of c-^^
mcmbrunc!!, and C'lnditioii.t may be pri--<-tit which n^d«r the ofwrtili
oxlreidily liinicull or even impos^ihle, for example, the alenis ni»y
tetonically contrac'tcd niid wi lightly applit.'d to tli« lM>dy of the chiW "^
to rend«r even the introduction of the hand extremely difiknilt. In oth-*^'
cases, il a long intnn'al ha* elapsed Kinee the nipliirv of the mCTnlireoc^'^^'
the cnntraolion ring may hare risen to euch an extent, and the lov*^
nterinfl gegnieot bo so «tn!t«hed a» to render the nperation dungrn>iu> *^
'a
EXTKACTXUN AND VKRSIUN
437
dcfrree, as the sltcTopt at verBion will probably lead to niptun'
TffhitiifHf. — The patient shoitlii lie anii'T'lliPtiwil anil plaoed upon
e ar lirautiUl lo Du.- «1^ of tli<^ bed, and lb<- dkuhI prcpura<i(mi> for an'-
ration niwie. Vention ahouM nev«r b^ »n<li?rlnkeii wiltiout an anrurate
■|is a.< lo tlio priM'iitalmn and pnfilinn of ihi' child. Th« aMoint^n
^pbe M>ver«l l>v ^liu'ile tcinH^ -to ns ti> allow one hand to be applied
' \U hHHT portion without becoming infw:l<fl.
iic vereion niav Im; acconipl itched hy one of two niothods— internal
lo tbo former th« entire hand id introiliicrd into the ulcnis.
To the latter only two Unj^fr* are pressed throujrh tlH> eervix; hut in
I mt-thoatti llif otltcr hand i* ttpp!i>i| ov<t the abdonK-n and controli! the
mKnu of the fo'lun.
\mtfnuil I'o4aUr Vrrnon. — 11ii« whonld Ixt Btt*'nii>te"l only after com-
I ditatatioa of the oerriz. If the membranes are intact, they are rup-
fcniiii, Hnj-t l'oiin:uoB, Hiiiuke of
Vto. 420. — Vrwiun: I'iuhhvkkhr ThucsK-v
Lkwkm Foot, bwuwimd Ahhkbt or Bvt-
tOCKK AT TKK PKt.V>C Itlllll.
mod the ham) u immediately inlnxluecd into the uleruit; the feet
then taxed and drawn thmujih the eervis. tin- •ip<-ration tH'inj; usually,
list necessarily, followiid tiy exlru<;tinn. The mcttwd of procedure varies
krwhat, acmrding an one has lo do primarily with a h«ad or a transTerw
I4:ts
tuiSTtnuK-W
im-Hcutation. In t1iL> fir8t ini^tancc- the tiaix) and arm most l>r introdiK^
<'<ij)i'iil>-nib]v furtlH-r iiiln tlitr gi-iittAl cadk! thiui in Ihc lulin- (Kig. IL 4<)-
If the child prfseiils by tlic ht-ad, the choiw of the hand vhicb is t<» ^
pnxsnl iiilo ihi'- iKi-nis d(.>|x-n<lii upon Ihe location of Ihc itmall partd>. ^'■
the liaok t>e directtxl to Ihc left, the feet can be neized most con»eniet» "til
u'ilh ihi- li^ft hiiiid. iiml t-iV>- rt-rm. (tonoralty :<[ieiikinf[, it w ixlTtsahh* t^
attempt to jiTn^]t only one foot — if poiwitjle the anterior one — for »t ««sl
traction w made; h[kiii it l!n; Iwiok vrill roluu> l« tiw- front. Thv fwt m»y la
dilTeren listed hv Iracinji the course of the thigh and leg or bv noting "<^*i
iflntion of thf gnwt toe. Having found lln; proper Uni\. iIh* nnklc cho «j1
be (trasped between the index and second fin^rs. and slowly drauii ihroLJS fz
the oervix. while IIh^ cxtenial h*&ni
controU and guides the morent^xxt
of the head.
In transverse prviH'ntationti <»ni|
fiMit is seized and version aeeoro-
plinhed in th« Mnia manner,
choice of the foot, however,
niatlcr iif vi-rv inhAidi-mlilv il
portaiiee. Wlien the baek is di-
ii'i-t<-d nitleriiirlr, (Ik- lower '»dp
diould be seized, an bv ^t Ant
the bock of the child is kupt
pet-ted towanlx the nvmphvfii
wbenyis, if Iht up]KT fo'>I
Kiisnl Ihc hiu'k may hirn in ttv
opposite direi-tion. (In the iilli«^
hand, when thr back looki? jwst*-
rieirly, ihe np(>er h the fnol *''
choiee. «iin«' triiction upon il ■*'''
rawse tlw Iwiefc In rotate tn tti*
front : while, if the lower fool 1"
st'ixnj, althotijih anterior nH»lt<*'i
uil! Usually occur, the up|R'r!'i'*J
tock is iiahlo to impinge up"D ^^
anterior portion of tlie pdvir bni
and grrat fon-w may bocoiin'
parr to effeel iU tliBlmlpii"*'J
(Fijis. 4ir to 430).
Xot a few v»»e* of tnm^r
presentation are cnmpUcatol
Iho pnilnfwe of an nrm inti> l|
a titlcl sh{>i)l<l Im> appliei] around
wrist and held lonwty by an ansirttiml. wliili' versinn i)^ performol in]
usiud iiiainu'r. In lltiv nny the arm ]h preveiil(<d from iMHimiin^ cxii'i
<iver Ihe head, and Ihe neewnily of frivlng il durinj; exlraetion is oini;
Whatever may have liren Ihe Dri<;inal po>ilion of tlie child, finn pn'
(ihould be exerted upon Ihe fundus of Ihc uterus as 900Q as extract
itil
Tic «1.-
-Bipni.AR PiiiMLii; ^'anaioN
(llimiii]).
vaffina. Pnder nuoh cirewini'liinees.
EXTKACTION AND VEIWloN 439
srdur h> fai-ilitate the deliver}' and at the Batiie time prevent
f the head or anii^.
td Podalic Version. — In other instances, particularly in placenta
sion may be attempted by the combined or bipolar method as
cervix is sufficiently dilated to admit two fingers. With these
ing part is dislodged and pusln^ upward, while the external
tally brings the breech downward towards the external os. As
K>t can be felt it is seized by the two fingers and drawn through
For the time being this finishes the operation, as extraction
be thonght of until the cervix is fully dilated, for it is extremely
1 can be effected only at the cost of deep cervical tears (Fig. 421).
«. — For the moihcr, the prognosis following podalic version is
I properly selt'ctinl cases, provided the patient be in good con-
ic eommeneemcnl of the operation. On the other hand, when
n the case of a (elanieally contracted uterus, or when the lower
nent is overstretched, forcible attempts at version may load to
of the organ and death.
gnoBiB for the child is fairly good, and depends upon the nature
«tion and the difticulty expericncc<l in extraction. On Ihc other
e operation bo undertaken through an imperfectly dilated cer-
e child's head \>c arrested by the external os, the lime required
iction is usually so great that death from asphyxiation is inevi-
reover, in cases of marki'd pelvic contraction, the fretal mer-
ry high. In nianv such cases forcible traction may enable one
he child, but usually not until after Ihc cord has been so long
as to have causet! pronounceil asphyxia and death, not to mea-
!8 to the head resulting from pressure.
I.ITEKATritK
'cber nehatiiUimt; Rcdoppfhi'ii SIciKslaBi'ii, etc Arvhiv f. 'lyii., 1873, v,
LoviHE. OI>«cn-alii>n» liivcrtiCB. cXi: I'uris, IIHO.
nier et Budin, Traits di- I'art di-H accouchcinenlH, IWH, I. iv, 296.
!. Traits romplet do» accouchement a. Xouv, *d,, Leiden, 1729.
r. Abh. und Beitniee, Wriribure, IR17, Theil I, 69.
De I'heiircux accouche men t den fenimea. Paris, 1609.
Mtnhined External und Interniil Version. J-ondnn. 18(14.
jeUjues faitfl mir los pn^Henlutions \ickMiRCH du fci'tUH et Hiir la [HMwiliilili^ do
^ par lea manipulationa cxl^rii-urex. Annalcs de gyn. et de pa-d!, 1843,
eitrase lur Oelmrtskiincir. Wiir/liurR, lH4fi. I. Alith., 69.
Dbt JUuriceau-Ijjvret'sche HarulKriff. Archiv f. liyn., 1887, xxxi, 102-
Bi-ience and Art «f Mi.lwifcn-. New York. 189.'). .^■iR-391.
I.e moyen ifiiiciiiicliiT l:i fernTiic. ijiiund I'enfant |ir(''Hcnli- iiii on iluux
pcenik-TK. Traill- ilcs tiiiilinlicM ilcs fcmmeH groJwi'K. (inie i'-«l., I7H1, '280-
m Malgaii^ne, I84M, t. ii, 6'J3.
^
>
440 OBSTETRICS
PiNASu. De la venhon par lea inaiiu^uvreB extemee. Traits du palper abdomii
PuriH, 1880.
(Quoted by Faral«iif and Vamier, Introduction k l'4iude dinique des accoucbemex-^ -(
Paris, 1891, 185-187.
I'roH. A Treatise on Midwifery chiefly with Regard to the Operation. Londiin, I *y J5.
Keynolds. The Value of Forceps in Complicated High Aneat of the Breech. Arx-a^i
Jour. Obst., 1892, xxvi, 586.
SMBLLre. The First ClaM of Pret«matural Labours, when the Feet, Breech, or L^r^-vsra
I'arts of tlie Fivtus Present. A Treatise on the Theory and Practice of Midwif ^^
eiithth edition, 1774, 195-206.
Veit, n. lJcl>er die beste Methode lur Extraction des nachfolgenden Kindeskopkf^
(ircifswalder med. Beitrage, 1863, ti, Heft I.
Whsand. Uelier Wendung durch ausaere HandgrifFe. Hamburger med. Mag., 1 ^tjj
i. 52.
WiNCKEL. Ziir Bcf'irderung der (ieiiurt des nachfolgenden Kopfes. Verii. d. deiiLB<>f]gj
(iesellHrh. t. (iyn., 1888, ii, 19-32.
AVkiuht. Dillicult Labours and their Treatment. Trans. Ohio State Mud. Sac, 1 S5j,
Sf»-88.
C'lIAPTKR XXII
CjEsarkan suction and symphyseotomy
1 Section. — Id tliis operation the child is removed from the
igh an ineision in the ahtlominal and uterine wall^. The origin
has given rise to a great deal of discussion. It has been gener-
that Julius C'ajsar was brouglit into the world by thia means,
1 his name from the manner in which he was delivered (a caso
)). This ex]>lanation, however, can hardly be correct, as his
la, lived many years after bur son's birth; and, besides, Jiiliu:)
first of his name, since there is mention of a priest named Cusar
^veral generations before. The following view, however, would
ear to be more plausible. In the Koinan law, as codified by
pilius, it was ordered that the operation should be performed
1 dying in the last few weeks of pregnancy. This lex regia,
llled at first, under the emjierors became converted into the
and the pniciilnre itself bwariie known as the ('(famin
—The history of Ca'sarean section may be said to extend over
s, the tiriit lusting from the earliest times to the beginning of
ti century. During this period the operation was occasionally
after the death of the mother, in the hope of saving the child,
iroh&ble that it was practised upon the living woman, although
orities are inclined to believe that ci-rtain passages in the Tal-
e so interpreted. The fact that Dr. Felkin saw a Casarean
irmed among the natives of T'ganda renders it possible that it
een employed upon the living woman at an early period by
he uncivilized races.
md period extends from the }-ear 1500 to 1876, when Porro
s method of amputating the pregnant uterus.
ig to Caspar Bauhin, the fir.<t Cajsarean section upon a living
performed in l.jtiO, when Jacob Nufer, a caslrator of pigs at
, Switzerland, npiTSlcil success fully upon his own wife after
n given up by the niitiwives and harlN-rs in attendance. The
T, that the woman had live fiKinlancous lalKiur.i later would go
t this was not a true Ca'snrean seclion, but probably the simple
an extra-ulerine child from the alulominal euvity,
1 Bousset, a contemporary of Pure, wrote a treatise upon the
581, in which he gave the histories of a numl>er of CiEsarean
441
ll
446
OBSTETRICS
Til, I
i
rix^fivi- can-fuJ in^tnu-lionit ii# In the 1h«1 im-tUml of nvusciUUug H9
ntxe^&Ty. 'Vhe. tallovnag ituitruiuentj^ tw required : I soalpel, 1 lonf bloBt-
poiiitofi scitiiors, 2 ili»»octing forwp*. 13 short aiwi tJ lous aptpry ci■IIlp^
uTi itlxldttiiiinl relrai'lnr, a iKi^dU^-luililt-r uDd a|>|>rii|iriu1tt tuivlits, u* wi^l
Of the mual sterUe dressings, HUttire maleriaU, and ganze Eipungee.
■ An inciKinn from lit to llf ctinliiiu'tron long itliauld bt- miido in tho liw*
piba with llie unihilioua &» itu itiiiMle jioint. In thU way injun' to ti\t
Wnddcr, whith often f.xti-rid* ont- third or i-ven one half of tho dinsii"
bel«-ec>n tlit> fty[iij)hvMA and unihiiiru!!, and hUo Ig the tower uterine if^-
ment, i& avoided. Tiie Rbdominal walls are ui^ualiy very thin and hired
hut littlt!, rari'Iy more than two or three clainpo being required to chwi
hiEnipiriiBfto.
Till- uti'nis will hi> found itiiiniHliatvly hi-neath the iiu'ixion. U «iii>i]lil
tlicn be dulivorvd through the abdominal incieion and not cut into until
Qw *<t\gf» nf th<- latter liave I>cen damped lojti^ther ponterinr to Ihe iKrrilt
and the wound covered nith a, eterilo towel, m> that all poesibtli^
ooniaininalinf!; iIk- iilxhiiiiiniil cavitr may bt- nvoidod.
The anterior surface of the uterus is opened longitudinally along »
middle line. Thi* i* besl acconipUshi'il by milking an incision a fc*
centimetres long with a scalpel, and tlien rapidly enlarging it with I***
srimtor" to 11 or IS (i-ntinu'lrv's. Tlic membmnes urir tltcn rupturt^, ti'
child is seized by one foot and rapidly exiracled. Two clamps are appli^
Id the cord, wtiicli ii* cut bctwiiii Ox-ni, nnd t!H> child hitiidfd to ^"
assistant. This takes hut a short time, and it is rare for more than
seconds to dapff bclweNi the beginning of the operation and the birlli
the child. Many aHihortlk'!< rt^ioiiimond thai an alteiupl lie mudi- to
the jK»-ition of tile plawiita heforcliand, so that tl»' incision may be amie 3
such a way as to avoid it. This, however, is not neeewtary. If the placei*'
lii-s under the incision it should bo rapidly cut through or pushed to o"
sidi- and the chihl i^xlracti'd. TliU i^ acivimpanicd hy a flight im^T«n»r *^
hR'niorrhagc, but as the ojieratinii is necessarily bloody, and as the Wi?«?*J
jng i* only niiinit-ntary, it is wilhoiit nignilii-ance. Imnx^liately aflfT tt^l
delivery of the child the uterus contracts down and hicmorrhage practic«UJ
oeaafrt. If thi- plnii'iitit nnd meiiibranejt have not bt«omc s<-|>iLrnlcd
tanenusly they should be peeled off and removed with the hand, care
taken ihiit no shiiiU of meinbnincs are left behind. Dii^infectlon »f
uterine cavity is not necessary.
To prfivent h«'in<irrh»g(;, Litxinann rccommendi-d tliat an oloslir \vt^'
tnre be applied almut the cervix before opening the Uterus. Tliii is. biJ*"'
t'ver, an unm-eciisary preenullon ; nor is it di'void of danger, as tlio proltfi^
compression preilii^fxises to uterine atonv and hn'iiiorrhfli;e afterward I'"
however, there is considerable loss nf blood after the delivery of tin- f**"*
the assistant should grn#p the cervix firmly btitweon )»* fingrn $ai
compress the ulCTine arteries. This effectually controls hicmorTbigc
is preferable Ui the eTiiployment of a nibbcr lignlure. as transient
Bion only is needed, and the fingera can l>e removed as soon as lite
acconipli.ll led.
Frit«chj is 1807, proposed o|>ening into the ut«nia tbrougb a i
t>c«Uj
i
Ci«8ARE.\N" SECTION
447
tmn»v*n OT«r the fuiiduK. iiixUvid «f In* (lit; uhuiiI iiittTliii<], tioldiiij;
ifaut. Uw itnit'W lit blood-vaiscU in that location hein)t, pamlk'l (o tlu> in-
euion, the heinorrliagc wouM therefore be less. His proposaJ wa* at oncei
.lertnl by manj- t»i»«Ti»lor«. Trinks. Iltibl. IlahQ. and H. Sc-l»roi>d«r huT*"
IpabltHlKN) talites.of ranefi ao opcratod upon, Iho latter having collected 94
'oMw. The n-solb; wrra exccllciit, but not bi-ttiT thuu those followtn); tlw
Enorft tuiinl im'i'>i4>n.
There would appear to be no especial advanloj!? in adopting Fritsch'e
utton, exirpt in (]ii> vmit!) number n( ca!H» in which it i.f desired to
lize the patient by eidBioK the tuhes. On the other hand, the intes-
[ and nrneniutn are iniire liabli- to Unum- «ilhffy'iil in ih<r utcriiH? wound
with the I'lnffitudinal inoi^iion. It is ur^eil that the fun<lal wound in
tm« likely to bv followed b>' adhesions betwovn thv uterus and tlie anterior
■tid<MniuaI wall. TIiia i.4 tu> doubt mrns-t, but at the namo tiiiji'-, xhould
infivtion of the uterine wound oceur with the former ineisiou. virulent
iitatt*rinl io nidft* Inihle ici gain aoccvii lu the p'noral iH-ritoii'iil ciivity ; whil«,j
^xf >t ocnirs wiib the latter, tbe tbeeses has more chance of opeitin); through ]
abdominal wound. I
No matter wiiieli incision haa "beea employed, it Ea then ohi^-d hy di-c^J
Knd fiiix.TlieiHl eatgiit nutunw. or. if jtrcferrcd, furmol catgut inay b«l
for brtih, Tlie former are inserted al intervals of about 1 («ntiin<^trff,
utend thnpugh Hh; vntiro tbiciin<!K8 of the mu;K.-ulan6, avoiding the
los. Tliey are then tied, and if accurate approximation a not ^eiiured,
loping ninrgiiu nf tin; wound are brought together bv superlicial cat-
i<~aturi.-« which exlciid tlirnugh the |H'rit<>niuum unit thtt uppiT layttro
*' Uic mu^ularis. Sanger rerommcnded the formation of a small flap of
P***lniwnin on cith<'r sidw of tlio wouiu], by cxcining a thin layer of mu«-
'■■'•laTw fmai its margins and uniting tlw flaps, by sero-wrous nuturrs. Thia
,l"^- ' ' iwcv.T. is not only uniieoi^^arv-. but alw con*i<lerablT prolonga
1. Any hlooil whiuh may have e^ap''*^ '"*" '''** C^'vie ravity in
fully Fpfingc^ out and the abdominal wotind closed. This 'ib best
Ibheil hy auluring the {terilonsDni, niuAcles, faiX'iK, and "kin in
•PtntP la)-rrs.
{!>) Pi/rrri Cirtarran Sfrtitm. — T'ntil afti-r thi* di-tiviTT of the child, tht?
"P*»ti»e step* are identical in the I'orro and the conservative <-'ierarean
***^'ni. In tti« formtT, howi^^'cr, ait the IkkIt of tlio iitt^nis i« to be am-
M::n.,.i if jj, unnece»>ary to remove the placenta. \b soon as the child
■nil. an t-histic ligalun; ix tightly IJi-d arrmnti llw np|KT portion
pU»i*rTii. The infundihulo-iwlvic ligaments are ihen ligated and cut
!i, nftrr which the nterus is amputated a sltort distance above tbo
li^ture. Tn prorent the atuinp from ulipping l>«ekward, a long,
hi nrvdiD IK p&sseA through it and allowed to rest upon the aMoiuinal
Tb^ irtimip U then sewed into the lower angle of the abdomimtl |
lite remainder being cln>4'(l tn the u«unl manner. Within a short
'(h* ctiim|> and ela^tie ligature iJough off, leaving a depressenl wound
'Wtli )tmU hy granulation. This operation ii' readily pcrfomH'd, but i»
'*'»h pmplnyed at prenent, Ixwaoite of the complicated healing neccasary,
1 tba ia-drkwp rc»T which results.
4-18
OBSTErTRKS
Al prweiit, when it w (Icsira)>1(' lo r('iiii>v« Uic body of th^HS
Etuiup is l>L'sl treiiifd lu in an onlinary i^upravagiQal hy.iWn.'ctoroy.
infiimlilniii>-[wlva' iind round ligumiiiti^ on I'Jtlicr i-idf an ligut<.-d M
distal ends, daniped iil tliHr tili'riiio i-ikI» »tid M.-verod. \Vil)i a iiin)(le
nf Ihc wis«irs. tlio broad lisaiiK'ni on either si<le is cut through dovrc
Iwse. AiJ clliplicii) jm-isioti i^ ihvu mndc throiijrh tin* |HTilnim'Utn
Hiitcrior sui-i'iiw; of the utonis, JumI abovi^ ihe iiliuliler, and a |ii'rito»i^
rapidly ])n'li'(l ufT tiy iiimnH of a pii?ce of game appliiHl around the
IIk' finger or the Iinmlli- of a wulpi-l. Tlic uterine arlcri*-!! nrti then is
liji:ntttd, iind wvcrt-d. after which Iho lioiiy of the Uteriis is amputated
peritoneal flap is iitiirhi'd over tlie ct-nical sHimp. which is Own di
into ihc pelvic cavity. The opening in the broad ligaments are tlieo
by continuouit i-ut^ul MutiirLis tliu palvic cavity k Kpongcd out. k
aMoiuiniil wound c1ose<l.
The opt-nitioii i* niidily performed, and can be completed to lei
than is required for an ordinary (la-sarenn sw:lion ; for, nu-iiig to Uio 1
of the puivic lloor and thi.- abdominal nallh*. the upper portion
cervix can be brought throu);h iho incision and thi? iiiliro npfi-atioi
plt'tcd ujioii iho Hiirfai'i' of the abdomen instead of in the depths
pelvis.
(c) Tofal Utifterrcloaig. — Biw^lioff was the firet to remove Uie
nteraH after Ca>sarean liecliiin, and at tlio pixHcni time, aoder Ihoe
a«uptic condilionH, thv operation gives eatii>factoTy reeulto. The tea
i» Jdenlicnl witli tliut cniiih<ycd in supravaginal mmpiitalioii of tlie
except tliiit after the ligation of Ihe uterine arli-ries the la^ioal V
cut through and the i-utirv ntcms rcmov^-d, after which the opening
vagina i* dosed with caigut and the broad ligament wounds are s\
Total hysterectomy is rarely indiralcil csccpt in cancer of the
in the 0(x'asi(inal eases of infeeiion.
(d) .'iiipra-iijmplnjgea! Caxarran SirtwH. — Frank, of Colo|
raportid'13 Ctt»*e>i iijion which he had operated by a new method,
<'onsiderH far superior to the typical Ciesarcan action whcuci'cr t!
any powiibility of infection having wruro'd prior to the operation. ,
prtici'diire a transverse incision is made through tlwr anterior abd
wall several ccutinu-trw above thv >iyin phytic, and the pi>riionwu«
rated from the po.'iterinr nirface of the bladder and the anterior i
of the lower uterine wpnicnt. After proper e.vposure the latter \
inciwd tniiisverw'ly and the child and placenta rpmove<l, and the'
dosed. By this niclluxl the cnliriT operation i» done extraperitoneal
according to it* invenwr may be safely employed tn cases in,
conservative Ca>sarean section woidd be conlra-indklilcd.
(■hoic« of Opi-mltim. — In the vast majority nf cases thi-
(Vsarcnn loei-tion is the operation of choice, an it in readily perform
givM most satisfactory results. On Ihe other hand, when lliero
pofxibijity of Jnfn-tion, complete, or at least supravaginal, hjstet
should he done. When the uterue is tlw: w«t of tumour forniatran.
as in thofe cuscs in wliidi osteomalacia is the cause of the jielvie def
or in which per^iiitejit !ia?raorrhagc resulting from uterine atoojd
1
CESAREAN SECTION 449
cutcs Sie conservative operation, i-ujiravaginal lijsterwUtiiiy in also the
operation nf choice.
Jd fining a Cwiiarean section the quostion ofti'n arises us to the ad-
ri»«K bih(y of sterilizing tlir jmlienl mi as to avoid the [lossibilily ni future
conception. Thiri can be GtT<>oled by t'lipra vaccinal niiiputntion of the uterus,
by ceicUing the tubes, or removing the ovaries,
Jt was formfriy believed tlmt steriliuatioii I'nuld bu effected by Mgating
th^ proximal end of eilher tube; but experience haw sliown tliat tlic llga-
tiii-T^-a eventually cut through or hccoiiiu absorlnjd, and tliat the lumen of
th^ tube may iiu1>irtK(uently become restored, and with it the possibility
**' future pregnancy. It was next suggcslod that the obji-ct might be
■cc-'omplished by applying a double ligature to each tube and excising the
pT-ti<in lietwi-en them; but the exiM'rimenls of Kracnkel upon animals,
•'^tl the experience of Zweifel and Cripps and Williamson ujMjn the living
^^^niaii, have liiiown that even those measures do not insure against con-
**I>tion, since the ligaturea may be absorlMKl and tlie cut ends of the tube
''*'c^>ineiinite<I. In order, therefore, to render a womiiu permanently sterile
^y an operation upon the tulx's, they must be exiiscd by wolgc-shaped
'neiesiona at the ciirnua of the uterus and tlie wounds cIosihI by Sutures.
"hon thiii is to Itc done, the fundal incision is prcrerable, as it can readily
** •-'^tended to the cfirnna of the uterus after the extraction of the child.
friterilization should mit be attempted by the removal of the ovaries,
•**'" the reason that the retracting uterus may exert such tension upon the
P'^liclw that the sutures may slip and fatal luciiiorrhagc result. I believe
*hat sterilization is Iwst and easiest elTi*tcd by supravaginal amputation
®* the uterus, but with prc>crvati<m of the tulw-s and ovaries, in order that
*■* inconvenience attending a jiri'iuuture menopause may l>e avoided. This
'^'Wf is based u]«in the fact that supravaginal amputation can be (Time
""*■* rapidly than the conservative o|MTatron followed l)y excision of the
"''***>», but more partieuiarly because of the more satisfactory convalescence
*''^r the former o[)i.'rat ion. As yet I can give no ren.^in for the difference,
"■' it is quite as marked as that observwl in the tnatinent of myomata liy
"PrBvaginal liystenvtomy and multiple niyouu'ctomy, ns|>iTlively,
The opinion of those authorities who consider that sterilization should
'l^Tn an integral part of every fivsarean section is nTtainly ojh'u to ([lU's-
'"'•l- If the patient is intelligent, the decision should Ih' left to her or her
fimily: whereas with the ignorant it is incumlKnt upon Hie physician to
*■ ^tiat he thinks is l>cst under the circumstances. Personally, 1 shoLdii \«'
™*"illing to sterilize the patient at the first ojN'nilinn, uide-s she comes
™n\ a district where proper o[ierativc help might not be avuilalile in w
Intur^ pregnanev. On the other hand, if .■'he is wenk-mind''d it di-^eased
t"** is liable to require repeated f'a'sarcan sections the opi.Tatiori is piT-
'wtly justifiable.
^rojn'jjiiV — When considering the hi-lory "f {'a'-arenti .-ii'linii. ri'fiT-
■» was made to the mortality atleiuling it in furmer linns, Sinre tlie
™*biIit8tion of the conservative r>|iiTaliiin by Siing'^r iu \X'>''l. iind lb-'
■Wtant advance in aseptic iii'liniijin'. there lui- Ihi'u a cnrn-pondiiiif
*ldj improTetnent in the results; (.'aru-'i) colleetni fi-oiu the literature
135 cast's which had been ptTfortiu^d l>etwc«n th* yeajv 18S3 and 18
with H iiiorlnlily "f W.-'iii per *«nt Since iheu ihe death-rate ba« gtm-*^^
uaily fallen, »n thul at prMcnl on uu Kvvmge lew than 10 {wr vent nf t^
Indeed, in the hands of expert operatun, Htill more fBVouraliltt r4Mi3
are the riili>, Thwji, Zweifd lui.t pprformed "(> Ciesarean sections with
and Ueynoldn 23 witli in» dcatli*. In '<i'da opiTatiuiui [wrfonntsl hv Ch
bnk, Schauta. I.<i)pii1d, Hrnnn, OUhauMeii. Zireifel, Iteyiioldii, Bar, Charl*
and Cragin, there were only 23 deatho — a grow uwrulily of 6.87 per wc
which boijiuniw rf<iiufii lii l.oii jmt a;nt on d«luciin>! the cases which we
infected prior to the operation. N'eiimann nL'|M>rt* 14 duith^ in 175 opei. ' ' ^m-
tions pcrriirims] in .Sjhuiiia'H clinic in tlie twenty years ending with 1911^^ -^
a grogs mortality of S per cent. Tlierc was a marked tmprovumcut as
twliriiniii- liWHiiK' mure (wrfirt, n» ihc itinrtnlily fL-tl fmiii 10.2 t" 2.-1 |
cent in the VJ and I'iH caw's, rehpcci ivi'ly, which were operated upon duri "w"^/
the firs) and stvond Wn yi'Hr» of the periiHl. In 20 Ca^narcan scvlic^vrxs
which 1 performed at tlie Johns Hopkins Hoi^pital there was only a sin^^r'^
death, thmijih wverul vim-* o[H^niled h|mhi hy my axftxtant^ etwl^-d faiaL B^-'.
Olshausen. in 190i>. reported a pross inoriality of 10 per cent in 91 Cst***'*"-
I'nn ntctiini" jHTfuninil nn ai'iimnl 'if con l.rac !<.■<! ir-Ivc*. iw comjiariil h i < Ji
4.G per etrnt in tlie «5 cai^ea njion which he operated himself. Thus it will
he "wn that ilie morndity fiillowinfi the r«>nser\«livv Ca^tarean w-cli****-
when properly performed upon uninfected patienia amid ^ood siirroucsci-
ing*. U in llii^ iieighhrmrhrifiil of 5 per cent, On llie oIIkt hand, it >.h(iuM !•«'
rcmembcre*! that when performed by inexj>erieneed oiwrators upon patiuot*
in poor condition and amid unhygJvuic surrounding, the results will ^^
most disastrous. i
The typical Porro operation and the snpravajiinat amputation of *h* J
uterus, with re t rope H ton mil treatment of the .■'lump, have >hown a sjirn- j
lar improvement. Tliu*. 441 I'orro operations performed up lo the yc*'" J
1891, and tabulated by HarrU. give twnie idea of the rapid decTMW '" I
mortality. From l^Tr. lo 1881 there were 95. from 18*2 to IS8C, !•*''• I
and from 1SR7 to 1831, 19« npiralifinK, with a nmrlBlily of fiO ]>er «?n<- I
45 per cent, and ?3,8 ^M-r cent respectively. During the same period tl"* I
monality following R'tnipi-rilomal In^alinenl of ihv etump wa« rcdw*^ m
from 85.7 per cent to lO.C per cent. In 177 operationii recently roporf" I
by Chrohak. Scbuula, l.;i'a]vild, and Itrnnn, the gross mortality w«5 1*3" I
per cent, which Iwcame reduced to 2-.'i pi>r wnt on dcdmting the cs-"*' I
which were infifliil prior to operation. On the other hand, wlio) C**J' I
formed upon infected patients, do matter what method lie employed. ** I
results of llie operMlion are still c.vlrcmely iim^atisfactory, Doktor. of B»»**^ I
|)cst. having coMeclod 22 such raseo, with a mortality of 23.5 ]>er <vnt - 1
Thiii marvcllons diminution in the mortalitj- is due to fcvetal fact*:^' I
Primarily, of course, it must be attributed to the cver-ini'rpaj'ing perfect^ -• I
of aseptic techni(]uc. At the same time, careful examination of the pr^^ j
before labour and the determination to o|>eTnt« while the patient ia I
good condition, insti-iid of only after the failure of otlrer melhoils of "^
livery, hare contributed markedly to Ihe improvement. It should he "*" ■
SYMPHYSEOTOMY
451
tliat ihi* U»l r»-^uli-" un- oliiuined wlii-n Ilie OfNTilion is nsorlwl
the end o( pwgnam-v or al the oii«-t ot labour, and thai th«y rapidly
e wohh: 1)u- lutcr in titi- wii>i)d »U^- it if {HTfoniKvl. In niv ox]>«!rt>
cnoialatceDce in tlie former cIb*s of ca^ce is uDiotvrrujtted, while io
Itur it i* usually morv or !<•«* ncnously inu-rfvntd wiili.
ieptated VaaanftH Sfction. — The perforniaiiec of consenative Cawarean
Ml dot* not iulvrffix- with fulim^ i-oiKs-jitiou, oh i« shown by Itu^ fact
e*en in pre-antiseptic tiaie« not a few caitet) wore re))orted in which
wwmiui had n!jKailfdly bwii stdij^s-lttl Iw lli« ojHrrnlion. l^v>pold
of a patient upon whom he operated four tiinen, while Alilfeld and
laum havtf rt-portwl last* of wnmi'it who iindvrwcnt five ('n->«rc.iin
ttan. Tht litalistics of llaTeii and Voini>r, published in 1903, ehow
MH with 2 opcrati'mit, SI with •'(, 5 with 4. oml 1 v-iko with 5 ojwni-
i; whilf KrUhtngtItob; mllei'led 52 tn.'<tant>e.4 In wliirh the operation had
perfommt for a third time upon the ^amu patient.
T>i' (wonrn'nro nf )ire;^anvv after a ('iiSMn-an s«-li(in, howm-or, h nut
ys devoid of danger, a* ^\oyer, Tarm'tt, and Kerr have reported cases
hirh the iiKrinc t'i<ratrix ruptured in iho tatler |Mirt of th<^ nuliMXpii^nt
Ition. Thii'. howcTer. is a verii- wnucual occurrence, C'ouvelaire being
Dj vnilrct liut 8 CMn-a fmni the tileratiin- up In llKHi. ll ik a\»n .■■tilled
the sdliei^ions which «iinvtiniei! fonn between the iiteniH and the an-
■iMjoniinal wall otvjuiionatly t-xert a dcM^Timis influvmio in huW-
pT«paaneie«. Aside, however, from the slight du»omfort incident
ir stn.'tehinfC, nn iwri<in« cnnMyjuii>ce« liavo h«vn oWrred, and in
few ctUHW Ihe aulf^teiiuent ij|ieratiAn haa been <lone through the old
>iins vitbnut opening into Itiv general peritoneal cavity.
t'aginai CaMnan section han already bc-n ivinf-idercd in the cliaptcr
I accouchement forcf.
Lapara-flylrvlumi/. — Tliis (ijx-mllon, which wax recti iiiineUihHl by Baudo-
be in I8V3, and rehabdital'.^i by tlaillard Thomas in 1871. aimti at
«nng the child wiiliout ojienlng Ihe pi!ritum>nl cavity. For thiK pur-
an qltli<)ue incision is made just above I'oupart's Ufn>iiient and the
X reacbrrl cxlrnperitonvally. After iu expin^ure. an incision is made
■t Uimu^rh which tlie cbihi is eitrat^tts). This ojteratlon. while useful
r»-anliH-ptic lim>«. if no lonjicr niiphiyc"!. inasmuch as Mter and more
»in rei^td arc obtained by the osual metltods of prooedHre.
"ott-tHQrt^m r«»»rrt»it Strlinn. — Frnni Ihc earliest times, when a pa-
t died undeliTered in the neigh l>ourl»ood of full term, Ca^taretin nrction
tonetimif perfnnuH imnutliately after Iht death, in the hope of
■J the life of the child. The number of children rcwu"! by llw
f^ore. however, has always been very small. In view of thin fact, and
ihhnrTwncf in which it in mon* or h»< juntly held by thi^ laity. I do
criDoder that it should he reeom mender], more satisfactory resjulta being
• from nrrvHchrmfM forri. wjiwrally n« (hf cirrvii jusl Ix-forc
iaiely afler death is more readily dilatable Hum at other limw.
■pfajTMotomy. — By symphys<y>tomy is mcAnt tliv division of the pubic
in nnliT lit bring altnul an increa;>e in tl>e i-a])iaeity of a oontraeted
uffk-iml to permit the pa:"«gr of a living child.
452
OBSTETRICS
J. B. Sigauli first performed the operation in ITJ", nml thereU s»*^'
ceasfullv deliverwl a ccrlaiii Mailame Siichot. of I'aris, who had a rUaclii*-'*^
pclvJB ivitli a tiiiijiipata vira of fi.5 c'i-nliiti«tn^ and hnd previoui'lv gi^' ^^
birth to four dead children. The procedure created a great »eii?at i *"**?
though when the pettivnt vr»» cxhihitod Ixiforo llie Faculty of Mvdic? ^k^Jffi
two months later she walked with considernble difficulty, and had a aria. ■ ^il
fi*tula from which she i)<-v«r rcoivcrwi.
Th<- operation was taken up with i^rreat enthuaia.Hin, and wa-i jK-rfon
upon 11 pativntx within tlu- firxt yt-Mr afWr Sijfflult> report. Oppo«il
to it, however, »oon developed, Baudeloeque denouncing it aa a " murdei
an<] uiiphiliivophical pmcctlun* " ; nod the diw^ni«tiou a« to it« mcrit;^ wm. j^:^Bej:
80 hitter that tlio Parisian physicians became divided into two jfro-*. ^fc^ju^
Oa-sdR-atis and Sym ph_vwaii«. As n rv-*ull of poDr tM-hniquo and Ha ^^^^g^
ploynient in unsuitable ca»es, sjniphyscotouiy soon fell into disrtfjHilo jn^jtf
was forgotten oxcepl in Italy, wljcru it wa* iwrfornK-d sporadicallr la^anj
the year li*58.
Thv o|H'rution yn» n^habilitat*^) in 18Gt! by Iktori«ani, of Naples, "w-^i
obtained very satisfactory re§ultH by its means, being able tj) rvpcirt. Ai
operations with 40 rccovt-riw to the Intcrnatioiin] Medical CongrcsB a
1881. It was reintroduce*! into France by SpinelU in 1891, who iuiprc^To^
itM merits h> strongly upon Pinnrd ihnt lie took it tip aitd ha« fiacr h*ya
its most enthusiastic advocate, bcinj; able to report in IftOO that 100 s_vra-
physcotomiiM had birii jHiif<tnn«d in hi» clinic- Tin- anatomical tfprvti
of symphyseotomy were carefully studied hy Farabeuf, who aecarafo/r
demonstrated ils theoretical possibilititw. Dr. IJoVrt P. Jlarrin pliyol
a prominent part in directing attention to the operation in this coonlr:
by a paper entitled 'riic Hemarkable lU-vnIls of Antiseptic SymphyMrtMn.'.
rwid 111 the 18'J2 meeting of the American (iyna-eological Society. Sii«n;
lated by this report. Ji-wetl. a few years later, performwl the flrst opwWi"-
in .Xmeriin, and was soon followet! by many otliers. ^in<>i> then tb*^*
tion of syniphyseolnmy im;^ bivn a burning oik. and wae the ninic 't'l""
of disiHssiiin at the (ierman (iyniecolo^ical t'ongress in 1K!>3. tlie lii-'
national Medital Congruss in 1897, antl the Obstetrical Society of fn^'''
in 1899.
Effect of Si/mphyaeotomt/ upon Uie Size of Ihe Pelvis. — Ab moo » ''"
sympiivNi* is cut through, the ends of the inibie Iwnt-ii jjmjh- from 3 Ic "
centimetres. Owing to the structure of the sacro-iliac joints, llw '^
innnminatn lUre outward, while the, tips of the pubic bnntw l))>coiw "^
pressed downward. As a result of tlicse ehangvs the capacity of the [*'"J
cannl becoim-* considerably incrcaswl, particularly in its traiisvM* S"^
oblique, and letw so in its anliTo-poslerior dianieletv. It is usually >*''*'
tliat the eonjugntti vera beioinea 2 millimetres longer for i^ach contiin^il
of separation at the symphysis. As the latter may amount to 6 or
centimetris without inipcriltin;ir (he integrity of the Mu^ro>iliac joint),
increase would aj;f;rc(rati' \'i or \'A niinimetrcts.
According to Ftirubeuf tliin eiitiinalo is not strictly i-orrect, v li*
increase varies with the size of the pelrie, l)oing 13 millimetrt^ whtn '^
true conjugHte nieasnres 6 ct^timetres^ and Ki millimetres wlien Wm^
SVMPHYSEOTOIIY
453
^timetnw. TliiH, lK>w<)v<-r, ila*» not repr«M?nt the actual cnlarge-
he fiuperior .'<tniit from an obi^li^trical point of view; for, u
piiiiiUiI oiil, "in- of III" iMirii-lal Ixtrtsett fits into the oponiag
fiag pubic boncii, thcniby (.■on»i(k-rttblv iiK-n.'u.->iiig tlie j^pace
433. — Duobjim BiKKniKi KrrEcT or HxMrtnttoTtnnr (F»nthniT).
'uT ilti' |iii»ii)ie of the hi-ail. Hiiderlcin ha^ ralnilatCHl ilmt vrlivn
bir bi>ne» gxjM- K to 7 cttiitiiin-trfK tl>e arra of tiw »u]imor strait 18
f<A bv '>U(! half.
littitio»». — Ak tl»v indicntioiw for Bytnphvwotomv are identical with
if pabitttoitiv, tiu-y will tie coiuii<ler4>d umlcr tlio !aitfr.
Uiod of Operating. — TIhi patirnt ^Jmutd lie upon her back with the
I* lit t)M> «•!):« of the table, and lh« flexed legtt Iidd bv ani'ii^ljmtK.
the external f^-nitalla, ]ilnii> Vvnorifi. and lower portion of the abdo-
>(p Iti-n >)iav(-(l and (-li^ne*! da <^ari>ruii>' »^ for an alHlominnl i>pt>ra-
verything exrept the Mon« Vvnwis and lowest portion of the abdo-
uiiild Im roverwl with «terile toweU. An itxriHion in made in (hr
line from a few cmtimctrps above tbo oppcr marf;;in of the aym-
almoKl to it« bitti-r mnrnin, e)it>.-iidiii^ through llut nkin and mb-
tm fat do»Ti to tl»e fa^^ia Upon its anterior surface. A flnfrer is
bnhlnd th<! M-mphvHin and «e|iiArati<H tho undorlrinj; tiMfu«a until its
parkin is perfectly free. This step h frequently accompanied by
t konnorrlinfK' fn>m the Hnti**«^ica! plexiin. TI»c alliiehment^ of the
to the lower margin of the symphysis are then aeparatM by blunt
, afkT which a cathirlcr iv puwol into tlM' urethra and pushc< it
■rd and In one Hide, llie ptihic cartilage la then cut throu^ with
(j£ knifr. eillwT from U* anlrrior or ponlt-rior surface. In lh<' latter
I U lint- pointed hintour^' U |)a»«ed behind the HVinphysii) and tine
ntad<- tram U'low upward.
454
OIiaTLTRlCS
In iiian^' cawat the pubic boitot do not spring apart after the syta\
j^S been cut Ifamu^, being hold tii pti^ition hy tho ittrang Aulipuliic
ment. although as Hwn as this has l>een isolatfd aud screred the]
gape (-ly^pnil ccnl imi-trm. Thcv should not bt allowed to i^-paratr
than fi rt-nliiii*-tn's, aiij tondcnoy towardit i-x<f*<ivc gaping ln-ing rffl
actt-d by ImvUig the aniislaDta make firm preeauro apon the tcocba
Following M-(-ti(>i) of till* HVin|»li)-iii», there iii iifually a profuoc Tpnniisi
orrhagc^. which is bcxt i>ontroll«l by paiking the wo^nd with aterilc
<,'1iiiii|>« ami ligiitiinw not hviug avuiliiWt',?" -
jVfter symphyneotomy. the cliild slioiUJ ti) delivpr«! by forceps a
vion, aii-nnling to circurnKtaiicn;, altliuiigh Z^fel and others rvcom
that the patient bo put back to bed, and labour aHowcd lo i>n<l irpoi
oukIv. During the extraction, firm prow-ure i^hould be niado upo;
trochanicrs on i-illier side to jiri'^frut ton widt> a sejiaration of ilie
pliy«ifi and cnuKtpicul injury to the aaL-ro-iliac joints. Owing lo tli
that Ibe anterior vagiiinl wall, bluddiT. and clitoriii liavo hi<-n de|
of tlieir natural eupp'tirt, tboy are cxpot'cd to considerable tension a
Ite torn tbrongh, nntvrilbftJiiiding rwry pici-aiition. By »ddnrti
thighs after delivery of the child, the ODdfi of tlie pubic bones are b:
togotbi-r, KO Ihiit the lignim-nlousi i^lnit'liiriTi u]wn thi^ir anU^rior
can be united by matlre^ or Rgure-of -eight sutures, and t!ie cxte
<jo«K<d in the umuiiI nianner.
Ayreji, ill tSilG, recoui mended that the operation l>o perform
tancously by making a xmull intiKioji ininn-diatt-ly over iho uli(ori> th
which a blunl-poiijicd knifi- is intrmfuood, the symphyaiti bein^ d
irom behind forward and from Ik-Iow upwanl. Tea yeani later Z
advocutiil that tho welion lie uiade nulM-utaneously by uieatis of a
saw. just as in pubiotomy. In eithor ment, the employment of eutt
iiiijjoMibli?.
After the completion of the operation, the wound should be o
with sti*ri!i! dn^wings and a broad strap of canvoa applied over th
chanters and tightly liuckU-d. ihe lattrr lieiiig well padded with i
to avoid iiijuriouit jiri's.'iiire. The after-treatment is estreuiely eompl
and onerous. Frequent cathctcrixotion is uect%:»ry, and the patient
lie an Iwr buck for thrtw or four weeks after the operation, rhirin
period it is well to re-euforeo the action of the pelvic strap br p
thv piiliiiit in a liniiiinock bed. i.9|>ocially devi>e<1 for t!w pnrpoM,
allowiii); the pelvis to vest upon two sand-hags.
/'r*j;;(i<*.vi.v.— (Viiifrary to the U-^uul >tj»tfment«. my esperienee lot
to eonsider ttiat symphyseotomy U a very serious operation, and oi
to Ik- lightly ondiTtoki-n. In many ca.-'f* tlic Iiieinorrhagi' ik fxctb
protusG and is calciilateil to disconcert an inexperienced operator.^
over, the vaginal Ii-ar* frequently extend through to the retropubic
and are not eusy to repair. Oecawionally the bladder i* injured by th*
end of one of the pubie bones, while more frHjnently Ihe olitonn in Wj
and given rise to alarming hiemorrhage. Such lesions nbould he it
inimrdtately, to n» to avoid communintion l)ctween tlve vafnna ■
ptibie wound, or the formation of urinary Bstulx. Uorenrer, if tlli
SVMPHVSia)TOM\'
455
^P ^iJIowvd to gnpc too wii]«ly, Aerioiw injury may be dimt: to tlu^ Micro-
jli^M? joints If en-oFB in technique have occurred duriu;; tho operation,
DT t-tav [ttiliciit l>p ulR-ady iiikvlcit, Itii- pruocnti nuijr uxtoiul to tbe pubic
«»«jracl null U'tui to iltnlructive KU|)[>imti<(U.
^H C^«3asideraltle apprelieiuiion h«s been exjiivrtsed aa to the potiAibility of
^^Su^th; of union al the eyinp)ij»i« pubis, und Kvt-ral c»>v- have bcini
re^AO ft *«] by MUlIerheim whii^h »err(! to e'how timt the (i|H-fa(ion iiiny
pm-rai^LiM'tilly mnioi Ui« piatient. FortuDstvly. such accidents arc extremely
Ttr^- ; ultbough tb« ii)T<>Nligution<i ot Variiivr by minus «f (he Hiintj^i
ny fehoir that there is greater motility at the drntphysis tiian before the
Lgttei'ation, the pubic boRM IN-Jng iiiiitH by n m»s* of fibroux tiwiic Hev«ral
^^F*t*iuetrei4 wide. This does not neixiMarily lead to diritiirbancee of looo-
'iw»l.i(in, but lln* pntit-iit>t fiml Ouit Hi<v lire more n-wlily. oiid nr* lw» able
^^ko f»«.>rfonn bard lat«iur, than lic-f ore the operation.
^■^ It appeare that ryuipbyiwotoniy it soinvtiniMt foUoved by a slight but
^^P^TnaUfjil ioore^Kc in the ftiz« of the pelvis, which is sometimes siiHicient
^H*' l^nnit Apunianenug labrmr in Mibwi|Ut-iit piT^nsnci(^«. A uuiiiIkt ot
^^f"*^'* iaHtaiiiTM have U»'n r^llwtiii by Mailaiiie WultT. Frank and others
^^B^v? fagi^ested that deliberate attempti- townrd» perinnuent enlnrgcmcnt
^^HV^M W ituule hy o-iteoplastic proreiluTea.
^^^^^Uh analy-iH by NetigebaiKT of i'tH cytnpht-M-otnmies indicated a ma-
^^^^P^P mortality of 11.1 jm-'t ee»t, while in the lUO i-aseii opiTattit ii|)on in
^B^**anl*if diliic there wer«- 12 niatenial drulliK; and evvn after deduettnc a
^Bl^nber of in«tan(ieK in which \w. enn-iidenil that the fatal ti'r mi nation wan
^^P^ to Ather cau.ies, the mortality v»g an hi;;h as 5 per vent. Bar. bafling
^V*" ouni-Iiitiifiti'i M[—n H'l oiKTsliiiii* iMTfunuti] by hiniwlf. Pinurd. Kiii't-
^V*^. and Zttiifel, i^limatefl the death-rate at 6.7 per ecnt. Tho tatter, in
^V**^7, n-ported n M.-rie» of 31 ^ui-ccKKfiil eaM«, but had 3 deaths in the foU
^^P^^n^ II operationB, a mortality of 1 per cent. The fii'ta! luortality «ra«
^B^ ptfT ivnt in I'liiard'ti, and V.Sn per cent in BarV ctitc*.
^H^ f>n (YiiTiparing the results followinji symphyseotomy awl f'lwarean ww-
^^P*^ in tlie i^me cla>« of cii»es, it would appear that little can be «aid in
^^Hpiir nt tlio fonuf r. In the tint plaee, tlie maternal mortality priuaU, if it
^^^^B not pxceod, that following Canuirean Mvtion. white the fottat mortalily
^H^ cotkidvmbly gnvltT. fn-in); 9 or V* )ht cent in t)M> former uu] pnuTtieHlly
^B*iith)ti|r \a the latter operation, Uorvover, if an error iit ina<le in et^tinial-
^H^Nt Uie rHatire size of the hiwl and pcKis. Ihe child ii> im-^'itably lo»1
^H *)th HYmphyMvitomy, white siicli an error is a matter of no c»oseipience
^H """^ Ta^Mirean section i" done. Furtherntore. (here i>s no coiupnriKon »*
^B ""Safl- mniab^^M^>nre following the two operationji. After the former tlie
^H n^iiire<i prnlnngi'd rest in bed in an uueomforlubh' jwx'ition,
^^L ^, afti-r the latter shi- recorcn in a t<hort time and with but alight
^H '"'»*«mit-nfe.
^^B AM lia^ rtimpared the rr^uJfs obtainwl in SS symphrH-otomies and 50
^H ^^fWD fertitin* [wrfunu"! in Zwi-ifei's clinic. There were no malernnl
^H '■^ik it, eilhi-r iwrics. hut the ronvalo-cenoe was mnch iii»Te rapid and
^H ^'WortaWe after the latter operation: and. what i< more important, thrwt
^H * fiw w*vt:> only were rwjuircd liefore the patient was able to take up
4
[a^in lii-r ordiiuir}- diiuva uftcr it, as romiiarMl with tliiHecD wcckt^ aft*^
As iIkwo n*»iilt.* tHfjiiiR- ^Tnerally Icnown liw? eiitliUKiusiu for erit^
|i)i_VKeotoniy ^^tliinlty <li8up]K.-an'(l, uiul inn«t oWtutriviiiii» uiDii; to rv^f"
rii!«iireun lo^tion m* u »a/>-r anit riifirc; salisfatlorv iipernLinn. The oilnr^^
of liie rvattion may be reaiiu.tl from tlw statement of Kehrer, that L — '
VMS, Zweiftfl, Frank, unil Buiimm wvru t)i« only well-kimwn tivrma
otiMtftrioijin^ vrho (x>iitinued tn employ thu o|)cnttion.
Pubiotomy.^ — This operntiun, which if mure prnporly dfMignatcd
lu-h(>tiiiriy '>r h<'li<»liiil<>itiy (frtiiii fi iy% ifit^ iamniir), con^tKl* in (khliiicc^
ing a tempoiary enlar(;emoiit of the (Hilvii l»y severing the puhic Imne t _3
oii« «t<]u of llie Kyinphy^i^ by nifiAiw of a tiigh iMir.
In 1893 Ui^li §ttitetl that from a eurffir^l p<^int of xicw \Mvr\' wrr
Iwn MTiouti fallni-it's in tin- ii|M'ra(i<>n of sTmphyR'otoiny. In tl»e lir^
place, the woiiikI through tin- rartila],'« was very prone to inf<x'tiou, aii.
hi-aktl but aiutrly, and vccoiKlly ihv iuci>>iiun in the mid-line deprived lim
urethra and bladder of their natural support, and titan expo»cd tlinii ■
wrioiw injur>' during thf deliver)' of tiic child. To oteroome thi - ■ "
ties he |m>fMw«-(I ihat llie n.
made throii-;h the pubie Imiiw! it
as h<- h<thl that llio bone vound «i>ti
hcaJ more rapidly and li« K-m ilah
I'l infection, while its lateral posili*
wouhl 8voi<l inlerffrcntf with ttir (s
lueiimeut« of the urethra and bladdi
)ind lhu!< re^iK^! lo n minimum I-
pa<-.ibUity of their injury. In iin~
lo wvor Iho bone, he inventi-d l^-
Qoxittlo wire tmv which is gvavzu.
kno«-u to sur|i;«>na by bia name.
(ji([li did n<il pi-rform the opr
tion until April, 100-^. hut liio «tij
lion was put into practieo by IVtou
')f Lugano, in IK!i7, who wa« £
lowi-d hy Calderini and Van *
\ehl<- in ISIPW and 1901, rp^pettivi^
Following the report of tlie !at*
till' iipt-ration was rapidly takttn
and modirie<1, w> that UirM> meth-
arv now available.
^ 1^1 Orij;inBtly, the anterior siirfan^'
I ...->-. I ''"^ '"""* *^'* *''P**'*t*l I'V "*" oMi*i^
inoision, beginning slightly above *
inner margin of the puhic spine ^ '*'
extending to the middle of tin* om''
of the lahiuui majiH. m>en hy means of h [Mir nf artery fnn^p* ihi.- •**' " '
ins adjUKltil to Iho |Mk>lenor siirfaee of tlie Iwne, whiih w«» thi-n scvi-f^'
In 1!I04, [>(xlerleiu modilied tlte opcralion, niid in«tf«(l of » Utkl' aiv^'
Vx-:. -I.;-).
l'l;BKlTOM^■
457
, iiiaikr a Hirinll imiiiioii. juHt larifi- I'linii^h lit iiiliiiti a tlnpT. imnil-
to and tionifwliat above Ihc (lulilc boiw. After r^'iiuniliiiK thi- {MTin»-
li ctirvml inntruiiionl, MtiTit-uhjii like it litr;^- am-iiriHti) Do«dlt^
pssicd liehiod the bone and pnsht'd tlirough the laliiuni majus. Thv
wv lh<:-n foMliniiHl to lilt! lower end »( Uiv tn^lnimenl. ami hntii^ht
rtn pijsition bv vithdrawiDf: it. In ISOiJ. Stooi-kel and Kannegie««r
ynrlM that ttw'ir nwpittivc cliiefi', Bumtu and Ixiipold. bad jK-rfonm-d
operatioo eiillrcl)' mibcutaiicauiilj'. F»r thiit purpoM! tlie iniilrtiiiieni
I'm. 4M. — SMOwitu PoitniiK i>r Patict \.mi (>i<ili luw.
through the upper end of the labium majus. and. tindvr llic
iDcc of a fingCT in the Ta^na. carried wp t\\<tn^ Ifn- jUMlftrior ittirfam
Iv puhie Wh; and bmtijfht 'ml throti|ih the skin al>ov« it;^ nppc^r man^in.
r^Wtm the pabic Hpine and the ^ympbrxis pubtH. Xhv i^v living tdjiutud
'^vilbdrawinf: tlu> iiiiitruiix^nt from abovo downward.
l^ll(intom_V hafl hcen BUPccssfidlr performi'd upon 8 p(itii<iitK in m_r clinic.
hj ihv iiiH-n and 7 tiniej< by l>'Mli^rl<-in'!i inrthiHl. and I shall therefore
Msrilie the tee)mii|De of the latter operation.
^tef iitiplying th« Ktnddi^r and rmrtum and nhnving the lower abdo-
tt and pnbie region, the patient i§ broiijfht to the edge of the table, and
fion^ for '<|icnilion in Ihr usual manm-r, Tim ]i^ are ln-ld bv a.'wirt-
■-•s. \n iuenion extending 2J rejitiiiii'trp^ inward from the pubie "pine i*
mndr jiiKt oboTW the np|KT niarj^n of the puliie bone, and Ihe liiwutu
(hrouKh down to it. Afu-r ineUing tlMt periosteum a finger is paeecd
the wniinil and' H^paratw the ti«*iie* fmrn the posterior «ijrriwe of
bimt Tben a larK^ pair of nurvcd nrterv fonvps or an efiiecially
vi IW'C'IU'. \» tTarried down along tin- piictcrior "Hrfati- "f Um!
mtil iU inforinr matgin in n»<>lM^, wlwn itii handle is «leprus£«l
n iiinnni-r that it« tip can lx> felt Ihmugh the iipiwr and outer
nf the labinm majuA. A aniall incision is made over the projectioo.
»
L
OBSTCTK1C8
through wbicb the tip of the instrument is pnslied. To it ow end
the Kaw i« nlloclKKl, wliid) i* drawn into ptisilion a» the iiistruinini.
withdruwti Ihrmigli ihc up|«r wtniml. The hajidlei are then studied
the saw and a ftrw movi-uieiit* sulHco to sever the Iione. Duriof; tlw^" ■ '^ ™,
nianipulntiuns cHre lOiouM in- takcii that the boac i» ncrwrcd in the dc»
din'rlion, and the movements continued until the fsv is (elt to mor
fn;dy k-nwilh llie tikin.
In liianj- vmw the ith]ii of thp bone gajte for i or 3 centimeins at Moa
a§ tile section is complete; but, when all the liganientury structures hat*
not l>eeR dividnl, thi» doat not occur unit) faction i* mad« upon tlwa
child. Upon withdraw-in i; the saw. blood ^ut^hee freely from both wound?^-
hut in «n of tiiy camn llu- bicmnrrliiigf' whs ntidilv controlled liv Tirrii prw-
sure with gauze sjioiijje*'. As soon as it is checked the child should U^
delivensl bv fiirciip" or writion, iw i* nwt (/invvnieiil. a* 1 <uin mx? no gnii
advanta^ in waiting for its spontaneous expulsion, as reeomraended l>.^
Diidcrlcin «iid Zw>iM. A* miction \* niudc the end* of the bone *il St
jjape iiKirf >i idi'ly. luu a M-paraiion of more than 5 or fi i5entimeir>s* nhoulc*-
be avoided bv hnvinu the tts«-i*lmit» make 6rm prussure upon the thigli**^^
After the iliild lm:i Iwen delivered, and while waiting for tlie M))mration
the plaectita. a small drain should be brought through the opening in t)
labium niiijiis. and the upper wound wutiired,
After the compleliou of labour, the patient is clcflncd up, a steri
dn'sding applied over ibe iiji|M-r wound, and a hmji wtrip of adhesive pl«--t
S to 10 inches wide passed entirely around the l)ody so as to make 6
and equal pn-wum ovit the i*ides of the pelvis and upper part of tf
thighs. The patient is then put to bcti, and, for coiivcnioneo in handhn^
placed iifwn a Brudfoid fmiue, in wbicb *bi? i* iillowed to move frrrl
She is not eatheteriaxi nule>is neoe«-iani'. and is kept in btx) for eijLii-
lo twenty-one days. Iwiug allowed to tr^- to walk on flic second da* afi —
(retting up. The power of locomotion promptly returns, and all of in~
patients have felt able In Icnvi! the hoKplial heforv the t-ud of tlw four^
week.
I have bad no expcrii-ucc with the purely subcutaneotis operation, l-^
in view of iis endorsi'nient by Biinim am! I-eopold, I fet^i thai it must •
quite as sati*fnetory as the metboil ju^t described. At the same time
wems In me (lial the po(.niiiiIit\' of injuring tbe bUdder tn »riiiiewh-=
lessened by separating the tissues p"»tcri(ir to the bone with the finger *
M sncli nn accident did not occur in any of my casco, while it wan oqi
in several of the Ifi eases rcjiorted from Bunim's clinic by Hocheisen.
11u> union foMowiuK the m jmration is very satisfactory, tn all b«
, onp of my eases at the time of discharge ihere wan a finn callu'> on iW
anterior surface of the boni', but no (ran- of the siirtion could be fdl npCT
its poKt«ri«r surface. In the remaining case. Iiov^ever, union had n-"
occurrefl. and the end* of the one cmild be felt to move freely on rolatir"
the thigb. This, however, did not interfere with Iwomotion, iis the juitir*
was able to walk normally and without pain. Aceonling to the radiograW
of Ifoebcisen. Ihis "ceurs ipiile freijuently. but fortunately give* risi- t" r^
Buhjective symptoms.
-(I
,i
I'UHIOTOMV
459
J'roynosis. — In a persoiw! i-iiTiiiiiunirA(ii)n tn Moiit^rcmivn' in ISOfi,
fh etJitud Ihut about SW pubiotomieit hail bt^-n porfa^lll4^d vith n inor-
Ky letwwn 2 and :l |«-r cviit, uhiio in 207 caww cnllw-U-d from tho
tmtnn.- by Maier in ]',H)T the niortaJity was .>.ii per ceiil. On the other
h}, only i [wttditi' liivtl iii a tfifn-g of 141 caset operaliKl uiMm in the
lies of BcHia, Bonn, Itn>«K^, and I'rajjiie, ntxl ri'jiorit'ii to lh« d-rniun
kaecological Si)cii-ly in 190T. L'l^ually the hiemorrha;j>e, which may tie
Ke pnifuHe, \» vt-noun in i-tuirnolcr uiiit i* n-ui1ily fniilrolktl br prcwturv;
r occsiiioiially aberriiit branthcs of the interual pudip artvfj- may be erut,
Ml it may iNtwnu- wwjowry m lay thu i-iittn; w«iin<l (ijK-ri in onlcr to
'■'tc ihe blowlini; vessel. Very except ionally, even thU is not possible.
I Ri>*lh(iru has lold me tluil one of hi* jinlieiiU diiil from uiR-onlrollaliic
'*i«rrliage.
AlorvoviT, (liv|i viLgiital tvars ocmKionully occur tluring the extraction
Uw child, and re<|uire immeiliate repair, while lew fmiucnlly the
klilrr or on-thrn i» injiirfc], cither by being pcrfnrutcd by Ihc !=harp ends
^i* lioue or as the reuull of iraclion. if proper curt^ U taken in dilating
^ liirlh ranal with hand hvforo bv|piinin)f the opcntion. and by avoHUng
* Ve viuteno: in extraction, these aecidcnts can ufiually ht> avoided. In
^«} of Diy caM» WB» ttu) bladder wouudod. and in only ouv was the
tijia torn.
ConvalMoence in gieoera) w niucli more Eaticfactory than after bju!-
rsvotomy. and the iMltenls eomplain of hut little pwn or di-tcorufort.
aieariy one half of the vom-a the puerperium is Komewhat febrile, but
^ one of my )Mi1ienl« wbs H'riou«!y ill.
j In many ioHtaQcc^ tliere is contiderahle o'dciiia aliout the viUra, and
■tonally hvmaloiDala of eonfiidvrable t^in.' det'elop. Uonmvvr. Ket'cral
F%«nt believe that tJw operation eonsi<ieral>ly increases the liability to
krtral phlcbitifl.
t ndiitiliiin». — Puhintomy \* ntit indiealiil in canes in which the oon-
p»ta Tern mcasiinw leo^ than 7 rentimelrc*. Acciinlin^ly. it jcarcely
|0T< into iijmpetition vritli Ca-J^rcan ja-clinn, except for the liroadeoed
^ttre indication. As far as my t>nia)l experience jii^titics' cu»chi»ion«, I
I lltnt ini^ may lonk forward to piiliintomy practically displacing Caviar-
\ •ectiMD in the i«n-f:alli>il " bonler-linc " eaTi<% as it enuble« one to sub-
ft thr patii-nt to the ti-sl of lahiiar and 1o 0]>crHte after aeveral hniin> of
tatMi-elage pains have demonstrated that the bead cannot pass throujth
f anipohor utrait. Pubiotomy can Iw Mif<>ly performed under such cir-
^Rlanret. while in fawan-Jin seclion the prof^otiis becomes progressively
K^i- the latcT in labour it is p<Tf"rmwl.
If t)M> future KuUtiintiaU-M Uuso Ticwfi, pubiotomy vitl ntill further
F»o« the fleld for the induction of premature labour, and practically
f away with the nw of tin- high fon«p«, veraion, or eraniotomy in n»od-
kt^ dej:Tr«;4 of contracted pi-Ivis when the mother \i in good condition.
} is alfto indirntcd in eertaio catvs of funnel -thu |hi I jiolvi^, and potaibly in
P* prtM-nlaliiinn when the chin hax rotated into tho hollow of the saenrai.
■h far IK) one ha^ reported a pubiotomy performed f»r lht>: indication,
^B^ M<>nl];nniery did a »ymphyseotoiiiy under tlic same utiuditioas.
»i'I I- trained u«i(UnU nn- Decoxsarj to its proper perl -— ^^^^^
Inver. nerious complications may ow-iir nt any lime, which »illscriou=
lt«\ the rwouiTCS o( i-rcu a compt-lcnl »ur;Kon.
I.ITKKATUHE
Abki.. Vtrrxlcich cirr niiiirrei-fi>l)(nnarhiiyiitphyN(!ot«niiound8«clio<iMuiHrm.
f. Cyii.. 1899. Iviii, 294-367.
AnLnt-u. Ldirburli dcr Uoburt^Lilfv, II. Aufl., ISDS, M7.
Arnn. Symphy*cot»niy, cir. N. V. Piilj-diiiic, ISSB. tH. I2tt-130.
Hah. IV ri>|>(^r»ti(j(i (■A«iS«iiin«' i'On?ipr»'»ti\'C. *lf. LtHwt^lruitiH. 189!). iv, IOS-!
Ia n-mphyH^ntomif . Sm r&ulUta iinm^^diutea ct ilcAgu4». etc. lAllMl^trliiu*. I
iv. 3n5-3S4,
Ij^^cidh di- pathulo^ olHt^ritak. I^^ri«, 1900.
BAdnsiXKXtvn. A. Ncniwati procddi pour pratJqiioT Vopirntion v^tttkMM. I'hnv
Pvm. 1823.
BAPDKtjooquK. J. I.. 1)0 Id lecTtiuo du pubin. I.'art dec M-KmrhcinonU, ticnir.
1780. a. 4«1-56l.
BAtiRiS. 'TTTt^ofiatiwia. Pr. Rouaicti, ctr. Btudl. IS68.
BinXRti'M, A Kniwrwhiiitto l>ri ciner IVrnon, .\ivhiv f. O^ii.. Ih85. txv. J32.
BiM-tioi-r. I>i(^ totalu Kxatiqxilion dixi M-)iwuii|ct^r<iii uiid ciirfiiioiimlAKD lllvrui. 0^
rHiKindcnili). t. S^h-nritrr Atrrtfr. 1880. Nr. G.
Braun-Fbr.'<w'ali>. VeiicT ilcn in dnn Ii-IkIod 10 Jahrra »ii«tBt^uhn(<n Sivt*(iaM(^
■tRML'. Archiv t. «yn-, 18(». li». .laiHOt.
BroiN. Taniipr ct Hiidm. Tntili* dit I'arl don luvoiirtirqiMtndi, 1901. iv. 495,
BuuiN el I>KiiiBLiN. Syiiipliya^tomicr. TamiercC Builiii. TnilA de I'Krl dcakMwai
menta. IMIl, iv. ifS-im.
CARoaa Die nvuMlvn KrKehiiiHw d«ti roiiwrvttiiviNi Kafwrachiiitl«ii niit L'l
An-hiv f. (Ijii.. 1888. xxniii. 211-289.
CHAIU.MI. PnnilliMti ciUm Ic* dlvi-nwn opt^mlionfl i praliqiicf duu Im vioou dn
L'ObBi*tri<|UT. 1899. iv. -.'80-296.
Chrosak. Qu(iU'd by RRLiiii-FrrnwAM.
CouvKLAiKK. Huplure dp lu I'iciilrtoe d'une uideniM ap6nition cAauionn*. A:
dp nyn- ol d'otHrt.. VMHi. iii. t-tltlAI.
C'luiii.i. Ca>inr«ii Seclioi), M.-.IUiil Rfi.wrd. 1901. lis. 0S0-70t (May 4, lOOIl. _
DikoKttun.f. ICxp.Diint. tJiiivnuchuuecuubvrdieSfjrmpfaj'aeotoaiie. Vcrh.d. dwiiw^ J*^
Geaoll, (. Oyii,, isiiS. v, 27-34.
Uober «!(« u. ueui' beclfenKrwwitemde Opcnttianeii. Arduv f. Uyn., 1904.
275-293.
DoK-rim. Kaiaprsphriitt twi Scpms. ArcJiiv (. Gyn.. IS90. Bx, 300-316.
P'ARABKiir. Siir In «yiiiphyH^toiniR. .\i>niilci> de gyn. et d'bbML, IBM, sK. 407-
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laes. ii. 297.
FiuENKEi-. L, K\p<<riiiioiilo (ur HtrhrifiihninK(I(<TUnwwjERMuk«itderBiM(«r.
i^C.yn,. 1«(WI. Iviii. 371-410.
irhnitt Ix-i iUt ^iartio Ckwmnm. %mtnilhl. f. Gyn., 1887,
CfSAKEAN SECTION, 8YMPHV8E0T0MV AND I'^BloTOMY 461
tnUNMiotz. De I'op^nitioii cAgBrieiiiii: r6|>dl4« chcx Iv infiiiu fi-nmie. ATiiiikleM do
gyn. et d'obst., 1906, ui, 135-147.
IIX. T»^io latenlizzsUi del pube, suit vantaggi, aua t«ctiii;ii. Aim. di oa. c pu., 1804,
No. 10.
.Atofmlachnitt des Beckens. Zentralbl. f. Gyn., 1904, xxviii, 281-290.
UN. II konservfttive Kaiaerechnitte mil qucrem t'undalschnitt. Zentralbl. f. Gyn.,
1800. xxiii, 1457-1476.
LBUtrsHA. Eclamptiia RTHvidarum. Kine neiie IiidikatiunHMtellunji; fiir die Sertio
C^emrett. Zeiitnlbl. f. Gyn., 1889, xiii, 901.
BBU. Hemarks nti the Ca'mrenn Operation. AmtT. Jour. Olmt., 1879. xi, 620-626.
^ktUe^iorn Lareiutioiis o( the Abdomen mid UteruH in . PrL'tniaiiC Wunien. Amer.
Jour. ObBt.. 1887, XX. 673-«85, and lO.'B,
ioHilta of the Porro Cit^arenii Operation iu all ('ouiitheH. Kritish Me*l. Juur., 1800,
i.«8.
riie Remarkable Beflults of Antiseptic Symphyseotoniy. Trans. Amer, Gyn. Soc.,
1802, xvii, 08-126.
*be Potto Cs«arean Section tested by a Trial of Sixteen Years, etc. N. Y. Jour, of
Gyn. and Obet., 1893, iii. 273-263.
wmn and Y'ol'nu. Repeated Cu'sarean Section upon tbc Sainc Individual. Am.
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tmt. The Comparative Value of Ciellohysterotomy and Cutliohyxteructomy in Cases
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^■■waN. Klinische u. radiologische Betrachtungen uber 16 Pubiotomien mjt
dM Nadel. Archiv f. Gyn., 1906, Ixxx. 09-137.
-.XAmu Kaiserscfanitt bei MaRtdarmkrebs. EeitriiKc zurGeb. u. Gyn,, 1899, ii,
BO-77.
hL. Ueber dem qiieren Fundusschnitt nach Fritsch. MonatHHchr. f. (ieb. u. Gyn.,
1800, 417-432.
"»rr, A Case of Symphyseotomy. Brooklyn Med. Jour., 1892. vi, 700-792.
rxBuKiSHER. Beitrag xur Hebotomie auf Grund voti 21 FaJle. Arrhiv f. Gyu.,
lOOe, Ixxviu, 52-105.
KsMK. Kympbyseotomie utid Pubiotomie. Monatsschr. f. fieb. u. Gyn., 1005,
xd, 228-.372, 361-374.
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Cbrou^ the Cicatrix of a Cu'iorean Section Wound. Jour. Obst. and Gyn. Brit.
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•^M. Jour, de M4d. et de Chirurgie, 1770, xxxiv (supplement).
*<HJ> und Haake. Ueber 100 Sectiones CucHareae. Archiv f. Gyn., 1808, liv, 1^1.
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1S79, iii, 289-295.
kB. Der fregenwarlige Sland der Hebolomie. D. I.. TuhinK*'". 1007,
ruL SuJla fcastroisterotomia. N'apoli, 1807.
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T71-781.
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Nr. 01. 1-54.
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1-lSO.
^*UBKW. Uetier den Kuiscrschnilt uiitt Nt-inL- Indikutioii Ih'I llcikt'iivi-n'iimTiiiLg.
Ziitachr. f. <ieb. u. Gyn., 1897, xxxvii, 5.13-.'>4I.
XiJKndnutt w^en Eklampsie. Zeilsrhr. f. (k-b. u. Gvn.. I'HHI, xlii, 348-:{.Sl,
n
462
OBgl'KTIUCS
I'lNAKo. He U ii]rmph]ri6>1oicie. Acuiides de gya. «l d'oM., 1803. xxxvii, $l-M.
Iiiitimliondc rop6mti(inc^iar>cniiocMundfirfeeiiiKpp«>r(.BVi.'c««llc(k 1* ■>'nip)tf
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Uui'HBKT. TiuiiA tiuoivcaii du rhytt^rotonioiokis ou ronfanUnMoit c^AiipD. P&i
1S81.
SiNQKit. livt fGtiiwnK^liiiiii l<«i ITt^niiiniyoinim, etc. Lvipag, 1882,
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iiitqiU. etc. Pitiii, 17711.
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HrnKi'iEKi.. Syniphytieoioniie odor Puliiotoitiie, Zvi\mUA. f. I5yn., 1900, xxx, 7** — W.
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nf Itogitnn, IHBI, i, 223.
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Sof-.. 1900. p. 2U.
TawiUA. (!ii«tn>.«<l)'trot«[Ti.v: A Stihwtltuta tor tfao Caxamui tkctioa. Amcr. ^Mi»ii-
Obrt., 1871. iii. 125-I3fi.
TiiAi-TM.ix.v. 8™ Sicbold. Vcrmich r'liWTr (irwhirht drr<lchiirljthCilfc, 1S4.5, ii, lO* 'l''-
Thinem. Sviii! Kau-fTm-hinulraiivn. FmiduUrluiil [, cU*. Urilriig^- lur <Mtb. u. K-^)'"''
IftftS. i. J41H61I.
Vah iiK Vkuik. Die H«lH>lonkic. ?^utnih\. f. Gya., 1902. xxvi. MO-S^S.
ViUMr.n. f^tudf luml. ct nidtaETai>hic|iic dc k nyniphyMlnloiuiv. Caiii|>t«« nai^A-'"*''
b gor. d'olwl., ik iQ'n., rt do p^. de I^iriit, 1899, i, 308-^'24X
WiLUAUH. Pi'lvic Iiulioatioiia for tho IVrfoniuiticc of (!W)nn«n8f«1ioo. Anier. *'l
lOOI, Scptranticr 28; THnd. .Vnicr. Gyii. Soc.. 1901. xx\-L 260-37B.
WoYKR. Eia Full iron Sp<:<ritiiiirvi)>tiir Um echoBUgcrcn Ulcruji in der hIuui
nc'luiittstuirlic. Mi>nult»>rbr. f. CWi. ii. (Jyn., 1S117, vi, 192-^00.
joibnitiiii" .''j'riiph.vwotciiiio. ZMilmlbl. f. Gyn., 1906, 737-712*.
l^'imt-wchr. f. Quit. a. tijm., 1897, vi, iZI.
cnAPTKK xxni
DKSIKUVTIVK OPHkATIOKS
niotoray. — XToAer tliie headinf; aro inrfudM all oppratinnn which
g iiU>iil II rlivntMi ill till' siw iif lUw fa-tul lii-HiJ. with a view to rcu-
if il* ilolivery easier,
t'rior Ui Uk' inlroduvtion of pudulie vorfioD aod forocpt;, artificial do-
7 could be cffeclcd only by meatu of oraniotoniy or fiiitirvDionty, onit
iVt "f wliicJi wiw rvsHrt^-d l<> in nirarly i-xery cufv of dlHicnll lahotir.
onlinjily, in foniRT timw, the perforator, nhar)) Umik. and croKlit-l
(be iinwt im|><>rtani iriKlnim<-iit> in the oh«lotrician's anuameiitariuiii.
.-tral dexterity in tlie eni|i]i>yuient of forci^pf aiid vcwion. ho*ever,
g\il alioiil a rapid cliaiige, und vniniuluiny upon the living child tieeanie
and rnriT.
ndiratum.1. — (Vaniolomy is positively eontra-indieaietl wlien the con-
ta Vera innuun^ Irvn tlian 5.5 ccnlimeti^s, ^inee in such cawti (be
linn rif the i-hild, even after tlie skull hai> hft'ii cni^lictl, in iitlritd^vl
jjTvater maternal mortality than Cie^reau iMxtiwi. On the other hand,
N4ttii aljiiTi* tht* limit, cranioiimiy nmy be indicated under any condi-
thai render the delivery of a mutilated child ihe most mnsenatitfi
Ddniv. m far a" the Aafety of the mother w concerued.
W\xe indi(4lioiut for it» piTfnrmiincN> vary markedly. When Dii- ehdd in
cnnioloniv is indicated wltenerer it will render delivery ea><ier. and
vfi-mhlc I" forceps or veniion nnless those operations can he undertaken
nut detriment to iIk' moibcr. .Ksthetic confliderationx simuld never
r the t^rator fronj resorting to it- On the other hand, if (ho child is
^ lbr> opi-ration \* juntiriaMc only in cuccplional chwh: indeixl, Pinurd
•nme iitheni hold that, in view of tlte natii^faclory results ot)tait)ed from
nfnmy am) Ca'Win'an '♦■cllon, it ohoiild micr Ih> [(crformed. Thiis,
nrr, raimt tie lookt^ u)>»n ^ too radical a view and one deinandinj^ a
n amonni of qnalifieation: for. ulthoujih it mu»t e^'cr be the duty of
' ian lo do hi-n bent to save the life of lioth moliwr aiid child, it
t> '-W nwlily cimii'ivahic tliat eonditiooii may arioe tinder which
ocrimv upon iIm-* livinj; child may not only he perfectly ju^tiRable, hut
imperatively demanded.
(Imrrally «peakinK, I'ranioloniy :thnuld not be perfornml upon the living
'' mother i* in ^px^A eondition. amid iiuitalile HUrrouodini^. and
.1* of a coi«iH-ii-nt o[ierali)r. I'lidi-r «uch im'iinwianct*, if llie
to labonr be due to a contracted pelvis or ao excessively large child,
464
OBSTLTlU(X
("tt'>irtrfaii hiHtiiHi oil' It^i^nnw laci-!-, inil>i<iU>iii_v, is preferaWe, iDasin ■»«!■
iiH llii- siighlly iiun'.u«;d risk to thv luothi-r it mo™ limn i-ont(K'iiKu1tvJ ^*^'
liy the rescue of lier otTxpriug. On tlie other hand, if ihe wotitan is
fwa until «hu \ms boc-n in the t^ccond »ttige of Uhotir for s considcTs - -^
time, and ha:* bLi>n xuttj(!C-t(^ to n.-|>(!tit«<] vaginal i-xaitiinationii ani) poni '^TWi
-1-
30
prt'wnts signs of infection, ("atiarcan seclioii is not indicalod, but theci» *
nhoiild Ik- HMrrificcil in llii; iiilrri'ilH of tlti: imdIIkt, inai^niwh 0" the luai '
nal mortality atti>ndiiig ('»sarean Becliou undt-r such circnmsiauoes i*
tlw! iiciglitiiiiirlioiid o( S!5 per rt-ni. .\]^in. if llie chiltl Js iwl in px>cl v
ditioii^ as shown by a too rapid or too slow hearl-l>eat, or by tlw pai
of eonniderablv qtiniililic'M of m<Toniuiii with a vi-rtrv pn'sciitnlioii. ilt b
is already in suoh )«Ti) lliat, against that of the mother, il is no long-"
L'lititk-)] to neriouit cuiNidi-rnlion.
Moreover, in country di^lriots, where the iihysician i^ unable to sw
mon niifficifnt ai^iHtnncr, and is without the rnvvM^ry appliaiicvs (or
awejilic o)icrnl!(>n, t'a^artaii ftprtion or pubiotomy should not \n' iindortak<
and craniotomy bfconics lh« oprratioii of clioicf. Bui evtu under ttiLi
adverse conditions the latter n^HfralioR ohuiitd t>e defcrntl bx long
posi-iblo. and should not bo resorlml to until deti\'ery bwoincs inipui
tire in the interests of lite inotlier, and titen only after tlm failure "
forcepB.
If, bowt'vcr, tbi; pntii-nt oluiuld agnin Un-ornc pn^nant, she simuld I;
sent to a city where proper treatment can be obtained, as t eonsKler that
phy*icinH win) n-pi-atnllv perfontis craniotomy Ufwn tW? same patient i
but little belter than a professiniial abortionint.
ilydroccphalus affords a positive indication for craniolouiy, whj
should I>c piTfonned lu wKin an llu' cc-rvlx is completely Oilau-d. In t
cases spontaneous laboor is out of the question, and wen a sucvessf*"
('ii\ian'«n wclion will only give iw a child thai u dnonied to die shortly •■
remain an idiot.
When iiistifH-mblc ol«it«clcs are enwunierinl during th<- i-xtrai-tioo
the after-coming head, craniotomy is a justifiable procedure, since ihe chi«
is alri'udy dead, or dies wtlhin a few miniiten after ilic naturo of
obfltaele ha^ been recognised, and before preparations can be niade for
dcliTtTV by piibiiUniuy.
Craniotomy .-ihould not lie performed until the external o* has Ixoii
completely dilated, as the iniju^rfi-ctly opened canal may offer a terir
obstacle to the extraction of the child.
Mflhod of Opcmiinij. — The patient should be brotighl to the f«: —
of the ))ed or tabic, pla<:ed in llio lilboiomy position, ami prepani)
for an ordinary obstetrical operatl -^
Cranioliinty usually includiv two sif
-^^_- first, tlie perforation of the bead i—
C|_j ibi- criiiiintinn of its contents; «,"»»*^
Fio, 42,v— SuKixjG'M Scinsoiu. M'oondiy, the extra«tioD of the tnutiln '*"
cliild.
liunierous instruments have l)een deviitpd for pcrf6ratinfC the head, f''^
moat vuitable of wbicli arc Smi-llin'g nciasors or Riot's perforator, Bnui? ^
:r»4
vould DPTVC ihe purpn^i- lulttiirably, but is Dol to be recommended
cc-ount of 11*0 diHiciilty wiiU wim-li it i» kept clutn.
f Ui« iwmi irt fHRaftcd ntid firmly fixed, perforation is acoompliMh^l
bal lillU- diRicully. With two lin;;ci^ iht- tur;^- or small fontanelle.
ijr be tnoii (ymvenienl, ix located, an<) tlie (x^rforator p1un}r<>d through
The opening u then L'nlargvd and the LD&lrunient briGkly moved about
i>l«rRl)CTIVE OPERATIONS
465
r»0. <3C. Ui.iiiiiii or i'LiiruKAnNO lie..:, i A:iii;l. ;Lii li \:-l!<»*),
Mn tbe Mkull. tm It* to iVtnnti-gnte t)]« Itrain to such an txienl that it
be vasiwd out with a douche of sterile water.
If. lifiwi-ipcr, llw h(*d in inovahlc alxivi- ihv *ujicnnr strait, it must be
U tised by means of pret^ure exerted by an a»^i^taut ihmugfa the ab-
iiial wall*. 'I'u atoid wonndinjt: th« matt-rnal Mifl partH, thv perfora-
ebould be iiisde through Ihe portion of the head lying in the neigh-
ffaood of tlw "vrnjihyii^ pul>i»; for. should Ihe inslniment slip from
ptkiition, Jl is less liable to inflict serious injury than if it wert; near
«Acmiii. In tuiti prcwuiitatious p«-rforaltou sltnald bo ofFected through
hnv.
To pierce Ihv aftcr-cominf: Iwad. the body of the child should be de-
Ked and Ihe iRKtrument carried into (he »kull in tUi; ndghbourhooil
ho lemponl imturc. If. a« occasionally happens, this point cannot be
:lial, the lioily of the child iihould In; irarritil up over ihe abtloniim of
iDolher. and perforation eflectexl through Ihe moulh and b«se of the
L WWn u hydrnrrphalic child j)rcwnt'« by the bn^-ch. and Iht* liewd
m^iii^d at iIm^ p*'Uio brim, the fluid ivinlents of (he skull may be cvacu-
by cultiaf! through the arch of one of tlw cerricm! vertdint. after
(A ■ mHallie mhtler ii pits9N>d through Ihe opening and carried ak>iig
vfTlebral canal into the skull.
AfliT tlM" hrwin ha* bet-n wasbnl out. although tlu' vault of the cranium
ipMs and (ifTers no further obstacle to laimur, the liaw of llic nkull still
iaili> nnrhangi-il. and a* tlw liiiiia^toid diameter measures between 7 and
466
OBSTETRICS
7.6 centiiiKitren. it i* Apparent Uiiil it miitiot be delivered tlir
rdly ('<in(ruL-lcd pelvis until it lias Itouii diminiiilu!it iu Btxe.
W'hm ilif coiijiiKnii vera enci^-)!* 7.5 cenliiiittlKw. die «olUp»ecl
maj be vxju-lkd by tlic utorinc contractioiu alone, or may be extroc'
Via. 427, — l)iuvM*K CiiAKioouMrr.
tDcaiis of Die forceps or a Riiger iiitroduM-d lhroii)i!lt tlic perfontion
isf. But even in pelve-i of this sixe it is usually advisable to mal
of & special iiiutniiiicnt for gratiping »inii cnniliiiig the ha^w of tli(*
The cranioclatt, invented by Simpson and modified by t^ari [traun,
ilie piir])"!»i* itKwt KHliel
ily. One blade is intn
tlirotigh the jXTfofntion
its free end impin)^>!l up
liiwc nf the Bkull, whi
fi'nesirnliii litade in ■
over the faw or lower f
of tlic occiput. The i
tlie end i>f the instnim
tliin tijililcmd. and us a
not only in the tubce I
sikuU more or less eomp
liiit nt tlie Afluie time i
liold is nbtaineil for tlie (
tion that is to follow.
For cTiisliing aitd ft
injr the head, Bau<lelocq
yoiiiipcr iuTOnled the et
trilie. Thiii ix CMKintii
very heavy forcepit,
hladem comc) cIomIt ta
and forcibly eotnpn^ Ih
wliin the viw at the O
the handW t* lif^htonnl,
iiuitnimenl lias been nut
to many modiHealions, ■
the lieitl biitijj thai of Tarnicr. At the same time It labours und
disadvantage that it aims to accomplish two purpose*— i.e.. cntshii
extracting the head ; and, un fort una lely. whenever it is «i oonatrnclvi
Fia. 428. — Head Cni^irED bv Chanioclabt
DtSTHlJCnVE OPERATIONS
1*«- .*K.ii eflii'ieul oni>lipr il is a piior liaelor, and vice versa. For thette rea^^
Uk?" «vpliHli)tnlK% »K Kuch. IK but lillii- umxL
Tartii«r, in 18S3, invented the bamotrifin. a tbrHstrladeil in.«truiiii-l
irlx-s«?h combiiMM ia one the idvanUgt^* uf the pcrlomtor, cnuiioctast, nt
Phi. 43I>.— TAmHiKK^ Ccn>Ai.i>nuBa.
e^j>ba]otrib«. One blade ii> flpear-pninliH), and after «>rnn); as a perforator
is r«^itfd into Ibc base of i}w skull. TIk- •(xt>nd liUib- w thi-n iiilrmlmiii
**v«*^ tho occiput and the thinl over llw face of the child. All three are
«rtic?iiUtcd, nud the vim: at tht- haiidlm it tcrewvA dnwu, wJtli tli« ni^tilt
Vft- will — T*»jriBB'« ItAflimiunic, ItuukrruwiJi-nM.
"** tlie b«j>c of Uie okull i.* friw-tiin-d in many direclions, utH the bead
CTiiUprwwnl inlii an elon^tinl and shapdesH inaji*. Tht* i« a
"'"'•TXmeni. ami lias beep particularly reoominondt^ bv Finan
nio'l fHtciont
inard anil liar.
Via, 431. — Tasxirs'ii IIashtihiiie.
.T
R. Simpmn. of Kdinburji;)!, d<>?i>tei] an inAJnnnenl known a^ Uw
which likewise consisls of three blades. The tip« of two of tliem
' ■ .(.^•ether and form a w-rftw-likc instrument. Thii' first jitTfnratr* thu
**11, ami by a rotatory motion in then worked into tlw base, which i^ frao-
■* ■"'-
468
OBSTETRICS
tttrtHl in iiiiuiy dinvtions by separating t]te tuo ltlA(l«M by iirtvuxin a.|^ft-«]n
tiiw liaiiilli'ii. AfitT lliw, Ihe tbinl I>Ih<Ip is iDtroduced ov«r Uie face m
occ-iput und )icn.-wv<l lightly in plucu. ibos
verting thu iru'lnimoul into h lypifol era
dost (Kift,. 433 and 434). Tlie baaityst pc». -^w
vpry satisfacton,' ro-ulU, and according lr» iU
invi'-ntor will c-ompn^s:' lite bn>fi of Iho iikull i anio
a mass 3,5 centinidres in diameter.
When [Jcrforating a hytimirphiiiic ehil«i ^ it
ii> iin)iorlnnt to remember that the braii^ ji
spread out over the Ulterior of ttiv tiknll SK.3t t
layer nf tiMiu! only a few iniUimctreH tl« mA.
When ihig is perforated, the ecnim filltnf^ llw
ililijtt-il vi-ntrieli^s of the Kmin i-«i-aiii-n anil Ibe
-kull eollap-es, after which delivery is n?a«:J(li
effv-eted. Oectisionally perforulton doe* lusL n-
ealt in tlie death of the child, which will m
after it^ liirllt. In order tn guard ngainxt t:iii>
most di>irewing occurrence, the obstetrit^i*!*
should not be eontent with merely perforating'
Ibc ifktdl at one jioint, hut :^houtd earry Die >■*'
htriuiieni back to the bat-e of the brain and »***'
il iiroiiiid sn Uf lu destroy ffTcc'liinlly IIh' u(-«1*'"'
portion of llie medulla. Especial care i? ne*"^"~"
sarv in this connection in order to avoid ** _„
phuuant eomplicutioiii'. IVrniw having rwa* ^\
rt'i>orted the case of an infant who suiii^' ^^.
<raniutiini\' and grew up an idiot. And a « .--g,
ilar case has bwn known In <n-cur in lt«Iliroi*'^''^^--\c
f'TognmU. — In moderate de|?rees of pfl^'"^:^.
contraction, craniolomy. if properly pcrformti^^^^"
Flo. 43S. — V.mirt or Bahii)-
TMDI.
U almost devoid of danger to Ihe niotlier.
the other hand, when tlie eonjiigiita vera nieusures 5.5 centiinetn-s i>r 1*?<^
the iiiori«Iiiy cxei-uds that following CiesaTean acction. It muM he reuim "^
Fio. 433.— Ai WHOM *• BAJULVar, DHmKTPutTitii.
bered, however, tliat favourable rp»idt.t arc obiatm^d only when the motlwF
ia in good condition; whereas, if the o;>eration be deferred until infectwr=^^
DESTRUCTl^-E OPERATIONS
4e»
md, it !« « ino«t H«rioii» pToceJuro, «iitl i» Attended by a mortality
1£ per wot,
yobataj. — In enibryotomjr the viiK'pra are rpnioved through an
in the thorax or abdomen of ttic child, or the Iw-nd it- i^evpred from
, Th« former operattoa i» known a» oviAcerati<m, the latter a»
Inn.
I'm. 434. — iStuemm'* Hu>n.YiiT, AimcvukrEb.
1; eei*€rrati'm is rarely entplovfi], tiK>ugh il occniiinnully Im*
rj- in onler to cffivt the dilivery of certain nton«trosjlic<i or
pulTerinj^ from uniuual eDlar);:em«nt of iUa ihontric or aJHlominal
mulling from tumour fonnulion or tlic acx-uninlation of fluid,
ikevfi.'* Iiwonie necessary in rate eases of lmn>tveni« pn-jtTiilntion,
I thorax or alKloinvii of tin- child li<« over (he HU[<erior strait and
u not BM-csnihle. Under nach eireiinislaix-e* an opting ih inad«
ra throaf;h the ilwracie or abdoniinal vail, aa the ease may be,
ty \KTgy. lu admit tVo fin^-iv, wilh vhirh the vitwra are tlten torn
n their attaehments and olowly extracted.
litnliott ix miirli mort- f reqii<-(it ly emplori.'d, and ie indicated more
ly in neglfrted IramtrerM prrxetttalion*. An a rul«. when twa
canes can Ite readily delivered by version and extraetion; hut
jidly the eoudilion is OTerl'Hik»i, and nwi:>tnnc<^' i« not culled for
I shoulder has bwome finnly impacteil in the pelvic eanal, the
krine «-gmrnt al the same lime tx-inj; *n strelchcd as to niake an
u msion prarlieally sinoaymoiis wilh rupture nf (he iitemi».
bh drnimslanoe* th«
^ be delivered only ^^
Elation, whirli can * ■
Km, -W.",.- Hiiii'^V l^f ''M lii^}k.
\
ae(^omplL■<hl■d hy
£nun*H blunt hoolc.
ilHv. in negWted AlmuliVr presi-ntaiinn'. dwapiiaiion is often
facilitated by the prolapse into tlie vapna of one arm. 'lliis
scixed and brought 1hro«g)i tlM> tiilva, firm traction should
upon it tn A* to pnl the nwk on the ntreteh a* much as pos-
jodex tinker of one hand is then pBSM<d over iIh- iH-rk and n»ed
Bo in applyinp RraiinV liook tn neeiinitely as pos«ihte, Wbow
o, tl» lip of the instrument is eov.?red by the (inpT «> n.< tn
Utding i1m> maternal M>ft part*. .Ml being in readiDess, strong
OBSTETItlUS
Iruclinn U now maOc upon the haDtllo of th« ia'ilniinpnL. which at
tiHtiip liiii« is giran u rotatory inoveiiu;ii(, b_v which ttu; ctTvioil vertol
arc di?art)culat<^<1, and on oantiuK^
tioii (if ihv inolioii the neck if ntaJ -^
ncv^-riHl f mm the IxkIv. ] t «ny rwr -
«nce is otTcrcd fay the skin, it may
ciil with «ciiw>r«. After <kv»pitat»
the U»dy is extracted hy traction op
Dm.- arm: or, if that be not availab)|
hy Tcntion. The head can fptujiKati
he cxpiBWCNl from the uterus bj mi
mi'iivres similar to thoae employed fo^
tile ficliren' of the placenta, but
Ihi-^- provir unsuc-cissfiii. a filler
introduced iuto the uterus and ins
into the mciutli of the dtild, af
which, as a rule, entraction is tea _
-Jp~. elTei'tcil hy tnietion upon the hiwiT JH»^
^ * Xyv If this is not effectual, delivery can b*-
n ^* Vt\ ■ewmiphiJinl hy mtains of u ecplu
[ 1 tribe or after perforation,
^^^^n i Zweifcl helievia tluit docMpitalt
^^^ftj eiiD lie rendered easier hy tlie uw o(
^^^^K trachciiirhri'trr, wliicli coiiKiiitc
^^^& tially of a double Brauu's hook. So
^^^^k wt my own oxpericuce goes, I sec
^^^^^^ neceasity for' the new instrument, n.*
haw always been able to effect
capitation l)y mean* of KrauuV hi
At^in, if tlie latter be not available,
operation can be mtdily [K-rformwl by incjini' of a pair of long eunrcd
«ii¥, similar to thi? eitibryotomy scissors of Hod^; while in ea-nes of
eily th<- hciid msiv be si>\erfd from the trunk by passing a strong conl
Fiu, ■las. — Vtrjuxrnxnoit wini IiR*tTMS
KuvKt H'MJK (AiDFrimi Tcxi-llnuk).
Filt <37. Rr. 438.
}■<•%-, 437. t3S.— SituniKo Moiiii or Althw or Bi.VNr Uuok (.\BiDrkmn Tr^J
DESTRUCTIVE OPEHATKJNS 471
neck anil using it as a saw. When this is i-iu ployed, the va^^inal walls
a*t be protected by a speculum, to prevent tliem from being cut through.
CDoca.-'ionally. in ht«d presentations, the excessive size of the whouUlerji
*~ prove a serious olistacle to laliour. In such eases cieidolomy, prtv
^?rf bv Von Herff and Stra-stmann, renders excellent service. In this
K~ation a pair of long curved Bcissors are introduced under the guidance
tl'ie hand and cut through the clavicles on either side, after which the
ulder girdle collapses and delivery is readily eilccted.
UTERATI^KE
^nbiyototnic rOpbaliiinc. Paris, ISHfl.
'■>EutcQi'E. NoMi'citii iiioyeii pour d^livrur les femmea contrefail«8 ot en travail.
f^riH. 1629.
tT3f. Ueber da8 tfrhni.-irhe Verfahren bei vvmuchUwiKten QuerkRen, etc. Wiener
aned. Wocbenm-hr.. IS6I. No. 45.
■ X-Iebft. EKe ZertriiiiiiiierungdeMSchultcrKurtelu (Kleideotoniie). Archiv f. Oyn.,
1 m.^. tiji, .S42-546.
laciCE. t^ebcr cincn (ciinHtiK verluufeneii Fall von I'erfurutuiii. etc, Zentruliil. f.
« ;.vn.. 1900. xxiv. OlS^Ml.
ARD. Ijc basiolrilie Taniiur. .^.nnales de gyn. et d'oliat., lAtU, xxji, Sll-Z^l uiiil
-«B-I42.
Hx Koi-diMaut fcelicide th^rapeutique. Annalee de i;yn. et d'obttl., I'jOO. liii. t-18.
rtMjN. A. K. lteli\-ery by Ihualysiti. Soottiah -Ued. and Surg. Jour., 1!HX) (.Muy).
pvHJN. J. Y. CraniiK-btHt. .Med. NewN and Uaz., 1860. vol. i.
ukHMUAKX. UetK.T die (.ieburt dcr Sehulteni imd iilter den SrhluHM-MteinHrhiiitt
<C-lei(iotoniie). Archiv f. Oyn.. I8fl7. liii, 13.5-1«.
KTiflER. I^e JMiiiiotrilfe. Acad. dem^. du Paris, IH83, December II. .^nnalcH de gyn.
«tt d'obst.. 1884. \xi. 74-77.
EiiTEU leber die Uekapitation. cle. Zenlralbl. f, Gyn., 1895, xix, 521-539.
CHAPTKR XXIV
OFERATIVK PKOCJiDVKliS WHICH DO SOT AIM AT DEUVSK
l\ thU chapter will be coDHideretl a number of prooeduKv uiiuallr <
nulc<I (w minor oiKTUliotin, which may 1)M;o;ne neeesHWrt' during pivfrnsn-
Ut)our, or the puorperiuin.
The Donohe. — Wi? (Ugtin^uii>)i Wtvi-on vaginal and ulvrinr doupb
aioordinf: as a cnnsiderabic qiiantily of lluid is injecl<?d into the Tapn^^^
canul alone or directly into tin- uli-rim- cavity.
Vaginal Pouchf. — FoUowinft the introduction of anliiteplic ruPlhr*— "^
into surgcn*. I)i« u*c of an auiii«,'ptic. praphglaclK mginal douche bvair
a roiiiine part of the conduct of iabour. in the belief that by iu mc
the coimllous pathogrnio niicro^irpmiiTn* hiipikwkh] In <'xii'l in the vagit
WH-rction of pn-^nant women could Iw dewtroyt'd, or at least rvnd
innocuous, and the rink of uuto-iuft'clioii mininiiwd, Kxperitncnlal wnc
howrever, hax shown clearly that, with tht' excqitioo of ihi' ^unoeoccii
ihe vaginal swrction durinp prepiancy rarely, if pver, harbonr^i pyn
Imttrria, and Ihnl tlic pruphy luetic vn^fiiiiil lioiiclio i« niintsi^sMin-. pi.
Iltprniore, clintcai Mpericnce Jul- demcnHirated that it in not only u?el«
hut wen din-ctly hunnfiil, «» it* routine cmptoymenl i» followed bj
greater number of febrile cases during Ihe puerperium than when it
■iniittcd. Thi)> quo^tion will be di>alt willi more ThIIv in ihe chapter «!=-
puerperal infection.
At^'ordingly. ut tin? pre^Mit lime ihe nig:ind douche ih i-niploycd
exceptionally during pregnancy and labour; as, for instance, when
pregnant woman pnvi-nlH a profuM! vaginal diHi'linrgr- duo to gonorrik
infyclion. In such casi's, fnur lilree of a hot l-t<i-I0.00rt bichloride
tion may lie injii-led into the vagina twice daily during Ihe Wl fi-w W
of pregnancy, not so much in tho hope of curing the disease as of avoid-
infection of Die rhild's vyt* during lalxinr. Thi# it) ill that can rca»nD
lie c.vi>ected, inasmuch as the gonococci an* rarely liniiled to Uw m
miic"^, but have uKtially invaded Ibc glandx of the cenioal canal, wl
they are protected from the action nf the niitix-plic fluid.
Many uullmrttiCK recommend tlie employment of a prophylactic va
douche if the patient ha» lieon Hubjecled to n-pi-aled examinatioiu dm
laUiur by pen'on>^ who bahitually neglect or<!inary a-iepiic preoautioiii.
parlicutarty if signs of infection are pnwnt. Owing to the un)M>i»ibi
of thoroughly dixinfecting the vagina at the time of labour, the ralu^
PHIUTIVE ?HOCKi)HHti* WHICH Do WTT AIM AT DELIVEHY 473
■^fh a |>roc«()are U questionable ; bul a douche consisting uf i«verml tiires
**^ hui <tcrtl« Milt Ktlution cau <io no harm in sach cases.
^Vfter the (int week of the puer|ieriurii. i1m> vngiiial <iimchi' is frequently
•^"Uplined when the lochia j>mii>nt an nffensive odour. It ne«l hiinlly be
■*>«i, tifttreYtT. that it I* of bul littU* viiluv n* a disinfectant, but merely
r*-«»«»3»B mechanically the secretion collected in the raging, and Iliun mid*
"^'^•.eriallT to the cpmfort of tltc piattrnl. Sterile salt solution or a SJ-per-
It solution of carbolic iiiii), cither alone or oomhiiicd witli boric acid
L I little oil of peppcTmint, mUT bo employed.
(IcaaionalU-, vlitit a puerpiTal tnftvlion hax bvcomv loculiKvd, and tia«
K'iV'&ii nee to induration at the base of the broad li};an)ent or of Dougias's
ruZ—^fMir, t)>e appliration of Ittnt by jm-ani' of nbiinilant doucliw of a hot
'If] markedly altpviates sufforiDg, hastens the maturation of the absceee,
prr|ian« thu iray for tt^ pn>mpt eMitimiion.
Ztcfore ^nn){ a vaf^al doiieh«, the external genitalia should be care-
fully cleaDMil and tlic patifnt placed upon a doudK-'pan ac «hc lies in
'"^1. ur bruii^il to llie edjie of the bed and plact^l in the oliwletrica] posi-
iHfB\ wiiit A rubUtr pad lii'Ueaih her. A foiiniaio-^yringe. conlaiiiinf; four
MOwri* and prorided with an appropriately sliapcd glass noxxle, preyioualy
"'••rtiiwd by boiling, JH
«^nipj(„cd. and tJie HuiJ
■Ur»^«i I,) run jQ under
">«*«Jerale gravitr pres-
*w«^. For Ui« first ten
■'->> M of ttie put-rperium
'^'f^iri nM-jilic precnu-
*"^ii.H >if>uM be ob<»erved in tlie use of the douche, and its adminislmtion
*n«»tjJd not \m jnlrui>te0 to the nurw. unlou one i* ji»unsl of hi-r c(mipcl«ncy.
Jntru-Htrrine Douche. — The intra-uteriue douche is not eiuployit] bo
/"*^ an the ulerinv cavity » occupied by the pnxiiict of com-epilon. but
**>^|U»!nlly U!**! immediately after lalmur and durinj; the puerperium.
-Vortnerlv it vtw eii^lonmry to give an inlra-ulcrinc doucbc after all
Irtcal operations. Such a pixM-edure, hotrever, is indicated only when
patient haM e.\b)bit4^^ I'lgn:' of infi'ctioii during laWir; but after de-
''*^ry in thfei- case* an intra-ulcrine douche of several litres of hot aalt
*'***ation doc* no luimi and tict-twionally i< pnMltiilivc of good.
Tbe miwl UBual indication for iU cuiploymeiit immctliately after labour
«Jton]n] by poMt-parlum hamorrhagf due to atony of the nlrriiv. In
-H rs.*«« t)w ailminintratiun of a dowhe of I or 5 litres of Itot xterile salt
'tatiiin trill miQally li-ad to efficient and pormancnl coiitractiou. provided
't Tt* of the placenta an.- unt r<'tiiintil in uli-rti.
J : r.i-ulcrine douche in al^ fre|ucntly employed during the pucr-
V^nm, specially in the presence of inffction. It ha;*, h'la-ex'er, been
<te«t)v ahu«d: for while it mu>>l U^ atlmitted that it is fre<)uently a most
^Qablft llM;ra[ieutic agent, it is nevertheless true that it may W directly
''•'Tnful, For thwe rc«»on» gn-ut care should lie taken in the sdoction
■>' tlif> ca^M in which it is employed. Uenerally iipeaking, it is contra-
i»dir«ted in all aum at »rtrv*ptococcic infection, inasmuch as the nwwstary
FlO. 130. — Gl^WM I>UVC«E TVHI
474
OBSTETRICS
iiiani[>ul»ti<>ii.< may ^ive rise to au exteDAJon of tlie proceseL Od the
hand, when the (-Miiptoinx an due to infL-ctioii by thu Ko^-allcd pit!
[aetiT<! nrf^nisms aKMiciatcd vilh rclcnliou of ijji; lochisl di»eliar^',
iiitnxliic-tion inio the iitvruit of Mt¥<Tiil litre* of hot will miluiino i> /"*
quentiv foUowt'd hv an iniiiiocliate fall of temporal u re and a ]»rtu»a
■mprovcmviil in l\w coudiliou of the patient. L'suatly a gingie don
hriajf:^ al)nut tlie doflired ri>flult, thou^Ji occasionally its daily repttii
may be ntxvfi^Ty.
Sterile wall iinlijtinn should l»e «nip1oy«i for intrn-uteriiift dAtichin^
^tcad of tho anti^'plic solutions which arc UBually HK^omntendi-d. since
latter, no matter hnw sironj^ ilicy may )>ci mad*.*, mi act only in a pii
mwhaiiical way, and cannot dcBtroy tlie bacteria which have Already in'
thi! endoiiietriiini. On the otln'r haml. lh(*ir u^ occasionally cauHV
death of the patient, pari ic iilarly wlien bii.liloride of mercury is employi
On Irtokiiijf over ilin litiTaliirt' ii|iiiii tbc i-ubjcct wveral years ago, 1
Iccti-d over 40 cases in whicli <!oatb from mercurial poisoninj; followi
uxe of «uc'h ;iolution« for iDtra-uturine injection.
Inssnmeh as the ailniinisl ration of an intra- ulcrintt doiiolw miixt
I'O reganbil us u wTioii* matter, it should he given by the physician
self and not delejuated to the nurse, no mailer Imw coni)it^tenI she
lie; MiDcc the most ri^ifid ai^cptic precautious are nevessart', and failure
liiia regard may result in infection of ilic {HiT.ivnt. A» a pn'liniinKry,
vagina should be douched out. Two lingers having tl^n been emploj
to locate the external os, thtt douche-tube in piusMtl through it nntU
impinges upon the fundus of the utenis. Four or fire litrra; of fluid
Ihcu slowly injected, care K'ing taken to insure a free return flow,
niirtng the puerperinm the cervical canal rapiilly dimiRi»li«it in calji
and, owing to the marked aiitciicnioii of the uterus which frequently occun
in this period, may hirome ao bctit as to olTcr a coioidcnihle olMtucle a
the introduction of the nozzle. To overcome this difficulty, traction is m:
upon the anterior lip of this e*T%ix by niomn u( a pair of bullet fo
a^ a result of which the cervical canal becomes straightened out so t
the nojab^ can rcH'lily he iiitrnducc"!. Occasional ly. the contraction
offers an olttacic, and the ncxzle is arrested in the collapsi'd lowfir ul
segment. Hy making traction upon the eemx,*aud cauliooelj ntortng
extremity of the clouche-tiilie, it can usually be passed into the u
cavity without furllicr dillicully.
Curettage. — By this term is iindirslond Ihi; removHl of the lininjt H"
hiane of the uterus liy means of a curette. The operation may be
cal«d in thrw conditions: incomplete almrtion, imperfect involulioa of tE
puerperal utt-nis, and certain casra of infection,
\Vlieii portions of tho placcnla and mciribranw arc rctaimd within
uteruA after nn inrompl'lf aburlwn, many authorities ret^miuend
remoi-al hy means of a dull curette. As a prcUminan-, the cennx. if
siit^Ieiptitly pervioufi, mu^t be dilated hy a Kuitahlu instrument, prvfv
tin« inodcllcd after that of fioodell (.ice Fig. S;ti). Tlie cunMtr is t
iRtroduced into the uterus and gently scrapes oiT tlie retained structui
The cmptoynteni of nu in»lnimcut, however, i* rarely Hdvii4ibl«. w it
il i
4
OfERATn'K PROCEDUItES WHICH DO SOT AIM AT DEUVERV 475
b«Uer to peel off the adherent placenta and mciubranc« with one or
flngCTV, while the other hand conlrolH their movetDcnt« through the
ImiiitiAt w»I!». AfUT Ihev are once loosened, the relatnwl Ntruotureti
t»e readily removed hy nuMii." of the fingers or an ovnni or piaeeiital
>rc:epi. Th"* fomwr procedurv necesHilatei; tlw iiitrmltK-tion of Uw entire
into the vaf^ina, and can only be aceonipliiilied under anie«the«ia.
Pia. 44a'-<7in»rrnL
After the uterus Ims been emptied in aueh ca^^, tlie fln^rB are again
luiml ami earefullv palputc it« cavilr. in order 1" make vure thai the
■ding fitnicinres have been «iiirely removed and all danger of 8ub»e-
qaait lurmorrluigo hatt been avcrlnL If the curette it ti«od. conf^iderable
[ jnttions of pla(?eiita may l»e Ii'ft iK-hind, which may later give ri*e to hlee<l-
I'^R atnl ni-w^isitate another operation. On se%*eral oeeawons I have w'cn
l«mMs in cnnMillaliiin in vhieh hwinorrlia^e hail persiMeil afl^r nireltage,
i**^ nn.ejtaminalion found that eoneiderable portions of the plaeenta, or
i-reti tbfi t-«iirc ctruvlure, had been left in ihc nlerus, the physician liaving
, feniovini only a part of tlK> deeidua at the previous operation. Sloreover.
Kllr^•ttap^ aluars earriiw with it the powihililj' of perforaliitg llw; uterii*.
ytin Walls in many cases being so nofl and friable that the aerident may
wnir despiu^ the exertiiw of llw,' utnin<;t caution, Forliimitely. the injur)'
K^^tterally attendctl by l>ut liltie danger, alllioiigh, if the uterine Mintenta
tnffcted. it may give riw to fatal peritonitis; again, in rarv caw.^. a
"^1> of gul may prolapse through the nnil in ihir iilcriM and iiuicitsnitate
"*• jor- opera I ion.
I'riilmbly (be mo*t juittilbible imlitralinn fttr eun-llagc in olwtctrimi prac-
^^ ta the low of blood during the latter part of the puerperinm. reinilt-
•B from impfrffit infulutinn of thf iitrrux. nbii-b is ffoijiientlv skMK'iiitpil
r't-h ibc retention of portioUK of the plaei-'nta or menibranett, I'lider such
iRKlonr*!* llie ofieralion giroi «xc«llent rc»ulU, provided it be nirriwl
III on swptic mumer.
Vort Kalliorilii^i recommend curettage in pufrpfnl inf^eium, in tlw
^*f that by its means tlie focus of infection can be nemored. The of
'^^ IK andoubl'.-diT boncSciol in a certain number of c«se». hut tihouldl
'O'liluled only in the presence of definite indicaiioUK, as the routine
*plovnii-nt of the curette i» frequently more dangerous than Lbe original,
>'^^ion. and luu' W In tlie di'ath of mimy hundred* of women. Ocncrtllj
'bog, it is iTontra-imlicated when the infection is due to the strepto-
nu, v under itnoh eireumstunccfi the lesions attending its nfe simply
''*'■ new areax for inftvlion. On the otlter liond, it i* often followeil by
r'^flrnt nwultn when the so-eailed putrefactive organisms are producing
Y* Hiiichief, and tlw uterim' eavily contain* niXTotie liwutr and oiTH->ion-
*|y Itfger or smaller portions of degenerated placenta. SeTerthelew, in
.''^ ela«a nf ca»w it it generally far bclU.ir to employ the Sngent iu cniply-
"* Ike ntenia.
^5'
■■"<C^
h-■^^
li/'
OPERATIVE FROCEDURES WHICH DO NOT AIM AT DELIVERY 479
finds himself face lo face with an alarming post-partuni haemorrhage, his
onl; thought is likely to be as to the most rapid method of checking it,
without regard to detaik. But even in such cases, the hand should be
carefally redisinfected, or at least encased in a sterile rubber glove, for
if it be introduced into the uterus without proper precautions, the patient,
although saved from death from hemorrhage, may succumb to a virulent
infection a few davs later.
PATHOLOGY OF PREGNANCY
niAPTEK XXV
ACCWUNTAL COMPUCATtUSS OF PRKGNASCY DUB TO DISKASB
m I'KKUNAXcy mav Iw MmciaU>4l wilh wrtsin iliftosAcs whioh rcHult from
■ lliu ('i)ti<1itii)ii itM'lf, or liy i>ilii-n> wliioli an* In Ih^ rf):iinli-il xo wvi<1<-nt«I
■ complications. The lalk-r may liatv (.'.tisU'd Ijetorv the iiM-vption of png-
I naiivy. or may havi^ )>H-n aoi)uiro<) (iiiriti); ils <i>unM>.
Ab a rule, all disrasfs whicb Huliject the orKanixm to a ponsMerable
ctniiii are ni;K'h more Marions ulwn iK-miring in ihc prt-giiant woman.
Thus, a !unjt which is partially (Jwtroywl or thrown out of fimction may
Miflico for tho rt'spiral ion of an nrilinarv imtividnnl, but be unable to<
respond to the abided deinatidM of prejnwuicy, ]»artip(darly in the lata~:»' ■
montK'. when the iMiIurj^td iiU-nis ri-striclK l)io mobility of the diaphragm—
Sitiiilarlv. nianv a woman l» unaware of the existence of a eanliac letion.
* ■ -
or at kflst icaii-i & very fomforlabk- cvifitiiicc, until the incrcaw-d dcmanil—^
upon the ai'tiiiiy of the heart inoident to pregTiancjr briiiji: afjoni broi:i'r-.«
compensation with lU attendant tiyniptoms.
In funeral, it may be >ai<l that pregnancy excrtiiA delett^rloin^ inllni-no
upon all chronic organic maladli-e. while its effect is UHuallj less niarkw^
in wuti' infiili'Hi!' priM^i'ssi-*. Tbi- Iatti>r. howevir. f^l^|lll■nlly hwl i» pr
mature delivery, and the adtlitional pliysical strain attending; the latter i
render thv c(nirM> of the diseaio much lewi favotirabte.
Fn^ancy complicated by Acute Isfectioui Diseaaea. — Rmail-paz.-
Sniail-pits ccmplicttling pregnancy etirrieK nilh it a more serious progno
than at otbor tiitiu*. Thns Vinny i«iiortfd n mortality of .lii per <.-ent ^
Vi!> caf««, as compared witli liS per cent in the non-pntniant oonditia
The lia-morrbagic fonn of ihe dircjue \» partiiularly fatal )□
fTomen, Mayer h^vin^ recorded the loss of 13 coni^ceutive cbi*c^.
Morcnvcr, Kinall-pox exerts n delclcriou* influeriii- njxnt tlH> pnxluet
conception, so that abortion nr premature lairaiir occurH in nearly one-ha
of the vuM.'f. This may be due to ha-iiiorrha^'ic changes in lite dL-cidi
or to the direct transmission of the diiwaso to the fcctus, witli ics snl»>
lijuent ilcath and cjipulslon. The occummcc "f inlra-utmne small-poi
'well aulhenlicali'd, a.« chihln>n are ■H'cai'ionaliy Ihihi in the eniptite nil
of the dUease or with distinet pock-marks. Mauriceeu is said to haw b^**^"
inferlvd in this manner, and the condition was well known to John llnta*^''
and Smellie. Conies reported a iiimilar caj^e in 1900. It is iitated tb*'
this is occasionally obscrvc^l evon when the mother pruM>ula oo ugn of tb^
m^
Aa-1DE.NT.\L COMPLICATIONS OF PREGNANCY DI;E TO DISEASE 481
dinra^'. Moreover, in duuble-ovura twin (jnynaiuT it iH>rncliinefi happcju
tliat one cbiM is <icliiittL-lv pock-piark«i, while the otlier ithnwK no Kigns
of llir ilif^'s^c
Bollinger Bnt snggetited the potwihiliiy of thv IranirnUHioii From mother
la tfBtns of the protwtiro influence of vaccinia, and otaled that when thft
mollwnt are Hwwjwfulty vMrcinnltfl ijunn^ prfgiiancv a certain number of
the children fail to lake wht'n vaivinnted soon after hirlli. Bi-liin noli^l
lbi» iniiuxvptihilil}' uncv in 'i9 cafrp;, and bt-lieved that it wax due to the
trsnami^ioti of an immunizing Kuhmanco throu)^i the placimla. Koltodi
lield simiUr ticws. On the other hand, most authoritje^ are wepticai t»
to tlie jiOHsiliilily of siieh an rtfcurri'nw. ami (insider tlmt unKWwrcs-ful
vaccination in young children indicates that ihev are refractory to its influ-
*nci\ or that the virus vnn of jKKir quality. In AG cn»i?s reported hy Wolff,
Palm, and (iast there ira:^ not a sin;;!e instance of succe^dful iiilra-uterinK
trfttiiimiK^ion.
Senriet Fnrr. — It ii* generally Mievisl that tin; [ircfrnant noman po»-
rvxfvs a wrtain tm'muoity to trcarlcl fever. Itruxton Dicks and otherii con-
»<i<]en<<l that thin nan dcinon.it rated hy tlitt fairt thai the dinenx*' occure mudi
tots fr«|ucntly duriuf; prcgiuincy Hum in the pnerpenum. OUhauftcn, who
^Lm held this view, wa^ aide to cnilcict fmni the lilcrnluru only 7 eating of
scarlet fciiT occurring in the former, as comfMiicd with 131 in the latter
pcruid. It ii quite pim^ihle, )i4>wfVi-r, that many of tlii^ pu'Tpcral cases
^•■To not c.\aiuptes of true M^rlet fever, confusion having arisen on at^munt
*:^f the raj-h which imHu-linuM occur* in ptn^qieral iiifivtion. The corroct-
^s«M of tUiii latter supposition is supported hr tlM- fact that many authont
lya^UcvL* in tlw intertnmmtminibility of i)k- two diK-u^-s, a point that ran-
«»^ In* dmioiist rated until llie maUrirti mnrf>i of M-arlH fever has boc«
^aacowTt'd.
Vht*n occurring in (lie early monthn of prpgnancy the diMti^e frpquonlly
«=aaa**-i alioriion. This accident is usually attributed to the high tempera-
'•••■«* of thu mother, though in very rare inntaiufs it may U- due to the
'^'''^^K.'t iranflmissioti of ilie disease to the fietua, Ballantync having recorded
*, c^^^i«e in which tltc child prtyt^nlu) a ehametcrifliv rash at birth. This
'**"^ , however, lias never met aith any general acineptation.
-^tftulM. — Measles is not a fni|ii<-i)t complicniion of pn-gnancy. hut when
* *><»ar« is vi-ry prone to cause premature deliveiy, which was oliperved
^ ICIotz in 9 out of 11 cases. According to Kollncr, tho proguoisis is much
'^**'*"aa ecrioa» (luring th« pucrpi^Tium than during ))n-gnancy. It i» slalnd
^^t- inlra-ulerine transmission of the disease to the firtus is now and again
^^^■-xi, Lomer. l-'iori, ai>d other* having nrptirtnl i^-x-h in which the child
l*'"*'^»«f«tHl a chanctcrintic erujtfion at birth.
*" 'hi/If ra. — I'regnant women do not ap|icar to Ixs atlackol by cholera more
'**^nrntly than othi*nf, although they succumb more readily to the disease,
**Hiiij niat*^ that the mortality among Ibcm in the Unmhurg epidendc
"^ 1«9-.' was r.T [RT cent.
The dun-ase exerts a very deleterious effect upon pregnancy, 54 per
•^ot of the cases, according to Schiitz, ending in abortion or premature
^*Wr. Till* may be due to various causes. Ono third of the women suf-
i.^ -^«""''-
10
eel
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Oct-a^
ii<»n«>
ACCIDENTAL COMPLICATIONS OF PBEGNA.NCY Dl'Ii TO DISEASE 483
^•evo nse lo tlit.- liryKipctaH may be traitaiiiilted from mother to child,
tbonjfh this is una»uul.
Fiinhvrtnorc. 8.-' a rulf. hhv Ki-ptio coiidilion uffer* a worse prognosis
in iiR^niBticy iluui al olht-r liim-s. Kniiii}; h»» rcportat several in-tlanoc^ of
miuniiiieiua of the offending hacterta to the child. In one case he found
that colon bacilli had bwn IraiLiiiittcd from a parametritic ab»cc$« to the
fa-tu*. and could Im^ dcinoiii'JraKii in it* lii>.'>uv)'. lie made xitnilur olperva-
ticiOft in au infivlJAU!! )mKi^s due 1<> an anaerobic liaciUus, sm well as tn
••■wral csMi) of Ktivptococcic infcclioa.
Oonurrhira. — The wrurrcnt* of gDnorrhcM in the prv^imt woman
ehoald never be lifjhllv retarded. In not a few inatanceji the ftrj^Digm^
invade Ihe dividua and give riiii- In inllaminalnrY (tiiiditioiiH witicli leatl tn
slwrtion. IJoiMKotci have been dcinoUBl rated in decidual endometritis by
\etiinnnn. Miflnv^jr. m}*M-3f. imd ulheri^.
More important. Iwwever, arc the conswjuences of (^Tiorrh<eal infec-
lion at till' time of lulHutr and dtirinff the piuTpcrium. I'-aving <tni of eon-
•sidemtioD, for the prex'nl, the fn-iiiienov of ophthalmia m^o^ato^^nl, to
-^hich refert'iMV hax alrtwlr Ix^ii niaile. After Inliovr the goiMXMH-ei. ahieh
SMve remained limited to the eervieal canal during: proj^iancy, mar f^ain
vtoctHH to the ptorine cavity and give ri*e In febrile phcnnmena. The c«>n-
«3iti(iii. al1hoii;:h rarely fatal, is always M'rioii?^. ninco it fn>i|uenl!y leads
*.« iiiviiUemi-nt of the ulcrine apiK-ndap-*. whicli nuiy render tin- piitienl
^^.^^nuanentljr sterile, or eren nece*«?itaIo operative measures at a later
«:Saii-, In rare in«tHnec« the ponowHHu* inay prmliite a general infee-
-Cri"*. Dabney and Harris liaviofT reported a ease of gonorrhtBal endo-
«r:«mliti8 which was ob«en*ed in a woman delivered at tlie Johns Hopkitis
f Xivpital.
TetaiMg. — Always a very danpfrous diH<ase, 'tetanus is forinnatcly a
wr^ir^ iHirapIiealion of prejmuicy, nor does it appear lo he more fatal than
**» Kkon-pH'^Bnt wmncn. Archambaud has R^vntly rcporttJ a ca*c which
**' »*>inat<fl favi'uralih.
^'tnlhrttx. — Anthrax, or malignant pustule, is rarely oheorved in huniaa
'"'■v^j^H ooder any dnianLstaneos, hut u almowt always fatal. ItoMowxen
'***-'*^ with tlirec deaths in pregnant women, and was able in each cote to
'*****»*itwtrale anthrax luacitli in the tt!»suo* of the child. A Biinilar ohwr-
""****^n was made by I'altauf. Ahlfeld and Marchand liavc rcporlwl a case
"* ^*"hich • child, bom of a molI»cr sulTeriJi^ from anihraji, dii-d a few day*
*'*■*»■ birth from the flamu di$caw, Jt remained doubtful, however, whether
^■^ ^yuM.- wan ime of inira-iiterine tran--mission »r of pnM-nalal infection, In
"^*''*-««.Jn animals, on the oilier hami. itie placental tTansinin^ion of anthrax
' " Yn*|urntly ht- dciiiniiMtateil en pTi mentally. The first obwrvations of
^ ■Iiarai-ti-r wer** iiiaiie liy Siraiiw* and rhamtwrleitl in IRS'J,
Pregnancy complicated by Chronic lafectioui Diseases. — TtibcrculoMs. —
it nm l»-liev(d Itiat pR-gnamv exertiil a lieitcficial cfTect upon
V^'- -, i1m> mother improving markedly bk lonjj as she carried the
K ***• '''^"'S*' ^'"' fr<s^iienlly siKxjumlied mpidly after its birth. At prewnt.
/**ifvw, it is generally conceded that its effect is almoist always harmful.
**"^>'ftjwr, the strain incidental to lalioiir aitd the «lr« drain upon the
Po^
4S4
OBSTETiUCS
Bysteni, if Ihe moilier iiurs«i tlio philil. [luil *iieli patk-nU down gtill farUier,
i>o thut thv final result is usually ha^teDtxi. I
On lh« oilier lianil, the? illsciw- dm* not appear lo prcdisprwp to pre- i
mature interruption of pregnaiacv, and it is not tinuniiAl for luU^milouj
pAtients t" givw birth to large mid wpk-mlidlv dwclopcd children at full term. J
In vttr)' o\i'<'|itional ca.ieit luln'nulo^i.i iiinv 1>« tra»KniitU-d Trom motlicr i
to child. Hsuser ( 1898) collected from the litpratiiro 18 oiises in which thi' I
trannni isxton of liihfrele bucilli wiw definitely demoufllrated, while Fried- M
munu in ]!>05 wat able to incrca.«« th(! niiniliiT to S'J, in li of vrliich doS- I
nite Iwions were dcnioniflnited in the fo-tai tissues, bacilli alone being I
present in the remaining 1(1 ea*i^. In fotigeni tal tiiberfnlouif titc iufwtiou I
usually occurs throu;;h Ihe placenta by means of the blood current, as is B
proven by the fact that th« niosL advaneed Ivxionx arc usually Hituatcd to 1
tht! liver. 1
Following Ihv d<»(;ri]>tiou by Luhmoiiu of the flrel catcs of placental
tuberculoflifl, the subject lias been cartifully stuilied by Sehmorl and hia
a^ii'tant'. In IWl-t Sehmorl and tieipet collcctt'd I!* such caw^; and, iv^
they were able to ilcmonstrale l(^>ions in Ibo placi-nta in 9 out of 20 preg- ^-
lianl women dying of tubcrnilof-iK, they hold that the condition occnrs hm^m
more fn-quently (ban is generally bt'lieveii, and ap'eft with Baumgar1oi^~~3B
and MatTucei tlial the incidence of congenital tuhcrctilosifi is greatly nndcr^^^v
estiumtitl.
Friedmann believes that paternal infection also plays a prominent par»^ — I,
and, in a wTi<-« of ing(>nioiis rxjKTlmt'nln upon rabbits and guini'A piyss-^jpi,
haa clearly shown tliat tubercle bacilli may be carried to the ovnm b^::zAiy
means of the spcmiabwoa. mid may rnnain latent for long periods. I^ — 1«
in incliui'il lo helii've that many easea of tiiberculosU which do not liecoir-^K-rs<
manifest until some timi- after birth may really be cxomplw o( gcrmin^^^^^K-^
infnc'tinn.
When one considers, however, the large numWr of tiibeieuloua wobi^^_-j^ .<
who iKTome pri'^'iiiiTit. and the very small proportion of ca.-M» in vhiw ^h^S
the trani<niission of the disease to the fa'tu» liaK Ikvu demonstrated, it
apparent that the tatter muwt be a very exceptional oceurreitce. Pn-sun*- ^
tive evidence in favour of 'tliis view was supplied by a case occurring
the Johns Hopkins Hospital. The mother had died from a tubcrcul
periloniti" a >hort lime afier delivery, and at the autopsy the exterior
the nterus was found studded with tuberciw, while the interior was «
ered with tuherctdouH ideera and cascoua material. The condition
stispected at the time of labour, and with a view of determining whell
t!ie plai-enla loniiiiiiiil tiibcrclf bacilli guinea-pijis were inot-ulacnl w^
portions of it, but with negative results, t'lilturt* taken from the inter
of the uterus during Ihe pucrperiiim revealed the pnwcnw of
bacilli- The child, howovi-r, presented no signs o( Ihe diae«se, and
perfectly well some months later.
It would appear, therefore, that in Ihe vast majority of oisw ^^»- J
eaw! is not tmnsmittcd directly from Ihe mother to the foetus, and tl
the latter is born with a tendency to tuborcidosis rather tlian tvith tlM* ^^
ease itself. Hence it foilow!< that the children of tiibereulous motlL
tat
•■M9
-Hi
ira
■h
CCIDENTAL COMI'LICATIONS OK PREGNANCY l«tE TO DISEASE 4fi
Mitili] Iw bmn^ht up uodcr tli« best hygivniv i>niT(jundin^, adiI itlioiiM
Dt 1r' niirHPKl l>_v llicir mollwni.
In \\ev of iho fai't llmt the tuWrculous pro««« usuallj becomes cxiki-I
rfaatrd afItT childbirtli, mnii^' uullioritieii reonmmeDd Utat abortioB bel
idtu!e(! SA a inalt«r of rotitiDe in all tubcrcuIouH women. This appears to)
t a somevltal too extrt-uiu point uf v'lrvr, tiiil I n'j^nl tho advicv uf Rno-
lorn a* Very onnM^rratlve. ilt> holds tliat alioriion ih indicalM — t, if tlie
roceas is atlend«>d by (wer; 2, if the larynx i» involvt^l; or, 3, if llii;
Itient i» vinaciflting tn itpite of suitable hygienic and dietetic treatment.
, bfiwevt'r, would no a step further and comitdiT it indicated in all ^-oung
omen in the early months of pn^piuncj, a* 1 Wliovij that it i* far Ih'Ilcr
n- Kueh ]>ali(-n1(t to give lh«ir entire attention to the cure of the disease,
ithcr than to run any risk of it« cxoecrbation after lalxiiir. On Iho oiIht
ini], wlu-ti iJio prcignaiK'y ik far ndviuuitl, 1 do not <><>ni'id<!r lli« indiu^tnn
[irPtnature lalwur joBtifiable, &a expericnee teachefi tliat its effttt upon
(r [tatit'nl if rgoile lu dek'tonoui' us iulxmr ul ttfmi, while the chaiKt'* for
le ciitld arc greatly diminiiihcd. Kxceptionally, if the mother is so ill
wt it Mwnifi itnprobablo that tiw will live until the end of pregnancy, tlw
•etatitui may be performed M>l«ly in the inlorMl of the cliiltl.
ilaiaria. — [>wpite the srHneirhal nide^pnnd opinion to the ronlrar^', it
•mill Hppi-nr that lh« ordiiiun' f<>nn» of inalarin liavo Itiil littlo inlluenw
■n thf) eoufw; of pregnancy, allhoutih (iolh has reported that 1ft ont of
ranc* rn<li<<) in prfiiinliirt> laliour, and Ji^lmondx Htalc» that this aocidvot
common in Africa,
have obsiTved 15 casi-s of tnataria compticaling prefniancy, the ding-
hiring itioiunKi by the d«-n)on?^lniIi'>n of the chamcl'-riftic pla^modium.
lo of these patients aborted, and in but two did pregnancy end prema-
ly. and tlwn only a wwk or «> before term. It in probable, liowerer,
ttit> {MTiiiiioua fornix of malaria tiiay liavii a iiiiieh moiv dcU-lt^notis
t. There is a nuirked Ifmlcnty tnwartls recrudeiireDce of the diaeaw
pivgnnncy and the puerperium, ju.tl oa in frequenliy ohwrrvd uflirr
c«l operaliona.
t ii, generally «laln] that \Xw disuse is frc4)nrntly tranfrmiltcd to the
, Kun^ U'lreTiug that conducive evidemi' of such an oecurmice is
[«4n! by thf pmn-mt! of i-lwnurtvrii'tii.- pigmentation in its organs, while
b says thai it is not unusual for thv new-bom chili] to liave charac*
ic malarial attacks. In a numlx-r of our cai^cs the patients were sufTer-
I iiialarin at tlie time of lalmur, but in no injtlance did the fa>tus
i;ni' of Ibt' dix'Oj^e. though in all siK'h cases its blood was carefully
iiiiUy examinol for malarial paraxit^ts.
.lie should bo administered unhesitatingly to women siilTrring from
during prc^ancy. as its oxytocic properties are apparently in
|i* under fuch c<>ndiliouK, *n that it can be n»ed with impunity with.
r of ai'lting up uterine i^mtractioni^
ilU. — Syphilis ifi one of the most important complications of preg-
il in one of (lu' mtwt froquenl cauMv of aljnrtion or pn-matur©
It shoaM be suspected in all cased in which a perfectly utlitfactory
nn for this orctdent cannot be adduced.
tuy ,
f«>*t
OBSatTRICS
When infection occurs during pregiianoj', owing to the vawMitaritr of Ihe ,
\iiii-t.-, the inilifti nore anf<uiiia4 tai^^r propor1ioD« timn unili-r onliiiar}* cir<
L'uinii^tiiiioofi. Tbe seoondftrr liwioDB. however, are often but siifrhtly inarit«d,
[and fr«|ueiitlr are praclically limiti'd lo tho (jpnitalia, where they appear
'«* large, cWsled nn-a^ which occiwionally anJcrgo ulceralit'o changets, ami
Min<!lini<'» l<-)u1 m the di-^t ruction of Kiipi-rfirisl [uiHions of tht^ rulva.
The intiucnce of syphi|j<i upon pregnancy differs materiallT. and thrMJ
cfa.'w* of fawn an- di:«r ingiiinliod. awonling *» infection ha* taken plaw:'
(1) before pre|[iiancy, (2) at the time of concvption, and (3) during]
pri'gnancy.
When inoculation with the specific poison has oct'wrrcii hofore concep-
tion, the discoM) nearly always gi*c* rifc lo abortion or premature labour,
more fnequp-ntiy tJie latlor. ije Pileur nhtainet! a Rtrihing illn^tration of]
Ihc dii'astronft effccle of f^)*phili£ from a study of the reproductive hiKtorif^I
iif }:m woiiii-n Inffiiv and after it* inci-plion, 3.H pi'r c<rnt of ihi- childn-n |
being bom dead before, as conipai'c<l with TS per cent after inftvlion.
In pn-maiun- labour du« to ityphilis, tbe child i* u>tually diiud wliwi it|
comes into the world; less fpe»]0«iitly it ia boni aliw with definite mani-
fcKtAlioiiK of ihf dix'iiH': ogiiin, in a Ktill ntiallcr nunilxT of c)m>. il. in
liorn without signs of the disease, which, howerer, make tlieir appear-
ance later: while oceaMionally, jmrlinitarly when the jnfivtinn liad occurrw
Nonrn yetiK previously, Ihe child may never manifest any sigoii of
diemm.
When fill' moliicr is infected at the time of coni.t'piion, tlio ofT<;irin|
ie alwavK siF-phililic I'nder such eireum stances. hoM-evcr. it is a i)Uestioi
whether the child owe* Ihc discanc to paternal or malcmal inRu«iicc». y*r
the other hand, when syphilis is contracted during pregnancy ii<i effei
upon the frelu* varies. If infection occurs within Ihc (ini few months. lli
fn>tiis, as a rule. likewiM- manifests signs of the diacase, but when jt flocni
later the child may not liccome infected.
In my c.xpcrii*nr<>, which is contrary to tliat of Foumior. fu-tul syphil
is freqnenlly the result of paternal infection, and many a man sufferii
fmm \hv tcrliitrv form ha-^ i.-n^'cndered a syphilitic child without infcclii
his wife, in *ueh raws the ovum is infected by syphilitic spiTinatowM, arr
in view of the discovery of Sehuudinn's spi rochn'tw twit poM-ibiliticH mt
be considered : in Uie one case tbe organisms may be merely mc
transported by the spcnnatoxoa, a* in PricdninnnV e.T))erimeula w
tubeivHltwis, while in llie other they are actually in the spcrmatoxoa its
In this class of cas<.>s the child may present manifest signs of the dis
but tho mother nevcrthetc^ may nurse it with impunity, wIktuis il wn
certainly infect aaotlier womatL This fact ia well stated in tlie diel-J
known a» Colles's law. the i-ondilion being explained by a previous tr
mission of immunity from the fretiis to (he mother. Not a few syphilc
phiTS. however, bclicii'e that the mother is likewise infected, bnt wiiV
showing signs of the disease, or ela* suffers only from a very altenu
ffirm — pofct -concept ioiml ttj'philis. That immunity is not always prodj
is evidence<t by (hose rare instances Id whicJi the mother is infected bj
ctiild after birth.
Att:UJH-\'TAL tX)HI'l.lCATIO\S OF PREfiNANCV I>tTE TO tJlSEASE
Tbe ctiniiidi'ralmii of the syphilitio lccion« of tW child and th« pla
Till be takt-n up in tbu rhaptor upon Difvasue of IW Orum.
Wht-rirviT wr obtain a hMtory nf Kyphilix iii i-itlwr jian'nt. no mall
wbelhfr infiflion lia« (Hvurnil prior to or at the iim« of funoopiion, i\
mntbiT (ihniitil at onra be placnl upon raclictti Kpi-citir Ireatnienl. as br
taaat* not »iit,v mav Mh« be i^urod, but, iii v'wvt of llio faf^t that llw uiel
cnric aaJts as veil as ioditte of potassium are readily transmitted througl
iIm- pliw»Tita, Ihc fu-tuif mav bii ftI«o trcjitw), lui matter wbetlier its' infeoj
titm be (if maternal or ^rminal oriRin.
In view of tbe ^-neral application of Colli-s's law, th« syphilitic cbildl
tboutd ncTer Ite ^ven to a wt nurse, but should be fed artificially in cn»e\
it6 own mollier i;; unaMi- to nouri^^h it.
Diseases of the CiroaUtory and Retpirat«ry Syitems. — I'atrular t.e*u>M
"f the Ufart. — While tbe work of Hlen^l anil Stanton, and moot recent
aulhonn, \ii\i\* to slmw that liillv if any Uy|KTtrophy «f tlw,* Wart tHvur*
dorinir preffnancy, the investijiations of Jamee Mackensie indicate that
th«m> Dormallr occur* a certain anioiiiit "f dcrannpinMil in the cardiac fuivc-
tMiD. He liaiies bin conolusionH ujwtn llie fact that the following coniiJtions
may fn'qm-ntly be noted: (1) limitation of the field of cantiuic n.-:*poD»c;
(2) cltanftcn in I)h> nX« and rhythm of the heart; (.1) dilatation of the
rtiiht side of the heart; (A) tendency to tcdema of the luu)^: (5) tendency
I '^llinp) i)f tbe vein* of tlte li*^; awl (r>) the <K'Ciirnrnci> of marked
I <<N 111 the Tcinii of the neek. \fi all of tbeire conditionH are more or
l«sm abnormal and are likely to iM-mme grcailr a(x.fiilua(cil in prngnant
^ *"iii II siifferinK from valvular )o«ion.4 of the heart, tlwre ia e^wv reanon
f*»r raiuiderin^ such eompltealionx as n)0--t »enouA. (luerard records a
» - ' 1 (if 'ix [H-r <i-nt in cwm-* of vnlvulnr diwiix- cumplicatinff pn-jrn«ncy,
m ■■ r-iilern tl>e couililinn more alantiin); tlian eien i'elain[iHia or pUi-cuta
p''*<*ia. Ilir stalot further that Sehlayer, Leyden, Macdonald, and Lu-
l*f vitslcy lout respectively 18, M, B(l. and I'HJ p«T will of *iich pulient:".
"hf»i4> figures, howcier, apply only to thow cvtf^ in which eompensaiion has
loriij- .iiirt- fuiltil and th^' condition is complicated by mial ehanp?s or tho
lox^^tiiia of pref^nancy. When all classes of casu are conM<icred, oi coimCi
"** mortality is mueh low«r.
Routine examination s1m>w# that heart Uvionit are prewnt in a eoniiid-
^**t*l«! proportion of csma, beinn obBenei! by r><'«ielin in 1.2.1. by Vitiay
"* *, ami by Fellner in S.l per o-ni of prejinanl patients. In a series of
■* <^«a*ca Fellner obwerrod the following lesions :
Mitnd »Ceti(Mai
Cunibtnnl mitral hiitnni.
Annie iiuuflicMTivcy
Aortic and iiiilrallcnuns
(jDccrtBin iFiiioni . .
Urocsrditii'
37
. fi
M
■i
10
^
■1
'^ aUi staled that only one wventb of HUch caseu showeil cardiac mnni-
'*"iniii^n,_ vher<>a« Donelin nohsl llunn in two thirds of lii« •erii'*.
.488
OBSTETKICS
liven when oyuiploni!i aro pivtcni. it wotiM uppcar llint snmp nalhon
havi; i>xa^i-rati-<l \\w .■■crion.ini.'KH of the condttioD, ina^nuuih as ttw mor-
tslity nott-'il liy FcUiicr and IXtmelin, in SM and 41 ciu«s rcsfxxrlivHy. vn'
only G.'i nitd 5 |ht <viit. From my ci»n t-ipcruiice. I Khowld siiy iluit
|appan?nlly functional cardiac niuriuuvii are rnxgiieDtly heaixl in prcgDancy.
while orfjsiiir Ic^ioni; occur once in i-ncrnl hundrt'd ca£«s, and urc acconi*
putiiod l>y ilvKpna^ and (rdi-ma during tlio latler part of prfieriann'. aiul
oecaBionallv j«»me defrree of cotlop.^ is noted shortly after labour. On ^ll•^
Ollu-r hum!, om* oc-ni^ioiiully ni'" c-n^iv wilh )>rrikon (■oiii|H-n^ili<>n aniiriciatii]
with BUch argent symptoms that the induction of abortion or prematnrp
lal«)ur i* clearly indiraU-d. In mir of my cji.«t'« \)w i=i,'niplom* wore imwt
alamiinji. The patient was a miilliparii suffering from uneompent'atpil mi-
tral (lijH'ftw. wlio collfipscd in llii- liii-t raontli of prejfnancy, with nignu of
acute dilatation of Ihc heart anil infcnue pulmonary iwlcnia. Death wa«
uvcrlwl by lilwxl-lrtting and th« induction of premature labour.
It is generally lielit-ved that tlio most untoward BMiiptoms are ohwrwd ^
in mitral stcno^iB, \.v*\i rc^anlvd thi» Ji-sioii n>s wiitlici^nlly iwriouK tn war-
rant the indiiciion of aliortion as soon as itio diacnowis is made.
Gtfiifrully fipi-aking. llit- |)rogno!sis i* gi>nd m long as compensation i
retained. I'o this, however, there are certain e.Tcepttonii, aa Zwcifcl has
leconliil two eoM-s in which collapse and di-uth occnm.^ in prepiuiit women,
who liad previously Ix^en absolutely unaware of (heir condition. On (in
olhcr hand, if compi'in.(H ion f«ils. and appropriate therapy dm-s not hrin
about an amcliorntion of the symptoms, the prognoii-t becomes ominouo^Ss
for even if the patient be saved from immediate death by the inductioi
of prematan- labour, m-Hous coin plications are usually in store for her i
the future.
Grave hejirl li-sion* (H>niplicJltin|; pri-gnancy prt-dtiipoee to preniatnr*^-^
labour, which was noted in 2».2 per cent of l-'etlner's cases. This acciileii
may re»idt from uierine ha-niorrbnfW direiHly nltribiitahlc lo the cardia
condition, from the death of ihe fieliis due to insutlUient oxvdation. or fnii
chunfTcs in the jilaecnhi. hi nol u few caw-s there is tnorv* or le** pfL:» ~
fuse hn-rm<rrha)fi' ininniiiali'ly foUowinj: deliven,-; or again, nt iIm- tmie
lahwur. owing lo the elevation of arlerial prewniv incident lo the uterin
contractions, compensation may fail and the woman's life may Ih' in per '
Mor<f>VL'r, collapse may manifeft itnelt immediately after the expidsiofl
the child n» a rcMdt of the marked fall in the arterial j>rewiire which 'Hvir
ut tliat lime.
If the I^^ion is fairly e(jiii|)ensiit>^Kl Ihe patient should be kept «i>i^
close observation, rest being ordered and digitalis or some otlter heart tit^
iieing employed as soon as symptoms appear. If this trcatnieni fails
bring about the desired nwull, pri'gnanty should be pmnijitly endi-d hj ~~'
most consen-atiw method available.
Tlie psychical disturbance* ineidi'nt lo lalioiir. and the elevation of h^
rial pressure bmtighl about by the alxlominal and uterine con I factions, t^~
der it advisable lo make use of an amo-thclic during the second stage,
soon as the rervi,\ is oomplelely dilated and the head well engaged in
pelvis, the (ermination of lalHUir hy forceps is indicated.
ACCIDENTAL COMPLICATIONS OF PRBGS.\.VCY DPE TO D!SE.WE 4891
SoniF lutlinritii')! nxi>iiiinftul rltnt wonii-n HiifTcring fmiti Kt-iirt IfHion:;
»hDuliJ l)« dbtKuadetl from Riarria)i;e. This, howe\'pr. nppt^ars in \ie an
extmnt' vm-*w, though, of coureo, whvn the Ic^iun it> ^Tioii^ hikI the com-
{M^tigition fnullv, the tlan^iciu of diilillx'Artng xhciiild bo vuri'ruUy «x-
jiUioed.
Mgwarditi/i. — Owing to tite difficulty in making an exact diagno«tit.
BiTocanliliH U rarolv n^rajniiHcd duriuf; life. N evert helejo, it U a moxt
wrionii c«>Riplicuti'>ii of pr«<giiaii<-y, und U odo of the fr»)UcDt causes of
HDdilcii diwili <iurin); tlie seeood B(a^ of labour and the firstt tvv haun
itf tlic ]>uer|iprium.
Ocoiiiionally ««» of liu-liycanliA are i^werred during pragitancj for
whirh nn t-xplanatlon can bo givra. 'I'huii. tn one of nty patients I found
the pHl>u--nit<' iH-tw'ivn I'iO iiini I Id diirinfc the liiKt throe nionthi' of rach
jinynanoy, hut wfiii-h rctiimwl to imrnml within a few (layn after delivery.
Ak a nitwl Ihoniugh phyiiiral and tirinury exaininalinii failed In n-\'val any
abuormality. we were force^l In make the uoiialisfaetonr an<l provisional
diafinoM* of iK-urotie la^rhyi-anlia.
Endai-anlili*. — .X<;ute cndocanlitiii may appear during pn^itaney, juHt
at- at DthiT liiDei^ It i^houl<l alwayii lie re^anUtl ».•• a KerifiiiK tualter. hut
f«r1ii-nlarly no at thi^i tinie, as in a xinall numU^r uf caxv iIm- ImcIctu
fiiving rise to it may be traniriiiillc<l to tlie fofttis and cause its death,
-while at mher linio ktiiiiII [Mirtions of tint vi^i-tal )i>n> ti|M>Q Ihi! Talv«!l
xn«y he liroken nfT and ^ive rit« lo ajMiplexy or einholiiini.
Vhlrgmiuia. — Thn.mlxiciif uf the mn* of the thigh, or phlrgnia>iia, is
^ *ery rare eoroplicatioa of pregnaney. F. ('. (loldsboroiijjh in I'JOl re-
fv^Wed a case oWrved in my wrTtcc and collortcd the literature upon the
'■■'.. It Khoidd U- n-;:anlrtl a* a rcri' m-rioiM rondilioii, jMrlii-tilarly in
f the fun't that inouiitioiui manipulations may lead to the detai^hment
f>f »nial) pnrtii-les of a ihromhiiit. which may then gi^-c Hrt! lo embolixni
*^f the pulmonarv arteries. The s^'mptome and treatment are dealt with in
« 'h^pur- X MM awl XLIV.
fultmtmiTtf Embolifm. — Kiiilioli.Mii of the pulmonary arlerie» t» a very
'*''«? eoniphcatioD of pregnancy. Barnes rfjNirls one case which ended
''^'^1 ly within a few moment^, while Sperling lian n'porled a Mcond
^'fi*?!! eventuated in Tvcorvry. The condition should alwayn' W home in
"""••i lu c-a»(w iif suililen duitli during pregnaney which cMUinl olln-rwise
" x|ilaiiied_
■^-•"pkjftevta. — VVlien prvgnaney (x^tirii in wonnii iniffering from ad-
I emphysema, Uk dyspntea may become so intense a8 to demand itft
■ ■ ■ 'iiial intcrrupliou. In a certain niimtier "f trtuv* abortion or preina-
'**"'^ bibour miurs sfionlaiifoui.ly, tin? unliiuely uterine iMnlnu'Iions U'ing
*-*'ilintrt1 lo inHiiflb-ienI aeration of tlte blood.
•Asthma. — Tlie symptoms uf n»thnia arc wiuH-liniw mart
^^^H.tjB nnxmancr In tome matientn.
490
0BSTETKIC8
toxit'iiiia. If UiU if itivfTectual, u nidml change ot Kir »(>metimc
''benelicisl.
Pyspnao. — Altno«t every wnmiui in th«' IsKt few wwkn of pn^gngncv
iulTc» more or leas from shoriDess of breath resulting from interference
with the iiiotilily of the dJHplirMgiii liy t)i« vnlur^nl tiU-nm. Dyttpiiiin
<)i-nirriiig in (lie earlier nmiitli.t of pre^naiicv is usually due to cardiac or
renal dii-ease. and dcinai)d« a tliuroiigh {ihvi^icul vsu mi nation. OctimionKlly
it follows; exec-Mjiiw dUiteiilion of the uteru*. a^ io hydramnios.
Vai-ices. — Owing lo the prcHiiuri.' of the pn^'giiunl utvrns upon thv vein*
returning from ihe thighs, and the fact that they are hut poorly supplied
rith valve*, ahnornistitics iu their ciiculucion are fre<iuently ohserved dnr-
Ping prej;nancy. and luanifiwt tlKmiselvw by thi- appcaranoc of raricow
veins. ThiflW may a^viime conKideralik' proportion* in the li^ or sbout the
Tulra, and give rise to dirttresfing siTjiptoms, In rare cases, particularly
fwhcD they are ^ilualtd at Die vulva, their rupture may lead to fatal h^mnr-
(Thage. When tht-j' occur in the leg*, niarkwi relief i* oflen oliialmil by
Ihe use of neatly applied bandages or elastic stockings. Active treatment
i» nwl«s« in vulval v8ri<T<w. but the palt<?nt Khuuki be caulioocd concerning
tile danger «f Iheir rupture.
(Edfma. — (I'>k'niu is a vi-ry frequent complication of prvgnancy. It
may be general and involve any [lortion of the body, but is ii2iiually lim- i
(■"ui. -i*i. *lim-i(« 'ir Vin.vA.
ited to the lower extremities. Occa:^ionally the vulva be<comes intn
u-dematouti. When limited to the extreriiilioA, the swelling u->u«lly res^
IAu;ii)t;.vrA[. complications or preonanuv due to disease 491
from pnutfure exortpd by the enlsrg^ uterus upon Ihe veins returning from
tlie U-jRA. On ttu* other hand, if it Im) ^eneralizod, it x» likely ki \>v a muii-
fivtatiun of lo.\a>iiii». ur even of xn ucutc nephritis, though oet-aiiionall^ Jt
nay he dne lo oilter enui^A. Similarly, ait«mii oS ihv tulvu iiiuy be purely
mt!duuii<,«i or h manifestation of mme gystcmic disturhance. i
TIm! [Mtiiint nliouli] be laulionitl Mt In the signiScaDcc of cedema, and
wbrnu^er it apjiear^ the urine Hhould be i-arefully «xnmtncil. If tlw kid-
■ ncy* are found lo k* doing their work properly, the Huellin;: ix pn^tahlyJ
uf mocfaanical ori^'in and u>uatty t» not amvimbk' to trvutniciit, though'
tbp condition may he markedly benefited by reatricting the movements
of the pau'^it, or <>t«i confining lier lo her bed. If the urine bt abnormal,
lln* rooditioD is more werious, and the woman should hi* *ubjei't«l lo the
irt«tniii)( atr<-ady outlim-d for the toxieniia of pregnancy.
When the marked swelling about thi- vulva is a Motirrf of diwoinfort
anil anunyancG, and if not r«lievi«d by medicinal treatment, relief may be
i;ivi« by puiu'turing the most dependent porlioii?' of lh>- »vr<>1l<-n labia and
allowmg ilie M'rum to drain olf. This ijlight operation lihould always lie
duDu under the ■Iriclu^t aKOpIit; pn.ranlion^. anil the labia afterward cov-
with sterile dretisings. inai<mueh an infection can remlily oceur and
■y be folIo»(»l by •icnou« wusf-ciueiiciM,
DiMuea of the AUmentaiy Tract and the Idver. — Icterw'. — l*re$rnaney
com parm lively hIiIoih LouiplicdtiiJ iiy jaiindict'. which is UfUaMy due lo
■titrrhal proces«« in itu! duodenum or to ehlotelbiaitis. The ealarrhal
tnety it generally without significance and undergoes spontaneous cure.
U thr «an»e time il should bv borne in miud t)ul jaundice Ls oorai<iomilly
ctated with profom>d lovifinia, ami may repre-<'nt the onset of acute
Im» almphy uf tlie liver, w tbiit n ean-ful Hrituiry annh'»is should Iw
lailf fiefore giving a progniuiiii.
Kptdi-niies of jaundice hare bc-n recorded in rarious portions of the
imrbl, in which tltc di»eaM(- ran ii.< UMial ooume in men and uon-pregiuml
rumen, but wart mo-t dif<astrous In pregnancy, an some of the women died
mnia and many niorx^' aborted or fell Into hdMiir prt*mal un-ly. Morv
cr»rrvt, it WDold seem thai pn^ancy immelimcs predispofiea to t)i« occurrence
r:^ i jaundice, ■» Von den Widen and olhei* have reo'jrded initanw* in which
I "^ ircurrwi in iiiwcMiV'^ |)ri7riian<'ie« and wan freijuenlly a'v*oeiatecl with
<~a-.afniogIabinuria.
^lt is generally belicTed that women stiffering from Jaundice' at liie time
f bbonr have a tendency to htrmorrhage, hut Ibis was not itolcd in the
Bw oatM which I have seen.
;lcwf# Alrophy of ihf Lirtr. — Thin condition will be considered in the
^^^^Tipter on the Toxiemias of Pregnancy,
tftdigeflion. — Tregnaiit women fn*juenlly tmlTer from indigestion, and
**» symptonts arising from it. arc someiimes verj' distressing. Kclircr ia
'^ v^wlined to altrihnle them, at lea<t in part, to the di^nuuie in the amount
*"*#((ialrie hydrot-hloric acid, which he considers u.*uhI in pregiiancy. Such
^^■iw ^hiiutil Ik- tn«li'd wilhoiil rr^ferrncf lo ibe existewe of pregnaneT.
Coiutipalion. — Owing to distention by the growing uterus, the ^om-
**»! wallf may bucome to impaired in tonJcily lliat confidiTable diHkulty
492
OBSTETRICS
i» experienced in eracuating the iioweU. indeed, it niftv be fiaid that the
niajority of pn-g'Daiit womeu i^tiScr from cou^lipation. This coadilioii
xliotild be oarefiiitv guardt>d a^inst in order ui nvriid atito-in toxical ion
and increased §traiii upon the kidueiu It ia beet OTercome hv appropriate
Ldiet, n.->i;iiliti'itv ill g'liiig III Kli>(>l, ntul i\\v iKi-iuionKi \iH.r of pill* of aloin,
'belladonna, and strychnine, the tluid extract of caj^cnra, or compound lico-
ricw powder. The *lrrjngi.*r i-athartJc* »)ioMld be avoiilwl on account of their
tendency to cause ahortbn.
Entrroptofis. — Tlic nciirajfthenoid symptoms which so frequently accom-
k{iany enteiopto^is, are ofti-n markedly ameliorated durini; prepuincy, inas-
riniich as the steadily enlarging utern* may tt-nd to restore the displaced
viscera to their nonnal pottitionn. The eonifnrt of the patienl can he add«d
to appreciably by the use of rational clothing, and especially by the applica-
tion of a properly adjuKltil iilni^niiiiftl ^iipjKirli-r. The condition, howc*-cr,
kis prone to recur after ehiUthirth unless (he patient takes on considerable
^flc«h. Act-ordiiig to JIaillart the improvement x* sometime:* penuaneni,
especially if Ihe relaxation of the alxlominal walls be counteracted by tlw
L UKC of u snugly filling liind<*r during the piierjwrium and a «uituhk- abdom-
final siipiioner afterward.
Sativaliim. — In csci'|itioiiuI iiisiantr* the wiUrary s<Tretion becomes
markedly increased during pregnancy. As a rule, this is not a »«rious
complication, liut now and again the amount of nliva is so gn'at as to
eau.-'e llio patient jtreat annoyance, and tiometiniea eren prevent her from
sleeping. One of my own piilii-iilv cxjKctoniliil Ix-twceii 50*' and fiOO cubic
centinii'tre* of clear fluid overi- day for several weeks, while Lvoff tiM re-
ported several cases in which the secretion in the twenty-four hours varied
from 1.000 to l.tiOO euhic eentimWre*.
The condition is usually attributed to a reflex neurosis incident to preg-
nancy, hut sometimes it i» a inaiiife-ilution of aHt<i-in|o\icalion. In the tirs-L
elaaa of cast-s the treatment ia very unsatisfactory, astringent mouth washi-!',.
hSnd even compnralivcly large dows of alropinc. being without effect. On tht^^
lother hand, when the condition results from auio-into.vicalion, markvil umi-1
iorattoD frequcntlyresults from placing iho patientupon a rigoronsmilk diet — ^
Gingivilis. — Kxwptionally, ilic guuiK of pregnant woim-n l)wome in
flamed and spongy, and bleed upon the slightest touch. The coaditioD i
■ .u»tul)y oWrved in run-down individuals, and ii* very rufractory to tiMt^ -.
nnent, although in many cases it disappears almost immediately after d^^
llivery. It i.t lii'st mi'l by llii: rmployrm-nl of iitiringcnl mouth washe-:^
"eepecially those containing tincture of myrrh, combined with Koocrnl Ion .^
treatment and an ahundunt diet.
Dental Varies — Torithaeke. — Many women suffer during prcgnaOiOT tn
dental cariw. which may be associated with more or les« so'ere tootlutcl
It is a popular belief that pregnancy prt^lispoMw to ilie mndition, an 't*
donced by the saying. " for every child a tooth." It is probable that
condition is ^nmewbat allied to Die minor degrcw of mti-omalacia win
iHi'iir only during pregnancy. Such patients should be referred to a »■
ful dentisl, and at llie saiiie time shoubi bo plated uptm the sirup of
liypophosphites or the luctophosphale of lime.
I
CENTAL tX)UPLICAT10.\S OF PREGNANCY DUE TO DISEASE 493
^JKmum of th« Kidaeys «id TTriBur Tract. — Chronic Xtphritiit. — Preg-
!T ocvarrinf! in |wtiri)te sulTvriDg froni chtniiic ncplintis is always a
Viu.% i-»iiiii)i('iiti'Hi, and Hill he tvinoidortHi in I)h< oliapler on lh« Tox-
luiaii of I'n^Tiaiicy.
Uiaheira. — Ulot, in lHt>i!. i>(ut«i1 tluil iiujnir ciitlil ■x-«7i)'iiitiiil1y be fouiid
in llie urinp of profniant wmnon; hut nftcr it v/as AemrnmiTait^} l!iat the
cnnditiitn wa« usnally a liicl'»^uria. the bcliof ^inoi] ground (liul th« ox-
■ loli'uce iif tTUi! diaMi-i «a.-> inmnii-^U-nt with (■onception. Tliis vii^wr wan
i-<jmbat(.>d fiTMt in 1»K'^ bv Jlsltbt-W! Duncan, vho yrai- ublf to tind in the
litemlure 1? eaMm in whicli pn.'jriiaiu^ wag complioaUMl by Ibi.' diMaWv
I^tor. Partridge. (Iraeff. Tate, and otlieni collected !*rie» of es»e« in which
till' iMutriaiion vM» nl»<'rv<i|, allhmigb Jt in not fn^juciit.
Diaiieles may exifil before the inoeption of prpgiiancy, or may appear
^^dpring il* coiirw- Tlie {^rupnoNtM U gi'iicniUy k-livvt-d to W oniinvus for
Bluotber sod child, and a review of the literature eJiowa that at Icaat 25
^Mf'F Milt of the molb'Tji ditfl in dialKlic wiiia, while prvinaliire labour
^(tMvurrpd in one third of the rases,
' Il i* inlcreHling In nole ibal T iif lb*- Sfi c)w^ enllceted by 4!rm-fe were
^-mtnplii'att.'d by bydranuiioH, and that in live of the.'v ^ujior nmtd l>u dttnion-
^»traU<d in (be liquor urnnii. 8ucb ob^rrvattniw Mi^igiwk-d the powibility of
^vtbe fiftal origin of Ibe f;l_v<wwiiria. This, however, is not tl>e cane, an<lj
^pilu! work of Kot^Hi, Ludwig, and UfFeri^eld t^bowx thai )^ueh an oeeurrenoel
i* ratlHT to be re^ixbxl an proof tliat the amniotic fluid i" a maternal
Ilnn^dste, since no trare of sugar can he detwied in Hic fo-tal urine.
Leipmann ha« etatvd tltat dialx-tic women are ]wrlieularly prone to
in/fvtion nl iJw time of UI>our, and that KangrenoiiB proce;(:«-> may occurj
ti the ulem?, in Ihv fonn of mirlriti* deoxiraiu, Jti>^l as are vometimesl
Mitatl iu oihvr portioiui of the body in non>pn^ant iudividiiaU.
On the other hand, too mw-h emphajsii; cannot he laid upon the fact
chat th<! mere demou-itration of 9u>car in the urint^ does not juxlify tite
«lia^uo$ifi of diatietes with Ha !>en(>uii jir'jgnofiis. With the ordinary Fehl-
^fig U*t, a diotiiiet reaction for nu^ar may be obtaine<l in about 5 per cent
^M oil women in the U»t uonthe of pn^ancy. Ordinarily this iit due to
^■actmnria and it of no clinical »iffnificance, but ocvoaionally u true glyco-
^Kiria i* present. This ocruri^ ahoul once in 100 or IM) ca-^n, and t)M>
■K-XBuunt nf glueoK- may vary from | to !:; or 3 per cttfll without materially
ie->«afflplH'atin^ tlve prognoeia, as the patiente suffer no diacomforl and are
*>i^Mfely delivered at term, after whicit Div sugar dinppcare. Moreorer, I
lr»^te M>eQ the condition recur in sueceedinf; pretnioncies.
If more accurate ebcmical mclbiHli )k- Uf*i, KUgar can be detected much
c^^k<ir« fm|ueuily. and C'onunandcnr and Porrher state that Iracvs occur at
"— ■ *'ivB time in tJie courw of wery pregnancy. The)- found j;lu«>-e or l«c-
In 80 and SO per crat of their cases retipecliToiy, and otx^uionally
' Ijlli varieties at ooce.
I -^^ TTiPf ihc^triw hare been adranc^-d to explain lliu producti<Ht of Ibii
^■^fcriely of glycosuria. Payer has shown that pregiiant women are lew
'^kmnt of sugar during pregnamy than at i»tber times, as lie wati abb;
' Jfffidlicc alJRKntar^' glycosuria in 80 per c«it of hi« patieuls by iiicreas-
4M
OBSTtn'RltS
ing th(r Ainoiinl at sxt^t mgegtni. In ouv of my patteaU tbe gljrcoeoriB
di^ppeured upon substitating another npt^ricnt in pl«c« of n hotn«-inade
sirup of HTtiDa and pruD(^» which she took in imineDfie (luantitica for con-
st ipnt ion.
Comniandeur and Porcher hold tliat tht! condition i* due to (li« in«t>ii-
r fty of i)w Don -fu lie lion tag breB»tB to convert gluco^ into lactose, as nor-
Kmally oeciint during laclation; while Veil bc1ie»-ca that it i* dopcndi-ni
ItipoD changes in the liver incident to lar^ amounts of chorionic villi and
f f a'tiil <!ct(i(liTiii gaining iicntsK to the niniornul circulation. ] am iiu'linrtl
to rcj^rd most cases of glycoBuria in prcRnancy m alimentary in character,
alrhuiigh it i* probabU! tliat the cxplnnnlion of Coumiiuidt.-ur and Porch«r
may occasionally hold good.
Thii^ licing the case, the firrt c»wcnti«I after obtaining o positive reac-
tion with Kchliog'B solution is to determine by the ferineniaiion tesj or
by the polariwope whether one hn« to deal with lacluso or gfuooM. If the
former is present Do anxiety need be felt, a» laeto^ria is frequently a per-
ffctly phvsiolngicul phenomenon. On the other hand, if glucose is present,
iha matter is not so simple, as it is miwt iru^xirlant to di-li-rniino wlx^lwr
it i» a maiii[e»talion of Inic diubctct; or merely of an alimentary or physio-
logical glycosuria. ITuforluiiately, this i» not always cuiy. TIm; former
LiJiould be diagnosticated if the condition existed prior to pregnancy, and
^ore particularly if Die ehnracteri9.tic ayinplotnK of tliin>t, emaciation, aD<)
dyspnira are present; while a probable diagnosis of alimentary glyeo-oiria
i» jwrmissihle if it di-iappcars upon removing sugar from the diet. Oew-
sionally. however, the glycosuria per»ii>ls notwilhutanding the nio#t rigoroiu
kinti-dinbctie rfgitnc; in snob ciifVf, the patient should be carefully watched
rand the urine t-vamined daily, an<l tlif pn'gnancy promptly terminatoii
□pon the lir^t appi'arunce of untoward symptoms. Fortunately, thi> will
rarely be ncccsiary, as the pnfient will usually go thnmgh pn-gnancy an^k.
labour without difiicnlty and the glycosuria will disappear during the fir»'%
days of the puerpiTium,
limitaturla. — The passage of blooily urine i« rarely nliser^od dnriv
pregnancy, and its occurrence sliould always lead one to suspect more
less serious le^ion« of the urinary trai^L Nevertheles*. Cliiuventone h
described an idiopathic ha-maluna due to pregnancy, and has collected '^T
jtimilar cases from the literatui-e. Hi* coiiiiderii that the luemorrhage
pr()hably due to histological changes in the kidney wliich r(yult from.
hepato-loxiemiii. He mentions, however, a case described by Albarran
which the bloody urine was probably due to the presence of varicose
in the wall of the bladder.
Ptflri-nrphritis. — .Aaonling to Vinay, altcntion was first nailed to t-
com plication of pregnancy by Hcblaud in ISiiS. Since then numerouB
amplcs have been observed. Vinay being able in 1899 to report 9 pcrso-
cases, whilf Opilii in 1905 gave an excellent review of the litcratun: e
collected 81 cases.
Tile diseiLse usually apiN-nrs in tbe latter half of pregnancy, wlien * *"*
patient, who has previously been perfectly well, or has merely complain^"''
of slight vesical irritation, i* suddenly seiwd with iuteiue paroxysmal pHii*f
JCKTAL COMPLICATIONS OP PKBUNA.SCY D\ili TO UlSKASK 405
UMiKlly in the right rciial r«;ion. lliis is acoonipanied br a marked ele-
vatina of u-itiperatun* nik) ucctfioiinllv by cliillK, l\w IcmpTutiire pureuin^^
a hectic cour^- On palpation one ki<tn«j' U found to be markedly oti-
Inrgi-il. AftLT A n-rlain time a large aniounl of punikiit urine ig suddenly
IMmmI, wlii>n tlw" iMiii disapiK^rs and the kidney IxH-'iimw uniallor. ihf
•rmploniii reappearing 3.4 tlte kidney tiitii again. If allnwed to go on with-
[lul ln^tni<>nt, pyclit-iwphro*!'' ur mIimi-ah of Ihtr kiilney may mnilt, and tite
ilient may succumb to a styptic process.
T\tv eomlilioQ rc«ulta from compn-wion of the uri'tcr at Ihv brim of
pelvic by tlie pregnant ut4yru» with flamming back of the urine, to
rhieh mii»l be added an infertious proccw. The lalfer may bi- due to an
t\ten.-<i<'U upwanl from t)ie biaildcr, or to 1ran.-> mission of iMeleria (hrougii
Iho blood or lymph channels or from the interlines. Itaeillus coli ie tint
a*ual infivliltg agonl. but th« «trcptfle(>(.TUi* or ^noo<Ken» >!( ttrtmctimeit
|«onrem«l. Ordinarily pain in one lutnbar region and the palpation of
t!»f enlariml am) lender kidney, a* ucll ii« the di-tiilion of the cnliirgiil
Rml wn^'itj^o ureter on vaginal exaininalion, should innke tiie diagnoMis
Inu*. Yet the (wndition if fn^ueutly miiitakiii for ap[>endtciltM and ocm*
lionally for typhoid U-xcr or Ml])ingilij^
llie treatment eonsi«ts of rr:Kt in iK-d and an abnndant but bland diet.
The palieiit should W emonraged to drink larg*- quantities of lithia water,
Dit 5 gniinH of urotropin should be admini^lcred e^ery four to six hours.
^t improremcnt docs not take place and tlie eondition beeomcjt alamiiiig.
prt^maluro labour should be induced without hesitation, as (he emptying]
ft the utcnif removes (he un*teral obstruction and allows of fre« druinag«'^
iiu tlie kidney into the bladder, the esiabli^hinent of which, as n rule,
fnllowed by complete recovery. If tlm process continues, pycio- nephrosis
boy develop and n^x'c^fitate nephrotomy or even removal of the kidney.
hmve »een (his complication in ten in^^taiiee:^: most of the patients recov-
■ ^TTcl >[Hii)lBni-cm>.ly ; in Ihree^ [inmintun: lalNiur wan indutiHl and an inler-
^bi|ili^ reeovcry followet), while in a neglected case, which was only seen
^Eft(*r uponlanMUH prcmalure labour, deaih resulted from a gi^eral svjilic
^K Floating Kidnrg. — 'The symptoms ariolng from a movable or floating
^ndney are u.-<ually considerably allc%'ialt.'d during pregnancy, au (lie <-n-
t««r)t«>d uterus tvnds to retain tlte organ in it» normal situation. In rare.
* a-i-tnncn, iMWwer, the {K-dicle of iIh' kidney may bivome twuti.*d and give
«- t— to intense pain, which may be mistaken for renal oolic or appendicitis.
C_.;an.'ful latii will unually Mtlliec for reduction, after whJeh Ww symptoms
i« iimt^ di!4p[>ear.
Owing to the incn-ai^nd laiily of the alxlominal wall following ehild-
ibe Hvrnptonin are apt to become aggravated when the patient )p!U
lit, unless she lia? taken on considerable '&<fh. m timt sulfioient fat ha*
about the kidney to hold it in place. A snugly applied bandai^e
N' woni throughout the puerperiiim.
pitiomtioH of Ihf! A'fdii^y.— Cragin Iws reporliil an imitance in wlilcli
IrialnvT o«;npie<] Iho )ielTic cavity, and has collected fi more or leasj
from the JitraaUu*. The coiulilitm i:^ rart-ly duignowd befwej
496
OBCTETRICS
owet
ual»
the oiiM^l of Ittlxiiir. thoiig)i in CrugtiiV cilnc it<k-iii{}t()in» nf tiKurcerMttdfl
led to Tsginal exainitiatioD and tlie dia^osis of the presenw? of a tumflufl
which wn* rciiiotx-d and fmiiid t" tx- a kidnfv. M
I'reifiuinr^ afior Hemoral of Kiihi^ii. — (^oncepiion eM>in«tinieR occurs in
women from whom oi>» kidney ha^ bwii rcnioni] on acvonnt of tuberoH
lo«iK. {tyctotifphnwis, or mmc oth(^^ li^Hion, ProTidod the remaininji; orgn?
performs its functions properly, prcpnancy may progrpsw uneTenlfulIy, and
in one of my ra.ti-i' the juitieiil wa.-* di-hvtTiHl at ti.^rni without incident. .\l
the same lime it should be home in niiod that the single ktdtK>y may be
tlie Klrain of a loxirniiii poorly; cnnr«quently thu urinv nhould b« tx
ined frequejiily, and the jJi-cj.Tiancy promptly interfered with at the
appt-MraiK-e of uiilnwnni Kviiiploni*.
Cf/gtilu. — I'l-e^Tianpy is occasionally iwii plica led by cy.*titis, which
u^iinlly due to guuorrhictU iiifcclion, though Ihv c'<Ion hacillns »iuy bu tli
infective a^ent. In view of the |io«iihility of an aacendin]: ureteritis
a rcsiiltinp pycloncphriti*!, Ihc cmiilition d>'iiianii» prompt Ircutinviit.
Fhmlini) Spli-rti. — Oira^ionally an wilargwl ."plfen r)c<nipyin^ the lowet
abdomen may be inii^lakcD for the pre<;tiiint uteruii. If pregnancy sup
ven^s it is u^itally uninllucnced by the floating otfran, which is ^r«duaU
forced into il« normal poKition tu the uterus enlarges. Occasionally, hoi
cv«T. pronoiinci'd jHTilonitic Hyi)i|it(>iiiM may a|i|K«r a^ tin* ri'sult of lorxion"
of its pedicle, when spicncrtoniy will be indicatcrl. 'J'Ih- literature apoa
th« sulij.'ct tip to IHtiT hiLs biH-ii Well rcvicH'cd liy lleil. ^M
Diseuea of the Nervoua S^atem. — I'araltjui^. — J'aralysis of cemral ortgE^P
sometimes occurs during pregnancy, and is us\inlly ussoeiated with toxsemi^i^
or M'ptie [inKi'-tJe.-, Thti", in the Invifmiaw tif pregnancy and eilamp'd^M
serious djstiirbancci> may follow oedema of the tirnrn or apoplexy. In ia^l
fectiouf proeesseH, thronilKisis may occur in the cerebral Teasels, and occobm
sionally emboli may cut off the circulation of large ureas of the brain an»^
lead I" variou.s paraly.->i'!< and eicn lo <lmlh.
Paraplegia of sjiinal origin occasionally occurs, hut. except in rare cas
of toMcmia. i* not dirtvlly ih -pi -mien I uimii the i*xi*lenix' of pregnancy
It does not ap])ear that spinal pai-aplcgios interfere with conception,
women suffering from them frequently Wome pregnant. Ill either crer
the condition is without influence upon the course of pregnancy, ami
many such him-s. indudtng advanced tal>ef> dorsali«. labour is uasy ni
comparatively painless.
Nmratffia. — Neuralgic pains are frecjuent concomilinta of piegnana
In rare iDstancex ihey are ven* oliatinate and resist all treaimeni. ttvm
they often <li«up|H'«r «[mnt«niinisly after taljimr. iJuring Ihe later moul
of pregnancy the head of the child, after descending into Ihe fn'l*is,
frequently compress one or other sciatic ncr\c and give rise to severe
along its cour^te, which is sometimes accompanied by )nt«ii«c musciL
s;)asm. Owing to its mode of origin, this form of sciatica is not amcna,''
to Ircalmt^iit,
iVfuri(is, — Whillield, Kulenlierg, and others have directed ntlenlton
»n idiopathic neuritis whieh occurs during pregnancy. Many cases
associated with severe vomiting of pregnancy, and os the toxa>mtc ori{
i^M
ACCIDENTAL OOMPHCATIOXS OP PREONANCV DUE TO DiaEAMI 497
of thp lallcr hsfi bcccHov ri?co<;ni»?(i, tho nearilis is conniderod tts a man!-
fwtfttioD ft tiif »am<; [irrKr-jw. and not Oi« n^nlt. of prvswure. It uxuaily
diiiapp«ars )i]MDtanei:>ut<l>'. but slowly after fUildbirth. The afTertioo may
\w Itmtti^ Co o Hiii];le iK-rre. or mar a[ipcar s» a nitiltipl^.- m-nriti^. Il U
chAractenzfy) hy iianlyi'in of tlic alTtvlnl r(-fiti>n a!<*(K'iatc-d with niu«oul*r
atrophy and the pretipnce of (he characterifti« reaction of dc^noration.
Tlicfp i* marked iiK'iisitivi-ni.-!M uloiitr llu' roiirw; of Ihc afftvliil wnis, which
u fre((ii«tiLly aj^sociatcd witli i^hoaliiiK pain'i. Scn^iliiliiy of tl)e parts 'u
^^ iMrktHlly imj>ain-d. and llu- pntii;ri()> fnxiucnlty diiffeT from panwthftiiie.
^H DocaAooaliy the symplonis are so seii-ere thai die induction of premature
^H labour may be jiictiftahlr.
^f Chorta. — I'H-tniaucy ooca.-iioDa!ly occurs in choreic iodiriduaU, while in
ran- inMancc* Itw diwovf dn«'S not apiH-Jir imlil oflcr coiiccjition. Iii ih«
firet da^ nf ca-^iM it is com pant tircly uniroportaDl, while in tiio latter the
(hoTOC monmimlA an? miuctimM *o intcuM as (o intorfcra with sleeping
•f tht' taking,' of fmxl- In these ram« of ohon>a graTiH the patient btvoniea
inaniai:al. and may aljort spontam-oti^ty. Tito appeamtiLi^ of fever is of
wriiiitx import, aiid at autopsy oridenmw of malifinant cndocarditb are
present.
Schrwrlc has wlh-etH 154 casr« of rhom rompltcnling pregnancy, with
a mortality of 33 |>t-r cent, and Ituist 3SA, with a monality of 17.5 per
t«i»L Fn'nch ami fiick* in ISlKi n-portwl SW cjws which luid liOi-n "1»-
in liray'-. Hospital in the previous thirty years, with a mortality of
<1 pef cciil. ilaiiy of i\w (.-arv* <ltd very wt'II upon Ui« usual nH'dicinnl
tTvatiuent. Ttiey are Mvptical as to the value of the induction of prema-
%.an Ulanir, but lay jiTvat stress npon the H^rioue prn;;no^tic import of tliu
^fftVMw; of fi'^i-r. Jolly, on the other liaiid, rii'umiiii-iids iiiU-rfcn>nee
i«a all aginvvatod cases, 'V\w only case of the prave variety which I have
d»«l, in spite of the fact lliut Aw fell inui prematiir* laliour s]>on-
iifcly fibiirtly after cntcriup the hospital.
Epii'pyg. — This diM-HM: apjs-urs li> have no ctTitt ii|sin prcgiuincy,
Ebfiu^i, ai tl»e lime of labour it may be mi>^tal(en for eclainp-'^ia by inex-
P*^»''e(>ccd oImhtv)*!*, If tho attacks an- frcqwiit, the patient slioutd bo
^^"C npon large diic>es of pola.'uiniii bromide and treated just as at other
BBj"'*'*'. As a ntle, it is not advisabte to allow the mother to nurse ber
' '''"**<1, as tai-ialion sonu'ltmes a|'|H-ani to ajigravate the distui.-*, while »cri-
'"*" itijnry mi£ht possibly be done to the child during an attack.
//ys/rrin.— Hysteria is a not infretjuent coniplimtion of pregnancy, but
not appear to exert a dolclerions infiitciice upon its course. Indeed.
l*hy>i<-al condition ofii-n undt-rgoav marked iiiiprnvmeiit at siu'h times.
ionaily, however, the IniHtcrical >^ymptoins may l)«'onie aggravated.
■y author* hare of late Ik«u inclined to attribute tl>e nausea aud vomit-
of prt^tuuicy to hysteria. I'liis is no doubt true in many caM>«, but
inly cauorit be regarded as the sole cause of the condition.
Trtitny, — In rare tnstaniL^ tflany may occur during llw course of preg*
'J*Ocy, MeintTi, in lA'JU. la>ing able to colWt Sii ea-Hcs from the liierature,
** time pativnts t)te di^-ase app<'ars only during prc^ancy and is absnnt
*^ oUier tiiuefl. Q. yi, lltouuts otKierved a vawe at tli« Johns Hopkins Ho»-
OBSTCTRKS
pital, in which the condition had appeared in 6 sui^ceasire pi^'iiniKu--.
A full resumi of the lileratiiro ie to be found in his sriide.
The ii'tiolojij" of IMnnv is nol cIvht. Formorlv it wa* tlwuftht to be
connected in some way with abnornialitits of the tJitroid ^tand, a.i il aome-
limvti occiirn-'l after iho removal nf that organ. Al procnl it ik hclinrt-d
(o bo iUw 1(1 tin: alxiii'iK* or iriifierfect tswrelion of ll»e parathyroid budiw,
and Frommer in 1900 dt-monetralcd Ihal fatal Iplany would follow their
extirpation in pregriant rnlihits.
(JoUre. — We liavo already referred to the slight ealatfiement wliich the
[Uvniid fn'qHeiilly iiiiikTgix'it during jirf-giiimr-y. Bigiianii hai n-jwrtMi a
case which, in his opinion, proved that pre;;nancy occasionally ('xeris a
pathological inlluciicc upon thin ginnd. Dtiring his paticiitV first prcgUBnc)'
thi- thyroid underwent considerable hypertrophy, hut reiumed to its nonnal
size after delivery. The condition r»-tarned in the second pri'gnancy, tl
enlargement n-Jiching«uch jiroporlions that death resulted from siitlotnti'^fl.
In rare instances pregnancy appears lo cause a rapid inen-ow in tin
fitG nf a thyroid tumour, which had been prei«nt before its inceptioD, auil
Ahtfeld. Albers-Schonberg, and Meincrt have reported cases in which
(loiin-. which hail iin-iiou^ly f:r"wn only Bhiuly or had remained staiionar* —
in size, became so large durinR pregnancy as to render tracheotomy or Ih-
operalivo rcrmoval of the growth m-c^-jojiry iu order lo prevent dralh fro:
suffocation. In my experience pregnancy play« little or no part in
production of exoplitlialmtc gollre, hut tht^rr i« im doiiht that it e.vvrts
deleterious infliieiuv u|»on the condition when it already exists. In
iriil itfitanccs tho tachvcanlia wa« greatly exaggeraltx], hut became |i
marked after Jminced or spontaneous labour.
Apoplfjg. — Apoplexy is rarely obscn-wl during pregnancy, though
is not an infntioi-ut romplication of tvlanip^ia. When it oct-iiM iiidv,
ently of the latter disease, it is usually the result of emiwit due to eoi
carditis, or to phlebitis of the lower e\tR'milie«,
Disturhantei of I'iaion. — Dismrliaiioes of vision are rarely oW
iliiring pregnancy, but inijuiriw should alwayn Iw made and the paii
cautioned i-onpt-rning their diagnostic sif^iificance if they appear, .\oiau
sis or total bJindne** iKTurrlog a( this tiintt is gi^nerally dtio to albumin
retinitis, and the first indication of a serious renal affection is soinetir
afforded by an ophthalmoscopic examination.
Siaeaaes of the Blood. — Permiiowc Awmia. — According to (>sh>r.
complication was first described by ('banning in 1842. Since then a
sidcrabti- liliTalute hn* accumiilai<'<I u))on the subject, which ts wed
viewed in DavU's article. The disease occasionally appears during p
naney, but most frwiuwilly not until after laliour, It is characterixisi
marked jiallor and anii'niia, which is a^iiof^iated with weakness and st»'
ness of breath, the estreniitios also Iw-coming (Fdematoiis,
A positive diagnosis is made by tho miemscopical examination of •"
lilood, when the numher of rf^ blood-cells is found lo he markedly di«'* '"'
ished. )[any of the corpuscles are irregtdap in shape, while nuch**'*''
varictii* are not iMfn\piemly oWrvi-d. At the some time tlM-n- is a i*"'* ,
ti\o ioerea» in the amount of hiemoglobin, thouf:^ its total amnunl -"
■mOFNTAL COMPLICATIONS OF PREGXAXCT DirE TO DISE.\SE 499
HKtdvnUy below nunnal. Ai^ u rule, the (lie«ase eada m di'atl) if it be
mat prnperlr treated, and marked fatty ilcgi-ncTalion of tliu vartoiu or:ga»it
M found at autopflt'. Kxecllent results are obtained bv the administration
■f FovI^tV Milutioa in inon'SKiiig do^c^. bcgiuniug with & drops 3 Itmi-s
B Ltvltamia. — Lmiksmia is a very rare mmplieation of pregoaiicir, ller-
Kwn anil H. SfUrt>«l«r \mag atilc to (.•olli-el from 1b« lileraluni only 8
kd It) examples respectirely. In 4 cases the disease had existed before tho
■)si>et of pTt^naney, whiU' in tlH^ remainder it appi^anil uflvr ilK inception.
K fxerta no direct effect upon gestation, though the asttocialion of Ihe two
Iftnditions may M-riou^ly alTecl the mother. In several int^lHiice» prvtualiirc
Bioiir resulted, after whioh tito .lymptoms uniierwont marked amelioralion.
^■■Sip diaffnofiis is rendered probable by the existence of niark<-d anirmia
^P^Baterl with enlargement of t)i« *ptG<>n, and i» plaoei) liey<in<l doubt by
FililTrrrnlial blood count. KsamioatioDs of Ihe fo-tal Wood by Sanger,
Bameron, and I^ubenlierg indicate that the rliaraeteriftio leucoi^yteii are
pot tran^millnl to the foetus. In view of the ^od results which somc-
Kinie:! follow s]M>uIaot>ouii premature labour, pregnaney may be terminate(t
rificially in serious eases.
Hamophiiia. — Althougli llw exidtencc of a Iwmophilic diathenis may
without e^ect upon gestation, in the third stage of labour it predisposes
t-«i olmlinaie ptHt-partuin lia-murrhag«^. In view of llii» danger, in ttie
r'Arv cases in which tlic conditions are associated, Kehrer recammended the
durtinn of abortion, though it is prubnble ihat the blit'ding would be
I difHcnlt to check after that operation as after futt-terni labour. In «
of extra-uterine prt^aiicy under my oWrvution. hufmopliilia proved
iBoit scrinua cuniplication nt the time of o)M'ration.
Lrad Poi»ftning. — C. Paul studied the histories of 141 pregnancies
[barring in women nulfering from clironie lead j)oi«oning, and founil that
ended in abortion or premature labour. Moreover, a large number of
rhlldren which were iKim alive perii*I»ed at an early f)eriod, only 10
■vnt remaining alive at Ihe lenlfa year. In Vi'^ pregnancies studied
l..i-win. <>M ciwlf*) in abortion or premaiun' Inliour, ^ children werv bom
kd, and 30 died in the first three years of life, thus leaving only 14 alive
wr- that pcriotl. niere i« no di>ubl Ihat tlie haul i* transmitted through
[ pl&ccDia, OS in a premature child examined by Lewin 16 per cent of
I liilal aei^hl of the liver was due to it,
IXMaesMa of the Skin. — Imptligo UerpfUformia. — .According to Dilhring,
p*»it was the firti t» call attention to (lie serious nature of this disease,
■kotign herpetiformiii occurs in pregnant women, and is eJtaracierixf^l by
r*^rficial pustuli», which are arranged in groups or clusters with inHam-
l^ory baM-K. Xi-u' lenions appear on the lionler* of older and enisled
^floent patches, while recovery takes place in their centres. The lesions
p^n- on the trunk, thighs, and in the neighbourhood of the genitalia, but
P^ly upon the face. Tlifv are accompanied by itching and constitutional
BW^\>i(>m*, chills and high fever. The recorded mortality is about 75 per
P^t, Debreuihl Itaving collected 24 casisi 0(*nrring in Austria and fier-
r*^ with 18 deaths. The disease, as a mle, does not lead to abortion or
600
OBSTETRICS
prifitmliirt! labour, ihough iiiaiiy of ihe wom^ JilToctetl witli it died undo-
livorw!. TIk' troalnicnl is purely patlialive.
Jlrrpcg (ii-slalwfiis. — This disease, more frwjuenllv known as dermatitis
lici-pftiforniis. is aii juHammatorj-. superficially iteatcd, multiform, bcr-
pi>tir»rni fni[ition, which iji characUfii^ br crythomatous, TKiculnr, poF-
tular, and Imllous Wioita. It owun* ixvasionally in pregnant w<nnon,
(Uid i* ac'oompaiiicd bv marked hurninf; and itcliin^. it )>un;u<?« a chronic
course, is often ailended wilh fever, iini! soinelimcs ends in dvath.
Diihring believes that it is proliably tosivraic in origin, though similar-
le^iona ^onu'time^ occur during the course of wpsh. In view of its deprew—
ing character, the patient inhoiild hp placed upon tonic treatment, while llw
ileliinff i* heil allayi^l by (ho iim of oinlnieuts or lotion* containing (til o
cade, carbolic aeid, or similar subslaiicpB.
PruritU. — Itching is oflt'ii n di«trcwing complication of prcffnaney. I
may extend over the greater part of Ihe body or be limited to Ihe gitiilall
Gciierul pninti* siioiihl be regarded a* a neurosis, which is pmldably toi
a>Miic in origin. It ofu-n gives ri^e to iutcn'^e sulTering, llio itching norni*^
times being so coni^lanl that the patn-nt is unable to elevp. In some patient
the lotut of ri^t and the nervous i^train attendant upon it exert a inarfc<
influence upon Ihe general conrlition. Hucli cases are best controlled b
the aiiniinistnitiiiu of nerve scilaiives and general Innic tn'atmeiji, \ Hgi
milk diet is snnielimen followed by excellent results. When the eonditi
is not ami-naMr lo Ireatmcut and tint jintient nhows morkttd sign» of cxhaii:
tion, the termination of pregnancy may be justifiable,
Ucnilal prurilis — pruritis rulvw — may Iw due to several causes, ainoi
which an^ irritating vagina! discliarge*. parasites or gtyeoRiiria. Wlw^^ -i!
due to the first-named caupo. the condition is best treated by tho admiOK: is
tration of astringent vaginal douchnit and the mainlenaruw of ah«ili^^:^:^=al«l
cleanliness. At the same time the itching may bo allayed by the empl^'' jy-
ment of ointments contiiiniiig icKaiiic, menthol, or carboliv acid. Pruri — 'tie
of diabetic origin is observed but rarely, but the possibility of its ofii ^ ~ir
reiice shoiihl nlway* be borno in mind end the urine ci^amiiied. If sugai w
preeent, relief can be obtained only by placing the patient upon a ri^
iintl-diabefio diet, while ut the winif timo ihe appropriate ointments sJw)
be (■niphiycd. (Iccasionally intense itching aliout the anus may In- dw
the presence of seut-worms, which are bi-st di-stroyed by the ns* of rtcr^
eneiiiata of infusion of ipiassia. If loca! nieasure* prove inclTtvIual, a d -^
of 5 grains of santonin at nighl, followed by Itochcllc salts tbc next tnt^^
ing. will often bring about the desired ri>su!t.
AhnormaliUes of Pigmenlation. — During pregnancy abnonualitiea
pigmeninltiin are not iiifre(|uwitly noUnl. whir-li are particularly mar"^-
along the liuea alba and about tlie breasts. In other eases iin.iig}itly
lowisli splotchc? — cloanjna — ajtpear upon the face. They are not amcu.
to treatni<-nt. but iisualiy disappear promptly after ehitdliirlh.
Ifa-matotiia of the Aljiloniirial W'alh. — Stoeckel has re|Htrte<l two
of biemutoma of the abdominal walls occurring during pregnancy. In '
OBiie the himour was situated in the slieath of the right rectus mnivle J
above the symphysis, while in the other it appeared as a large mass is t''^
in
^«1
--.•I.
pDENTAL OOMPUCATIONS OF PBEONANCl' DUE TO DISE.\SE 501
Bit hypogifltric rpftion, which was mistaken for tbn head of the child.
■ coiHlili'ni ntxulled fropi rupture- of Ihv iuferior and superior t*piga«trii;
iHelajation of the Pelvic J ointt. — Owing to the great TascuUrity inci-
kt to pTcgnwicy, llw various pelvic joint* »tway« i^liovr a wimi»-h«t in-
fcB«d QiDtility. Owafiionally, howe\-eT, the softening of tlie interariicular
tUagi* at thi! symphyflifl pubis at)mil« of such ahuonns) niotioD in the
It U to inu-rfi-n' M^rtftiivly with the <-oitif<>rt i>r Ihv piilieni, tvho tiulTeTH
n tnten»e dragging pains in the pi'lvis and lower aUlomen; while st
taunc time Ih*- g«it may be tn pnifoundly ultcn-d a« to «ugge«t the
itence of cerebral or spinal trouble. In sueli cases the application of
ghtly filling Imiulagi- about Ihe thigh* i» followed by marked iriiprove-
ai, ihoui;h o«aiiionHlly ilie symptoms are so pronouiU'Cil that the patient
bligi-d to take to her bed. The condition ui^tuilly di^ppearH *|)onIa-
\y during the n»ur»e of tlie puerperiuni. but in exceptional inntancea
persist and give ri^t to such grtwt dixconifort that it may bvcomc
ity lo "wirw" the joint.
Similar relaxation may involve tlie eacro-iliae joinis and cau*« groat
viug. Particultir ailonlion ha" lately tx^n dinx^ted tn its fre(|uenry
signifloanc*! by (loldthwait and Di^food. In many instance* great
ef may U' alT'mhil by iip|ilying Hdhesi>-« nirips, whii-h e.\Iend out-
»1 from the posterior surface of the Kierum to the external portion of
thighs.
Acddents dnring Pregnancy. — The pregnant woman is exposed to the
piWiSibility of injury' as at other times, the proj^iosis not being mat«-
y itllcnM ew'pl that iiU)rlion fnqiiently <)C<-urs. l*re)(nancy itself
be complicated by accidents which are incident lo that condition. tl>e
■mporlani being rupture of an cxtra-uliirine pregnancy, rupture of
BlemM, and premature separation of the placenta — all very Berioua com-
>tion8. Ilieir mode of production and treatment will Iw cnnoiilcrcd in
il in til" ai'prHj'riale chajiters.
orpcAl Op«nitioiu daring Pregnancy. — Formerly il ws* believed tliat
prrforrnaiice of surgical operations during prej^iancy would almoi^t in*
iMy hnng about abortion or pn^'tnaluriT lalKiiir, even tlie exlniction of
>lli In'ing ctmoidertil a serious pmcolurc. .At present, however, thanks
i«>-ia and a jierfected surgical li-rhnrqiie. many opcrnlion.' can Ike
I'd at (hi* (iiiu) with but litlle addtlional risk. A<x-ordingly. wIh-U-
■ confiiliun arises in the pregnant woman which imperatively demands
!>>.«I (n»imi>nl, iIm> necessary o[)eniti(>n mImuM lie porformwl witlMtut
latinn. .\t the same time, if tlte indication is not pressing, it is advis-
' I" defer inter riTi!n«(> until after laliinir. w n* not (o Mubjvet llie ]ialient
u added strain.
A rwimr of the litcmtnro goes to *hnw that ampntations are not more
KjETona than at otlicr times. Several observers, notably Polk am) Cragin,
V reinoTed the kidney without tenninating pregnancy, and numerous
ar" 'in rtvonl in whieh pMraixrphrilic or briwd-tigametit ab*c«*BcB \\a\i-
ii^wnnl. Tumour* of Ihe generative tract' c«n liki'wi*c be cxciw"!
luNtt gK»i riak or markedly increasing the dongier of premature labour.
602
OBSTETRICS
Th(*e <t»ndtti«ni> iir- concidcrwl in ihi- (-ImpU-r upon ihv Compluminn o
I'regnancy by DUcjses and AbnommhtiM of the Rcnerfttiv-e Tract.
Appi'tidicitu, — App('iulici(i» proliiil>!y wt-cuni u» frcquL-nllv duriiip pr
iiancy as at other times, inil until rfoemly it was conipamtively overlotvkiV
in grwit purt, no doubt, bi-cuuiw of tbe difficuily of dis);iio«L£.
It should lie FPjianb'd as a very serious complication, as mitny minm-
diu if not oiH-rat^-d upon, while the mir^cal procedures undertakon for i
relief are fn-mienily (ollowiii by pretntiture lalMiur.
Prfgiinncy dow- not predispose to its occurieoce, hut in <!&seti nf
disease in which Ifie appHidix has become adhrnrnt to'lbc appondn^vs c
iitiTU!^. (^xunrbiition niny result from the traction exerted bv the enla;
ing or^n. Mon^iver, whc-n lh<- pmec-«x \\iu vvt'iicuiili^il in iiW'i>< fonu
tjoit (he ni]>id decrease in the size of the Utentii following delivery in.
readily brin^^ aljoul rupture of tho abscout walK
Tlio »>'niptoms do not differ from those observed in non-pregna
woiiit-n, bill Ihi- <'<iiidilion is frcijiK-nlly ovcrlookt^i. as tin.- pains an- oft
cotisidircd ai- biinj; due to the prejjiiancj itself, while tlio distcntjon
the aliilotriinal wall- by Hh- euhirf^i'd nlonis innkex ditlk'-ull. ibe appreeiat
of the rigidity and muecle-f-pusm, which are usiiallr valuable dias^no^tic ai
One should always i-onsidi-r ilift piM»ibility of jip[H'iidi(-itii^ when a p'
Tiant woman cmnplaina of pain in the right side of the abibiincn, n
cialcd U'ith iin I'lfvatinii of ti-tupcrutiinr and pidw. providi'd M>me u
satisfactory explanation for the condition cannot be found. ]t j"hi'i« '
hawevtir, he iviiicnibi-ri-d that pyelitis and influiamatory roiidittona of zJ
appendages may pve rise to identical symptoms. At the time of laboL.
and duriiij? tin* pucrpcrium its rwopnition is still more difficult, and nwui,
women have died from perforative peritonitis with the diaj87ioni» of piii'r"
jM^ral infection,
Operation is indicated in alt cases in the early montlis. I^ler in pn>!-
mincy llit' prwi-ncw of the enlnrp-d uti-rns renders it dillicull to expose tie
parts satis fatlorily. and may seriously interfere with proper drainn;^ sltimld
iL prove iK'c<'"Jary. In view of this dilHculty. it has l>ecn aaggested tint
tho uterus Ih! eniptieil by aa-nndiemfnt force before opening Utc abdoowa.
I. however, do not believe ihiil it is neccssarv-, and am convinced that its
general adoption will add to the jrravity of the o^ii-ration. In tbo earlv
months abortion is not likely to octur. provided the uterus has not Iwvd
Kubjeeted to much manipulation; in the latter nionilu premature labour
is frw|neiitly observed, particularly in cases of abscess formation. || may
Iw due to one of several factors — manipulation of the nterun, fever, and,
whi-n an ab^trss has formed, to the direct transmission of liacluria fmni
it to the fietns.
Inlf^tinat Ub»lmction. — This rare complication of pregnancy should
1(6 treated upon general aurgieal principle*. I have mxta two casM. In
the first intusKuseeptioM occurred at the site of a tubercolar nlc<T, and
death followed n-setlion of the gut ; whili> in lh(^ second case oltslrDetioo
was duo to constriction by a peritoneal adhesion in a ease of tuln'reular
peritonitis. This was n-lievwl by operation, and the patient va» deliv»«d
at t«nn, but dit>d some weeks later from miliary tuberculosis.
Iw
JENTAL aiMPI.H:ATI<)NS IIK I'11K(.:\A.NC\' DITK TO UIBEASK 3tKJ
Ul-ERATHHf!:
kHAMBk Appentlieiiia iioRi|>IiraUnj[ PrtfliMncy. Aiii^r. icntr. ObsL, 18Cr7, xxxv,
-32».
8ch<nui«nnK-liaft and Gcburt rompticjrt durdi Strama. IlprMi1« u.
ArbeiWB, I88S. b. 131.
KLfiLD und MAcnuiiu. Abtfcld'a I«htbudi der (ichurtidiiiir^?. II. AuH.. liWI, 2311.
' nu»-tl!'ii<'-KnKit«. KompnMion diT Tr»«jM8 in Fnigr van .S(-hil>l<lriiM.-tiiK'li«'4-lluii|c
i* dur Cmvjdilsi, TmehiMtamir. Zenlnibl. f. Uvn,, 1995, xi\. 4S4-(.>8.
^^miKiiAdD. 1^ l^ltinoa pendaitl Ift groiwrww. La ftcvuc MM., tHSfi. 413.
^K.uvnNK luwl MlUJunK. A Gftoe of Si«rl(4 Ft-wr iii IVvitiiiuic)-, nilli lufprUuu of
the FuiUK. Tnuia. KdMtmr^ <>M. Soo., ims. xvtit. 177.
kn«i Itoi'LLt. Gri|ifH' (It purip4rali(i!. l.'nh«t4(tTi(|iia. I8!>ll, lU. I9S-SN.
■-SvBh 1)n the ThnrnilxMui uiul EiiilxiUa of L>-iiijE-iii Wocuni. Tnuu. Land. Obnt.
H Sur.. iwi.1. iv. sa ia.
^ku. t.'clvriiitnuteriii^ Vacctnalioii. ZHtBclir. f. f!»b. u. tijni., ISB2, vm, l~3l.
^BiUu, Timtdimno r tcni«idB&ML IM. ItHut^lriitue. IKNi, i. 174.
^Vr. Ih' lit ulyi-nniirii' |>liyiiio)i»n'|u<' fhvz lex firmniOK iid roiirimt, etc. C'uciiplua niB-
B Jiu) tir rAntl. <li.ii iciaKWfl, 1880, xliii. 676.
K.u'vr.KH. IVIicr MRueboD- ODd ThicrpockcD. Volkiiuinn'* f^tminlunii kUn. Vor^
inttR, 1877. Xr. lift.
Chima tinvidanini. Tnuu. tMinhui^h Olut. .'^oc.. IMI1>. Jjiniiury 12.
Tbe influtnrw of Leukii-tuui u|>oii PrtiinHiicy mni ImIhit, Aiticr. Jour. Med.
\ SrioH^ I8W. .V. S.. xpv. zs-ni.
>^CTu.i. Qiiolvd by LuhaiM-b.
dHK. l>e I'Mnuiturte de In BitHwiit. Aiiiuileii <ki Kyti. pI d'oUt.. 1901. Iri,
I-ZI9.
tXDEfti Ft FoiutiKH. Ilefhcrrhci nir In nu-rvn urinAirun cbvi li> fummc dticciiitc.
ArrhlvoK r-n. il<- mM.. i'JU*. rxnv, 2211 nnd 2;i2A.
tiuUrlin Jtf b aoc. d'olittt. <li- fum. Mar* 15, 1900.
Coascnitol I'dvu! Kidney obstnicliii^ the l^rluricnL CuuL .^nuT. Jour.
:., IBBB, sxxvib, 30-1).
tb> ramplimiiic Pn«tinn<r>-. Tnum. Am. Oyn. Sue.. IIXH. sxis. IIS-13)).
Tii afiil lUiiiUK. Rrpnrl of a <')ij«> irf nnnnrrhnsl EiidnntrHitifl Ina Piitk'iit dyiiii;
. ibr Furr]vrium. I)iill(-tin of the John* Hofikiiiti Huap.. ItlOI. xii.
PiwriK-nil IVrniiimw .4nii-inia. Trann. Ainrf. fiju. Soc., Ififtl, xvl, 42,^'4:w.
iHu Inipt^iim.' tnTjietifonnU. BMiticr, Bnx(| «1 Jacqurl. Ia Prati>|U(< ilemiMto-
qoF. IIMI. ii. Vl.'i !>2a.
C(]iitrit<uiiu<ii>r#(iidi>dMmnliapMlMM^oir. L'UlMii5(n<|iie. IHt)6. i. 41-57.
Impctiico HrrpHiformii. CutMieotw UcdidDP. \m». ['art II.. 4.10-430.
Ob Pttftpvtal Dbbnw. Traiu^ l.<rti.l. Ot-t. Soo., liwa, sslv. 2S6-285.
MjOarin and Pn^uiie}-. Mrit. Mi-<1. Jour.. 1809, April 29.
nSKU. Prtirr )Hirrpcnlp Kcuritu. ctr. Dfiitarhc mod. Wodicnwhr., ItHA,
10-121 uhI UO-l-Wt.
jx. TliF InOiKticB at tnlliKna* iiimi Wotiwn. Tmiw. Ivdiiibur^sb Utwt. Jour.,
i. xvH. 12,
Oen a. Stfanngrncfaart. itmaUueta. t. Gtb. U. Qytu, ItKlI, xiv, 37t>-<tl7
' «wM37-5a(l.
^^%i. Tn nun di tiuiumiHuoaip <ti iiiorbillo delta nudrv al (out. Procuniurtt Jahimd)*-
rirhl. lUOO. xiv, 721.
KR. L-btrMit^ ■yptulili-iW'. PmIm, IWl.
and Ricw. Cbores gnvidnram. Pnrliliuim, ID06, bcxvit. 178-104.
604
OBSTtTRIfS
diiEnuANN. Exp. EScitrnge «. Fniftr kongcnilAln TiilicrkrltMuiUfnubcrtniiiUBA, (fc-*^-
Virt-how'B Archiv, 1905. clxxxi. 151)-I79.
FnoHMKit, V.xp. V'prsueJic xiir pnrathymiiikalon tnautTiKicnx in Brjnqi auf DLbinpK**
u, Tetaiiif. MoiLfttBUchr. I. G*b. «. Oyti.. 1906, xxiv. 74S-761.
GA0T. ICxprriincutcllc Bcitrosc >ur Lchrc voii ilcr Impdutg. Schmidt's Jkhrtiudtr *~-
1B79, clx^xUi, 'JOl.
Ga(iuiu> ct Bufi. TulicrciiliMC piilmnnaire. Atvnucbcincnte et (nolwliMi dni; ftrtniiw^^*
Bii eoiiehwi, ll«)t. 2t»7 -■■Jm
((XidTKK. The Surjni-nl TrvBliDPOt of AppcndicUia ocimmn); during Vngtaacy. Pliil**
MomW.v Mr(l. jour.. 1H!)9, i, 170 IT*.
GuLtwaoKouoH. Juluii Hopkins H(i!ii>ltut Btill.. 1904. xr, 19.1.
QoLirrilWAiTiind OumnD. A (^niidirmlioii <if Ihc I'clvic ArUculntjnnH froniMi Aunt — *
Patb., luid Cliniiiil Slundfiuinl. R'<?I<in Mod. niiO Surii;. Juur., 1005. diii. 5$J-''>i)B- -
Gin"!!. Uclicr dcti Kinflum dcr MBluriiiinfeetiiin uut Schw-siigenirfaaft. etc. ZeiUtbi. *^-
t^eb. 11. Clyt... 1881. vi. 17-34.
Gkakmb, I>ie 1-diiwirkuni; <ki< DinlwU'i int'ililtis, utc. Gnwfc'a SMnmlung tMtt^oae^-^
Abhamllungrn, 18CT, ii, )M( fi.
GiPfilt.vlici. IIprxl«lil«r u. Srhwwi^nicluill. MunnlMiulir. f. Geb. u. Gyik. IBOO, ASH — —
»77.
HaPhkr. 7jiit Votvrbuiii; der 7\ilivrkiiJ0Hr. TleiilM'bcs Arrfaiv (. Uiti. Hud., 1808,
221.
Hbil, nil? Coiiipli»itinn f(it\ 8chwuiiKcriH'hufl, Gv^rt ii. Wochtmbnlt ndt WwxkmL
Archiv r. (lyn„ 1907. 1-xxxi. 120-128.
Hbrmak. I.TiikaTiiin and I'r<-t[iiitiic,V. Ijini<rt. IWII. ii.Oi'iobrr 12.
Uicxa. A Cuiitribuliuu to our Kiiowlt-dgv of Pwrpond Ummuwb, elc. TmiiA Louih^
Obrt. Sot., isri.xii, 44-llS.
Jolly. Die Iixlikation dm kunsllicbun Abort us bei der Bchandluiig voa Nmnwai un^
Ps>'cho*cn. ZrntnUbl. f. Gyn., IttOI, xxv, 1lll!>-1170.
Kehkek. Dii- Hiu-itiophiUe bei trvibliclwui Geschlcehte. Archiv I, Oyti., 1876, t, 301^
2,17.
Die pb.vs. u. path. H«f iphiingeo dor nviblirheTi Bo^ialoriciioe «iun TnMttUB inteti
Bi-rlin, 1005.
Kunx. Ik-itrAffo iiir Polhologic dpT S^hwnnftrm'liafl. .\nrhiv t, Gyn., 1887, «i
448-475.
Kdi.ijicii. Thi! Protective Influrjine nf Vnoctiwtion, ett. Amer. Jtntr. Qbat., II
xxii, 1078.
IvliiiKiu. Buktnialo^i- dcs Gi^iiilulkmiuli^H di-r achnungcrcn, krcimcndcn tDid pucqi
nilitn Kmii, 1»97, l«0,
LuttE-OKyf. I'l-ber die intrniitcriiie l'vbcrtni)cljiark«it dva |jiyii|ipj. ZciLrJtr. I. tie
11. Gyn., llM«i, xii. 321-327.
LBMLBUit. Quoted by Ribonioiil-DoMMiKiiuti vt l.vpB||^. Pr6cia dXJbcUtriqut,
642.
I.BVr. Ilfthcir intn)iilcrin«< Tnfc-rtian mlt Pnt-iimonia croii|><ue(. Arrliiv t. exp. P»i
gie, xxvi, IBB6. .MI.S,
Lr.wiN. t'clicr die Wirkuns dcji Itlpia niif d\c (ivbnraiultcr, Bcttitier klia. V(
Bthr.. IWM, xli. 1074-1078.
LikfMA.HN. I^bvUw mcUitiMund ilelrilia doodana. Afchiv f. Gyn,, l903,lxx,'U
444.
iMHKB. Uelwr dii> Bedeutung <l«a Icl«nui gravidmum, ele. Zdt«dir. f. Gob. n. 0]
1S86. xiii. I69-1K.1.
Ulurro in dcr SibwiuiiH'nK'luill. Zfiilmlbl. 1. G>ii., 1889. xiii, 826.
I.vnwia, Ein UeiiruLg lur l^thologic du t'nuJuinuMcr*, ZmlnJbL -I. <iya.f Jt*^
1 xix, 281-284.
it-X-'I DENTAL COMPLICATIONS OF PREOSA.VCY DUE TO DISEASE 505
LomJE. Mitm] Htauna in Preguinc}'. McdintI N«ws, 1803, Ixii, DM«nib«r I.
I.varr. Pty»limiuii pcTEiiriiNnw Rrn%iiliiniin, Ro(. Frommel'a JKhnwU-rifht.
LvsccH. PlamiljJ TnuiMiuBiiaun. u'ith Refiurt of « Ctue during TjrphaJd I'Vvcr. Johns
Hopkiu* llmpiui Rrpixta. 1002, x. 2t&-322.
IL^cra^vziE. Tlic Uatrmul HtHirt tn Pr»*iiiuicj-. Brit, Med. Jmir.. I901, ii. ftllMKU.
tlA^v^'i-i-]. RMterrJifi apnimcnlnlc iiilotno al paiwHeitin dol vcnvno ( iilwrnxilHrv dui
irmitofi bIU prole. Ki-viXu criiim di t-lliiioi rtird.. 1900. i, 221-22!).
Uaim-*mt. t'ctipr dni iiunkliKcii MiiilhiHi dvt Srhwanjcrwlmft uiif din Rntoroptoso.
ZmlrallJ- f. tlyii.. IWK). wiv, J34i-i:K3.
Uajcljivbkv. Kodnnictriliiiik'dduBlinK«Di"TlioirB, Mnnniiwtir. f. Gttb. ii. Qyn., IH9ti,
rv, 213-218.
Ul h.kw. Watcrv Dcolini-htuiif^ni bciufcHchdcaEinlluiucitder Influciiamiif dcni wdlil.
rVxu»l»i>]i«nkt. Miinrh. mod. Wix-hcnvhr.. IHQA, Xr. 41, OAJ.
HxTMitJi. ApfiFiidicitu. Mtdiial Hn-i>rd. 18tM. xlvi. 070.
N'WfrNM. Trmiwnuitdan inlfsutrrinc dc b piiruiiumie. i-U. C.\iin])(4-.« mi<liiii <{«< la hoc.
d* UiilnlDc. 1B8B. Mai in, 187'ig4.
'•'■sou* XX. fi-hcr puapera.lv riirnia-KoncirTlion. IklurnaliiHbr. t. Cieb. u. (lya., IBM,
iv, 100-115.
"■■ ^leacKLD. t irfwr da« Vorkonunen von Kohl I'bydrn ten tin I'nicblwnawT !)« DiabDtnR
iW MiilUr. ZfilM-hr. f. 0«h. u. tiyn., lUflll, Inii, 1H!> 22!l.
^-••■■•i-ms. rntmuFtiuntEpn iibiT die Cuupliraliim dee Tuerpcriuai mil SrJmrlaoh.
akWv r. oyn., iHTii, ix, ino- ifl.v
* * n: IXr P)-FloiMrpluiiiii f^vidanuii et puerpwarum. SMtaohr. f. tieb, u. Ujnt.,
low, Iv, 20ti 2!M.
PnoTprnd Anmnia, etc. Riuifln Mrtl. anil AuK- Joiif.. inRft, xcix. 454-455.
BeilniE lur Vuci-inaliui M'hwiui|R'n.T Wocluirniiiivn u. NvuKi'lionrncr. Arvhiv
r.Gyn.. IM)I. Ixii. :i-lH-3».V
-T*iip. ZiiT Ai>iH4n|6o dpf Hadi^rnLninkiipit. H'jon, klin. Worhpnuchr., 1888, i,
Nt. IH.
anoK. Oiabplcn in l'n.-|[»aiKy. MMtical Rccont. 18(15, Jul)' 27,
Cotuidtnt'irmM nir quelciucn malodini silumiiip*. Tfa6ic dc Pnrii, 1<M1.
■ '(^icr <ioii FinfluNt dr» Zurkcnt aiif ili>ii SioSw-pchaol dnr 8ctiwaiiMcrRi, «ic,
UrautjHtir. t. <ieb. u. Gj-il. 1800. xi. 7(i4-HOa,
~Uin, L'apprndinUdanafciinipfioirUiBVcc Ingrcwinig. AnnalMdoxj^n. et d'obat.,
ISOO. liii. 357-3R8.
Traiib«niuck<T in llani und Fruchtw'aaiiu'. ZeiilnUU. f. Uyn., 1806. xx,
US-«ri2.
HUMx. Tub«mil<He u. ^cliirani^eriirhall. limuliBrhr. t. (j«b. U. (i)'o., 1906,
^^"^^* Jinn I K.I, t'vta-r die t.'«licnDuiK tod MilafarandbacUlMi iMriin Menac-licn vrni die
Uullcr aof die Fniebt bd Puxtuln maligna. ZciUrlir. f. Uet>. u. llyn., 0107, xxxvU,
342^552.
Ma. Die aPUlEU Inftctioaiiknuikbcitut in atiolo)|ri«dier Be>i»huni; iitr Srhmu^r-
wkrunntpThmfaung. Volkmann'* i<aniniluit(; klin. VortMge, St. IT4.
•OKa. U«iUr Lrakiiniu bet Sdiamnternicludl. t-ic. Anhiv I. tiyn., ISSS, xxxili,
l<VI-2ia.
*^^^BiiMt. II. tiKtrtiL. r^li^ dt0 TtltN.■^<'Il^o«•l der meiuvhlirhm Placnila. MAnrhtaivr
Md. WiicbnHcbr.. 1001. Ii. 167G-tR7<>.
**^^^Woc«. I'vlfFT Clinn« jnavklaruni. D. L, Kr^nijpJ«^r|i, 1808.
'^^tBusDca. tVfiiT winJi-riioJte Scbwaiigcnrhall IwH Unealer LculcAmie. Archlv f.
(lyn.. 1809. Ivii, 26-35,
^^l-R. LtFtipf dcr E3nltiMi dor Cbokn auf Ui-nitnutiou, Schwanfcen<r4i»/l, nalMirt u.
I irMiHnbrtt. ZcntnJbL t. Gyn., im4. sviii, lim
«*^-
1)06
OBSTETRItS
Spbick. Zur Kasui^Kk dm {ibMinUivii Vitagaav* <ks- lyptMUbtcIUni to*
Mutlvr uu( cliu Fnitbt. D. I,, Btvaluu, I8tt7.
gPSRUxu. Zur Kiwui«tik dor (Embolic der Lugcnarlcric wlibmid der SchwMi^iuiliB ■ C^
etc. ZuiUKbr. I. <it»b. u. Ojiu, JB83. xxvii, 438-455.
SnUMXt. and Stakton. The Hi^rt and CimH&tian in TrRKiutiKy awl iho PiwvpMri
I'niv, of fvun^lvniiiu M«I. Hull., IWM. xvii. 202.
.STRAitM ct {^lAMHSRUCVT. (JbTnpt«# rvnduii ilc 1:1 hoc. de biolotdr. lltK2, itnvrRihn? X
ft (lececiibiv 16.
Tatx. PrcKnnncy Awvx'i.itr'l irith Dinhrliw. Am. Jour. Dbar.. ItKMt. liiJ, IU-(3.
Thouaa. Ti-tuiiy in FivKiiaiK-.v. Ji>Iiiik Hupkiim Hatip. Hull., IHM, vi. 8.>.
TiutONi ct C'antam. itcebt-Trhcii siir tc chnll^nk iuia(i()iic. Zicglcr'* BcilMgc tar pa. *: H.
AiiAt. u. (ur»lli^ Pitlh.. 1HK8. iii. is»-:^.
Vxrr. l.'cbcrdid Glyrmniriu der Scbwuiigt-rcn. Miinciioncr mod. WixrliciiHhr., IttCtA, a,
1'1»7'I438.
VrNAV. Malttdica VKlvulnirm ct grmgEaaE. Archivm de Tocolopc, lSt3. SOS.
Vnccinis i-t VHriol« au count d(< Lu KnuwMwiF. l.)'oi< MM.. 11*00. inArH 'J5.
ViNAV et CAbK. I^ pyao-»i5phrilc BMviclMiue. L'lJbHi«ri.|UP, I99fl. iv. iaa~2S&.
ViTANX.*. Siilln trannniMmbiliU dell' jn/cxioiio ccJnrirai delU. tnadn: ai f«to. Kifomu
luedicA. 1890. Noa. 4Haiid 49.
VuN Dc\ Vki.ukn. Ictcfui fcmvidnrum. ncitrngc mr (rt^b. ti. Gyii.. IJJO-l. viii. -Ha^-*!!)
Wkkdt. itoltngt (ur l^hn void Icl«riuip«viMi&derSpb«tmBer8i.'Wl. Archivf. C*yii.
l8nB.lvi. I04-12S.
Wbittikld. Puerperal Nwuitia dua lo Vomliin^ of Pngauiey. I«nc«t. 1B8S, i.
a27-a3g.
WtLUAUs. Thu Iiidticlion of Immature Labor tor Otbtt than the Unul Tndiea^t.iai<
Maryliuid Mini. Jour. 1BB8. xxiv.
WoLrr, Uebcr Vcrerbiinjt von Infoi-iionskrankhciti-ji. Virrfaow'n Archiv, cdi. 17;
^WBirxL. I'plwr plolElicIre Todeafnllf \-<iii Scliu-ariKvnrn U. Wophneriimeo. 2iPn,t.nM
f. Ciyii., 1IW7, xxj, 1-lfi.
KtinnlliclKT Aliortiu Iwi Oiorvs gmviduum. ZcmtralU. (. Ofn., IflOl.xxv', I 171
OHAITKR XXVt
THE TOX.eMl.lS OP PHEGNANCY
the preceding chapter we comid©r««l the effect npon pregnancy of
<liM«MW vrliidi exUlcd bofuit- ibt iiun;|>tion, ilk well fn of otherB
taay »ccur aa accidental complicatianH during Ms course. Wo «ltall
[ileal with ecrluii) di«turbaoc(s which nwult dirvc-tljr from tli« prog-
;eon<Iition itAolf. aai] are not due to extraneous cauwit.
rnrtunatdy, in tlic vast majorit}' of cases pnttation puntnee a pcp-
^ pliyKtologtcal cotifMC and i« nol altcndiHl bj untoward cymptoins. At
fm» lime, iIm'tc ii> no oth«T condition in which the border-line belwoitn
li and iliwasG ix \ixs sharply markod, Ginoc a very slight irregularity
I«nl5cc« tu convert a physiological and normal into a pathologieal and
mat state.
he gcn«*nl inetalioli«m become* profoundly modified during gesta-
■3 b showB hy the fact Utat during tU later montlis tl)i> pregnant
m iAojv» up nitro^n and water li> a far grt-ater eiitr-iit than at (itlior
, M) Ihnt it would appear tliut her intenial " hoiL'«ke<epin^ " u oon-
i) upon much more t^cononiical lines tlian fonnerly. Murcovcr, it \*
ble that the excretort' functioni* are more liable to mn-iouii derango-
, •ioce tlH->- lire called upon to care for the eliminalioa of the wa^le
ictH of the fietal ai^ well at= the maternal organism. For thi* n-anon
vomcR. who are j)erfe«rily well at other time^, may suffer from the
inn of eiTtain metabolic pntductt.
nTncrly it wbm bc4ierod that the releution u( Huch KulNftanoc" gav«
B abaormalitiesi in tho function of the liver and kidney.-', and Icil to
rodoctioo of the condition which we no* doiignale m pre-eclamplic
lia. or even eclampsia. Following the #ta(ement of Boucluird that
ejjTTiant women lulTor to a greater or leaser extent from auto-intoxiea-
twrtain French obsen-er*. notably Pinard and Bouffe de Saint-Ulaise,
IciTd the KUppoeition that practically all of the abnonual manifeata-
■>f pregnancy rent upon such a ba^Js. and that mich mild conditions
f^t headache. satiTatiao, or certain skin eniption^, on the one hand,
h a iprious iliAea>^ an eclampsia on the other, reprtiMot, respectircly,
and the advaneeil >IageK of one and tlie «ame prooeH, which they
if as brpato-toxiemia. Veil, in Germany, advanced a somewhat
view, but IwM that all of the disturbances of pregnaney. fmin
ahonnnfllitiefi in pigmentation to eclampsia, nwult from eytolvtic
following the vntranoe of chorionic tiasoe and ftttal ectoderm
007
^b
50S
OBSTETRICS
>l '^3
into tlic mtittfrnal circulation. Moreover, Stone, Strausti, Ewing,
others in this country teacii that albuimDuria. vomitini; of pregnaih.
yellow ulrophv i)f tln' livvr. ami ccliimpsiu art- uU maiiift'^'ttilionit of 'T"
lurbod iiH*lul"ili--'iii, and .OiouUi be groupetl togethLT under the coeuir
heading of toXKinia of pregnancy.
Ah the result of my iiivuNti^liou» and thofC of my «K<iittant».
conviticiHJ tliai siidi view* are erroneous and only render more dif _
the appreeialion of the several conditione concerning which our knt»-
cdgtf is still very frnffmenuiry and um-crtalii. Chemical analy.iis of
urine, aa irell a& the hUtolo^icai fltudy of tissues obtained at auta
clearly indieatos that <^t>«!ntial and oharactcrifitic dilTorCDCCit i^xist bcti
Ihc variou* niri(}iti"ns Ihu* groupeii tojtether; and I believe that
ftroliabiiity of the eventual rerogiiition of their caueativc factors wil
greatly incrcnwd hy conniderin^^ tlu-ni iteparately, and at Uie Hame
candidly admitting that we are just beginning to realize our profc
ignorance of the suhjcct,
Moniiier. it should be borne in mind that totally differrat patltoloj
conditions may bo accompanied by identical clinical manifcstattoD
that a proper chiHinralion cannot be baniHl upon the occurrence of
fivniploins a9 allmniinuria. fever, coma, or convulsions, but must dc
iifion our al)ility to isolate certain 'pi-cific pnisdtiini.s principh^, orj
demonstrate distinctive pathologiLnl lesions. Unfortunately, tlie for
as yet out of the question, but thi; latter has already been iccompltJ
along oerlnin lines. We shall therefore consider the following groupi|
"toxa'uiia of prcj;naney."
Femidous Vomiting: of Pregnancy. — Wo have already referred In tTi
ordinary type of nati^i-a am) vomiting, which h noted in the cttrly wcdu
of gestation. This occurs in one third to one half of all pregnant woiomi,
uenalty nppcjiring at abont ilu- sixth week, and disappearing siMinl»nrou:iij
six or eight wo<'ks later. Under such circumstances the patient suSen
from naui^ea, or even vomits shortly after arising, whence I)h^ term " moi»
ing sickness." In other oases the vomiting occurs ai more freipicnt inter
vals, and occasionally lasts for a longer period, while exceptionally i
Mtiitinuc.t throughout the entin> pregnancy.
Ordinarily, however, such vomiting is attended by no more senot
suits Ihan the actual discomforl connected witli it. and many women
sider it so natural an accomjraniment of pregnancy that they do not oomplsil
of il. Others, liowcver. soon demand relief from the physician, and niarko
improvement frei|uently fidlows the adoption of more hygii-nie nirthods o
living, the regulation of the diet, the relief of const ijvat ion, and the ingeg
lion of small i]uantiiics of fo'xl In-fon! nristng. In other cases medicinil
treatment is indicated, and the fact that no single dmg is uniform!
succi'ssful deiiionsl rail's that a specific cure has not ret been discovenK
In some in-itanees the first remedy administered is followed by iramediat
relief, while in other cases various drugs may be employed tu eacce»«io
without result. Relief often follows Ibe administration before meals of
capsule consisting of 2 grains of pepsin and J grain nitrate of silver. On
laic of cerium in S-grain capsules, or as the olIer\-escing prepam
■n CM
VOMITING OF PREGNANCY
309
« of iodine, dilute hydrocyanic octd, cocaine, or bismuth are also
fwoinmriiilvd, aiuil ocnviqiLully givi^ eicfllcnt rvnulU.
Oncwiniuilly Ute vridiiting Iteeniix^ more fmiutint and wvero, !m> that
ba exlnnne cefies the jiatieDl i^ unalile to retain uutriinent of any kind.
Tlit> t'ondilion i<; then di.-»i<;naU>d as prrnvious vomiling, and. accurtling
to Pick and Lwow, wcim alHiut onci^ in l.'ioo oastw of jinifiiAncy ; hut aa
iilatisttcs are bas«l upon hwpital work (hey give no clue as to its
fecidcntw in private practice, in which 1 believe it probably occurs onoe
tn several hundred ca-v-i. Il wnidd aiso appear to l>e more fr«5qu«ni ainon;;
the niTurotiL- wompn of France.- and thb country than in England or Ger-
,nuiiiy, Tnlike the nimple morning Kickncxs, pcmiciouR vomiting h an
Pxtrt'iitely wrtous condition, and frequently Icada to a fatal issne, no matter
'Iww (n-atiil.
JClioiogif. — fntil comparatively recently oar knowIedg« coneeming ita
■etiology wn» i'Xlr\.-rnHy di-ferlive, aiid cvi-n yi-t our infonnution i» not
''ntirHy Mjisfactory. In my monograph ujion the snhjcct in lJti)(J,*l idated
[tfaat the evidt.'ncc at prt^M'nt available ju«(iBe« the ditTcn^nliation of three
■■M lit wrtoiu Toniiting of pregnancy; namely, reAex, neurotic, and
'xamiie.
Till- reflet variety, a>^ it* name implii-*, rc*utl» from Ihc prt*eiww of
'^'H'lrBialities in oilier portions of the body, and particularly in the gen-
^■^tJvo tract. T)tu». it »ometime« happ<>nit that it is awociatcd with retro-
"*«k>n riT the olerus or an ovarian lumimr, and immi-diatn relief follows
"** neplaoemenl of the uterus or the removal of the tumour.
Attcmlifm »»« fint diniHt-d to llui niitrotic variety by Kultenl>ach, wlio
***t**d in ]8!)l that the vomiting of pregnancy i^i usiuilly a manifetXation
**' • neurosis, M>mv«*lial allied to hysteria, and is rendily amenable to su;?-
P^*t\\f in-almHit. Diniiiil oliocnatiou ntlrtrd.* abumlnnt eiideiio?' in favour
^* "Uch a view, as il ia well known that many women, who are apparently
^P^H the v«.Tgc of d<!ath from i^turvation an \\\« ntwult of vomiting, nnddenly
*"^^m* IwltiU" aponunemialy following a threat to induce aliorlion, Mi>«>-
^^^- prompt cure fnxjumtly fn1tow« Or- cmptoyment of most varied and
V* iillc mi*lb<Hli> of irealnient, xuch oa the uoe of an electrical bstlery.
K -- ivaa laliT found to ba entirely out of order, or the applii^tion of
^F^^tnut mi'ilicauii'nl^ to the c«;r\ix or Hk- u«( of leeches, lIoreoviT. it
f*y 'k> a-v4tJiii"l that the cures following dilatation of the cervix, as reeom-
■•''"•Ii-il l,y (-V-jN-mun, should be n^ardi.fl merely as duo to fiuggeslion.
H^ In ihtt tiitaMiitn variety, on the oilutr liand, tlte condition {*, a»mctaled
^f*'^ a profound diflurbanee of metaboltRm, which la manifested by ehar-
K*|^<^i»tic eliiinpii in 11m> urine and the prescfico of delinric lesions in the
"**^ and kidney*. It was tir^it ikhown in my clinic that tlie urine in such
cR>«> pTEsenu a high ammonia c«>etlicient, indicating that a much grealer
H T'^l*>rtioa of tite l"tid nilrogen i* excnrted in the form of ammonia than
H '"^^l. Xnnnalty, in the liMt half of pregnancy the ammonia coeHicient
I T"*** lielween 4 and & per cent, hut in toxiemic vomiling it may rii« aa
%b»B 10. 20. 30. Mf ev.-o 4'> per cent, and in one of my cases reached 48
^ fCnnt )ntl liefore denth (Figo. ■I4«i and 447).
H Uitlbews Dai>can iti 1879 pointed out thai tlw condition was sonie-
510
OBSTETRICS
limt* aMOciati-d willi mTiouM iur{mtic diforiWe, but ihJs was not geocralljr
reco^niat'ii until the work of 8loiu>. Ku'ing, unil niysiilf tthowini that io
many a{ the fatal casea Icaioiu were preient in the liver, identical with
those occurring in acut* yellow atrophy. In such cases there is a profound
necrotiiH of the wntrnl portion of the !oliiili>*, whili; the [M>riphcry n*iii«ini j
inUct, Aiul in <>«<• of my i-ases itie (ioi^truoiion of tissue was so j^ieat liut,
practically nine Icuths of the entire liver was thrown out of function {Fig.
PLC.
L.C,
\ RS.
:m:^r---:':-
?Sr
N-
?.-■, w.,.^-,.
,-■-.■ ■■?>>
^-<
PS.
Fill, 444.^I.iv);ii rwiM Cadb or Viixinxu ur PnuiiiAXrr Snuvis-a Axtft*
P. L. C, iivM* cdIIii "howitiic (xtty dcttnuration: L. C, unchancrd tlwr cvlli; .V.,
IKlPTOBi*; F. S-, IHlTtol »(■«*.
444 ) . Tliese lesions are absolutely differeni from those observwi in ecU^'^P'
Kiu, in wbidi the pruci-.iit it O'svutislly Q!ie of Ihrombosie, and be^inv ^
the periportal spaces. Accordingly, if anatomical eriu-riu are of on» i*-
ill diffcreuliatinp morbid processes, it must be adnntlc<l that toui<^^*^
vomiting Hinl ivlpimp?ia arc ub*ohit<ly distinct diRtiscs, and have onir C- *"
points in coiiiiTion, namely, that tht^y both occur in pregiuint womm *
orv manifestations of disturbed metabolism.
jil
VOMITING OF PREGNANCY
511
H the nmul ctianf!i» atv ilcjfviwfailiTv in cluiractor, biuJ arc practtcally
^Bltmitwl Ii> lliv M-vnttorir piirrimix uf tin* kii]m-y]<. In tnaiiy instaiinv iha
^Btrf)it)n'liitTii of tliP 4-«uviiliitiil tiitdiliv i» iif>-niTic, ami llurir 1»mtiut ar<' filled J
Bwith dfbris. Such l«.iniis are atteent in the rare cases in which desth.^
^neenry in Ihe reflex or m'tiroliv rorivttcs o( vomilinj;, u» tli« pationb dift
^Bunply from tuarvation.
H It pIh>iiIi1 nnl bi* Iwlic^ctl that the Li^seiitial prnot-ss mnfiisU in th« hepatic
Hand rcDvl If^ionn, but nitlxT in an nmli-rlyinf; toxn-inic pnicisM In ivhich
HtiM7 are dup. TIm* exit-n^^ive <liirtru<'lion of liver tisene serves to account
Hfnr at [i-aot ii piirt of the uriuarv cluin)^^, n* it miy to iatertvTv u-itb the
^intermediary Biases in proleid iitelalmliviu that a eonsiderahie |im[)nrtion
of nitro)^'noti» mnUrial nmy fuil to W rouvc-rtcd into urm. and oonse-
tifi)ftitl> tie uxcreted sa auiiiionix along with other incompletely nictnliolixed
*Qb!^tsncee.
Sjftnptom*. — Ordinarily, jH-niiciAUS vomiting Iw^ins a* the »imp)«
nsiuea and Tomitini; of pre^nanfy, irhich gradually htMromcd so fre<|ueQtj
ami «!vrTe that niithing can he n-lain^-"! hy ill'.' ■■loniafli. I'nformnHt^^ly, '
Kthe nxTO M'verity of ihl^ :iyni]>t<iin givi.'s no clue Vj' to ih« vari4!ty with
Hvbkh one ha» to deal. In the reHex and neurotic types lltv vomiting may
^k»iitiau>f for wrt-kji, and lliv [Milifiit ^railiially l>(>(i>innt more nnil more enui*
Hriilnl, and eventuallr dies o{ Btan-ation if guitahlc trealiueol be oot insti-
In toxn'Ritc vomitin)^ niinilar >ymptom» may <-\ist for mhuo time, and
the tme condilino may not be r«'«>gni»ed until ihv )uilicot begins to romit
^ ooffpc-pniund-ltko maK-riul. whirh An: n-jwl* in large qiiuntitioit and wilh-
**ot appareui effort. At this titiie !-ympio«is iDd>i'ati\'e of to.vtemia appear,]
111*?- patii-nr Ux-'orning torpid or violfiilly cxcitw! and soon parses intOi
* ^KMidition of coma, which in iwca^ionally ao-ompaniod hv convuUioD^.
1^1 9*<Hnc tnirtanav *^lixht }aundi<v may develop, anil, towards tite terminal
'**i#f c- of ihi- dixeaitf, (he iirin<- lii-comrs ^n.-nllv diminiHlKx) in umonnl, and
' /lins alliDiiien. tasls. and large iiuanlilics of bli>o<l. t'ornierly it was
. - lit tlinl in Um' Uilt ^tagf-" of the diwH"' fover fR^qnt-nlly occurred,
^***1 vas owociated with a rapid and thready pul»e and pronounced albu-
"^■•itaria. This, bowwcr, ha* not b«n my experience, as fever was abeentj
^ •U of my fatal fa.'>«i. Xor doi-s iIh- puli^; alvra^i bw«nn^ riipi>l, as OD^
"T^^ny [taticntA dit-d Hith a pulne rale of 96, while aihuraen appeared in
'■ ■*" Urine only a f<^w hour* Wforc d<-ath.
Exceptionally the dii«a^ may lake a much more rapid vour*e, and the
**ieiit. aft^T a few duv" of ordinary vomiting, may hcgii^ to eject blood-
^UtM material and ikUHH into a luininolcnt or ronialOM) cfinililion and die
lin a few days, without emaciation. Id such caseo death is evidently
tMoIt qf an acute toxitmiu, and not of slarvution.
Itu^noiiw.— From wtiat luu buen said it is apparent tliat a correct
its is a malliT of supreme importance, ae the neurotic and rctlcx
>can b«- rrailily cuml. wlwrt^is in Ihc loxicmir vari(-ty AUirlion should
ivntnptjy iniluciil, in the hope of arrostinff the prooc^ l>efofi> the o^anicl
'■■n= have U-cyime w> pronounced as to lie iiM^ompatible with rocotery. ~
irdiugl;' when fiue luu to dt-al with a cnx: of p^rtitcioui Tomiting a
612
OBBTETRICB
tfaorongh physical examination should be made, and if any sertoue a
mality of the generative tract be detected, it should at once be con
on the assumption that one has to deal with reflex vomiting. On the
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Fio. 445. — ^Urisaht Chart, Neuhotic Vomitino.
In this and the fiiltowinR cliaria each squarp cor-
respomU to I gramme of nitrogpn and 1% of
amninnia. Total Nitrogen: Black. Ammonia:
Red.
— ' I—
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Fio. 446.— Urinaut Chart. To:
VoHiTisn, Recovehv Ajte
DucED Abortion.
Total Nitrogen; Black. Adu
Red.
hand, if no Icjiion can lie dotedod. Ihc diagnosis lies between the neu
and toxa^mic types; and, unfortunately, a positive diagnosis can be :
^^^^^^^^^ VOMITING OF PREGNANCY 613 1
Honly hy a careful chenitcal exaniinnlion at the tirino. ah it may readily ^|
B hH|i{M'n Itint two vomen may appear to be equal]}' sick, and irft odc will ^^H
~ W fluffermg from D«iirotic aod the oilier from toxtnnic Tomiting. ^^H
■ .. I 3 3 4 S 6 T e S 10 II 13 13 U IS ^^1
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Fed. 447.— t'aiKAKT (*juirr. Toxxuic Vourmo. ^^^H
To«al Niin«*a: Bbdi. Anunoiua: Rnl. ^^H
'inn' iinimrT 1<^1" an- of nn mlui* in ihi* coniwi'lioii, and even ^^^B
nation hy the Doreniui^ inelhod of a normal amount of urva H
rcniy- four- hour H|>ocim<-n ha» uo «tgiiifican<.-<;, ax an identical reao- H
vf'U hy llic animflnia. so that a urine may be considerHt as nonna) ^^H
ri?ality the p«.T<x*ntit^- of area u gnstly ralucvd and rvploccd l^y^^H
OUSTLTRICS
ammonia and ninHio acidii. Acconlingiv llie (Iwinxi inforniaiion tnn mily
\x oKtained by dftvrmining ihi; ainouui at tnul nttroKmi hv Kj«lclaUi'^
method, and the nmninnin bv thai o( Schluiwinf; or some uqnally satiiifar-
tory pRKdlun-, aud then il<>ii>rmininK tlH> ratio which tltv umimnt of nilr>-
giai nuiiained iu Ihv ammunia bvart lu lliv total nitrogen. Unfortunately
■nil Im
Flu. 448.— <:iuiiT SiioH-iNH AuuoKiA Corrricicvr is Two Cojiwa-TTTive Pkcdkami:
A, toxiFiliH. Blul It. nputoti« TollUtillB
such inwitigaliona ratmot !» carried out by the phj-^ician in his olliw.
rcfuiirc the wrvii-M of a traint^ cheiniBl, and involve a delay of forty-ei
hours (Fijrs. -Hri, -l-lfi, and 447).
If tht> Rtninonia cm'tTicivril Iw found to he Dorinal. tlic neurotic i-i^
■hould iKt di«>:iiitsiioatcd: whereas if it W incroaHwl. and partioularl >'^
it much exeeciis 10 per cent, a diaguotU of toxocniic vomiting should
unuK*.
I'rognoitU. — The pmjn>osia is extremely palisfa^^tory in the reflex ^*
iifiirolic varieties. In Ihi; f'mncr P'lii-f jmiinjiily follow* the cornvi -*
of ihir ftenital almormalily. while in the latter cure can usually be pffw*
within two or three d«r« by ^ogpfxtivo tn-uttm-nt. provided the phyoi'S-
is suHiciently sure of hiniMtlf and U able to imprean hit) Mivf upoa tf^
patient. On the other humt, the p^D<*tlo<^i« is alwuy>j grave in (he toa:^
variety, as w<; Imvo no mt-itn;^ of di-tcnnining lh« extent to winch tbr tui^
nal legions have progressed, and whether it is possible for them to lui'ler ^
repair, even if the iiiuierlying carnre of the toxemia l>o removed by prompts
t«'rniinating th« pn-gnaney. lii any cv<rnl, it iilmuld bo rmnemberwl ifc-
a certain proportion of i'a.tes will di« no motier what may \k d<>uv.
Pernicious vomitinj; sometimes recura, and many women *a(Ter rp|>i^
(.■dly fron» the neurotic rari«1y in succeeding pregnancies. Unfortunalf^
ACirrE YELLOW ATROPHY
3 may aleo occur in ihu luxwmic variety, tlumgh the mere recurr>.-1
voDutinj; in w iiiliMKiiHfnt prt-)^iin<-y does not necciiearily indicate ti
I bu l>i i\i.'m\ witli tliu HHiiii' type, a^ I hare seen two psti«ntii who sii
tti from touptnic roniiting in the 6r*t prej^innty, aimI from tlie iM-urnd
iity in the i4ci?ni>d ( Kig. 4tH|.
J'lratmi-nl. — Fiirmerly the treatment of pernicions vomiting was rerl
tttiiifactory. Thia ^fas in f-rcat pnrt tliiv tit l)u- fiict that in the neiirotil
■uty cuivs H>nK-lim(« (M:curnNl when llie patient wils almost in p^Jromifl
1 cntii^pteotly the ph\'fliciaii usually defcm-d iii'hicinj^ ahnrltoD in lliel
|»e that *ueh an ouktmie might iMxiir in his c»>e. (.'nnMt|uenlly, when]
wu dvt'-nnined ti> initTri.'rx>, th« pa<i«ut was usually m ill that df-iilh
It inevitable no matter what was dnnv. TIm recngnition, tK>wov«r, of the
rcnl trpe» ipf roniiling juKt (loMTilM-d affordti valuable information a:;
tbo tn-niment to be pursued, ami inilicat(^« that ahorttnn i« aomi-ttmw
rfnnnM uniM-crMarily in nctifotiv va>«ii, and frei|ueDtly deferred too long
tvaxic vumiljn^.
tlw rvtlvx variety, lite dii^plnotHl ut4)ni« vltould W repUcvd and Mtl
ili'iD t>y a propiTly Ihtin^ [H-^^ary, or the ovarian tumour iihotild \m
■ovtfd. a» the ca>« may Ik. In the ncumlic vari^-ly llic |>aliciit should
*ot In brd and kept from her fntiiily a^ far a^ poM.sihle. Site should Ite
ined iiy the pbyiiieian that her condition is not serious, and will not
lira active inlerfc-imcu. At the Minti titne i>1k Mliould rvcvive large
unt* i>f xaliiie solution hr the rectum, and for a day or ^n nn attempt
llal Ite made to adminiF^ter iu)uri;'huicnt liy mouth. After a fevr days'
twwfwr. fniull quantities of fluid »»uri>^hmcnl should bo admini^turod
•>«)ui^l inlt^nalii, and tlic patient ai«.->ured that her <y>ndition will pnMi
[i tJun a nlxirt time. Ordinarily, if tite physician is sure of biniAelf and
>H-)> ihf alr«ilule ifintidcftce of the [Mlirnt, ihr* ri'Mult will ii»ualiv fol-
bnt in exceptional instances more radical treatment ia ncce.viary, and
|*v)ln(v rn*t curu should he iiuistcd upon. In such casca the patient
he iMitaled from her family, and pliK'od in a well n^^ind tided hos-
lio the hands of a competent and trusted nurtie. I'Ddef Aueh condition*
fgimi ju>.t iiidii-iited will bring aUfut ihu entire disappcaraiwe of
|onu within a few days.
I the toiKtniti variety, oD the other hand, prompt inducti<Mi of ahor-
tbe tftratiuent />'ir eicellfnrr, aii<l '•hoiild he |MTform<-d as soon as
aosifi IS mude. If po^ihle. the use of aijft^lhe»ia should he avoided,
ii-mx dih>t»l hy a nii-riliwil lent. If. how*i-er, haste in iiii|)erative,
kthdic should be given, and tlu> uterui* emptied aftvr dilating tbo
mniD* of a Qondell or Ilc^r diUtator. though if it in very rigid
ln'-tcrofomy is the hcsi meih'Kl of pnxixiurc. KollnwinfT the ojicra-
Ipaiicnl s))ould be piven cipious saline rivtal twmuta. and for a
^e, at least, :h>; adminii^lralinn of food should l)C re]u;arded an a
sccomlary iiuiwirlance. CwHl relii-f ii> womeltmee oMainet] hy
|*a(re. and leaving 500 ciihie centimetre!* of a l-per-ciMit solution
irt»mnt'- m (lie ■.lnn)Jii"-h.
low Atrophy of the LiTer. — T\,\\t condition, wbicb hna been
;.'Qated t* icln-uB gravis, typhoid icterus, etc., is a rare but
516
OBSTETRICS
very wrimia oomplii^ntinn «f pregnanfv. K(>rkrin^ in 17<KI iraa Uic first
tu report a tatai ciu# Id a pregnuDt womnii. bill tinci.- th«D erery oisa wtio
has i-(m!iwl tint <iJw^w lias Initl ulrt^ apcn the iiMWK'iiitiou. Tims, Thii-r-
ffliltT ruiiuii iliai 62 jwr cen: of ihe H3 cawe whidi he coUecietl from ibo
lilfrature had wccum-d in pw^aiil w«m«ii, wliiU- Ijuincke placed Ibe ind-
dewv at GO per rent.
In uciilr vi-lldw nLro|>hy th« liver rapidly diiiiiDiuhea in weight, which
in n coiiiparatively tihori timv QDiy be rixhii-cd to ks6 than one half ot the
nonnal. It« (-ap«;di- rn'Miimm u vrrinkUiI apfiv-aninrt: and thv i-ntirt- urgun
I>iT(int<« M»ft<-nml. On secticHi it varies fnrim dark r«l to alino«t chranie
yellow in t^tlour. and upon dw^T vxsiiiintilbn t-ach lobule in seen to prewBl
a ycllowifh cuntiv imrnHiiuUsl by a rtildii-)i piTi|iln'ty.
The hintolo^cical dndinga vari' aocordinj: to lh« severity of Uie diaeeH-.
In mild ca«e« tlie centre of each lobule ha^ undrrgonc »i.*vroKi« and Itu-' ,
i'i<ll» of thi- ^u-riphcry prena'nl an alniotit normal appearance, while bctwtenr:^
ihc two y a thicker or thinoer layer of cells predating more or less li^^
vunccd fatly dogi'ucration. In other can?* aliiiwl the fniin; purendi;:
of eat^h lobule is destroyed and is convened into a granular mass ^s::,f
nwrolic drbriji, while about the periphery «nly an occasional well-prest-n" -m^d
liver cell i* N'cn ; at the .-atiie time the interlobular sjiact-s « illi Uwir bloo-J-
vc««elH and biliary ranali; are but lillle <:hflii^ct. The kidtiey^ pra^«nl ^i^i^ntt
of afiite ni.*phriUK and lli<- vpilhcHul cell* lining tlw convolutcil tubuln^ aarw
in all stajcet) of dejp'nerution, and in extieinc ca««s are entirely necro»t.ift
while the lutnins art- filled with ca^ls and d^brU. On the other band. t\\t
);]<iiti<Tuli ami ibe wiV lining tin- colkt-ling uibuW arc but litlk* ehanfcT*^-
Acute yellow atrophy of the liver may iieeur at any pevioil of p*"*^
iianey, Bcalty and Mati(M>i] tiaving dcwribcd caseir at the sixth and ei^^^'"
weeks respectively, UKiially. however, it Hp|M-urs during llie Intor tiioi»tVi--
of prepnuncy or in the first days of the pnerjierinm.
In ai-ulc I'W^eif the "vrnptom* may conur on *n iiuddenly a* to ■ro*''*
a suspicion of poiaoninR, and in »onie inBiancw the eoodilion has l»**^
iniKluken for phosphoni5 or sonic other form of poisoning. Thu« it a*"'J'
happen that a woman, who pn-vioiiiily wa.-« in appan'nily iMTfwt ht^iallh, T*'*-'^
he seized with pain-i in the alidomen. intense headache, and poisihiv m^*"*'''
vomiting ami purging. In a short time she becomes torpid or vinl"""'-
delirious and iwon pafiaeti into a condition of coma, vhiefa ma; or ma.y ""'
he dis'turlnil by convulsions. In mopt eases the eoma continues for a *•*
houi* or days iinli! ilealh fiipi-rt'encs. bui recovery may •K^iu'tonaily w?'^'"-
There is generally a eerfain amount of jaundice, which may vary fr"*" ^' '
mere diwcolouialion of the conjunelivie to pmnoiinced genvra] icteru*. ^^1^
vomited matter is frequently blood-stained, and sometimes a:ssuiiieft aroE^^"'
prouiid apprsirame. The urine in diminished in anioiml. very high-wJou^^'y'
and contains alliumen. ail varit^ties of oa.-ts, and frcnueuily large i]oai!ti^^'^
of blood.
The symptoms are identical whether the <-oudition occnni during pi-*^'
naney or the (lueriMTJum. antl. if convulsions apin-ar, it is naually misial^^f
for eclampsia. In other easies the coume of the di*ea»o is le-- ''
in its early stages may simulate an ordinnn,- pre-eelamptie tnxit-
NEPHKITIC T0X.CM1A 517
UMli<-G!. tiowcv4>f, soon appears, antl th^ pfttient Kradaally Iiecomw nion!
d more apathetic wxl torpid, and i-vtrniiinllj {MuutCM iotu a vondilion of
tna. vhivh uflually terminates in deAili. In this rla-''!' of caws th« diminu-
m in the Hi^e of the liver may l>e irat-ed hy percussion, and in one of my
tienb* tbi; urt-a of liepatic duh^'V'^ bix-unte iliniiu itched liy more llmii one
If iu (lie (-i>iir-«> »r a week. Sponiaui'oui^ birth of a dead child is not
usual.
Clii-inicHi t'^aminulKin of (In- iirim- show* rhangcn nnalogoiu with UkmB
vaiiy detieriiied in toxemic vomiiiiij; and Hinilar to thoAe observed in
Dte ptio»|)h(irus poisoning. The total iiitm|n*i) may or may not be
niuiolied, hut Itit partition always pre^ntii marked chants, the urea
inn always diminished and the nmnionia covHicient ^ri-stly vk-Tatwl.
i»rt«>v>-r, then! it- m niarkiil incniiM- in tbo auiido a^-itU, and orysiaU of
Di-iD and Iyro=in may be demonstrated bv appropriate pmcedun.-s, ■
It in t^'tdrnt titut, juct «]> in loxa-mii- voitiiting, the underlying factor
tlut priMluetion of ai^nte yellow atrophy of the lifer must be a profound
mis. i-onn-miuf: niio«M> origin we are as yet alieolutely ignorant. Like*
', ihv ohaiigtv in ilie liver and kidneys (inft lie regarded aei secondary to
and not as the primary manifestation of the diireaae.
Thr diagnnnii' cannot alwayc Ih' miule fn>m the clinJail manifeTXations,
I a already indi<-ated Ihe eondition U freijuently mistaken for eclampsia,
p^»ti|,'h till- iipp«-aran(i(.- of jaundic« tibnuld always l>e mgjn^tive. On th«
J liund. i\tt> pronouitceil ehangc^ in the urine sbmild IihkI Io a positive
giKMiie; but in (he abeence of a thorough cbemieal CKaminalion it is
iQlla only at autopsy. The prognoeie te alway* bud, the pomibility of
<*er^' depending upon tho extt^i of tite organic lesiun^; and an tliia
iitl !■■ dvlemiined during life, one t^Itould be most cautious in expr«8»-
a hop«' iif ns.-oiisy.
If tbe coodilion occurs during pregnane}', the uterus should h« emptied
fmfMy aa u con«iiitciit u-ith the oafety of the patient, and the various
r«tAry OT$n>n^ stimulated, as will lie der-orilied under n.rlum|>«ia. During
_ iinerpcrium the latter i<i (Ik* only treatment available.
Mephritio ToxKmia. — TtiU eoudition, om JIh name implies, 'a associated
primary lesions of the kidneys and is uaually noted In womfiS who
■ulTenng from chronic iH'phritiit prior to prcfpiancy or in whom an
'■» originaK-s diiHna iliai p*-rii«l, and should be rogardi-d a*
- with arsmic p>irouJng. Fortunatelj it U not of very frequent
rrvniif, ihotigli it should lir fmr»l in women HnfTering from chronic
nli* or in tlMue who preHeni a hiiior}' of urituirr dioturtianctv in pr^-
' pre^ancie^, as it ts my eiiierienee tliat the ordinary pre-eclantptic
fnia i" not very i)ronc to nxiirrenoc.
Fhe eoodition may appear at any period of pregnancy, and may OOQ-
for a connderablp length of time. It le usually aecompuni«d b;
tttdft, geoenU malaise, heailache. and marked <rdcntu. and ociiKionally
Wular symptoms associated with albuminuric retinitis. In other cases,
rw-r. th« paUenl may complain of little except aHlema. and with the
in of the urinary cliange*, which will l»e divcrihetl Ih'Iow, may appear
tly nick, yet ncvertlielew tht may suddenly pass into a condition of
3.-.
818
OBSTETRICS
coma which maj/ k' uccompunivd bv convulKioiu, und fitlher He or slowl;
recover. 1b the more chrouic fonn? of chis vari«tf of toxneuiia bolh
and white infarcts are fn!(|i)ctiily iioti^tt in the plsccnlu. and occaeionsU;
(>C«iip}' Ml grt-iil {lart of il «'• to intorrort! nhiio-it (niiiipk-tuU with its (u
ti<wi ; BH a rwiilt ihe child, whose vitality is already seriously imjNiirGtl by t
loxoemia. i>i impf-Tfct-tly nouri^lu-d und frc<]iK-ntIy dii.*8 in ihv lutu-r intintl
of pref;iijincy. Indeed it may Ik Raid that, with the exception of STphiii
chronic nephritis U lh<r most common cauoo of spontanwiis pnimature
iaiioiir.
In many inctanceii it is impossible to difTereniiate this form of toxxmii
from llic ordinary prtM-cloniptic vorii-ty. nlllioiiph iht- urinary finding aru
sometimes strikin;;ly different. In the former the urine may lie normal or
even incresMiJ in (tnunlity. allhoufxh it ctmtninK larjn' amnunU of album
and voflii. On ohvnitcAl exnminaiion the amount of total nilro^ra a*
aa the proportion of urea in UFualiy normal, while the ammotiia coeflidi
is nol incrcawil or cvin may full k'tow iho ukhrI limits. Tlie latU-r coi
dilioR should idways be regarded with suspicion, as it freiiuenliy indica
that a ura>inic attack is itupcndin;;. If the patiisnt i» not won until t!
i»t«et of convuliiiimK and coma, (he condition in usually miiitaken fur eiclam;
sia, and Id many inntancve a positive diagnoeie cannot be made witfao]
an MtilfipKv.
Pro^itlMl convulsions and coma do not appear, the pn>>^(uiii in t
variety of lo^a-inia ii? gixnl m> far aif (Iio iinuHiliatc life of (he mother
iM>noerniil, Iml in view of the frei|ueiicy of placental legion.-! the poMiibilJ
of the premature liirth of a dead child i^hould alware he eonsideretl. Ni
rally the ultiinat>' ]ny'f:riiKi« it t>«d, w Ihir ^Iruiii of pn-giiancy iii^ually aoci
tualt^ Ihe original nephrJiio pn)cea«. The Ireainient is identical with il
which will be laid down for pne-eclamplie toneuiia. while if convulsions or
(■(iiiiH (UTur tl in nion;; ihc *uiin' ^'ttnoral linu* for eclampsia.
Pre-eclamptic Toxsmia. — This i-? the mobt frequent variety of lax»
of proguatiey. and fur miiny yi.-nr* wks cii-i'h-n-il a» lis wic rcpresentaii
It occurs several linics in i-veiy one liuntlrcd prejjnancien, and i* more (
(juent jn primigravidie than in women who have borne aererol child
Fortunalcly it ]•< usually readily amenable In treatment, thoufih if neg]
and oecttHionalty even nolwitiislaudiiig the most rational treatmioit, it
temiinuiv in (vliiiup«iii.
J're-eelanipiie toxa'tiiia usually appears in the hitfi;r pari uf the fvcoi
half of prt-ffnancy. and oei-nrs but rarely in its early months. It sliould
susfx-eletl whenever the patient eoniplaiUA of headache, laiuilnde, or (lyJenia-'
aud particularly if the iiriuL- is diminished in amount or coniaioii albumi'ii
The :<^ymplomM vary fnun >li]H;ht ntalaioo to lh»:>e indicative of profoua»,^
auto- intoxication. In thi» event the patient may complain of Mven- an
pereielont headache, violent cpi^«tric pain, or rieual di^turhancea wbii
may vary fmru slightly impain-d vision lo complete amaurosis. In *ui
cases the ophthalinosw'ope may reveal tlie chnra<-teri>'tic ]c*ion* of albumin
ric retinitis : but in other instance?- they are absent, when the derao^i
of Tinion must be attributed to dc^iieraiive ehangv» in the hifiher nerto^w*'
cenlret. I^ow and again the patient may suSer from hatlutiuatioitt, to*^
oua»,^
an.^^
rbi^l
PRE-EKL-UIPTIC TOX.KMIA
Initlrr ou ihe ferg6 of infinity. In rare inslaiici'^ Ui« uooiuii may poM
into a soaiQolent conditiou. which griHluulIy dvi'pcDs into coma, usually
followed by (k-uih; whiU- in oilivr ww* tygtirjd ii-tainpaiu iimy .iiiiM-rvfin'.
Wben till- ri>\;ciiiii» in iimnounwd. the child, a^ vol! an Uie moliwr, may
suffer, and not a fevr c»ses Ivnninalu iu the spoil ttuiixiu« expulsion of a
dcsd pmnaturv ficliLS.
Tlie total fliiiouRt of uriite may be (greatly diminiBhed. and sometimes
faiU as low a« sum lo 3*^0 cubic c«fitimi*trii* in the (vri-tity-foiir hour*. It
ttouBlly coniuiii* u varialilr <|uamily of albumen and numerous ciistti. ('Iiem>
ical exsrainatioQ gives Tarying roaull*. according to the gravity of thu
lAxstnia. In mild ca>«« tbe amoiint of total nitro^n and the rotattre pro-
pnlioa of iis. Tarings const itu^itu is but little changed, but in more pro-
aiium-"] oaj*^ lhcr« is a cnnsidi-niblc 'tiniintition in tli« total nitrogen, with
irhit^ti in aiiMK;iattH] a dt-creajo in the perit>nlH)j;e of area and a iili]jht increaao
in the amount of ammonia and the ainido acids.
TIm^ i-bwnical dilTcrfnliuiioii hi-iuivn the tU'plirilic and pnMwlampttc
*yf»es of tuiifmia in not aUays easy, and, in the abwenee of a definite hii*lnry
■»/" prc-f-xinling ncphrittK, in MimvItiiKV impowiblci In tlw- former tlw uriiio
TTM^j be nornial or even fninewhat iocreatied in nmotiul, and ii loaded with
JKj(-»*imen, whUe the total nitrogen and ure« show little if any change. In
tlx^?- UiUT, on the other liand, the urinarr oiitpiil i.i usually con.iiilerably
<ii M-m-iitiii-lv^, and (he total nitro<^n and urea greatly deereaficd in amount,
^rm^zM whde allnimen ii* niwrly alwayn prcwnt, it it nxually Ices abundant
tl-K^m-.Mi in the nephritic type. The«e differenees, however, are not constant,
^■» « • frw)nenlly a poniiitc diagnosis U only possible at autopsy. Fortunately
"*"=^ diffiriitiy in diagno^lieaiing )K-twf«u llic two processes bt of more impof-
froiii a scientific than from a prai^iml point of view, as th^ trest-
lo he employed is identical in both cases.
Tlie projrnostB in prtMs'lamptic tuxu-mia i* unually fair, but it ia en-
i^It iliqM-ndcnt upon the amenability of the symptoms to treatment. If
' ^"twi inipfiveim-nt din's no| oeiiir, pn-tiialun- laliotir «hnuld be induced
*^be hope of preventing the onset of eclampsia, in sovere cJLMut the
-*~^]gvnous constituents of the nrioe assume their normal relations within
*v days after spontaneous or induced labour, while the album inoiiD con>
may persist for irvvk* lH-f»rv gradually disappearing. Cbronir i-enal
J j" '"^^'■^wm* rarely renuli* fmm thi* typo of loxaimia. and it is my experience
"**■ * It b unusual for it to recur in sur«eeding prtj^nancies. Thi*. of couri«,
*<at a unirt'niai rule, but it wnnid appear tlist one attack confers a relative
^^ ■*»anilT npon the palient. just a* in eolampsia. Acconlingly. when a
,» ****nn "ulTiT* from tiixa-mia in n*p(Uit"'<l pri-gnancies it may Ix- inferred
J~^* it is of the nephritic type and is dependent upon the otintenoe of a
""^^nic ncphntis.
VrM/mrmf.— In the eliapter u)mn Tho Managemtqit of Pn-^nancy,
^*^«ili(.n wa>. dirt'clcd to the nwewsity for the frcfjuent and routine cxami-
^**-"io of Ihc nrine for the purpost- of mogni-ing this condition, and of
^'^^'•nling Ihf development of eclanifKia by nuitahlc treatment. Even in
'^''•Taal ca«efi thene eiaminatiorn* should be made once in four woelca dnr-
^ the fint six inontlts. and every two weckit during the la.'it three months
520
OBSTETRICS
of pregnancy. The patk-nt »]iould uIm> bo <»ulin»«(l to notify the phyxi-
cion whntcviT «he ^uflnni from butdaohe, disturbance of vision, or cetlema.
]{ the presjent* of albumen l*, delected, or the phvriieian does not feel wiH
isftcd with the condition of the patient, the entire amount of urine pa^c
in lh« twwUY-f"vir hour* ulioiild Ikj mos^unxl, and tti
oiitpui (if albumen, att uel) as th« total amount of niir
p-n delermiufd and it« partition studied, rnfortunatelj
thi« i« prai'1 im)il<- only uhire th« wrticM nf traine
chemists are arnilahle, but in general practice approif
niatc result* mtiy he ohtstiied by thcr vse of Eebach'4
alhiiminonieter and Ilorenius's nreoineter, and a* tin
urine coutuitis hut i^innll umonnts of ammonia, such est
maliomi arf tur more ri-hable than in toxAinic voniilit
and acute yellow atrophy of the liver. For praeitcal piir
p»»c^ the amount nf totnl nitrogen may bv approximate
by dividinjc the urea reading by two.
E^bach's alhuiuitiometer is n graduat<^ lc#t-taV I>n>-
vidiKl wiih a stopjier (Fig. iW).
The reaction oonsisT* in the precipi-
tation of the albiiininnti* )iultf1ancc«
by a solution consisting of picric
«cid 10, citric acid W, and distilled
water 1,000 ;;rnnin!e>i. In order to
ci^timate the annmnt of allmmeu. the
tube is filUn) to thv mark U with
urine and afterward to R with the
reaifeiit. It is then corkwl ntid gejit-
ly inverted ten or twelve time-i. after
which it is allowed to stand for
iwiMilT-four hoiirH, when tht^ amount
of precipitate is read off on the scale, each
division I'tirrMponding to I grainmt: nf allni-
men to the litre, or one tenth of one per
t«nt.
Doremus's ureonieter. which is repre-
siiiti-tl in Fig. ■J.'iO. eimlilo' one tn wlimnte
indirectly tlie amount of urea after decom-
posing it by mentis of tH>dintn hypobroniite,
the reaction iieing aliown by the folliiwlng
fomiulo :
COX,H, + .1XaORr =
3NaBr -f CO, 4- gH^O + X,
The- potaMJum bromide and cnrbon dioxide
are dissolved, while ihe nitrogen gas rises to
the lopof the tube, where ii can lie measured.
In employing this apparatus, the large branch is filled with a 40.p'
cent solution of caustic «>du. lo which is adderl I cubic cntimetre of br
mine, the two together forming a fresh solution of sodiutti hr|)olHQi&tt
rio.44'J, Lsbach'b
Fn». 4Aa— DonCNV*^
^^^^^^F PRE-ECLAUPnC TOX£MlA 521
^fler tittt mixture h«H itettletl, Ihe nharter branch is tWeA wilh urin«, and
1^ ninnD); the slop-cock 1 cubic centimetre of it is allowed to enter tlie
loniner branch. Its admi^^ion is foI)owe<l br an active formation of gui^,
vhich ilrircM part of the Html out of iIh- ttibi; into llic ntljoiiiinjf bulb. ^Vhen
H» procen ia completci], iIk amount of nitrogen formed 1^ rend off from
Dctsm&er J^nijary
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FlO. 451. lilllSAltr trHAKT.
Vn nrti Willi ir uommik; r«oov*ty ■uidft' milk iliPl ami r««l in bed.
iciIb, v»A division imiicjtting tltc presence of O.QOI jtramniit of urea
^Mi!h cubic centimetre of urine. Vtom this the tola) amount in tho
cimo) iH n-ailily tnlculati-tl.
Ordinarily, if the urea output U normal {20 to 24 fmnime't per diem),
~ - '' n slight amount of alhnmtii may br repardcd with iiidiffcr-
^' -. if a ('oujiidfmbli.' (juantily i-- pn-^wil and tli"* ui*ii at the
^^^> tune falU below Ifi or \'i fEnmmt-s 'Im> jMitieRl choiUd he regarded
H_bi Berione danger and xbould he kept under clo^e gnpervifion. Touring
W^ liniv tile t we utv 'four-hour KpvcimcD of urim- should be examined dail}'»
1
522
OBSTETRICS
and the Inuitnvnt botwd upon the rvlatiTC amounts of albumen and
pn.'M'iit, a» well »» upon die ttubJM-tivo syiuplomK. (iJer Via. -tSl.) Tbi
Kiiililcn n)ipearA])(« of ainatirusio, mii] mon- piirticiiliirly of pain in thi
ppi^'actrium, ohmild alwavs tie rej^'snlii) wiih .iiiApiciou, iw it if freipn^ntlj
the precursor of eciampHJa. If the total Ditroj^u anil its partition be deter
iiiiniil, A rii^e in tbi^ ummoiiia liK'fTidcnl should be cnii« idcn.il u* fuvoumbk
while a decrease belov the normal limits usually indicates that trouble maj
be fxpt-cted. M
T)»! piitii-nl Mlintild Iw pal to Ixnl, or «1 lojiat ooulinod to her room tfl
pla<-cd upoD a rewtricled diet, meat'^ and liie stronger vcgBtables beinj
intordiiTtA-ii ; or. better »till. for u while fiw ^iboiild di-jH-nd wliOy upon milk;,
which is not only an excelleni food, but alio a mo«*t etTicient diuretic At
UmkI two qimrU should be cdiifiuucfl in the twenty-four hours. To n?licw
the nioiiotonv, ^hf luay be allowM Nniall qunntitiw of lottuci> faliid. itTVtd
and butter, and occasionally a little berrinf; roc as a rel)»li. She atbould
a\ho lie Hindi' to take lur^* (;u«ntitie» of fluid in the lOiape of pliin
water, Buffalo lithia water, or creani of tartar lemonade (I dram lo tin
pint).
In moft ca»C!< tlti:t treatmtmt will b« followed by a niarktsl nnHdmrat
j6f (he symptoms, an increased urinary swretion. a docrcaw) in (ho amo
of allnimoii. II rim.' in tin- auioimt of urc^, and a prompt n^tum to iwi
conditions (Fig. -4511. If the desired ri'siilt is not accomplished, 8 b
pttrge of Rwbelle or Epsom siilt* sbmilil Iht givwi daily, and the cutan
functions stimulated by a daily hot [itiek or swwat bath. If under ti
nient the symptoms disappear, the albumen becomes less and the urt^^
«rv]i.''iil ill iimounl. the outlunk may Ik? eonsiileriil excijllcnl. On the r»
hand, if the albuuien steadily increases, and the urea decreases in amf»i
while the siibjectiTc condition of tho patient reinuimi unehanged, tlic p/
nosis bei'onies ominous, and the appearance of i^aiiinoleiioo and roRia
I'clainpsia can probably Ir* avoided only by the induction of preinsti
labour, no matli-r what Im* tin* ptTi'Hl «f pn-^iuiney. If baste if 1
essential, ibis is easiest effected by tlie intr<xluction of a Ixiu^ii;, but
the imlienliiin.-' are uip-nt accouchevtent forx* in indicated, and may
effected by Harris's method or the iutroduclion of a t'hamp^tier de Ribf
balloon. If the ivrvix i» ko rigid ihnt neithiT of tb«v proced tires is appU
ble. vaginal CiEsareaa .section alTorda a moiit aatisfactory maans of rapid
delivery.
Unfortunately, we are not yet am]i]ainicd with t^ie ac^tual toxic ogimtfl
agents concerned in The production of this variety of toxemia or of erlan^
MH, and eoiiwi[ui'ntly the indiaiiiim.* utT>iriln(l by the mains at prMent
available for studying the urine are only relative. Thus, it sometimt^ bap'
pens that the urinary findin;;a and clinical symptoms so improve u
treatment that one >s inclined to feel that all danger has passed, nevi
less eclampsia suddenly *iipcrv.iic>i. On the other hand, om* iKvasiona'
fools thai the imlueiion of lalwuir is inipi'ratively demanded, but nfb-r
fcrrinf; it for somi? rea^n. the patient may unexpcL-todly make a miMt
isfactorj' recovery wiihoui an untoward manifcHlation. .Snth «.xp«n<
indicate that our knowledge of the subject is far from complete; but
undg
verffl
ionaiT)
^^V PRE-ECLAUPTIC TUX^MIA 52? 1
K pfVKent bII that i» poi§iiiblc is to follow the dinxtioiu just giv«ti, aui] to iutvr- ^M
^M hn wbciKvvr the uriuary lindingH and clinical ejntptom* inilw*!*; that the ^M
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<n)«ttiro labour H
T haiKi. many H
auil ■ _- - ; -vlampsiu, as tlie pniiiipt
pri'M ' - - - -— A-lainptii' toxiviuiu (.misti—
smlil' _ ::> drt'ndiHi (lisonst-.
i?[ii;;;i "ji #ucli propliyluxiti is al)so —
till- ]■ -- i:i'licat(W in;;;lccl on th>.' jiartr
iiiiin " :iw case, Imt the rule is mi t
tt'lii'. -.■^ ii I liave RH-n (.Tlmnpiiia oivu -^
lie . . .- There the urine liaii been exmik^,
,- - ■■ rred onlv a few dayrt Ix'l'ore tl»
pbi.
int. . ■ i*niia ooi'iirriiiff in the iirej;iiiuL
v]- ' ;-;ially cliurupleriziii In- cli.nie ai~-
It'n - > Irtss of O'>ns<'ioiisnes.s fnllowcii
til' - "i-tion is not, however, ulricllv finn-
an -ij:henticakil ca;-i?!- of eelainpsia w ic
nl . . i-'I also tliat oiher toxjeniie eoinlirii -
w . . -I'.i.iV which arc likewise aeeomimQiiil j,
ji _ " 'i only alisolutely eliiinielei-jsiif feat -^ -:^f.'
.. - ■ .■ ;-:r-ions which will be described liiler- _
t. - J-' to show that eclampsia occurs aU* ^^^
!■ ? diinost impossible to ilelerrnim- its it -m. < -
. ■ -^.-is. inasmuch as few praetitioniTs .i*-«T--
; ^ , ■ — 'f cases in private practice to permix «
, - ■. '11 the oilier hand, hospital rcconi.'i "*
__^ - ■-. :.U'a of its frotjueney, for the reason t '^ ~»-
■ ■.' rvmairn'rl at home unless they hail 1 ■» =
. _ 1 '.■ would iuilicale that cclnmjisia occiir--^
1 i;iifii cnttTing lyiiig-in hospitals — iiui-*i*
„„_... S' ■: 10.717 tilHiars. HI canes of ecktiiiiHiii (0.7.V','.i
{1.J7';-)
(().34<-; t
. ;- "Mn by Lbhlcin in Irtill, and by Vi'it in 1* - "'"■
, .. ^a'.^lii.'* fTom the various clinics in Ciermany, nlV'^*
,:\ .-^T,*. In the former there were 335 instamfs '
-- .-s^-*. And in the latter !)0") in 1-1!>,3«6 eases — a p -•'^'
, ..,, •■: restwctively — 1 in I'lO and I in Iiifi. Theses — *'^"
-I*'* :' (Vlamp^ia- hut Liihlein dilTerentiatcd lietween t "^ - '^
"" ~ _ .^v". sxtA xhft-'^ occurring in patients who wen' in t
. jp4, -i Tiu> disorder, and found that in (lie latter the rat "^
'"^ ^.. ,,!r;— one in 331'. ^
"*■ ■*" ^ .(-v* 7.-Jirii«'>lb' i" frcipiency at different times, Cassauiavi ^^ ,
' ■ ii ftr^wr'* elinic in Pari- it was observed many times mo^^^^^'
""^'^ ' -uttK »«i* tl^" '" otlicrs. Thus, in 1872. there was 1 ca***^*^
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I
ECLAMPSU
fi2S
labours, as compared »-itb J to T30 and 1 to 130 in the ye»n
I Ui»tory. — Zweifd ha* rcporutl a eawr of <v)amp«ia occurring in
lontb. but an a rule it is not eiH-ouDt<?r«({ before tbe m^coui] half
cy, and biTomes more freqiii.ijt the nciirtr Icrm is approached,
nrrully r^talatl that •() to b>i yvT t^i-iit of all citnoe occur in primtp-
cn, Knapp, ()lshau!N>n, C'aesamayor, and (ioldberg reporting a
of 71, 1!>, 77, and 80.4 per cont nhipoctivcly. In nil probability
worv Homcwhal too hi^b, iiuL-*mu<'li a* they are Itaniil upon hox-
iec. Nevehheletts, be this as it may, it is ceriaiu lliat in tlie
iparons vonHii are much more lialilc to the dtNonler.
ntgruncy and hydraiimios appear to act as predisposing ta<!lora,
fionditioo being noted by UhhauHtn and Cas^mayor in 8 and
t of Ibvir cases of cclainpiiiH r«>T.[i«';ivdy. wheroai* for all bilioiirs
Btio is 1..1 per cent. It is possible that heredity someliroes plays
te production, and Elliot, Ohtutuxvii, and Piniird liuvc reporttid
I apparently confirm this riev.
imptic convul»ou tM>melimes occurs uithout warTiinir. "like a
■ cl«ar »kv," in wom*-n wlto were apparently in {H-Trcct h<?alth.
jority of cases, however, the outbreak is preceded for a loDjrer
;ieriod by pn-monilory "yniptom* imlicative uf a t<>](a>mia. among
Wturoon being tcilema, beadache, epigastric pain, and poMiibly
« of viKion. .\l Ihc eumc tunc thu urim- Ihxihiics usually di-
qnauiity, vhile album<-ii and c^-ts-ai>d a marked ditiiinuliou in
I of urea are demonstrable. '
^ack may come on ai any tim<^. eomeliincs while \\k [Mtient i«
If she is awake, the firnl sign of the iiii|>ending convulsion \i. a
^ioD of the eycK, which won begin to roll from side to side.
I are usnally dilated, less often contracted. Tla* conruUive
appear lirst about the month, which begins to twitch and is
ne utile, the iiitin* faci* Iwvoming dislnrlol. Thi-ip' i^xtend rapidly
IS, the body, and finally to the le^js. They are usually clonic
r, tfiough »oinctimc« ihvy take on a Ionic form and the patient
[id. The brunthinju; i« sterlorouit, iIk^ fa(% con):eslcd and fluiihed,
foams at tlie mouth, and often bites her tongue. Durint; the
which may ta.it for a few {•ccond* to Iwo minii1i''>. iIh- woman
lly uneon?<-ioufl, ami after ilie movements cease passes into a
i coma which IimI* for a longer or shorter period,
irticularly when tlte disorder apiiears in t)»e latler jtart of latwinr
the poerpernim. a single convuki<m otdy may be observed, an
led n-wvcry ensuing jifter tin,' patiuil emerges from llw; coma.
>wcver. tin- f!r«t In the foreninner of vWwr conrulsions, vhich
n nnmtter from 1 or 2 in mihi. to 100 or more iu fatal casee,
U between them becoming shorter in inverse proportion to the
II rnf irutaiH-Cf Ihcv follow om- enntlier so rapidly that the pa-
ra la l<e in a prolonged, aluio^i continoouti convulsion.
||USon of llic coma is verr variable. When the cnnvtiUionF are
OBSTETRIC*
«(
it
'ic III sc\er«' cafes Ihe otma persUu from ono conmlsion lo Another -k-,
lU-iitli may renull wilhout hdv awakvniDg from it. Id raro instaocc^ «
fgte couvulsiou fn«y lit; fwlltiu'wd by pmfniitK) cunm, from whirii t-Tk^e
lic-nl never emergen, though, m a rule, death does not occur until afte
ijueot repetition uf the rouvul^ivi- Dltuck*. The imitiitliiilc vontv
l-u(h ii; uciiiilly ii'di-imi of ihi^ Iuu^^h or apoplexy, (hough if the fatal Lw
flpoiiixl for iicreral <la,t's, it is usually attribulable to an aapit»tion piL
nonia or a puerperal infection.
In mortf casj* iluniig the !«oiitiire the artonal pre»>ure H mark^t-«3Iy
rinon^ii.MHl, iind the piiUc is full and bounding. In severe cases, howe^^tj- «■,
'it is weaker and more rapid. lx'ci>intiig nion? fi>mprcH<:ihlc mix] Slifonu v^s^' jtb
<wch Mt('>.txvliiig niitrtii^ion. In many rana^ the temperature riitc^ lu a ^^s^r
conHiderahle height from the OD§et of llio disease and gradually fall
the patient improved; jomctlmeH. liowfwr. it rviii»in> noniial. A t<'nii»«_:^ n
tiirv- of Il>4 or lO.'i dvgrrf.^ i* not unusual, and in fnut i-aM'n tt may r«f>«u
107 or 108 degrees just hefore the end. As regards the cause of this el
tiou. there im much di^cn-pancy of opinion. Olxhaustm iidivrmt that -tiie
poUon which gire-s rii«e to the crlampsia alio stimulate* the thermal eta.'^'rv,
while Zwcifcl holds that the fever h nearly always of infectious origin. n^/i'
fuel thiit (he uterine loi-hia hnv<' iHin fimiid to he pi-rfiTlly Klerilr Jn a fa a.s ui-
Iwr of cases speaks against infection being the sole cause ; hut tliat i*r i*
often riwixHisilde. especially in thiwc cases in which the fwor por^^lM ii*
days after the cessation of the seizures, there can he hut little do»:ait.
Moreiiver. it would seem that women suffering from eclampsia are «■»««
susceptible to inf(«li<in than usual.
While the convuUiouH are hy far tlic most important clinical mnoi "J**
tation!* of e<lunip*ia. and ewn give the disease its name, instan^ces ari* ^rarf
with in whiih they are aluenl. Tlirifi- such cnj'n^ wcr- rc|«irtcd hv Sk-litr -^*^'
in ISO';, and others by Meyer-Wirt/.. and Kseh. while two casn-i have ixvur"^"^
in my clinic. In tin- majority of iustaiicc^, the absence of conTalsin *^'
tacks has led to an erroneous olinicfll dlagnoaii', ll» condition havini I* '''^_
rcgunl.ii uf. uneiuic coma, phosphoni- poi-rf>ning. fulminating laHeriil _^_
foction. WiilV di.ii-flM', or acute yellow atrophy of tho li»-er. In fact, » o^^-^ ^
reel diagnosis can usually he c^tabtiKhed only by ihc deraoniitratKiti
tj-pical wlamptie le>^ions at autopsy.
According as the diwnler fiml appeart before or during labour or in ll^^
fin't hour* of the puerperilim. it is deHignateil as ante-parlum. inrra-piriiir* *
OP post-parluni I'tlampNiii. It is gi-ncrally staled in the tcxi-liooks thai if
laist is the least common: hut that the oonclu«ioiis a* to tho relative inc:»*
denee of the dilTen-nt vartelitv arc by no means unanimous iB abown \f
the following table :
AmB-pmtt'M.
Olnbauiwri 40%
Knatip 24J%
(Wdberg 29%
(ItiMMi aft";
lU'iiilnin: , 49.S%
lKTK*-rA*Tt'H.
Vort-rui
Wi
U\
0«.«%
l«^
57%
17%
229i
42%
M.fi%
2D'!!;
ECLAMPSIA
S27
iilnl^ llinl oiM! thiri] of liiii caiMw occurred aHer the birth of the
er^nallv. 1 havp obsonwl the poi>t-]iiirtuin variety in eninpara-
ituUait*.
uld appear from ihe slatistics of three of tho aiithure just citod,
iff-parlum ivlniiipKiii oavur* li-s.i frtijiK-ntlv ihaii llu- iiitrn-parlum
, iind my own lij^rea wouW l>t> tiiorv nearly in art«r<i with them
of (IrfNm and it'.'itibiir'f. UUIuiummi has reochtvl a similar con-
id cousklcH' Ihul thi- coutrnry j^iati-niditf of miwl aiilhoi> arv diiv
I thai thny haTc failed la n-nn^iiilHT that in the majority of oaM>a
Qtraoiionii K?t in with ihv firtt otnvr.tKioD. so ttuil if the patient
n iR-fon* tin* M-iznre il i* often vt-ry ilitltcult I" deienniiie with
Wtety one hatt to deal.
hpartam eclamp)-ia may icmiinatc in (Vrcnil wayi^. A« a rule,
rtf in aii<l a pn-niuture t-hilil in tiora xponianeously, or tlie uteruii is
hv it|><!nitive pnieetliin''*. Som^time^ the putifiit di<'« undirhveri'd.
II Doraber of caiv^ labour dorv nut supcrvriK-, and if tht' woman
tl>f attack »hc may jtiire liirtli to a dea«l or macerated fccttu some
rirard. In such oa»o» it is Mievwl that its death is tht- direct ro-
he eclanipfia. Now and o^nia the patieut may n-wvi-r from the
id yiv<- liirlh <» a living child al li^rm. while in very exceptional
ler bein^; perfectly well for a lon>;er or shorter poriod. she may
L'carr«>ci; of Iho M>izure. which may tvriniiuite in any one of the
lioiicd aliove. Siicli cases have been described by l^eudet, OU-
and Itffon.
atucic o<^-tir« during laly>ur, lliP pain» n«itaUy incn>aM> in fre-
iiid vereriiy, m> thai ttie child will be bom Honicwhut sooner than
ftvr vliich thv conrulsioo* ttcncraJly n-aec. On the other hand.
t v*j»», or whi-n there i^ fmu- iiii|H^)iment 'i^ti;.!!);; ily»ti)cia, the
nay die undelivered, unless oj)eralive measun^ an' undertaken,
ott-parltim eclampsia tho attack usually come* on soon after 6e-
nd reonverv often occur* after a lintde ctinvulitioii. In other case*,
', Ihe seizure- follow one another in rapid .■^^r■^^^!(wion, and occa-
ranse death. TIm- gi-neml ln-lief that eta.*** of this rariety are
;ireljr titau^ i- denlocl l>y (])l>)iauM'n. wh'< unuil a luortality of 35
iiir ihiilaiio--.'* iuve bci'ii n-purteil in wlneli Ihe disitrder did not
til Hverol wek? after tlie tiirtli of tlw? child. Il is pmbahli;. m
|M)int«^l OKI by Vail dvr Velde. tlint the vant majority of such
Dot eclamptic at all, but liial the scixun» vert; due to other
instaiK'es iIm- ani-t i* [in^-iiltil by u distinct aura (OUhuu^en)^
[if n^Dally liickin);. ihe convulsion coming on eillit-r wilbmil warn-
fter the ap|H-amncv of »ymploms imlicative of pn>-4i'lamptio lox-
bas been pointeil out by OlslutuKt*!!. si*\'ero epigastric pain i'* a
1 precursor of the seizure, and is a sign to which ton much alieniioii
ly In- |«aiil.
^muvulAioas are always followeil Ity UDonnnciousiHiM, and. monmvor.
It mav not imlv not n^^icmber the attack itaelf. but «v«a haw oo
S26
OBSTETRICS
recollection of otrurrfiuces which hav« tnkra j>liicft Ji'vwral hour* prftvi
to it. This is a Dot altogilhiT uiiti>niiti«n i)h«en<alioii, and may eometi
have an importaiil. lnyirinft from a ni«iico-lfgal point of view.
In /> jKT (viil iif l/(ihloin'T< aiitl in K^ |ht vonl »( Kiuk)<{>V ai*t» edsni
was followed by markttd menial derangemeQi. My own obaervations L
1
Fi<i, *S3. — UsoiAnT C^aht. Eclaufhiji. Dtim 48 Hocm ArrcK Ouwcr,
(GmIi aprutnirn ■imlvinl Hrpurntely. Figiim uu tftl (ida iiiillenic graiamw cl i
and poraeiittiKP nf HumxiiilH : »□ ngln ntir, pfrcvnUwD of altnunva.}
mo to bcliovi- Ihat thp experience of tht-se flulhon was f\<t:-ptional. allhon^^
it must not be forpittvn that menial derangemeut following irdompt*
Gonvul»ion>' U one of the well-reeojiruiifed van<-tiv« of pinT|jeral inaanit^-'
but whether it is a direct ni«iiU of tin- disea*© or is dne indirectly to infi^^
tioii has not vol iHt-n ilfiDim^lrati^.
In rare instances, se the result of permanent cerebral livioDD iaeUt^ -
to eclampsia, a krmuint'psia may <lti'clop during the puerporinm. A c*-'
of this character, occurring in my praclii-e, wim reported in detail by Woo^^
at llic 1!M)2 meeting of the American Ophlhnlmnlogicfll Socittly.
More fr<i|it(-iitlv Ok- piilit^til stifTiTJi fmm iliBlnriied viition during tT"—
latter part of pregnancy, dne to an albuminuric retinitis. As this it ^■
acconipiinini.'nl of an acute iiophritiii, vetampxin does not almyx detdc^
The oiilcome in such caACH is dependent npon the further course of the i^^
d«rlying diwasc. hi other caw* the visual di^^turlNino! i* Hnatt>'n<lo<i
demonHtrahie changes in Die rtttina or optic nerve, and in to be r^ntn^V
nwirely ae a manifestation of the general toxeniia. complote recovery n^*
ally following' within a few days iifter ihi* Icnnination of pn-^rniincr.
In a small number of cases the patient becomee markedly jaundic^**^
BCL-UIPSIA
529
during or junt after the conniliiive seizure:. Tbia liign ih of gniTe
Rtic fflgnificancc, and ini]icfltt> wrivux hepatic Itviuns.
■mpriia may ocvur iwt nnly dtirtttg Uie miirw! of aa nrrlinnry g<»t«-
jt woi i>l»en'ed by Mayghcr ill tbc false laliour acooiupattyiog extra-
pregnanc}'.
) uriae during llic ociamptic wMzurv unually giTM cvido:Dcc of a
I r<>iuU innuIfifienRy. It U tnTariatily diniiuiaJuMl id aitiimnt and
lily alroofll eniiroly supprB'wd, sk in the case trharted in Kis- 453, in
:niIv T5 rnbic ci'n I iiiii't !>■-■> "t iirtiu! W4» ]>a><wl in nixUTn li(>ur<. On
wpioal examination various' types of vauU are found in graat abun-
altbotigh t\w hyaVinv and granular varit;tiw pnilniiiinuliv EpithHial
lao occur, as well aa ifialatcd rvnal cclK vbilo blood la nearly always
nuninnria i* a]inoj>t noDAtanily prewnt, and fre<|uently it) tu> pr»-
A that it is oec«Hsar}- to dilute the urine tn ttcverat times it« bulk
an arc'nralc d*4vrttiinalion can bi> made by im^nni of the Cnbaoh
In the majority nf my cases at leant 1 per e<*nt (10 grammea per
-if nlbiinien wn* prvscui during the acute Ma^- of the diMM»i\ vrhile
uistancf 3 [RT rent wai- noted. The albuminous precipitate ia
I
Pin. 4M. — IFmik*BY Cbaht. Eci.AMr>iA with RKimrHT.
XtUoftcn -^^^^^ Aaiaionia: RkI. AII>uii»-u — -
<P1Cun on HkIii ■«) Ml u in ChoM 4Sa.)
ffid of lioth M?rum alhurm^n and -v-nnn globulin, and in one instanca,
the relnlivir am»iint> of ea«^b were determined, thu Ull«r was
U-l per cent.
580
OBSTETRICS
•
L
The high alliuin«n output it only titmporary, and rapidlv dieappt^^cm-m,
UioHgh iistet* may !« ohiHTved for neekw (Fig. 4"»4). The npid df€r«**a»*«
in ite amount waH carvftilly «ludt«l liy EiiivrfrOD in onv of my putic^xx t^,
who Fvcovvntd, sjieciiiit'Dit bt-ing taken ai the tiin« of coaTui^ionit, aiic3. at
fitiir-hour iniervalB during convalcscencp. l>urinjc th* i-elaiiiptic ai-rsm^^-k
thf uriue (vintaim-d l.'i'd jut wiit "f ulbuiiivii by wvighl, «» (.■nmpan.i] w i tl
0.S5 per iieur Ivr^ilve bourH lator. It is inierestin^ to note thai tla*:*j*<
high grades of albuminuria do not ncc»!)urily indicate profotmd rc>K3^
k'liiou^. u^ in oav <>t my cjim^, in uhich ih^ tirin« cnntatiti-d 18 gratnrm mtsa
of albiimvii piT litre, att veil n^ quantities of ca:it6,on)y a mild degvneratX v-«
nq)hriti8 v ae found at autoju^y.
The total nitrogen of the urine, aotiinated by the Kjeldohl tn«thM]. it
markedly diminished in (>dam)»^iti. aiul at Iht- mme lime there oerure^ a
profound alh-niliiin in t)i<- ]'n>[Mirti'>ii.-< of the varinun <-i>iii|K>undi> of wh acr^li
it in rampOM^f. Thiift llie urea, which normally make^ up al>»ut four fif"<:l"»»
of the total, is rcdueixl to lu^ than oun half. On tl>c other baud. tli«.^rf
i# a rdative invrease in the ajn<mat of the attiido acidi» aitd the vart«r»'«:3*
fub«>tauceA which are prpcipitateil by pho«pho'tun(,'»tic acid, such a* cJ^'^j'^
tiitiii. urif acid, Hv. The study of Iho Isi'lmviDiir of thi' nmmoiiia (if«s-*^V
dent is of particular interest, Wilh the onset of convulsions a decnw--'^ "^
if usually obwjrvcd ( Fig. 455), which w "oon followed by a marked lis*. _^__j
tliat the ammonia cocffit^ient usiially remains relatively high for a »arufc;>^ I-;
length of time, lu our e.\perienee thi» eondilion i* of favourable inipiit^ '^^
as ill «-veral fatal oarte» tlw ammonia coeflieient waa low, wbih: tlH- olb- ^~
signs and symptoms of the dis«a^e were accenltlsted. ^„^
During eoiivalwceiHX' ihu urine usually r^'turn* to a normal couditirt* ^^^
but at the same time the increase in its quantity and nitrogtinouK i-nnie*^
cannot be reganlnJ as king enliK-ly due to the eliminaliou of matenal-*
whose nti-nlioii wii» siipiMwed to have caused the dis«»se. We uow kaoi^ ^
that somewhat similar changes are observeil after normal labour, when th-**."!
high nitrogi'DOUK mntiuit nuwl Iw atemnitol for by the involution of th
ulenin ami oihcr puerjieral changes. Although the alhunioii usuaily Hear'*'
up rapidly, it fn-quently shows a slight increase when the patient i*
)illow<-d a more lihertil diet. On th« other band, the pooisieul ptVM.iiC'^:^^^
of albumen in the urine for »evcra) months indicates thi; existence of
ehronie nephritic?, which in mnet cases was preei-nt before the eclampti* -*
attack, bill occasionally ap[H-ar* lo liavcr rtiiulted from it.
I'/itliol'igy. — After Uayer and U^er ha<l demonstrated the pri'^uw
albumen in Die urine of women suffering from this disorder, it was giinemir
Ixlievcd that the fundamental pathological lesion in eclanipsia wa» a d
|il!riii?<, find for a long timo tlie condition vas considered to be tdeni
wjtb ur:emia.
This view, howewr, was gradually abandoned when it wa* fcuind th^
only a small proportion of ibe women suffering from chronic nephriti'Ii:
wl«mpsia; and still further lutHlifications Iwi-ame ni-d^wanr afltT it
bei'n shown that llie iirine did nol nwcs-iarily contain alVmuien at llw Ir
of the eclamptic attack, ScliroHb-r, tnger^lirv. and Churptntier having «
lected respectively Sa, U8, and 143 sudi cases from the literatune. Its a
-C-
Vtn. <*5 — r«Dt*Br Oi^rr. Ef«-»>i«i» with Rucutkbv.
Tom) XUn^n - Auuuudu ItnJ. Alluipm
"''^u lire itxuallv Ihose nf an iwhIp nephritiB with markwl ilncenerntiAn
*^ necnwU of Ihi- miiil •■pitlidium. ari.lin«rily, this U tbc only TWial
*'*>Ti, Ihtiugli o.x-a*i«nally it m»v b.* Hn];rafl«i upon o ilironic proccs*.
*^ti fnniHl kidney changw in oil hut 1 out of ;ii;n i-».-hw coUrelwI from
"^ literBlure. in whi<h tlic dewription wsi* suflieiently amirale tn Up of
*•«, Forron ut acutu or chronic nephritis irt-re pre-ent in 4fi ami 11.8
U
534
OBSTETRICS
primary lesion of the dUca&e, and consider that the entire pmreiw i^ iiw
to an impainiu'iil of ttif ki-palic function — ii kvpalvtnxamia.
Sevoral obwrvcrs Iiiivi- deitrilHil X\w pn-wnw "f hii-iiiiiliiiiiiitn !■( Mirj-
ing MW. jiiisl U'lit^nth tlic iaj«iili- i)f llir livnr, I'nil/. Iiavm^- nHunliil a
fatttl liuniiorrlii^c*! fnitii ilic niplurt' oT nui-li a utruiiurt! iuin tbe fMTitoiiml
cavity.
Viiri<iu» »tutvtni^nu liuw bvvii nuidi- convcniitig \\w ]>atlti)l<ij;iail Rmlin^
in till' l»raio — (Bdonia. liypcra^iiiia. anemia, tlironitioeis. and aiioplci:r litriitg
SlfMK niHTAM.1^ mnU 1'l.trKVttl. SlTI.. X W.
-M-
d«)!cnlK'<i a^ Ihe main Ircioiix. I'rulK noted oslama in -13 pi>r <«nt, hvf
u'tiiia in :W [kt cenl. nmi U|i»ple.\y in Vi |nrr t-enl, while lhi< brain
apjuiivnllv norriisl in only ID per «nt of his ra*i.->. Sotiinori. in ■'W nut of
li-i uiilii|)i4ifv<, in which (he nr^ii vsli rxaiiiinfd, nolril ihe pr<?yi>nc« of thlW^^BiW
in thv &malk<r curebral Tcsselii, and re;^ixlt>d them as lh« catue t>t —^he
small areuM of n<'(;rii>"iii whii-h air *> nfttm ohwrvwl.
In nioiil <'n^es uf eclariipnia I)i<- heart i.'> iiiort' or Uvf inrolved, and -^wra;
[MTfi-ctiy norniiil in only H out of In^ antop^ics aiialy/nl hy Pollak. V«-
cording la Schniorl. Ilm i^han^iN UKiially ■■nn«ii'l in dvffi'nemtive pro«— a^rcf
in the myocarditim. which are f^erally rc};an]ml aa hcin^ due to oriaKvaF
i>ia. though at limes tlie%- may he atTribiitt'd to Umi use of cblomfarm i» ■ ''
iFMilmrDt.
Following Sdiniort nnd Winoklor many ohservers have demons! ratitl ^ '"'
proBCDce of giant oells in the pulmonary capillaries which ihiy harr id*^'^'
tified wilh the so-called giant cells of the placenta — nnmclv, maiden ^^
syneyliuin. Schmorl formerly iM'licViil Ihat their presence proliaMy *"^"
plained the origin of the thi-oinholio pn)cir»w« observed in variuu« iirfiJ^
But at present they are iv^arded as having no signiGcance. a« Ihev** j
BCLAilPSIA
535
frmiiHMitlT found iii |ircgnniit Hr<Hii«n ili'iitl nf oilwr iliteaM^. 1 Iiim> frtv
qiMntlr iet-n i>iiiiilnr giant ci'lU and eieii portions of ritnrionic villi in th<-
■ nvsctft of Ihr tiliTU'' in vniu-s of nurtiia) );t»tiiti<>n, aw) in tlwuo «f Itui
tulw in estru-uti-rine j>n?;n>«n»_v (Fig. i'>1).
iu pitlM-nt^ wlio Imvv (lull wvituI diiy* afti-r lliir »^«-Mtii)ii "f llw! w>ii-
iiiUiiiiiK. in addition to iht? loHiunn juttt de^ribed, lirunoho-pueuiuonia or
TRCinua evidences of puerperal inft-clion arr fm|ucnlly noted.
^m It i« uppnn-nt, lh«n'rnn>, tlint llie iiinin I»ions in eclamp^iia are found
^Bjti the liver, kiduovri. Iioarl. and brain; but in view of the niarketl di«-
H.cn-]ianirT in Dm* ktaU-nicntu of iIr- vori<>u« uullu>r< (imciruin^ their rela^
^littf frnjuencr and iinpurtam«, it would iecm, with the eitvption of the'
characteristic l&iiona in the liver, that the anatomical changes arc not cod-
J^tttjint. Aroonlin^ly, i1 muKl )k- a»iimi!d ituit IW i>!<M>uiinl fitaiufi! in the
^f inrirbid prowls is the eirrulattnn of some an yet unknnvn tonic euMancc
in thi> NoinI, whirh givos riw to iMioiia of varving intennity in tin- dOtvivI
LUigan*.
jVltahgtf, — 80 many hypolhcftes have been advanced conccniinj^ the iFti-
f M'larnpKia Duil Zwftfi>I ha.i aptly di"<i)Cn'>l''ii >l a^ "thti diHeaMe of
- " t iiforlunatelr. exurt knonli'd^ ih ^^till lai'kiof;.
Knini Ihr varii»*l pt-rioil* it wan iiintidt^rci) iw a diafnliT of Hlc ncnou*
ayMt^nt p<-culiar to preimancy. Ttiis oont*ptioa i« no tnnjcer cnlerlained,
[tlK>ti|fti Ox-re it no douht that the iH-n-ou« •ty^itPiii is in a condition of far
It^ari italilc ti(uiltliriiiMi during pn-^nuncy than at otht^r (inie.4. Thin fn*.-!
ihoh Ihiii coik-I naively demonHlruitil by Blumreich and JCunti, who ehowi^
I tliat <'unvitlHion« nould be pruduccd by the application of far omallcr qnanti-
lieti of |«iwdi'r<Ht crealtnin 10 ll»e eerebral cortex in progiiant than in non-
prvfrnanl animald.
'ITii* tliMiry wan to a wrtaiu cxU-ut n-luiliilitaliM in IH93 liy lli-rlT, who
Whl that, owint; to a faulty devdopUKnt of the uervoua jiy^tem, a certain
' nombKr nf womm an; particularly pmnc to txlampsia, so llial condititms
vliioh in tieallhy individoala are of but little i^ijinifivanee would W ouHWient
to pitc riw to the dii>«fl»e.
A> a reautl of t)ie work of I^ver, cilampHia «'a« ideutitiiil uiih unemta,
and thi» view was only ftlowly abandoned after it had betn wncluwvely
I dfniiinHtraifd that the two cnnditK>iii> had hut little in common.
Spif^'llierfi, in 1810, advanced the llieori.' thai the cm-ulaliou of amni<Md
itim i-arlHitialc in th<- MiknI wii^ rcspouKihle for the seizures, hut. chenticall
Jyoiii haviDK failed to ^utMtantiate tliin olatcrnKiit, thr idea wa# lOon
diHIinl.
The Traul)i--I{iiHeni'lcin theory, wliich held that the oonvnUions were
n>«ull of an»mia and luleuia of ihe hraiu. found wiilisprcnil ai-ii-pl-
for nuuiy y«-ur>'. hut was ullimalely abandoned in view of ihe fael that
^h euoditioibi could not be Hetiionst rated at anIopKy in the majority
*•«*. 3
Il^lrire ani) Rodel. of Lyons, in 1884. -laj^^eiited bactonal invs.iinn ai H^
ptiologia-nl factor, but udduod no evidence in -iupport of !;ue1i a
^ _ first investigation* were ninth; hy DoK^rix in I8«5. Following
Vu« a ouinlNrr of other observers, anwnfc vjiom may he ntentioned Blauc,
OBSTETRICS
At ihe same tJin« numerous other theoriea have beeo prainiilgstcd
alon^ raoK or less similar lines. 'i1ius, Ascoli ho)i]» Ihxl the affectioo
is due l'> ail ovprprcMluclion of nyni'Vlinlysin ; wlulc, <m il»c inh«T hand,
WtiichhiinU lu'livvM that hU experimental work hIiowd that it is due lo
a direct cvlolvtic action exertnl bj- the syncytium.
Ucpinann (.-onsidi-re that thv eclamptic poison it rnnlninod in livi ]>mto-
pUiim ')f itic plHCT^nlnl ce\h. In liiti experiments he fauod that the iooca-
latton of juices extraclcd from the placenta if without effect, whcrcj* whi-n
tlic dried timl [Minilcrcd or^ati i* iinjiloyi^i charnclitrislic ■ym|>|rim:< folio*.
Fie Ihfrcfoiw liokU thai eclampsia rewulti whencTer the suppoMtl toicin
fails to be " fixed " bv the placental eclU. He altributci^ a i^imilar prop-
LTlv to ihf »i'!l» of the brain and liver, a* lie found by mixing Ihem with
eclamptic placcntfll tissue that symptoms did not follow inoculation.
whercHi* Ihcy prompily (MTurr"! wtum (lit; pliK-ental liiwuo ahmt? was «*«1.
It ia evident that tho advocates of the varioos " btolojpcal " tlieorias An
not njrree amonjr ihoniK^lves. Moreover, as Ur* «mtml expcrinienbf of
WnriiitMT. Labhartit, I'ollak, and Martin have given negative tv-ndts, it
must Ih' ndiiiiCUil that the evidence in favour of such ricws is not cionvinc-
iitg, and that at pret«ent it i^ advisable to ntupend judgment vnm-erning
them.
Tlic pn^ciil stiiltii' of tlic! i)U(-iitioii mav Ihcn-fore W Mimmnrixnl th*
follows: The clinical history and anniomical findings afford pivsumpliTss
evidence tliiit the d'se»s«> is due lo the cironlalion of enmv poiiutnoitK sub —
stance in liu- MikhI which give-> riw lo thrombasiit in many of the 8m*lle~^
vessels, with consequent de^ncrative and necrotic changes in the varioo. s
orgnns. But, ul tlic **nK linic. wo are ahwhuely ignorant nmcerning tl^^-
naliirc of ihc ofTi-iidiiig >«Iw1ance, and hesidir*, the ev[MTimcnial evid-iw^^
thus far adduced in favour of such an a-tiological factor is not convineing
Sclimorl nl one linn- lielii-viil thai ih« thrombotic processes were tnai ~
possible by the action of a tlbrin fenncni set free from plaeenlal oi*Ils uhi«^^
had <wcH[M'd into the malcrnal circulation. His later investigations, ho
ever, tende*) to invalidate tliis a.-tsnriiplion.
Se\enil obsen'ers believe that they hare demoostraiei! Mm jui iii ^m ^
of other siibKlnnu's in the blood senim or urine which might explain ^t^ ^S*
prorhiciion of i^-tampsin. Thus, Mas.sen de-M^rilieil an incn^sti in li-o ■ i
miiini-s. and Kollniann thought he demonstrated an unusual amount of
globulin in thi- hliHHl .■uTum. Their resitarchcs have not yet k-en cwnfini».^csl
and their caiicliisioDH mnst therefore Ik* accepted with rewrve.
f)uring the past few years a numlx-r of atitbors. particularly F*>1iB ■*"?
and Dienst, have advam^d the tluviry that the diwjisc may W due to in**"**"
ication with products of the fieial metabolism, the maternal organi>m lic-i '^^
»umetimi>i unable to accommodate itself lo the increased work ne«s»***^
for their elimination as wt-!1 «.« ihiit of its own excretory piodncts, Th^'
argue, therefore, that under such cin-uin-^tano-s ci-rlain poiponoii* iii«'*^
rials could lufunudiite in the system and eventually give ri.^e lo orgal'^
lesiom in the mother.
This view nwives a certain autouni of >.uppor1 from clinical expenrtlfC*
since, as is well known, the cmvulsions usually cease soon after detiitn;
ECLAMPSIA
539
^Hrrbllv in rare va>ici> the ilenlii of tlir ftptu« during pregnanrjr is imincdiately.
foUoireil hy recovery. Moreover, Banm «»<) C«:>tnigii<t lmv« lately dt^nwn-
nlnilM thai th« iranKitiir^Km m ihe moiher nf iiiilLHtuu.H>s injec^ied Lnlo llio
L fiKtus wik*s almost imiiie<Iiali.'ly after ita death.
^B The advocates of the ftctal origin of pclainpoia alM adduce as an argu-
^nieiit IIm.* fact that convtiNtonit »oniGtim«^s apjicjir in titir child vliortly after
^Hla birth. Ca»ei of lht« ctiaractKr haro bc^ii re|>or((v] hy Wilke, Wnycr.
^BSrhmid, IlintHt, aod olhtTi^, and in wrcrol iuRlancc^ characteristic le<!ionH
^»»<iv oliwrtwl in thi? or^ns of the fa-tuc. Kurlhprnion-. le^inuti idontii'ul
with thotw ui the liver and kidnoyi of the mothem have hoen oh«i>rvcd in
^Iho corresponding or^ns of children which were l>om dead or die<l wwn
iflcr driivcrv. Such observation* have Ik-i-h mwde hy Srhmorl, ("hamlx'r-
ti'Ui, Bar and liuvel>i*e, Knapp, DiensI, and myself, and are coni-idered
lically in Dicnxt's nionngraph.
The olberTationH of Kri>nif(; and Ftith, Zangenicii>ter, Sicili, an<I others,
bpnn the osmotic pre^ure and cl'^rtrical conductivity nf lliv helal and
natcmnl hlmul Afiy that lltfn- is mi fiihihimi-iilal nhji't'tioii In the ai-i^pt-
anm i>t 'uch a theory; hnt at the same lime. 1 do not Iwiieve that the
(hfmnnatration of Iwione in the nrgnmt of tin- f(i-tu>> iK-co«(irilr utfnrdif L'vi-
f]«Tn<-« of itti i-orreclnosa. To my mind xix-h flndingai simply prove Utat
y are the nwnlt of tlte circulation of some suli'tance in tiie hlofxl which
■dif to thv [iirmation of ihromhi. with HtdiuHpicril iii-cro-iiif. atthouj^h as
the evideDi-e ii insuilicieot to indicate whether it is transmitted through
plarcnta from the fo-tu« to llw tnoiher. or in the op|io#ili: dirw-tion.
Tlif study of the mt'laholii'm of tlut mother durinii; lliv pclaniptii: vtatit,
^l luirticuliirlv the chemical examination of the urine, have add<?<l consid-
ihly lo iiiir kniiwh-dgc "f l\w dii-stw. Not only tif the total nitrogen of
urine markedly decreased, hut tliere is aim a striking distortion in the
Nation which thi? variotw nitru^n-conlaining compounds normally bear
Olio aiK'itH'r.
UasM^. in I8ti5, found the relative amount of urea greatly dirain-
•ed, and llrlouin a fpw ywi* later stated lliut the mppoH auitHriqHe
'the relation Ih'Iwvco the amount of nitrogen estimated as urea to the
>tal nilnigi-n — wii> pmfoundly allen-d. Normally thin ratio rartcs between
ind *J<i |KT c^t, wliili- in prc-eclamptic M\H-mia and colaiii|Hiu it i*
'■^'^•t.ly rwiiiced. These findingi» have been abundantly confirmed, and
t^eTeral inMlawvi' wo hnv<< found that Ivwi Uian onr half of tbo totftl
^n>jp>n waa excreted aH urea. At the same time appropriate dtctnical
l»«id» show a relative iniTcaM.- in Himc of the other nitroj^-noun com-
J^*!*. \\T\ i-omplHi* "tiidiiw alon}; iIh-hi' line* Uavi- hivn madi- l>v Whil-
. 7B-hfel. Stiiii«>. Bw-in^ and Wolf, and others, aa well as in my clinie.
^y all show an Increase in the amido acids, as well tts in the compounds
*hioh are precipitated by phospho-tungntic acid, flich a» uric acid, creatinin,
xanthin huvin. vtc. The sum total of iIm-so .luholaixi^, however, doea
CTirri»pniid to the entire amount of nitrogen contained tn tlie precipi-
■n (hat llw di-licit is dmignatiil a-x tl>o *' X-Reit." It is interextinK to
Uial the dctiril i-< j^reater in eclamptic than in normal urine, hut as
rWin iitowMnl »l ifaic rciattup il may War to tlw cau—lion of cctamp-
Kit
Bin: altlioiigli lliu Httiflv iif the "nitrogen {wrltlion " t«n<lii to imlkAtc
thni the nitrogcnouH miHaboliEm U imriou^ty impaired, and that the waste
prodHft* «rc I'jini inn !»:■(! in a stntfi of im-oinplMc nxidution.
Ret-ftgiiisinR these facts, Jiweifcl attempted to Hod some iruperfeetly
oxidized ImmIj- in iW uniic vrhidi miglil pi»«il>ljr give rise to eclampsia,
und Hiicct^inliHl in de in onat rating considerable quantities of sarcolactic ai-iil,
which was also found in the oercbro-spinal fluid by his pupils, Kiith and
Lwkonnann. Xotwilh.ilaiiilinjf Zweifi'l's i-an'fiil work, if dw^ iwl nvm
llial wi- are jitntiHed in considering lactic acid as the cause of the diwa-*,
for it ebould be remembered that it ha^ been found in other conditions, ami
it may vrell )» ibai i1 i* only a rcdult of the lymviilninn*.
The intimate relation existing between the thyroid ffland and inetaW
lijim Iwl Nidiolwin lo assume tbut wlarnp^ia miijlit be due to lhvr>iid itKiif-
ficienev, and to recommend the use of iti^ eitraet in the treatment of tli"
diiicasc. Lnnge found that hyp<?rlrophy of tliv tliyroid wa^ niiu of tliu usuiil
concomitants of noriniil prcj^ancy, ajid that iis al)aenc« predispowpil to the
oceurreiifc of a toxa'mia. but pxprc«-cd himself vcrj- contx-nativcly «W-
ccniing the rclniiou lic-twwn the two idnditioiiii. "
Ot late a similar function baa been a^crlbod to the parathyroid lwdi(»--_
and Va»>al<- and Zanfrognini found Iliat their removal fmrn pn^nanl uil^-
mals was followed by albuminuria and convulsions. The fact, liowe^-e^^Ki,
that ximilar symptoms may follnw pHnitliyrniilmtomy in non-prrgnani au _^'
mals indicates tliat the condition is not true eclampsio. At present it ^een^^ns^
advii^abk- to hold botli of thei% theories sub judicc. and to await tbe n»t^Ez_tfH
of further inva>tig>ttirins bi^forc drawing dctlniti! conelnsionn.
In summing up the jctiology of eclampsia, it may be said that the d— .^Hw^
case ii^ awonipniiicd by characteristic Icions in the liv«r and by striki"-^ in^
changes in metabolism, hut that il.t actual oau)«e is still unknown. Al C^- tM
same time it may l>e tentatively held that it is the result of an auto-intoii» _f \tai
tion, which is prolwibly metabolic in chnnicter. hut wu are w ret ignnnK-nrsii
whether the change originates in the maternal or the fielal organism or— ^ r irt
bolii, I bi.'lit^ve that it is prob(il>lL' that further *tiiity nf llw nietiiln.'IF ^lisat
both in normal pregnancy and eclampsia will eventually a^ord the solut:9~ ^lina
of the probieni. and I know of no other more fruitful or fascituling E%r (i<-f>)
for rpscarch.
yinjniwia.— The i-ecogiiition of eclanipsia usually offers no dilfii
ll might W i.'i>n rouDibi) with acute [loisoiiing from strychnia, pbo«i>)i
or nitrobenzol, as in a case reported by Schild. However, such iosta — ^mnm
arc exlri'incly rare, and earefid irujuiry into ilic history of a gutivnl sb- -oiiW
prevent error, (icncrally »pmkiug, one is much more likely tu make — tiii'
diagnosis of eclampsia too frequently than to overlook the discaw:^*. <U
uraitmiu, epilepsy, acute yellow atropliy of the livfr. and i-ven hysteria 04/
simulate it. Consequently llicy should he home in mind wliencver ravrvA
sions or coma appear during pregnancy, labour, or the puerperiuin, and wI'Ih/
he excluded before a positive diagnosis is made, Occasionally it is iiW^Ws-
fiible to make an accurate clinical diagnosis, am] in »iicli is**f» only tb(
finding of characlnTlslic lesions at autopsy vrUl enable one to he praitiRai
to the nature of (he affection.
ECLAMPSIA
541
" Proyitont. — The projcnofiis is aln-ayg eorious, ecUminU being one of
the tnwt duigcTOUM ontMliUcini) with urhicli th« obtitetrician hait b> d«ftl.
nie itiali>rual mortality varies from ?0 to 25 per ciail, and Ihal of IIib
ffEtufi from 33 to 50 per cent, although Porak anil StrogaiiolT rvport
eerie* of -17 and 113 cases with a maternal mortality of G.3S and 5.31 per
tt reepeclirely. Such fitvourablv nwulUt, tiowtwr, aru very exceptional.
A" a rule, tli« progno^ift ifl more gloomy when the seixuri^ t^nie on lie*
>r>' or (luring parturition, wht'reaf* poHt-parliun eclamiisia is consiik'red
ilantteroUM. Kecviil (ilnlistieK, hovreviT. indiraU- ihiil the laM variety
mnrv wHoum llian ix gcneraUy Iwlievtii. (iiwn. Zwfift-l. and OI»linuKun
atiog io«t 6.fi, K.S, and 25 per cent of llieir cane^ respectively.
There te considerable diecrepaney of opinion concerning the relaliTe
»ii in primipnrvug and inullijiarouK Vp-omen. Tho*. Veil in 902
givai a corrected mortality of II. S per c«nt for the former and 19.3
cent for the latter, and Goldberg states the disorder ig twice as danger*
II* in tlu; latter, Olalinuxen, on the other hand, believer that there is no
[difference in the two groups, and Zweifel states that the mortality among
III* patients wa« 3 timii' greater in primiparffi (16.6 to 5.5 per crni). In all
'Inability the prognonis really de)>endii much more upon tlit m'verity of
fiB atlark than upon tlio number of children that the woman has horui.
In individual casejt it i» often t^itremi-ly dilfK-uIr U> predict the course
of the di:^«a»«, wmie patients dying in the first seizure while othern recover
after a.4 many a* 30. Wiorkel "Uti-* that he has never ohsenwl rvcovwy
Rafter more than IS eonvaUions. but my own expericnfe doe^ not bear out
Bihis BMcrlinn. At the same time, there is no doubt that, other thinga
^■being ei]tial. ihe propnonin ItcnmieH mure and more WTroiis with each eoD-
jB^Uion. although their abRoluto number is not of mi much moment aa the
rapidity with whidi they follow one another and the duration of the coma
afur each attack.
Valnahlc prognoetic data are also afforded by the condition of the pulse
JKimi temperature, Wlten the formi-r n-tiuiinn full and tirtn IH-Iwecn ihu
Untucks, the outlook is usually good; uherea.' a weak, rapid, and thready
pul«e ti«ually indicatiw a fatal issue, [inrtieularly if the tomperature is high.
Vaquez lia.4 rt>ccntly called attention to the increase in arti'rial pruuiire
klcforu and dnring the eelsmptie attat'k^. and points oiil that the persint-
FniY iif a hi^rli prowure is always i>f bnd prognostic significanee. even wlien
Hie other symptontH seem to improve. .Apoplexy, paralysiji, an<l onlema of
Die Inngs are most eerious complications and usually end in death.
If the edampsia comen <i>i during pn-;gnaney Um* progtMMis is very
favourably affoeted by tbe death of the fiftus, the convulsian-s usualh' ceas-
ing toon afterward.
Trratment. — (a) Prophtfiaetic. — The prophylactic treatment itt mfli*t im-
portant, and ia identical with tliat rerommended for the pre-eclamptic tox-
^■pmia ip. 530). Indeed, the chief aim in tn^uting the latter eoiulitinn is
^Bn prev<>nl the powihie outbreak of eelflm{h'i]i, IK-nco (lii> necetwity of
tvgular and frer|iient examinations of the urine, and tlve immediate in.stitn-
l^^in iif appropriate treatment and diet as soon as any abnormality u do-
^Hprifil or symplomn appear which iiidicalv that the climimiiivc pmceiMS
OBSTETRICS
are at fault. Hy lli« <'mi>lo.viii«nt of l\ie*e prwauiirtimrj- mPiwurc*. anil
by pn)ni]>tly imliieiiin prcniatuiv lutmtir in Ihoiwcasfe v\m\\ do not iinprovu
or irhidi iM'comi' pr"!irtwsivi'l_v wopm! umior tiv»tm«>il, lln' (nnjiM-Hry «f
ml urn [Klin will 1h> givatly liiiiiiiiihlw-d ami many raluaMt* lives saved. At
present, liowcvtr. dispiti; all w« ran do. <ui«i!» «f vcUinp»i« will nlill occur,
and suiiu^tiincji oven in ]ialieiitit who apparently have respotuled ino^t 4atJ.4-
fartorily to prophylactic treatment. Thus, I could cite spveral instance*
in which, nn<|i'r appiiipriHtf im-aKiiri-s, ttio i<n1>j(^(it't> Kviript»tn:< di^ip-
I>i-ari>d, the urinft and iln nUro;,'en<ni;i fonten! ini^rea^Kl in ijuantity and
the alt)mm>n deerea^'d, and yi't, jii*! itf I waf n>n}^-»tulutinj; tny84^lf upon a
moKt Ktiliofurliirk- D'l'ult.a convuUion (xt-iirnil. M()i«(iver,om> of my |Mli<niU
who wa.i appari'ntly perfeclly vvll. ami who^« urine had shown no abnor-
mality the (lav )»'{(>»■ Inh'iur. }iii<l nn ii'lainjilii' m^iznn' juhl aftrr <|i-1iviTy.
SuHi exiH^riwift's have convinceil me thai propliyJactic treatment, niiile
productive of untold )Coiid. in not invariably oticit^wftd or always appliraUk*,
nor Likn t H)in>o with Davis and Kdfrar that eclampsia is always a prevent-
able affection. Such a satisfactory condition of alTairs can hardly obtain
until it!< JVlioUigy in perfix-tly uniit-rntrtiKl, and wp are in {uiMiwion of mnm
accurate and reliable methods of foretelling tlie outcome in caees of pie-
vclamptic trixn'mJa.
Kxperienee ^oes to show that the oases acMinpanifd hy inlwna an' nun
readily inncmilili- to tr<-iitmi-nt and Icir?) lik«)|y to eventuate in eclaniphia^H
than those in whi<-h it ia absent. Thi« point vm eniphasixed many yeai >
ago by Stoltx.
(b) Curadvf. — In thu prcsencu of actual eclampsia, chloroform sbouL S
lie administered durinfr the oonvuUivc altackx in the hope of (rutting thc^am
short, after wliicli comparatively larpe doses of morphine slioiild i>e givi ■■=«
hyiMMlerniicully, beginning with a quarter of a ^rnin and repeating it, il
necessary, until 3 dnses hare lieen administered, althoujjb some hnhl t)h^ xl
bfltfr rtwulls foUnw llu- ad in in titration uf .'JO tn (><) grains of chloral hydn^M-l*!
per rectum.
Diuresis should be tttimulated by the subcutaneous injection of «^k
wilulioD aa well as its administration iu large ijuaiitities jH^r rwtnm. 1^*
tMiwcIs slioiild be moviil l)y a strong cathartic, preferably 1 drop of emlr^
oil in a dram of olive oil placnl on the back of the lunjEUC. or I or S <>ii
of s saturated solution of Kpi^m salts adI1li^iT^Ie^ell throRjfh a siomE?^^ *
tube. At the siiiiif timo u thicl: cork or folded lowel placed between
teeth will prevent the patient from biting her tongue dnring the altac^^
Ko food and iii« little medicine as possible should lie adminUteretl by
mouth ait lon^' an thi? pulicnt is unconficious. since in many instatictt
ticli» find lli«ir way into the air iias-iHgi"* in.vti'ad r)f beinft swrtlhiwwi.
later ^vc Hue to un inspiration pneumonia. This complicatton is
likely to occur if the patient ii* kept on her nide.
When piinvulsinns have occurred during pregnancy or labour, T Mi^*^
tliat delivery should be i-fTitrtiil a* «onn as is consislrnt with tlie '«ti't*' ■''
the patient. There is. however, eon.'iideraWe divei^jenee of opinion up*"
this pnint. Veit. ('hurpentier. and dc la llar|>«' advocate the admiBisIf*'
tioQ of morphia in large doses, and do not interfere until iIm- cenii
ECIAMP8U
543
HBit <y)fnplrt<4y ililatnl, stx) thm employ forcopei or rentiMi. Duhnwen.
H^Kififcl, aiitl nioiit AnM-rican aiilli<>rili>»!, di lUc ollutr liiinil. lutviHiiK! rniply-
in)^ llw iiliTus III Hti cnrltcr pcriotl, jiruvideil it can be done vithout aerious
iiijun Ut lli4' uidtlii-r.
■ The qut-*lti)n UH In Ihv udvisiibilJlr of exrly »{>eralivi> intt^rff^rence, in ■
my oiiiui'Hi. I'lm only l>i> ikvitlod by dct«nuiiiin^ the proporliou of ca^e*
ID which Hip nmrul^ionfi ntaw afu-r tiMt ttirttt of Hie vhilt). SlatUHcn
U-ariii^ ii|H>ti Ihin |M>iiil Imvc tieen iitl(IU(«i] by Dtilinisen, OUhaiiiiCR, and
Zwt'ifi-I. wli" D'lted a ci?7iwa(ion of the seizures either iiuineiliiitrlv i>r khiii
after delivcrv in ltII.T>^ |i<t n>iit, K5 |H-r oeiil, and lUl pT ceiil nf tlit^ir ea^e^
^ r^lievtirdy. Zweifi-1 Te|M>rIs a nniriality «f SS..*! per cent under esi>eclant.
B^od M.3& per cmthI under activv Irvtttnient. •^tid^ing fnim IIh-m' figure:* it
would H)>|N-ur llml |>n>m|>t deSivery ii tndieated wlienevcr it can be accotn-
plistivd in a coni^FTative manner.
^H In Ibe majority of cum^. eron in anle-partum ecliim{wiA, »|>eeily delivery
^^\» faoilitaied by tlie fart that uterine contractions come on or increase io
force mon after tlw onwl iif iW diKeam-. and Iiittiitir usually purKue^ a more
K rapid i-oiir*!? tlian u^ual. Thus, in many innlani.«s, after the fir-it few con-j
rulHiuni) liie cervical canal if^ found U> be already obliteTat«il, the only re-
ti«t«nm; to tlit! birth of the child iieing olTt^red by tlte exleriiwl im. Vfhen
tliiH i» the ca«. delivery is readily accomplished by dilating the cervis by
llarrixV method, a« dt^'HIwd in Chapter \IX. In thiti way. pr^vvided tliat
thr external 03 will admit the tips of two fin^rii, complete diialatton can
^^>e readily and hannli-wly aceomplishcd in a surprisingly short space of
^HflMb Th* diiM ohouh) iImii he dKlirvn-d hy f(>rc«p« if tlw head te low down
^^ii Um^ pelvis, or by verttion if il is ooly slightly engaged or movabli! above,
tiie [■•■Ivic brim. ■
If, however. lalwur hm not set in and the cervical canal i* inlavt, the
■iMetiaa nf rapid deliver)' benoinvs more complicnled. and it becomes necva-
(n dvtemiine whet]>er it h more advinable to adopt e\|HH-lunt Imit-
ri*nl or to attempt to ha^ften delivery. In hotipilal practice I am ennfldent.
tW |)h- iH'wt iniiivit» of the jiatifnt will W Kerviil hy ihe prompt jierform-*
of vaginal Owtiarcan section. In private practiee, on the other hand,
operation in not uilvi>ahle, unl<«# the olMtelrician is a eoinpeteill Bur-
nn. and t-an emiimand the aerA'ices of at leant thrwe traintol a><i»1ants.
tiiLfi e< mil nf ihe ituction, a niampetier de Kil)es lialioon mav lie intrtH
'Osil. if lutheient iin'liminary diluta(i<in eniJ ix- cffwtt-d hy uniail steel
vXJatora, Ollterwise rapid deiiveri' should not lie atlemptnl, ami lite phyi-
''*"> should plae« hin retianec entirely upon medicinal treatment. I do
*"** vdviicati? manual dilatation of t)ie intact aiul rigid ecrvi.t. af the opera-
™'> U extremely tedious, sometime-i requiriOK several hourK. and nearlyj
^^"^■^Y n»nlts in dix-p rervica] learc, which sometimes extend up into tht
'"^^'r nteriiw xeffment and give rive to fatal hemorrhage. Tlie Mme may
Jp *»id of the oae of Bossi's dilator. ■
H^ ftalbertoma. in ISK't. reconimendei) trpioni CRMivan «celton in inch'
^P***^. and his example has been followed hy many operator*, hut with
P'^ltaratively poor rvwult«. I do not believv llial the operation Ia jusli-,
"^W i-icrpt in tlie occaaional caiics of eclanipiiia occurring in women withj
544
ORSTETniCS
■I
miirk<!i]ly cnntracled pelvfs, as in all other ceMft AfMvcrj nut be pITorfed
more safely and nrarty as promptly by mt^nns of vagiimt CfftHirPon sevtion.
AfitT tb« birth of tbe child no nlli>iti|it nlmutd )« tiindc to )iiu<ten tlie
third stage of labour, as a moderate loss of blood should be encour^^
rather than i-horkod.
AftL-r the delivery of the placenta the various OTfrana of eliminatKO
should be titimulutcd as cn«T|^tically aa possiblv. If tlu- bnu-eU haw not
iiiovi-i), n Kii-(ind dosp of croton oil fthiHiM l>e adtniniiitered. SwealioK idiouM
lur ciJiTnirax*^! bv tbe further uw of hot pack«, or at Irast l»y covt-riti); th--
pAtient wilh a riihlH-r Kh<'et niid Kurrouiiding hor with lioltles fdlcd wiih
hot wnti-r. hut lakiOi; every precauliim to prevent her from Iwing bnmol.
Pilocarpin should not be n»od on account of H» tendency to prndare
wdernn of the lunRS-
Diuresis should be promoted by the subcutaneous injection of salt «olu-
tion. ai< nvlt ax by copious hi)i;li rental cnciiinla. In vit-w of tbe supposedly
id nature of the eclamptic poison, Zweifel advocates replacing the salt
ilution by one cnnlaiiiinft 5 gninime* oiidi of wHiiuin chloride and wviium
licarbonate to tbe litre, Mnci5 and I'ierra. in eonAdiueiiec of tlieir observa-
tions upon the froi»iu|; point and [■bloriily conl.-iit of the bhxid and urine,
obfcct to the u^^e of salt solution in the treatment of celai»p«ift. Their
teaehingd. however, do not accord with our ctinicnl cx|>criencc. and str
(Mint rail ii'tttl by the expi-rimi'nts of Tiioiii[>!ion, who d em onxt rated Uial
the tlow of urine in do^ is sonietiiueK increased as much as 300 per ceiit
after the subcutnmfius injt-clion of large qiiunlitie« of ^alt glutton.
If Ui« ])alienl doe* not show marked signs of iniprovcmeiil «hortly after-
delivery, from 300 to 500 cubic centimetres of blimd should be wiilvdraHD —
If beiH-ficrul ri'Milts fi>nrtw, ttii; pitKi-dun." mny bi- n-pi-iiled if nwc>isary. A«^"»
the avL'ra)fo woman possesses from 8j to H poundi of blood, .inO cubic e«niu —
iiiciriw wiuikl ffpixwril from \ to } of il« total bulk. Accordingly, if U
amount nf hloo<l i>t dranit otT and replaiH^d by an infusion of an ujual tjuii
tity of salt solution, the remainder of the blood is so diluted that, for ]
tie»l pitrpoNCK. } or ( of the total poison hA.-> been n:nuivi'd. and this aid
often sullicient to tide the patient over aufRcientJy long to allow Nature
rcasMrt lii!r»clf.
It is genertilly stated that bleedini; is imlicated only «rh«n (he pulw
fufl and houndinjr. Personally, I have blinl with most e\colteul rci-n
a niiiiiliiT of patients who^e pu1:>e wuk lliin and weak. Thix enperiei
would certainly seem to show that veiiesectiou is indicated in all casctf
which dt-liviTv of the child is not followed by a cessation of the ooavulsii
no matter what the condition of the puUe.
niyroid extract has Ixvn advocated in the treatment of eclampsia ''-V
Nicholson, who advises that 70 to 80 grains he givi-n daily diiriug *:«*
attacks. It was used by Strumer in a eeriea of 41 cases with 6 deaths. ^» *"'
by liobcnsteiu in 6 cased with 1 death. Since other (herapcutie mwwi* *"**
were euiployai as well, it is impossible to judge of its efficiency. In Ihc * **?*
instances where it was used in my clinic favourable n^'sulls were not rl
The use o( parathyroid extract had be<>n sujiigMtcd by \aiiiwlc, ijul tJi^ -
regarding its value are as vet too meagre to warrant any cottclusion.
B$ iid
tif^--*:"-!
I
UCLAUPSIA
M&
In 19D4, KrSnifC emplored lumbar pnncturo in 3 cDMs'of cclampfiis with
apparmi iH-Dcficiul n'stiiiK. He foiin<) the rcrcbro-Kpinal fluid under in-
rraweil Ifusiou, and noiM a pressure of 400 to 500 millimetres of mercurif
conipaTwt with tlic norniiil of HO millimclrc^ Heiikiil liail einpbveil thia
mnuture in 16 me* prior to Kr<>Dig's report, but failed to note any appre-
ciable elTcvt. Titles tnkee a Eiinilnr Tie«', and holds thut furoiinibic resuits
Iaru mec with in n-lalivitlv fen* iiiHtant^^ and are tmually toinpnrnrv; whilo
J'liltak, after filiulring tlte bistolof^ical chan)rffi in the brain and cord, pointa^
opl that Ibe punrture muet be done vny tarly in the di*ea.*e, if any benefit
u to be derivi.ll from it.
Itmal dtTapc'italinn wa? pi.'rformMl in a caM of evlumpoin by EdebohtftJ
In VM'i, nithiiiijili it bad pri-vimii>ly t>een sujin^fotnl bv Sippc). KdetmhU'
coneiders that it nets fanmraldy by relieving the intran-na] tension, and
thiTfby favniir.t tlic reHumptton of tiHnary tM>('tion. The Kubjivt haj> been
rpviewed bv Cbamberlent and I'outt^on. I'inanl, and Sip)H>l. who helierv that
^^tl may bo nf vahie in caw:* of total xuppre<'>iiin following iklivory, but u
^Kyvt t"wi few pa.-«» hnre been operated upon to permit a proper eatimation.
Hot ita Taloe or iiM)icali<Hu. |
^ Toratrtim Tiride. which is highly praised by so many American writer*,
iia by no means a specific, and Sturmer's Etatifltios from tliv Eaft India
Mt-ilii-nl Srrvieo, vherc it wan uiwd for twenty ycani, show a maternal
tnoruilily of 4o per cent.
In view of the mark<!d liability of eclamptic women to infection, all
Oprnilive prneodiire:! mufit be conducted in the modt rigidly aMptic tnanner,
jMirtivular care beinj: taken to avoid the eon tarn i nation of the vagina and
the h«n<U of tb*; "[n-ntt'ir by fax^nl mnlmal.
^ Prenunable Toxmnlaa, — Under Ibin heading are inrlnded a number nf
^fcnndiliuna ocmrrini; during pre^aitcy and the puerpcrium, concerning
■%-bimc nature and origin we are as yet igo'imnt. but which are most read-
ily explained by i<uppo«ing that tJ»ey are dependent upon *ome variety of
«iit(vinlountion.
Tertain paychoiea clearly belong in lhi« category. In Mime cmv* tliey
^uv definitely associated with pr«-ecUmptic toxsniia, and diuppear aa the
«iDdiT)ying cnndilion become* nmeliomli-d.
^ J recall one patient wlto. during the later months of pregnancy, euffcrud
^nom delusions of pervoculion. At »uch limes large amounts of albumen
^rcri* prft^nt in the urine, while tli« urea output was grratly diminished.
>Swi.-at l>Htli§ were repeatedly followi'd by an immediate improvement in
• he cnndiiioii nf tliu urine, after which the mental condition became nor^i
^OmL, the delusionis reapfKaring, however, within « few days, lo again di>a|H
H|e«r onder tlie same treatment. Complete recovery followed delivery.
Again, some cases occur in which Uic moxt cftreful study of tht) nrioQ
^aOs to reveal the slighted e\-!dence of toxtemia, and yet the mental de-
*-anpeni*T)t promptly disiippoarH upon the employment of milk diet, Teat«|
11)1 ctiminative treatment. On the oIIht luind, nio«t of (he pxyehofAa'
arriog during the puerperium are to tte regarded aa mani festal ionii of
", and lire directly due to the abpr)rption of poisonous niateriaU
i-d by infectious micro-orgaiiistns. ^^^^^^^
M6
0B8TLTRICS
Mfliiy cnsies of peripheral neuritis slioukl alfto be re^rdeil as due to
tnxicniia, and we have already referred to its frequwit associatiaii with the
vomitinK of pregnancy. Lindemann. in a futiil ca**-, dcHrly slwu-pd that
the nerve lei^ious wore asjaiciuti-d with iK-jn-ncraliw clistigei' in bolh tlwi
liver and kidneys. On the other hand, as far aa can be oacertainml by
elinical observation, euch an as«ooiati'>n is absent in ovrtain (■&»«. but
t-veii hi-Ti' it ia piTiniwil)1<! to tN'licvt; that ibi- umlorlying fueUir inu«t be
an aiilri-intnxicalion of some character.
LikcwitK.' iiTtuin n<iii-(M)iUag:ioii» sliiii diwascs are eusccptiMc of a sim-
ilar explanalion. and luinietiinet) readily yit^ld to a milk diot and pmper
eliminative measures afler nbslinately n-slsling the usual Wat am) medici-
mil tn-iit incut. Kx^'-nivi! ^ulivalicln, U')ucH iu)iii<-timi'K tH^riirs in prc^iant
women, ia also probably due to a toxai>mia of Boiiie liind, as is particularly
»hown in tho aiM-n ii.tMK-iat('d with vomiting of pr<.'griiLni.'y. At the *»tiK
time intense salivation may occur without audi an association, ami reflirts]
all renicdiul njiaxures until the pativnt h placed in iK-d and put u))»ii a
rigon)U.-< niilk diet.
Dinnoser, iSondern, and others have insisted that aiito-intoxication
from Ihc iiitivl inal tract playx a proiiniient jiart in thi> production of niany
of Ibe abnornialittcs of pregnancy ; and the former holds that most cases of
vomiting of pregnancy artr dne to .■•in-h a i-ondili'm. and iimnidcrK that ihf
presence of indican, indol, skalol, and ethereal siilpliaies in the urine affortb
strong evidence in favour of such a view, tilat^Ksner has shown that pro-
found Kymplouis of auto- intoxication (■an Im- pr>Hlu<red expcrimun tally in
dogs by reversing the direction of inte»linal peristaUia. In !»ucJt cases
marktvl changes arc munifc«t<il in the Hrine, which consist particularlr in
a diniorlion of the relative proportions of iin niirogf-noiis c»n«iitucnts.
' Occasionally women suiTcr fmui asthma in every pregnancy, but at n<
other time; and l)ien.> i* a certain amount of evidi-mi* available whicli
points to its being duo tft an underlying tnviemia. Thus, I have Mvn wt —
cral patients in whom the n^tbtna could not W O'lrcn-d by medicinal Irea*- —
ment, but yielded n-adily to milk diet and eliuiinativo nieaxurc:<; llioi^'%
at no time could changes be demonstrated in the urine in support nf i'^C
Htoxipmie origin. On the other hand, iu one nf niy aiHi<A the condition
bsBocialcd with pre-ectamptic toxsmia, and disappeared Bnly after the i
duetion of premiitnn- Inbour.
Occasionally conditions occur during the pucrpcrium which can in-m
be explained upon the assumption of an underlying toxaemia. Thu?, 1 hi^
upcn threi- women whii«- urine wan apparently jK-rfix-tly normal go througi^
uneventful pregnaney and labour, and on the second or third day of
pucrpcrium pus* into a cnnato^e c-onditiou, which persisted for several
but from which they slowly recovired. In each in»tance a cjiroful chemi
and microscopical examination of the urine was made, but failed to ren
any abnormality. In one of my patients there was xlighl jaundice, and *"
olinipal ayinploimt were such that one wa» forcM 1o ronsider Iho poesibil^
of acutfi yellow atrophy of th<! livor. Ar all of the canes rc)Cov<>n^,
is natarally impossible to speak positively as to the nature of the und'^
lying conditioD, but notiyithstUDdiug thu ne^jslivc rocolta obtainud by th
h
TOX.EMIAS OF PREGNANCY
547
study af Iht- urim^ it » dillloult m explain iU prmlurtiAn bv auj' uther
cuppmilinn than (hat nf a profonnil loxirniia. Thtit licing the caw, it miut
lie »')miH»<) that w« orrssionallv have to deal in ot)st<?tric» with oonditions
vhicb ID all prolmliihty arr toxiumk' iu origin, but coucvniiu^ vrhcmc twturo .
we are km wt iib«>lut«ly ignonint.
LITERATURE
ZvRlniltil. (, tiyn., liUKi. xxri, 1X21-
l.'Obitl^tri(|uej
^n^Lt. Zur o\p. PathoKonoM <lit7 r.k1»iii|Miu.
IS2S.
IMK. Rat-il d^montM quo t'<r-)ani|uiiR cut iilia mnlAdio microbinincT
1RS». iu. 481-505.
Lea mtw (tea KUntpliiti««. I,'(>1>>t<^triquc, 1!)03, nil. in3-2ia.
B«R*r iiirrRiur., I^mnna ilu toie vt duM ifina ch«x ics^lampIiqueaM lea (a^uti iantal
dn [cmmcB ^lniiiptii|ui:K. L'ntmt^Iriiiuc. 1B9T. ii. 2611.
Hmc'^ ct CAiTTiiniM:- rontrihution & I'^luda dn la pathofc^ic do I'Mampik pu•^-'
p^nle, ctr. Atrliivrs ilu laM. rxp. (•! d'armt. palli.. 1HU8. k, 603-711.
iJUattt. .\ Taac o< Acuto YcUow Atroph)- ol Uie l.ivcr. Medical Rcrord. IHOS,
alviii. 274-^5.
Slaxc. Patboff^iiic de r^bcUmpMe. Archirea de lomr.. I8CH), xvii. 7'I7-7.V(.
Li'MHEini mid Zi-s-n. Bxp. und kritiiw-hc lli^itrnftc iiir Pathognicw dor EklaiiipM«.
Anbiv f. Oyii., IWW. Ixv. 736-785.
[tminn. I^^na air rauto-iiiinxiratiim. Paris, ISII7.
L'rre i>k Sti.sT Hlaihk. LAiiuiis aiiM. (|uo I'oo trouve daiu I'tebtiipsie. Tb#w de
Puria. IHOI.
Foie el Arlathpne piierpt^nle. Annaleadej^n.et d'obri., IMSlI, xxxv. 48.
Iji» autn-intoxiislioiu gravidkiucs. Aniukn dc gya. c< d'obsU, 1808, 1, 343-374 «t
43i-tS5.
Quek{ucs ca« d'acvht <ctlainplU|Uea aana albuouDUrie.. Aanaleii de gya. el d'otxl., '
two. bv. 7(i 77.
(iutanii^ Wueheruiiiipii dea Sj-uL-ytiutna. Zenttalbl. (. Uyn., 1897. sxi,
«jtTria. ('-onlnhulinn i^ rilludu iht I'^laiupno piterp^rahi d'aprrfa un« alalU-
tique <k la Clint.iue <(e l871'-i»(W. TIimu <le I'am. IM".*.
SKItLfivr. ToxiHt^ dr i^iin iii^ktcnial c( fn-lal dana im am d'^danipiac puor-
ftnle. .Vn-hivea clinjqtiea <l« B-vflvaox. 1894. -lii-iM.
ItoetMfelMS cxp. ct anal. path, mr lea rauaca de b mort itu fa'tua dana I'tclanipai*
paerpArak. Xouv. arrh. d'obsl, ct de gyo., 1805, 17J>.
^-^H 1 Manu.KNT ct Dkmont. Itn-Jiercbca exp. aur la toxicity de I'urinc dana lea dcr-
niera moU de la groaaeaae. Coinpua rradua aor. do biol., 1H02, iv. '£T'3H,
rtuMfKJmnu. Ki-lampaie Mna nlbuminuiie. Trait4 prstKiue de« accouclmaeDU.
Pana. 1SH3. i. 009.
Traltcmeat de I'MampNe. .\iiiu1m de gyn. H d'obit., 1S9S, xliv. 488.
CoDlribulo alio atudio dolla alUmiioni placentatre nella e>?tanip«* piter-
pHsle. tjvoted tnna Am. Jour. Med. .S<i.. Oct., IWXV
lALB tt Bi'f;. Faila h I'appui dc la lulure micrutiii'RiM de rMampiie puei^
pAnUe. ComplcH rendiia aor. de biol.. IWrJ, tv. 244-245.
•mw^N. A No^vlTreatRicntofUbalinuteVoRiitiiiKinPreipiaBcy. Brit. M«d. Jour.,
1873. 1. BST-rOH.
Arm. Tbr Pm|>liylAxi» and Tmtnieot o( Bdampaia. Tboiapcutic Gaaettv, July
15. IBnS: aton Trans. .4iner. f.yn. Sof.. IHH.V
Edanipaia, .\iiUi- aad Post-partuni. Anwr. Jour, Qtwt., IBOB, xxxvii, 4C7-480.
548
OBaTETRJC'ii
Db la Barpx< THaUncnl of ICclnnipsit- Jour. Ulwt. and Ojru. BriL Emp., ISOfi.
Ix. 102- IM.
DfcLoHr: ct RnocT. M^moire «ur I'^tiolo^ bnot^rienne ite I'^dompdc lUatunt 6ant
I'Ari-h. du tocoloKle, 18S4. )i.(l2l.
DixKNT. Kritiacbe Stiulien iiber <lic thtllio^DoW) der KUiunpidc, etc, Arcbiv f, Gjn.^
1802, Ixv, 36»-i64.
Dm EkbtmiHiicgifl. Zenliulbl. f. tiyii., 1905, xxix. 354-304.
DiSMOSKR. rirr Vomitiin gmt-idanim pemidainui. Wko, 1901.
I>6DEitutiM. Zur Frap.' d«r " Eklanipsip." Zentnlbl. f. Uyn., ISOS. xrii. 1.
Dt'nnmcN. Ilcbcr KkUiiitHii«^ Thdl II. Archiv [. Gyn., 1803. xliii, 40-101.
UOKrAX. Cliiiiral LticMircnn Hepatic Diivasc* in flyD. And Obnl, I^mmIou U«d.Tin
kod (mxvtlv. 1879. i. 57^59.
EnEnOHLS. SitrRicRl TrentmRiit of iiriRhl'i Diwam. N'cv York. IWM.
KiKiAH. TboTrwitninil of Purrpi'fal i-Iiknipsua. Mvdicul Rucotd. December 2. IWfl,
and JMmiiiry 'J. IKOi.
Eujcr. Obs1(.tri™l <'i;nlf. Xcw Yi.rli. 1H73.
I'ltnt. Eklampsic! ohiio Aiifallu. %^>ii(nilbl. f, Cyn.. IBrw. \\\. iWS-iW.
Kwixii. The Pftib. .^n.atnmy nod !*atbvgciicnii of the Toxvmia of I'ngBaacy. ,J
Jour. Obirt.. 11HI3. li. [45-165.
EwiKc and Wulk. Tbc Cljuicat iSgnifiaiuice of the tTrinary Nitrogen, ete. Am. la
Ob«l.. I907,iv. 2WP 33a
Falk. (WtivUe li.vdTO|)iM'hH Dogenaratioii dcr PWcdm bci einer QdamptiMtea.
Zratralbl- f. n>-n., ISJIT. xxxi. 1073-1078.
Favre. L'vber uine M«tbodvi d«r NVphntrtnniie uiid iibcr ScbmutRenchndMiiani i
I'^kmpuc >uf bitkt«ruiI-ph,VBkaliH<b<!D Uiuiii. Virrbov'n Arehiv, 1892, cxxq
40-61.
KxHUNO. Die pDtho^ni'flC uiid Delmadluii^ dcr Kklampwc itn Licht« dcr bcalig
AnM'hniiimKvii. Volknisiin's .^arninluiiK hlin. Vorlra^, N. F., 1809. N*r. ^4$.
gritl und Palhogvouoe der EkUupsie. Verb, dcr dcuUebeii GnadL f. Gpt., 19
239 -261 .
KincNKR. Tbrombi Coiiipowd of AicglutiiiAtod Red Blood CoipiudM. tlniv.of reiv'
■ylratiin Mtxi. Bulli^tin. 1002. So. 0.
Fon<i<Hr.iMr.R ami Stkw.^rt. On the ToKicity of the Urino. Amer. Jour. Mci
Soion«s. K*:pU-tiiU-r, 18Q!I, xv. 297-303.
Fi^M u. Ixii«KttMA?t\. llfbcr dcii Narhwrin von Fbiirhinilrhiniln: in dc't Zt-rebn>-
MpinHlHuwiKkuil [■^klaiiip[iiK'h<>r. Ktiitnillil, f. (iyu,. lOOC. \xx, 41—43.
Ubhukb. Zur Avtiolo^e der I^le^pe^d-ukknlIlMl■. Z«ntnUbl. (. (iytt., IMS,
37» 3M-1.
Ulabm.xbr. Bxpvrifiieiitvllt<K Ciber die Obntipuliun. Wienor kUn. Woch
1904. xvii. 1205-1200.
GoLnBRRii. B«itr»K xitr EklanipHi*> nut <in,iiid voti 81 Fallou, Archiv I. Gjm., U
xU, 395-320: itod 181)2. xUi. 87-102.
Onnn*. Pusrpftra! l'>Unipiiia. TmnK. Araer. Oyn. Soa., 1803, xvui. 141-174.
Odenard. Etude de lu punu&tbiliU n^nale cbcx lea dcUmp4ique« p*r lo prooMI
bleu do mfthyl-^ne. ThAao dc Van*, 1898.
Haeolsr. Zur Fre^ "Ekl&inp«iebBcilluH" Genie*. ZentnJbl. f. Gyn., 1802,
090-998.
HAi.BKRTutA. L'ebor die Aetiolojiiie der EkUmpda puerpenlia. VotkmMin'a J
lung klin. VortrogB. 1881, Nr. 212.
F^klampma Kravidanim, Kjti<^ n«u« Itidikalionw4C«Jlung fiir die SocUo
Ruf. Zeiitnilbl. f: V.yo.. 1889, xiii, 901.
HiuiiriN. Contribution K l'<tudc du diapioiitie dc i'hopalo-lOKhdniie ^luliil^B ~
Th#M de Paris, 1809.
ISOS. ndl
TOX.EMIAS OF WIEGXANCY
549
t
Verb. d.
Ztttochr.
TUwdoj
UENKKt.. ITcbcr Lumbotpunklion bei KkLunpiit. Z«nlrtlbl. f. Oya., 1004, xxriil.
r 1339-1334.
^Haarv. Zar Theone dct Kklnmpidp. Zcntmlbl. f. Cyn. IWZ. xri. 230-233.
HiMtBr.orr. CoiukWration mi U pnthofif^i^'c '1'' rAclftmpaie puerp^nlv. AniMlna de
gyn.rt il'oJMr. 1893. xxxix. 1-8; 109-120.
IiMiBBB aii4 VMTTfiK. .\ lliniiil Rxperiiiiciiiiil Slucly of ttiwmu. Anter. Juur. Ued.
SctsMM, 18&4, cviii. 177-193: ■X.V-J^H.
l:faKBsuEv. Boitrax «ir Alliiiiiiiiiunc wahrund dor Sr-hvHnmnrbafl, der lletmri und
der EkUmpair, ZvUnchr. t. Cell. u. «j-n.. 1881. vi. 171-'.flJ.
, JtvoK:!*. F»iini)lkcJi iiitd MelA>ta«c von Lctwrtcllen IkI i':klam|MriG, *t«. Uurliner
Idin- Wothmnrhr.. 18811. itiiii, JSIS.
LTKMiurM. I'clwr tlypMviaada Kmriduram. iScilMhr. I. (!rl>. u. Uyn., 1891, xxl,
300-aO8,
(l^nMi. 5lullipcl ].<!hrrMlki)-(Iimi»l>iiH.-. '/.ieiAer'a Ik-iln'iicr, 1888. iit, l-:iO. j
iKxArr, KliniMdiir Knihiu-liliiiiKi.-n iilwr CklnmpiiUr. Iti-rlin. IHtM, I
ttfihcrr pticrprrnlp tlklnmpiw uml ik'n-n BvluiiiilluriK, Rcrlin. 1900.
PK•■UJ'>^'^. i^ur ArlioloKir tim) Thi-nipic diT t'.kliimpcie. ZMiltulht. f. flyn., )fl07,
XKxi. 341-346. J
Kvi^Kln. t'cbcr Ijunlurpiunklion lici KkittaipM?. Zcnirulbl. F. (iyii., 1004, ll&3~^
MSA and IMl-lM'i.
KiTna uttA Fi'TK. Exporimen telle triilvrsui-bi>iiKi.-tL iilwr HkUtiipsi«.
dMUrhim ^k-jitU. f. (iyn.. 1901. 313-332.
HAW>T. UtmerVungi-a m deo bioloiciacfaen Tbonfirn dor KkUmpriu.
f. OA. a. Gyu.. lOOS, liv. 244-281.
Lu<oM. Conlrlbutian i I'AuiIc de <|iulqM>a (imnHi Miornulos d'fcbnifMio.
Pacw. I8»». ^
LiMamox. Let irt^ma et Ics rotiquv* hcpatUiun tht* Im f«raine* on 6lal <te fvit-
(wnlitd. Tlite de Paris. 1808.
KLzvsk. Cum of Puerperal CoDvuUioiu,n-itht{ctiuu-kL Ciu.v'iiHaapiUl Haporlc, lS43,j
|V'LKTt!R>irrr(.-ii. Q«kt«riok>iturbe UnUrviwliiintt dea Blut«i bci Rklunptie. (VorliidiRBn
MitliwOunK-l Zcniralbl. I. liya.. 1890. xxdi. 138.V1387.
Lnmu-VN. Zur Avtiokxcie ii. Thcfapie der Eklunpno im Worbeiibett. ZrotrdbL f.
(!yn.. IWIQ. XXK. 603-008.
Zv AcIMoRia dor Ekiampiw. liimchcBor iStd. Woc^icnirhi'.. lOOA. Xm. 15 and SI.
iJXMnUMX. ZtiT patlL Anat. de* lUMtillhttnti Erltrtyliriiii der Srhvnuii^rcn. Z«d-
inJU. (. allR. FkUt. n. path. Amt., ISOZ. iii. OZS-A.W.
l»a»<iTmM. I'm o( Tbrroid F.xtnwl in Eriuiip«u. Biill. hyiug-in IluapiUl, N. Y.,
IflOS. p. 68.
UOm-KPt. ZuT llAiifiKkGil. PrognoK und Thcmpic der ICkUmprao. Verb. tleriteuUrben
ikt. L fiyn-. 1B9I, 177-1711.
{.traAMtv, Die Puctpcnt-cUsmpiie. KrgebnlMe der kUr. Path, und path. Aoat.,
iai6. 1. 113-174.
Hf tutflvbr. r. Q«b. u. Ojiu. IMk^, 447-473.
^^Lwow. Hypetwneas Kraridarum. OcuiMbe Medidnil-Zvitunf. IDOO, xxi, lOIS-tOIS.
HiM. KT PtiBiu. t>u point congdlalinn et de la tcaitre ca phloraras du «ng et de
I'uriiM, etc BuIL da la acx. d'obst. du Piuii. IWa, v'm. 2.12-271.
1lun<(. V««iii<Im uber den Einfliua inlrxveaAirn liij«rtioi) von PUtcnlAr-miliatant
auf dem entanen (^ncutiMHUa beim Kaiunrben. Moiutic^hr. f. (ieb. it. Oja.. 1B06,
xxw.saa.
ex. j!t*)>'baapT<Mlukt4i d<-^ Sloff^wliseJH afa Unnrlic der Eklninpntc. Rvf. Zen-
tiaU. /. <J.«.. IBM. XX. 1208.
lUnutB, <^°t«d bj Lafoo. I
^
sso
(IBSTETRIfS
HBrBR-Wmw.. Klin. Stiidic-n libcr F.kUmpnic. Arrhiv f. Gyn.. 19tM. Isxi, l,%.
Nkwku.. Erluiiipfdu in tlw IWmIoh City HoHpltal (or the Patt Kiftwn Ywra. Boatou
M»rt. and SurR. Jour, Novcinbcr It. 18OT. '
NiCMuuuix. Ouc of Piicrponl RcULinpiiia Trcal«i) hy 1 jinw Uimm otThymitl Extnct.
Jour. Obirt. und Gyu. Brii, Kinp.. 1904. v, 33-37.
Oi-HtUtmEN. Dcber Rklunpme. Vollcniiinn'M Sniamluits klin. Vnrtrdffc> N'- F., IROIJ
.Nr. m. I
Svttio CitmanM woKon Kklainpxic. ZanlralhL t. (ryn., 1900. xxiv, 03- I
Opik. Zonul .VerruKLv <ir tlw [.inrr. Jour. Medititl KaMttarFli. IIHM. xU. 1-17-167. I
pKiJi I.EttKDK.x. Heitrnffc imt pnlh. Anatomic dcr rucrpcrsl-ckUtnpibc. Virebnw'fl
Arcliiv. 1893. cxiii. l-4.i, I
Pick. I'cbcr HypcrcincnH Rravidamn). Volknunn'* Smumiiuig klin. VortragiE, N. Pj
Pii.LiKT ut LtriENNK. LdaioHa du foic duiia rMniupnti nvoo kt^ro. Noav. arrh. ,
d'obat, cl do ityn,, IfiSB. iv, 312-3I17. I
PiNARu. 1)(3 In dwapdulntion rftialo lionii I'^ulainpuw. Aiinaloa ilu fyti.vi d'uli«>.>'
190A. 2nic. K., iii. 103.
POLLAK. U«ber Luaib&rvunktion bei Eklanapaie. Z«ulraUil. f. Gyn., lUOG, ttt*
870.
Krili>cbe-vxp. Sliidietj tiir KliriJk der ))ll(^^p«lnd«ll F.kUmpMO. I^ipiif u. Wian, 10M J
PoBAX. Tmitciofnl du I'tfcbinpnic piitrpiSnUc. Anuak's du Bj'n. el d'obst., 1900i, Ui,,f
T9-9ti.
PirTKK. 'I'lHllichu .N'ophritiii bvi (ivburwuduD vluie Hkknv|taie. Aivhiv f. Gyn., I9U
Ixxvii. fitSHU'il.
Pkwt«. liclwr d*n ftiwt. V^rhnUtyn dor Xierm Iwi dcr I'lirr^icml-pklanipHli). ZoiUrlr.
f. CJeh. .1. tiyn.. xxtii, 189'.'. 1-S3. j
l?eh«r Eklanipoie. V<iRinii~BdlAjtc An drittH'h, incd. Worhonwbr.. IHU7, l!H. I
Qutxf'XK. .^puti- libera irophie. Noihnn^l'a nput-ii^Uo I'Siih. u. Ther., 1899. >*to-l
Raykk. Traits do nmlndieB d«w rainii. PnriH, 1839. J
RnKiiiTiui. l-fui tirtva <l4t» iVkiinptii)iti!it. TH^m; Ac Pari*. lOOA ^^1
RiriF.RE. l'iilliuE^ii[- <■( Irail^'inont di- r6;iiiitipBii.'. Rins. 1880. ^^|
RcwRNHTKiN*. Tcbor ICklurtipsii?. Mnnatjurhr. f. (Sfbuituk., IHftt, siiii, 113-430.
ScHtLD. Sefim Ffille von Nitrobonxol-wriciftiinK. Berliner klin. WucbcnK-b*
I8fl.\l«!iii, 18T-I89,
ScnLrnr». Zitr Rklampwd ohne KTitrnpff.. Z«ntralb1. (. Oyn., 1907, xxxi, 107-1-
Soiuip. l-:kluni|>«i; bi-i Mullvr u. Kind. ZeutnUbl. f. (iyn.. 1897. Kxi, StX-Vtl.
gatMnni,, Path. anat. rntrmuchuni^m tibcr I'licrpcnU-rklatnpgrii^. IjcipiUK. I80S —
Zur L*brp von der gkUmpMu. Archiv f, Tiyn,, liW-', Ixv. 50I-Gi».
St-HitiiKOKii. QHotiMi by InRcnOcv.
SotiTMACHER. F.xpcr, Boilriixii «iir KklarnpHic-fntRr. Bnltrilfte tiir GA. u. C^
IWJI. V. W7-309.
Sntn, Rxp, ttntrnnirhiinficn mir I'alhaecnRBc drr IJklampnic. .\rrluv f. C-^-^^
1906, lixvii. 63-98.
SiPPKi.. llic .Ncphrotoinie bei .\nurii! Kklamptindier. Zenlnlbl. (. (iyn., lOM,
1311.
SOTBBL. Cnntritiiition h I'l^tudi- di-i ixn-l^ii 6cliuuptif|u«<i «t pltm pwitwuUiiw di Im*>^ f
thog«nie>. Pari*, 1891.
SnwiEi.KKHi:. Kin Bvitnu; lur lA'hrp von ditr f-'klarapfilo. AinnMNiM im & ^■"
Arrhiv 1. (iyn.. lH70..i. 383-3111.
SrnwAKT. ToKifily o( tbu Uriiiw i'l Pptunani-y, Am**. Jour. Obat., 1901, »liv, l^*"*"
576.
Sru.tB. Toxn-mia of Proiciianry. .^niRr. Gyn., 1903. iii, StS-ASQ. ^
TOX.EMIAS (W PREGNAXCV
55t
SnuuK*. The Toxirtnia ot Pr«Kiuiir}-, Amor. Jmir, Oliat., I!>(>r>, Ivil, I'l&'lBl.
SnHMAworr. t'eh«r die Bchatnillung <Jur EkUmimc. iCeiilnilM. t. G^n.. IMI, xxi,
1303-1313. I
SruiucKK. riNt}r-oiiwCai«8<if F^^UiiifitiM Trwited hyThyroid hxIrsnL Ttkdil LoiuIohI
^^ Obrt. Sof., 1901. xl«i. I3B-
^fcAkxiKR «i CiiAuaKiuJiVT. Sole rrinilvii i In rvrbafi'lM) da b losldiA du tiAniui ma-
^H gam <Ui» ttxux Ota il'iSrIaniptiiD. CVmijiUw rvn<luii <le la w>c. du l«i>l., 181)2, iv, 17^
^V 182.
^HFiuii>nn.i>KiL Anib* Atri>i>)iy of (lie Liver. Zieitinnii's C^'dupeilia u( IIh- I'ractiMi of
H^ Modirine. Ani. rd.. inm, ix. 242-305.
^Phibs. L'«bur Liuubirpunklion Iwi Kkbriipxiu. ZvulRilbl. f. Cyn., lIHMi, M» O.'iH,
^"'ftiOKnio.'c. The loBuenveof Sodium Chloride oil iheSwretiuiiof Itfiiie. Britinh Mod.
Jmir., ]«XI. i, T!W.
(AM tiKtt Rekkih. Uvlwr die Qtltiitkcit tin Hani«. 7rf?lUrlir. f. klin. Mnlixiii, IBOB,
xxx\. S2-T9.
AX MB Vblob. Ekl&iDptbi puerpundif (srdifortua. Ref. FTnmtuol'ii iahraalMririil, .
1807. 752. '
UULIL Raf. rrommel'sJnhrmlioriehi, tiMj.'). \t\. 41)1.
Aquio. VakuT iGBcnoBtniue d« I'^lt^valioii d« la iiiwdnii nrUrli-Ue au rttura tie.
I'MUnpaa iKicrp^ralp. Itull dc In «nr. d'olml.. I'srii. lOOfl. ix. 34-4(1. I
^Vbtt. ret«rdie ttehandluuK <l«r EUaiiipiiu. K>tge'» FMl>chrifl. tHUfi, iUI-120.
^H ITahcr .\lfauininurie in der Si^hwaiigencliall. Bvrlin«r klin. U'ui'hciisdir., IWi, xxxix,
H .^l2-.'>4n. Nrv. Ti aiid -J3.
^B IKe Vencal«ppuiiK d«r ChurioiixitiflD. WieshadcR. t005. 1
TinjiAtin. Exp. imd Lrilivhc 8tiidirn xiir I'athnKpnue der lAlaropnic. SlonaUwltr.
1. (Wi. u. flyii.. 1HW7. V. 411-137.
Wm-nntHiiT- Ffp. t^tiidtni uticr die Kkliini[urii:. Ilculirhe airtl. Warhetim-hr,. IDOZ,
x.x»Hii. 6.'4-«.'S, So. 3.5.
WKiOdiAairT u. PtLTX. Exp. itludicn liher Kkluniiuiu. Ifctiiacbe Ried. Wocbeiufhr,,
^^nairNKV anij Clapt. I'rine ChauctB in ("nvnaiiFy and Puurjwral )^'laiii|iMa. Ainer.
^ fij-n.. low, iii. 121 -itm.
%^'u.Bm Kin Kail ran t^inptialilU dvH Kii»l«a Ih-i tliUiiipHiir di-r ^lull«r Zctilralhl.
f. Cjn.. 1883. SftV-SeS.
^VtUJAlO. PcrukiiHIv VnmiltniE ol PrcKnamy. JfihiM Hopkins tl'iii|)tla] BuUeltn,
IUWB, s»-u, J I -»■_'.
ToMtnlc' Vomlriiitc nf PrrKniutry. Am. Jir.r. H«d. 8d., IW)». cxsxii. 3-'3-35*. '
tnt-ULi.. Uhriiurfa der (wtnirtjihitlfp. IMI3. M. Aufl., 536-.S47.
l)t<-Kl.KH. Bnirag xur l^hrv \-«d der Kklampou. Vir«'liaw'« ArrhtT, 1808, rlir, IK?-
333.
iMiMBK. Ziir modenwn Lvbrc der EklampMC. Miincbtuwr ineil. WorhciiaBhr.,
1(NM. li. 7-11-
mSM. 1^ Fall ma EktainpM« M HuUer inid Kind. ZentralbL f. tifn., 1805,
arMOXUn. Rcf. Frommel'ii Jakn-Bbcriclil, 1005, xix, 804.
iilMIIBIIl nnUTBiifliiintcm ii)>cr die Blutltcwlialfcnbcit uod die Hanindirrtina
bri Eklnmpar. Zt-itarhr. f. <>!>. u. Gya,. 1903. I. 3H&-407.
Zur Ri>h*iidtiiiiK <i<^r KkUiopien. Brrk-bl iibi-r 129 hier l«obactitrfc Kalle.
Zartfklfal. f. liyn.. ISB5. xix. I'Jcn-rJIH; tJ3H-l'i.V>; I2QA-12T7.
Zur Aufklamnil der Hklain(>nr. Arrfaiv I. Ilyn.. I<J04. Ix.xii. I-!*?, luid Ifla't. Lxxri,
3.TB-.5ft>.
<;Ul dr-r QitatDpoe u. ibre CrinwqiMuiieu (ur die Bebaudluug. Miiutliuiter mcd^
'Mtwudtf- )«O0. liii, 207-390. ]
E
■ ^
CUAFTEJI XXVll
COMPLICATIONS DVE TO PISBASKS .INIt ABSORMAUTtBS OF TBg
UKS'tlHAriVH THACT
Diseases of the Vulva and Va^iUL — Varirfx. — Varimw roin.-* 8otiiftliine«
appear in liiv lower piirt t>f (lie- v!i};ina. Iiut an^ titorv Hiiiimnti around thu
vtilvA, vrbi'n- t.lii'v iiiiiv nltiiiii (-mixidi^nilili.' |>rii[Hirliii[i:< iiikI givi- risv !<■ a
eeoiiatioD of Vfuiuht am) dUcomfort. TrcaUneut has practically no ertert
up<Hi Uic liK^tt condttiou. In rurv iiutttiictif tliv variva may rupture during
pregnancy, though this accnlent is more frequently observed at the time
of labour, when profuMi and oomi'titntai fatal hamiorrhagv may rv»ult if _
appropriate s\irgical treatment is not available.
infiamm'ilwn of Bartholin's Glands. — I'yogcnic micro-organiBin* autyr:^^
gain ar(^-H> to Rartholin'fl glands and gira ritte to abooesa formation, fsr^r'ji
§uch cu^cs lliP labium maju^ on the side alfoct«l hecomiM svrolK'n aii^^
painful, and on exatninntion i* found to inoloae a Iarj;e collection of p!i^=s_Aii,
Most often the infwtion is gonoirlitpal in oripin, though other bacteri ^— ia
arc MomctimLK a^ui^iatod with the gonocmcuw. A«ide fn>tu Uiv pain on^^rnBid
discomfort, this coniplicatioQ U always a po»<sibIe source of danger durin^^^n^>
labour and th« pucrjwrium, since it may be Ihi; iilarting-point of a putr-^^r-
peral infwrtion. For the?>e reasons, whenever a labial absoeaa develi>]p-w^
during pre<nmney it i^bonld be o}K-ri<'(l up and drained; or, better stiT-aU,
the entire pun ^ac aibould ))e excised.
Relaxation of the Vaginal Outlet. — In multiparous vomea the cmpL^mBm-
tinu incidenr to pn-jfuaney not uncomiiioiily causai the anterior or ]>OBteriu
vaginal wall to protrude through the relaxed or torn outlet as a dixtiir
cystoc^ulo or rcx^'towJe. Tlii,t condition isi generally awoeialed with dmggi- ~^^i
pains ill the back and lower abdomen, and often intcrferw) with loconiotM
It in not umt^-nali1(> (o trfntnu-nt during pregnancy, though tiie nymplu
may be tetniiorarily relieved by rest in bed.
Va{finitis. — Tliii cntiiplication has already been considered la Chap
XXV, under the beading of (ionorrhoea.
Colpo-hypfrpiasia cystica. — Tliin rare condition, firat diitcribcd
Winckel. is iliarnotorized by the presence in the vaginal mncosa of nu]
oufl smalt cavities filled with clear fluid or gas and forming elereti"*-^ "'
upon its surfaco. Although not amenable to treatment during pregnais-< — '-'
it Wiually disappears soon after childbirlli. Th« nwcarclic* of Lindi-ntA -^
nindcr it probable that the diwHsr. iu many CAsf^ at least, in due to inf«^^^^
lion with Rncilhi* terog(-oi-!< i^psulatus, and Jaeger has been able to prodKn*'
it ccperimenlally in animali;.
5S2
DRVElXJPMtXTAI. ABXORM.M.ITIE8 OF THE UTERUS
553
^m DtKuet of Uie Cervix. — Endoc^rvicitU. — (JuitorrhoMil infection of the
ccrric*] ctoal i« frvquuuilj^ o[M;rr«<] during prvgiiitiK:)', tbv must protuiiutut
Mjrmpioni Ih-id^ a pfofuso luul peraidtent Icucorrhica. The trcKtmCDt hoM:
■irawly been mniiiderad. '
ICarriiionui.-^About once in 3.UU0 rasm. acconllD}; to Samey, pregnancy
ia complicstetl by «»ri'inofiia of ll>e cervix. It is ntoxl common in womvn
lNttirei-n llw thirtieth and fortietli years of life, two thirdii of tlie cases
ciiIIm'Ii^ I>V Surwfv havtU); ixi-iinwf within thin iImmi^i-, whilv tltu jount;-
Bit pati(>iit waA Ini-tily-xix ycariii old.
Ill tin; majorily of inKtnnow. t)iv condition has extxttrd Iwfore concep-
tion, hut may mtake il.4 appearance during pn^aocy. A hloody, fouU
nndling vaginal dif>c)uii^ is vuggrtlivp of malignant difiea»c, but unfor-
fmutely the early ata}i[ej are often unaccompanied by «y>riploiii!), and may j
enatpc di4<Tliim union a vaginal cxaniiiiation to made for some other reason,
and sQ indurated and excavabii ultwralion of tite cervix i» di«covere().
I'n^uiticy tends to bring about rapid growth and extcfuion of a pro-
existing carcinoma. On the other hand, the iiiulignanl diwJt»e inf1ueno<(«
j^Lprefi^ancy very unfavourably, alMirtion being noted in 30 to 4(1 per cent^
^^«f the caM». It likewi>« predii^iroiics to tite occiirn-«<.-c of phiocnia pnevia,
■nd at the time of labour markedly incrmw^ the risks of infection or
Rpnntnneouti rupture of lb** nt«ru8. In ndvnncni ca>H>!t, the cervix may he *a
indurated by carcinoma I ou*; infiltration that dilatation is eitlu?r Impo^eible,
or may be accompanied by profuse )ui-iii»rrhn);e. In t>4)3 (»a«k coUocUMti
by tianrey, the mortality at th« time of labour, or during the puerpcrium, .
wtm 43.3 prr cent, 8 per oust of the patitnbt dying undelivered.
^H The treatment of pregnancy complicated by careinoni« of the cervis
^Hiffen acvording to tlit- period at which the diugixwis ii> made and tlu;
^Kxtent to which the disease has profrreesed. If the condition is detected in
^Bie Sr«t half of preguanvy and the procnw lias not rxiended btyoiid tltv
^Kvrvix, immediate bviteroctoniy should be perfornuM], Sarvey having re>
ported 26 ra^nal opiirationx without a dmth ; hut I connidi-r Ibal a radical '
^K-lnlominal operation will materially increase the probability of a pernia-^
xs^nt Clin.'. On llio otlwr hniH), if l)i« caw is inoperable, gotaliim slwuld
allowed (o continue in the interests of the child.
In the second half of pn-guancy th« choicr of trcjitment is based tipon
Lnilar indicaijon.", except that the large size of the uterus materially
Emplicates vaginal hyxtcnytomy. Ileitce. if a raiheat operation appears
Tuiablc, laparotomy should be performed and tlie uterus removed un-
i«)«L In inoperable cuwv pregnancy should lie allowtnl to go on to term,
t» ^^ then, if itponlaneous delivery ia out of the <|ue>tion, Ciesarean section
■tTrnmiiLd be performol in the interrvts of the child. For particulars concem-
^jr~g operative treatnioit, the nvder id referral to tlie articles of Sarwey
^^^*d Noble, the latter having collected the results obtained in 16fi caaefrj
HPfc^rvni iK-rween the year* lfi8« and I8;i'!.
1^ Oevelopmental Abnormalities of the Utemt. — .\bnormalitif« in the
Hp^^Tdopmenl or fusion of one or both Miillcrian ductir may reanlt in mal-j
^V'*>nutiafM which sonetincn poww^t an olj^Uftrical significance. Variouft ^
y *'BgrREB of inalfoniiatioo — from an almost total absence of the nfents oo
554
ODSTETRICS
the one band to H» flupliuUian on the olhvr (utcnu (lid«lph^) — are «D-
couutcreti. The acroiupa living liia^rams (Ki^ 4fi8 to -Kid) give aa idea
of the Duture of Hit- more- important vnrictii-s.
Pr^gDuii.')' niaj' he ii*»CK'i»U'il uiili itii> wm »f Uumu ■ualfiiriii«Uoiis, |>rcf
Tilled all ovum tie cast off from tlw ovariet) and
no »i-riou$ ob>tiivIi- bv opprMvd to lite upward
paisagv of the iiperniatoxoa and tlteir subse-
<liivnt union with it.
I'reijnanfit in thf Rudimrntary Horn of a
Itouble Vicrm. — In this condition the courw of
pn-^naucy i* t'liiHiiu^l lu KcriouK nioditicationi.
We ou-B to Mauriceau the lirst diMcriptwu of •
i-^ii> fif this chiinii'li-r, lint idiuic. Win time i|uile
a nunibcr of e.\amplt'9 have been re[)orted.
In 78 per cent of the fH mM-a i-nlliiliii fntni tin? litt-niHiri> bv Kflhrer
ia 1900, the pruxiniul end of tJie rudiiueutary horu did not ouannuoicate
Vta, 4fiB. — DiJWMiAM or Utkh*
m Umioomim (Kahnir).
Pl0.45g.-
■Pn:Bt5« PniCTuio-Dnntt»tiT«
(Kebm).
Vta. 400.— U-mtim Bifounir Rl-MJtx
(Ki-linO-
Flo, «ftl.— Uteiiv* Bitttiwi" SKPTtm
(Kchrer)
Tta.*ta.
Vtittaf Ibcowm Ukkkiulis
l-rKnVX ftlCOBKB tTKtOOI-LITI
HvillUKVI MIT lI'MLt (Kdll*"'"-
witli the uterine carity, so that in thet^ pregnancy must have folI« ' ^^
external migration of the ^[lerriialouia or tlie nvuin.
^ELOPMENTAI. ABNORMALITIES or THE UTERUS
555
Thr occurrence of pregnancy in a rudiriieDlnry liorn in dependent upon
Ihi- i]t^vv)ii|>iti*;nl of luirnial decidual and pint'vnol tusue, and U aUo iwrcom-
pABicd tiv th« r<innHli<i(i of u diviituii in iIk- non-prvgnant lioni, a^ wvll
m* by ■ marked incn-aM^ in iu ci»^ riiit^v tlirn- it tnx rommnnit-ntion
U'tw<T-n Ihw iwo tivrDH. which is but rarely the case, a pregnanoy in tliia
Eituation i* a very ■eriotii' iNii'iirn^iKx-, Miittv niirnial dclivvrv t» trupo^^iUv.
|jf iIn! mnwular tixeuo of the ntdinii^utar; Iwra is poorly developed, as is
Tio. 404. — FxraKAXPT is a RrfiuncstTAKT Ijtrr Dmtitnnc llmuc. KxrrjtVAi. UimATKut
or UTim (KtUjr).
• HMWifi h ririrwl fruKii Iwbiiul. To (Si> rixlil ■" •►>•• ir»n-diT»Ioj»il ulmw, wliirh. artrr
II Willi fi^ Ihv ttilTiial imt, ilrviaU-- 111 iKi- "aht hhI*. ,^I1iic)i«n1 Ut t1ii> n»mu U Ihv ri||tit
lutw, wkleli k» iioniul. T)ii' iivmty a uS lliv ii>uul ■!»'. uii( a) lu liibrr ami lo>v*r porlioa ,
b Ibr rs>r]iUB tul«uin of pn^anry, ti|>nngiii)( fn^iii ihf li-fi Aido ui lltf utenia At IS
.WUttImI o* U ■ iBUsnila/ baml; on trmciii|{ Ihu lo llu? Irfi 11 inon(« into Ihp tudiniMiti
' bonL On (Ihi t>ii>lrnur ■nrfxv ol thii bom w • laiiK clit irtimriiliHK ''*'' (">•)>*
TUptarr. PnrtniilinK llmiugh lJii> mit arr- plaro-iiMl naiuaiw, Tha ii-fl liitia
nil (nan III* aalr* ulilr ut tliii niiliiiii-nlar}' liiini, Tlii- Mi nvB/y in HatlrtMiLJ
niw linn nil Um WPll-itrvrloiinl uli-rua ialirslr llir line of llii> Mrtin' cavity.
Km i,e.J,' tjullaiin> l)ii- mimr nr tin- lull MiilUr'n iJiki. Uvtweca euuld ll Duntaini ■
AuMm; wlim it a r>|iracni«l by iluiiol IIdh ii oonaina o( a «iUil oiuicular funL
'**'*a«9lly the caw, sponlaneouf mptiire occnra wilhin the finl fonr months
1^^ Icada tu Uiir dvnih of t\w pnlirnt from intru-pwritonenl ha'morrba]!
T^«-« accident was noted in 8" and 4T.C per cent of the cases collected by'
^^^*»(pr and Kfhn-r n^pi-c lively, in IHH4 und IWiU. The marked dilTcr-
iu t)i« percentajres ih atlriliulalile to greater ai-curacy in diafcnoniji and
l^**» frvqneat rvt-ounte to «i»fraliv« interference, since the appearance of
^*»«er'>i work. On the ollwrr luind. if tW muM-ular tissn« is abundant
^P* pregnant !»om may liv|i«rlr'ii>iiv iionnnlly. aixl the prtynaQcy go on
^P** tenn, the ftetus afterward heing gradually eliminated by rappurative
V"x»»Ksea, or converted into a Uttiopa-dion,
556
OBSTETRICS
•
llupture is slvay» attended by «erioiKi intra-peritooeal faamorthage,
which usuhUv «ndK fatnlly if operaliTe procvdunM htc out uud<:rtuk(:ii,
82 per wilt of »!udi pati«nt« ia Kchrer'i* wriw haring iierished.
The existence of pregnancy in a rudiitieacary horn can occasionally be
reooguiiwd during the early months, a positive diagnosis hannt^ but'u mu«k
ia 20 per cnnt of Kehrer'a caoes. Whon a tumour corresponding in siie
to the duration of pregnancy can be detected alongside of what appeare
to iw the sli}()il1v onlargiil ntcni:', lhi< condition wboiild always be tliouj^tl
of. In diffyifnliatinp it from a tubal prejtnancy, it ia important to re-
member tbtit in th« fonner the roiiiid ti^uiRut i« f«U coining off from the
distal side of the tumour in.'^tead of from its proximal or uterine portion.
In the Iat«r months, a diagiioniit U ut>^ually not made unit) false Utiour
sets in at term, when tlie uterine cavity would be found to be euipty. In
other crtsi.-i' labour diwix not tKviir and the child diw; but no abnormality
is suspected until one attempts to empty the ntems, when it ia found that
itii cavity i* empty and that tbt- child lie* in a mc to one side of it. In
such cases the ^ac nni>t represent either a pregnant lube or a rudimentari'
horn, and a nalit^favliiry dilTrnntiution can ulwayji \k made by d«tcrintntni;
the location of the r'>und ligament as de^crittcd above.
Trftttmrnt. — If Ihv condition bo diagnoi^ttciitvd, trcatnuMit consists it:r:
prompUy opening (he abdomen and amputating the pregnant Iwm. Thiei,
OiRTUlion wa* first pcrfonned by Siiiigur in lt!K4, and ha>i since hewn r*^
peaied on -14 oivasionn, wiih a mortality of 13.3 per cent (Kehrer an*
Wells). Too frcqiicDlly, however. th« first suggestion of the uxistcDce
the abnormality i* affnnlcd by the »>*inptom8 of iiitra-peritoneal h<Dnio«-<
rhage, and an operation is usually undertaken in the expectation of flndic
a ruptured I'xtrii- uterine pit-gnancy.
{'/■••grMiiri/ In I'leni.i t'siftiniU. — Occasionally only one horn of If
iHeriis is devfloped, tlie opposite tube and ovary being lacking or arisii
from the lower portion of the uterus. In sueh cases prvgnsncy usual
pursues an uncvcnlfnl course, and the condition ia only occidculolly mc
nised at the aiilopiiy lahlc.
Prfffnanrtf in V tents- llicomU. — When the two boms of the utenis
well devi^liipcd, hut no coiin<s^tion exinU bei.W(>en them, a.4 in uterun di
phys. or when they are partly fused, as in tbt! variouQ varieties of ote
hioorni*, prHgnamry may oi«iir in either horn. In the very rare in-itai
in which a twin pregnancy is observed, the two ova may occupy the t\
born, altliough ikkv and again an ovum ba^K been found in each.
When pregnancy occurs in one horn of a bicornuate utems, the otr
undergo<« KympiiOu-tic hypertrophy and a distinct dwidua ia formed in-
cavity. Ordinarily there is no interference! vrith the course of pregnaw
and «pon timeout labour may bo looked for. Much more rarely tbi-
pregnant horn may partially fill wp the jielvic cavity and give riiw to »«!ri*= "'*
dystocia similar to that produced by tumours of other origin. Nagel ira*^^^*
fion« thni- ca.'K's in which labour could not pTOe(*d unlil this stmoluri' /' ""
been pushed out of the pelvio canal. In two other instaneai — one repur'— ^*'-^
by I.>ohlt-i» and one obsem-d in the Out-Paticnt Pcpartment of the Jnft^^'*
Hopkins Hospital and reported by Bettman — the non-pregnant liom o^^
1>I8I>LAC'E]I£NT8 OF THE LTEKUS
nff7
^^ htnicUal Uw yehiv caTil.v ami Rave rise to niplure «( the uterus. lu the
Isltur case, ttic i-umlilioii wiu iivl R\^;igiii»<Ml nl tlw tiiiH? of Ulwur; tbo cliild
preAenleil bv ibe breech anil wxn o.\tra<'1<Hl wUli <vinNi durable diUViillir. The
^^ womun (lied thir^-eix hours later from a gubpcritoDe*! haiiuaioma follow-
^m iog at) iiicom[>k-tc rupture of tlic uterus, vhich ww clear); due to impactioa
^^ of tht> un(i-pn.-;,'uatit horn in the petvia. Werth lias reported a caae ilU
vtiicb the n'>n-pn^};niint horn bcvntni7 ivtrofli-xod. 1
Thv diajfuosi!) in usually not uiaile, as in th« majoritv »f cwvn aponJ
taneooB labour occurs at term; altbough lUlban states that a pathogno-'
m<inic *i^n a afforded by the paljialion of the vc«ico-rectal ligament, as a
]d extending upward from the bladder over the top of the uterufi, aolj
ling iMttU'Lvn till' two round ligaments. Our owd patient had given btrtlii
8 children witliout any su^piciou of the existence of tlie defonniiy having
Sonietimi^ da- exislent-e of a double vagina or a douldo ocrrix
its one on tl»e alert The former may occur uith a norma] uteruii,
rbpmtn the lallt-r iimdition altixnt invariably indiuito iht- rxiiiluDCie o^
double, or at leajit a bicornuate, uterus. WIwii there is only a sin^lai
errix, iw in utonu birorni* unti-nllix, tho condition always c««tpCB ob^r-
raUno. Dnieits the fntient is subjected to exuminatioD at an early period
'i pTtrgnnii<y, and ll»« dfprtwion noted betwfun the two halrvs of tbo
leni" niy*^ w ilue I'l the true niato of affairs.
DtTcrtioDla from Uterine Cavity. — Fri-und and Sehickelv \iaw reported
Btis in which the pregnancy develojiod in a diverticulum from Ova
iti-nnv cavity, w that thv fo-iMB lay in a nc xurronnded by uterine muscle,
mI connected with the main uti'rine cavity only by a narrow paMMi^. It
apparent that it would be extremely difficult to reco^ise such a windi-
onlnMi the fln^rs wore intnMlui-iTl into t)M^ ulortne cavityi and tlial
may fi^e rise to serious complications at the term of latiour. '
DUpUcenenta of the Qteni. — Anltfifzi'm. — Slight di'^'row of *nto-
rion are frwinently obt^ened in the early months of pre;;iianey, but an.'
mally without sijriiiti<-«n<*. In th»- Iiikt montlw, pjirticiilnrly wh<'n tlw
IviH is markedty c<)ntrBctt'd or the alxlominal walla arc very lax, the uterus
ay fall forward, llw i^KS'i^K being occaoionully m marked tluit the fundus
ijdoably Itelow the lower margin of the sympbynifi pubis. Kven in
rkcd in^tancee of the som-hIIo] prailulttu abdumm. the patimi may
iitJain of varidUN aiinoyancM, mun^ eH|)ocially of exhaiL-iion on exertion
,. *M >tniKjnD)( pains In the back and lower ab<loDicn. Marked amelioration
'■■^Bsiafnily fnlbiw* lite wearing of a properly fitting aUlominal cupiiorli-r.
Anteverinen of the pregnant uterus is occasionally observed in patients
'*^^«»o have pretiiHisly licen swIijivImI to operative proeedun-A for the relii-f
*** nuiptoms incident to retroflexion of the ntcrus, piarticularly after
al flxatton. k^fi fmiutntly after an improperly performed ventro-
rion. ami now and again after shortening of the round ligaments.
•n is accompanied by marked discomfort during prepnancy. andJ
■ of labour mav pivc rine to H-ridiui dv!>to(ia. which will hn
tl«n-d in rhapler XXXIl.
Rrtrodisptarrmrnt of ih* i'ttgnnnl I'trnit. — R«'troflexion and rctro-
f*^>liini of Ui« uterus are fre(|uenlly oWrred in uon-pregnant women.
OBSTETRICS
uniiallir cauik- more or li^^" triwuiviniii-iiix'. {hough wcaMmnallv Ihn
wnditioD nia.v exist for yeatv without any abnorms] inanifetitAliou. In
women who have ui-vcr Wriie children, inllHmiiintriry or othpr chan^Res in
the cndoKn;trium, n^^ultini; Imm ctrculalorj- dt.<[urb8nf« iiR-idiiit to tlw
displacement, otfer a serious oijstacle to tlie oixnirreooe of pregnancy. In
paroui^ u-nmvn. on the oUrt hund, this inHufuce is le«« pronounced, but
pregnanpy, wlten it opcunt, is [imiii; to oaHy iiitt^miption, n.-troll(Uiion bviD)^
one of the nio*it frequent caiiirLV of spontaneouii abortion.
In the viist majority of rastw of [inigiinncy compllculcd l»y retrodJEpUce—
ment», tht- utcrru« wai; already out of place before eoa«eption; alUwu^lk ,
ati hifci hii>n pfiinted out by KcitUT und ollter>s (he abiiomuUty may tri^ ^
during ^<.t<liilion.
Prfjiniiiicy is «ion> frotjuwitly miuplic-atcd by retroflexion thiin by relrr z
version, though the latter usually pives rise to more serioutt »yinptoins.
either rase wvcml evcnliuiltti<» an- po^i'iblv; Ihe displaeetnuol may undfr;
spontaneous reduction witlioiit anv in term pi inn to pr«?jrnaney ; al>or(
may otiur: or, if nrithiT Ukcw plfuv. the utt-rus may beooniu incarccra
in the pHvic cavity and wcriouw cjuwiiucncea follow.
If Ihc disphicixl uU-ru>f is not niHKrrciit. spoiitaiwons n-ductioD usu.
occurii dnrinj; the second or thin! moiirli. This is rewlered pmaiMi.-
HTi cccc-nlric liyjHTtrophy of the or^^r^
ouin^ lo which tin- anterior wall
eomcit more rapidly distended than
jKWlerior, kimI <'ni«.:^
ing alwve (li« supe-
strait erentually di— •« *
wp tlic rr^t "f till" "«-■ *"'
nw. After Ihe far^^iu*
)ui.s nni-e pasH.ti ^^
promontory of ih^ •*<•
(-rtnu tlicri^ Is iki few
of a recurrence of t-^
cnriditton. II or<^"» *'"*'»
sponlanonuff reducti*
is not wholly out
th<> iguestion. r*
when udhcriion^ <■*
since Lbcy often '""
conn? >tn-tch4'd airf '^"■"
ca>^ionally disapp^ *'
without any <"^^j"
fcrs better pn»f-
than retroversion ; indeed, a- lliihr^^en and Keitler havo pointed nut. v\;
llic latter iiimlilicHi i> iiinrkeil siMintamHius Ter>titulion is almovt impo^ilili "^'
for iIk- reason Ihal llie cervix riws ahow Ihe sympliy.si« pal>i«, while ib^
fundus is held back hy the pioinontnry of Ihe sacrum.
In a certain iiumk-r of eases, especially when the fundus is finalj
^
^
Vta.AOIi. — HAccuLA-noN or RrTnon.cxKa PBi:a»*sfT Utb«c»
at
- •♦n
DISPLACEMENTS OF THE UTERIS
550
wnt. jircjinaiic) may ntnitiii uniiil('mi}ilcii for n lonj; while. Tliia
ifoKiOj^atioD ii rcnilereil jMwttilde l>v ()iv markftl iipunni grouib of tlie
inU'rinr wall of tlie uteruH, whil« tJH- |)»sUTKir wnJI ri-tiitn» its original
lituation aiid forms » cavitv in whi4>li one polt? >if iW fivtiM ix TiHaifl«<l.
ETiw w-caJIcd sacculation of tlie stenu has been dewribod in detail by
))d!iam. n^ihrs^n, anil nllu'rt. Owing to tlti^ abnormal position of tlio
enix and !)»■ fad llial the prt^eiitin^ part licH far below it, serious diili-
^tit* are 1.> In- )-ji|KCt*d at tlw time of lal>our, which will be wMuidcnfl
,rhD(.kT xxxii.
Abortion is roininon in pregnane itv* ooinpli<'atcd by rcl rod ik place men bt.
tuKtuillv occurs in the conrre of the third month, when tli« growinj; uteris
F»>i, 4M. — iMrApdnitrinw nr RKmii-i.i.xto t'>i>.<>N«!n I'TUitn (Hwy*ii-r).
wHI fill* tl»e peUie cavitv ainl, l»enrnning irritatoil bv tlw pnynure
'liicb it IH nabjcctcd, bcRii^* to contract, and thus brin^ about the
IfUm of Itw ovum. In oiIht ra.-u4 tlii^ almrlinn n^nlli' from an eudo-
rill); which may hare etir^lol ticfore the on^rt of prc^inancv, or have
' produntl by cirruUlorv itistiirhunw* incident to the di''t>la<'<Miient.
^* termination is particuUrly likely to occur when the sacrum posscssea
V>urkcd vertical concarity, ^iocic iIm.- proj«c(in|; promontory oppotes a
"^OQd olRtacle to spontaneous restitution.
tt pregiiat>c>' c>ntiuuc» aud tiM- dii^pluccment U not reduced in tlte
*tTin] coiipic of i-vrnt", or a.* the rexult of nianipulationa on the part
* the physician, tl>o uterttii will continue to increase in mui until it com*
""^Wt BUa the pelvie cavity and. U'inK unable to free itself, becomca
***I>*rtHl, and wp hare what i* known a.'^ in('irf>Tii(i«it, TntowBrd ctfect*!
J*"** to pmoiin*. «>riH' on >Mi«neT in «'( roTernion than in n-lmHev ion, for
r«n*on that in the former ll>e wrvix conipreHsefl the lower portion
hiaddi-r at an earlier i)eriod. Incarceration ix aecompanied by
rintio Bvmptouii, tlie wunuin (»mplaining of pain in the lower
560
OBSTETRICS
jmrtion of the abdoiiKrn anil back, and disttirbancet) in the fuDctioiu of
tlic! urfMiru, bludilcr, and R-ctuiu. \* the pelvis booouiM mure and mon
lilled by t]ie ^'rowing utt-niK, the pre»ure upon the neck ot the bladder
and urutliru Ix-iumvs «o intense Bs to vnutu rvti'Dliou of the urine witli
cunKiKjia-iit nvenli.-> tent ion. Heed, however, holds dial tlie ischuria shoDld
not be attributed to mere luectiauic-nl pressure upon the urethra, but i^
due to compn^^iou of tin- {H-lvic >;anglia bj- llie Vwdy of the uleru>, witAi
rcKiiUin); jiaralyjiin of the motor nerves of Ihc bladder. Itut, whateier > %■
cause, when the retention has rcaeh«^d a certain limit, tiw ovcretrctcli-^^l
viccus Mju«e»« out a small amount of urine ■! freipicnt intcnraU, but ne^^tr
eniptieii itM^lf — pnntdoTimt iticontinence. If the condition is not a>^B>^n
reliwed. the symptoms Itoconio more intense, eystitis develops, and ^tk
bladder walls Invonie Ihii-k and irdeTnaloiiK, llie iiriiio luvmrnv hlnmly, i^^^nil
eventually pingreiie of the bladder may result, necrotic portions of its lin »ag
membrane l«nng wist off and finally t-KpelUt! through ihe urethra »^- iOi
iiitenHe erflm)^<-like pain». In other crises the weakened walls of the bla'L^1<:f
are iinjibU* to withstand the diKtenlinti and rupture occurs, followt'il l> J' '
fatal peritonitis.
()tfa.->ionally the iiivruif may undergo inflammatory changes as tlw
Bidt of Ihe pressure to which it is suWjecleil, and become densely adhe,
to the .■>iirn>iindinK parts, whilu now and af;ain the organ may be fo
down and out of the pelvic cavity and emerge tlirough the vulva or
In some c»»w the ix^-tum is coinprfswd to such an extent that defcca*^
becomes impossible and gangrene results. Ileus, however, is an esoeedi:
rare complication.
ttottschalk foiii"! that Ihe following were Ihe m"»t frequent cauw»
death in G7 eases leporteit in the literoture up to 1894:
of
IVritonitiM of \-e:iinil nrigin . .
lineiiiia . . , ,
Kuptiiru of tliu Nudder.
Septira-niitt of vunintl origiii .
Gatigrono of the hlnddor .
17
l»
II
i
3
oi
A r^-trodicplBccineiil of the pre-jnnnt litems should always be au§p€<^ ™
when a woman in the early nifnub* "t pngmincy i-nniplain« for any If "-^^
of time of frei)ueDt and painful micturition, especially if there is a hiat^^'J
of antcciiinil utcnne Irouhlc. hin>ntirienei; of urine <Uiring pregnane*-^"' *
a niost suggestive sign, and always calts for a thorough va^jinal e.\an»'^^"'
tion. With the bimanual method, the soft hmly of tlje >it«nis will be f«i
iH'ciipying thr pelvic cavitj, while the cer\i!i is fon-ed up against llii'
pbysis or Jies above it, according as one has to deal with a retmitexMP ^T-^
retroversion, It should be remembered that a pregnant tube ly-ing biifli^^
the iitonis may give somewhat similar signs, and this paesibility sbouH w^^
be ruled out until careful cxnminution has nhown that t!>e slightly etHttftC^
uterus d(K'K not lie in front of Ihe soft mass.
Trratnifnl.^it the condition Ih- doteelcd in tlw first thrw montln ut
pn-giinncy. bimanual Te|H>sition of the uterus should t)e attemptiHl. tJAti
by traction upon the cervix by means of a tenaculum or bullet forrepe.
DISPLACEMENTS OF THE UTERUS
561
^V^liyftaitioi) liae bfon efTected, a property Btting Sinith-H(Ktgi> p4»Mry
■bid bi- intniduccd. On thtr ulhrr hiiHl. if tivsse simplu tnana-mrcs fail,
m patient i^bould be left alone until well on into Hie third monUi, in the
pc that c{Miiit«urou« mliiction may «tUl occur. If this lias not taken
suj bj tbal time, ii nionr delL-rniiiiid vfToii at rcplocciuvnt otiould bo nudo,
lib llw patient in the knee-i-hesl pcMilton. If tliii* ]>rov«% timtuccesHful,
Biction can nifually be i-lfcctcd by bimanual manipulations under anas-
l^'h«n denM> adbeeionii are present, various procet!iin'!i havt> bom reoom-
■Jih) — till- foruiblo ultvmpt to bmnk tlw^m up under anK^tbi-eia. altompttf
Kkmcq tbeu by meann of a aucoeiMion of vaginal packs, Uut cotj>eurynter,
■he " VAtchi>pring " penxary, from (Imi aec of which Sinclair hat re-
■ed excellent reaulta.
■Gmerallr «p«iking. Ihwe methods are not to be recommended, and if
B ntenu canon) be r^placMl umter Mn»«lh(ui«. Inptirtilomy iihotild be
Bormcd and the adhoiions ^.'paratcd under the (^idanct^ of the eye. as
Bmimcmle*! by Mann and Fry. In several of my eascj< Uiifl cour^ vaa
■vued with moiit nati^fiietort' rr^ulte.
lun tin' otiur h«nd, if Miiiptniiis of incartK-ration miiicrvenn, prompt
■tmcnt i« impenitiTe. The bladder ishould be immediately empti^.
Hi cannot nlwayn W aooomplixhttl with iIm: ordinuiy- ftinah- aitWtcr on
■rant of the elon^lion of tlie urethra and neck of the bladder reenlting
Bm the di^placr-iiiciil (Fig. -IBfi). «o that in many cam's a long, rtoxibli"
WrameDt mii^t be employed. Its introduction may often be facilitated
Bmaking traction npon the c^rrix with a tenaculum. After the bladder
B been emptied, atlempti !>hould be made to replace the uterus — under
hithoia. if necessary. Itut if tht« cannot Ih; cITci-tcd, mo#t authors
Biw emplyinjc it immediately, either by dilating the cervical canal or by
brtonn;; the corpus Ihnmgh the vaginal tbuIi. I belic\'e Ihal bvtlcr
BBllit will be obtained in mch casoit by laparotomy. This operation,
Brtfer, ^bonld never be attempted if symptoms of infection or gsngrcae
m (invenl, i^incn thi^ weakeneii anil netmiic bladder may )h- injuml, or
Km adbesionti may )« encounten^d which have formed mer'the uterus,
■Kically ithutting it off from the alMlnmiiiul carily and Tvndt-rin]; the
manf of it almost impot<sib)e. tinder these circumstances the ubtitetrician
Buhl mntent himself with emptying llic ntonis in the most con«<Tvntive
Banef, which iwmi'timft* in ljp?it elfi-cted by incising its posterior wall, as
Kvnginal hyptcrotnmy. and then rely npon palliative Irtwlment.
I Xtfl^ra/ huplacementt of the Pregnant Uteru*. — iijlight degroef of lat-
B displacement of the uterus during pregnancy are relatively fi^quont,
■ wrually have no »>ffect npon its cours*' and do not give riw to symp-
Bi. It aitould, however, b« ttome in mind that iiimihir conditions are
Kn'times mistaken for talnl pregmtnev. In tvo caMM repotted by Lolilein
B Oottwhalk the uterus had undergone a considerable degree of torsion.
I Irfi margin showing marked rotation towards the right, which in th«
Mnd cue wa« associated with retroflexion.
MPnbpn of Ihr Prnjnani UUruif. — Impregnation in a totally prolapsed
vu ia nvT rare oo account of the difficulties «tt«uding • sncceMful
562
OBSTETRICS
«>ilu«, l>ul if the prntapdo is only pHrtiiil if if coinp<ini(ivi-I_v fn^^iueni. iii
dui'li <■»>€= lh*r I'tniii. uml odaKiniHilly u |K>rti<>ii of llio 4»qntB, may pro-
trude til H frn'OtiT iir U-sxt <'.\t*-nt fnim Ihc vulva diirin^ (he i-arly tiiniitlis
bul nri pn-KiiaiK-y jii^rosucp iliv iiU-rtm gradunlly nHot tip in tbe pelvia,
and, »s Mxm tu it ba«
~~1 piiKM-t) Ix-vdiid tin* niipfTioi-
i^lniit, prolapse ii^ no loniff «
poesibli*. On tUv nihijs'
tiani), if i1 rolain.4 it^ atn
narmol position, fympt'ii^;-
i>f iiii-iir<rtTali»n hp[m^:^
during the Uiiixi i>r four— ^
muRtli. himI ulH>rli4>n in K_~
inevitable result, there
ing no c»*v» on rt-win!
H'bich prt'jinanry lia.f j
gn^scti to tiTtn vrilli
itlerua nutAide of the btr-»«
If tbt-n> id a (<-aili
■ ■iwunlii pnilajM^ du
preKnanoY. ihv nt
i^lioiild In- n-pUui.-<l und IvanA
in position hv « »uit.^l)li
IKiwury. If, liowrvM-. ly
)M'lvic lloor be too rela&>^«l
to pLTinit its TPlwilion, ''i''
putit-nl I'lwiiild U* ke\A tn •
rcL'uiiilient |»o«ilion «»• **''
aK possible until iifff-r •*"'
fourth iHonlh. Wbeti ''"'
ccn;iK n-adit^ to or *ti>i'"
ly [»rntrii<le# from "*'
vulva. IIh' gT«"te*l dei*"'''
ni*!"!* is nti-essary, a> «'*''^'*^
cased of fatal tnfpclioii haw l)nii n-portcKl as oiTUrrin^ t-ren nilbnul '**'^
intterDit examinalion. If the utpruii lift* oiii»i<ti> of ll»! vulw uxl »«i"*n
be replaced, il nhordd be promptly t-mptied of its mntenlK.
\f1ii-n (he vagimil outlet iit ntaH^-dly n-lnxul, th« roiip«ltsd ant«>rtor-
posterior msinal waltn not infrequently prolapse during pn^rnanrv.
t)ioiig)i ihf ol^Tus may !<till rctuio it*; normal poeitioR. This conti'^
may give rise to coi»idera1ile diiwninfort and inti)rfen> with Imyiniot
It ia notamenable to treatment until after delivery. At the tinu- of !»*■
tliCM^ (■frm-lure* may Th- fonvd tlown in front of thw pn'«onting pari
interfere with itf descenl. When thi« occurs they should bfi «r*
rl«nit«fd and put^hcd back ovc-r it.
In rare instances a lieminl protru.fion may occur through Ihi- v
thi- anifrior or jH)»tiTior wall formini; part of the sac. Such a ■"
entrrocrle iiiav form a tuinottr of antsidcrabli^ >ii»> filled with iut.«
P«(i. <CT.^PlKiUf">:ii P«i,"ix*>iT I'lMiirH (Wonniv).
DISPLACEMENTS OF TUE CTERUS
563
has roll«ctoi] ?7 iiutaiicc^ fmm (he literature. IT tlic condition
I during {inijinaiirjr, Um.* (mttriwiiMi .ihritilil Ik rc]>liived aud (he ft-
tept in Um! rvcuiiilwnt potitjnn. At the thiii' of Ulmir it iiiai' svri-
inliTfvn' willi tin- Jiihiiimr nf tin- lu-iul. In kiii-Ii vvufm tin; niiim
I 1w piuiliLil up if |>OBsil>lf, and, whon tliiit cannot U- il»m-. it ntiauld
tl out of Oh- wuv an vn-ll n» nmv Ur. aud lliv limd delivered poist it.
ftperlruphu: Elonijttli'in of the f'errur.— An ahiionnally eloiigiitut cer-
rioufly inlerferw willi tlie occnrrcnrc of eoiin-ption. l.nt. aw o rule,
tal romplieiite ilii- <i>urM- of pi>-;{n«iii-v or laliour. Tti« mint usually
Kchorler and ntore dilatuble ao term is approached. In one of my '
Wt tfie »«|r'""' I»orlioM nf i)w rt-r\-i)( in th" iwrly monthx wh* 5 COl-
«s in len^h and the external o» protruded from the vulva, vhereu >
it luul uiHl(T)(<>n« niarkcil Miflming «iid l>ecnm« rediK-ud lo Dunnal
Mon^, eo that labour oceurreil i-])oniaDeoi»ljr.
Mil" tHiinna of the CVri'W.^In very mre infttaiKi=< llie crrvix. par-
rly ita anterior lip, may becoiuo aeulety wdi'matoun and attain sucli
rttoui 8H to pr»lriid<- from iIm;- vulva. "Wu* condition i« referabl«
I ansiont?iiro!<i%
lay diMi]i[M^«r al-
ia Kaddealy as it
prd. .folly, in
ttoA aide lo cul-
D caaet from the
Hie.
mtjo.— pK^inan -
•lUTinj; in aoni-
(Terinif from in-
I h*mia w wi
\wvd liy tho ooii
. altlmUKh. o«
II llw iniTniiJH-< I
ihduminal pre?-
tlic pn*\'ious de-
wy tiet»in4> ai:-
led. Genera) i>
njT. th« ht-rniii
I be treated pal-
ly hy itvt and
e nf a truiw, op
I- (rrulinent U'
leferred uniil
delivery.
ny curptioDally.
tmu nuiy form
(if llie oonlenl^
inirntnal hi-mia,
wveral can* are on r»<ord in which rfii><<e])t)an hati occnrmt
vircunmlanMM. Pull literature upon tho subfuct will Ik- futind
Fro. ina.— pKKtiKANrr i« Honk <tr I'-ramrB oowTAixnr ra
IvacrMAt, CtMti. (KiHailwri).
fifti
0R5TETR1CS
in Ihc arliclM of AdnmH anA Eiiwnharl. iho laltrr having n>|M>rtw) a e*»
in vrliicli oik liom '>r s li^-v-nuinlh^' pr^nant hi<M>rnu8tP iitornH nrcupid
tlie riKht iiiKiiiniil cHnal.
L'mbilk'tl hrmm iiru frii|iwml,v notwl duriof; pn-gnancy, l»ut are usu-
bIIj- withoul offwt upim tik- coixlitioii, During tin- wirly mnnthii thi-
uteruH is not in tti« neighl>aiirli<HHl nT llie liornial npening, urhilt- lal<-r,
when iIk' fuiiilus n-achm its le\e\, il b usaally too large to gain ac(v»i la
tl. In exceptional casts, however, when the alidmiien fat niarkvilly |M-nilu-
Fiu. 400. — llui»iA or PKKQKurr Uraimt (A<kau>.
louB, 6ttch an occMrrwii* is not beyond the range of powibility. and *tvccrv
rench iii«an<t=» aie on record. Much morv common are the easts in vrt*.i**>
' the cicatrix o( an ulxluiiiinal incision jieids In thtf incrva»vd inlra-abdoir»> ™
prp*«in; intidi-ni to pregnantv. and along the linea alba is format a her**'''
nac into which (he pregnant uierus often makes its vraj-, hwng Ihen tov-f '"'"
merely hy a thin layer of skin, faecia, and pL-rilonwiim.
A similar condition i» opcasionally "Wrvftl in women suffering '*"*"
markwl (ii'i»/'r.vi> nf (hr rrrii muirlrji:. Fig. Itll* represents a (wtieO* _ ~
whom n hemiu of l!ii» kind iK^Hirnad snddenly during labonr. Ordinar' v-
Buch hernia have no effect upon pregnancy, allhougji they iniiy add mi »" '
ediy to th<^ discomfort of the patient. Temporary relief it> freqirDtf'
obtained hy holding llic utcrii* in it* normal poiitinn hy a properly fllli***
liandaac. At the time of labour, owing to tJii' Io*fi of muR'ular WW '"
the abdominal vnlU, the tvcond i^tage it liable to be prolonged. anJ ^*
employment of forceps is often called for.
Diieaies of the Deoidna.—fn non-pregnant women the eiidometrion if
frecjucntly the aeat of lesions which are grouped together clintcally lUtdll
DISEASES OF THE DBCIDUA
ii6o
thi' pWTml htMuling <>r mdometriti*. Cnrofiil hi*lolngicii1 ciamination
showii. however, that tlw term is usually a minnoiner. as ilw clianK*?^ are
p-«Tnlly tm]ihkr raUuT ttiui iiiilHriiimiinn' in ilmruvti-r. Thr inos't im-
pwrluit Tamlies a«:
)I>'|>rr|ilii«tic- i-iM]»inv(ritU— gL'niTuI liypcrplaEtn. localixwl hrporpUsia,
jxtlvpujil ^rovtiiB.
(ilamlulnr •■iMlomctritii^ — glaiidiilor Inperplasia.
luli'r--tilial fiidnuK-iritiii — l^Dfral hrjMigila.-'m.
Artili' aiwl «iiImi<-uU* Mu)oinvtriti»^)i)llamiiistory chanf;e^
IIm-m' (■■>ti()ilii>n.-> iin- ifmliilviic-s of inon- nr U-s» .liuiilar Kvioiw wnir-
riaf in the ilot-idua. cxi-pjit. <>f cmin*. thai llw latlor sue mixlifinl hy the
^iKUiIii^i<-ill i-hBnK'lcriKti<-]< iitciih'nt tri ptvgiuiQCV.
In Un- va^t majority of canes, as was first painlini out hy Veit, the
sJ*K~ii|na) afTix-lion n^[in^>Dtit Uip exlenHion <if n \tsinn already lifting at
;tii- time o/ .im'>[nan<y, con<v|tlioii occurring in a iiterus atTecied by ooe
tt Ihi* turiou* fiinti!! (if fit-
JJnl eodoinetritia. In rare
It. howi'TiT, il may Itt- pri-
try.
It i» ecnrrally Ik-Ih-vhI
ttint fiiilnm<-(rili?< is almost
i»t<t>c«»arilv ONMM-ialitl witJi
M«.-riIilj, |)m> aliDoniial *ecre-
t»*>i» of th<' ulehiH- ^Ui)d>
ini«*rfi'Hii(; »'ilh ini|inrgiia-
'i**ii, ami. eTen if fono«jtlion
'**HTt»rB. (he di>«iiNxl irntcnHU
<l(>i<«, iu,i offer a favouraltle
tti'luM fnr ttie iinplanlatioii of
111.- Kvuifi. (^lu-lainly this h<v
'"'f ii>< ju>itilieil in any marked
Ri^>Ue tif Ihtt afTLvtion, and
^ri-ry |>IiT>it'ian can ret-all in-
>l«n(i-:ii in tthicli lln- (lalifnl
"■'•i^iuiid ■tfrilf uiilil appro-
l>riut>> tnntnient h»I roitored
"'•^ *milnTnHniini tn ilit wtr-
^"al tv,n,|>iii>n. On ih«* ollw-r
"»nai_ ijifihi doj(rwii of cndo-
•^'■iniU dn not. ac a ruli', iii-
''T^(^ with wnwplinn.
lUffwf TbiiLfiiing of ihf
f''- ,„, — llrjiar. Kalten-
''' 11. Kai-i'ho«rarowa, and
""km Imve dwMTil>«l a general hypprpla*ia of the (k-ridua, in irliich
"'^nipirifintn''. ini.te«d of lierominf! thinner, a? if generally Uie casft after
IV fptf fevf month*. tts.unnw unusual proportions. Tlw rendition fn--
fkol/r nvutt» in alwrtion. a» a larj« part of the nutritito material in-
FlO. 4T0.'-DeCIDOA rOLTTIMM <ttutiu«).
5C6
OBSTKTRIC-S
'■•<>
Fio. <71.-
-RMDOMETHin* DunDVA t'YUTlMi
(Itmiui).
tetidiHl tor ttic fa-tus iK diri^led to iiouri«hiiig the <]ccidua. After abortion
»r latmur. a thickL'timl dwidun may cAuae nl>Dnn)ialiUi« in lite •m^parnXma
of tilt' iilacviitu.
hvtnliuJ Thirk-rtiintf uf the Ocadna iDedthia polt/ptuca). — In Uim
aJTivtioii fliL* tiiiire (iwiJua is i-oim-wlwt lliiokeiml, but its cliaracterislk
fcndirv (oiifii'is in ibv- [■mji.'cl ion uf irirgiihirly elijipttl, koob-tikc iiu>u<»
from the inner surface. Virehow Rr^t desoribol thU cnoditioa us deoiilua
tnlwroHu or [Kj)yp<>Mi, and consid4rn.Hl it to bo Kvphilitiv in origin, whirli,
howifvor, 18 not always tlie ca^. AblfeUl »UH&' tliat it in frequently oti-
sonvl, wliomiK Itulius boldx Kiat it occun but rarity. I'orM>nally I bavi'
never nit-t with an inMiin<-e.
Olandultir Hgpcrplatia of tht Dectdua {Kndonn'trilis decidua gtandH-
Iiirit). — Ooeadionalty niarki<(l hyperplaiUK of lh« glandular structure^ of
the decidoa is present, and ii- tLsually n^^ocJoted with peiviirleucc of Ihr
gkiululai' dini*. Tlii* HfTcclion ritiimmiily nianifeKtit ibielf by a prtifuie
secretion of clear fluid, wliich may dnijble away ac rapidly is it is prodacml.
or b« n-(aimtt in the uterus Ut tie suddenly diachar^-d . in large iiuantitiM
at variable intcn'alit — hjfdrorrhan gravUtamm. The amount of fluid ei-
p<.>lb-d viirii.w C'in»iderably, (luni^h Ahlfeld haa ro|H>rted a cjim' in whioJi
it exceeded .'lOO cubic ccDtiiuctres on twreral ooca^ioni:. This condition
pr(;i;liidi.r» tlii- fu*i(ii) of ibe dciidiia vera and n;llexa, and IheoreticAlIy tlie
secretion should Gca>>o during the third or fourth month. In tbo oonsional
instanocM, liow<'Vcr, in ubich il bontiniii'it (hroti^hnut pregnancy, it muiit
be ssHUined that fusion of thme etnictures ha« faik-d to oomr.
During the larit few \v&v*. con^iderablf <1 ii^i-UKKion has arisen ooncornini;
tliu nature at hydrorrlm-a gravidarum. Stoeckel, Meycr-Riiegg, and others
Wlivve (Ivat it docw not n>ull
from changes in the dmdua.
lull IK i^im|ily duf to prcnia-
Hire nipture of the membranea
nvA (ho i-seapc of (h« liquor
amnii, which is not followed 1>t
■ tic iinmcdiato termination uf
|)regnancy. The latter (if
Kcrvor, in 1904, collected Mt
ca.iea from tlte lilcmtiirr ia
which a period varying fmiw^
fifty In one hiindr^-d and I*
ty days clapseil luiwten (I
niphire tif Ihv mcmbraoAt
the lermi lint ion of pregnancy. In such cases (here occurs a con^taul tfi-.
ling of unuiiotic fluid, and cxaoiination of llic plaivnta shows that 'b'^^t,,^
branes havr* tiwoiiu' rflrdcli'd about the maternal end of Ihe pird. »
Ihcir cavity is far too small to t-ndiwo the fffitns. Van dcr Iloeven iDCk) -
tn 11... ..I.t ..: I 1 u:. 1 -I'.* •< !.._■ _» .. . - ' •■
^h„
*ny
to th« older view, and l»ases Jjia l«elief upon the analj-si« of speciroons ^> T'
fluid espelled, which dilTcr* from the liquor amnii in bavinK a V>vet r-^ 'r*
gravity and in not contnininjf ulhuminoits materials or urinari ixin8Vv\,
In rare ca-tes the openings of tlie uterine glands may beoMoe Oopi \\
mSEASEfJ OF THE DECIDUA
567
I
nnall rrloition cj'titii being ronn«d whkh project from the surface of Ihc
decidua, giviof; it u inxlnlntpd s|>poiiniJu.-e, Ttio nfTccImn h*» botn il<^«?rit)«l
I)}' tlfgur. sill) Bri'iiK a* e.ndutnftrHix ryutiiit.
Alrvphic UniiomitritU ilfridtia. — limlcr Ihia lit?a'liu]{ Ilogar, Ahlfeld.
and othi?Ts have dc^criktl a dim.-»t« in wliicli Ixr^^ p<>rtionK »f tliR ilwidua
n-ro and lumttinu tindt^r^ atrt>[ihi<: dijtn^ Hiniilar to tUo^ which occur
nomially in the portions cormpondinj; In tlie lateral margins of thi! utvnix.
I'hcv olTtT no MiffiTfrfl i(iM ax to it:< ft-tioloj;)'- ^'"^ (^n^Ider that it interferes
with lln' mitritioD of tiw ornin and in a frequent c-aiiw? of al>ortion.
Avulf Hndomflriliit Srciilua. — Aculi^ iiiltiiiimialory li^iiin* of the
cidua not )nfrc<|Denily follow attempts at criminal at>ortion, though now''
•ikI again tlivr may occur without *ui'h a history, casei having l)eca re-
111. ir_ i'> I I 'I >L 1 V!M .V, iiu»> X 2«nx
rtrini )>y [tooat, Emaniicl and Wittkowiiky, and othur^. Kcferenci' baa
ready liccn niadu to tlwi Wimts of the cndomctriom which are nonHHiuiM
Miiiiiiiiiti il with gonorrho-a mid Iho aculi; infirlioufi diiu-a»cs.
la one of Kniauiid '» two uih« bacilli were obtained in pure cnltura
&x>d wrrx! likewiup prewot in the Mrtiuiix. while in llie other cultures
n«>t made, hut cocci went demonstrated in tlie tiMuee. In many initanc
1 hue liwn able to demount rate llu- iiTe«en<-ft of wicei in section-',
j^hctOMinnally in culture*. IIicm* ohwnationy prove ix-yond doubt t\u:
jBlfsrial origin of the iMionii, and il in pnilmbK^ that future Invoetigationa^
VtU liiiym tlut KQch conditions are not oncoranion.
I hiTp altionhHiTn'd num<-r>iu< ea.»r* in which Ih« deeidiia prcftenlod the
^ttanctiTultc features of acute inHaiiiination, the rcra and mcrotina being
I thickenfd bdiI tln-ir cvtcmol surface covered with a jt-llowish punilent
*xaSM\t- I'nder the m)cr(»<-iij»e \h<- li.4)iuc wa" found to Ik- infiltrati.^l witli
I'qoacTtei, and presented the ti'pical pietuie of acute inflammation, with
Itiev aJ fbf'M' aix-a* of necnwi*. More commonly, howifrcr. the changpgj
tir it/n xurk^ • *'*^ i^til.v a few leucocytes arc »eea lying ljotw(«n t^
ilaiWn^
568
ORSTETRICS
lfa»1on-)t)c>' and Neumann hnvi? been altU- to (I«fn4iietrnli> the pr««;
o( (tonococfi in several ca^s of acute intlamniatton of tlie decidita; it
[trohaSte DmI mvh oomlil ioiiK nn- qiiiU' (iimmnii. and notilil sltvc lo esfilaiit
the inifiiii i>f nol a few ta.^<.'s of abortion.
'I'liv vurioii« forms of i.-ii(lon>i'lrili« diH-i<liia cotiiplicattng prcguunc}- n
the most iinporiaat fa^^lore in ll>e eaiisation of apontaneoun abortiou, a
th« fxisttTif*! of i-OTnv otiL' of ihcni xhoiild In; •usikft^d whenwcr the pslif
ooiiiplaiiis of a wiiwaiioii of weixlii in tlie lower alHiomeii assoeiatetl willi a'
RliglHly liliHid-hiniiuil (ir <lirly lirnwiiiKli diKliargv. piirticularly when llicre
ia a histori' of ^tnorrhuud infwtion or of repeateil atmrl ioa<.
It i» purini»»t))k- lo uuiimi- Ihtil fnich conditione, piirttcularlir tlie hif):
plastic form:!. MtiietiiiieH Meriounlv interfere with the iiteoliauitMii of t1
third stn^re of labour, ovrin<! lo tlif utiiiormal coni'it-teiu.'y of IIk' (locidua aii
the ooniMnjuwit (lillit-ully i'X|M>rii'n('ed in its oeparatioti.
EndometritLB is not ami-Datilc to treatnu^nt during pre^ancy. Shonl
the patienl. prescnl the jilighte--*! sifin of its i*xi»tt'n<-ft afu-r iitiorlion
childbirth, appropriat*^ niea!'uri« chotihi at onn- hv in^titutt'd. t^iuee t
oonditioii fni|iii'iitly pcri-J.iU to ii .■>li;i;ht decree, and may hecome sertouiil;
aggravated iu a !riibM.'qiit.'nt prcgnunvy.
Hflrilin. — ride;*!* it r<»iilti> from infeelion, metritis in a very rare eo'
plication of prefriumcy, and when it vxit-U wax ui'uully prwent l^efo
contvptioii, It j>nih:i[KM'i-s to atmrlion and t.-> not aiiii-nidtle In tn>aiiiK'
during pie<niancy.
Prri-utirine Infiatmnal'wn. — Wl>pn pr<>gnancy 0(HTir» in «x>men siiffe
ing from peri-uterine inflammation, considerable diMtomforl may re«ul
from till- stretching nf o!il adhesion*. \ot uncommonly abortion r»i*ul
Now and a^ain the intlamniatDry changis nndei^ exacerbation duriuj
prt'giiancv, and may cvcn(itat<- in ahBci^H fonniilion. which is accomiMniLi
hy the usual .Hyniptoma of pi^lvic peritonitis. Very except ional I y nipm
may occur and givo riso to acute ppritonitif. which usually «nd» fatally
unle-is appropriate operative mtHi^urc--" are promptly undertaken.
/'rrgnnncif coniplicuhd by Tumours. — ^I'rcfrniincy if occnxionnlly ooi
plicated by the prexenci- of ovarian or uterine tumours. Although, a*
rule, they do not muliTially affcci ilji courfl-. they fr«|ucnlly offer a mark<
o!»taolc to lalwiur, anil will therefore be considered in detail in Cliapt'
XXX Jl.
I
literati: HE
Ai>AM8. Hernial of iho I'reKiuint I'tonw. Ainer Jour Ohtit,, 18BS. xxii. 2'i5-"J46.
AatiMEui. L'l-lwr KtKtuiuetritin doi-jiJiiulia tulviusu-ixilrpotti. Arduv t. Oyii., 1870, \,
I8S-176.
HydrorrhotM unividaniiii. 1^ii<loiiiittrilia alrophiesns. I^tirbiidi <ler deb., U. A
1898. 253.
Bgttwan. a CniN) of l4tbaiir in a Riconiuate Uunis, itiiUoUn Jolin* ItopUos IlOip,
1«K. xiii. 57.
Bkei's. t^clier c^'nUliic tlcgrncratirai dor Decidun vera. An-hiv I. (lyn., I8S3,
■lfB-189.
BuML'M. ITvbcr ICndoractrilii ducjduu pnlypom cl lubcroai. Muiifbe«i«T tned. Wi
onsclir., l«iW, Nr, 2H.
!|riili-nlH in iliir tfchwanpinrlBift. AirWv f, fljm^ ISftTI
i>i iiKMK\. AuMM<4iiinK«ti, air,, def sriiwiaiigeivn liubiiniiuUcr. Arctiiv f.
1899. Ivii. 70-'i23.
t4»KXH.«irr. Fntl van flvrnii iitxiiinnliii iMimu doxtri iilori Knvjdi. Arcluv (. (
I8HA, )U(vi. ISP-MO.
EMAyiieu Zur hehn vm ikr ICndomvlritU tii dvr Schwangcnwhaft. ZoitNrlir. f.
U. f;>ii„ IW5. *x»i, lH7-litH.
PjiAXiTKL iukI WiTTKiiMmKi. I'ebor l':iMlout»tniis in tl«T tlmvtdjtiit. !!«il«cliT. t.O
u. (iyn., xmii. xxxa. Ml 11.
Fur. Cii^liolumy in itia Tnstineiit of the Iiiranrtsled rruKiunt I'lenw nltea Imdxi
|j*e, Amcr. Cij-n. and Ohat. Jinir.. I8!»9. xiv, 2S--Z7.
tH7rr«ii»i.*. Zur l^hre vou dor Rtiri'vurajo uteri gravidt. An:hiv f. Gjm., I
xlrL 358-383.
Hujun. tjn(lia(nniai>vlMi«(iir8(J)«'mD8Br*rhaft inciiWinUtcrutbitiiRits. TSmUnOA
t.r.ya.. IB(M. «xvui. l-II.
Mtmam. Kyaca-bilduniE in dcr Itenihn. Moiubwhr. f. (Scburtafc., 1M3, xx\. Sap-
pknnent'HFll, II.
■Die [intKn iter Ih.Tidun iukI diu Hfilrorrliota i^mvnbnuii. Uoiiataarlir. (. (Jeburliik.,
1K3. x»i. *M l:>l.
m-ixu iind Uaikk. BvtlnRc mr PrntltoluKiu tltw Kiuii. Vinbuw'a Arfhiv, IK71. Ui,
Iftl-IIKL
-WxxKax. Vnciiuil I->il«m(i.-ltt in PrccnaoO' >UMt lAbour. Tniin. Anm. (iyn. Soc., 11)03,
»Tiii. X>\-X>7.
''^ *o«^Kt<. t)kji IiilcMioilRinphyHem dcr Siiiden, et^. Afvblv (. Ti«fl)eilkiindc, 1008,
vuii. II. -I'i5.
'**»— «^i[. t'ubcr ailutPD Oedctii dcr Portio vugiiulia. 'Mtaelir. 1. Gub. u. (Iyn., IBM, lii,
3»I-4«I.
^-^^t->~Ti[MHJtr.ii. tHfTiiw llyin-rpluKiu dur ItocidiM *iii lOtiik ikr (imvidildl. Kritsclir.
f. tkb. u. tJyn.. lH7»,"ii. 22.1-231.
^"■■^^^^^ iicwAfDW*. [Vwr die KndcauoUitiD dcriiliUilta rhprjnir*. Virrhmr's Archiv,
IWUI. liiv, ua-iii
_ *^^^»iEiL IhiJi Nulwiilioni (tn ilajificltvn l^i«mn, lloidvllirni. I'-HIO.
^^*~»~i,iai. Mill Roitnig siw i{olr<ilkixi>in und KelniTrnniin <ivr nrliv-BnevniD (jebiir-
, »ii<m«. MnuaUmri^. t Cw!.. ii. (iyn., liHll, niii. 2MA-30.V
^•^ *:»«3rTM*i_ AslMoRiu d" Kol|>ohypwjilMi» ryalini. Wkmnr nied. WiwlionHthr.,
j^^ IWT. S». 1-2.
'***^«-.ei>. I'l-lwr ArhwrxIrvliiinK iIm ricrtin, Iwmndoni dun Krevidon I'tcnM. Itoulwho
„ »»iad. Worbco-rhr.. ISOT. Sr. H.
''^^*" 5*i, Tlip Stinanil Trwilinnnt o( Irtrduribln Itetronoxion ot Ibc 'Ir^vid I'UinM,
„ "«fM». ,AnwT. (!yti. Soc.. IBOH. sxiii, IM-HQ.
' ^-^^--mjucv. »cf rhapici ,\XV.
^ ^"^ ><irK«ir. HiKUiiiv il'iinu (oninn, (i(r. Tmtl^ dua iiMbdira (Ids (enunna gnNiKi^ 0^
^^„ lr.M,T. 1.. HfrOi,
^^^^K«-Ki'Kuu. Kih>iitl«rxl'iii|[ ohm I'DMfbrvctmng tier 8rfaa»niRnrlu(f t. Zdbohr.
f . («li. u. <iyn., 19(M. U. ^lO-Mft,
■SAf-wu EntttirknluniCNfclikr den UUfiM und dcr Sp-hwdo. Vdt'n Owtdbucb der
fiyn^ UW7, 1. .5«3-«M.
Tlnrx**)*. See (.TwiiUrr XXV.
><«u. i>ne irm„fnd aiwl 8ixly-Hx Cuiea of OkMwr of tlw Pn«n«nt UUinM, «tc.
Jmwf. Joii, ,tf«l.. IB9G. sxsiii. 873- »«2.
'»■'**'•- '»•!■„/ ifflrullexioii .>( Ibv Uraviii (tk-riM, Mr. Tranx. IriKiifam ObW. ttoc.,
672
(IBSTETIUCS
Aniida, in tho early pan of tlip nixlh century, wrote mtellif^ntly aboiit
uii hyildliJifdrni rnolc. nlllimi^'li In- Imil no ilctir iiii-H of iu naliire.
Owing lo its (K-culiar a|i]»earantf anil tlii' f«ft that il fretjupDlly con-
tained no liUL'cof « fa'lui'. the hyilatidiforni inolo Htu" u. source of not m liillc
Kpi^-ulation to ihe early wrilew upnn medicine, and all sort* of iheorie* ircw
adruocfd cnnwrning its nrifjln. As the name implies, the condition uti»
irinj( ronHidcnil to W niiulnjTniiA In the livilatid cv»l» ohsorvni in other [larts
of the hody. (Joeie. Ferey, and others lielievinjt that the vesicles mntsined
worm-iilie ^t^u■t^l^<«. !)■■ tiraiif held that ihi- vejiicti-!' were matnrr ota,
while ifonie authors tlioii^hl tliat each represented an ijarly prejinancy. It
S
Fiu. 474. — HKcniiK nr IIviMTinimiiM Hni.K, oKnivrvn rmursiUinitK or Sftrrrri'it ix'
I.X.1<»l.tN>'l> ('KI.Ul. x 7-t.
S,t ayiicrytjuiti; I'., fi»niijil r-fidrimiip villi; ^., l^nKhiuit'tt vtflb.
is proliable lliiit many nf thr exlniordinary chw» of multiple (tPstilinr^t^
n-('ordi'(l in the cariy literature, aiuh as that nf the t'onntew llapittat
nho was believed In have ^iveii hirlh to 3f>5 vrobryoa at a single laboiii
were rtuilly iiistantiw »f liydntidifonn molr.
The true nature of the affection was first reeognised by VclpfAU an
Madame Hoivin in 1827. and sinw' then it lias been universally admitle
lo 1m> a disejiM- of ihe eborion. N'uiiieroiLi iboorie:- were advani'-d a» to lY
rifiliire nf Ihe lef^ion. until Virchow in IS-lit Kt»t<-i1 Ihul the prortr^ *i
e.^u'CRtially a niyxoirinlou* ib-generaiion of the connective Iihih' ut tl
chorionic villi, and (k-f^ipiated it n^ myxoma ehorii. This view oblaini:
HVDATIDIFORJI MOLE
573
Hinitnediat*' a«v[rianoo and ]iM iU jn'onod until 1895, vlmi Marclmixl
dcm<>ii)'tralitl Uuil tlw eMH^nluil f<«liin> of ibi- affwlton wii» to be found
inot 141 iuikIi iu Ibi' KlrnDitt as in \he efiillidiiil <-i>t<>rin;; nf ihc villi. I|i-
|tiiiu(.-(] llml l*>lh tin! MiK-vt.ium iiiiil l.iiii);hiiii»\« luyi-r itf <^i.'ll)< miilerv«iit
profuBe aiut irr«)pilar proliferatiou, pvnetratiu^ XiUbucliV tibriii luvir hikI
making tbcir vay inlw tin- dpptlif of Ibe ducidiu. and nut iufretjuently
jMiiii iIn! ulpj-ine inuiiculaluro a." mvll. Al thi- hamr tiim' iW Ulo<id-vwwj)<
I of the U.'niiitiul villi dii^ufiiteurt-O and lh« i^lToma dp)^lUTai<>(l. fa ttiat in
tblvntu'iil iii>(~> it.'* itiK'Wi failiil to Inkir up tlic UMtid liiKlolo^icul i^tninit
and ill* celU prewnlwl a nwrolic ajiptarance. Slorwiver. ina-iniucli a* lire
fluid <'«nitfnl» wf lliK vmicbw faikil hi give ilio HianiclvrUtiv rvaclion for
motria, Marcbaod foil jui'tified in altrihuiing tlieni to n^detna.
^K TbiK work obtainiil uliii<»l itiiiTi<-i]ialf ntt-i-ptnnn-, aru] viR-i proinptly
^Beonfirutt^l by many inrL'Hti;;aloT», anion); whom Xi^uniaim, Fraeiikol, Pick,
^BUarrr, Sdiwab. and Van 4)>t llorvrn may bc^ mpolioiivd. Fig. 474 repre-
^■(enU a t«rtK>i) throufch one of my Apecimena, all nf wliirh abundantly
^■nmfimi llan-ltand'tt vit-w.
With the di«in>'ry iltat the «<i-oalb><) ■■linrin-cpttlu-lioma n-«ullt'»l fnmf'
« malignant prolift-ration of ibi' epithelial elenu'lit^ at tbi' chorion, and
liartti'Hlarly lliat it was piveailiil in from one third Iu iint- linlf of lh«
i<finli>d i-anes by tbv pspul»ion of ao hydatid i form mo|p, great inlereet
iiM- •■ tf> iIm- nature of thtr latiiT i-ondition and the n'liilion vrbirh it
ore to the production of lli« fornter. Tli« ^iniilarin' in the microscopic
^•tnivturv of ihf two jwilMilogiral pnnv-KW!* made it appun-iit Ihil then.- mu«t
^lenetie relatiomthip b«tweeti (hem, ami tlw (|ue»tto[i armto vrhelhor it
Inistf^ in all cam-*.
Nvumnnn. in IMUT, h«ld that it *a* {MMKiliti* to dilTorvutialf Wtwoen
tifomis of bydatidiform mote— muligliunl am) Ijcnigti— one of vrbich was
' Ihr (iihrr wu:^ Hot folloMcd by lh<- d<-V(!lopnu>n( of a clmriu-qiillidioma.
Mtw roa-iidered that in the former the proliferating epithelium invaded the
•j'mna, while in the latter tt war limited to ||k- prripbiTV of tin* villii«.
■L und rmilb-y likewise lielifve that thew nre tvro forms of mole, which
Ti^rT difTicuh to I^epa^a!p. inai^ntuch o*- ihry ihink Dtal in the enrly
H. at 1(10*1. IIh- difTercnceM an- biob^jial rattier thau hi^lological. Tliiit
!»«■ vifw l»B« been generally acoeptwi. and all antbnrilkii how ugni; that
i» iinprM^ihle to ;ir<-<]ict the noti-nmo of a given case of hydatidiform
»1p liy il* lii>li)]ogiiiil ap))earanc«'.
Marrhand, in hie original article n[>oM the sulijert, stated lliat in many
ihrovarien were likewia^i the »ni of cvHtic i*)uinge«. and St«>cekrl,
^tMW, dcmnnslrated that the cvfU wen' fdhil with clear contenl.4 and
r wallf wen- made up of luiein wlls, Since then nnmemu' writer*
■wn that the formation of the Intein cwts in a frit[Uinl, but not a
'^ttmI. a»w>cialion. In wwh eaM-it each ovary may be conTeried into a
'>'t-v>ilie iiiaii^, wboM> individtiid cyslii vary from a fvw millimclnw to 5 or
^ntimi'tro in (Imnicler,
A> liili-in (y^l» <lo not oecnr fretjuentiy. tlteir a^i-utciation with hydutidi-
^^•^>i inoh.' ha» given riw to u gn-al d<*l of diwiistii'ii, eerlain writers )iold-
^^K that llicy ulaud in some etiological relition lo thit niuk>; ttlhvn that
574
OftjTCTUKS
Uicv utt> aa<!nndar; to it ; while a third KtDU|>, re)>r<!«N>nt«il by Wallarl oiul.
Hiiiti, i.-uui>i<U-r¥ thiil ^iinilur diHiigiv irLviir in noriiml pn-^fiiBRcv- I am nrttl
[ireparixl l>> t'lprt't^-^ ii ili-ciili^ »[)iiiiiin ii))oii the xiihJMt, tiiil <v>n9>i'|t'r HihI
ill i^tmo «!(».>'■ Ht lesst lli« )itv-vnc<' iif the ry^lic fnriuutiun ie. iwifl\ a
voincitlcnci'. 'riiiii'. in oik- of mv [Hilivti(». wltow; Kitiud [iTvjjTuint'V cDdcdJ
ill the expulsion of a large mole, hnth ovaries were uonvcrteil into lar^'
polyrvi'tic liilcin InniouT^ It if unhkply, howovi-r. thai Ihi-y borv any rvln-
tion to the mole, n* thi' licsi pn-iciiaiu'v wa.- iHTftHtly tiiirmut, and xH tliaJ
lumoiirK wvK Kiit!ic'ii-iitly large to t-aiiMj )'i-riou« < tlvt'tw-iu at the time ufl
lalmur. I
CattsalioH. — Virctiow and Veit Afilve that the development of the con- ^
dition in (ie|M?mleii1 iijjun ondomtttriiit- dmn)^. ILaiX'haiid and nn»l rw:i-iit
writt-rs, howover, hold that such changes are 9ocon<iarj-. At the 1901 nieet-
ing of ihe German Gymccological Oongre«s, Aii-hvl .ilatcd lluit he had bc«i
altlo to produce the condition experimentally in do^ by destroying the
vesdols going t" llio dceidua, and thereby inlerferinif with ttw natrition of
the chorionic villi. His experiments were very briefly reported, and until
Kalisfartory and conclusive Mid«uoe «f their romwlncg* if adtluoed they J
hhould be received with caution. <>n the other liand, it ia not uuliicely i
that In nuuiy coax, at lea#l, the procue origiiuilcs primarily in tlie ovum.
plaU)<ibiIily tieing tent lo sulIi a view by the fact thai in rare tmei ol twin
prcgmincy one "vuin mtiy he pwrfwtly norma!, while the other preMut*
the lesion in ijuestion. It is hardly probable, if the endometrium ven
the primary caiiKC, that the ehangint would be limited to one ovum. Char-
acteristic wrti'it of tliii* kind have l»een ivporled by Kahii-Beiuiinj^-r aiwl
Bimtianm. J
Cliitiail il'uilory, — Il^idatidifonn mole '» n rare diiv«M, occurring, ao^
cording to Madame Iloivin, once in 20,000 case^v. On the oiher hand, tl«
Ftal ii^tit-i^ <if VVillianiKiin would indioate that it may bir fuuitd abuiit oomj
in 2,100 cases. It may occur at any period of reproductive life, hut in
particularly frcfuuiit in the third di-cade. having iKtin noted between Ihri
Iwenlii'lh and ihirtielh years in 41 and 38 per cent of the oaw.-* <tiili-(t»?dl
by Ddrland and Kehrcr n-^iKwtireiy. It likt^wiix* appear* with compara-l
tive freqnejicy after the fortieth year — in Ifi and 28 per cent of the eai««J
aceording to Ihu Mime author*. J
Tbi! process nsually comes on early in prejmaney, rarely niaking itil
appeanMU'c sftur Die Ihirtl month. When it derelojw 0(>mi>aratively late id
dix* not implicate the entire chorion; bwt whenever a eonsideralile poHiou
of the membrane i^; involvi-d. atrophic chanpec affectinjr the fcetUA are con-
-itantty found, mid Hit- i1evi-lo[iiiH-j)t of thi> latter ii> materially influeiK^->l
e>i'n when the iliwea>*e is relatively mild in character, fn the former class
of casi'!^ l)ie f(Elu» die:^ at on early period, and often undergoei) compli-t*
diHM>lution, all trace of it dlKappearing exocpt the maternal «nd of \hm
umbilical conl. .\s the chorionic villi arc nourished by the maternal bloodS
(he coiidilion may persist after the dcnlh of the foetU'', and the ^>inlu
attain considerable ^iroportions, though spontaneoiui expulsion iisitally occiiia
Ijcfore the sixth month. "
The clinical history is rery characteristie. The uterus enlarges inncii
HYDATIDIFOKM MOLE
575
I
npidly (Han iviuil. m that the fnnduf i* oftt-n found at the level of
'ir nbovi' iIh' uiii)>ilii'iu> in a woman wl\<> givm a liintor)' of U^ing onl,v llinir
r>r fonr iD'Hiths iircgiunl. Aflcr a lonj^pr or shorter period inori? or ]Bba
profuM- tiiriiiorriia^- 0i.vurA, nhtch |>t-nti>ts until the tnolc i» ami off epoD>
tantM>u.-<ly or reiiioM-d by the physician.
Iri B »niull niitnbrr of can-*, Ihv hyportropliic villi invade the uterine
wall, following the (M>un>e of venons channels, and in extreme inMlancM
ttiv entin? muwnlnrin may bvcomc diKintvp^titl. Thin hnppcDK in vitat is
known a» ilie dt^truclive mole, durneien^lie e.\anipl<>!i of whicli luivc Imwu
reportnl by Krief^tT, Volkmsuti, Jan:>l(iky. and \\'aldeyer. Now and again
the growlli reai-hesi llie peritoneal nurfa^^c of the ulnnin and givi.*^ ri>« to
pvrfontion, followed by fatal intra-perilontul hvniorrha^. This eompli-
ration wa^ ohHerred hy Wilton, Kladame Itaivin, Ourrr, and otherx.
In rare ini^tajice«, at varying periods after the expuUion of the mole,
tmM puqilinh or reddish tuiuoiir!i may appear in tho vagirin or aboitl the
Tolrs. ()D microscopic csamination. »f ler ctcii-ion. these are found to consist
for t)i« i»o«t pari of hlood. through which are aealtonM) drojmicftl villi t\mw-
ing the charaeterietic epithelial clian^«. Id a number of caseti recorded
the uliTU* w«« |n'rfi«lly nonnal, and (-omplvto exi-i>toii of Ihe nodule was
fnlloved hy jieroiaDeDl recovery. The question hafi aceonjin^ly ariwn
wlit'lhvr KUi-h tunioun rcpriMCOt meta«tit:«c« from a cliorio-t^pithvlioma or
l-'io. 475.— nmjtTTDiroBM Uolk. x tti.
IdnmoD <il UaitA-vnmi4. I) V., .IfifHli^ villiM-. Hyn.. pnili/antinc qmtyUuin;
If. W,, umiiw *idl; V„ vp'io.
^B «v«li^anl hydfltidiform mole, or whether they are merely due to the
^F~ iial tmiiKfHirlat i(>» nf purticW nf a l>eni)fn growth. Neumann and
^^ -..M lake (Ih- fornior, while Pick and Schlngenhan.XT in-line to the
r"**«T vIott. Tin- oWrralion* of Vi-it. Polen. and myself, concerning the
r '"^^^■**I*ortation of villi in nonnal prc-n»ancv, lend u M-rtain probability to
Initrr thi-nry. alHiough the iiw-slion mu>l remain to be tvttled hy future
"tigation* (see Fig. 475).
676
OBSTETRICS
A*idi' from the pofflibililj- n{ Hio ilovi-lDimifnl of a rlwrio-cpitJii>linina,l
wbkli w^durtKi iu l*i per «eiil of tin? 'iHi cafli-s aiialvzi'd by |''iu<Jlev. IheJ
hydHlidifnrni iiioli- in a •^mnw- «IFwlii>ii, ^iln;^• l)f>rl«iii| milml iin iminc-]
diau- iiit>r<ali1,v in It) per i-uiit uf tlio liJii iDnlaa<«ti whi<^h lie collcctul froiuJ
UiB litc-raturv. dutlli boing du«^' lo htcmorrliugv at tlic tiiii« of nperatioa iu
3 per cent. In perforation of llie ultrnia in 2 per cent, and lo infection in 51
yr I'liil of llic tti^cK. \
IHaijnuai.i. — Hvdalidifonii iiuilc fhonld nliiray'' Ix? siispeclPd when hiPin-
orrlia^- oit-un; in u |Miti<;'nl wIkimc til(Tii>i h coii«idrrablv larjjrr llinn JL
Khoiild In> for tlx- duration of pie^tiancv, tlmiijch in not a f«ir cat^ea aimilarl
syniplonihi iiri' n«tt<d in lirdrsiiiiiinti. A p'l^ilivp diu^noKii; muy W niiiilt! |
v\ivu (iiii- find.'' oiiL- or nmii' n>siili-s in tin? iitwinc dii«vbiir):e9, or when llio !
fin^^er introduced tliroii<;b the conical canid is able to palpnU* tlii* cbaTiuv.|
tvrii'lif j;rn|M>-like mftwww.
Treaimeni. — Oving to its inherent dan^r. but wppeially to tht- po«-
fiMv >ubH->{ii<-nt dfvcliipiiiciir iif a cln'rifM-jiilliptioiiia, tlio iiteruH tiltonld '
be emptied a* Hoon a^ a pni^ilive dia^oriiii ji^ nindi^ Ity nK'fln^ of a j^u/j.'. \
pack or a Kht^l dilnlor. tin- (t'rvix gtlmuld lie dilated MiUUeiently to admit i
two lin;^-rti, willi which Ihe (growth i^ pcvled otf from tin- ulorinc wall aiidi
then r«'movcd. Cnn- should Ur luki-n llial tbe mantpulalioiis an: niiiik' ftsj
L|fentl>' as porisiblu in order to avoid a poriiiililo perforation of the iiteriw, |
Fwhoi'c nulls aro likelv In Irnvv turn wtMiki'iiiil Ity l)i<- invasion <>f the growtli.
After reiiiovai of ihe mole, Ihe uterine cavily should once more be esplorwlj
lo make J-urc thai it is ihoroHphlr empty.
Every woiiinn who ha^ .-iifriTcd from a lirdatidifonn inole should
oai-efully wati'hed for the next few Tiionths. and if ha-mnrrhufre makes it*
!i|ipt'ariinc-<- l)ut i]lcni» *boidd lie cuivili-d and ilie i«rrap)n|^ ^ubjoeleil to
microHcopic eiiamination ; and, if ttie charaqk-ristic Ivsion* of ehario-q)t-
tlii'Iifimn art' found to Ih? pri'-senl, imniedinli" hyiil^Teciomy is imin'raiive.]
in Ihi- hii|H' of avoidiDj; nieliistaw^. On the other band, as has already!
been pointed out. vufrinnl or viilvnl iiii-tnsIii-'t-< iKva^ionallv ocour willtitiit <
any appart^nt involvement of the iiteniB. I'nder such circumstanc"eH Uicy
should be excised, hut the uterus left in placr. nt thv tiislorv' uf Bioiibir
reuses bIiowh tlwt the majority of the patients recoror permanentlv.
f Chorio<epithctiom« (Drtidwima niaH'jnum). — Tlii'i li>rm is applied to ■
very maii^rmiit vaiit'ty <if ntcnne tumour which devi'Io)iB after a fuH-leriii
labour, abortion, or hvdalidifonn niole. and in rarL> inslauees before thir,
laiit iit twpclliil from the uhTiif. Strictly Mpcakin^, ihi" MidiJ4:r1 kIiouU Ik
considered iu the section upon the palholft;;y of the puerperitim, but owing
to the fri*ipictit ^-nctic rclatiiiiiNhip of thi» lumour to Ibc hrdutidifortif]
male, it is best considered in this place.
Tlw nature of tlie firowth biu given ri«- lo a •;reat do«l of discussion
and various appellations have Iwen flujyiesled for it, ilie mo«l impcirlant
heinj; sar<-'>iim dtKiiduo-cclliilare. i^yncvttoma malignum, and cardnoma^
syncytiale.
Siiniti-r r^-ad bis fin^l pn|icr npon the subject before the Onitan fij
colofrieal Society in ISil'i, and IwsihI bi.i report upon ibi' foltowinn
A wmnau, tw«nly-lhri-f yiiirs of aye. aborted in the eiphth week awl
CHOKIO-EPITH KLIOMA
577
itevpo in<»nllu) later. At autopsy four lurp?. soft, rctMieh. fponftv tumnutx
wiirt* fnuiii] ill tin- iiUTiiitr wall, wiili iii<-tu.-<liL'av i-xliihiling nimilttr charac-
tPTLitit^ in Ibe luD^p^, iliflphra;;m, iLiith rib, hih] ri;!ht iliac fuH^a. Micro-
ocKjiic i-MHuiinuiioi) Mlif>wi,il tliai ilic tiiinoHr «iu' inailv up In gn-wl ]wrt, of
liliHiil t^pscL's lN>ui)ifo(l liy lar;;o coIIh, wliicli Siin^r iilcolilii-it n>' iJccidual
'vU*. The nii'lit*l««''^ pri-sciiiiil ii »iniil«r appiitruiKV miil Iiiul n^'tilUi!
from tlu! trai»pii nation of tuiiinur iiiaN«d tlimuKt^ the venous cbanaeK
A" Sdit];^T U-lk-i'itl ilial the tumour wsw ctvrivcd fmm divi'lim} n*1U and
ua.-i iherefore of eo«nwtivi-ti>s«i- orijtin, he tleHijinattMl it iU<-itlual Mrrumif
itr sarcoma utrri ilfcuiuo-rfltuhrf. The aj>p<'iirsiice of hi" nniin>j;r«pli iu
l>*!f;t, in wliirh ita.'« 4'oUwtPil all Ilial was ihcii known ii[>on the ^utiject,
iTrattft pmfniind inli-nvt, and was soon followed hv the publication of tnany
hiniilar vtL»*.
(n l'<!»5 I published s monofp^ph upon the subjcc-t, in which I n'pnrted
a uaiie and rolii-cted 24 others from the literature. My patient uiui a ual-
*'«o, 470. — Diinsi""™* Mii.mviw, tinowiiru Altrduui AjouuracHeNT or PMniAar
TlTumrK, X ItO.
rval woman «bo hail a Hpontaneoui* full-t4-nn labour. A wtwtc later xhe
'>oc>d a small painful mMliik- upon iIm' ripht labium niajuK, which rapidly
r>oa«^ in hixe, so that two wwIcb latur il had attained the size of a
K rfg, and rc#rmblnl a hspniatoma in appearance. Shortly afu-rward
uxx^erwMiI nflrmiic chansf'-K. which were iu>voinpani«l by a profiiie. foul-
H iX3g fliwhaxp". The patient i;raduallv grew worw. cvimlually devel-
. .J am. Dongh and IiIikhIv ex per (oration, and tinally AM »x months afirr
^i»r«i»I— y. The naliin^ of Hut vulval tumour wiin not ^UHptvted diirinx life,
g. Autopsy lhi> lunitM weri' found to !■■ Ktuddnl with larjfc numbeTV of
f^j^^ii-* *>i 'i*r\ini! 'iiA". whi<'!i n-tu'intiliil plnrt-nlul lisKue in Hpi>^arnneft
_ ^_^f f "' *'"""'''' j("'Wlhs wiTi- prcM-nl in Hie kidney.^, «pl>-<-ii, sinl ovary,
l'*'tff. ^ ^/jt*ll nodule about I centimetre in diami^tcr was found in llie uterus.
'J
580
OBSTICTHICS
fouR<J tiiich rnrinaliunH in H in>l»n<>«; liut n«il)wr he nor fuh^cqiientfl
inv(«ligttore bnvc been able to addut-c a saliitfActorj cxpltuuition of thcirfl
sig:tii6caDco. I
In IHUS. Wlsf^irow and >Schlaii^DliHiifi'r tnado a contnbutiou, wliicti foi^
a time lhn-»u-iitil In nvi^rltini our idi-as criiit'irniiig ilto nignifit-aii»: and
origin of chorio-fpitlKdioiiiala. Tlipy dpscribcd j^eiMralized metaelaws fol- _
l«v,iiig wrlain tt*nit<>m»ia of tin' t««lici«, wliii-h vivni iniide dp of »rnc'yliuni,l
Laii|,'iian»'a (vll.->, and fvi-n of Mtrufdire.- ni><einh1inK chorionic villi. Tltvirl
oliKLTVAtion^ have iK-t'ii iibuiidatiily cniilirnu-d by Hk'l'I, Tvacliur, Frank, nnda
othcrH. I
In such t-ai^ew, Schtan^.'enliaiifiT awiuincd Ihat jiortionj' of fu'lal nivni-l
lirano had Iki*ii iiiiliidiHl in ihi- (crauima. uik) Ktidil<*nl_v bi'g'aii In pivdifvr*!
ale aftf^r Iviii-; dtirtnani for _vnarf<. Uirvl. on the olher hand, hohU iKhI.b
fiicli an »!'siiiii]Hioii iif iiol ni-i-CKjyirv, and con^idof* that ifuth a fnrmatioul
may dtrvelop from iindifferenliated fu-tal ectodflnn comained iii ibefl
leraloma. I
Clinical //^i>tnry.— Cliorio-opilht'linina inay occur at any e^ during dicfl
cliildlH-arinfT juti'mI, and atwavK follows a prefriiaiicy, whether the lattrrl
terminates in ftill-lenti talmur, atKtrtion, or hyilaiidiform m'lle, tlif IriiI t^n- 1
dilion being notwl in nearly 60 per cent of the ca«». In several instances
it originali'd from an extra- uterine pvogiianey. ■
Ordinarily there is no ^Ui^picion of tht^ existence of the ^^wth durin}n
pregnaney. or oven iluring llie fir.ii few ueek^ aflir delivery. In a ^mallfl
number of eai-es haemorrhage in the laiter part of the puerperinm may bej
the first indication of il# exi»la>cc, though llii« Gvuiptom U ueually laekin;. I
rla more than one half of the ca><es the fint indiiation h the apjiearancc nf I
FTaginal or siilval int-IastaiK's. 'rhe*c are ui^ually imt notH until sniue ueek^f
or mniiihn afli-r the piKT|w'rimn, lliou;;h in I'oten and Vajwuier'n ea^H* Ihi^y
apiiearcil before Ihc cxtnision of the mole, and in luy cam; one week after _
a full-term Inlmur. The dt>velopnienl of ineiastaM» in the lungy U n^iially I
avioeiated wilti pulmonary i-yinptoms. eoiigh, and bloody ex pee to ration. M
tliotigh tlu'.->i- are frcrjui'mly hiekiiig. Oenuvionally. n* n-[i<>rtt-d liv iliir* I
itiann and others, the growth may perforate the uterine wall and give rieel
to fatal inira-piritont'H] hiemi)rrliag(\ VuIom diagnosi-d and removed l»yB
operative proccdiircw. the tumour rapidly causes death, the majnrttv of ■
palienfj' isueeunihiiig wilhin lln- first year, liidi'etl, it miiy be said that thin ■
is the most rapidly filial malignant ijrowth wiih whioh ue are aii{UHint(^l, I
though oecai^ionally ea^'S are eneountered in which permanent cure follow**
a Dimple ciirettagtr, Imt mkIi a fu^-ouraliU' ouicimiv ocx^unt ta rarely that iti
does not justify Ihe poflponement of radie^ treatment. I
DUignwis. — In ii mntiderable number of ca«'*. Ihe diagnosis is not
made until iiieriiiL' ha-morrhage. oeturring at a varying |>erii>d aflrr the '*
I)uerperium. necessitates curettage, when the mieroscopk examination of lhe<^
*^eropin)r» revi-al» i-haructenst ie change*. In other instance«, as has alreadr^C
Imx-h said, the orcurrenceof vaginal ineta.-1a.^-> is \\\<- flr*l indicni'tnn of thef^J
dxistenee nf |he growth,
Tl)e possibility of it- developnn-nl should alway* Ik- home in nimd wh«n^*3
ever a woin«ii has expelled a Jiydatidiform mole, and the appearance oft -^^
UYURAMMUti
581
Ilia>niuTrha^ nr of nllicr iiiorv olnKura eymplonia Hhoultl be an imperalive
iDtiii-alinn for ftintia^ aiul tW inicrwicopK^ o\aiiiiiuiiioit nf llio vcrapingx.
Trralmrnt. — If cun-ttafK- rovoale the i'xi»li'iicc of characl oris lie lesioiw,
i 111 in lit ill c byslerei-ioiiiy in iiiifienitive. On tin.! oihvr luiml. witeii vngtaal
niL'taplawFi oa\y art' pn-wiit. the indicalioiL-* fur iliin ojwrnlinii jin? not an
Huirl.v niarki'd. ■" wo kiH>w Dial iii ^onie ^uch lsh'^ the- tilcruH cantaii)i> uo
gnnrtU, ami (liat llie cxtiKJoit of tlic vaginal tumoiirM may W follnvttl It;
complete rt*«»Tr>'. If a liintntir in the iilcrus is liiaftnospi). hystorwtmny as
wfll aA v.xcir^init of iIh- mi.-tii»taH.'» ti^ indimU-d, thnii^li llii- ihutioK for ulli-
Biale r«'<)vi-rv are vt-rv !<ii;;)i(. Full Iilt-n»liin- u]>nn tlii^ huIijihI will Ite
fiNiui) ill itic articlM of Siinger, SlarcJiaiitl, VVillianis, \'i'it, Teaclicr, Ui«ol,
aiui Frank.
Vifftuf Myxoma of the Charifiti. — llivntau ainl Kbcrlh liavo ca\M atleu-
liou to a ran- afrc<'It4>n nf ilic chorionic nirmbranc, in wliieli it-< con nif live
tiiwut' Uvcr umicrsnes myinmaloitA dc^ntrration and h<xiiiiii-M ewn^ertt-'d
into a ji-llT'liki- KiilKtaJico analagiiiu to tlie Wlurtanian jolk of the diM.
Tlii« lavtT may aiiain a tliiclinesa of i to 3 millimeln.^ but diwH not apptwr
^K In cxvri any uprcial infliicnct- H[»on pr'^'naiicy.
^r J/yjoiwa Fibrosum of the Chorion. — Vinlmw ralliil altcjilion lo thi* favl
llial a gn-aUT or Iii"h.t numlirr of th« chorionic villi, which cutpr into the
^_ formation of the plac«nta. may lose their oHffinal MrtK-iuri' and lake pari
^H in iIm' formalion of a ttimour niadv up of di'nw connvrtivc tiwue with
^^ Urjter or unialler an-ai of nivxoniatnm* tiwiie si^tterwl ilirou^-li it. A« the
rh«n)f<- u limik'd lo t)H' plait-nta. it» oD^idiTalion will Ik- deferred until
iIm* lunionrH uf that stntelure are !'Iiidi<'d.
DweaMfl of the Amnioa. — 11 yJramnios. — By hydratnnio!> w iindorKlaod
Ihi> jinx'iMf of an i-soiT-ive qnantity of litjuor amnii. Kxaelly wheii the
|imj«T limit i.- jw^v-id fannot be Maieil wilh acenraey, for the reaM)n that
Ilbi- aull»oritifw do not a^f.'C a» to the amount to lie eon»iden>i nonnal,
F'ehlitt); placing it at ifM) am) RanHner at 1,877 cubic ceulimctr(t». though,
pnrrally ^pmking, a <|uanlity grc«t«r than S litiT« may ccitainly tw con-
Mdvnn) exi'e-viive.
Minor de^nx^Ts of hrdrsraniox — S to 3 lilre« — aie common, but lite more
markt^l gnulc^ are of infriijuent occnm-not-. In nin^ caixM \hv ulcrun may
efmtain an almoet incredible amount of liquor ainnii. Kii»tner having
itliwrtinl 1.1 litrw, and Sehnoidrr !Hi liln-s at the fifth and ciith inonthx
nf {irt>;n>anry respectively. In mo-^t («!«> the increa^ in tin' amount of
tfniaiiilic 6uid ii^ qnile ^iradiinl. bat exceptionally it takex plac« very sud-
^_cl*>iilr, mo that tlio ulcrus may Itecome imnnmsely dimeiKltx) within a few
^^p^^^>~-^ictiU hydramnuM.
^^ The fluid in a ca** of hydramnioi> i» usually idvutiea] in ap|>eanuK-<>
^"•3 c^mpntiition with lliat which is normally found in tlte amniotic cav-
*'^> althnuj^h Prochovaick states that the former ocoantonally coniainit a
i¥l»tly inrrraw-*! amoimt of nr^sa.
~^tini<igti.^\n vii-w of the fact that there is Mill coiKiderahle diHeuti'ton
*'• the sDiirte of tlte li<)Uor amnii in nonmil pn';(nniuy, it is nianif»*lly
f**»»<*ible in nianv i-ajn-s to j('*e « salisfaflorr explanation for it* fxcesMii-
OL-lion. Afi w«ii gaid when th« phy«iol<yy of the fienu waft dealt vritli.
4
5S2
uitsTmuifs
it nitisl be tLtflumed tirnt the amniotic fluid u usually derived in gn-al p«rt
from nil- niMtliiT, Ihnugli the iiiveiili^ationH of iMmidl mid otltorci it-nd lo
show that it is not a mere exudate, but i)> modilU-d bv ihi' !^^i.Teton- action
of the Ainniolic cpitlit-lium. Likc-ui»t-, \Vo](T ba.-< shown ihal jiroDoumitil
}i>'i!ra:iintoA oi^urs in rabbits followiug double nephrectomy in tlte \»»\
days of pregnancy. Moronver, the fact Ihal amniotic flnid i» pTte^CTit in
ccrtnin easct in which nunc abnormality of the fu-lu* pnx-titdcK tin* [lo*-
siliilily of urination, affords eoncla-ivi' evidencv lliat it is not always derived
from Die f(ptal urine, white the ex|H.'rimeDti- of Schallor appear to demon-
strate tlmt Die f<ptai kidnerx function normally only l<> ii wn' Mlighl cKtitil.
if at ail, (luring intra-iiterine life. At the name lime it is probable that
ftctal urine is paniMHl into tlio amniotic m^ily under certain path^lngical
conditions.
(Jencrally upcaking. writers upon hydrHniniuM »1ate that thi* «xcmc of*^
amniotic fluid may be derived from scTeral wtureca — from the fcetna, from
the mnlher, from lw>tli fu'tus and mntbiT, ami In ranj cam(^ fmm the ,
amnion itself.
In Minii'lhinjf li-?v tluui urn- linlT of tin; cum-", eari-ful examlniilton »r
the foetus after death reveals the presence of some abnormality wfiich may
or may not bear a Mii>>al ruiatioa to the dbwui<e. Thun. Uydramnim is]
sometimes, thou;*!) not always, noted whi-n the feetus presents ^itie aliuur-
niality or deformity, panieulariy liciuin^jihiilii* or *|iiiiii liitida. I'ndiT
such circumstances many authon bi-lieve Unit the sui>er abundant fluid
the Insult of an e:tc<^^'i^e urinary secretion, tviiich in bniujiht aboul by Ihu
simulation of cerebral or spinal centreti which have been <ie))rive<l of their
UKual coverinf.'*. jii»l as happens in the piqnre expcriuients of the pttrsiolo-'
gUtf. Hydtiininio.-. is also found as^oeiaK^l with oilier defonutlii^, luch
a* hare-lip, the various varieties of club-foot, ectopia uf lh« bladder, etc, a»
well as certain tumours of the kidneys.
More frequently, however, the abnormality which is supposed to pni
rise to liydramnim i.^ to ho found in lesions which cauwe olwtruciion to (he
circulation either in the cord or within the [iptu!(. In other insiaocu- tlw
condition is attritmted to renal chanj;es or to abnormal r I ies> in ihtt ruianeoai'i
functions.
Salling<T hait shown that an oWmction to (he circulation in Ihf ombil*
ical vein is accompanied by an exudation of fluid from (he external snir-
fttce of the lunhilicnl cird and from the fcrtal surface of the placenta. Tln«l
[he attributed to Ihe persistence of the so-called vnsa propria of JunKblntli.
which. spriripiTig frotn the fn-tal end of the eord. lie between Ihe cliorion.
and amnion and usually lieconie obliteralf^ in Ihe second half of pnf—
nancy. Analogous observations have lieen made by I>>\'i«on. .Vceonlinp V
Framjiic, oblitcrativc changes in coats of the arterit* of the chorionic vitl-
may lead to similar r»mlt«. Leopold and Bar have shown that the obstt
lion 'nay l>e due to stenosiji or thrombosis of ihe umhilica) win, wh3'.
Fi'hling ha* nttrilmli'd It to torsion of the cord.
More frequently the obstruclion lits« within the fiptus. Thus Opi*
obstTved cirrhotic ehun^-s in the liver in all of his eases. Others tu^~
attributed it lo sypliilitic changes, thoujch my cs)iurieDoi: leads mn to 1=;
UYIlR,\M.\lUg
fi83
^Bievv Hut lucK i» un unimporUni fac-tor. aa livilrainiiios i]oe8 iu>t xppear
Hhi om-tir inui-li more frequeutlv in syphilitic titan in uonnal children. In
^^EMKlpi<Iera)>k> proportion of vatvf Hw. nlmtriKt ion t<i i'iri:-tilHli«»i ik <Uif tn
^HBoiiM- iil)[i<>riiia]ili«-H. ThuK Wix'nc foiiHil llio ri^lil auHdc aliiioiil ■•ntin;ly
^KitIii^I l<y a rbabdouiyoiiia. Iter olirerviHl triouxpid initiiHiriencj and
"BWiHJtie diao^-fs alwut the pulmouan' arteries; I>.-l)e(k>iT, aortic stenoiiis,
and Niptifrrdin^ n narnming nf \\w ductus Itotalli.
^ft .Miiny nuilioriiifs U-lii^vi- l)ial hydniniDin" i^ dii« tn an i>x<-(>HsiTc urinary
^nivrt'tiiin n^ulting from renal or cardiac Iwions, As has alreaily b«n
pointt?d oul, this Dinlc of origin cannot be ac(f]>lcd for nil cjims. Opitz
■thougitt Iw had dfiiionAtratMl that tlie liquor aninii in hydrainnioa oon-
taint^^l a iymplia^.'nijm? sulititsncc, nhirh is normally ubfcnt. Ilf cunNidi^rrd
thai il.t pn>wn(\- in ihc liiuitM!^ <'f ihe fii'tiLi r»-snlloil in ihi* i-xtrailion from
the iutenillous spaei?s of the placenta of a greater amount of Huid than
imuJ. Thi« &4M:twitaIC(l tiivraaMil vxi^rlion on ihc part of tixf. heart, which
tfjUtiaHy resulted in itt* hyperlmpliy. Afi a consequence a larjnr amount
t( lliiirl einrulakil llimugh tint kidniiyn, gtvin;; riw to an inircaned urinary
crrtion.
Jt i« graicmllT lM!lii-\cd that the a'tfolfiyicai imporfann- of Invri!aM<d
ac-tivity is utrihingly illiutralcd in liydFamuioA occurring in single-
am twins. WiUnn ( IWJ) analynfl On- hi>'tort<'>i of 101 ciih-j* nf hydrani-
liiM, .11 of whirii occurr«>d in single and the remainder in miilliplo preg-
nnicy — l"i twins and -I triplet*. Twi-nly-two nf Ihe twin>! w^-re nnioviilar
kin "rijcin. and nheti one cowiders that thft* are much less frei'inently oh-
■erved than douWe-oram twins,, it is apparent that something ooniiected
' with Oh* foniivr mii^t exert an apprectahlr int1u<-m-e in (lie pn>>)netion of
ibe di:i>>aiie. In such cases, as a rule, the escess of iiipior amnii is limited
tn a single amnton, while llie olher contains a normal or diminished amount
of Huid. At auiopsy the heart and kidneys of the fwluit AulTenDg from
hidramnios am found to tw both rclaliToly and actually larger than thoM
nf the normal twin. Wilson attrihuied this diffcrt-nce to the preitenoe in
tiw single placenta of an area of circulation common to both twins, and
Mievtid that one, for Home roaiton, n>cvirod a larger amount of btood than
the uther, Ihis eicess giving rise to cardiac hypertrophy which still further
■•weniuatnl tlwt comlilion, ami in lurn was followed by renal hypertrophy
E'lh increased secretion, lie considered that the primary cau»e for the
ffrieuM' in the amount of fluid rweivcd by tlw two twins was to be found
"^ «lionrnialit)» nf the umbilical cord, by which tlie flow of blood to oiut
' ' '<! was n>nd(*rpd more ditHcttIt, as in the cases which he analyzed the
' t«l twin alwavK presented »omc ahnnntinlily of that structure — T«ta<
^**a*aton» inwrtion. eicewive length, or marked narrowing.
^TThe inodc of production of hydramnios in such coses has b^n cousid-
to detail by Schati!, Werth, Slrassmann, ain) Kiislner. The laft-
til] aulhiTilv iM-fieves that the cardiac hvpertrophv corner aliout in thfl
^»aner alr*-ady miDlinniil. and leads to a stilt further increa'e in the
"■•""nnt of circulating fluid. Evi-nlually the heart becomes umf]tial to it-t
E^^ aiul in^uflicivncy rv^ults. which is followed by signs of obstruction,
^ptiuularly io the liver, thereby i-oiH))leling a vicious circle.
Oc*^
OBSTETRICS
SniiK> iitiiIiori< roni^idor th»t l\w #kiu ]>Ik.vi' » not uiiiru|>(irUn1 pari iu
tlu) oxc«Miv« formation of liquor atunii. Budin in one cara vrss incline to
attribiile it lo a larfri; nu'vu*. rhmngh which lio Itolifval i>«'f3'*ive extitiatton
occurred. Furtliennore. Wil-i>ii am! others cou»i(ier that oxceBaive cutane-
ous activity is (iftliriii\< nssiK'iatc"! with wiriliac hvjKTirnpIiv.
la a nomll iiuuiIkt of ca.ien iullaruitiatorv coDcliliona of the aiunio& itM-lf
«re iK'liovinl Id plav n pari In Ihu production of Ihv condition, loading In
increased eMidation thmuKh that nicmhrane. ^^
Occitsiomillv diwiiw* of tho niolht-r wliit-h »nj attended hv circulaloij^l
disturliaiucs. |iartii'iilarlj larthac and renal affeplions ami viweral syphilid. '
Ivud lo ucdenio of the plan.'ntn, wiih iucrcai'i.d trun^udxtion into the ainni^_
otic cavit}'. One or otiier of the condition!! jUHt mentioned may aix^ui^H
for the cxCi-wivT produetion of aiimiotic fluid in a cnsidc ruble proportion
of the cases; bul at the Baini- time Ihey do not always alTonl a n> I is fat-lory
oxplanaliou, inasmuch a>^ in many instances cureful H-ar^-h faili- to irveal
the presence of any lesion which can be tLupposed lo play a part in tl^^
production of the anomaly. ^H
Siftnptrjtii*. — The symptoms accoinpanving hydraninio* arist- fnmi pnrt-ly
mechanical cause*^. and are duo to llio pressure exerted by the over-iiis-
timded uterus upon fl<ljnct-iit or^anx. The elTitts are particularly markc
io the respiratory ftmctioiu, and when the distention is excessive tlie
lient may xulTcr from ^vcru- <lyipn<m and cyanosis, and in vxlremc
be able to breathe only in an upri;;ht poriition. U'^lenia often occurs,
cially in the lower extremities and abmjt the viiiva.
It is surpri.'iinjj; what ^ri-nt dr^'rces of ab(h>minal distiiition can «oi
limes be borne by the patient with comparatively little di«t>mfort. allhou^
this is the ca.■^> only wJien the aoiiiii illation of fluid has taken platr- ^nulu
ally. On the other hand, in aiute bydraninioi;, a much sliRbter degn*
distention timy lead to distiirhances duflieiently M^riou^ tu thr<.-uten ibe lit
otthe patient.
Piagnuiiiti'.^ln miilitrHte degnvs of hydramnios, palpation and pi-reu*-
sion enable one tn feel eoiifiduiit that the tluctuant tumour if the distenddl
iitenis, in which » readily hallottable ftetufi can be ffiit, althoiigh the beai j
sounda are heard with diiKciilty.
The exci?«iii'e cnlargi'ment of Ihi' abdomen due to multiple prr^nnr^sJ
occasionally renders the dilTerentiatinn from hydranmio« almost impos^ibl^ J
and, mon'over. the latter ii^ a (rivpiciit eomplicaiioii of the fornier ininiiiti"-^::^
Thus it apjiears lliat the hvdramnio.i is usually detected, wlwrea* a m(^ ^
liple pregnancy associated with it often pas)K?s unnotici-d. On tlic otl'.^'.l
hand, in a multiple prc^ancy not coniplirated by hydrainnio«, the di^ ^a|
nosis is comparativelv ea-v, inasmuch as the uterus offers a firm con^i'ti^t' gin
to the touch, and careful palpation will mi'eal the presence of wreral toaa^KiU
poles and an unusual number tit small parts, as e»>ntra>t«d with a mar -.jfi*/
ductuntion nitd the di^ieiilty iif mappiu); out ibo f<etui= in bydramni"*— ^^A
When the uterine distention is cxeeKtive, llic diagnosis of h>draa)S!i^^|
l<eeomff» ereii more dillicull. and ninny ciws are rccortltil in which ttw (--ch^^^
dition was mistaken for a lar^e <ivarian ey^toma, with lite n'snll dial i^^^l
contents of the ainniolic cavity vrvre wncuated by meane of a trocu', ir^H
IIYDRAHXIOS
5A5
inu-
nlnmy vn* [H^rfonnM. Inijitirv w In il)i> po»iitiilily nt |in^n«iM;y,
Inrcfal Dxaniiiimiaii n*j)l pvncrully «<rre to prevent such an prmr.
Kx<T^wiv(' alHlDiiiiiml i-Htnr;;i'iin'»i iltte tn a.->i'itKi rail ti<ii«llv he Hiffrr-
alialed by tht' characlrriiitic elmii^^'s in pcrciiK8ion. I(i raro iDs1aD(.t!s
fgnaiH-y. coni]}lir*t<xl by a \Brge ovarian c.v»Io(na. may lur mUlakcn lor
hydramnioa. In MtiM- cases, tlic (k-teclion of two tumours — one correspond-
ii^ to Ihr- titi'ni^ aiiil llir ntlicr Ui titi- rNvl^vill p<-niiil ii r^rrtvt diiigijoitis,
liut ID otltf'Di lliv rniulilion may cscajH' ili'tci-tion iiniil afttr chiiilitirth.
Trratmrvl. — Miitor yr«i)«* of Ityilramtiia" rarely rtijTitrr atlivv tivat-
On the other hand, when the abdoim-ii U inimetisely distended and
fpiration U mTiounly liamp<'nil, \)w ti^rminiiiioii of prc(fiiiinfy w urgently
itdicatitl tiu matter to wUat iteriod it may have advann^d. In ^neh caatM
inlt-rfcri-nre i* i)»: nioix- ju^liliahle sinci- i-xpt-ricnw loaclic* that prvtnaliin;
itiuur fn<t|uenily occurs sponlaneoui^ty if the patient h left alono, ami
I children arc oflcn m jmorly dvT«>l'i;K-d or «o d<>forni(t<l llitil tJioir chauciM
ftf livinjkt are uiiniinAl.
In sucli vafci-, tlip i^ymptoniii can Ix- promptly reltet'ed by perforating
ihr mcmliranes ihrougti the cervJi, afli-r whit'h tho amnlolio Hitid drainn
^—off and labour pains kI in. U'hen the abdonim hits Itecn vnorniou^ly di^
^Kmilnl. and the onurs« nf laliour partieiiiariy rapid, lh«re in an incr«ased
^KaIc of atonic Itsmorrhagu durin;; and ju>il after the completion of the
^Bhinl fia/^. For this reaM>n tin- utt'riiH xhoiihl In- carefully wati.-hod and
ajipropriate treatment in^tilutnl at the tlighlest a'ign of danger.
Otiffifhtitlramnivii. — In rare instanci^ lh4- amount of amniotic fluid may
fall far below the norma) limits and octaeioDally be repre«t'ated by only a
eittiic cvntimvlri'* of vicar,
Wid llittd.
The xiiolo^ is even leas well
ndcn'loni) than (bat nf h^-drani-
.faggard. in 18!»4. re|K>rtfd
in which lh<' f<cliiK pn--
an imiKrforatc urethra
with absence of nnv and cyiiiic dc-
^nwmtioD of tho other kidney.
I jumI be tliviefore concluded ihiil
^Uw lack nf amnintit- lliiid wa.t iIm'
^Bivult of nrtn-.<ecrelion of urine.
^Ble Ukewi>v collected «cv<-ral iu-
^HUnti^i rnim the litnralure, in
^^^lijdt till! anomaly was uasociated
' 'Vitb rumplcic al>M-nce of boUi
When oligo-hydramnio3 occunt
»rly in pn-gnaiu-y il in ntlMuh"!
Ik' teriouB <t>a.4e<giiencea to Ihi- fiehii. a* ai1hi-;<)oit> may lie formed betwiMi
utemal siirfaw and tlw umuion and give ri« to wrHni* dcformili».
jl'bi'n oct-urring Inter, its effect upon the fcetiii:. llHiugli Ie»i marked, in (piil«'
diaracteristie. I'imIit Mu^lt circutnslumi^ the latter is i^ubjvctcd l« pRS-
Ftu. 478. — Ooiara»H»»K or KoniiitH Oi.too*
■thkauNUm lAUfetill.
s^
OBSTirrRics
Kiire fmm oil fides uid lakes on a peculisr a)>pearai>c(<, and ntao; minor
lie form Hi PS, euch a^ dub-fiiol, nrv fn'(|«t'iilly nlwrtt-J (l'''& ^'8).
lo some vHfv* nt uligu-hvdrMiiinios, llii- ;>kiti ft llio fii'ltii* is innrkcdly
lliuketii'd . and pix-stiitu n dry. k-utliiTV ap*
Ix'aruiK'V, Mi»i »ulli()ritii!:< nttriliute (tus
tn th« Ufk of amniotic fluid, but Ahlfeiil
JK inclined In Utlicvi? Iliiil it i» the ciiusc
mill ii'il llie result of ihe rosdilinn, laiw^r
ihc skin loinn may bt- so niarkM a* to
iritcrftMv with Ihc nftrmnl rittMDeouH fuiu*-
tions and thus Aa away u-ilh one of the
irourw* "f the liquor amnii.
Amniotir Adhesions. — In oliRo-hv-
draninios, and occn^toiiully even vhvn ih«
liquor amnii U prennit in tu>nnal amounts,
adh^sionH may form bctwts.'o lltP ainninn
and Ibv iiurrHrc of ilio fit-iu'i. Aiivinlin^
lo Siuionart, Chauasier. in 18I«, was llic
firet to din-ot attention lo l)ii? con^Utiou,
nnd itii ronsetiuence! verv further Mndied
by Moil tfioni cry, G. Brnun. Ktistnt-r. Ahl-
fftd. «i)d others.
The effpcis of amniotic adhesions arr
vuriiihlv and dejH'iid in grvat niiumre
ii|ion l}ieir location. Ab> a rule, w)u-n Ibcy
develop eariy in prepiancy they Rive ri»i*
to wriou* di'formilii*" itf the ftrluB. Tbt'
following abnormalities have been directly traced to the enndiiion: Ki»-
i-ephnlwrle nr hemici.'phalu*: fis^nrtf of the face, jaw, or lips; flvTin! «f
the thorax with ectopia cordis, and
vvi-iitration willi hernia of tb» um-
bilical eortl.
i^
Fio. iTV. — FlsfiriiAUK'ci.it niwn.T-
IMG raou AHMtrnv ADiiEaioNs
(Ahlfdd).
no, 4a0.— AMri'iATiiiK or KiMttKna ni: Am-
Kionc AiHiEMOKa (KOirtner).
Tm. 4
■II- -V-I|-I---|LI\1,
In other instances, amniotic bands may eneirclr an extrcmiiy i»f i^^
ferine and *a vompront it u* to It-ad to i^lrangiilalion and enheequeut span*
ABXORMAUTIB^ OF THli PLACENTA
887
■nipuUtioii. Fig. 48(1 irpre»cnu iotra-uti-rinp ain|itiU1ion t>r thft
Mgen. and Vif. 4H1 anipiiutinn of ihi- nriuK. productil in lhi» war. Snaa
'"lias reportfit Iwo ca^s in wliiih the iii«tli iif tin* ficlu» was atlriUutnlili- Ii
>tnin^'ii1alti>n ot Ihc uiiibilical curi) by such liaiiiJ^. li\ct.>pt)oDallv amniotic
adhi9i(iii> tiiuv give ri^t [<> dvl'x-ia. aiiil HanliUtlM-ii )ia> rt-pcrtod an installed
Ijn which firm adiieeinns exu-oding from the placenla to the back of the
cliiM «iTiuu>l}- inttrfi-n^ with it« birth.
InfiamrHati-tn of the AmnioH. — In rare eases indammator}' proceescfl
Imfitiiali- tliv aiiiniwi, Th<t>^; urv ii«^iiallv aw<K-iiitixl willi i^imiiar ehangva
in the eltortoD and decitlua, and rentilt from alienipts at criminal abortion
^.or fmni thv vxtiiif^ioD of au infection that has originated in the decidiui.
^B Cyit of the ^mniVfii.— Kow and again Hniall cyclic structnrea, lined bj
^hrpical epitbchum. may be fomusl in the amnion. Thry gcn«Tany r«»ult
Hfroni the fusion of aiunioiie foKU uith Hii)i<<v|Utfnt retention of fluid. Spe-
cial fltlcntion hat) been dvroted to
U>i» wiiltji-ct by Alilfeld. TIm; >ainc
il^^rver liaii aliM dcrvribed a der-
i<l vyA of tJie amnion, which
not. however, bear critical
xa mi nation, inaamuch u itu!
•wall ]iiarlicl4» found in it ver«
pmbalily mere concretions.
Abwmulitiet and SiKasM of
tlu Ilaoenta. — Abnormaiitie-a in
•oB, Bkap», and Weight.— Vw
ivirmat placenta i>i a flattened,
roundti^, or discoid or);aii. w^hich
l»Terag>w fmm 1.1 n> 'iU wntime-
in diameter, and from 1.5 to 3 cvntimctrofl in thickucw. It i» rda-
jvdy larxer in the earlier ttion m the later ntontlta nf pregnancy, and
varies conKiderahly in size
at it-rm, though, generally
speaking, the thicknew ia
ill invi-ntc proportion to
its area. The placenta, ax
a rule, prt^M-nli* more or
h^iia rounded oullim-H, but
now and again wlien in-
»i>rlcd in tlie neighbour-
hood of the inti-nial m it
may luki» on a horseshop-
like ap|)oarance, iti two
branclte* running partially
around the orifice. In very
rare inotanccci. M* in one '
n*i">rl«i l<y Taurin, ii may
bmad annular organ vbicb cndrclea the nterine cavity jii^t ax in rar>.
gnoriiua animal*.
Fki. *82.— l't»c»rT* h'K.vnmuTA <Hyrtl).
Pni. 4K3. — Pl-U'I-MA ltlpA«TIT*.
5Rd
OKiTETRICS
Fid. <»!.— Pi^cKWT* TmcjuinrA (Bjrrtl).
The normal rull-li-rm plmi-nU mi an average wcijrhs ahant one Kuttli a*
much as thi- t-liild— i. <?.. Homewliere in Hit- iii-ijililHiurhood uf WW grHiiim«s.
K\wpti>ma!ly ii iimy Ih- L'iiii*Kii-nil)Iv lu'avier, Ia'vv liaviuR reported a iium-
iier of «»i» iti whith it oxcivdi-d l.UUii grntniiKV in w«'iglii, lu diM!ii)«il
conditions, on the
other hanil.Uii)^ pro-
porliwn no loiiiti-r
holds ft'xxl. a"*! "i
£yi>hih« thcplamilii
may weigh one
fourth, one thinl. or
fv«n one linlf a«
much as tlte ftetuA
In albumin uria it
*Iad DDdergoea a
rvtativfl incnsafQ in
weighi, duf alinwt
entirely to the im-
jitTfi^ct dvvi'lopmi^t
of the ftptiis vrhich charnctorixes nuch (^nditionii. The largest )tlaoenl«
with whioh we are fainiliiir an- ohM>r\L-il in casw nf jfvn>*ml dmjwy of tlw
f<ptU)i und jilnotiito. Jn a (.-u^e of thif chuructt-r under my ob-vrvation tiie
i.weiji;hls of ihe fti'IUH and nf the plaoenta wei-e 1,110 and l.^on gramme
'Tespoctivuly, and Cohen Iws reported a case in which the latter weighed
S.^OO grant mc^.
Multiple I'lacenta in Sin>/}f Prriinntiri'-.f. — Ocowioiinlly in a single pirg-
nuncy the pluci'iila \6 divided iuto .^veral parts, which may tie abMlute-
ly dislim^t or m(in> or lo.v*
closely miited. Such abnor-
nialitie* have bvai ntiidii-d
I more pflrtieularly by llyrti
ind Itibcmont ■ Di-ttKiiigni-v,
tlie latter stating that ihey
occur nb'itit oncv in 'Mii
in rare cft«es the pla-
petilu may bi' oblong in ^biipt-
with an aperture of \-ar>'-
rlng me sDmewben^ in Itifl
'neighljoiirhoiid of its een-
Irc. To llii* ubuormality
HyrtI ttpplii^d the term pla-
ettita fenfstmta. More fre-
quently the organ is more or biw compU-lely divided into two lobei). Wlierr
the division is incfiinph'te, and the vessels extend (nun one lolie tn Ihc oIIm'K
before uniting to form the umbilical con), we xpeak of a placenta •limiiiial'X
nr hijmrlila. Acmnhng to Ahlfcid, thin anonuily iR noted &lM>iit once ia
600 cases. Agaio, the placenta may conaist of tn-o i-epurate lobe^, |]»e ves-
Fio.
48*L — CoKHcnion Pbctabation ur Puctvi*-'
SKftr rtKx . (HyttI ).
A»MmUAUTtl« OF THE PLACENTA
580
FrI. M6. — Pl^CKKTA MlCMma»M-|M (VOD W«ln).
f»U of wbich are perfectly difilinvt and do not anit« until jiiHt ttcfore cntvr-
ing ihr vwi—ptactnta duplex (we Fig. 487). Occasionally the oF;gao may
l>e made up of three dUtinet
lobps^placrnla Iriptrx; while
ill wry rare iiistniwrs' it fUHy
rxiDiii^t of a numt>er of >imal)
lobm. llyrll having; d«scribcd as
many ait *even — pltuxnta Mptur
All ot ihifnc cnnditions nv
rolt from abnormal i I i«A in the
hkind gtipply of the dvcidna.
Generally r>|)eakiQ}f, llio ptirlioti
irf lln* iiTUiii vhtdi in to be-
cnnte converted iutn lite chorion
fmndofium. and Inter into thi-
fiilal p>irliou of llw {lUmnlii.
in that «'hi(ii h in eonlitel with
the nioti higlily TUK.-ulariz<-d
linn of the dceidua. If the
SKularization. infrtoad of bvin^
irai-lti^]|y limited to a >iiii;L;le
area, devflnps in wvera! ticparata
jKirtioim of llto di-cidun, itome
anomaly \* botind to ooeiir. Kudtncr believes that eertain caseH of
]iJa<-eiita bi{i«rlila or duplex owe tbi-ir origin to extensive iiifnrel forma-
liiin by whieh Iht! iniorvenin^ ti»ue is dealroyt-d. (hvasionally thin
ifl tindoutilrdly trne,
(ml 5ueh an cxpla*
nation cannot be oe-
ei'ptetl when (Ih^ va-
riodn lobes or lob-
nli« are Mparated
from one another by
apjtarenlly normal
Mn-mbraiKM'.
Ill rare in-
fitanees tltc deeidua
reflenH U i"i abun-
dantly I^upplied with
blood that the eho-
rioii li^'P in con-
tact with it fails to
iindertro atrophy.
I'nder sueU eireum-
ittantiM. the entire
periphery of the
ovum IB covered hy
i
ha. IW.— Pu»eK«T» tti-n.KK, ■mi Iwo SrctmrrtnuATB
SHU
OBSTETRIOi
fitnctioDiii)^ vJIti, i^t Ihiil iIk- [ilnit'ntji, iaKtnad nf iHring ii diK-oid or^
limited to the clecidu* nerotini, corrwponds to tins eatire vhoriaii — pltUfHto
mvmbranacrit, 'Diis iilmarniality ilocs not inlorfom wiili the ntitriliuii uf
the oruui, but occu^iouallv gives ri^c to prions compltcatioui' duritii; tho
third i<tiigf »f InlMiir. HJnce the thinm^-out pln<^-ina i* not r^Ailtly *('in
rated from its area of attachment and is rctaintvl, maniial removal bccon
ing atcasMTy.
An important and not infrcijuent anomaly is the «>-cslled placenta
cetUuriata, in which ono or mtiro .-•iiiall nccei>«>rv IoIihIoj' are (h'vi'l<i|Mv|
the membranes at some distance from the pcripberr of the main placcnt
Ordinnrily they an* uiillitl lo th« latK^r by vitMmlar cnnnwlion*. Ot-canion
ally, however, theste are lacking, and as a result we have what are knovii
as placmtfT spuria:
The [ilact'iila xunTcnturiala is of considerahlo clinical importance,
cause the acceNiury lobutw are Kiimulimcv nrtaitKnl in llw ulvntx aflcr
expuUion of th« mai
placctita, Hiul may ffi\
riM? to wriouA ha-mu^
rhagi'. For thifi
one should always Im
in mind tlic po^-^lbili^
of Uifiir exislt-m-c,
the examination of tt
«rii>r-birlh kIwuM in
t>e limited merely !<« tl
in>^p('ctiiin of (lie pli
it-'DtA, but should i'xli-i
to the membranes
wi-ll. Should »mall
roundish de f oct a be
pn-M-nl in the JHltcr ik^
^hort dislam'e from ihL_=d
placental margin, ih^M
retention of a rurrm ^
hiriato lobo should tk^c
'Vni'iK'ct''d. If, in such cawcs. the sli^Jhte^t signs of hiciiiorrha;?* oi-cur. lii^fi
hand i<tiould In- iiitnidHOi-d into the uterus for lh« purpnmi of localinj; ait.
removing the offending slnicture.
Pliuenitt niiir'jinnla will be considered when we come to apeak of inl
of tho placenta.
In eici'pliimn! int^tanccs the ftetal surface of Ihe placenta iiiav presci
a central depreuion surroundtiJ by an elevated portion, the amnion fxte
ing from the edgoi of the former. Tltis condition is designated la. p^aa*^
dreumvaUala, nnil is due to a prnjifcrntion nf the villi at th« margin
the placenta after ihc dcrniiii- ntliichinent nf llu' amnion has ot-cnirred.
Dnif in MrviTiil Imitilri'il cuhk the placenta, instead of Iwing insi-rlt^''
ujM>a tin.' lateral watl-t or the fiindn.'< of Ihe uterus, is implantt-d upim il
low«r uterine M^cnuit in such a matinvr as more or Ivxs completely
Fw. 488. — PuictSTA Majiqixata.
Ill , 11 ^^Bi
ig ai^^
ibrC^S
ISFAKCT8 OF THE PLACENTA
SOI
■triTlap (In' itiU-mal tv. — placeitia pra-ria. As this cntiititinn '\* imiivniilnblr
k.-uMH-iuUiI uilli Iwiii'irrlia^- ihiring thi- Hmt nU^ of latKnir, anil U h nukil
kerioiiii ooiii[ilii-iilii>ii. it vrill bv dvult with in a <cpiarato clmpliT.
r IhieaMl of the Plaoenta. — Infarct Format ion.—'Yhv itii>»l fn-iju«nt hI>-
nonnalitj of tbe (>lac«Qla cansi&tfi in the devflopniefit of certain deficn-
i-rnlivi* cliin^i', which hnvc bivii vnnoii*ly dc-vi^tiHtiil an «fiirni», nlmphv,
pUccntiliH. h6paiii:ation. apoplexy, phthisis, fatty ami fibro-fatty degetiera-
tion of lh<- placf-nta, etc., but u-hiiih arc inrvt nppropriutfly di.'vcribvd as
^Hernial tnfanrU.
TIww »lruc1nn« vary matfrially in fine, shape, and appearance, and
are best d»?wriiied under tlw followinjr heailinKs:
I. 8iuall, uhiti-'li or yilnwiKh fibrouK formations oocurriug upon eith«r
the ftetal or uiali-mal tiiirfai'i' "f Iho plaiiiita, and varyin>E iu siM from
■nau hardly vi^ihk- to the naked eye to thow havinj; a diunieter of iwvoral
utimetre*. ThcMS randy attain a lhi<-kneit.-i ttf aiore than a few millimo
and are t^harply differentiated from the Hiirrouiidin^ placental ti«fue.
'. On Hiietion ilirou^-li tin- filai-i-iilu nne frii|iii-iitly wes w«d^i--i^hupiil
tm irregularly rnund aivas, irbicb are iii-ualtv dull while in eoiour and
liiibit a nirialnl, fibrous ap|H-«ranei-. They pn-u-nl a tlrikiiig coalnu'l.
I" llw fivrroundin;! tissue, whieh appear* to Im* perfec^tty normal.
.'t. l^-™ comMiordy, (-onxidenible portions of Ihc ptuvnita are itnptical'il
in lliv procesK. and une oecatiionallv fiudn one or more cotvletlonn ronverteii
Bto a pah- while, di-nw, mon; ur h-*-* libmiis area, in which the ti^uul spongy
lure of tiK plaivnla is lactiinf;. In other instances n larjre portion of
irrgun may he iiitoIvc) iu tlte change, <hm? half and eoim-times nearly its
lire iiulutaiii-e Ucinfi iniiiliealcd.
-4. Ntil infre<|iirnllr a limad rim «f whitish or yellowish- white material
olncrned exleiiilinii; for a vari'ing di>lan<H^ around Ihr? margin of the
ftjil turfare of tlK- plarenta. taking "i a larger or smaller portion of its
ipbery, and oroasiouiiilv forming a eoTiiplele ring around it. Tl)c*c
Jb rary from s few millimetres to 3 or -I centimetres in hreadlb. Tliey
'•«> bvDcath i1m> amnion and rarely attain a ihirkn*^ of nion- than a few
"'"■liimetrea, cierpl at tbe extreme margin of tbe placenta, where it m«rgei
tt*o Oie mtfnihrancM. Tbi* eondition if known ax pttiefnta tnnnjiiMta. In
^^^^rtain number of caM>8 tbe iMnti. inMtead of lieinir siluatwl at tbe margin
~^ tin- pliiiinla, lu'j' Himrwhrn- iK-twwn it and iIk- centre of tbe organ,
■■*** forming a broad none more or Ic* parallel to the peripljery, hut »«p«-
^'^^ fmrn It by apparently nonnal platvulal tissue. To this condition tho
muryo [ilavrnlir U soroelimeri iipplicd.
». In rarer m-^lances a larger or vmuller portion of Die placenta is occn*
by A ptnkirJi or hrickdu»l-C(douriil. im-gidarly Hha{H><I, more or Icwi
which U tiltarply marked off from tbe surrounding tissue, 8uch
I usually mo»t prominent on the matental surface of tlic placenta,
~nrn>ijuen(lT exli^nd through its entire thjekne*s; lliey ate some-
u^**"** leniHtl rr'l infnrft*.
^B Siill mi'M- rarrly. wnlti-nil through the ^utMlano- of the placi-nla. arc
^^™'n mun(|i"h areas Tarying from bright red to almn«<t black in colour, amt
""•wring fnuu one to Ihrw wnlimelrcs in dinuTCler. They are appar-
OBCTETRKS
t-nllv t.-ompn«-C(l alrno^l i>ntjretv nf blood. ai»l nre sliarply tlilfrrfnl ialM from
ih« snrrxminiinj; riBsiie hy a capsule which pr^'som* a imin- or less iibrntis
appoaraucv. Tiicy inaj' owjiir i<tugly or in coiisidiTiiWc nurnlx-ni, -o tliat
occaMonall,T the entire placenta in xtudiicd with thein and presents a nodu-
lar surfaoe, and on eoclion an appcsnuicr wliicli I'inurd )ia.< aplljr dcwriln-*!
M pieifNtt fruffi.
These ^tnictun'« arv s]m dffiignatcd sk ivd infarcts, though many au-
thor* prt-r>>r to ii[>eak nf apoplexy nr hii>itiat(iir» iif tht- placenta. TIm'V
difFer markedly in struetiiri' and appcaranL-e from the other form of so-
valled nil inrnri'U, and pniliably hnvv nothing in ironiiiion with them.
Frfifuenci/.-^yiiauSv uiiite infarcts are lo be found in every placenta,
while itimiliir nniw. measuring 1 cciuiuK'tn- or more in diatwier. wijn-
obftcrved in 63 per eent of 500 consecutive placentae whicli I examined. If
not prt'm^'nl in excessive number;, they pn<#ei% no elinieal !>ignifw-Kncf. and
aerordinj; to tlie rmtearehe* of Eden and niy.*elf are to l»e rc^rded as sign*
of MTiillty of the orffan. On the other hand, when they arc of large i^ize
and ahund.int. thry may nKurhanically throw out of FimcLion #n grtitt a
portion of the placenta a-* neriomly (o interfere with the nutrition of the
fictUK. and fomettmo cnii>P il« dcntli.
Modf iif Formadon. — Aecording to the resfflrehes of Ackermann. Orlh.
Eden. Kcrniuiiftei^iid ntv elf. iiifarcl ("rmiition i* the iiliiiiiiitc n-wnll •>(
oWileratini; endarteritis in the vessels of the chorionic vUli. and is brought
ulKiut in the following manner: \f coon lu the eirrulaltnn Ihroiigh the
arteries of the chorionic villi is interfered with hy the endarteritic proei^K*.
necrotic changes begin to appear at llieir periphery ( I'late XIV. Kig. 2).
Owing lo Ihe fuel lluil the !-yniytium i» in dinrt contact wilh the mnli-niiil
blood, the changes occur Brst in the lai-er of tisstie just beneath it, niul
nisnifeft Ihcm«'lves an eougnliition neciwis of l^nghaiifV layer of eelU or
the tissue nhicl" Ims rcphiii'd it. AnIIh' prmi-ss Imtoiih-s mon' ninrk<il Ijiis
is griiduullr converted into the eo-ram] cAiialiited fibrin. A tittle later iht-
syncyiiuin heconit^ iniplicali-d an<l iindergiM's n »imiUr change, llic fibrin
then coming in direct contact with the muternal blond in the ioterviltnus
i^patiw. A* a »'on>'i'fpienee. the l)liiod imim-dialejy adjoining Ihc necrolic
tissue coapiilalcs with eventual fibrin formalion.
I When necmlic chnnges oenir niniullant-ouHly in •K'tcml adjacent villi.
I the maternal bloo<l lying U'twivn them umtergnes coagulation, so iIihi cTrn-
I tually a mimlH-r of villi b<^ome fiifed togeiher by Itbi'n. Still furltw-r
^^■Changiw tbi-n <Hnir in Ihe slmniu of inc inriin-eralai] villi. Ibe <i'lls nndergo
^Voeagulation netrosis, and finally the convirsion into fibrin bcfonu^ so ex-
tensive llnit large ureas lire produced in which only the sKudow^ of tlejEen-
cratetl villi can be distinguishctl (Plate XIV, Fig. 1). ITIiimately the
outlines of Ibe villi disappear, and the entire mass takes on n hom^^fe-
neous tihrinous apiK-nrnnce. in which it is impowdhle lo di^tingtiinh ihr
component parts. For full iMrliculars concerning the process tin* reader
is refern^il lo fuy monogrnph upon tlie subject.
StefTeck nnd nmnv ntvnt writers arc tneliiM>d lo attribnie the flHriilig-
point "l^'tbc priKivK to intliimniatnrv and degenerative change* in tW "ie-
CYSTS OF THE PLACENTA
ii03
id Ihtit liwir fnncluflinni* wore tia^ iifinn faulty promiiira, in Ihat th^se
uulhin <-<>nH)<kTitl Ihal Itie wWn makiti;; up the soH-alliil i|<^i<luttl »cpta
vcn> u( tnati-niiil iti.-li-ail of hvtai origin, km ha* liwii r«.iHlt>re<1 probable
l»y recent iiivf^tlgationis.
B«d JQfarcrU of the pla<i'ii[« «re lea frfquenll)- gliMTv«il. In some
caaes thiT are u^soeJatod vith albuminiiriu on lh« part of tlm mother, which
WM pn-:*'!!! i» .i;i. 11(1. ami i;r piT LTiii uf till- iuiH« riiilwriitl by CttKn;*,
Roi-i^T, aifl Manin re-|iectivcly. rnlike white infarcts tbey podseas a
ojiisHicrahIr i-liiiiral Higiiilii.'anii- Aiiil. wIuim-vit wII nmrk«.-il, an- AAtncialed
vilfa imperfect development of Ihe ftctus, uul mmetimes fniise its death.
rnforhiMiilrlv. w«- an? irnt in a pi*ili<Hi to rxphiJn wiii»fiii'Iorily ihi-ir mixl*
of roniiatioii. and must be conienl with pointing out Ihe relation whieh
ittt-y lnHir to ulbuminuna on Ihe one luind and to impprf^ct dcwlopmiiot
^^ the child on the other.
^H Rt-d inf«fx:ti( arc not, at a rulu:, olwervt-d in tlip pUoimteB of eclamptic
^wnmen, tieinj; Doled only in thope c*mi in which the onNei of the disease
^ui* Urn pntr-ttHd by di»lin('l mul coiitiniu'd ntpbriltc di«liirl>iinop*.
^K t'g*U of the t'laetnta. — Cystic stniclureB are fntpiently obNcr^'ed upon
l^lfr fiHnI Kurfaco and otvai'ifHinlly in Ihe dqilhu of the ptacn-nla. Siiudl
cymU a few niilliioelreA in diameter were notet) in ilfi per cent of tlii> ca.4eit
•^ollfctrd hy K«r-
•n auuer. Larimer
•^•>»«, occa):ionally al-
^*inin|; the iiiie of
» lemon, are obeenred
^w I ran-Iy.
I 'y*ti projocting
'^»^«ni the fu-tjil i«ir-
'■c* of Ihe placenta
•*>* derived from thi-
*^h«iri(iiiic incmbnine.
•» i« nhown liy the
^ct Ihal the amnion
* an be read i ly
*t ripped off from
'*>^UL Their omtenln
*** mtnally dear and
' ■^atn^inn-nl, but are
*'*»Mtiinea blooiiy or
^■Tiniotti in charaiter.
^^le <rall». wpt-cially
*■*»* jMftiona adjacenl
'''* ihi- intervillous t>pac(«. arc ltiu>d in t^at part by a dull whitish mem-
™**n», whilr oCT!»*ionftlly a portion is owupiwl by a white infarct.
^^ On microAmpic ejtamination. the lininp membrane i* found to b<' made
^^p nainiT of one or tnore lavcro of tolcralrly largi^ rpitlwlial cells with
^^^IibA vi^imlor nurlei whir^i frp<|uent!y prefwnt varion^ (legrew of dcfp.5i>
L/^iKm. Htn' and there, ramapondiiig lo iht- situation uf a white infarct
Pio. 480. — CrwT or rLicxm* ( tllrnnuluHcr).
im
OBSTKTIIICS
the «i^I» ttK' *l)i*nl ftnd the. wall r<»ni>iitt:< nr filrrin. The nwoarchw nt Ehreo-
(lorfvr, I'pitter, lie Jong, Vafxmer. anil Sctiickeic have irimrlr ehowo thai
the M'lU^ ill •|uc>^l)<iii (-"rn-ijtotHl tv \Siwe of Langhuiii^'e lny«r, ittid uro de-
rived from the Imjihotilitiitk- tiw^uo which fi>niih the rpitlioiiul covvritig »(
the Hioriotiiv meiiilirniu^, and Ihm the ctsl* r<^ult from their dc^iienitioo.
The cYiiU occurring in (lie d«pliia of the pUt^ntA rarely es«>e<l 1 ctoili-
mvtrc in diami'lrr. TIh>>* rn-qui'iilly ocxriipy the cciitro ot sn infarel. an.-
Hiled with gniiiimiji nmii'iii.-', Hrid wi-rv iriistnken liy On' hMit wrrili>r« fnr
ibtH^^wiv. In olher cast* Ihc conicnls are cWr. Such slructurcs may he
deriviil in om- <i( Iwn ways: either liy the unftoning and lircuking down of
an infairt, llie cy»t-wall then consisting of fibrin, or more frei|uen(ly from
lh« df^'fl(tniliDn nf ihv Imphnhliui ic (tIU vrhicli make up mo^l of llu*
M-caUwl decidnal *tpta. In the latter case, ihe iralU are eonipnaed of
cell" identical with tho:K^ ob«Tvii| in tbv CftU occurring upon thv ft^tal
Hurfaee of the placenta.
So far aji pn-wnl i-xperienot- px-s. erstie formalionn. wliclhrr ocenrtiiig
upon Ihi? ffftal Biirfa<v or in the depthn of llic' platviila, are of inltnwt
puri'ly from a pathological jxiinl of view, and UKcrl lillk- or do inflwno'
upon iJie course «f [jregiiancy or labour.
TwHoun of the tiacfntn, — John Clarke, in 1798, defiertbcd a mlid
tnmoiir about the Nine of a innjt'fi fUt, whieh made np a large jiart of the
placenta. Since ihcn a numlR-r of tumour*, varying in *\xi.- from that of
a pea lf> Hint of a iiian'.-< fL>«t, have been de.'ieribcd, something losx ihan 7(1
being reronled. Dien»t and I'itha, in 190J and 11H)G mtpCgliTCly,
flhie to colirct -18 itiii) TnI ch><i>« from the lilerahirff,
.Xocwniing to Virehow. tlie most freituent variety of placental tomoilr
in Ihe myxoma lihrognm, whioh i» of varying sWm, and i* eompoiMd in grvtil
part of fibrous tistme having abundant oval nuclei, with lypiral myxoma-
tous ATvof- m^aUcn•^^ through it. I'ntil n^i^itly (li<- plavenlal tumours ha<f^
been variously designated, and the 36 examples collected by .\lberl itpi
dusMificd u» follows:
wi^^
Myxuiua fibroaum
Fibmmn.
AiiicioTiiu . .
Sftrwinin. . .
Hypcrpliuia of chorionic villi.
14
lU
0
The researches nf Dienst and I'itha, Itnwerer. I'how that thor are p
ticallyall of iiiir typi'. ami iiiii.-.i.*l of maw.ic!* of chorionie villi willi imnvei
hypertrophy and hyperplasia of their terminal vc^ivU, mv that ll»0^' may
dcr»iguat4'd iiJ^ chorio-angioiiiiUii. In many in.'jtanoe-s tlie tninour in
neetc^ wilh the chorion liv a small pedicle, in which an aricTv and v>^
ean usually be distingnUhed, and Pitha holds that lliv onginmatom tf^^
dition ohotild be attributed lo i<om« interference with the circnlHtiim
thew ves<ieh.
As the chorio-angiomala do not affect the mirrounding placental ti*s-
they do no h»nn unh-'U' they involve sa considerable an arva a* to tliro
large part of the placenta out of function. Albert, on llw utln-r h;
DlSliASES OF THE PLACENTA
S&a
f MA* llal tlkcy cxtirl u ilcletvnoti^ JaRiKncc upon tlw coonw of pn'^aiH-v
«tiii lalKmr 111 llw 'Mi «!■«■>. i-i>ltivlc<l l>j him. mily iiii<! Iliinl "f itw tliil-
iliva wiTc l>oni iilivi- ur ui-iv imniixl in tixv. I'rfiiiiit tin- hilnmt wiis iKtIol
in 13. and hvilraumuM in -I ia->lan(.-4->i. TW Itmioiir ruriiialjun ii|iiH«r<-<l Ui
inU'rr«T« ttitb Ihe soparatinn of the plaoenla, as iU nianiial mnoval wiu
itny*t»ty in 3 cji»c», while ha>morrhage during or immiilialcly after l)w
thin! ulttjcff of Inliottr (mciirrcd 5 llmai.
\\'»)z, in lHOfi, i|p!4>riliMi a Biimbcr of miiUipIe tumours in the placvnta
jirrw-iiting a "truclun- trpical of im-x<>t«ny>m». Tliwc lit- <t)n»idiTi'»l wi-ro
inetMHtajM^ from a .■'iuitlar iniitoiir in tho li^. whii^h ori;;inateil diirin); prej;-
nancT, If hie interpretation is correct, the obewrvaHoii rppn-s^-nU u unique
jialbuiogical condilinn.
Amniotic CaruneUs. — Tundra' Ihis Tume have bwn dcscriixil rertain
iHH]ult?> whii'h ix-iUT U{Hin tim fo-tnl ifiirracc nf lh<^ platHMita, a.< well as
upon the free amnion, ['fliallj' l)»e>' ap|>ear in the iieiffhlioiirh^iod of the
in.'wTtiun of the mnl u» iniilUpk, mu»il<i) or ova), opu'jue di-vatioiii'. wliicb
rary from liiw than I to A or 6 tnillimetroH in diameter.
t'ndiT iW niii^mM«i»' ihi-f an* Mvn l<» ho niinii- itp i>f trp'ml BtratiRi-fl
qtithHium. n»e lowwi laver i« cuboidal in fiha|)e and is eontinuoiisi with
l!w umiiintiv cpi I helium, whiU- llw upjKT hivt-ri btH-omc nion- and more
ELalteoMl, aod nlaiu lew and ]eAt vol! as the sarface U approached. Huch
»IruriMn"» are of fn-cjui-nl wTurrcnc* and wi-rt found by my ami^^tunt,
80I0D B. Dodds in 60 per c<«t of 300 placeulft. As yet ve ar« ignorant
"f tb^Hr Fijnii'i canoe.
Infinmmnti'in of ihf Placenta. — tinder the term plaecnlili^ many of the
•idur wriieni dericrihcd rliaoffes which we nour reco^irie as infarct forma-
tion. Morwvfr, a* hiw aln'ady K-en Mid. umall plaenntal crittit fillwl with
CTumou-* contmts were formcrlv )hnii;:h( to be al)«*3ws. Ilenw it follows
'hat tni»t of tbi- H lull- It) (■tit" in lh« nbiiiidnni rarly liurruliin' upon inllain-
mahiry lesions of the ptac«nta must be ret-eived with the Breatest caution.
At tlM> fumv limi> arutv iiiflammalion of the placi>t)la iM onatiiDnally nwt
>i^th. It is not s primafT condition, but is due lo the exU'nsion of a similar
JiroccM fn»m (he dwiduu. iIm- latter rcstdliiig frnm an cxao-rbalion <>f a
|>TW-exiating clironic ;;onorrlnea or from an acute iufection duo to the gono-
■*«»<mii or other pyogenic bacteria.
In «PTOraI in^tannr*. upon t'xaminin^ i^vtions of ptati-nial liai>»i> under
mtrrn*cnpc. I fnund tlw dccidua wTiitiiia innitralctl with Icucoc¥l0!i and
■To-iilinj; tite cbaraclt-riHlic pictun- of an ai-iilt' tnllainnuilion, while Dio
**ljarenl intiTvillouH spacoi were crowded with leucocyti>s. l-'mnijuc ob-
•■*• twl Mmilar oot>dilton#, hut U ini-tincd lo beli«Tc> tliat in nmi't in^toncftt
***^ implication ot the placenta is secondary to tin- death of tlie fietos.
TubrrmliuM of Ihf I'lactnUt. — TuIhtcIc fonnation in tlie fa?lal portion
**' the placrata is eslretnely infreijuent. For particulars coneeminjc the
which'have thus far been reported, the reader is referred lo |1k> chap-
Upon th<^ rhyxiology of tlie Fieliis and u|>on the Infetriious Disea-tea
I *^*ij ■ . ; L' Pr^mancy.
I -.iian of liif PhrfHta. — Small nk^reoivt nmlnlex. i»m«(inM>»
I *^^'cmmng in tlie form of Bat plaijut^, are fre<]nentljr observed u]mn tlte
t<^.
596
OBSTETRICS
nisl<>nial i>»rfa4>e nf the pliu^onta. Ami are ncxuuionftllr m) uliundant s» tn
tvijee it to n?»embk> n pk-cf of ctWD'i' e«nd-pHpc>r. Friiukpl fhowt^t) llial
Ihv chalky iiiat«ria] ua^ iiMually <ii-|»»iiwl in ihi.- iwcrolic Iijwik- i^Hrmiind-
in^ the aidii of the " futlcnttig " villi, as u-dl ss in tlie auperlicial Uven
of thf dwidiiu m-niliiift.
When the aloio^t iiniteml oc<>urr«»(v of degen«rativc nhan^^ in the
plarpnln is rvmcniboiivl. it (ihniild Ih- a mutlvr of tfurprine. not that oalcili-
ration U oM'ssionally tuex wiili. lint rntlior that it t* itnl noi«d in Hlin»:it
fTVT)' pliin-iit«, iiiakniiK-ti n< n;i|iHn'»tly idcul <i>n(litionri fur itti fonniili>>ii
Hrc fonstantly prcrM-nl in tin- liiitr ninnllir' of pret^nam-y.
Abiwrma! Ailk'-rrnrr of thv I'titfrnltt, — !ii llw vast majority of vancn
the t4>nn mtherent plaivnta \» a lui^noinor, Aint'i> tlte intorfi^reiKt' «-iih its
i'Xptili'ion i" iiMially due to alinonnalilie> in Iho iilcriDO c'tntrH^rtione rallMrr
than to nhnornial adhoHions iK'tweeii it and th« uterine wall. Tn rare
inetanci.s. on Ihc oili<-r liinid. \\w adln^ioiiK may In* *o linn and extemiivc
that Hpontani-ous ^-paraiion tjecnniPH impoM<il>le, and otx^asionally rannot
be (■ffpcti'd vrvn al HiilopHv i^xM'jit by tvaring I'ilht-r iIh- placenta or the
iiterin*' wall.
Ni'Uinaiin and llrnvf 1iuv« r(«('»t1y vxaminoil two nlt>ri in nrhicb this
condition iibtained. M iiTascopir examination in ('arh ca.'^e showwl that tlie
decidua K'rolina wu« ahno-'I <-n[iiT-ly ntwnt, and llial tlif chorionic villi
wer« in direct contact with the uterine muM-Ie and the coniiectire tii^iM
Hcparating its fibrw, I'mli-r such oi renin!' la nciw The nbwncc of llie spongy
layer of ilie decidua readily explain;; the clinical phenomena.
Abnormalities of the Umbilical Cord. — VnrialioHs in Itufrtiim.
— Thi- iitiilnlitul cold is ii-iiuily inserunl ec-cent rival ly wjwn the fielal
iiurfa<-e of the plat^eota, Bomewhere between ile centre and peripln-ry.
A cciilral iuiiertion
is less common, whil*
in a still smaller nnm-~
iH>r of caeiw the June—
tioD haft taken place
n«ar the margin, giv—
ing ris« to a iniiditio^
known as bnUUdttf -
piati'nla.
In S.tMKI plaeefllK=:
i'\iimin<i) at llie Jolir
ttopkin!< ilospiul th
insertion was eccen'
in T3.25 [kt cent, t€~--^
tral in IS.LT. jxr
and marpnal in t
per cent. Thww va
atlons poiMitii no d
ica) r^if^nificance.
On llie other hand the so-called relami'Htouit in«friurn 'if Ih* rorc^—
insertio velanieiilOHi — i^ of considerable practical imporUncp. In tlii»c*>«-
Fio. 4Da— Uauitkai. Lshkhtiun or nit Const. B*iti.kmmw
3i
AfiNOHMALITIliS OP TBE T-'MDILICAL OOIU)
59;
1^ dition the tmwIb of the i-oitl »parat« tomv dietanoi- from th*! placental
^k margin and make tbeir way to the latter in a foM or umition (Kig. 387).
^^ Tliw Riocl*! of insertion wax notod in 0.81 per i*nt of I.I.S'.U plAoi'iiln; ex-
Iaiui[K<d liv Iji.'fiHTV, and in !.:.'& pt-r c-unt of our caws. Acx^onliug to Uiroii-
i>H it occur* ninf limft" more rr»r<jucnlly id twin lliun in (linjilu prc^ancttv,
beinf; noted in S and 0.5" per cent of the pase.* ros|)eetive!y,
Its modo of pHKlnctiou lias given rise to a great deal of speoolatioo.
So long as tin* old view* were in vogue ponoiTiitng ll»- part played by the
allantoiK and tlie amnion in the formation of the unitnlioal eonl, Sohultze's
ex[»lanalion oMained almost oniverwil acceplanw, Accnnling to this, the
anomaly was the result of abnormal adhe«it»as between the uinUilic-al vtm-
rie and the chononie mwnhrane. whereby (Ir- amnion was preve?itpd from
applying itself in the ui^ual manner to the eonl. .\t prt^ent, Iwwever, the
nllantoi!' ik kmiwn to ptar an inKignifu-ant part in the formatinn of the cor<l
in human beings, aince the rewareheH of tlis have oloarly iihon-n that the
nbdominat pxdit-le — Ihu forcninner of the oord — is prcs«nl from the earliest
periotis, and reprettents an extension of the eaudal end of the embryo, in
^H vhtch llie allantois is n-prc-M-nled l<y a mere epithelial duetlet. Moreover,
grille cord U not provtdiil vitb a Ktiealh of amnion, and llu-refure abnormal
adhesions of the umbilical vesicle can have no effect upon its eovering.
Kran*]ue, in I9<M), advanced the following tlH-ory a» to the mode of origin
«if the vclamentous inserlion. In the vast majority of case<;, the abdominal
jinlicle exionds from that |iortion of the chorion which i* in contact with
the mo*t richly vascularized portion of the dociJua — ordinarily the decidua
vwfxitiiM— so that the cord becomes inserted upon the placenta. Occasion-
ally, however, during tlie first few days of ])h!jinaney, the area of greatest
Vascularization may lie in the dtvidiia reflexa. and the abdominal pedicio
thtm lakea its origin from the portion of chorion in contact with it With
Che advance of pregnancy, however, the area of vascularizal ion shifts to
tbe deeidiia Mrotina — the xite of tltc future placenta — while the abdominal
Ijele retains its original position, and from its mnlemal end the vesoolu
»sten<] lo the plmi'iiial margin. IVtcri, while rt-i-o^-nining the fallacy 0^
^hnltze's explanation, is not preparctl to accept that propot-ed by Pranqu^
As Has oln-aaly bM-n pointed oul, t)te velamentnus insertion a nntMl oom-
f&aratively often in twin pregnancy, and in single-ovum twins is supposed
play a part in the production of hvdrainnimi. According tO'Lefi-vre, the
Dtlttion not very nneonimonly predisposes to premature labour.
[When the placenta is in^rtcl low down !n (Ih^ titenu, ilx; velameatous
ris may extend partially aeroew the internal o^ — vasa pnevia — and as
^Sitalaticm prngrefisea lie prised upon by the pr<.iH-nting part, thi^ intrrfeienoe
^•nih the circiilalion causing asphyxia of tin- fieliis. In rare ca--«s ^oeh ves-
E~ ' are torn through when the membranes rupture, and the fwtu* bleeds
Jcath. The full literature upon this subjectup to 189S lias been eol-
ed by Peiser. while Knapp has reported a ra»e in which the aooident led
;he death of both twin.* dwelopi'd from a single ovum.
Variatiotit in Len^h of Cord. — Normally, tlic ombiliral cord arcrageaJ
ut 5R eenlimctrr:i tn length, though it may present marked variational
I.E to 198 centiroctrea (Dyhrenfurth and Flyrll). In rare iiwtances it
OBSTETRICS
m«y be so short that the ahdonuii of iln; fwtu* i» nltnost in muiftd witl
the plaotnta, but uiulor such circumstances a congetulal umbilical iKToii
i.t alway> present.
Accdrdiog to Kallenbach the oord must l>e of a eeriain length in orde
to )x>niiit iif iIi'livtTv i)f thf child — that is, it mtwt bv i^iifticicnUy long ta
reach from its placental insertion to the tulva, 35 centimetres wli«i tl:
plactMita ii« iii^crlcd !]i|;h up. and 30 centimetres when tow down. A<
matter of tni-t \\ ran'lv iiiea.>«un'»i li-iw than 25 ci-nlimetri'-'*.
On Ihc otliiT hiimi, it not infrci)Uentl.T happen:' liiiit cords which actu-
ally, exi-etx I ihir normal in length may Ih> *o twiHt4'<] alH^ul the child ai^ to
Ift-comc praclically. too dhoit. Accordinply. one digtinguisboe betvera a
lute anfl atridf-nlul or rclativv Kliortncnf uf th<- c»nl. Rilhor »r Ui<
t-niidilipii^ may ;;ive ri.-e to sertous dystocifl. Brickncr, who has carwfuU;
xtuditti llit^ sulijit-l. Ktati'K that ddivcry cannot (K.-(-nr iniilcr .luch cin'uin;
^tsncra unJoiiM one of the following accidents occur: ceparalion of the pi
i-«)ta. invi-Mion of the ulcru^. umhjiical hi/iiia of the f«>tiw, «r niptuM-
the cord, the last two lieing of infre(|neM ■oci-urrenw.
lluplurr uf Ihf curd niuy result fmm atiwluti' or acridmta! xhoiini'
Iteing iluf To lli« foniM-r in Dyhrenfurth'*, and to the latter in Ahlfeld
cn^v, in which iIk> cord measured 44 ccnlimotrea in Icuglli, hut wh« tightly
iwiiitcd about the ftirtmi. Ordinarily an eiti'&'wisely lony vorA exertii
tk-lcturiotu; inRui.-nc«. althon^'h it pri-<li»po«cs to the formaliou of loo
during |>rcgnnn('\' and to |>rolap»<- at the time of lalmtir.
KkqU of the Cord. — It if cut-toniary to distinguish bvlwpen false a:
true knoUt, the fornter l>eing due to *]ev<>lopin(!Dtat ahnormaliliiv in t
cord, while the latter resuU froiti the active moteinents of tlw child. T
knofK iH-ciir v<'rv friipicntly, and (K^'aNionallv art- of thi^ mo«t fwmptioai
rharactcr. Ordinarily Ihey are of no clinical importance, hut oecasionall;
they may be pidlcd so taut bj" to comj)n's's the vtsuiirls urnl ttTHd I" n«phyxii
of the fofliw.
Loop» of Ifif Cord. — The cord fn'<jiirnlly hccnmcj' wrap|ic<l aniiiiKl pn
lions of the fivtun, and in cTcry third or fourth cax' of laljour the ehihl'i
n(M?k will be found loowly encircled by mie <ir more \>mfi*. In ran' iti'lani
tln'ne may prodiK* stranKidalion. In most of Ihcie cases, however,
accident is not <luv In any druwing taut of thtf loop, but ralhrr (o
fact that it i}i«-M not liecome lonncr in projHirtion as the neck of ihe chil
increases in «zc. In other caws, loops <if Ibe cord may so tightly encirc!*
the body or one of the extremities of the child as io give Tm> In
deprnwoiu, which in extreme caM^^s may eventuate in the strangulation
gangrene of the affected |>art.
in single-ovum twins in which the amniotic partition wall has
broken through, it not infwHjucnlly happens that the cord of one fict
may bwonie wrapped around some portion of the other so tightly as
cauiw its death. A nuuiber of ca-tes of thi& character have li«en coll
by Hermann.
Titnion of Ihe Curd. — ,\» the result of m<ivenient.* on tlie juirt of I
fcetus, the cord mai' become more or less twthled. t)ccasionally l)ie toi
eion is so marki-d ft* to interfere neriounlv with the circulation. The mm
%
^^V l^^r FtETAL SYPHILIS ^^^ 599
dtreme def^recs arc obsened onlv after the death of ihe foetuii, Schauta
hm-in^ iwjmrtMl a vkm^ in whieh 3$0 VwwU were ootvd. Id rare ini'tuncK*
Mparation of the cord ih produced, thou>;h this U possible onljr after the
d(«th "f flio fivtux in thv parly iimiilhsnf pn'gnaiicv.
Infiatnmalion of the i'uni. — A» lonj; an the child is alive infiaiiimatory
tniidittnti* urv rarvlr doKh], but afliT ito death the Whurtomuu jcllj i»
fnuod Id be inflhratod with leuoocytcK. Xnt uncniiiiiioaly obUtcrative
r)iaii<ri% 'Kviir in the vcst^'U. the lumiiia becoming aliiKx^t cvimpk-tdy
ijit'liiitcd. This IK (^pivially lialiUr In iii'<'iir in M[ihi]ii>. althuufcli il i" oIi*
xcnvd in otln-r enndilioii!^. and. as has already bee>n pointwl out, ia lMilii>ved
tu In* an octAoional factor iu tlu' prtMhicI inn of hydnuniiin:>.
In rare innlanct^v raricfs of the eord may bo &uhjwli'd to undue pretwure
an llw h^iilt of i>U('li clian^t^K. Mrivr ha» n'lKiriiil a cast- in wliich Ihw
drath of the fa^lus was attribtiiahle to the rupture of HUch a slruclufi'.
I'Htnourx of ihr ford. — Tumour formations implicating lh« cord «rfi
rmrply cwn. Ha-matoniala ocoaftiwially if--«u!l from the rupture of a varis
mith KiiliHiimiii flfuKion of hlixxl into the conl. In om< tn:^laiH-r 1 ubwni^
»iu<h « tumour, .1 cenliini'irt?!' in <lianicti'r, al thi> fiKal end "f llie ci>rii.
Jklyxonuita and myxo^an-omiilu iwvir uliio U-cn dvocritH-d. Wintrki.-I htu
ra^iftul two van-a fil tuirmnia of tlic cord, while Rndin ban destirilxH] aa
^{ipan-nlly typical dermoid.
C'liaitie >>truciiireH o<i-iuiinnally oeeiir in llic courw of the mnl, and are
«-J«^i(nia'<''l a» Inic and faW cyst^ respodirfly, according to their mode of
«*ne*<). The rornu-r are aluay.i quite ^nall and nuiy Ik- dt-nveil fnnii ix-ni-
n^mta of the umbilical fltalk or of the allanloiii. while the latter may attain
a. ntn^idi'ralile xiu- and moilt from liquefaction of the Whartuninn jelly.
>^aias ho^ di-MTitied a case of the latter variety and c^illwuil tin* literature
u j»on the (iiihjix't up to IHdt!. A« a rule tlwy are only uppureiit. aiKl r»^»ult
'rw^ai tJte Uijuiifaclion of the niyxonuilouii tiseiue uf t]»e cord. In otlier csttee,
^L^i n-porlti] liy Kleinwachter, they may develop from the flurt of ihe nm-
b£J jral v<!^irle, which i* iHcltidetl in the <-on).
rtEdrma of Itif Cord. — Thii« coudition is rarely noted by it«elf, but not
t*** '"rtijucnlly coniplicateji (nli-itinlnus ennditionit of the fivlu*. Il in very
^'^•rnimm in dead and maceralml chitdrvn. In one of my cafes, in which
*-^»*.^ t-btid vMn bom alive at full term, the conl wit« 3 ctiiiiimeln'^ in diam-
* '' • '*" and nx-mblwl an *>cl in appearance. M ierwicopie examination showt'd
f*t iIn> condition wsh .Mitijdy due In an incrvM^e in the ainounl of Wluir*
*'-*«» i*n Jelly.
TceUl STphilii. — Syphilid i» Ihi; mottl fniquenl catii* of fwul ileath in
***= later months of pnynancy, ami. m vas »aid in Chapter XXV. may bo
^'^'■••rmal or paternal in orif,'in. The motluT may be i>ulfertn)[ from the
■"*^we al the time of conception, or may contract it during tbi- courw
prefrnaoey. In the one cafe, it is believed thai traOftnisf^ion to thi; fo^tuti
""'»^rH through (he ovum, wherca* in iIm? other it tafcwt plw-e throujih the
'*'*M>enta. .As a rule, the lalti-r mode of infection is poeaible only whiMi
tnoilwr \t inoculated during the early monllix of pregiianoy, tltough
itfnnii are or(:ajii<tnaIlt noiml. So far as iny oan ex|)eneni--<' g"">. I
inclinral to lidii-vc lltal in ma«t in^tanow the diiwaiic h paternal in
000
OBSTETRICS
orif^n. iinil ii' IrnMHiiiIk'd Uy llic ^pLTmalujEoa. In i^ucb Mtaes nt^nmMr
will or will mil coiiiracl ihit cliH-aKi-. ucwmlin^ at) the father does or ilues
Hot pnwiit iiifiTlioiis In-iuns at tlm tiiiw of coitus, Siuc« Ihe*? an\ iixUHlly
a!>»ant, llie fa-luit onliimrily b<.<coiu<»t inoculatvtl, wltile tltc moUter eficapcf
— Collea'a lax.
It luis Uitig Ih-ou kn'iwn Dinl & §y|)hi]itic infection ejiert-i n most dele-
' teriouii intliK-ni'e ujHin ihe jiniilui-l of win(H^|iiii>n. It fnijiu-nllv ii rtvpi'ti-
silile for the dpalli of the fo-lus and its premature expui^un from the uterus.
Lets coiniiioiily t\w child in kmi kHvu ithowing dixtim-l nianifvsUtionit of
the disease, while in other cases Ihey do not api>ear udiII a later peritid.
It i» of tin- gn'a1c*t iiiiimrliMKr tlint llir pnictiliou«r vhould become
Uiomughly familiar wilti the ehara<-ieri.-<tio legions of fn'tal and placoiial
Eypbilis, us upon their rwognilion the future treatment of the patient often
depends. This i" n point csptTially worthy of finphaxis, iiUL«m;ieh a*, in
consecjueiice of i;;norancc or design on the part of one or Imth parents, (he
firit i mi III II I ion [lull ilic plmicinn lunii of the exisieniir of iho diwaw i»
often afforded by Ihe birth of a dead child or the appearance of ^yphiliiic
irti^iala in a liniig one.
Syphilis not only gives rise to charaeleriatic lesions in Ihe skin ami iu-
lernal organs of ihe f<flus. but aNo aileiti' ihv plsrenta, eo that freijumtly
a diagiio«i)> can be made from an examination of th« latter org;an. This
fact is of special imporlanee in thofu cuw* in which the fa'tus u bom aliw,
or when an autopsy is not pennittc'd upon a dead child. The appcarauoe i>f
the syphilitic fietns varies mutfriHlly according a£ it is boni alive or dead. J
In either inxlHiici' it is marknlly lUiikTsiax-d, and the MiU'iitiinetjus fat i»^
poorly developed or entirely lapkini^. In the living child the skin pr««*ms^
a dry. drawn appearance, and hai^ a peculiar grayish htiv. It k very brittle -^
(wpwially a1 thi- fle.ior stirfaccs of the joints, where abraiiions readily n.mw \
and expose Ihe underlying cariuin. The skin covering the B'>les of the fee
and palni!' of ihe hand!" t* often lhick(-n<'<l and glistening, and i»uggwU tb
oondttion observed in Ihe hands of washerwoinon. In other cases, c
tcristic cutaneous lesions are noted, particularly the npiHiirancv of pfi:
phigoid ri>sicle!< upon Ihe palm* of Ihe hands and aolei of the feet.
If inlra-uterine death has occurrecl, the freluB rapidly undcrgoi'S nu
eisration. the »kin peeling off upon the sligbtwl touch and exjKWJng
anderlying disc-olonred oorinni. Tniutiwrienccd persons bare regarded H
condition in itself as due to frvphilis, but it is by no mcsns pathognomon
since it oceiint in all macerated children, no mailer what the caui«e of diia»~ j
At the same time i1 must be rememlicred that this defect may entir^^
obiitcrutc or at least obscure Ihe s|«ciflc skin lesions.
The legions in the internal organs consisl esMnlitlly in interstit
changes in th*- lungs, lirer, spleen, and pancrww. and oaieochondrilif
the long bones.
H i* generally slated that Ihe lungs frequently contain gummat
nodules. Thetio, however, were lacking in the specimen* whieh 1 l» -
examined. In many ea>e* the lung* an.' enlarge), pale, and scarcely f
when thrown into water. On mieroseopir examination the alveoli are fo
J casl-oiT epithelial oeljj^^^^JjKj^jf fatty dcgi
elL^^^^^uro^jf fatty dcgvwy|i^^^^
mCTAl- SYPHILIS
601
calarrhal {iiii>uinoiiiA. tW pneumonia nlla nf Virclmv. In other eaMs Die
lesiofl oi)n»UU in an iitcrvasc Jit Iht' tuurtlilial Ui^wi a^KOciuled with pro-
nouncnl round •cvU iiitillratioR, bv which thv alvmli iin> cgmpraMod, but
do not becoDto <|uile iinpervioua to air. I'liettc cliao^^ haT« been exhaiu-
livi'ly Ktiidkil by Hi-llcr.
A* ihi* rtTiill of hy[»ertroj>hio cirtJKwii», thu liviT untlcrgiio* ft markud
incmAe in size, and according to Itti^ its wvi^lit may equal one tenth or
rrcn one oighth of thai of Iho whole body, in»tt-ud of orn.- tbirti<-th a» UMial.
Fn<Ier tltn mixmi^-ofw tli«re U n marketl inivrea-ii* in (he ronncotive tissue
snrroundiDg the liidiTidual lohnleti and acini, with bore and IIktc ernall
amut of rriitnd-n-ll infill rat ion.
The !ii>leen likewiw! uiiderjine^ interstitial ohanjccs and increases niark-
nlty in atxf. si) thiil it freqtwnily neighii Ino or UirM- limi-n aa mticb oa
Hit- «tl. »■«. 4112.
s«Mi«l, whiHi, rnu>:hly ajM-akinj:, ia one three-htindmltho of tliv body vrvigliL
*H>e ]iancr<?as also preKnt« interstitial changes, and is slightly larger tlian
•formal,
The revognilion of these lestons requires some little jiatltolo^iral expe-
dience, though if tlH> liver and ^|>li<cn arc found markedly increased in size
^L«id Wright iIh- dingnosi* of >y|ibiliK is pi-niii«il>lf.
A miu'h innre chara<rteriiiti« «jgn, and ow wliicli it n-sdilr detected, ii'
■"■f' r^pyl by eliaogcs w-curring at tin- junction of the opipbyj-i* with the
'^is in the long liows — Wi'gm-r'ii l«>n<* diMn>«-. Konnally tlw two
am >vparatc<I by a narrow, whitish, slightly eunwl line. O.S to I miUi-
»«>rtn' in diameter — Ou^rin's line — n-p^wenting the area of preliminary
■^■th-ifii-ation, nliieb constituIcH the .icafroldiDg n))on wbicli the new hune
■* ' ■■■■■•). In ovphili'. on the other hand, Ibi? undergoes c'hanicteri«tic
*•!.. -"onuiing ronverieil into an irn-giiliir. j*ggi'<I, yellowish line 2.
^1 vr mnrn ni)ninietre» in thickness. In advanced eaw<i this alteration
602
OBSTETRICS
hU. iVS, — NiilIM.H. I I LI M. hlt-
is ii*w>ciiilwl witli ronsifieraWe sofleiiing and the furaiation of a mft pt
Iweous material, vhicli (KX-a» ion ally li-nd^ to i-<iitipk>le ncparation of ik
epiphymB (Fig*. 4iM and 49S),
I'lwn iiii(nwco|iif«t i-x;iiiitiinlimi of Uie no
ninl epiphysis, as eliowD in Fig, 493, tht; carti-
tagi' t^^ellg art' fuiitid to Im; urniiigvd iu paralk')
mw» at right anjflw to Ouirin's line, while
below it i* the typical bony structure of th*
dtaphyifii^ with it« inarrovr cavities. The lint
IlM'lf i* foriii<>d )>y a di-|XMit of Umv saltn In
tween the miKliao ends of Ibe rows of canilag
t-i-lls, uiid i." gradually invadftl by the iicwlj
formed Iwue.
In syphiiU, OS it; illnslnilcd in Fig. 49j, tk
<'hiing«->i are due tn oHtorhinnirilis:, »» the
fiiilt of whicti there U do longer a shaqil
niiirkt-tl Jiiiin- of pn-liitiitiary coik-ilimlion U
tween the cartilage and ihe growing iKmfl
but areas of bum; fonuRlion. calcification, ai
leuroc^'tic and aniall cell inHtlration ant four
scattcn-d irregularly through the lower portion
of ihe cpiphy.iU, giving an irregular ap|K-aran<
to this region.
Thwif changes hare been carefully studi^
by Wegner and H. lluller. aiid are most readily remgnisabk at thv lov
end of the frinwr. uml fairly well at the lower ends of the tibia and radiii
Tliey are les-i ek-arly detlnetl at llit- upjier iiul* of thv lihia, fthtila. all
femur, and only in rare
instance can lh<>y \m}
made out at the ends
of ihe rill*. They arc
exIreinelyoharBclorisnc,
nud Ihcir detection jus-
Iifte,i one in making a
positive dia>niosis and
placing the patient un-
der specific treatment.
I'laccnUsl Sypliitia.
— I'nder the influence
of syphilitic infection
the plaecnlH undergoes
verj' characteristic
tfbftngvs. It becomes
larger and paler in col-
our, and if the fcetus
is dead often prcwnts
a dull, greasy appear- ■-- -
anco. Pto. A9t. — Brmtunc Fiktal Oinrrsiti. x 80,
Wit
ir'
PLACENTAL SYPllllJS
603
Ita ioorcaiw in size \» v^ry marked, and actwrdiiig to Uk- mMrcliw »f
Corrm-Oiax aiul Schunlj. which I hn«« in-vn tiUr ut cunUnn, in^itiwd of
one »ixth it may represent ax much a^ one fourth or ev«n a lar^r frac*
ItOD of (he vnliru body weight uf the (cEtuH,
Still more charat-Icristtr. howi-^cr. nrv llic cluingiw in the cl>i>rii>ni('
villi, lo witicli Frankvl cnlW altt-ntioii lu IKTS. In ^yphUis the villi,
when lea-inl o»t in mII ^nlutioii, arc seen to have lost their characteristic
arhoruitcent app^wrance anil to have become thicker niiil iiiiirv cluli-i'liapi.-'l
(Kips. 4!t5 and 4Pti>. At lh« Komi- timv then- i* a nmrkiil liwrease in the
number of blood-vestpelK. which ili-uippear almost entirely in advancod caw*.
"Hiia rvKults partly from cndarterilic- change*, but jirincipally from a pro-
VWW. 49S, 4!M.— Xfl«M*i. AtiD 5tpi»i.Iti<- CwHWilr Vrtu TKAMD our ts IUlt 8ol.LTniM,
t(uaim.T Uaummkix
tifcnticm of the stroma celtx, which lose their normal stellate apiMWrancv,
l^xnminK round or oval in nhape, and closely packed lo^^tlM-r.
Similar chanRci* are flb!^'n'(-l) in KOctitin« made from han^n^l npi-ci-
actu. A* will be wt-n on comparing Figs. 497 and 198. ihu individual villi
mre in«rki*lly increased in *ixf and almofit devoid of hlood-itMiclM. whilo
thi'ir stroma is made up of closi-ly paektd. round, or oval cells. Thin
,a|)|iearwKf> is so characterii-tie as to enable one with a little practice to
a pmbahlc dia;:no»i!". and at tfic same time afford:' a Mlinfactory
ination for tlw jwiir developmi;nl of llie foElns.
The work of NeUfi. 'rhomsen. liohn, and othen tends to i>hoir that the
dwDftw iu»I dwcrilwl. while very sngjicstive. are not absolutely cUara«t«r-
ktie; and the latter hold.^ that a jxKiilivc dia^o«tii cannot be made onlcsa
the prcM-nce of the tipirocha-te pallida of Schandino is demoostrated. I'his
^aik
604
OBSTETRICS
lias been itono br Wallich an<l Ijoradili, Mohn, Schnltz, and raaay uthen,
and doubtless will soon become a routioo prorwlurc.
It is geiierally »lat(.>d llial difitinct sypliilitic lesions, vuning fnmi «
marked t)iick«nirig i>f tbe ijiwiibriin'; Hi distiuet gumma formatiou, aw
fntltionlty aolfA in
tbe dccidua. I ua
iocliiicd to bolicvc,
liowover, that titan v
of the conditiuDS
vtiivh have beco de-
scribed as such hare
no <.'onii(x^ti<>ti with
lues, but are aiuil-
<ig«n» to thr va-
rious hyperplastic
oonditions of tbe dc-
oidua, wbiob were
formerly attributed
to tl»e !«ain« cmt*.
Zille«. atMl many
of (htf <'4iHi(T wrilirr',
described giimmata
occurring in lh« fro-
lal portion of the
placenta. 1 hato
nt-viT ini'I with such
lesions, and am of
the opinion that care-
ful histologioal Mludy
will show that tbt?
majority of ilio «v-
i-alk-d placental gum—
iiiata are momly in—
farcts in varioiii^^
stages of develop——
miint or d^encto— "
lion.
Bondi, in isoa
directed attention Ic^^
rhanges in the urn
bilical cord, which h-^
iiiinj'id<Twl very char
acteristio of syphlll
»nd his findingi^ har^
bf-en ctintirmed |]^,
most HUbmeiiucnt wr *
Icrw, Jlolin bavira^
been able lo deniPtvi
Fifl. Wr.—Kotaixi. Vvia^Tkioi Plackxta. x XO.
Via. ttHS. — STriiiLnic Pvu^Tcrm Plal-kkta. x '>().
DISKABES OF THK FlKTUQ
flO&
^HTHte tlK! BpirochxtL- itaJli^U in 50 per cvnl »f tiis va«i». 'thet*- t-luingo^
^BDrctir iu IIm- vi>«m>tK. imd (^v)ii!iiKt. in atloiiia »f their waW*. an<l tpiicorytio
^Huriltr»lioR of Ute lipacvs Itctweeo the miuclp fibrw. Similar cliunfp;s anj
^Boled in thL' adwntilia, while the iniima i^ more or \es» tliickoned. j
^m Oeneral Dropay of th« Fcetu. — In this rare condition. G5 instances of
^pwhich have Ixx-n (-oltivti^^d by r(jiMiuil}'n<% tliv fuHii* aud p)ac«nlu are mark-
mIIv (iiivmatouji. Aa thi' naull of inflKratiou with scruiu the fnrnu-r may
IAtlaiD iinini-n^ projwrlinn^i and the latter be increai>ed to three or four
Ititnra its nonnal nize. In a case under mv observation (he tatae, at the {
IMrtenih MKinlU of prvgnanc}-. «'df;h<^H) 1.1 -ID and the pluciiila 1,800 granimcs.
Cohn lia^ di^^ritied a plawnla wi-i^hing ^.MOO griimm<9.
j Although a good deal lioa been written upon the snbjeet, no aatufoc-
torj' rxplanalion of the anomalr has an yet been arrived at. Formerly it
I was tiiippom-ii to rebuilt from o^detnatoui- eondition* of the mother, but the
rrirarches of Ballaiit}-ne have shown that this ricw doc-* not alwavK hold
foKMl. and thai in iho majority of the pa*c* i^wlunitted to a iliorongh study
jeions were noted in the organs of the fretns sufficient to explain the pro-
luction of the condition. It is inteieeling to note tliat in several rases
raliLvted by Seifert it WHs atiriliutMl to fn-tal leukieniia.
Thf diw-aw- always leads to the death of the fo>)n*. which tn no in-
^^anee survived its htrth for more lluin a few lionn. In the majority of
^■l«c« ou reounl labour was spontaneous, thougli occasionally the increaxed
^Bze of the fivtuq uud lh<- plno^nta may )pve rise tn dyotocia.
^y SUeates of the Fstns. — In mo^t text-l>oaks upon olHtetrics, numcrotu
Tnnrl'id condilion; of tlie fa>tus are deMrilxKl und<.T ihii^ hcadin);. llie
^Aiajoritr of tltem, howerer, are of IntiMyHt mainly from a palh»lo|gicaL
^Hoint of view, and hove no obstetrical significance, exnpt in thoM- vM»e* <
»»i whiHi ther lead to nn incn-ane in tlii- hiiik of lUe fo-lns, which in turn
r»iay give ri*« to difficult lattotir. Accordingly, they will twt be (i>n*idiTwl
in tUii place. iltoutfU certain of them will lie referreil to in the dmpter
F«ctal Dystocia,
LITER ATirRE |
Der wriMW Infiiret dcr Itw-enta. Arehir f. path. Anat,. IBM, acri,
Rnnnalun ii. |»(h. Aiml. iter mtrnarliliclwii I1»ranla. Vinrhow's FiuiUrlirift,
BrrUn, 189). .WIMllS.
Uultipln ncnnnklryatan dut Anuiion. nerirb<« u. Arlwileii, IRS.*), ii. liOtf-
■JOi.
Vfie VcrwnrtwunKcn dca Amnion mit dcr Otivrtliirfap iler FnichU Borirhio lU Ar-
litltan, lHti7, iii. ISIV-t&l,
-2«mwMii|t dcr Natwlieluiur much nxlta Kindsa wifaraoi) dcr n«(>uii. Zcllwhr. f.
Gob. u. Gyn.. 1897. xxxvi, 4(17-172.
^ ^^faaigct dm Krurhtwaitnni. I^cfartiuch il«r Gvb.. ISM, II. AuH., 271. !
^^^«:wKi., t'elier rlin Bbuenmoli!, uiiw cxptriroun telle Siuilie. HabtlilalionHN-hrift, Er-
^B Ibuxcd. tool.
^K>aiiun- r«h*T AniDixiM> der PlaranlB. Anluv t. Oyii.. 1808, Ivi. I44-IMI.
^^^Aiji-mrxK. GentinU Dropqr irf Uie t'lrluo. The Dubojc* of ifae Fcdui^ BdintMirsh,
^B ISm. i. lOB-lM.
006
OBSTETRICS
Dam. ItnJieivbeK pour iwrvtr k I'tiiMaire de I'liydmnniiw. Tbtoe de Pari*, lABI.
BARiiKLi'.iiK.v. Cicburt bei AmnionanomalicR. Zeidickr. f. tieb. u. Ojn., 1905, Ivi,
BiRNHAitM. BUMnitoole boi oincm ZwiUingKJ. MonutiwcliT. f. (M>. u. Uj^q., 1904,
xix, 175- ISO.
BoiTiN, Madame. NmivvUun rcchL-rfhwi mr In Duliue, VorigiBO «l le tnuteinciil de kt
toole vMciilAira, Pnrii. 1827.
BxAii.t, G. Lig^tur <lcr Nabolacluiiir tluivk Aiuniurmtrnniee. Zeit^ehr. <1. Gw. f,
Mntt »i Wicii, 18A-I. ii, l!)2.
UkkhulL' iiail Kbekth. DUIuKOti Myxom «l*r Kih&ule. V]rrhow'« Arrhiv, IMi7, zxxii,
191-102.
Bhickxkr, a Xew rtympUxn in tlie DiuKiioaiM «( DyMoria du« to a Short Umbilical
CoM. -Ajucr. Jour. l>b»l.. 1902, xlv, flI2-.WI.
BftiQiiKi.. Tumciirii dii plnncnl* ct tiinxnini pliiorntaiivH. pRrifl. 1!M)3.
BoNUi. I>ie Bypliilitiarlien V«ruiidtM^iug«D dor Natiubchiiur, Arvhiv f. Oyii,. 190S,
lnix, 223-246.
BwiMN. Nulv Mur'uiii; tumeur du tordoii ombilioal. Fvniiiies en mui-hoa *i ncnivMii-
»&•. 1SU7, i;»-IM.
Taniivr ti Budiii, Traits deo I'lu-t de» accoucliemetiM. IH86, ii. 276.
(^jiuxY. lliknorrbaKieii pliusntaimi dc rullmniinuriv. Thi^se de Purii, ISOl.
Ci.ARKE. Arcoiut of H TuRitnir foiiml in the HubatAnrc af the tluiiuui Pbtmita. Phit
axophii^ul Tnnmctiunii. I^Ddou. 1798.
Cork. r«brr iJah AbHtvrlicii d«i> F<ioliiii bci Ncphriti* dcr Mtiltcr. Zcitarhr. f. Gcb. U.
Oyii., IB88, xiv. .5flft.
CannKA-DiAK. Du rhypcrtrophic plurontairc dftnn lea riu lie ayphilin. Tliite <l« )*»r\>>
IHBl,
UiKNflT. Uebcr den Uuu ti. die HtnlogcnoK ilcr I'iawDtargenhiriiltitu. Z«tl4CJir. 1-
Geb. u. Oya., tO03. xlvUi. 191-281.
DoKt-tMi> and ticiwiiK. (.ystic DimiK of the Chorion. I'nivani^ Medical Ibeuirs-**
Miiv, tHlW, Ak^-Tim.
1>1HKt:N>-i.ii<rii. Initrnriu ulrri Uxlinu:! diuvh EU kunvi) NabelBtMBK, Zmlnlbl—
(iyn.. IMfi.'., i\. 801 -*H.
KiiKN. Dtciduonia Malij;iiuni: A CrittFiaiii- Tniiiit. Land. Obst. Soc.. IBBO, xxxt^"*
Hft-162.
A Snidy of ibi" Idiinan l'lui<<-iil». Jour, Path, iiti.i riarlerioIoKj-, IH97. v. 26A ■-'(■^^^
I'^intxixiiirt:!!. Cyiitca uiid cyntDidf Bildiuigni ilvr tiirniH'yiolieii PUcvnla. W ^Si^
IWO.
l<'tiii.i.\<i. I'etwT die phynolo^Bchu Boduutuug den FmchtwuMtnL Arcbiv I. (i^^^
1879. xiv, 231-244.
FlKiiLKY. Itydatifomi Mole. Am. Jour. Mvd. S«.. 1903, mx\, 480-^19.
rrinukiy Churio-vpithclioiiui Mn]i)[niiiii t>utaidu at the Ilaccnlal Site. Jour. ^^^^
Mod. Am., 1904, xliii, 13^11-1357
Frabkkbi.. Di* l(tHt<ilu|j;iv der UluiiMimolc. rtc. Archiv f. <Jjm.. 18(W. xUx. 4R1-^^^
f*iUNX. ('borion-cpitheiiomntoiM Pr«lif«nitian)i in Temlomata. Jour. Aid. Htd. )^^^
19()«, xNn. a4S. 343. _
Thf (!|inical and Mirro*™pifal Varintion* of Chorio-«!pilheliora»,etc. Kow York V^^^
Jour, I9O0, kxxlii. 864-867.
KlU.xiCKi.. Udwr Vnrknlkiinitvn dcr I'huvnta. Arrhiv (. (ijn., ISTl, ii, 373--3S2.
I'pbcr PI]((<«[i1jtrn'phitiK. Ari'luv f. <Jyii.. 1K73. v. 1-54.
pHAMguft. Annt. iind klin. BentiofhlunKon liber Pliicvntarc«kninkia«en. Zeitirfv*'^
Geb. u. Gj-ft., 1884. xxviii. 293-348.
U«b«r biatolo^wbc VcrAndcninigcn in dcr Placenta iind ihre Bexidiiinmm sun t~^*
dcr Frucbi, Zcit*thr. 1. Geb. u. Gyn., 1897, xxxvli, 277 -aW.
DISEASES AN"D ABNORMALITIES OF THE OVUM
»17
FKAKQvfc. Vie EnUCcbung der t-cliuiwntiiison Inserlioit der NsboUrhnur. Zoitwhr. '
t {'rf>b. II. Dyn.. 1900. xliii. IU-I-ISSl
.GAMtim. Mciixv 'lux Frifhtwaswr*. Mooalwrhr. t. GobiirUk., IflOiS. xis, 3^-33.
iiue. (^iuImI tty Kosnianii. |
V(jO( (iRAvEvtiKiBi. Ul>«m-atic4i(ii itioditne nrioroH. FrHiikturl. IS6S.
1aju>. Bntng tur Lchrc vmi iten Cj-idtii) <Ict Nnbolsrliiiur. B«itra|^ xur tieb. u.
Gyu.. itM6. X. IS^^MR'.
iKi.LKiu Die l.unguaerkrmnkungcn bci MigeUunier 8.v|>Iiilis. Ueutochvit Arcfatv t,
kKn. Mnl.. xliii. I.*>)l.
IcxuK. Adharenz iter Plactuita. ^iWL'hr. f. (iti1>. u. Ciyn., I9l>t, xlv, 272-Z79L '
IIbru^kv. I'cticr VcnK-hliiiRiiikKua <)cr Nnl«l*rhnure bci ZirilllnKm. Arrhiv f. Oya.,
IBOI. xl. aSS-'JlW.
iBi'iui^tx. Itii[><iir cinr-nChnrin^pilhclionui mit nchwnrcr intm-pcritoncnlrD Itliitung.
BritraiR! lur <kU u. (•}'■>., 1004. viii. 404—417.
Ziir Kmkb ikr Bomrtiftkeit unci iibcr Spootan-hdhingm van C'ba«io-«pit1ulioiiii>D.
BMtntee ur (M). ii. r.yii.. llHlt. vili, 4IK'44T.
Il^m- U«b«r iIm Chi>«io-cpithcliinit in ikr Vainnu bvi aunut iKouiiilai Uunilalien.
Wwa. 1903.
irinu l»ic Bhilgcfow iler mcDarliliclicn Niwhi;ubiirl. Wicn. 1870. I
lAU(i.tRi>. Siitr (III 4 lliicnhydnuiininn. .\mi^. Jniir. OImI-, IWII. Xxix, 432 -I' (ft,
lAKunikv uoil WALiiEiKft, 1'Riut)«nnKili.' Ill VvrbLii'iiuiic mil ilvnt I'luru*. ctv. Vir-
clxnr'o Ah-hiv. IM7. xli. .^28-531.
1)e iu?(i;. l.'uUtr dux F.nl8leliunt( von Cy«lmi m der Pbwicnljt. .UoiuMMrhr. (. Oeb. a.
»CJj-ti.. 1900. 3d, lor;-l(B2.
trxoRLCTK. Zur Lnhre voni Frui-htwnflMrr, elf. Arrhiv- f. Oyn., 18W, Iv, RM -M".
Kjuin-Hexhikuui. MyxUDiK rhorii bui «iiM>in ZwilliiiKMJ. I>. I., (iietavn. It4l7.
KAi-Tm>*cii. Zu kuric Nftbolw-Juiur. l«ltrbuch der (icb., l&!i:t. 31(V.
fCANTUAtX. Uianuaou oni IVcidiKniiu MuliKiitun. Traon. Load. Olut. Sot-.. 1806,
xxxrili. 171-1*4.
JCajnuat. I'tbcr Tmubeonuilen. An-Iiiv (. Oyn., IBM. xlv. 478^503. '
^K aatu.tr Vint. Ziir I^re vnn (l*r KntwirkduRK (Uv Cjmtan il. de* InrarHoR in dir
^K meaw-lilit-hcfi PImoiiU. Zvilscbr. f. Huilkuiutc, IDOO, xxi. l-Sn.
^^BL.DNn.vrnrKii. ICiti tlcitnk|{ >ur .^tmliimio (1m l>u«1ua oinphulo-mcicntnricu*.
^r Airhiv (. C.yii.. 1876. x. :i3»-:;47.
^^kajtrr. Eineii^ ZtriUitif()i>ki«ntu: veUmi-nl'in Iiucnion; Yerbliilinig licMer Fniclit«
^" unUr d« CiwUirt. Arrfiiv (. nys,. mWt, li, itMMiM.
K~rtmMASs. Zur tioEhirlile dor Traubmoiale^ Ardur f. Gyn.. IDOO, bdi. 133^160.
fg^t^KiiKK. VM roo inUMitidlcti MoknbQdunK. n«rliner Beitrige mr ticb. ti. (iyn.,
IW2. i. 10-15.
^^K vrxin. llydraniiiKM. MiiQur'o llHii(tl>iirh tier fioburUh., IMO, ti, t)>i7 571t. ,
^^^Ichrfarbe I^mnta. elr. M>ilW-< Haiiill>iu^li dtir U«bur1^.. 1880. ii. IU4-m5. ■
^^pLfdMV wiM iiorh nictit bi^kannte EnUtchunicninurbc nmputirvndcr nmnioliariier
^M Fiikn a. SlraniK. Z*ii1>rhr. f. <Jiib. u. Cyn.. k.i. 44^-158,
'"^ BKUUMI. Queliqiica donnicii i>ir la fiMiction phywolagiiiiie ilo l'&miu». .Aiiiudea de
Ryn, et d'obm.. IBTft. U, :i41'::J>l,
T>e Cliuorlinn v^Qamcntcui* du mrdcn. TlWao de Pnrii>, 1806. |
»!«. FruriitmuncT und Ilydramnlns. Arrlilv f. Ojti., I^ft, ix, R!7 .110.
nmpfotU cxUtiuit cntre Ic poidn du (a-tua ol cchii de plnoeuU. Tlii^wt de l^riit,
1000.
^nt. Wcitcrc Rdtriige «iir Kamtnin iler oeltretoTiwIwa Tittf^cit dm Amnlon-
tcphfaeU^ ZviUchr. f. Trt'b. u. Oyn., IWHt. Iviii, -.>4I> -J.'.7.
oiAHti. I'clicr die KiHcnnnnlen "dendualeti'' (iuafborulito, Mr. UamloM-hr. (■
CM>. u. Oyn., ISM. 1. Ilft-^SS; SI3-M0. i
610 OBSTETRICS
Walz. Ueber Placenta rtiimoren. Verh. d. deutacbea path. GeHcUBchaft, 1907, x,
279--'82.
Weiisek. Uelier hereditare KnocheaaypIuUB bei jungen Kindern. Virehow's Archiv,
1870, 1, 3a^-323.
Weiith. EiiiHcitiges Hytlrainnion mit Uligohydramnie der zweit«ii Frucht. Archiv f.
Oyn., 188L>, xx. a'>3-377.
WiLLiAMH, J. Whithiixie. Ueciduoma malignum. Johns Hopkins Hosp. Reports,
1895, iv, No. 9.
The Frequency and SigniHcaooe of Infarcts of the Placenta. Amer. Jour. Obet.,
1900, xli, 775-BOl.
WILUAM.'*o^. The Pathology and Symptoms of Hydatidiform Degenetation of the
Chorion. Trans. London Obst. Soc, 1900, xii, %3-338.
Wilson. Hydramnion in Cases of Uni-oval or Homologous Twins. Trans. Ixind. Obsl.
Hoc., 1899, xli, 23.5-272.
WiLTov. Hydatids, terminating Fatally by Haemorrhage. I^ancet, 1840, i, 691-*J3.
W:nckkl. Teleangiektatisches Myxosarkom der Nabelschnur. Zentralbl. f. Uyn.,
1894, xviii, 397.
Wlahhdw. l'ci>er die Patho^ und Hi8togene«e des sogenannten Sarcoma uii^o-
plastiqiic. Virchow's Archiv, 19(12, clxix, 220.
Wt)Kii7,. Eiii Fall von Hydrunmios. Zentmlbl. f. (iyn., 1895, xix, 58(>--^l.
WoLKF. Ueber cxp. Erzeugung von Hydramnion. Archiv t. Oyn., 1904, Ixxi, 224-
257.
ZtLLEH. titudicn (iber Erkrankungen der Placenta bedingt durcb Syphilis. Tubingen,
1H85.
8lt>NTANKai'8 ejcpulvion of llic ovum inny »o<riir ul any [htIih! i>r |iny-
tuiH-y, and is varioimly dp«i]^ate(l acL-ordiDg to the degree of developineot
vhicli th(^' [imduct of V4>acvpliriii tui» nituimxi. Tliiu<, il i» vu^tomun' l>j
•paik iif uixirtion, of niiaoiria^. or of pn?m8ltir« Uhour, nwiHttiviOv,
accordion a^ pregnancy bas terminated before- the r<i\twiith week, iH'tweeu
the Mticlmnlh will tflrenlyi'ig'Iilli wwk, or at a later ])<>ri«d.
Prior to the eixleeoth week, owinj; lo the imjierfect dcvdnpmont of
tlio placvnta, lliv vnlire uvnm often comeK away iiitnet. Kroui l)int time
boil, iKiwerer, iIk* plaoenia forniii a definite oT)^n and llxr exptd^fioii »f an
intacl ovum is exceptional, the lalxu, as a rule, being extruded first, and
followt-d afUrr s longer or nhorlvr period by Dw placvnta and inembranra.
.Uter tlw? twcnty-eiplilb week the eour» of lalnnr differ* but little fmm
that obsHmcd at full ti^rm. and the child, if properly cared for, may surriTe.
its ciiaRCi<tt of m doinj; increasing in Hlmo«t geumetncal proportion with
vnry additional week.
Aa the term abortion is Ktmewhat flaggeetire of a criminal procedure, it
I* rart'Iy emiiloVCTl in |Hi|iutar jiarlmici'. all eatef terminating prior lo the
period of liability lieiog designai<^] as mi^^arriage^. Antony medical men,
oo the otiM-r hand, tin- latter term if btit little ti^, and it is customary
Kaptrak of all caiw* i-niling l)ef«r«' the twenty-eigliih week lu abortioiic.
Frttjufnet/. — It is diHicult to arrive at an-nrate mnolttsionii eonoeming
frtygnencT with whieli ypontaneoiio abortion oceiint. InaKnmch as a com-
/*»«"*ltTely •mall projmrl ion of cuch cai«# arc treatnl iii tin- lying-in Iws-
[p't'^Lh, Wve HtatiHlicii baM>il upon their records woidd ^ive too low an eati-
'"^t*. On the other hand. sufTicienlly larRo series from private practice arc
^*** arailable. though MalinK found that IH.XIl |>er cent of ihe pntgiiancits
^ S'jHlo patients ended in «l>ortion. Frani Htalnt that aWirtiun oci-urreil in
l"*"-^ per cent of tlw ca*a* admitted to the lying-in hotipital at Halle, the
r^i<3eDt being more than twice as frequent in mnltipanp a> in primipam.
•s^onserrative estimate would indirate thai nl*fnit ever}' fifth or sixth prcg-
r****!y in private pmelirt- endu in ntKirlion, ami the percentage vould be
***^"*"*««ed eonsiderably were Ihe very early cases taken into account, in which
is profuse 1ok« of blood following tlic retardation of tlie menstrual
ocj for a few wet^m.
•Stiolnfff/. — ]n tile early months of pregnancy spontaneous expuUioii nf
•warn i< neau'ly alwaya prccetlcd by llie d«th of the fytun. For tliis
611
612
OBSTETRICS
ruaeuu tlif cunsidiiratton of tho etiology ut abortion practically rosolre«
ititelt intif det^iuiiiing iho cauM> of fixtat death. In thv later montlin,
th* other hand, the foetus is frequently bom alire, and other factors mu?t
looked for to Mplain its cxpiiWion. Fa-lal livjiOi may lie duo to ahnomiu
tics occurring in tho ovum it.self or due to wme disease OD the part of tl
inollivr. and now and a^in of the father.
(d) The death of lh« fa-<u« is fiuqucntly dui> to abnormal i I ic!! in I
tlc^'olopniciit of Ihc cruiiryo u-hli-)i are in<^ou»iiitcal with fo-tal life. Mti
ofk-it, howt-viT, it ronult.t from changes in the fa>tal appends^, whi
interfere with its nutrition, such as excostin- torsiou of lh<? cord, hydrani-
nios, hj'datidiform mole, or »yphilii^, In the ln«t Ivro u(r<.-clion» the nutri-
tive material coriveyi^^ liy the materniil Te^aeU to the intervilIou» apaoos
mcri'ly !<unipi-s lo nourish the hv|)ertTophic chorionic villi, little op
remaining to be transmitted to the child.
Again, other dtKcawH and itbnornialilics of the plaei^ila may lend to t
ifaine rwulf. Thu* Mortlon* and Frnnqut' have dtscribeil an obliterati
endarteritis in the vcsst'ls of the chorionic villi, indc|jcndcnt of syphilii
which iiitcrfcn?* with the fcctal circtdation I" such nu evli-nt n* Ut U
compatible with life. Id other case^ the abundant foruiatifm of red
white infarcts may throw so large a portion of tho plac«i(a out of fu
tion that the n-niaindcr is not HulTtcient to «upply tho netxlrt of tin? f(i-tu*T
Abnormalities in development, such as placenta prrevia, low iinplantatian
of the plaoenlft, or vidamenlim* in.'M^rlion of llu- curd, n^ well a* promotti
Eeparation of the placenta, may likewiee bring about circulatory conditi
inconsislcDt with fa-tal life.
(ft) An wa* jmintiKl out in the chiipliT upon the Aecidi-nlal Compli
tions of Pregnancy, all acute infectious diseases have a Tendency lo lirt
about the doutli of the child and its ^uWqucnt expulsion from the nt
The fatal rwult is usually due to the tranKtiiiniion of tiixines, aix] occ&si<
ally of the specific micro-organisms from the mother to the child. Pol
ing with phoNphorus, lead, illuminating ga*. and other «uli«tancc« may lei
to similar results.
Diseases of tho heart and kidneys may likewise play a prominent part ^
the causation of fo>tal d<-ath. lu the former it is utiribulnl to imperfi
aeration of the blood; in the latter it may result directly from tJH> accum'
lation of excrement itio>m subi^tances in the maternal blood and Uicir f\ti
quent transmission to the fo-tus; or indireclly, from the fact that la
portions of the placenta are thrown owl of function by extensive infarrl
formation, [yi-ss commonly diseases of the liver or lungaof tlic mothi.T may
be indirectly riwponsihle.
Ftetal death is sometimes attnbulable to malnutrition on the part
the mollier. although this is very exceptional. <*n the other hand, it i*
tmiisual for women suffering from wasting diseases to give birth to fi
developed children.
Abnormalities in the generatirc tract ltkewi«4> play an im[Hirtant part
in the irtiologA' of abortion. Thus. de\'elopmental anomalies of tile nterus.
or imperfect development of iheiionnally formed organ, may bo rMponsiblc
for conditionx which arc unfavourable for the implantation of tlie nvutoud.
I
I
P ABORTION, MISC-\RRIAGE. AND PREM-tTLTlE LABOUR 61S
Utor for the ttci.'clopmeDt of the plscvntul cJrvitlutiou. (Hirooiv inetriti* it
H,\»} «upposiH] U> ai't iu llic Mtnte way. Dense adlicsitms about l)i« tubes and
ovaries, nuultiiig £roin intiammatory procefiw^^, only rarely interfere witli
Uie vxjnnHton of tbe nlerutt siitlicieiitly to givo rUu to abortion, (ui]ii!e in
nio>l vAfvi the Ijiind^i of adho^ions •^udually »ln>lcb and Ihtoiiic eloii;;ate(l.
DiiiplattiiK-niit uf liie iiK-ru;^, mum particuiarly retroHexmn iind prw-
tiipM>, are Jit)it]y considered as inoat important fnctors in the cnuontion of
abortion. Ad a mle, th« interrnption of prcgnaney iit dtie !eis to the ab-
noniial position of the uterti* than to changes in ibt endoinetriuni iiteldeiit
^> the diifi>la«'iiK'nl, In the rare cuivs of iiicarL-eratioii. howewr, the a«ci-
tli-m inuHt be attributed to the porsiMent alinorma! {lo^itinn nf the orxan.
Tbe nwst important conditi<m of the generatiTe tract leading to Iho
pmdnclion of nbnrlton is ufTordcd hy di<4-4i>P« and aSnnnnnIilii.'-* of ihe
(lecidua. In ihft hyjx'rtropUic forni!* of <Iei'idiml endrttinnritis — dceidua
lioljpoiia — the bulk of the maternal blood brouslit to the placental site goc*
lit nourish III*! hyperplaxtic dwidua. vhile in Ihe nimphie foniif Die uondi'-
tintu are unfavourable for the normal implanlatinn of the ovum and the
d^-nrlopmcnl of llw- plnc-iita. Mnrc importiint t^lill is the part playt-d liy
chronic glandular eudomointiti and acute inflammation of Ihe dceidua.
Tbe former U lunally accompanied by hemorrhagic ehan^, and la the
BKwt frequent ««•« of altortion in the wirly months. The prewnpc of
QiroiiiatA in the waltit of the utema must be looked upon a.i an occasional
factor, altortinn reeulltng Ic^s from the mi-cluinicfll etTeet of the tumour
itself than frtim the c)iang«> in llw^ diieiduit incident to it,
McFayden luu directed attention to cpideuiies of abortion occurring in
cattle, and lia^ i^liotvii that thi'V are due to a fipecilie micro-organism, vhich
lead* tn tbe iii(fiTuj>ti»n of prifrnaney when ii)oeulHle<l inUi thi- (r<-nitali«
■f heailiiy animals. Analn^u<i conditions do not occur in women, and
■Itlmngh bacteria are fr(<qnenl1y pre«ent, they are eimpty the well-known
p^genie or puirefacli^'e >'arieti<M.
In A few ca»ei the cause of abortion is to be sought for in reflex inUll-
racc9 which take their origin fmm h^ioiw of the genenitive Iniil or from
irritative conditions about tlie breasts. In very rare instances tlie accident
ii attributable to intense mental emotions — anger, fright, or grief.
It in etulomary to distinguish birtvrecn prrdifjvmng and exril'tng eatiMt
at abortion. Tbe Ynriou.* factors to whi<-h allusion lias Just been mnd«,
pmlispose to flborlion. while the exciting cause is often of a mechanical
nature, soch a« a slight fall, jar, or orercscrtioa. The etatemimla of the
patient cono-ming the latter, Itowevcr, munt tie revived with caution, as
in many canen thev art? merely incidental and have no connection witli the
inlt-mipt ion of pregnancy. At tlw Mme time it niui>1 h<; admitli-<I that the
apparently healthy ulenis in certain women posaesses an abnormal degree
•f irritability, and will react to stimuli which in others would be without
*ff«l. Tn swh jMilienIs tlw i^lighlcst riolcnce. euoh as coilu*. a ini**tep,
tripping over a carpt^i. or a ride ov<-r a rough mad. may bring on an abor-
f ion ; while in others llur niosl violent exercise and tlie rudest mani)iulation->
>nny lie lH)rni> with impunity. Occasionally u nimple bimanual examination
he followed bv an abortion ; while, on the other hand, everj- (thysieian
41
6U
OBSTETIUCS
uin nuill ca«t« in which a. eouud has btn.ii introduced into I1h> prcgiuin
ut«nt.i without ill ettecu, and in rare inntHnne*, in the Inter monlliii, thi
rcpt'titi-d intrtHliK'tiou of s lurgo bougie, or «Tcn of a Champctiflr de iUbes
balloon, will titil to brin^ almiit utiiintttctory iitmnc <.-oiitnU'lion«.
(r) t*racticull,v the only paternal caufc of abortion ie E>-phitis, which, as
hnx alrcjidv Ik^l-h said. fnMjiK-nlly liMidK ti> cluuigi.^ in tlu; pluvKiitu and
the or)(nn.-< uf thi; fii>tti», which bring about its d«ath and its premature
expulsion from the ulcrus.
To »tini up, ()k- nioKt important a)ti<^ogical factors in the intcrruptioo of
pn-gnaiicy in tho tin<t four inonlhi> are endometritlii and ut«nne diHptace*
ments, while after this periiMi i;>*philis and Brighl's disease play a similar
rvlti. Thu*. Sciitfx. in 48r> csm-)! of inlm-ntiTinc dwith owrurring in tlu;
latiT inonih.i of pregnancy in Pinard's clinic, found the underlying cause lo
be i-yphilis iu -tS.T, albumiuuria iu iy.8. and diwuws and abnonnulilii-!' of
till! fii<tu« iu 11,1 per cent.
It is not UDUiiual to ni(«t with women who give a history of rcpeateil
Ijibortion or prcniuturc laliour occurrini; at about the «imc liinc in u nuinlxrr
of succi-H^iitv prc^rnancii'.i. ('arcful examination of nudi patients will u»u>
ally denion»lrate the existence of an endomelriiis or a uterine di^iplace-
meul*. if lb<! intorruptioii liux occurred in the firvl half of pregnancy; uDd it
ia only after the cure of the underlying condition that culRsotiuent prt?g-
uancic* can be expected to progre** to full Icrin. When rejieateil prenia-
lun> labour has occum'<) in the MVond half of gt-^
tation, signs of albuminuria. Bright*!) dixea^c, nr
Kvphtlis will usually be diHcovered, thougb ocmvion-
rtlly no xati^ factory eX|)laiiation can be ndduced.
I'tilholoyy. — In the first half of pK^iancy. t
intnuxliatp cnuxe of the v\pu]eiaD of the orum in
Iw found in hieiiiorrhngic change* in the decidua.
Concerning llieir mode of production we mui^t con-
(o>i' & profoiihd ignornnce, although when endo-
raetritiii is the underlyinj^ cauw; Uieir origin is read-
ily underetood. These changei, which are most
marked in the dctidua >HTolinH. are followed hy
degeneration of the aCTecied tliisuett, mk Ihc ret-ult
of uliieh Ihc nttachraont of the ovum to the uturine
wall becomes more or Its* lo<iseiied. and the product
at con<-q>liun comes to act as a foreign body and
gives rise to uterine contractions, which, after a
lunger or shorter perioil. bmd to its oxpulsion.
Hnmi-times. especially in the early months,
entire ovum may be oxpcUed after a few premoni
lory ^.yinptoms, and nut infrwjurntly tlie entire de-
cidual lining of the uterine cavity is cast off at thoJ
same time. In such cnR-* u triangular sac com
away n-liicti reprc-wnts the decidua vera and U mai
up of hInod-vlaiiH'd tissue several miUimetr«!s in thickness. It l^ontatl)* iil]
it« interior the roundel vwicular ovum, covered by the dccidua reflosa,;
I
I'M). 400. — Kaki.t Aniiii*
TION, UIOWINO Uk-
CIDVA ItKri.KXA xntt
Serotisia vrrrN I>»
OENEIUrK ICuHKTO,
XI.
ABORTIOX, MLSTAKRIAUK, AND PRBMATUHE I.ABOUK
015
UoTP fnnjuviitly, howi-vor. l)ie ilccidua ruru rvmiinf in utrro, wliilcr the
oTuiJi. fiirroiiuilM] by t!w- (iwiiiua reflexH, is expslled. Oin-asionallv only the
ivflvxa is torn ihrou^. arid u *li«ggj-, more or Iws Kpl)i:ricul striicturo is
nwt off— tbc m-uiii HwrrniiiuUil by llwi i-horionifl rilli.
An pregiuiiiry hiIvhiki'^, the ex|«iUion of llw entire ovum is olwervod
k-wt freqneDtly. 1*0 lliat after the fourth month it is the role tor the inem-
LrantM to ni|>1iirv and the fwtus to be oxpollinl bjr itself, followed hy the
Fvi. MO. — TimnDc-'i !li;ni:vi>iitAi. H.guatuii* (Un^u). x 1.
iilH and UM3iibrant?a. Ocoa«ionallT the intact ovtim ntar be csjiellHl
I at a laltT period, niiil 1 liavv Mi-n *i-v<t«1 miuv in which lhi» ocytinwl
-attr ■;• tlM- !*ieiith or ei|ihlh month. This, however, ii* very tinn^uat.
cnurDC of prvmaturv lab»ur being identical with that obwircd at full
In many in.'^ianeeH the process of utmrtion occnrs Tery .ilowly, so that
blood jtonml oat between the peripherr of the ovum and the deeidua
an fipportiiniiy to cougtihile. I'ndtT jiucK conditionn. tlw nrnm on
v*x|ig|aion i* Kurromtdnl )iy 11 eH|»iiIi* of i-lotti-d hl<MHl of varying thick-
with diyi-ni-rai'il (liiiHonic villi i*raitcni| ilir»U)ih il. In it^i interior
small cavity filled with clear tluid and linc<) hy a thin, glistening mem-
(tlK' amnion) from one point of wbioh hang* the umbilical cord
i
616
OBSTETRICS
lion
I
aod the ]iartia]ly degencraU'd fu-Iui'. Suoh »ilritclur«# »m da^'ifivA at blood
or carneoiu inoUs, ucoording to iheir appearance. In the former the capsule
of ooajtrulati^d lilood is rod in colour, while in l)w Inltvr it presents a palo^H
appi'aruacf.'. tli« ri-wult of fil>ri« foriiiation ^Fig. .Wl). ^|
Now anil iheii. iho interior of such siructuri;)-. inslead of Iteiof; Iin«l br
the smooth amnion, may pnvont nu irrogulur nodular upptoiriuKv, wliich i«
due to tbn fonnaltou of liipiimloiiiala of vnryinK !*>»> iieneatli tho amnion
and cliorion, Thi* oomlition, to which Granville applied the term «i-uii
lyberculomm, has buen more particularly »hidifd by Brciu;, who dcti^at«
it as tuberoua mbr-horial hamtioma of the ilccidiia ( ¥i^. oOO ) ; wliilit Hcrr
Hart and Taussig described the oanditi
0* htcmutoma mol<; iind tulMtrauM flot:
mole, re-HtHK'tiTely. Brcus believed that the"
InbL-roti* nppeflraiicu was the result o^
hivmorrhagc into enlliipN-<l folds of th
amnion, while Gottscbalfc, Walther. Har
and othnn ei>ni<i<lerp(I that the hiMnol
rhnijo was the primary factor. Davidsiilii
and Tau*«ig take the view that the dinpr
jmrlion between tho *iM of tl>e ftBtna
the ovum is the result of hydnmnioi'. nw
after thi^ death of the former the amnioL
fluid is grndually nhsorln-d, when tl»e
diiiidiinl amnion becomes folded ujMtn it
self, the liloHd being effused into its fold
Id all uterine molr.-t the fwtus U
lively siiiullcr in size tlwui would natnnd^
ly correspond with tli« menstrual hiidor^
This fact indieatcH t!uil Hk- process is
gra<lual fonnntion. and that a eonsidci
able period elap^f.* IxHww-n the death of
the fuitiis and the expulsion of the ovum. Not uncommonly, induied, tlw
ftetiis may uiidergo TOmpletc dissolution, or be rt-prcwnted incndv bv •
!<tub of umbilical cord hanging from Ihe interior of the ortim; wlulft iaJ
rare in»t«n«>» nil trace of it may di>app.'ar, and. after resorption of tuHj
amniotic fluid, the ovum may be rejuvseniid by u solid mass of varying '
size, oonipnsi'd of chorionie villi eml>cddcd in <'oagulatcd hlood.
In other eiutcM the o\Tim is not converted into a mole, but nivrelv rep-
resents u thin-walled cavity filled with fluid, in which hanus tlm dispro-
portionately small ftetns, or the remnant of the umbilical cord after il*_
absorption,
Oiffoltithn of the dead fo-tiia is jmssiblc only in the early weeks
prepnanoy. and cannot oceur after it has attnintxl any «insideral>lc pr
portions. In the latter class of cusm the retained fii-tu« may undern
marxnUion. Tnder such circumstancai the brain degenerates, the boi
of the skuU colUpw, the aljdomen bectimce distended witli a blood-^iL.
fluid, and the entire fwttis takes on a dull reddish rolour <Imi to etainit
with blood pigment. At the same time tlw skin soften* and |kh-1» off
a. sol. — Sectiok rilUUL-litI UUM>D
Uut-K. X I.
ABURTION. MISCARRIAGE. A\D PREMATIRR LABOUR
fiI7
I
• Bli)()it«et toudi. Iraring Ix-hind tlir Wighl-rpd <-<>rinm. Thr inlt-mnl
i>t;giuii' biTOiiM) Mitl xiKt frinblc. aDi) ]osc 4h«ir cnpacily for lakirifi: iip the
tutwl bHolu;pMl stains. In rarpr in^taDccf the ftetus bcpomps comprcMcd
ami UkcK on « i]r_r, giarohiiii^rii-likc n|i]H-ara»i-e — inHmmifimlion. Tliin i»
rarely obeervtj in ortiinary almrtjon, but U Dotwl with ooniparativD fro-
qtiraicjr iii lurin |irognaiii-i<«, wluin one fcEltu tias diod al an varly pvriwl
vhile tbc'otliicr haa gone 00 to full rlcvfilopm«nI — f«vtu« papt'ra(«ufi.
In very cjcoplioniil ineUiKfei the ta-Xas nwy be rvtaincxt m uUro for
a liHig [)«.'ri<wl. iinlil the dffxwiition of limp salt* hikhj il wnviTi* it into
what ia Icdowq as a HthojuTiliim. This pl«-n««ienoii, ilinugh extremely rare
in utcrinu prcfi^ann' in human boinge, it relatively (v>mtnon in Ihv lowu-r
aniniaU. In i-xlni-ulerinc g«>-#UI)oii, on tlio otlicr hand, iiiu-h » eoadition
U wrt of nnusiml ooenrrence.
VliniatI Uiflnrv. — from a clinical iitandpoint il ix « matlor of coDi<idfrr-
aUx impcirtamf tn dixtin^iiih the period at whioh tlte pregnancy ii ter-
minatnl. When it nocurs in tlw firrt half il i» nol unti>nal for tlw oviini to
be <-3(|H-nnl n> a wholi*. while in the #«i<ond half of pn-gnani'v the (h^uim of
erentH is similar to that obwrved at a full-lerm labour.
The onwt of abortion i* u^iitilly pn-wddl by wrlain premonitory symp-
tntni*, the nio-^t important of whidi are ha>morrha^ anil ]>nin in the bade
aad lower aixlomen. Lo»s of blond, no matter how xlight. in the early
mnalhi' of pn^iancy, xhoiild alwavf lie n-giinh-d with mispicton. for if it be
not a promonilori' nyiii|Hoin of atiorlion it iisiially indicatui the osistem-e of
a hyp^^Ti'ladic cudometriliH or an abnormal implantation of Ihc placenta.
Wh«n duit (o the formvr the discharge is ntually nol mry profim, ftnd i*
of a dirtj' brown or hntwnHh-red eolour, while wtien due to the latter it is
ipt to \k mnrv ptnUtu- and dixtinclly bloody in ebararler. Tho premonitory
bitiedinjc may fK-rxUl for vi^kn or U* promptly fitllowis) liy ihc <.-:»: pn I !> ion of
the ovum. Indeed, in mme ca«efi the latter event may occur bo rapidly as
to «ur]>riM' tlio pati«tit.
Wljeji a patient in ll»e flrst few nivks of pregnancy liegin" tn Iom; blood,
and the tlow in auminlM with jmin in the lower alxlomen and ha<'lc, an
alionion is tfirfitUnfii. It, howeiLT, doi^ imt In-comr immtnnit nnlecif thu
hm)orrh«f!« be profu^ or the cervix coiLiiderahly dilated ; cve-n in the latter
(Sjv it in not imiMKuiibU' for (lie dUturbaucr to inib^idc. and for pre^ancy
to go on without interruption. On the olht-r hand, nipnire nf the itii!in-
lifaorK and ocapc of (lie liquor aninii iiMlicate that abortion if infvUabfe.
When a)K>rtion l't;<H>nH-s imintnenl. Dm- hipmorrltagv it: usually quite pro-
fuw, though as a rule not liulftcieiit to endanger llu- life of ihc woman.
At tho Mme time she experienww severe crauip-like pains in the atxlomen
Am to the uterine contractions, which later become distinctly boAring-down
in charactvr. After the ccr%ix Iwii' l>coome Bufliciently dilated tlw detached
iiTuin may be expelled jntacl from tiu> iilt^rui', and wImui not retained in the
nf^a i-omefl awav sati'^fnotorily. This is known an rompMf abortion.
Xnt uncommonly, on the other hand, after rupture of the memtiritie>>
ifld the f*<-ape of iW anmiolle fluid. iIh- fo-tu* alone i* exp«'l!"I. while the
placenta and memhranm remain in tlte uterui—incompMe abortion. In
Mtrh caw* the Im'morrhage n^ually porvisU until llie n-tninei) otruetures
CIS ^^^P OBSTETRICS ^H
HPexIriHUnl spnnwiMKtusly or are n-moved arlilicintly. timagh the paind
uHuallj' cease with Ihe cxpul»i»n of tin- ruetii^. Aft«r the uterus has ridl
itself of the prniliu't nf contwption, the lismorrhagp and pain c«i#e. nml ai
priK-(».4 iif involution be|{ius, ideiilival with tlial olworvwl alter tuU-tcrnij
labour. '
Treatmvnt. — Prophylactio treatment is most important, allhougli. m
• rule, it IK not available in women aborting for the ftnt timc^ Tf. how-
ever, the jialient pawmls » hlsiurv of repeated abortion or premature
labour, pn'wiulii)nary iiiuA^tiree should be iuetitutcd before eoiK-optiou Iia»
again taken pla^-e.
The genemi and local condition (hoiiid be oarefiiily inve:«tigaio<i arnfJ
any abiiorniHltly Mibjwlod to appropriate treatnienl. If the patient has al
n>tr(i flex I'd uti'rus. the orgail should Ih- rrplnced and hrM in position bTJ
a properly fining pi-^sary. If the dv«in'<l nwull* an' mit obtaimvt in lliis
way, V4-nirrKiunpi>ii.Mnn or some other tmitablo operation should tie per-l
formed. If endometritis be present, the patient should be curetted and
warned ngiiioKt becinriiiifj prcjinnnt until sufficlonl linur ha* ela)MKl taj
allow till' iiionis to rei'ovcr fmtii the iiiinbid eondition. If the symplomAJ
reuppiar. llic operation should he repeated. If there is no abnominlily inj
the generative tract, tlie porisibility of syphilid in either pnrent slmuh! Ih
borne iu mind, and opprnjiriate treatment instituted in suspioiotiii oa£es,1
The uriiie nhduld hIwiivk \w furefully exninincd wilb a view tn di^lerminin^J
the presence or abseiice of renal lesions.
If psst ei:{M.>ncDce has shown that the patient has an irritable ule
and is prfdu«po»e<l lo a'iort upon the sli^htvst provocation, coitus should
be interdicts! dnrinj; pri'ifoancy, Hud iho patient be cautioned ngain.-d nrfr-J
exfrtion, particularly upon the days during which the menstrual |ierio
would onlinnrily oieur, and Ih- fncnuru^eil lo lead a eAreful, well-order
OxLitenee. Moreover, she should be in.strueted to take to her bed iinm<!
diolely u]ion ihc appearance of any untoward symptom,
Trmtntrut of ThrealfWii Ahortinn. — WhcnCTer symptoms of Ibn^jiteniii
abortion appear, Ihe patient should be plHci'd in lni] and Wept in a return^
l)enl position. If pain* oivur. a hypodermic injection of i (Train of
phine sliould be adnliniste^f^ci at once, to be foljnwwl by l-graiii rectal suf
jjoKilDriiw of extract of opium, repealed at intervals of every four or sil
hours. Belti-r n-^idtx arc- otcaxioually obtained by rombinio;; the npint
with thccxlraets of hjoscyanius and viburnum pninifoliuni. The fnllowii;
suppository, adminii'lercd every four or aiit hours, aeconling lo cirot
stances, often gives most satisfactory roiulti;;
R. Codjm sulphat , ... KT. K.
I Ex(, hytHcynmi Hf. j.
^^m F.it. viliiimi iinuiirotiL Rf. v.
^^B OL tbwibmmip -,,,,. .... <i. a.
' tn niliny imtfimcc-s lh« symptoms rapidly subside under snch (rcatmenl.
but the patient should be kept in ImI for at li-n.*1 a wwk after their <li>«dB
poaranee. in the hope of avoiding any repetition. ■
In other cases, the pain yields to the administration of sedativvc. ItuL
ABORTION", MLSCARRIAGE. AND PHEMATl'RE LABOUR G19
hs-RM>rrlui^ jxT^iiiU, nod w« t\wn havi> In decide how Inn^ we an- jiKli-
Bed in permitliii}; thv bloody iik>nne d))>r)iiirgc- lo fiiitiniK'. iind wltdher
UwTP ti any probultilitjr 'hnl tk- pri-jEnaiicy will |ir(i)frc.-« iionnally.
So long as th« lotu nf blood doca not «xceed that usually observed at
the mcDstnuil period. ().(.■ flow i^ not ni-ciwurilj im-ompuliMc with tli«
Contii)Uani.-<- of pn'giiiiinv, and may \>f i«;riiiilt«l t» go i>ii for «omf time.
On Um; other hand, if it bemines ^o profuse that the [latttuit hcginii to Jihow
sign.i of aitiemia, the uterus should be eraptit-d by tlie methodB to be de-
scribed later. In many instaucv^, notwitliiitandiDg appropnate trenlinent
and niit in bod. iiliglit ha-niorrhiign- may pt'ntinl for rt-ri-rul wii-k*. and it
llH-n boconxM netxaiKary to aiw^rtain wltether there is any jio^ibility of the
IH«]iiuney eontinuinK. Unfortunately, (his problem usually require* wr-
enl ynvk* for itf solution. Thus, if hiinnniml examination nhovn at the
end of two wneks that the utenia> ha.4 remained stationary in size, one is
jnEti&ed in concluding that the fa?tus lias penshcfi ; while, on the nlber
liand, an tiKrvOM' pmbably indiraU« tlml (he fu-ttiK i» ^lill alive, but doea
not neceeaarily mean that pregnancy will ^ on to a happy termination.
\6 foon as wo are conriiux-d that the fcetus is dead, the iitertis should be
pniniplly emptied. In siu-h <ui.'<eJi nothing eau Im^ gained by delay, as abor-
tinn will inevitably occur sooner or later, whereas temporizing treatment
Mmi'linus cxpoMtii the |<ali«iil to M-riou* dangvr.
Treaimeni of InevilabU Abortion. — When ctinvin(«tl that abortion is in-
pvitable, partieularly in tho«e cases in which the lueniorrhage i« profuse.
llu> uterus should !><> emptii^ in tlio mii*l coawnntive maiiiKT, tho dinice
of proeednre dept-nding upon the degree of dilatalinn of the eervix. If it
be Riineiently patulous lo admit one or two Sogers, the patient should be
anitvtlK'itxi'iI, brfiiighl to ll«- edg«? of tin- lied, and pn-part-d fur ojieration-
The carefully stchliwMl hand, anointed with nlerile va-ielim*. having Ixvn
tntrmluctil into tlut vagina, oim- or preferably two fingers are carried Up
into the uterine cavity, and, under tho guidani-c of thi^ otlu-r han<l applied
over the alMlomen. peel off the ornm from the uterine wall and slowly
Mlract it. If IhiM cannul be effiH-ted tlw oruni should be brv^en up by tlw
ftbger and the fragiuents extTaeteil by nM-an.i nt a plan^nlai or oriini for-
re^M. under llie guidance of a Snger within the uterus.
But if. as often happens, the cerria is not sufficiently dilated to permit
ihe inirrtduc'ti<ui of a linger, the mttiimI canal ami vuginu kIiohIiI Im- packed
tightly with a ^itcnle gauze liaiidago, an deseribed in Chapter .\\l V. WWn
renwTed at the cmJ of twenty-four hours, the pack frequently brings with
it the intact ovum ; but, -even if this does not occur, the cervix will generally
lio tnfficiratly dilatnl to permit tlve inlroduriion of tW Rngi-r. when Ihe
ovum i«n Iw reuiovcil a* reoommended alvivi*. In other easi^ Ihi? iniro-
faction into the uterus of a laminaria tent, which has been carefully
nltxcd by mnms of dry lient. givf* mo«t Mtisfactory restilts.
Except when the ha'morrhage is so profuse as serinunly t<i throaten the
palJmlV life tlu-se methods of procedure an- preferable to Iht? rapid ditata-
tioD of (he ferrix with a (•notlell or wimr "imilar dilator, followed by tlw
hnmediale nmtoval of (he ovum by nteans of a eiir«tte or |>olypus forcefw.
Unretirer, (he cerrix u sumclimex so resistant that it is impOfv«iE>le to dilate
620
OUSTETIUCS
il eutGcK'nily hv uiwiu at nielalHc dilatoiv to permit the iotnHluclion o(
the fing«r, the ^nploymcut ot which, in my opinion, i» essralial (or tliK
l)n>jM-r pvacuation of Ihf uterus and the carfifnl v\plomti<>i) of its eflvilj
aflcT rcnHiviii of ttii* civum, iu order to itiakc sure that ii in perffctly <'mpry,
and that thi^^n- 1* i-'>n»equeni\y no danger of eubeequent hiEiiiorrhage.
No dotilrt the uterus can be satisfactorily evacuated in mcttt caac* by
me«n!i of the rurclte aiit] polypus fnrcviM. hut no in#tramc»l luu crcr beeu
inTciileil which will prove an elllcient substitute for tJie carefully trained
M'lisi^ of Kiuoh irhen it lx?como>i necest^arr to ^atifify one's ivilf thai no rem-
nantfi of the ovum are i^lill ri'taiocd in llu) ntt^ni^ On HC7«rxl occo^ioiu
I luivp Kivi) pHlienLt auffering from jirofuae ha>inorrhage folloirin^ the
suppo^ thormigh removal of the product of conception by curetting, but,
on intrnitiiciiig the finger into tin- viti^rus, I have found (hat it *tili eon-
laineil Ihe bulk of the ovum. K\periences of this kiiid have therefore Iwl
me to do avray with tho um of iUKtrumeiilif v\eupt in very rare coik*.
Morwtver. in addition to the fact that ihey fulfil their object only impor*
feclly. liiey are not devoid of dungiT. Kvery gjruDcolodist is familiar with
caw'i in wliidi Iht? Miftwied uti'ni* lias lipt-n pi-rforattHl hy |1m> t'lirette, and
knowa of rare intilancea in whieli a loop of gut Jiae prolapsed through the
openinj; so mado.
When ihi- ovum has lieitn cspollixl intact, a* in rompleti* abortion. Ihert
is no necessity for further interference ; and. as a rule, if the docidua vera
in not Mist "IT, it it not ailvisalile to ntli'inpl iL< nniovai by means of the
curette, for it is usually exitelled spontaneously within a few days. .\t the
same time the physician should always t^atisfy himself by careful itLspectioo
thai the tmliiv <ivum has come iiwuy. and that portions of it are not ro-
lained. In inooniplete Bl>ortion, on the oiher hand, the retnineil plamnta
and membranes should he removed manually by the methods already tle-
iierikd, since a-^ i^in n* the uterus i.-> emptied it trontracls and tlut danger of
hwrnorrhage ha^ pushed.
It often Imppi'UK thai the physician dms not we the patient until some
days after the expulsion of the fietus, when he is suminom^ on aceotint
of the iwrsisli'iit liMts of blood. In such cases the cervix is usually ftmod
to be retracted tn such a dejjrei? tliat it will not admit the finger, but it
ran riaiiiily lie sulHeicntly dilated by uienns of a (Joodell dilator, aficr which
the remnants of the (iviiiii iire reinoviil by the finger. In othet me^
infci-tion lias resulted, and the uterine discharge may lie very foul -smelling.
In snch eim-* tlic ecrvix should he dilated and the uterus, after being emp-
tied, should be washed out with an abundance of fterile salt solution.
If the symptoms still persist after thL< proiedure, the uterine wall has bran
invaded by the offending inicnj-orgainsms, and we have to deal with a
ease of puerperal infection, the treatment of which is considcmd m the
appropriate chapter.
The treatinnni of abortion in the *ceond half of pregnancy and of ptv-
matun- biboiir is identical wiih that already deseril«il for full-terra labour,
and does not rerpiiiw further nwntion.
iliMtd Ahorlwn. — This term wai. upjilied by Oldham lo tlie voMrx in
which the fii-tus is retained in tlic uterine cavitv for months or Vi-ara after
iBORTlOX. MISCAItRlAdli. AND I'HEMATURE LABOUR
its dnih. The condiliOD occtin fretjaentlv in mures, cows, ami slievp,
com pn rati vely nrelf in women. Seventy nsea were oollccted from
liU'rattire Iv (Jraefe in 1896, and lOj lir E. Frflenkel in l!>03, thoi
I tun convinced from tny ou'n v\|>friei>cv Uuit Mticli ligarvM give o vd
inadequate idea of the fntijwiiey of Ihe condition.
Rct«ntion ui«y exim for a lon^ period witlmut ijivin}* me to symptotu'
and sQcb a poseibility tiluiuld iilwn)-« Iw bornv in mind in the ca<4- of a
abortion oretirrinii; in it woman who lia^ been for mine time A'panle-I fron'
her )iu«)>and, inasmuch as an error in this regard occasionally resalts i
imparaltlc damage to Iter elmracter. In other c«w» the patient may believe'
tirnutir (o be in the »6venth or eifihtb month of pro^^ury, ami yet on
examination the uIctuh will bo found to rorrctpond in itizc to that of a
omch IttM aJvBitn^i {H>rii>d. Mr>re freiguenlly, however, Ihe jMiltem may
present signs of threatcmd abortion, hut, after a varying period the losa
of blood and tho puin diKapjKTar under appropriate trejtiment, tu) that then)
i» apparenlly every pn>>-[>ect that the pregnancy will go to term. Some
months later the phyi-ician will bo confitllcd on account of the failure of
tlw abdomen to enlarge, or lJi« occiirrencc of rcgnrMiiv change* in the
bmst. wlien upon examination the uterus will be found to be smaller than
it was at tlie time of tliv thrcateitod ultortion. N'ot uncommonly the con-
ililiuH, afttT [icriisiing for some timo williout symptoms, may exert an
a|ipreciable clfcct U|xjq tlw patient, wh) may Fud<Ui)ly begin to Io^m? tWli,
offer from a foul taste in hur mmilh. perhaiM pn-stmt n flight cle^-ation
of temperature, and oecasionally symptomn of mental derangement.
AtTor<li?ig to Veil and Oraefc. Ihc nitration is lo b<? attributed to a
ImcV of irritability on Ihe part of the uterus, which dots iml contract ua
D'lul onder the stimulation exerted by the dead ovum acting a:s a foreign
Cm^vIt. In quilo a number of casca tho fcctus haa been retaim>d for moni
tlaaiB one year, am! in one instance for twenty-eight yvim. After cxpnl-
■»*»«3 tho ovum frequently presenU tl»e characteristic Rtruetun? of a hu-ina-
^'^ma mole; in other caM-Ji thcrt* an- w* mnnifi^tationx of botnnorrhago, and
"'••^ Itas to doal with a so-called "dropsical ovum." In one of my eases,
^'^ ■ rh had porsirtcd for more than one year, tho fcetus was mummified, the
niotic fluid almost entirely reaorbed, and tlM> placenta tran*formi^ into
infarct -I ike mass.
"Wln-w*er the di«gno#iM i* e«tabIiiOH-d boi'ond doubt, the cervix should
*%Ut«I by moans of a vaginal and cervical juick, and the uteru» emplietl
its efiDtcnIs. In t^vcral instances under my observation the cervix waa
>~«^i>tant that iU dilautioii bv means of «tn.-l iuxtnimenlji was out of tho
l^^^tion.
ISTKRATTRK
ft*
■v^ Dm) tttlierO« mbcbarule Ilaeinitum iter Deddun. Ldpxig u. nien, t)t!>2.
•^^iDtuni!*. Zor Lcbr« von ikr Mob iMemaliwuilam. Archir f. Oyn., 1902, Iki
tHl'3|fl.
Heber Uiiavii Labour um) Mimed Almrlian. VoUmiann'a RatnaiL kHi
< . rj^BB. S. v.. loal. So. 351.
622 OBSTETRICS
Franquk. Ueber histologisohe Veriinderungen in der Hacenta und ihre Beiiehungeii
zum Tode der Frucht. Zeitsrhr, f. Geb. u. Gyn., 1897, xxxvii, 277-298,
Franz. Zur Lehre des Aborts. Beitrage zur Geb. u. Gyn., 1898, i, 493-S14.
GorrscHALK. Zur Lehre von den Hamatonimoleti, etc. Archiv f. Gyn., ]890, xviii,
134^169.
Grabfe. Ueber Retention des menachlicben Eies iin Uterus nach don Fnichttod.
Festschrift zu CbH Ruge, Berlin, 1806, 3S-79.
GRANVILI.R. Graphic lUustrstionB of Abortion, etc. London 1834.
Hart. On the Nature of the Tuberous Fleshy Mote. Jour. Obst. and Gyn. Bnt. Emp.,
1902, i, 479-481.
Mauns. The Antenatal Waste of Life in Nature and Civilisations. Jour. Obst. and
Gyn. Brit. Emp., 1903, iii, 307-319.
MBnTTENS. Beitrage zur nomialen und path. Anatomie der meDSchlicben Placenta.
Zeitechr. f. Geb. u. Gyn., 1894, xxx, 1--97.
Oldham. Missed Labour. Guy's Hosp. Reports, 1847, 105-112.
6ENTEX. Des causes dc la mort du produit de la oonoeption pendant la groaaeMB.
Th^se de Paris, 1901.
TAnssio. Haematoin Mole. Am. Jour. Obst., 1904, i. 4.')6-472.
Vgit. Vorzeitige Unterbrechung der Schwaagerschaft. Hiiller's Handbuch der
Geburtshiil/e, 1889, ii, 23-57.
Walthbh. Ein Fall van tuberdsem, gubchorialem Hfunatom der Deddua. ZentralbL
f. Gyn., 1892, xvi, 707-710.
CHAPTER XXX
EXTHA-UTKHISK P^EdNAyCY
Ik rxtra-tiltnnf prrgnaiic^ llu- ft'riiliwt! ovum in nrrt'iitt'il «t *niw. pninl
betwtvn tbe ovarv ati<l lh« ijloni«, atul tlicre un(lGr<!<x.-« more or less cwin-
|ili-ti' ilnxJupitit-nU Krtiipv: grMation, w'hi<'li b iuiiii(!tini(^ UM.-il uh a iivnony-
nmas ternj. has a broadt-r meaning, inai-mtich as it includes not only tho
u»u«l foniM of oxlrm-uti-Tin<> pn:!f;iiancv, liut ilno Ukwc in which tlii! ovmn
is implanted in the rudimentary (lorn of a bieorniiale uterus. Ileferenoc
liw nin-aij.v \wvt\ made In Ihis i-lii>j' iiT <mi>o in rh8i>tiT XXVII.
for a long lime extra-ut«rine pre;nian<^y was of interest I'liietty from a
jwtliologii-al poini of vit-w, bill »inc<! IhS-f. whvn Tnit finfl operated upon
a tase of ruptured tubal pregnaney, the snUjeot has atuinnl a murkiillr
prwtit-al inlL-Rvl, a* is munif<^t<tl by the itnni<:ii^- literature of recent
v«rs. The history of its development is trean^l in detail in tlii> mon<»-
gti\t\i'^ of Campbill, lU-ckiT. i'urr>-. Tail, Wcrth, and Webster.
Prior tn 1876, extra- uterine pregnancy was ronaidens! fc rare an
aifi-ction that llenni); stated that even the directors of large obstetri<-al
■ nstiiutiiinK mi^lit nwer i-ntwinu-r a raw. and Pnrry was able to collect
only W»(i instanc-cfi fr«m the entire literature. It was only with the griidual
<'<^rvlo)nnvnt of abdominal xuigcry tbut it« rplatire fmiacncy became roc-
"j^niwil. Thus, SchrejirV, in I8fl2, <M)llei^tefl 610 <yii«8 which Iiail N-en
'**r*'>rt*'d in tlw pr^Miimg five yean*, and recwntiy many operators have
P'*»<!ti| on reronl large series, Kil^lm-r having operalwi U|M>n 105 c«m9> in
5*"** course of five ycare. while Noble encountertid e.\lra-utenne pregnancy
'** from 3 to -I per c*-nl of all hix lapnrotominii.
-fUiotoyif. — rnfnrtiinutely, concise and definite stateraenti* caimiit Ini
^^■«lf cDMCfTntng the irtiotnpy of the condition, nllliinigh ijuitf a numtjvr of
**I*l«iiation9, of greater or lees plausibility, have been advancetl. Broadly
*'*^'«.king. thew may be divided into tliree main group: {]) Conditions
^ni^i ipti>rfere meehanically with the downward passage of tin* ovum;
* *- i TIhwc ri'iuiting from iriflaniniHtory diwasc* of ilic tutK*. ovarivs, and
^'"''^ii- p>TiIiiiiii-um; (-i) Physical ami dcvd'>|inK-ntiil aliltormalilii^ which
**"**wr decidual fonnalion in the tul)pa.
T. Conditions wAiVA Inttrfert Mfchanieailg witk tkf Downward Paasagf
*A/ Orvm. — (a) Fritro. in 1779. firrt tlimotcil attention (o (hfi fact tliat
' t»(neal adhtwion^, by oompre«»ing the Inmen of the tube or by inter-
na vilh its p<Tistulsis, might cnuN? the am>t of the o\iim.
< &) beopold, Ilmsilau, Beck, Wyder, and othen have reported cases in
b they tidiev«d (bat polypi projecting into the lumen of the tubo
033
624
oaSTETRICS
hnd interfi-red vritli tlic dv^ociit of Uk- ovum. It is quite possible, bower
that such structures were merely decidual flUtgToii-tli.4, and appeanid oi
Bfter wncvption.
IP {c) Some »b^rvere believe that uijomnta or other lumoiin, «itna
In the wnll of tl]c tube or in adjacent organs, may so compress Ute tu
lumtMi a.-> l» interfere with tlie pasflnge of tlie ovum.
(li) Schroed(?r, in 1887, but more particularly Tait, a few y^n Uilt,
advfliui'il Ihc llRHiry tlnit the m««t frwjHi-nt cauH.- of tubal pn-gnancy wi
an ei)do.-<al{)iRgiti!i. whence had renidted destruction of Ihc ctlia and ill
coiL«oquvnt ce^utiou of the dovnward current, which vra« thought to pi
vent the entry of sjicrmaUizoM inlo the tube.
This view presupposed that fertilization occurred in the uterine oavity,
and was baMd upon the belief thnl the ciliary current irat dinx-tcd down-
ward in the tubes ami from below upward in the uterus, the entry
Hpermalozoa into Die uterine cavi^ being thvrvby factlitattHl, while th<
awe** to the tubw was renden«] very ditTieiili. The work of Hofrnfi
and Mandl has demonstrated tlie fallacy of these suppositions. Mo
over, animal expfrimenls arid a ffw ol««Tvations upon human bcii
nuke it reasonably certain ihat fertilization occurs normally in Che tul
pvery progtianey being therefore primarily tubal. Acoordinglj, Uie pn
lem to be solved in a case of extra>uterine pregnancy is not how
spermaloitoa may liave gaint^] hccckk to the tui>e*. but why Uie fertilized
ovum failed to make its way !o the uterus,
Tait'n llieory found many udhercnl*, but careful study of i^pecimene
tuincd at operation go to nhow (Imt in mont catto^ it in vitliout foundutii
1 have been able to demonstrate the presence of cilia in nearly ev
[ircgiiiuit tiilie urhich 1 have exniniricil. while 7it\M kkw Iheni in motiou
three out of four specimens which he examine<t in the fresh condition.
((•) Abel. Kreisclt, and othcrji boUeve liiut the firtiil (.thi volutions
the tutw occasionally persist in Uter life, and hinder tlie downward!
of the fertilised ovum cither by conjilricting the luincji or hy inlerfe
with peristalsis.
(f) In 1891 I^andau and Ithcinflein and the writer demonstrated
presence of itivertirula from the lumen of the tube, and sii^geiiieii
fertiiiKeil ovum entering such a structure would eventually be arretted at
blind end, and there might undergo further development ( Fig. h(fi). Fi
a number of years I believed tliat a considerable numl>er of my caiies
originaltrd in thi^ way. In meh upeciinenst the fa>tal ^ac lay entin^ty ontJii
of the lumen of the tube, being separated from it by a layer of tissue
varying Ihiekmv (««• Fig. .W8). After further exanuuation of my
mens, while not wishing to deny ^vieh n potsibility, I am of the opinion
that these conditions can Uf^ually be more satisfactorily explained hy sup-
posing that the fertilized ovum liud burrowed beneath the mucosa of Ihe
tube, jtist as it does into the decidiw in uterine pregnancy.
Now and again, in s«'rial stvlions thnuigh Ihi- pregnant tube, it is possi-
ble to demonstrate the presence of aciwssory himiua — lonu pKKfjww whilfl
i*xti*nd from the main lumen and continue pnndlel to it for a eonsiderahfl
distance, and then rejoin it or end blindly. I have not»l such a conililinn
I
ihat :
KXTRA-irrER!\E PREOSANCY
625
Ffitnjil instances, uod !«l' no roLMn why u (<!rlilizt<d ovtun arrested in
vncli n Ntmc-tuiv nhonlt] not go on to farther devotopmenL
Sometimes awestwrj- tulnal ontift. iiU'tciMl of oommunicfltini; with On*
luiDi^ of the tube, rt'pruscut mere cuU-de-ttu:. That the fertili:u'<l ovum
1-...
I nlll'Cl.im FWIM TIIE LCHKIt or TrvK.
■V he aiT«!itMl in r'lirli n utructiiw ami no on to furtlwr development wan
KiK-huiTdv d<-mon«tralcd hv licnrotin and Horzog (Kij;. 503).
(ff) Uuhnwen h(^)iev«ii tliat in ncrtyinnal in«tnnrt« the arrMt of tlw
"VTnn may be liue to puerperal atrophy of tlw tube, whereby ita normal
P<?ri8talii> U nmrkeitty inifMired.
fn. ■DO. — l*an!!<ANCT w \ccziuom Tc&il 0"tivv (llMirotin and ITtnos).
inrinUaiUi tf, oiii'iuiis •>< iwcpiani (■llilm ; C. blind DOJ of ^intr ; ti, blnaiU
elut tnotalulDf: rmuuuiw o( nrvm.
(At In n eonifiiieralilo number of the ca«« which I have examined, the
' corpu* luieiim was pitHiit«l not in the ovurr wrnspomiing lo the preg-
uuit tube, hut in tiie oppo^tite one, indicating that r^fcrnaJ migration had
62A
OBSTETRICS
occurred, and that tli« ferliliml wvuin hud miKic the transit of Uw privid
cavity. Sippcl believes that surh a phenoitienan inaj favour tli« pna
duclion of cxtru -uterine pivgniancv. since ihu fertilized orum mflv aLtaidl
Hich iiroporlifln^ during il» in ignition »* to pnvcni itx pnsKH^r Umni^n
Ihc tiik-. I
II. Condilioiu) rtiulting frrtm Infiammalor)/ Condition* of the THl>e«%
Ovarifa. and t'eivte I'eritonieum. — As lina already been said, Sdiroedea
and Tail |K)inlfd utit Duit such eondiltotis may n'Kidl in the prO(lucl)i>q
of tuba! pre^-nanivy. Tliia view in sup[xirted hy the fat-t that many cases om
vxtrn-MtvTisic pregiittiicy have been preceded by pelvic inflaniniatot? trouhlflJ
Thus Diihrssen, Manill and ^'hniidt, Kii!<ln»r, Peli^riii-n, Itunge, and ittheni
were able to elicit s hiotory of ^norrh<eal salpinptis or iiitlamnialoi4
conditions of Iho n|ijii-niln^-K in iiKiie than two thinU of Iheir ca^i^ Afti»
it had been di'mun^l^ated tliat ihe arrwt of the ovum was not due to tha
dwtniclion nf tho eilia hy Oie in (I am ma lory prow**, grwit difficulty wafl
experienced in explaininj; the connection helweeii the two conditions. Ii?
I!)liV ()[iitz fiiinul definite histulogical iiitlnmnmtory ItvionM in 15 out of
23 specimens, and in evi?ry inslant*. whether such l^ions were present oi;
not, noted thnt Ibe tips of many of the folds of the mucmu had lHi»n>4
fused tw^ther. so that the seetion presenti-d the cribriform appearami
charaettiristic of the so^alled " follicular Kuljiingitie." Similar Wions wii
usually ])ri's<-nt in Ihe n<>u-)ireji;nant liihe. He held that aueh a condition
alforded a very satisfaetory explanation for the arrest of the ovum, as h^
asHtniK.tl that wmie "f tin; canal* i'nr!iiM.'d lntwt-en the adherent folds eiuie
Itlindly at one end, but communicated freely with Uie main Inmen at
other. Accord inijly, it would only he necessary for a fertiltM-d oruni
enter one of th<*e rulx-dt^-mtc in order to be arreste^J, and thus lead to thfl
developnienl of a tubal prejrnaney.
After Himilar oliservalionc had lieen mnde hy Mi«holitseh and ntbe
this explanation was enthusiastically aeceptei) by Werth. wito fonaid«
it of almost universal ajipliiation. 1 have frequently observed ibe sam^
condition, and have no doubt that it may l»c a frequent tt-tiologienl factor^
hut I am ini'lint'd lo a;^rt-i' wilb Kermauner that one should hesitate before '
giving il a loo ;;ent'ial acceptance, ^^
III. Plii/.iieiil and Df.vflopmtnlal CandiiioM which Farour D/ritJiid^H
Formation in (he Tiibe». — Webster believes that the explanation for the
eonijmralivi'ly infreijiient oceiirn'net" of i-xtru-iiterine prcpianey 18 to be ,
found in the fact that the decidual reaction, which he considers e»sentia^H
to iIr' pni[H.'r im plan til I ion of the ft-rlilized ovum, readily occurs in th^^
uterus, but is usually hukin^r in the tubes. He holds that tubal pregnancy
can eorai' uhout only when the tulws arc capable nf this n-aclion. Further
more, he considers that sm.'h an i ice urn- nee pmbaljly repre-sent* a ri>»er>irt
III an wirlier type, and may therefore be looked upon aa a sign of de
acy. Thi« view was indonu'd by I'antellani. Mandl and Sehmidt. Wonns
Alnericke. and others, hut the belief is ha.-wl ujwn iheoretioal considerat it
ralhiT limn upim nnalnmfeal obnervafions.
I'roiu wliat has just been said, it i* appttn^nl (hat tliere t» no lack
theories eoneeniing Ihe ivtiology of extra-uterine pregnancy, luu) the qw
EXTRA-rTERIKE PREGN.^NCT'
627
tion wliich tm lure to ronaider is vbich of them is correct, or vhetber
any one u of uniwniiil application.
Throretically it uouUl appi-ar llul I'erUin «f [lie in<«hanical m[i<litiun«
raeottoned ahow must frix|uciitlj- play a part in the production of the
•iTiKtioii. On thi> other hniiil. it mtii^t be uiluiitU'il that tliv<Tt)ciila from
the lumen of the iulie ami the »o-oalle<J fotlii-ular salpiii;;itii« are freijuently
i)<itt.-d, trhiif liiltoi pri-;;na[icy occurs l>ut com pant tirdy rarely.
The greateit hlow, liuu'<-\er. whioh tliciie llieori^^ liavt' MtifTerod in from
the expt-riuivutal work of Taiiilurlcr and Ma»dl and Sdimidt lltese
iiivoi|iji:nton> i-\)ieriiiiontt-il ujxir niUhita by ii|)i>Iyiug lifjatiin^y to varinus
nioa§ uf the generative tract shortly after copulation. WheD the li^luro
vnt Bpplitii III ont! utcrim* coniu miiiit^ diKtaiicv 1h-Iuw tlic tuluil opt'ning,
oTa developed distal to the ligature as veil om in the norma! honi. When
both eiiniuK were ligitvd, ova dcvdoix-d only distal to the liguhirc*; oil tlm
other hand, when the tigaturen were applieti to the uterine emis of tlio
tuU^ fxira-ulcrini; Jireji^inncif did nut dvti'lop. although dt-od ova euukl
demonstrated in the tulie^i aliove ibe ligatures In a series of control
ex])crinH-»t«, only one tube wa« ligatvd, wIk'H the same n^tult wait obtaiiM-*!
on that »id^. whilv tJie oDiit honi contained normal enibryoa.
Thew etp<-nnicnts apparently t^hou' thut in the rabbit, at least, aomo
C other factor than meitr mi-cliaiiiiiil iiiii'rfi-rt'nce with the <h>wnwanl juissage
ef the ovum is »ece*aty to the production of tubal pregnancy, and thia
Vandl and Schmidt mught in a {treliminary dtvidual n-action. Tin- fact,
Iwwever, tlial roost of the repent work upon the anatomy of the pregnant
tut*.- sIkiws tluit the decidual formation i» never abundant, iiud is Tre-
qoenlly all'tgi-ihi'r aWnt, would iiiiliiatc iitrongly agniuHt viieh a view.
The only positive vxpcrimental work along theec lines was reported
by Nat^k many yuata ago, but it I* proI>>B))ly open to Ow. objection thai Itc
d'tl not dLHtingDish carefully enough between the uterine eomua and tliu
tubv* in the lower animuU.
The idea that the affection is a sign of degeneration or reversion, while
^^^bienwly intrnvtiug aiu) to a certain extent borne out by facts, vanool be
■*30ept«I aa a universal solution for tite ^iroblem ; for in many in.'^taneea
P~** condition occurs in pcrfii-tly healthy women who live amid the Ijest
P •■ ^nwnd inge. Moreover, it* great rarity in tlw lower iiniuial.-i also ^pcak^t
P**iiirt soch a view, and Bland Sutton states that in his large experience
^** 'Ote toologieal ganlen;^ n{ ]>indon he ha." never met with tubal prf^oancy
^* 4nimahi, and believes that all «ueh cases reenrded in the literature are
^*»« to confounding tlte uterine eomua with ilw tulie*. Thi" »tatemeiit,
^^■•fver, apjiears somewhat too radical, as Waldcyer has reported on tm-
**''*>btcd ease in an ape.
In vi«w of the considerations jnat addueetl, it is apparent tJial t3>e
^'^ology of extra-uterine prepnancy i>> not a simple matter, ond that there
I* do nnireryal cjiu.h- for all eaix^. In many instaitcen tlte arrest of tlie
wntn in a crypt renilting from follicular salpingitis, or in a diverticulnm
frtai the lumen of the tube, may afford a satii^faetory explanation. On
ifae uiIht ftand, in a certain proportion of cimes even the most careful
(liiunl history and micro«copieal examination of the specimen will fail (O
KESTrFTRICS
rfv«al « mugiUtt muwf for the ■.■oadilioti, which will tlini remain a* gn
a problem to us as to our predecessors,
CUusificatiaii. — Th« fcrtili»xl nviiiu tnav lie arnvlui at any point ai
itH wny from tlie Graatitui follicle lo the uterine cavity, and may unde:
(lOTcIopmciit in the ovurv or in any portiou of llic IiiVh-, jriving ris«
nvariiin or tulnil pn-^-nancy rcspoolivcly. It in extremely doubtful wlieihi
tilt' onim can bcconic iuiplnntcd upon tbv p«ritona-iin) and a primary'
abdominni pri'trnnniy folloM-,
Ovariftn Pregnancy was first deseribod in the sprentccnth mntary,
Mercprns ant] St. llvuricc. •flcr which it was ((iiierally Twn)fniw>d unti
18^5. when Vclpeau statLyl
that nonv of llw nMM.vhivh
had been described up to
Ihul limv afforded poucIu>
ajve evideni'e of ovarian
origin. Similar viL-ws wen;
exprmscd by Mayer io 1617,
and were indoreed bv Pou-
etict. Allan Thomiwtn, aitd
others. Thifi scepticiiini va^
jirotmlily quite ju»lifiablc at
the time, since mort of tbe
early casos collected t-y
Canipbi^l, and (iur^ui were
i^iinply dortnoid cysta at Uie
01 nry.
With the exception of
Mayer, the possibility of
ovarian prejunam-y lins al-
ways bi-en admilied by llir
ncrinan writers, hut
^trenuouBly denial nnti
1*101 by lite Engtifih aulho:
ilies, particularly liy Tai
Webster, ana BlaiHi "Sutti
tndooil, ft« far as I
ascertain, only 3 caacii
reported in Kngland diii^
ing Dip nineteenth century, namely, S by Granvillo in 1834 and 1 by
Oliver in 18915. In this country most writers have followed the English
anthoritiw. althouph I'am- admitted its cuistcnc*- ami not a few opcralors
have reportivJ douljIfDl caws: hut it was not until 1002 that ThompeMi
demon!<l rated a perfeetly eonchisivc *pecinieii.
At the prewnt time no one doubts the poasihility of ovarian pregnancy,
and cTc]] gnch critics as Blnnd Sutton sik) Webster harp l»en eornp^IliH£>«!
to admit tbut their prcrious scepticUm was not juatifled.
Up to 18TS there exiftlnl no definite criteria by which such cases enttl*,#!l
be jn^gcd, and many specinien.4 were described as orarian progoancy wlbi
Fw. 50*, — I>i«iiiiAU ii.i.i iimATiNO Tii<>tifKt»i'iSist.t-
MEN IJI' OvAHIAK PBIWlS«!(t.-Y (Allipr, O.VIl.).
EXTRA-CTERINE PREGNANCY"
629
I wudI
^^ «faio
■wpt
liAtl DO claim ta Hiicti ■ titlv. Id tlisl jvur, howvviT, Spie)^lberg formu-
lalvd oertaio i^tKliiiooa which lie held must tie fulfilled in onk-r to justify
*wh II dis^iiuKiK, 111' drmiinclvd (I) tliut the lulx.- ou llic alTcrtixl eidc
he iatacl; {2i that iht- fti-Ul .-tac occupy thi! [Niiiitian of ihe ovary; (3) ttuit
it be ooniKcti'd with tlit^ uterus bv tlie ovariuD ligamL-nt ; and (4) that deH-
nite ovarian tituue be found in iU wall. When judj(ixl liy Ihcw uritcrin.
the majority of caMw uhich hstl been deecribod up to liiii time were found
wantinft, ami Kubo"<(iifril invi-slif^nlion Iiak hIkiwd that a iiumii«.'r of nsv*
vbioti he considered concluiiivo are likewise open to very (.'i>n-'>i<li'ralile d»iibl.
Ah far an pag»il>k-, I liave gone over the aunx of ovarian pre^ancy
>rted in tlie lileraturt- iiji lo January, 1!)U(!, and have cluuifii^il th«ni
pontive, highly probable, fairly probable, and doubtful, acranling to the
extent to nbicli Spii-^i-llH-r^'H cTitcriu vtnn'- ftdlilhil. Thirt^vn KiKvimi^nM,
which were carefully deacribcd and studied raieroscopically, clearly belong
in tho fiM caU-gori-. namely. thoM- of Goltx:halk, IH9.1; Ludwig, 189fi;
Kouwer and Tusuenhroek. ISflft; Crofl. Iftofl; Anninu and IJttlewood,
190I ; Hol»->n. mil:.'; Franx. laoi; Thompiwn. IwaS; M.ndt-s .K- U-on and
UoUeraan, 1!)03; Miebotitseh <2 cawti), 1903; Boesebeek, 1904; and Web-
ster, I9M.
In ibi' »i>te« of (lOllxilialk and I.tulwif; the pn'jfnaney had ^ne to tenn,
but in none of llie other II had it pro^rpNi'ctl k-yond the f'>ur1h month.
All of tltc^e MjM^-imen:> u-en- nuhjuctt^l To («r«-ful mi«ra««eo)iieaI examination,
and tlie cridcnti' roiicemiug their ovarian <irigin in ko cunclusiTC us to
convinoc |}m> nuiKt M-eplitial.
I liave claMiified It otlter ajteciinena aa highly proliahlc. In many in-
Ftancv« there is {}rac1ically no doubt a* to thirir niilitn-. but uiifi>rlHniili-ly
iwnie were not examined inierottcopieally, while others had lieen preserved
■» long that aatiitfaclory differentiation of the tiivmi' wa« out of Ihr qiMM-
tion. In 9 ca<W!i of thi« f^ronp KC^tation had not ndvam^ed bcvond the
fnartli montli — thow of tiranritle. Ilein. Mnle, tiottM-hnIk (tl4,Stl and
tIH>-i), Si'hn-mk. Frank. Hinion. and Fiith; u'hi]i> in tlie other 8 it had
resi'lM-d full temi — tliose of Waller, Spiejielberg, Ijeopolil, Kii^tuer — Fick.
Hcnfvld, Martin, I^irn-n, and t>oclie. 1 have not thought it noceoMry
to cDD-iider tlte fairly proliable and doubtful cBi«« in this connoption.
It id inlen>ting to note llvat in om- third of the 30 positive or highly
prolnalilo cAnea Ou! pre^nanrv lind from- to full term, and in several in-
■tauoBs had eventuated in lithopsdion formations which had bcvu carriod
for yean Itefore being removed. Thin would ap|H-ar to indicate that the
ovan- can accommodate it*elf more readily tlian tlic tube to the growing
pn-gnnucy; but at the iiame time it should Iw remembered that rupture
at an early period ia the uiual tenuination, at) is ahowu hy the fact lliat
II of llwr I.T pottilive csmts had not progrwtted beyond the fourth month.
It is aUo important lo ttcar in mind that the pn^naiiey may l>e destroyed
at any early period without rupture, and give ri*e to a tumour of varying
aize I'OQsiiitin); of a cajmiile of ovarian tis.-<ue enclosing ii mflxi' made itp of
hlood ami chorionic villi, which may or may not contain an amniotic
rtivity, as in the .4]y>i'im4-ns of M^ndes de lj/«n and Wt?li*ter. .Sueh oliiwr-
raliooK ninder it prol*able that a certain proi>ortion of ovarian Itsmatomata
43
fVSO
OK.TirrHK'S
luav KtliiuIlN fijinM-til tin- reitiiiiiu- <jf an early iin'RHanrv, l>ut soeB~Ti~
iUaguitfi* i^lunilil ii(i[ Iw ii)u»i<lt'r»il iiiiU'w niH-roMopii-al cxniniiiittiun rcvcjil*
tlur pn-sciiu- i>f chorionic villi,
Acconling tn Li!o|wl<], ovariaii jircgiiuncy rceultH front the fcrtilizatioD
of the onun Ix-fon' it* tvi-ajw from llie Criuiniai folli<'Ii'. Monwvftr, Ittt
bclieies, when seToral follicles mature at the same linie, that a deeply
lying OIK' may ruptiirc inio a mori- superficial one wilhniit iIh: wK-apt' wf
iU OTuni, in wliteh evunt thi> lalttT may be fertilizeti hy dpemiatozoa rater-
ing through the suporlicial follicle. Such an occurrcuce woiild afford a
satisfactory ex|ilaniili<iii for a pn-jfiiancy otiC'U))ying the c«ntral portion of
iIk- ovan-, and the fact that tievvrai inve:^lit;ators, following the example
"f TiiwtTibroek, huvt; denion;.1 rntwl corpii* liiK-inn i-elL* alwut tlw ]>erii»lieTy
of the ovum would also apeak in ita labour.
In ovarian prcgminev tho ovum Jtsfllf and it* mode of implontatmn
do not differ eienHially from tlial observed in the uterus, except that
a ili'tiniU- ileeidun is lacking, w ihat the fn-lal t-cloiJcrm invader lh« orarian
Etroma directly ami opena up its blood-ve»eU.
Tubal Pregnancy. — In thi» by far the mmi frupienl variety nf «xtn<
uterine prej^ancy, tJie ovum may develop in any one of the thnw portions
Amnion ,
sriiw cavitv
Cervix.
Partially jeparali
pia«nU.
Fio. SOS.— I»fn:iuirni*r Puboxajcct (Bunmi).
of the tube, giving rise to an interstitial, istlimic, or ampullar prggpanc^-*^
spoctivcly. In rare insUincc* it may be implanted upon the flmlmati
r*3[treniity, and occasionally even upon the fimbria ovarica. From
primary types certain secondary forms — tubo-abdominal, tubo-ovarian, an^-
broad-ligament pregnancy — occsi'ionally develop.
According to Roscntlial, tlie tntcratitial is the rarest variety, havii:
KXTRA-UTEAINK PHKUNANCY
6ai
ifcumd in oolv 3
c«nt of the 1.324
X of tubal |in^j;imiinv wllicli
fhv bolloclul (mm tiK- litorntuiv, whik- Wcinlm-Jiiicr hiu> utile lii itilloet ouly
:io <?SM>)« up to I'JOJ. t)f .'ii i-auM unalj^Mol l>v ItlatliD slid Orttiruatin, 4ii
^wcn? aiii|nillflr. » iHthmk, soil only 1 was interdtitial. More nx-ciit wriU-re,
Uin<ii>utUnl, mU1» that tliv i»tlinuc rurk't}- i» tlttf <wnimon«itt, «D(1 thin
aim been my eiperienoe.
Anatomical CatMidtraiions. — (a) Mode of Implantation of the Ovum.
-Prior to the work of (iraf H]mh> an<l Platen upon tho guinea-pi^ aiw)
rnman, mpectiTvK, it was ffcnerally taught Uiat the implantation of tliu
Brum, n)n>thvr in the uu-riu or tul)e, ww dependent u)K)n the formation
[of a irt'll-dovL'lopcd dccidua. I'etcrs, howi'vcr. demonstrated that even in
[the uliTUH llii:* vrn.i not nviv*9»t\, urn) KlioMX'd oii<*irty that in )ii» upM-iinon
oTuni had burrowed down into the depths of an (edematous en<lome-
^trium, wliooe sinmm cttlU liud nut yet a«tiininl a ehanu.-ffri»tic decidual
appearance. Moreover, as the ovum was comptctelr shut off from the
uii-rinv cuvity, it luw apparvnt lliut tlw; dccidua n-llrjia cmld not havi"
been fonneil by opjirovthH from the deeidua vera, aa moa formerly iKlievexl.
^ft This work, which lui» completely nrvoliitioaiM^ our oonn-ption nf the
^*B!iode of implantation of the ovum and the development of the placenta
ill uterine pn-yiiiincy, uppltt^ ujually wvll to the lulw, although verlaiu
of it(* anatomit'Kl peculiarities usually nwessitale a diffenrut outcome.
Tlie oruiii niiiy Iwcimie arn*t*'J in any i>ortion of thf tulw, and accord-
ing to Werib may booonte implanted in either one of two varieties. Id the
fin't or columnar variety, which if- very rare, the ox'um becomes attached
In tlw tip or nidi? of oiw of III* fold* of tlie mneou ; while in the jgucond
l>r intercolumnar variety, implantation occurs in a depre^ion between two
Vihln at tlK- [H-riplu-nil [wriion of the lumen. In eillu-r event, the ovum
not remain upon the surface, but at once burrows through the epi-
lelium, and comiM to lie in tla* timue Ju«t beneath it. By tluit time it^
ripliery U made up of a capsule of rapidly proliferating; wtodermal cells
- — the trophohlttst — irtiieh Konn invade the ifmrounding tiKKUvv, and byj
jfjrtue iif their eroi^ive properties brinj^ alwut de^teration of ihe muscle
^kad connect] ve-tiseue cells, which eventually bceomc converted into fibrin,
^^t tlie .*arne time llie blood -ve^t win are opened up by the invading fretal
ciclb. and the maternal blocKl is poured out into spaces of varying eizo
Ijfi-Hg ciitin>Iy within llw trophoblaitt. or tietu-een it and ttte adjacent ttsiue. ]
In tlie usual, intercolumnar motle of implantation, as soaa as the ovum
pe-ottratu the epithelium it rames to lie in the niuwular wall of the tube,
■xa«i is eeparatetl from its lumen by a laj-er of tissue of varying thtcknma — .
t^^ capBolar membrane or p«eudo-rctlcxa (Fig. 508). On the ntlier hand, J
Ek« tlM) very rar« columnar mode of implantation the ovnra lies in the]
ant^nior of a fold of mnco'a, and except at its base is surroiindeil on
*U iiijAi by tubal cpitlx^iuni, so that it ha.4 but flight Hpace for ex-
Oon. I
In recent yeara, every spocimon of early tiilial pregnancy which I ltav« \
luw xervMl tn «trcn^lien my hdief that the implantation oeenrs
^i" * "the same manner a* described by Peters in utenne prejrnaney.
' w is correct is sltown bv the fact that it hag beoi indoriied
bv Fiith, (Iriffitha, Aachoff, Kiihnf, Krt-isch, Prternen, Andrews, Coure-
laire, Lockyer, Werth, I'fanncDslii-l. Kroimr, Voigl. Kcriuuuuvr, Borkejcv
kikI BiiiiiH-y, Wtill^ifii, iitiil iiiiiuy uthcrs.
I'hi! furllivr (Icvelupuunl of prc^uancy ilcpcnds in irn-ut part upon tlu-
)Hirti<in of tlitt tulii- ill wliiili iiii)i)Bniulinn hXA nccurrtx). When in tiii^
ampiillH, l\w i;rou*tii<; uviiin pmbes foruanl iU cnp^itlxr mcitibrauv iiitn
llio tulittl liimvii, wliicli «vi-iituull,v niiiy iM-i-ome wo «>iii[)n»*t'd n.i to ai>pear
an a iiwre crcseeotic slit whose wnlla are almost in opposition. If the courw
of (In? |ir<'giiiiii('y Im iH't iiili-rnipliMl. tht- i-n|»iilBr nii'niliriuift may ru>»e wilh
the ueiiihinmriiig imuona bu tluii tlio lumen of tin? tuU- may become obUl-
cnili.'d ill Ihf DitiiKiliulf viiintty of the oviim.
On tliti oiIrt hand, when implantation occnni tn the JAthnius, and par-
ticularly in lliv portion tiiitnitdiutvly adjoining itio iit^Tiu, the khisH ^n>
of tin; lumen jireoludi-s the pi»ssil)ility of sui;h expanMon, and a» a con-
w'qufliw iIm' Kvnui invndi-K tin; tiiW wiJl jifriplii-nilly to il» lumvn. w>
LC
tut- ^W. -JiKiTnoK inioiiT™ ArxiiTiiMcjir <ii' Cimiiiux to 'I wax, UUli. XW.
Dre., ili-ridual vpUn; L.C., Lkii][>iiu»'ii vrU'; Syn., tiynFylJuai ; 1'., vilS.
tliat tlio latter nifty evf^tuiilly kefon>e coniplptely t>G])flTat«d from fht ^
dertying miiHclilurix and In* siirniiiiidi.-i1 l>v fii-!jil ti>»iio and villL
((f) DecvituL — Bland Sutton in t8!H, and Fiitli and IJritlith? a f'-«r yraf
later, jwinled out that Uic docidiuil miction in Hii- In'"- » i^ i.i>i1iin<: liU
EXTRA-LTERIXE PHEtlNANCY
633
McnsiTo at; wa» t^nornllv Iwlievod: while KUhno, ARchofT. anJ KrpiK:li,
in JWtit, wt'tt! vi-ry !i(vj>lir«I a" In iU exinloiK-e. nml ithUi-ihIM lUiit the
<^lh, which had foriuerly twti di'.-«iTii>eiI lU" decidual, were really ol fiutal
origin. TbCM: ouotcntious have bwn stistain«d by tao»\ yabsequoat ob-
r^— 8«mn?i HHiiwiMU l-'iiBHimiK or !>i:tiijL-Ar, ( LiJjt i>< Itiiiirr Trii«. wiiri.K TBI
Vuvu> HOT ui or Kiktai. Dhiuix.
■n.ra.. tiibul niumsa: miur., miundan*: J., ilrculm.
^«^T(i, SO that al pnvpnl no one- clairoti that a diitliml t^ntiiiiinu-i decidual
*"^»lirane in fonn»^ »* in utOT-inc )>nviiancr.
^>D the other hand, it i« equally ornmoouit to contoiid tljiit a dmdnal
*t ion ill idwav'' lai'kini;. m.h it i* piMihlc by ojin^fid altitiv In ili^tinj^ish
'«~1 iml n!ll^, and lo difT('r'<iitialiTk'arly Im^Iitci?!] ttH^m and rii-tal ti^IU. In
^C" riwwM HiL- funntT arv api^aroiil ly aliM-nl. Imt iiion- ti»ually Ihcy may Ini
^^1^ in iliBcreic jiatcbcfl in tlii> ti|M of mine of t)u' fnldn nf (ho miiOMa in
•letghboiirhnod of tho ovum. FiirtlMrmorc, oarffiil stn<ly will occasion-
«fnalil« one to distintitii^h dividual rcll- K-altcnil Im-Iwwii the fiplal tiH-
at the plucontal liito l Fij:. .lOii), Iml in noiii' of my upmnipn^ hare I
JiP*^*' aldf to iiltH-nc a dif-idual iiHinbrane analof^ufl to tbi> dveidna rora or
Bf^'itiDa in nterinc pn>fman<;y.
H Tliat the authoiv who deny tbo existence of decidual odle in the tube
636
OBSTETRICS
31icn)M,-opicii1 sM-tionH throuj^li the sac iD the early monthfi show a ,
slight hyjKfrtropliv 'if lln- iniisolc oelK Hut no apjiarvnl im-rraiH- in tliciri
UtiinlxT. b^xt-i-)il ut Oil' i)lHiviiifil file, the tube wall is eonsidcniUlv thick-,
tned. iind iU tellii are ^pru'iiil uparl hv a-ihiina. At a >itill more udviiiioeil '
prricK) ttio muiH'ulur coii6titui?ntK of thv gestation ^ac appear to dimlntBb
in nitinIxT, mi that at Aill leriii iiIiikiaI tU «iitin: thickno-K^ i» niadi- up of
a coniipclive tissue [xKir in et-llK, with only here and there a muscle fibre.
Tins iiiiiifati'w Ouit iIk- iiiii^cuhins of the tiilH> dtHw not p(>«:>is» Un? tame
tendencv to hypertrophy as that of the uteniH, though occasionally it is quiii'
inarii(.-<1, Piiuird havinj; rcfiorlvd a t-aM> in nhioh the fwtal sac contracted '
80 strongly that he iiiisiook it for a pregnant utenis.
In mofit fttjifs l\w exttrior of the tube givt* tfvidfncc of p<>ritoDilic '
involvement, nml a coiutidiTable |><>rtioR of t)ic thickness of tlu> fn-tal
Muc is oftvn duv lo peritoucal adliceioni;.
In onlor for i^imijilile tubal Hhoirum tn occur, the ftinhrinttll i-xIn'milT
mufit rL'maiu patent, but in other i2a,ics itii condition varivt'. bc-ing «ome-
titiiii' ('hiM'd, soint'tinii'S opt-n. \* u ruli>, the luniiii of the luW tvttnmuiii-
catcs dircttly with either end of Uie fiptiil eac. Lkm commonly, liowerer.
this iiiniiininicalion i* noted only at one end, whil« «lill more nin^ly the
ftptai sHc is conipleleiy shut olT from the main tumen. A Mtisfactory
exphmnlioR of lh<-M' ililTcri-nws hni^ not vet Invn adduird.
(/) t'tcriiir Changes.— la the lirst three mivuths the uterus undergoes
convidcniblc hyiwrlrophy, and ils i-iidometriuni hccoHits eonvvrlwl into a
dccidua similar to that observed in
ulcriiiL' prfgiiMticy. iitid differing from
tI only ill u leui itnirki^d ilv^elopiiK'Dl
of the spongy layer and a greater
?)ibiindan(-(> of hlonil spaces jusi Ihn
nealh its free surfaeo. Soon nflcr tlie
di'iilh "f the fwtiis Ihe decidua U
thrown flIT in small pier-us, and ocm-
itionslly ns a Iriaugular cast of the [
uterine niviiy. I1(> di.M-hargi* ii^ tuually
considered of marked diagnoL-ilie sig-
nificanw; «> mueh m that in doubtftil
cases many obaervers reoontimiid cu-
retting l\w uterus, and heee their diag-
nosiH upon the presence or almcticc of
decidual tissue.
Trrmiiiiilifinx of Tuhal Pregnancy.
— According to Tail, the univerKal fatii
of tubal iircgniiiicy was ruptnro either
into ihe peritoneal cavity or hciwtien
l)n- f<ilds of the l>road ligament, oc-
curring not later than ilto twrlfth
More careful .-iludy lin" nhown that the great majority of eases
iSrSon. — l^TittiijiB DKcinc'A mui *
Cake or t':(TnA-riKiiixK Pukckamty
(ZwriM),
week.
terminate nt «n early period by abortion after rupture Ihnmgh the ca]*-
auhir membrane. Very G:iiccpl iooally, the pregnancy may go on lo fall
EXTUA-tlTEllISE PREGNANCV
637
tt>rm widiout ruplun-. a» in i\w vomh* n'portod Uy Saslorph, Spiogolbcrg,
Cliiart. (Julxwillor. Kinanuel, Kreund. and olhtTc. My wllwtJon also eon-
laiii« a Hmilur i^pocimeu.
TuM Ab'Tliun {lulm-iulMii ft wpdtrf).— After Werth. in 1887, Iind
ilirectnl attention to the poi«ibility of tubal ubortiou. it lioe griulually been
v-V
up™-
^■*- Aid. — EA»«.»Tini*i.Pii»;c<ci»icT, wrtiiA»<i«T»o5i or Ovrv tmo LvMim or Tone x 0.
fr.c, btoiKl-dnt; n, dwrignic i^lb.
^^""ojiat rated that tlib i» the iw«*l freqiKrtit nuleoinv of tubal prrfcnancy.
*^ rtiatkt^i i-hanfi^' of opinion whicb tias taken platv upon Ibis point U>ing
- *^***"l^ indicali-d by llw fotUiwiug lignrt-s: Ihiin, whvivag. in 1893, Schn-uck
- '**H»| „pjy (j tases of abortion in iiUi ca«>» of tub«l pn-giiam-y collwtrd
t,***** the litcrtlnt*. the reports of Martin, Wornwer, Mandl and Schmidt,
, * ^'-iiip and tilil«c)i. comprising 289 ca«c«. show that "8 per rent ended
.T^ ^Wrtion ami .only 22 [ler fpiit by rupltirt-. Aocnrding to Martin.
^^■»ias lermination is the j^-nvral nile. spontantwus rupturt^ occurring
V in tfao6c cases in vbi«h occlusion of tho abdominal irnd of the tube
t.
ib^
638
OBSTETRICS
prooludw; the- po^^ibilil;,' of mi ultortioii. or in which thv ovum, bein,
iiL*<'ruil ill a h^Tiiia of iiiticoiia, biirmws (iirwtlv Ihraii^h the Itilic wall."
Tfav frciiiK'tiiy uf tubal ubortioii <li.'|x-ii(ls in gtval purl upon the original
ttite of im)>liintatioD nf the ovum. In ampullar prcgtmncv it ia the
rule, whereas intra-pcritoncai rupUiro is the usual outcome in ielhwic
; naucr. T\u* diffiTi-iiiir is prolialily ihu- In tin- fiu-t that in tUi> fonii«r
' tubal iumcD is sunicicDtiv putulou.i tn jKrmit »( a certain liegrei^ nf expan
«iuD of the fd-tui »nc, whon-as in tiio latter thi; liimcD is so small tliat this
Li inijjoDtiiblo : und a.4 i-xpniiHion can »i.%ur <3nl_v toward* thi> peripher;^,.
t-arly riipturo is the usual temiinaiion.
Tubal nlHtrtion rr-AuItt from the [x-rforotioii or nipturi' of tlw cap«ul
menihrane or pt^udo-rellexa, and tliL-refore does not differ eAueutially froia
intrn-pi'ritnniiil niplunr, t-icfpt in ihc fnet lliat in the ono caw lh« hwmor-
rliagc occurs into the lumen of the tube, whenf«!i in tlie other it takei
place into th« peritoneal cavity. Accordingly, the term " tubal abortion
could tie well Tvplat^d by that of jntra-luliai rupture, as suj^est^d
BiTkch-y and lionncy.
The ininiiHlinte conMiiui^nci: of tliw ha-mnrrhap' is the loOMntng of Iti
t-oiimvtion Iwlwwn Ihc ovum and the tiitic wall, the former becomiog'
original
licpreg^
iiicr th^H
r expan<9
his
OlflS
>r-
I
FRI. Sll, — TUHAL AhODTION, OVCM OKtSa KjrtlltliEP VltMOVCIB dailBUTm
<K(tl>-). X 1.
cfJinpU'lcly <ir [iHrliiilly jH'jiaraieil from ils site of iin plan lotion, tf tllff
iteparatian is coiiipk'ti\ the iMitirc ovum i* cxtrudtil into Ihc lumen of the
lube, and gradually forred by the effused blood towards the fimbriated
i-i)d, throu);h uhich it may be c\trudc<l into the prntoncal carity, vhtn-
ufwn Ihc hiumorrhafic iisiuilly cch»w. On llic oilier hand, if Ihc sqiaratioa
is only partial. Kic ovum r<>ninii» in xitii, and the ha?inorrl»aj[c conltnu
A<«ordin^!y, we distinguish between compiffe and ineomplele abortio.
the latter occurring far ?nore fr«|uently than the former — 10 to 1, acta
ing lo Won User.
In ft Kmail niimhcr of ca>!es the avam may be ottserredin th« mA ot
JOB I
I
EXTRA-UTEIUNE PREONAXCY
639
abortioD ( Fig- All). TUib', unionjc lu^ owu uprviinpiut an two which hIiow
the foettu surroujided by its iiienibrsneo. protriMling froiD the dilated fiui-
brialcd i-xUcmHy of l\v tiiW.
When thv tueitiorrha^ ie iiioiliTati! in amount and the oTum remains
in nia, it may bi<cx)riK- iiilitliKlt-d with blood and inrreuM markedly in
aize, \M!iag, oonTerto) into a &truc'tur« analof^oiu to th« bSood or lle^hy mote
olMem<d in utirrim- abortiniw (Fig, 5H). Thv hainurrhago usually puriiistK
an louj^ as tht- iii<>!« rvniaiUA in tli« lube, ami Ihf. hlootl slowly tr!<!kle«
from tl>e fimbrialtHl vxln-mily into thu pc-riloncal cavity, u-hi-rp it becomes
cnvajiHulutud, giving rue to an httinatocele. If t)io fiiiibriftliil ttjttretnity
ifi occlud(.>d, the tube may grwhially
bttfitiie di:>t«ndi.>d by blood — Affwm-
totatpinx.
Aftrr incomplete abortion email
purlicii^ (if Iht! chorion may n-iimin
attachc^l to the tube wall, and, Ih?-
(.■oniiii); Kurruundod by tibrin. give
rJM to a ]>la<wntal polypitx. just aa
it' often not<^«l after an inrompHc
uterine abortion.
T.r. -
..Om.
B.C.
r.r. —
X 1.
*'-f^: hfaul-«lat;Ur.,«inun;r.ll'.,lub«iralli
V.T^ uwrfiw «iit ol tube
FlO. A13. — UtllMIC pBKbMA.'X-lr. Hl'lll UK
Trx l>Ar« 4rnnt I-^jurr Miuiani'^i. Pk-
KIOD. X I.
f^iuplurr iul'3 Ihe I'erilottrat Curi/y. — .Somewhat less than on* fourth
**ie €«M* of tubal pn-j^aiKy end ailhiii tin- first twHvo wecke by intra-
l"*"" t«ii»pal ruptun*, which uEuaily occurs spontaneously, but ocnuionaily \*
"- n-iuit of Tinlcnce. (jeneralty iipeaking, whvn rupture occurs in the
*"*** few wc*'kn, the pregnancy \» situated in the proximal end of the tul*.
*^«irt di)'lan<i- from tlw; t«rnu of the ulerux (»<)e Fig, 513). On the
V**^*" hand, when tlw ovum is impiaoted in the interstitial rmrlion of tl»c
.r**^- rupture oecui* later than in the other varieties — as a rule, not nnttl
, ^^T- ihe fonrth month, mmetimes cnnsidernhly later. This difference is
*^ t<> Ibt^ fuel tluit the inten>litial [lortion of Die tnl>e i* (UrroiiudocI by
'^Ue tnuMulature, which react* promptly to the stimulation of png-
T^^T', «nd hy iU hypertrophy allows the orum to attain a oonsiderable
"** hfforc nipltire oceurs.
^^^^e prime factor in tbp causation of rupture is iIm? intra-mural em-
■^wAina of Ihi- ovtim, nod tW cowseqwnt inra«i"n and weakening of the
'*•* (rail hy iti« ectodermal elenient-*, and later by the growth of the
■^I'-'ifwii^^ villi, though .fa<'olii' lioIiU thai this i* the i-aw only in the early
'U; atu) thai later rupture results from the mere mivhnnical dintcn-
i
640
OBSTETRICS
Itiin iif |}i4- IiiIm>. lU ilirpct raiiso riiav be violi'titM^. tiiicli as vai;insl fjisni'l
ination. coihw, a Tall, or oven iiiirr ovcn-viTluni, liioiijlll in lite vast majority
of c*fv» it (K^-iir* iijxmljiiuwiiBly. I'miL-r such circumstjiuces. rupture ie
liroii^ltt aboHt either by direct perforation by the grouing villi or by th*
u'cakened tube wall yieldinjr to s i-udden <i«.f*» of pn^wiin* in th« intra-
villiiiiK sjnKt'j', following lli*- sudden ojMfiiing \ip of n larRO v«asel or the
closing of vtiiouH chaunelA by cliorionie villi. The evidence at prw*nt
avniluble ivcmii to iadicutu Uiut perforalion hy fo-tnl (.•k-nutiU ix Ihc Irm
iinuat faclor, oxropt in^Hiajw when the nrtiin is situated in the extreme
pro.vininl end of the tube.
If rujiliire oecun* iu lliis way in nn otherwise iioniial tulio. it is appar-
ent tliat it vill be likely to occur at a uuich earlier period if the ovum
be arn-i'led in a divfrticuUiui from its hiintii. us under suoh circunifllances
it will have only a portion of tbe hibe waU to penelrute, instoad of iU
(•nlin- l)iii'kiiOK<.
Ocmsionally, seroniiarj' rupture omv ocviir in a tnlie tbe seat of 3
])riiiiiiry tiborlion. Iliniigb IbiK i» powtible only wlien the fimbria litd t-nii i»
occluded. I'nder such eimintstanees the weakened tube wall yields to the
])ri>sMirc of tho blood, which ht)» Imi'U )x>uni] iuto it< lum<m and can fiud
no oliicr means of escape.
KupUire UKually occurs in the neigh bnurlioml nf Hit- plact^-ntal inte, and
either into the peritoni'al eavtty or IK-Iween the folds of the liroad lijta-
nient, dciwnding upon the originul tsite of Uie ovum. Tlio terminatioiu
of (he two condition:- diffiT so markixlly that it will be necessary to con-
sider them separately.
WI1CJI riipturr laW-* place in llic peritoneal cBvity, Hie vntiiv ovum
may lie extradeti from ihe IuIk-, but if the rent be small, profuse hmnor-
Fio. in. — RvrrvuKit \iiPin.i.\H pRKaxtrtit. x I
Am., luiuiluii; O., ovary; /'., iilHrcutii; T., uU-riot- cail ot lube
may occur witlwut its escape. In eithi-r ereut. the patient imi
pdtalely shows signs of collapse, which may rapidly end in lUulh. If ll
Ittemnrrhnjie doi-s not Wd to a fatal termination, the effevt of niptu^.n>
varies accordiog to the amount of damage sustained by thfi nram. 3?
^expell(>d indiet into the peritoneal envily, its d*-atli is inevitable: and ix"-
!l«*« the pregnancy has advuncttl beyond the third month, the pmluit of
EXTRA! 'TERISE PREONANCV
641
V conception will b<^ rapidlj ahAorhcd, a.i utsh nhnwti Ity Leopold's espcnnienU
DpoD animalii.
Ill IK ><til) Ihou^hl l>jr mutiy tl>Ht under Hucb cinnimstiiDpea the placenta
may i)«co[ne attached to any portion of ihi? ptritoncs) Mvity, and there
eaiabliiih vawular t-oniiections which will nmdir runlK-r d«-v)-i<i[uiioiit fnm-
Biblf. I dn mil briivvo liiuL tliiK otn occur, 8.4 it U liijilil.v impro)>aMc that
fxtth cfMinwlinn* eoidd Im- )stalili.''hiil IwrnFc ttwr ovum lind licoomo irrci>ar-
ahly daina^<d, not to apeak of tlio ucj^tivc Gviden(« afforded by Ijcopold's
pxpuiinivntc.
<>n tlu- other haiul, if only the fn'tit^ <«cn[M.-s ut lhi> tim« n( ruptiirp,
. the effect upon IIk' pregnancy will vary accnntini; to lh«- amount of daiiia^
Btttiftamnl by iho pJarenliL If miu-h diiniag^tl, dotith of Iho tirta* and
"liinninalion of tho pregnancy is inevitable, but if Ihe jireater portion of
iIm- plmiiiiu Mill ivtainA iIh nlliiirhinenf lo iho lube, further dirvclogiment
Ki>) po^ible, and the fwlus may go on to full term, giving ri?« t« a f»-calted
Halxlomiruil pn-gimwy. In ouih caM-« Uie tulir uiuy doM^ down iijh>u ihv
placenta and form a »ac, in which it remains during the rest of the pr^-
nanry. Or a portion of Ihv plsccnlu may remitin atlachi-d to the tube
I wall, while Jta growing periphery extenil^ beyond it and estahli^thft* con-
Intvtinn with thv surrounding jwlvic orgnnu. L'n'lcr such circumstanoQsJ
one may find the plneenta ntiachetl partly to I)m( uteru.-i, pelvic Qoor,i
rectum, or vren Die inliwtiiMs.
I do not Iteliove, Itowovi'r, that tlwr placenta can hecnnie direetiy atttchecl
to organs far remove] from the pelvic cavity. Ntieh ha thv stomach and
diaphragm, for in-naiKp; and when mich ('i>nHf(linn< are «lt*erved. I ron-
Hider tliat nn« haA to deal with a famad-liganient pregnancy, iu which the
platmta ia situatMl upon the upper porti'Hi of thv ftctul rac. which had
become adherent to the organ in ifiie^tion.
^^licn tite fcctus csca{)c« from the lub« it id nearly always enrrounded
•by iu nteinlirane>, and most niilhontieii lH>tiev<! tluit furtl)er growth in
tnipoeeiblp iinlcits it in surrounded by the amnion, tliough Kciornl obscncrs,
nntahly Both, liavu reported ca»e!< in which a full-term fretus lay perfectly
freo in the pcritniical cavity, and all that waa left of its membranes waai
)nnil in tlit' lulml *iu: ^
Ruplure into the Broad lA^atwiti. — In a small nuintH?r of cases rupture
ay occur at thu portion of llw iiiU- uncovered by pcrilonai-nni. na tlwt llw!
iteni-« of the g^tation pac are estrudwl into a space formed by tlw sopa-
ilion nf the folds of tlw hmiwi iigiimi-nl. Ocncrally speaking, this is the
[)«wt fnvnurahli^ variety "f rupture, anil may leniiinale either by the death
if IIm> ovum and tho formation of a bntiti-tigami-nl lnrmaloina, or by the
furtJieT drvp(opnn"n( of lh<- jm-giiiincy bi-lwiTn the fold* of iIr- broad Ilga-
niMit. Till* nuti-omis de|>einln largely iijifin iIm? degree of enmplelenesa With
which the placenta ha- l>ccn s(-|>ara)o<) fnim its tubal atluchmi.>nt.
If the placenta remain* uttaclnd to llu> tnW on Iho nide opiKxaile Ihe
int of niptiirc. it generally beeomes displaced upward as pregnancy
Bees, and comes to lie aliove llie fn-lus; but wlwn il is silnafcd ni-ar Ihc
of nipturv it gradually oxtends down l>ftwei*n tlw fold* of the broad
nent, being implanted partly ujwa Uic tube and partly upon (he pdvic
642
OBSTETRICS
ronuevtivo tU^ue. lu eitlior vrciil, Uic foDtnl mc \\m entirelj' oateide
Iho peritoneal cnvitj,', and aa it Increases in site the poritoiueum in grad
nlly disR-cli'd up from tin- pelvic walls. This ooDilition i* (li'nijpiati.'d
tTtTi-peTiiuneal or ItTvad-ligameni pregnane!/, and was carefully Rtudied
Dcioimcris in 183fi. Uccaiiionally the broad-] iganivot i^c mar rupture st
a laUT pt^rimi, and the chiltl be «xtnidwl inlo llie peritoneal cavity, while
t!ie pUcenta retains its ori^nal position — wn/Hdan/ alidomin€tl pregnancy.
TIti! )nip')r(«iK-r of rupliiro into lh« broad ligament wss paiiicularl
emphasixcil by Tait, wlio believed ilial it vta* only imilt-r nucli circiini
I
Fla, m. — Bhoaii-LkiahBki- Piii:<i-itN<** (ZwnM).
Maiii'i'^ thai exlrs-utt'rini- prcfinaiicy conld g» on to full term. Bui »\
tiihal pn-gnaiU'V doi's not nwPN*arily enti in niptiire, it is evi<U'iit thai
statoiiienls wert' baw-d u|>on imptrftTl information, Tbo frequency of Ih
mode of niiitiue sitfiii* to have been considerably overoatinialrtl. Il
iioimI in only \ oitt of 3*G caws colliclcd from the artiolcs of Mandl aiu
Scbmidl. KiwUkt. uiid Fehling. and only once in 50 «pecimi.'n» of wt
nterino pri'^nancy examined by the writer.
The eo-called tubo-utfrinr prfgnttnetj rt-sull" from Hii- gradual rxten^ioi
inlo the utiTicn- i-uvitr of tm ovum wbii-b M-n.* orifEinnlly implanliMj in I
interstitial jmrtion of the tiilie. Tuho-ahdominal pregnanct/, nn the othe:
hand. i« derivx-d froni a tubal profrnaucy in which tlw ovum has b"<i
iuMTiid in tbf m*ighbonrhood of the fimbriaiwl extrwrnily. and graditnlt
extended into the peritoneal eavity. T'nder such rimimstanoi^ the |>o
tioii of the (a?tal sue projectinji into the peritoneal cavity forme adhcsi'
witli the Hurrounding nr^ann. vhieh nfton »eriai»iy eoniplicato Its rarnnns
at operation. Neither of Ibese conditions is ^-ory common, nor do th*
de«*rvo to !«' elasMifiiil si-paralely; in reality, they are mcrv-ly prt-jroaiii""
develnpcil at unusual portions of (he tubes.
EXTRA-ITEKIXE PRliGXANCV
64»
I
Hhv l«nii tubo-orarian prvgnanct/ U iMnploviil nii«ii the fvlsl Mc is
cnmiHiM'ti [Mtrtly uf tubal aod partly of ovarian tiiuiuv. Such cases owe
thior un);iii lo tliP (level opmcnl uf un uviim in a tutKMjrariaii cnt, or tii a
lube vhose fiaibristeil a\tr«mitv waa adherent to the ovary at the time of
fertiliznt ioti. 'I'hvy an- thvR'forc primarily otlhcr tubal or ovariflu in ortgia.
Abdominal Pregnane;. — I'dIjI comparativoly nvt-ndy it vnn ^nerally
belii'V(>d that tlH> ovum c«uld bo implsiiUH] upon any ))ortian of tlie peri-
toDsum six] give riiw li> a prinian- n))(ti>niimil pn-f^uiitcy. Tliu*. in
Horjccr'ii ataliiitiojt abdontinal nia^ rword«] twice oh fTer|uently as tubal
prejtiuincy. Liter, houorcr. when the spwimens were more care fully
Ktudied, it brcanic apparent thai Ibe jfrt'Ht mainrity of alNbiitiiiuil priig-
naocie^ were secondary in cbaraeler. having rceulted from ruptured tubal
pn^gnancy.
(Sradually d<Mibt bc^ian to ho cast upon the exiiilenec of primary aV
dominal prc^naiK-y. en Ibal at prf«eiit nti>«t anltiors. while admillinf^ iln
thriiretieal potoiihility, are extremely seepiioal as to its aetual fKX'Urreneo,
HIbimI Suttoii pofittively itenie* iU <KTurn-nee in n-onien, and eontcndrt ttint
it iit not olnienred in i)h> lower animaU. He holds dial the ftniHii|i of ficlnl
saica in tlie abdoniina) cavity of the latter does not afford cnnclumo evi-
dtrUM-, hut rather fonKideni tltul thev are due to llio ritpttire of a ul«rin«
liorn with the c.\tni>iian of one or maTe embr^o-i uito t)ie abdouien. Oera-
fmnally, a* wax "Imwn by Zwrifot, Marliii. V"i^, Ia-oikiM. and Worth, llm
fertilized orum may Itecome iniplantod upon the fimbria ovarica. .Such
cases closely Ttwe^lbll^ primary uhdoiiiinal prx^jiiiuiney. inaomucli a» tlx.' stir*
face to whieh the ovum ie primarily attaebed ih m ainall that a.i pre^aocy
advnneoA the inar^in-i of itie placnla ir(»it\ extend bcrvond the primary seat
of implaulaii»n and lat-oiiie atlaehnl to ihc surround inj; organs. Ihns gir*
iag the impression that it was primarily implantc*) upon the periionteum.
A eareful micrchimpieal cxaminalHin, however, will itiiihitt one In differ*
entiule lH'tii'f><n llj<' {*>• fiDditionti.
Fate of Extra-uterine Ftttoi. — As lias alr<Mdy k-cn pninted out, absorp-
tion if ibe unitersa) fate of small otubryoii which are extruded into the
peritoneal ravily. tinleu the plaeenta retains it*^ attachment to tho tube
wall ami Mtill offers condilion.-< suitable for llw eontinuanee of lite circula*
tjnfl. MoreoTer, the rnnni; freliij if^ frefjuenlly absorbed while xlill wilbiu
the tul*. a" i» shown by lln* fa<'t llmi »p<in o|Ntiiinji tiarlj p--<lnlton sacs
it is Bometimet) represented by an amphorous mass of ttaeue attadied to the
umbilical eord. At limes tl»e only indication of its previous exi^tencv h
foDiid in a .''mall |N>rtion of iIm* eoni ban^'inf; free in the amniotie eaviiy.
Ob the other hand, whim (he fo'tiL-" has attained a certain sine liefon- death
it cuiuil Ipc absorbed in this manner, and mast undergo suppnralion, muni-
■■ilinlinn, lithnpa-dton, or adipriei<re fomiation.
Profi^nie hat^leria often ^in access fo a ^talion mic which i^ ai1hert>ut
*o the inte»liiM's. and give rise to nupfiHratinn of it* conlenls. Kventually
the absoeas perforates at the point of least n^itttanee, ami if the patient
doea iMil die from wplJra-mia. portions of the fcetus may he extruded
tiininKh the alKlominal vail or into the intestineii or hinddcr. aecordinif
to the tituation of the perforation. This ouleonie is partionlarly frequent
&44
OBSTETRICS
311 broad- ligninonl pregnnnoie:*, on account of their proximity lo the rectnm
and the liability lo infictinn hv iiitt^^linul liitck'riii.
Mnvimificatiatt aiid Hthopitiiiun f'imiatioH have atr«a<],v been rcfcrrad
to JD the chapter on Abortion, un<l ore dealt with fully lu Kiirlii.iiinciKtQr'K
iirtiolo. TIk- lalter is genorBlly re^ardod as Ihe inort facniiraWe <if the poa-
»lile eventualitioB in caM»^ of udrtincvd (•\trtt-ut<-rini' pn-)^ttncy, as in many
iiii-Isnco lln* i'alcili*ii pr'nliii'l of I'diiiVjition may l»e cttrri"l for v«ir» as
a haniile^-i fonti^ Wiy and tlo uo baini, unless it Rives rii* to serious
djrslocia in a «tiW^uont pregnancy. In itereral ioslanvcij « litliup^ian
iiaa I)oen known to remain in the abdomen for fifty years or more, iuhJ tlw
lilerutiire ef>nlains muni-roiis cjiw-s in uliiih a pcri<Hl of Iwt-nly to ihirly
years elapseil liefore its removal at operation or autopsy.
Until iiiori- rarely ilie ftrUw nmy U'l'inm* convcrlcil into n yelloirif^h
greasy mass to which the term adipocere is applied. The fally material
is supposed (<) Ih> un ainnioniiical snup. bul a i^tiwfiu'torr explnnalion of
ils fi>rmatioTi has not a.^ yet been advanced.
J}m'a»fs of Ejira-iiirririr Ovum. — If an eitra-utorino pregiianey goes
on without interruption beyond the first few weeks, ihe nvitm i* f):]MMxl
to all the diseases whicli may occur in ibc ordinary uterine form. Thus.
Schauta, Werlhcini. and MidmtittK-h Iiave deseribcd mbal ova whk-li I»nd
become conxerted inio hii'matoma moles. Hydatidiform motes have been
obwrved by Otio, Hecfclmghanw-n. WenwI. Sykow, am) fithcr": and liy-
draiunios by Teuffel, Welwtcr, and others. Ablfcld and Marchaud first
(lescrilied a ca^e of eh«rio-«pitltcli"ma ttillowini; tubal prt^iancy. and Bi*»I.
in lfl03, wa,s able lo collect leu addiiiona] cases from Ihe llleralnn.-. It
is interesting to note that Kpiegelberg and llolst observed the occurreiu«
of eclanipi^ia during iho. faW lalmnr in cams* of advanc«il extra>utcriiw
pregnancy.
Symptoms.— rnrortiuiHtcly. Ihe manife.stationif lajonging lo an unin-
lernipled c.\tra-ii ferine prc;.nianey are nol characteristic, and llu- pntieni
and Irt phy.--ioian am usimlly culircly unaware of the cxisleut'e of any
abnormality until rupture or tubal abortion Dccun. Ordinarily titp pstMBt
toHi'idcrs herself pri'pnant, presents the usual subjcetivc 'Symptoms, anil
possibly suffers frimi sli);ht |iains In one or oilitr otarian n-gion. which diu
ri'^irrds us the usual concomitants of her condition. In rare iDstanc«e.
indeed, slie may havi> no idea that .*bc 1.^ pregnant, and rupture may occur
and perhaps prove fatal, e%'eD before slie has mif«ied a single raetisimal
period.
Suppression of the menses U not assoeiaied so regularly with tliisi con-
dition a.t with noniiii] pregnancy. U-ing nott^l in only -(3 per c<"nt of the
cases obi-erved by Martin and Orth. Maudi, Bonilly, and \Vomi.i»-r, Tlxw!
^tat<tnlcnt». huweu-r. do not carry as nnieh ^-oight as would appear at fiml
sight, for frei|uenily the ha-morrhago doc--* nol represent a gi'nuJne men-
slrunl flow, but is due to cndomolntis, or lo the fact That ihe dilatoil v(«t^>l#
in tlie uterine dec'i<iwa arc not covered by a layer of fa:<lal tissue. Mort-
over, the death of the extra-uterine ftrtii* at an «^arly perifMl. if not accnm*
panied by rupluro or alMrtlon. is usually a»>ociatetl vilh more or less atcr-
ine htemorrhage, which is fre4)uently mistaken for the muutnial flaw or
EXTRA-LTERIXK PREONAXCV
m
hr an «irlv aburtion. IIm' lalter belier lieing itill fiirllK-r (■<>nRnn«d hy Uie-
diM'har^ or dtvutua.
^^ In iDSfiT oNMw tht- fiM mnnifcxlaltnn nf the nbnoritiil prvgnoncj U
^Btli« ."uddai (Nvurrence of iDtcn««, laiicinatinK T>am in one or oilior ovarian
^"region, which is mkiii follownl Ity fninlnvu', the jxitit'nl rapidlv jMii-Kin^
I inlii a onntlitinti nf collnptie. This indicates the oct^iirrGtuM* of aixirtion or
niplnrc. In ihu former mi^^ iht- pHlionl tii'imllv nillio prnuiptly. wheivn-,
if rupluR- liH« ofcurrvti. ihi- iiilUjwo dwiMjns, th« (ait: hc(v>nuM pallid,
and the patient complains of intense pain in the lower abdomen. 11ic
tvmprnlurc mov lie pcr»i>>teiitly xiibiionnal. und an examination of the
lilood ^Imnr.i a marked dimtnullon in Iho niiiiiliiT of rt-il iiirpiiKolex und in
hiT amonnt of hirmo;;lohin. Dcnih may occur within a few lioiim unleiv
he tiA-murrlm}[i^ is cliivki'il Uv iiiH-riiiiw nivuiK On llu- "tln-r hand, in
io«t ca«e» of abortion the general mnditian is not aa atanninf', and tJie
}MtienL pradwftllr rtt.t>v(?r«. Vaccinal e>:aminati«n a feu- day* later fre-
ijuently revealh the presence of a large tliiciuant nia*< which filU a greater
Iftw^r portion of ihc |«'U*ic cavity — prli'ic ha-inatoi^le.
In the earlier text-books nn ^^'nll■co^l]£y. lia-iiialoei'lo vm con.iidcml aa
dtxtinet di>c.a«o, and it was mainly owing to VHt's obeervationfl that it«
imeetion with extra-uti-rine pn-gnsncy wa« eslnbliohnt. It i* derierilied
difftuf or mlHarii. according a.- ihe collection of blood occnpies a con-
i-id(-rai>le jmrtion of the pi-)vic ejivity or i» c-onliiN-d to tin- m'ijL'ii)M>nrh(HMl
of tile tlmbriatnl end of the tube. The dilTn^' variety usually occnr^ when
prp-eximinjf ailbe.-<ion.'< about the pelvic orgttn* facilitate tho (roo^ulalion
of blood and aid in tire formation of an organized membrane over it. tUus
fhutling it off from the peritoneal cavity, Acconling to Sangi'r, thit
liiar^ ha>matncele. on the olber )mnd. dew.'" not rwpiire tht- pre.«'noe of
ibnionx for il« formation, but results from tho grndiuil trickling of
looii from tlw li»d>riiiied a^id of the liilie, (lie nnier |Hirtiiini gra<lua]ly
coagulating and becoming organized, tlins forming a rap<nile about the
UMff Ilui4l iHirlionA.
llsmatncele fi^miation, for tile roost part, promises a very favoumhlo
rmtnatioii. for if left alone the niHxh gradually iindeigoe* «h«)ri»lion and
iiia|ileie reeovery occurs. THorn has repottfd 151 ca^reg with two fatalities,
Ft'hling !tl rast^ without a hiiikIc death. Oeni»innally. ttowever. if
bii'morrhage j)er^i'<t.*. Ilie iBpmaloeele becomi-s larger and larger until
*' finally rupture* and its contents are ponn-d nut into tlw peritoneal
•^vity. Such an aerident i* speedily followwl by eollapsc. .\gain, laeterla
*mnctinies make ttieir way into the mass fn>m tlie inlexliiH-s and eituw
*HpI"ir«ti<in.
^^ Jf (he p«tient flurrivcs the raplnre of a tubal pregnancy, a gfetnulary
^^^rlnminal prrgnancy may rc«ull. pmTidvd tlie placenta han not iMwn Mijia-
^nrtixl to too gn>at an ejitent. Fmler ^nth eircuniKtances the usual symp-
tom* of pregnancy persist, except that the woman cutTers more pain and
fv^^\» the fu'lnl movi-menl:! more acutely than usual. The pain is due
pAi-tly u) ^retching and possibly to contractions of tlie f<etsl »ao, but prin-
■^iTM^IIv to tbe piilUng «|iart of adliiMion^ which have formed between the
Uac ajid tbe vanoos alidominal organs.
Au
&46
OBSTBTttlCS
lu a small number of mbw in which llie primary rupture liad Ukt-n
pUco bctWL'L-u thi.^ fnliU »f lh« broad ligament, tecoNdarn rupture into xhe
peritonc-a) cavity may occur at a later period, and the patient may Weed
to di.<ttlh, or cW u iievondarii' alxloiiiinal pregnancy may result. In sui'li
casM the (mtun lies vithin the peritoneal cavity, while tlic plan-nia remiunt
partly within the IhIw and (>«rlly lietween the folds of ilie broad ligament.
If a secondary abdominal ])regDa»cy or, as now and again occura, an
imruptured tubal pregnancy goe« oh to term, false labour «(* in. a^snciote<]
with diwtinci pnin.t xtinilar to tha'ie occurring in the early stagai of lalmur
in nonnal pregnancy. They are due to uterine contractions, since thv fwtal
Mc coiiluin» 1^0 few miiiicular fihrc^ that ii cannot contract, and of course
cnnnot lead to the birth of an estra-uterine child. False labour may lajl
for II few hoiirii or «"»H>nil <lny*. and i* socti followed by tlie death of the
child, alliiough in a email nuiiiiier of cases the fo.-tal moTeinent« have been
known to per*i»i for a cimsidcrablc time after iho wsaatioii of (1»^ puitw.
After the ib-ath of the firtns, ilie placental circulation gradually b<v
<'onie« aljolifihed. the amniotic fluid )* absorbed, and the ftctul sac rclinctii,
so thiit it occu|)ies a iiiucli smaller !«i)ace than formerly. The alHlotnen
coD!-e(|iiently becomes frmaller. and its change in sia- is soon notiw-d by llw
patient, .\fter it.« initial shrinking, Ibi^ tnniour may n^main sialionan' in
sine for u number of j-ears. the child becoming mummified or conTiTt-?'!
into a lilhojitiHlinn; wltiie in rare inslanro cuppurativo cluingo niity Icail
to its gradual dischar;.'c or to the death of the patient from pejilonitis.
Cumhined and MnlHplr I'rfijnanriff. — Parry statit) in his nionogniph
that 82 out of the 500 cases of tiibiil pregnancy collecieil by him were
comjil icatcd by it coexisting intra-ulerine pregnancy. He designate<l thr
condition as ramhined prfrjnanni. The suhjivt has .■*inoc been invi-slignii-d
by Hrowne. I'antellani. (iiitiwillcr. Strauss. Zincke, Neugebaucr, and oUwr^
and the condilion upiji-iirs l/> "ccur tolenibly fri'iiuenlly. Tims. Strauw. in
1SS8. was able to collect only 32 cases from the literature, while Wcil»l. in
IflOij, bad incrciiscd thv numbirr of cnne-s to ll!t, to which Xeugebauor in
I1K»? added many more cashes.
In raiv instiinccs twin tubal pregnancy has been olwiervcd. tlie embryo*
being sometimes found in the same Tube wbili; in other ca»cs there «-&«
ft fcctii« in eacli tube, both showing the same dcTelopmenl. S&nger and
Krusen have reported ca.se.* of triplet tubal pregnancy.
Ui'piTited Tubal I'regnancif. — Parry collected S cawos in whidi tubal
pregnancy had occurred a second lime in the same patient, and stated tbat
Primrose, in 1594, was the first to deiicrilm such a condilion. With tlie
increased employment of abdominal surgery, the abnonnality has l«*n ree-
ogntstil (jTiile fre(iu<'ntly, the fiist *M-ic> of ciiscs a-as rcporttfl by Abel in
1S!)3, and .si^sin fnllowid hy tlio*e of Dnrland, Weil, Varnicr. niid P^•^la-
loifwi. the last author having collcried HI caves. In several instamii^ only
a few months Imd elapsed between the two pregnancies, while in oilier* Ihey
were separated by an interval of w>vcr»l ycai*.
KfffHf of Ertni'Vterine Frrijnanctf upon Suli.tf/jai-nf TA t WftrnnB-r.
Tin? presence of the products of an old extm-ntcriiw pregnancy oa-aswniill^j
gives rise to dystocia and neccsiilatos the performance of a major ufcete*.E
EXTBA-UTERINE PBE«.\A.\CY
647
al operatioD. Thus, in the cases reportn] by Hogenberger, Schauta, and
J^nger, CRMrrati K^lion wai^ |HTfortiioi) ; uhiU- in another, reiwrlcxl bv
Utt, the Mm« o]rerati(in wouUI have bc«n necessary had nii.>icarriagi> not
occurrvd at the ttixlh month. UcnDigecn. Dibol, and ItroMi indttcctl prc-
niBliin.- labour, and Stein and Cheston rcitorted to eranioioiny under siniilar
viKuaisluon*.
A» a rule. h<iwev<T, dysiwia i» not I'lu-oimterol. Funck-Brvntanu hav-
ing collected 9'i cases in which spontaneous labour occurred in patients
still c«rryinff lh<' nftitain.« of a previoui ex Ira-uterine prwgnuncy.
DiagnoiiL^l'ti fortunately, the symptoma to which uninterrupted eitra-
aU-ni"- I'n^^iiiificy gm-» tim.- «iv UMinlly w dliglil Dml the woman doe*
not consult a phyi^ioian. and a.-> a result the diafino^t^ is rarely made before
nipliirc or al>ortton w-cur*. If^ however, a putii^it prvsi-nting the u^ual
totibjertiTC and mhio of the objective nviiignotii.-) of [irt-^inncy Im> exauiinMl
fur any reason, Rnil a unilateral lutial tiimiiur be fonnd, the dioffDOHtB ia
fairly ivrlain, cnjaiially if »Ih' Iiok livn ^le^il« for a number of yearx or
a long inten-al >ia>; elapsed since her last pregnancy, in such cases t)w
(ilrrun in Honivwlial ontarifed and itofioiiocl. while the IhIhiI (nii»our U nntl
and doaghy, and correb|)on(Is roughly in siie to the liuppo^ duration of
[m-jniancy. Ttw? firsi pwilive diagnoxi" of tinrii|)lun>l tubal pregnancy wiis
made hy Veil in 18»3, and in tliis country l»y .lanvHn in IHHG.
A* a matlt-rof fact, hnvmtr, it my often )uip[>cn« that when laparot-
omy is fH'rformnl for a supposed unruptured tubal presnaney » tiimnur of
Mrtiif Killer origin i* found. On the other hand, the nnnipturcd prvgnanl
tube may prnlnpiio into llotiglaiiV i-ul~iU-sar and he rni>^taken for the body
of a rctroflexH pregiuint uterus, so that an attempt at its reposition not
infretjuenlly Ii-ad* t" rupture and otriuionally to death.
When the fstns has died In-fore the occurrence of rupture or atmrtinn,
iTTont in diagniwii' nn- common, and many eu>4-« are miitakcn for incom-
plete uterine abortions or for tubal tumours auuciateil with uterine- lM>in-
orrhage. For this r^'Hu-on im attempt sliould ever be made to empty the
ut«fiiH in a fOM of suspected iixnnipletc aliortion unleM the tul>e» and
warier hare lurn previously fuBlpatcd. If a careful examination nhows
llui a tumour i.^ prt^senl on <-ither iUli; l\w, po^utibility of tubal pn-gnuncy
dioold be seriously considered.
It IK generally taught tliat the diMlurgc of a dixtinct decidtial cast from
tli« uterus, without evidence of a fcetus, is a characteristic sign of tulrnl
fin-gnancy. Uul that now and again «uch a Ktnicttire may \k dioehargi^l
wiilti>nt the exinlemf of prvgnancy of any kind was demonstrateil tiy flrif-
filte and l)akin. Ott awl Avers believe that tlie presence of decidual ti«*no
in the ateru)'. in the iili«ence of a ftetiis. atToril* con<;ln*ivc evitlfnci? of the
existence of tulial pregnancy, ojipceially if a lumoar mas-i can Iw detected
or line side. In doubtful cases they recommend curettage for diagmistie
pnrpoHii. lily own experienc«> has lauglit me that lite presence of decidua
insvlCT snch circumstances usually alTords strong pre*umptiTe widenw, but
ttiat il« alrn-nec i» not an ••qually oonvineiug negative proof, for occasion-
a.Ily the dtyidiia niav have been cast off at an fvrly {lerioil and bvrn replacnl
Vby Donnal eiHlometrinm by tlx; time the patient is examined.
6Vi
(1B8TETRICS
The dingnosi^ of hibnl aboriion or ruptitn*, nn lh« nther hand. ii»u«Ily
ofTera no 'lifRcuIty, aotl idinuM be inadf witlmul h«>)iitaHou irli«never a
patiout who ik Iji-liovid In lie |ir<-ji:niint hft.-i (^miilitimtl nf puin in lliv Inner
jiart of i\w alxlotiieii, and suddenly b«comeij fainl. deathly pale, and sinka
into a slate of collupi-c. If llit- colUpw Ik-c-oiucs mori' pmfoniid Hud ih'?
ti-fiipcialiirc if # III) no rum I. niptim* lias pn>t>alily mvurnti. On tin- oilntr
liaiid, if rapid recoverj ennues, the probabilities are that one lias to deal
with an abortion, and the »ut>»ec|uent foniiution of nn lufmatotrdv wttli'w
tile ijuestion.
As hii^ alri'Jidy hi-ca pointod out. mptnrc may ocriir at a Tcry early
perimi, I'von before the patient believea herself pregnant. In view of liuch
a ponsibility. tln'rcforc. one >i|i(juld n-jjunl i^nddcn collajuw ai<«i)ciflli.-d »ith
sviiiptoiivs of alHlfliiiinal lin'iiiorrlm^> in a woman diiriiiK the ebiUiliearin);
perinil. ns primti farif eiidvncL' of a ru]il«m! tubal prppwnncy. Uy *o
iliiint;, and opi-rallnvr {iroinplly in suitable chm'.i, » numlH>r nf liveii will be
saved wliicli otherwise would ille^-it^blr be Wt.
Tcry often the patient conies into tlie haxtAn at lh« phj-xieiMt Mmc time
after she has recorerod from the primary shock due to abortion or r«p-
iiiii\ UiiiliT xiK-h ('irctiniNliiiii't!* vaginal i-xnmtnulion nill ^how u mat^ on
one side of the utenjK which in usually mistaken for pelvie iiiilaiiimatory
trouble. In a small numlHT of cjikc.*, u iluc-tuant tumour ran Im; felt pos-
terior an<L lateral to the uterus, and when ejkploralory piinetarc tlirotif^h
the vagina n-veals the presence of a dark b1oo<Ij fluid, the diugnosis of a
[ii'lvic bii-iiiatoicle or a broad-1i)^aiiicnt hieiualoma i.s a»un^l.
If the child has siirvired the niplnre, the dia^flsis of Bocondary ab-
dotninal pregnancy is rarely made nniil false lalKiiir supervenes, unless the
pliysician'it nlleniion i> pHrlioularly dirt-cliHl to the pn-vioua hiiilOTT of ih^
case. if. however, n careful physical e.vamination is made, the uterus will
be found much smailcr than it should he for the ilunilion of th« pregniincy,
and more or Ii-mm displaced by the ffptal «ac. which makeii up the gTeater
part of Ihe ab>Iominal enlargement. Moreover, the child can bw palpaln)
much moro n>adily than usual, and itn movement.* are often very {tainfiil
(o the mnther. In doubtful ciim-s the introduction of ft iH>und into the
iiterus is prrtnii'sibk'.
The JiagnosiH of broad-ligament pregnancv can he made by fimling tlw
uterus |(uslicil to one Mde by a tumour inlimatcly oonnecleii with it. whii'h
at the same time depresses the vaginal vault instead of being high up in
the abdominal cavity.
The diagnosis of eomhlned intra^nterine and extra-nlerioe pregnancy
is rarely nuido unii! ruplurL- of the extra-uterine pn^gnanry, nr (ho prr-
ststence of symploriis afii-r llie <'\pulsion of the nierine fwtUA, ItMuU to a
tery can'fiil <-xnniiiialion. The condition has never been diagnosed in the
liter months of prf^gnancy. ollhough in »«vfral instanccx Wit prcscaee of
twin* was recognised.
After e.xtrn-Hterinc pregnancy has passed full term the diagnosis is
usually easy, and is based upon (he history of pregnancy followed hy a
false labour and R gradual decrease in the size of the alHlomeil. Rxaniina-
tioQ shows the uterus to be practically normal in mzc, «nd displaced to a
EXTHA-LITERISE PREGNANCY
649
vaninj; oxlcnt l>; a lai^ lutiioiir more rir Itwt iiitimaUyly coiitMvU-d with
it, in whii-li lhi> <>utlim« of tbo diUf) can ociwtioDally be diHtin^uishMl.
To ri.TnpiluUlo. a (Mixtiiii-f iliugiiiiiiii i» noiw>ioiiii11y iiia<K- bt-forc rup-
tarr. but iu tli« tasl majority of ca.'M.ii ihe condition oArapia* nvojtiiilion
until svHiptoiiis of it))lii[wt! point to tht protmbilily of mpttirc or abortion.
Id advsitcM) cam's careful examination will n^ually disclose (lie real eondi-
lion nf aJTaire, and when full tvnu lias been pas»^ tlie )ii«lory is so chaiws
leriBlif tbat mtHtakCM nliould bnnllr ixriir.
TrMtmest. — As soon as an unruptured extra-uterine proffnancy is pot;!-
tivHy diagiwiHi], iln immtttintv removal bv laparotomy if KTg^KtilU- indi*
t-aliid, sininp rupture may oocur at any time and tbe patient die from bwmor-
rbap- lieforv opcralivc aid can be obtainiil. TIh' imporient-e of imnMnliale
operation cannot be too stronf-iy empliaflixeii, and all metbods of treatment
wliiib aim at ilestroying the fieHiK and l}iu!> terminatinfr pn-jnumcv wiib-
"111 operalion are absolutely unjiL-tiRable. Thi* applis not only to tbe
UM- of flerlricily. bul «)ko Io thv injtvtion of variouft poifxmoiLS HulKtanci-K
into tite ;9>ritalion sac. Kven when «ui'li procedunv are ii»vc<>s^ful, the
ilan^fiT III lb<- ntotbcr i* by no mean* at an pnd. cince rupture Himetimcfi
lakes plai-e after tbe death of the f*ft(L-<; ami, even if this aceident does
not ncx-ur, llw nrli'Dlion of the product of concvption rcndere the tube a
useless or:^an.
Tait, in 1883. performed the first laparotomy for the purpose of check-
ioji hacmnrrha];!- fmm a rujiluni! lulial pri'mTiancv. .Vfli-r be- bail demon-
i4ratMl t)H- caoe iritb which tbe opi-ratioD could Ixt performed and tbe
nirprifinglr good rtxulbt obtained thereby, the procrdun> eanie into general
It-'*. Its beneHcent results were clearly demonstrated by Acltauta, who,
■ftvr a careful »tudy of the )itcralun>, found that IS.'t casc« opcrat<'d upon
and r^l eases trented without operation presented a mortality of 5.7 and
8«.y per ctiit rcsptttively.
For thciM reaiumn, whenever w« mc a poiwibly prc^ani woman in a
^tale of profound collapse, and presenting a deathly pallor of the fac«, a
PUtnormnI lem|H'nilun', ami other ^ymptomn of intra-aUiominal luL'inor*
riia^^e. immmliaie operation it ilcmanded. unlcw, indeed. Iter cfwdilion is
so di-<pi-raU- that death i* imminent.
The abdomen should be opened rapidly, under cocaine amesthesia if
ncetwary. In nmny i^m^ IiIoikI npitrt.'< from iIh! abiloiiicn a* »onn as tlte
peritoneum is incised, and completely nbseurn; the field of operation.
Pntler Ib^-w? (■i^■nm^'lanctw ttw' hainl ;tawi-d down alonp>i<!c of the uterus
wixe> the tubal mass, which is then clamped on either side by long forcepis.
The hvmorrho^ luiving ttcrn controlled in thi:< way, the Mood-clots are
n>miiviHl and tlu- fl>>td of ojn-rallon i.i cleoneil up. after which t)ie operalbr
will he alile to ren)oTe the mass and replace the clamps by lif;atnres, under
Ihe guidance of the eye, at omparatite leisurv. After the fa-tal sac haa
li«-n laki-n away, it i* not ailvisabU- to Hliempt to remore all the blood from
the peritonei cavity unless the patient's condition is fairly Botisfadory.
-Vol infriijiientlv ibc appi'mlajii-* on llie opposite side may l)e the wat
tif chronic intlammatory lesions. Some discretion shoubl be exerci«sl as to
tlieir nunoval at this time, it biding far Iwltcr to allow them lo mnuin
650
0B8TCTRICS
lliao to prolong the opcTatJoii if Ihe palie^t io in « verr bad condition. In
drnpcraU' Clue* it \» advimbio to livgin tho ^ubcittiutous or intravenous
[infusion nt sti-rilv snll Miliilioit wliile thi.' im!<hiwuit pn-pamlioiii^ fnr Iho
^operation ar<- U-inj; made. In leas sovere <-nM!-i jjnoil nsuliii follotr tht? in-
tixHluction of »vn'nt1 btrra of it into tbc abdoniua jiut before tbe vonnd
is cloned.
lu orrtain coses of tubal abortion, Froeliownick. Martin, and others
adrocnle atlenipting to tstvo the Itilx', if piMsibli-, bv «pi-iiiiig il bihI rvniov*
ing ibo product of coaceplion. after wbicb it u clofieU by sutures. Such
a pnKTMiiirft may npc!ii«i«niiUy In? adviMlilc if the palitiit is in good mn-
dition. but proof U still lacking that a tube a» treated reguint) itt^ norrnil
fuiictionK.
A freshly ruplurfd tubal [ircgiiiiiicy ibould tint I* attuclo'd Ibrmiglt
Ibe vapinil, for tbo reason that the procedure is often more ditlicult iliau
a laparotomy, and afTonU but a liniitiHl vii>w- riF tbf Held of operation. wliil«
there is always n possibility that it cannot be completed by the v«gina]
route, and ibat an evonliial reM)rt to laparolomy will Ixrcomo ntTox-qirr.
If the patient is not seen until the acute avinptnm.i have siihitided and
Ihe effused blmni hsm htxronio eiicapvululed as an lia-inaioci-lv. i»be should
be. put to bed and carefully watched, operative procedures being iBstitutcd
only when the IiirinnlixiOe sleadily incrcaws in siac or pnwnts symptoms
indicative of suppuration. This condition, however, rarely pre-'«nt!i itself,
^R<] T)n>rn ofKTul.'d ufMin only (! out nf 157 such fa»'». When, bomtJi-cr.
'the occasion demands it, exeellent results are obtained by evacuating 'he
IwRiatoccIe through an indsioa in the TUginal fornix and packing the cavity
wilb sU-ril« giiiixc, as has hi-i-n rwnriimendtil by Ki-lty. St-jjowl. and othen.
ltroail-1 lament hieuiatoinatu should be treated in a similar manner.
In lite hil'T imiiitliK, the tnalnient nt extra-uienne pregnancy dilTn^
markeiily accordins as the fo?lus is alive or dead. In ver>' rare ca*«fl a i
living fn'ins niny bu im-Uwd in an unruptured lulial or ovarian sac. or '
lie between tlie layers of the unfolded broad ligaiuent. More fre<|aently,
bowcvTT. ono has to deal with a »wi>ridury iibiloniiiuil j)regii«»cy. with Ibe
child lying in tbo ((eriloneaj cavity and inclosed in a aoc conipnseil of the
fo?laI membranes and newly formed ailhei^ious, Iho placvula being vithin
Ihc tuln; or bmndly implanlod ti[Hin tlie floor of Ihe pelvis. Whatever the
anatomical condition*, the mother is constantly exposed to the posjuibiUty of
suddoti and acute twniorrbnge Mi long as pregnancy continues, «nd accunl-
ingly prompt laparotomy is the only consei-vative metlmd of treatment.
When tbe child htis nt^^rly attained the jwriod of viability, certain au-
tborili<-j( nrg<? tlie projiricty of deferring tbe operation for a few wveko in
ilB interc-stH, Such a course may be permiBsiblo in exceplional cases, pro. ■
vided Ihe incrcan'd daiiger!" of waiting aro can^fully cxplain<-<l to the p«li«al •
and her family and accepted hy them. I
In a smalt number of cases the operation i^ comparatively easy and
[Iio ffvlid sue i-an bi* ri:-mov<il a* nuulily a* a large i>v«rian erst. M'W i
frpipii'wtly, however, the fn-tal sac is markedly adbercnl lo K.nrr>iut»dint:
organs, or the placental attachment is spread over a broad anu, tlicn^U
markedly incri-asing the difficulty of Ihe operation. ^.^^H
EXTKA-ITERINF. PREXJNANCV
651
Now and again, in Uroad-Iigamcnt pivt;nanci«> it vrill be foiuid thai
thv portion pf th(< bnuul liKumiiil iintncdiaMv mljoining thr iitorn* htt
not been Hpnwl ajiarl ]>y l)io fcnivinfi: nviim. ami uniior y^iii'Ii rirouiii-
slaac«a (he entire sac may be remored without fjreat diflicultv hy ligating
vnaels •! thv {K'lviv brim and ut lliv uterijii; cornu bi-forc iltvmpling
«»icl«Ati»n.
As a nilo. howerer, the complete removal of the station sac is by no
e**y. and can only In- vKin^U-d by removing tlio wieni* at well.
BThen, an oceaj^ionalty happoji-i, it is apjiarcnt ihat the operation cannot
c(inipli-li-d without murkolly cndan^crint^ the life of the patient, tlio
xhoutil be im^iHcd, the j>hioenIa being avoided, if poit^iihle, and the fwtu.4
itractcd. 'I'lw margintt of the sac arc then stitched to tW abdoininai
Qciniou, the iiiiibtlieal corrl ia eiit olT xhort, and the eavity packed with
lerile piuze. ihv placrnita bein^ left in situ and aftervrard allowed to come
piercnteal. Thin nieihinl necessarily entailf a prolong] convales-
, but is much safer than any attempt at removal of llie placenta.
i4-ciii> tonally, however, partial w|Mirulinn <if Uw plact-nta giTes ri»« to nuch
ifa&e bemorrlia^ that it* removal must be elfcctcd at any cost in the
Kipc of pn-n-iiliiij: imtii<-<li»te death.
The restdis followinif laparoiomy in advanced cases of extra-uterine
pn^HiK-y WTlh a living child have improvcil markedly ^ini.'c tho intnv
Inction of aseptic uK'thods, 'Phis fact was cleariy shown hy ilarria, who
Nillerli-tl 27 xiieh c«m'» iM 1SK7 and H.l additional c«ite» ten yi-aw later.
■ith a mortality of !>3 and 31 per cent re^peetively. Xevert hele^ii, tlw
^)»rBtinn It, cttil one of the most dangerous whieli the gynseeolngist \*
IIm) u|>on to perform.
When (he f<etU8 if, Aptid the conditions are much more favourable, as tho
agfn> int'ident lo hieiiting fmiri thi- placental xile an* mark<Hlty dimin-
i»lwd. For this rea«jn the operation *j|iould be <ieferred for six or eight
ii'kx after fn'tol di^lh in onh-r tn jxmnit the ohHleralton of tlw) maternal
Hood ^aocs in the placenta, and thus render poirKible its removal without
ai>rrhag<-. In »wh (.ilv^, however. •'Itnuld dangenmii Kyniptoiiii' )iU)wr-
prme. immediate interfen-neo is indicalc<l. On the other hand, the opcra-
jiin should not l(e ili-fermi liy> long, an ihorc i* nlwayi* a jtowtbilily that
l»c fietal sac mar become infectral from the mtertinal tract, when a fatal
?ritnniti« may n-Kult. Liisk. in ISHfi. made an eamwl pIco for prompt
in nuch ea**s. and supported his contention hy a hmg array of
»li»iic*.
In a HUiall number of eason of advanced extra-uterine pregnancy, opera-
*& through the vagina haw bn-n recommended. I'his method of proeedurv,
TtT, ha* a very limited Held, and llcniian i:^ riglil in Kaying that it
_^ l»e (>t-rform«l only when the fn?Ius U lirmly imi»acled in the pelvl»
"'H dcprenes lh<' vaginal s-atilt lo siich an e»renl a* m make il pndiablo
_ilu*l ji can be extracted without diflicultv. In all other ca*<'s laparoiomy
(he ii|H.-ralion of choice.
652
ORSTETRICS
UTKKATURfi
Aiieu Zur Anatomiu tier Eil>nt«rHc)iwau|iKrtirliafl tieW Boiiierkini^D xur Entwickw-
lung dcr incnuohtichun riniviila. Arcbiv f. Hyn., 1801, xxxi:t, 303-430.
Uebur wie<icrhollv TiiWiiKriividitiil lici ilereclbon t'rait. Ardiiv f. Ciya.. 1K03, riv,
Ahlfklk. ICin FaU ran fictrromn uteri l)uei<,^ll>-cvlhllll^^ bvi TulxMiM-hmnguncbiill.
Moiutam-lir. I. <iel). u. llyn., 1895. i. 200-213.
Andiif.h-h, <>» the Anatomy of the Pivguanl Tulw. Jour. Obsi. »ad Ojm. BriL EmpH
1903. iii. 4ltM41.
Atmmi and I.im.KwttoD. A Case of PrLnwrf Omriu) PNgtuwcy, vtc. Trauo. Lob-
duu Olut. Soc.. 1001. xUii; Lwicet. 1001. i, 100.
Aitcnorr, Aiiatomio di^r ICxtniiilcrinschwanicentttuft. ZJc^r'n BcilrAgn, INS, icxv,
H. 2.
Die Itcxiiihiiiigen <lcr ttiluincii I'lanmtA xiini Tiibvnuhort untl sur Tubunrtipiur.
.\frhiv i. (iyn., 1900. Ix, .ViS-WS.
Xuuen: .\rl)vili!n iitwr die Aiiat^ u. Aclioloijic ilcr TuIcnucIiu-sagerwJuflcH. Csn-
tr&lbl, I. allK. I'Atli. ti, (utlt. AiiHi.. IttOI, Nr. II a. 11'.
Atehk.. I>>d(luii in itie [Jiitgiiuna of [Cxtra-uicrini! (Yt^nsney. Ainer. Joor. (IImL,
ISffi, «vi. 2av-3fW.
BecK. Ectopio Fn-guuiioy Twice in tliu .S«me I^ntieot. Ihu Second Timv counpliekted |
by Intcatin&l 1)t»l ruction. Aincr. Jour. Ohat., IdflS. xx\-i), 570 -.^TU.
Bkrkblev uiid ItoKVKY. Tulnl (iHtitaliou: a Palhixlo^ioJ Study. Jour. Obat. and
(lyti. llrit. I-Jiip., liWfl, »-ii, 77-nft.
BoBSF.HCKK. f.in BeiiniK ii)r Ovarialgniviilitai. MmifttMcbr f. Oth, u. Uyn., I9M,
XX, 613~fl33. (KrBHnxunedip-d)
VOK Bi>rii. ItochltuHiitigc Tiilnnichiv:iuK«riic)uitU Rupliir bn St«n Monat. Knt-
bindimg den fn.-i in dcr ItaiirhhAhtc Ichcndcn Kiixlcn durvb LApnrMoRiiii jm 8t«tt^
Motjal. MntiHlwchr. f. Gub. u. Gyii., 1H99. 782-794,
BoniLi.r. Notvi Dur la in^mwiui: oxtra-tili^rinc lirfei de I'vudyic de ni>()uante obswa-
tionx purnnnollvK. [41 tij-n^pnlc^ie, 18!)H, iii, 1-16.
BseftLAU. Zur AetioJogiu unJ putli. Aiiatomiti d«r ExlnLUteriniidiwancefaeliaft, Mo>
nnliurhr. f. r,Ghiir1>ik., IKtt:), xxi, Siippicnieiit ItofI, 110-124.
Bxiimi. Qi)otvd liy Sjinicer.
Bhiivtml a Coiitriiiution lo the Iliilor}' of Canilnncd Inira-iiiorino snr) ExiniHiUriDe
Twin PfCKiiancy, Trans. Amur, llyn, Soo., 18H2. vL 444-4112,
Oaiicuki.!.. Abluindlune utwr div Si-IiwaniKnwtutft uuMcrholh dor n«tii>i1iiutt«r.
Tmn)Jat«d from the I'^iidish by Tir. Reker. K«rlvuhe »ad Freibuf^ 1841.
CUBfTOK. (jiioli»d by FWck-BrcnlAiio.
Ckiaui. [Jcitrngc xur IxJira von dur Oravidilax liibaris. Zvit«rhr. T. Heotkuaiie. U87,
rill, I27-14((.
Cmdtki.iirr. Mote «ur I'anniomi* ilc in rMAchic Aaaa la gMMaeav labain. Ootnptw
nndu« HOC d'olMt.. de gjn. ot dt- picJ. dc Puris, 1900, ti, SO-fil.
CJuekfuea points du i'anatomio dcx groa»— g lubatrea en dvuhitkin. etc. Kctuo ds
Kyn-, 1902. iri. 51 -«4.
Croit. Au .Inmnuloiw Cine of HetopiP Prctnoutcy, prwlwbly (.^varinn. I'nuM. Loniloa
OImL Sni;., 1S>00. xLi. 310-3J3,
Uakix. Qisl from ihe l!t".-/u« luiving all llie C'liaraclera of llii- tHTidiial Mi-nibralM^
t'oiiiid in Coimoction with r,rlopiF (icatatiun. ctr. Tmim. (.ond. Olnl. Soc., 1897,
.iJixviil, 383-388.
UKuauKitm. (irtuBcacs extra -ul^rinca. Jour, dc* conn. iD6d.-elur., Plub^ Dec, ISM.
DiBOT. Quoted by S«tig-r. Mniwtasrhr. f. Oeb. u. Gyii., IW.;, i. 21-28.
EXTRA-UTEftlXE PHEC.NAN'tn-
653
DoBMmr. Scduig Fallo in frubm EDtwirkctmiKiutniliun iinI«rhrorh«ni-rTubcnich«iii)-
gmcbftftM. Artiav f. r.j-n., 1«K. Uvi. JO-ViS.
DuciiK. !)• la sroMMW ovat«?nni!. Thha lie Lyon, liXK,
DoRUAXi). KeptMtod Extrn-iilvKne Prvipuuicy. Abut. Jour. Olirt., IH08, xixvli, 47»-
4DI.
OrmuMKx. Ueber oi)crmtit-o Bchimdluus, inabcMuidure die vAKinuIv (Viclii>«oaiio bel
Tiibimehwu^notult, nolut 1<c(n«rkinif:uri au AxdJoloKJo ilur Tulwnchmtnjpr-
tcbatt iind DeacbraibnDgcinMTuUnpulMica. Ar*hiv (. r.)-n.. 1907. lir. 207-323.
KiiAKveu Eiae (wnnagjohre getnigcnu MxImiitohiiHchwaitgcrscluiri. i{«ntraJbL (.
Cyn.. IH94. xvlil, 1306.
I'cuuxu. Die Bodeulun^ tier Tuhonnipttir iinij <t«« Tiibuabom flu- V«rlai)f, Pro^un
and Thanpia der TubarsnhirikUKcnrWt. Zdtwhr. I. Gob. t). Ujrn., 180S, ssxviii,
6T-10a
nuxrs. I'eber ExtnuUTiDndiwsagmwhaft mil beooiidurer BeriickiuHitiKtuig dcr
OvariolicnividiliU. Zentfnlbl I. Cya., tmH. x'a. M.V
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FitKTvn. Doilr^^iD mr Aiulotniu der Aua^nMBcrMn KxtntiitoririEntvididi. IIoilniKe
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K»!«[:K-RKKvrA!Ci>. r>c« xroMicMM iiu^rinm Kirvensut ftH b KmwwHw i.>xtnt-uMMiw.
ThJMO de rarii. 1808.
Fi-m. I.'cbcr die I^bdUinK du Kica in der Tube. Archiv f. <i]ni.. ISOI, Ixiii,
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Uciior Ih-ariBlncliwatiKenidtiirt. Ileithitcc xiir Geb. u. fi)-n.. ItXtt. vi. :ill-3.1l.
Qnnea. OvarialHrlivanxirrwhail. '/jculrMi. I. Oyn., Iin4, vviii. 3!)l.
(iitjnjRii. (hnuiut Picfmuic}-. British Med. J«ur., 1001, ii, 0G3-Uei.
(tuncii. Zgr AetioloKic dvr TubetiachwniiKcnwJutt. .^riUur f. <iyti.. 19(10, Ix. XtLV-
n»nKi. RritnK hit Analomle und Aciinln)[le <ler Cirsviditiu tiihari* on dor Ilaml
MMa PrApsrUw von TuliUTnub. Arrbiv f. Cyii.. 1898. Iv. 65S-713.
GomciULX. Fin Praparat vnn (VvariaUrhwnngcnK-Ju(t aiui der 3.-4, Woclic dor On»-
viditat. Zcntnlbl. f. Uyn., 1B86. x. Ti7.
Kn UlfanldypbnpftdwHi, d:u Ricirhxnilitt al» Fall vnn rdncr HieratndcMchwanxcr*
■rhafl wlkT ))mierk«iiRwtirtli ial. Vurluuidlunjean der iIciiImi'Iiuk (•cm. (. Cyn,,
<]kixvilj.k. (trajitur lUuKtRKimaof AbortioaMid l>t«Dan(uof Uennlriatiim. Ixiiukm,
1834.
GKirrrrm. Not* na th« Important* of a l>«ldual Caa an Ktideaec of F/ttn-aterinc
tfCilBiiDa. Tnna. Lomloa Ubit. .Sm., 18M, *xxvi, 33S'34a
(katalinn In the FaQotiMn Tube, and the SlrveturaJ Chnngm ihttt lake Pkee in ita
WalU J.«ir. of Palbofcity ai>.l I*»rt«ri(.k.|Ey. 1«IH, v. 443-I.W.
livmm. The I^aomta in l->Uipic ticatatMin and ila (inM-lh after Ihe llnatli of iha
Polui. Med. Pim and (Imtlar. ISM, trli. 320.
fhTiMiui. Die OnrMtwhwnnflBndMft Ttmi palh. anal. UundpntnLlv. tHull^ut.
ISHOl
GOTxanujcH. Ein Fall vnn jEirirhwiliigcr Extra- iukI Iniranlvriiicraiidttftt. Ziuam-
neniitellunf timl UeUaditunx <teranlff*r F'ftUc. Archiv f. liyn., 1803, sliii, 223-
Wl.
Hakri'^ OpMBtion of IVinuuy I^p^rotimr In Caw of Kxtn-utcriiHr PrcEmuH-jr, wiib
a Tobukr Rcrord cbawinic ibe Kcultn in 27 U'oincn under 26 Openlon, Amer.
Jwir. Obe*.. I8(i7. \k. 1154-U<I7.
WcilcTD Fartitfbriltc iter F.atlitnduiiK ektopiaobvr lebeorflUcsr Friidttc diirch Koo-
OotMHi*. Uonatwdir. f. Oeb. a. Cift,.. 1807. vi. 137-lSe.
654
OBSTLTKICS
HakT. On tltt< AUetcod Growth of th» FlMtnl* in Extra-uterine G«aUtioD a/Wr tlte
DiMtb <it the tU-tuB. Anusr. Jour, of Obrt., 18»3. xxv. 721-73>^.
Hkckkh. Boitnixo "n Lehnt too der SchwwigttnrJuLlL auaiBrluilb (l«r tiebannuttM-
hiMe. MomtMohr. f. Ooburtok., IRSg. xiii. KI-123.
II2IN. BienbwkarbwnnsvnwiMtk AkIiIv (. path. Aiwt. u. I>li;t-aaL. IMT, i. 513-537.
ncrNHti:*. Itnitntffi! xur I«hm ron dorTubenKntvidlUt, ctc^ S^taetur. t. C«b. u. Gyn.,
1901. xM, 38.5-434.
t.Vbcr tiihiuic (Sniictttiiig dcB mcnurhliolwn KbK MonktMchr. f, Gcb. n, Cjm., 1902,
XV. 315-322.
Hrxxto. Uc Knutkhciten dcr ICtlcilcr uod dio TiiltcnwiiiranicnnK-Jisft. Stutteut,
Iir76.
Ukmxkwkx. .\i)diiniiniiliicliwurigunrbaft bci cuier HcchitgcbiiTcndim. Archiv f. Uya.,
1870, i. 33.'f 3*a
BsNHuriv et HKRZoa. Anuiiiuliu* du ciumI dv MiilleT ooininc <»U9e dea RTaanan
ci^lnpiqtioL Itcvnie do gyn.. 1»SMi. <S3»-A40.
HeiULvN. 1)ti Llvliv*^ liy ihu Vimeiiih u> Bxttu-utetiiw (kntaiioa. Tnna. London
Obit. Soc,, 1887, xxix. ■l2»-*55.
IlKBirBLU. I'riwr «inpii Fall vnn OvurialiiravuliUit. ulorine Sclio'uii^rwluilt. Iji^p
nrDtoinio. tluiluiiK- Wiuiicr klin. Wochfiiwhr. I8S1, iv. 802-801.
TlnrMKiKR. Ziir KniintniM dcm iiomuilcn Utcniiwciilcimhaiil. ZcnInJM. 1. Iiyri.,
1893. xWi. 7M-706.
IIuaKKHKiuiKit. Itcrifht oiu (lorn IIch«mmcn-In>titut in Hadiau. St. PclcMintn;.
1863, 1J2.
jACiitH. NotcH cliniquuK lur 82 oui <lc fi;roaBi.wiu IuImuiv. .\nnnli» de gyn. cl d'obrt.,
IWK, Ix, 268-273.
Janiit. I)u I'Dvidiirte rtiuit la fuiiiiiu); mm iiii)d!licu(ioriH pvnil»nl la grniiwiwai uI^ritR
Thf«c dc t.jon, 1808.
Javvkim. a Ob« fH Tubal Pmipiuicy ot Unusual IntorMt. Traiut. Ainer. (Jyn. Sot,.
l«8«. xi. 471-I8<.
KeLLV. The Trentra9nt of EttrH-uWriiMi Prci|[nHiio>' nipturad lii Itie Ekrly ^loiidu by
Vaf^iuil I'unclurv and Dminugv. Trsnii. Ainer. tlyn. Hoc., 189fi, xxi, 190-209.
KbilMaO'kii. Bcilri^cc »ir Ai»tninic dcr TuhcnBchwnnircnvhafl. R«rUn, 19(H,
KoLweit. Full voii SchwaiiKerachall iiii OraaCnheii FoUiltd. ZentnUb). t. Gyn,.
\m7, \xi. 112a.
KiiKincH. tteitntit iiir AiiaUiitiie Mud I'alliolniQe dor Tulnrtcravidilat. MorutMchr. I
(Ich. 11. Cyn,. 1800. ix. 794-812.
KnuueK. Ui I t4innich linden iibcr die tubani Klein IwiUidk. .\rriiiv f. Gyo., 1V03,lTviii.
.S7-108.
KltrHKVMEwrr.K. t'clicr t.ilhnpiidKin. Aiwhiv 1. Oyn., 1S8I, xvii. t!i3-3SSt.
Kt.'itKK. Iteitnii; iiir Aiial«iiiie (1«t Tiib«iwrbvan|Ecrarluift. Marituri;, 189D.
Kt^NKit. IXt Fipk'wJic Full von AbduininiiliwhwjinRCTirhaft — nine Ricnilndi»
scbwaTHW^biif*- Vorh. <lcr (teiiMrhnn <Jwi, 1, Oyii.. 1890, 21^-3M.
Ucl«r rNtrnuicriimdiwaiiEmthiifl. Volkttumii'ii Sanunlvins klin. Vortrijie, N. F..
IHSB, \r. 244-24.V
l,*M)*ii itinl Hbeinbtris'. Beitrn^ lur iialhulugiiuUHMi Antttumie dcr Tube. Arcluv
f. Oyii.. IHai. Kxxix, 273.-2fla
La.iok. BeilnifEi- zvir FniKP dor DocLduuliilduiii; in dtr Tube, vtc HoruilMclir. I. Otb-
U. r.yn.. liHH, xv, «-7I. J
LiAit^EN. Sw! Tniiilurier. T
I.KiiPoi.D. Ziir l.«hre von dcr (imvidiuui intcrnliliulin. Arriiiv f. (lyn., 1878, nil
355-3IJ5,
Ovuriiilschwaiij:i--n«'lmft nilt LitliupadioiiluUlunR ran 35>iUiri)te« TJituct. ArrMr I.
(iyii,, IMti, xix, 21tH2l8.
KXTRA-UTERINE PHEGSA.VCY
655
I
r
LbopoU). BcitragciurGn>v-idiUa«^xtrauii>nn>. 1. GravidiUsiDtentitialu. 3. Gimvi-
diUs >ul dor FimWia ox-nricn bet. I'Un infundibulo-ovarlca. 3. (IravldiUa owia-
I Ii>. Arriuv t. iiya., IBW. Iviii, 6X-i6&.
I iteitnuc nir Onividilu cxlm-utcriaa. 4. IKc OnvUliUa tubo-ovnrinlia. Arrhiv f.
I dpi,, 1809. lix. 557^94.
IxxaCTML A CiuH of Iiio«nipleli> Ttitxil Atmrtiun sliuwiiis Infmmuml Imbftddbl at
tb« Oviim. Tmns. Ijamioa Olut. Sue., liKKt, xtv, Ifll-ldO
LrOTi'M. EkTiitai-kmrliwaDBWwIiull mhea aimna.hr ulpriim Sdiwkniteiwliaft, tte.
Wk'niT klin. Worhnurhr., ISOG. lie. 60O-AO4.
l^mK. The UaaralwUty or tlie EafIj- ferfumuuicv uf LjipnroUitnjr in V*ae» al Abdom-
inal Pn^nMiry. HritiiA Mrd. Jour, IR^, ii. lOKMCKiO.
MJkXni. I'vbnr dm (rinprvn Usu dcr EtletUn- wiluvnd luid aiUMttwlb dor Sdiwvngu^
Mrhart. MonntAvhr. (. fivb. u. Cyn., IKI7. V. Knpmxunsidwft, 130-t:t!}.
Ueber die Kjchtuiif! dor Flinuiwrbewccuiu: iin nionaoMiclwii L'Uims. Zcnlndbl. f.
Gyn., IMS, xxu, 323-32S.
HaViil und S<THuirrT. 1)citr*KC nir AotloloKJe und peth. Anatomia dor Eil(?itvinK-bwui-
genvtiaftvn. .\rt*iv (. <;jii.. 1898, Ivi. 40H87.
H«iniv. Kill roll vnn Ovarioliwhn-jiDKcnN'hafl mit f'^iviiKima pnllj uli^ri. 2eiUrhr. [,
fwb. U. Gyn.. 1803, xxiii, 17^1.
Zur Kcnntniiii dcr Tubanch«nu)0inchikfL MonaMwlir. f. (Wsb. u. <tjn.. 1807, v,
1-7 Mill :m«-^>4«.
Hakhm und OhthmaN!). KleitciwhmnEcnobttt. Ptu Kranktwitoi dor GikiUr von
A. Uaniti. [Vrlin u. Uipiig. lfK», .-Hit- 300.
U»TK«. Krilik dcr Iilxtn>iiloriniKliw»B|cncliafl. «tc. Criuneii. 1845.
Urxuch ny. Lf»N et I1i>i.lkha.n. I>e la grOMeaw ovarii^itnc. lUnie do iiyn., lOOQ.
ri, 337-lfJO.
MtKiiunoi. Leber OvnmlgmvidiUt. Zcitoehr. f. (;eb. u. (^yn., 190S, xhx, fiO«-&22,
Zur Aetiolo)^c dcr Tut>onnrhiranmn«-)uft. Znurhr. (. Gob. u. Qyn., 1908. xlix,
42-«2.
VoKKCKK. Zur Aotidofpe dor Tubon-icravldllitt- SnnimluniE nv^itiivivr Abhaod*
limgen aui dein Uebielu dor Frauoafaeilkiuido u. Gob.. 1900, Bd. iii. II. 4 ii. G.
KBCQRnADF.M. Ztir l.ctirr voii dcr ZmllitigMieliwanffcrarhaft mit brtrroiypMn Bits
irt Fnii-ht*. l.e>)>ii|L I9(f7.
KuaLK. Rtunark* on Kotopic I'rcguanoy. Amer. liyn. and IHmiI. Jour., I80A, vi, 107-
171.
iMjtmL <H-Nruui Vnvonaty. tanret, 1890, ii, 341.
rm- I'elN'r dio l'raiclM.-o dor .^iinicdhuig dca Kiea im RileiUr. IMlivhr. (. Gcfc. n.
liya.. 1902. xlviii. l-3».
f-^Tt, IMtnkgo tur KenntoiiB dcr ektopuchcn FurmoQ dor ^tohwiuii^rwhaft. Laipg^
imH.
* *TT'i. t'ober Tubcmchwungerschiifl mil BorucknchtiKUDK oiiiea f'aBvn van Gtavjditaa
Itibarla innbrlo hydaUdom. D. I.. GroifiwiUd. 1871.
^'^XTrixiW. DieindirfachoSrhwiinjcer»rh»fl.dicE3ilfiaii«ri(nt»vidiitti,etc ZatUchr.
f. Ol.. 11. Gyn.. 1906. xxv. 373-113.
^^WnT. Kxlm-ulertnc I'roKniiney. Londno, IS7ft.
^atbmko. Zur 1«tira von dor Kxtmut«rinacbwangnrwlwfi (OfkvURtaii orarialia).
ArrUv 1. Gya., 1870, xiv, l.'56-164.
^^^TkUMiA. SuUu gnvkUniB uitmrits rc«idiviinu<. AimaU di <wl. t pa,, 1901,
So. 1.
^<^tM. U«t>er (Be Kinbcttung dco monarhliehen Eina. Wim, 1809.
l^WEaaiw. noitr^Kc mr patlt. Anatomie der Kravidan TJibe, KaHin. 1«E.
l*rt!nfEm»nxu Extnutwine OrariditiU. Verb. d. deiiUohca GiHiellMfaalt f. Gyn.,
I9Q3, X, 1M-Ifl9.
656
OBSTETRICS
I^xAOD. NoiiTKtiix ilocuraonti pour Krrir a I'liutoire de b growMoe cxtm-ut^rine.
iXniuileB de gyn, «l d'oUt.. 1892, xwcviii, l-ll; 99-118; 181-188.
PnociiovrvicK. Kin Bcitng tar Meknnik daa Tubnuborta. FtiM«cliriri i)«r Uea. (. Ceb.
u. fijti. iu Berlin. ^Vioii. 1F»1. 260-29.^
Zur MokHQik <!«« Tiibvtiubortii. Archiv f. Uj-n., 189S, xlt\. 177-341.
HisKL. Zur KcRnlnUii tlcc primJuvn Cboriocpitheluimi dcr T^ihc. Zcitadu'. f. Gtb.
II. Gyn,. IWM, Ui, 154-189.
lUiiuoK. I'riniaty Ov»rijiii rmtiitioii. Trsrm. I^ndon Obnl. Stk-., 1902, xliv, 21A-221.
RosKNTH.^L. Kill FkII iatruinuraJvr Schwunguntiluift. 2votnlbL (. Gyn., IDtW, xx.
1297-1305.
RtiKQK. DcitRiLic Kur Mt\olo0^ dvr Extrautario^nviditiL Arcluv (. Gyn., IMO,
bot.e()l>-723.
TMtfAji »ur Anatnrnie iler TiiIjar(P«vidUiit, Arrhlv f. Oyti., 1!«H, Ix^-i, fiS2-fiT4.
B.tNOKK. Uebor einun FtiU vuii eklr>inHc)it>r DrmingmehwauKersrlmft. Zentrullil. 1.
(!>-!».. ISII3, wii, US.
Ueber auJitiirc Xiuiuitoeele uiid ricrvn (>r)CMii«>tinn. Verh. d«r doutnclwii Gwl f.
Gj-n.. imiS, 281-302.
Coiii^plion itnroh Hin iiceeiHoriifche^ Tid>«nnHliiiiii. KaiMrwclmilt beilinp durclr
fn^here oktopi.«phc Schw»iigursrliii(l. Munuttwcbr. (. Oeb. ii. Gyn., I8BS, i, 21-38.
BKXTunpH, (JiioUiil by .fyiioRnllicrg.
StiiAiT*. licitni^surCaaiiiiilik, ProKii"* iini.lThenipie<lere.vr™uterincn.'WiwiinBer-
Hch«fl, PraR. I«1I.
TubaniehwHiigerscluitt [iiit Hui-tu»U>iiiTiiol«', Ilentralhl. t. Gyn., 1903, xxvii, IWi-
1403. J
VON ScHKK.NCK. Ueb«r ektopiachor Gmridililt. D. I., norpnt, IMS. ^
RtMiiND. TmitcmcDt den (crOHwawii oxtm-uUtrinetL Annidox do gyn. ut d'ab«t^ 18B8,
J. 241-310.
SlunN. Knll von rrinurOvuriiiliwIiwiiniretwchad. %!ulralU. f. (!yn.. ItMW, xxvi. 1179.
SiPPKu Ueber uuwwro I'olwrwnnficniiitt rfcs ICLpa /entralbl. f. Oyn., IIWI, xv»,
2a0-2!».
KpiKuELiiEiia. Bine au«KBtrafCtin« TubcnfichwanRcnrluift. .\rchiv f. Oyn., I87D, 1,
<(I*H14.
Kiir Caniifitik der nx-arinlnthwvigenirhaft. .Vroiiiv f. <!}'n.. 1878, siu, 73'7f>. ■
Sria.v. (Juuti'd by Fuiick.Rrentano. I
SntAHNt. Tiiliargmndllikt liei g)«ichMitiiwr iiilmuteriiter Sell waagemr haft. ZciUrhrJ
(. Oeb. II. Gyn.. VMi. xilv. 2B 38. f
StrrroN. Tlw I'unU Omtion on Abdoinlnnl T^mouiicy tn Women. C«ln Dogi^ «nd
RAbbitn. I.tini«t, I<M)4, S. 1&2I>.
Tubitl I'r«i|niiin<7'. Kttr^rnl ))i>«M«N nf Ih* Ovariaa and F»I]o|)4fiii Tubes. PhiLv
dolphw. 180l,'3I3-32fi.
T.*tNTrrnBR. FtioloKie de 1» itfowe»w« ai-topi<|iip. Tln'^se lin Pari-, IWW.
Tait. I^cpttircH on ICrttipic {'ref^ntuicy >">'J IVUio UuiiwluoeU. UimunglMni. fWU^ ■
1U7. I
Tatijih. Kxtra-uierine ["renniuipy' A Cliniwl Hid Opentiv* Study. Lomlm. 189*
305.
TKUPrsi. liydmiuiiiou liei P^xtnutOTJiutrliwunftororlnrL ArrUv f. Gyn., ISM, xril,
A7-ftl.
TaoMnus. Orariiui PraipMncy, mUi Report of ■ Cax. .\meri«an GyiMPohicy. 190^ J
i. 1-1. 'i. 1
THnRV. Ueher lleckenhAmntome. VollinMRn'a Sammluiig klio. VortraiCB, X. F., St.
IlBu. 120. J
ToTii. Beitrnge lur Knigc der ekUipischen ^k-liwanieeriwluid. Archiv 1. Oyn., 189^1
ti, 410-I1J2. I
EXTKA-UTEBINE PREGXA.NCY
667
TnsBKXBuoKX. Un CM de gnmeme i>v»rieiui« (GroMcoae tUns ua toIlicul« tie GttaS).
AuuIm do 11711. vt d'ohM., 18SI), lii. iyrsiZ.
DhdR- Uf»«iKt(ui oviuii. MoutM-Jw. (. Oetmrtuk.. UW7, x. SSd-SW.
VAiLviKit. Rvddive <1« groaaw Htopjqtio. CompCes reniiiu aop. d'otiiil., <te gyn., ct
Je pord. de I'on*, liMIO. ii. 3W-301.
VnT. Die l^leitcrnebimnRcntcbiifl. 8t\itl)part. IB8t.
Leber [>eiH)rtii(tuu tier Cluirkiitxotton. Zeilivbr. f. (ieb. u. Ujm., 1901. 46lt-AOi
l>i« VenrhlcitpiiiiKilcr Chnrion«iU«n. Wiealjudiin, tOM.
Vrltkaq. TraiWeomplelderart ilcBuimurhcmcnta. I'uris. 1835. t. i. 311.
VuioT. Sdnrangerarlialt buI dcr KinibrU oviiricii. UonfttiMrhr. (. <ith. 11. Ciyn., IHyfl,
via. ■.'■.'■-•-23a.
Zur Baklung dor CftjMuluia Iiei der Tuli«n^«ruigBnchkft. Areh. f. Osm., 1903,
Kviil. «42-«6a
Zur BihliiiiK der iDterrillAien Itutinw. etc. Zcit«chr. f. Uel>. u. <^rn.. liKH, E. &57-A78.
WAI.UIMCN. Ziir inikrmropUrbcn Annu der TiihentrhwniitcvrM'hnft belni Mwiaohan.
Anatomurlii) lti>tt«, I^IXi. xxvii, 359-^77.
Waltkh. Kinisi: Ucolacbtuocm iihcr .SobwuiiKcrwhaft niiawrhmlb tic* (IsbiLraiiitMr.
MooatMrhr. (. (MjorUk., IHItl. xvii.
WnatrEii. ICetopie IVegimney. ICduitninifa and Ijmdon. 180.1.
SXtwfy of n t!pcdiiMn «r Orarun rrvipiaiii^y. Am. Jniir. <^brt., 1904, 1. '.'R-t4.
Wbumci. tleber gleichBeiUKe Extn- und IntmutvriiitTavidital. Munuiucfar. f. (iob.
D. Gyn., IMS, r^i, 7S1>-J71.
Wnu Leber wipilHhoU« luJuitencbwansenH-hsft. Pnucer nied. Worheiucbr., 1800,
No. I, 2. 3.
Whwvbennxk. Ueber intorMilieUe SflmniKTwhii/t. Zeitachr, (. (.teb. u. Uyu.,
1904, U, .17
Wknsbu DIuMnmole lin pAloilvr. Alle P^fuhnuiccii itu Llchle der ueuvii Zvit, Wle*-
hiideti. 1»I3. M'Sa.
Wkrth, lleiirLiKC "»' Xiioi'Miiiti uiid wr iiwrstivun ttehandhiiiK dor Kxlniiitvrin-
■phvanKcrwIuft. .Srutl0ir1. 1SS7.
I>ie KtlniitlvrinnriivanKerarhAfl. Winrkd'' llandburh der n«lnir(i>liiil((i, 11)04,
li. J. (U.V-1018.
Wkktiimw- nmiiatnninkotc bci TubaurfaKangcnKbaft. ZcnttiilbL I. (!yii., 1903,
xxrii. 144)3.
Wfujuuic (^ntrilHitina to the N'nrnul and IhttholaiCMiil IliMoIni^ »r the FiJlopiuu
Tulw& Aiuer. Jour. Mwl. .Srienna. tkdubvr. IHOI.
Winunicn. Ratrnjcc tut KcnntniM dcr Kxtrauterinf^m^-idilHl. lteitr«|^ 1. <icb. U.
(Ij-n.. IBM. JI»P-.Ti1.
WTftKn. rteiUnifc tur Leht« v«ni der I'lutntuteriiucbwiui^nrlMft tiad dem (>rte dt»
ZtuiuiuiMDtNlluia mn Orulum und SpermstoKwii. Anhdv t. Qya., lfUl5, Kxviii.
• 3Z5-W7.
Zsun. Zur Aiuunnle dor adiranmren Tuh« nill bcvnuUmrr ncnir)iM<-hluruiit d««
Btuu ikr tuliareii Pbcento. 'Atiiacta. f. iJeb. u. tiyn.. 1803. .i:ci-i, 7»'143.
ZnoLK. .\ Caae of Eitrm- and Inim-uleruie I'mgnnnry. Amcr. Jour. Otiat., 1902, xlv,
ZwKttn- t'cbcr P.xiniitciingmridilut und tctro-titvmie H&nutume. Archlv U
njm.. ISO), xli. 1-01.
pathoijOoy of laboub
CHAITKR XXXI
DVSTW^tA DUE TO ANOMALIES OF THE EXPULSIVE POHCtS
DynUiria nr diffiruU labour mav be due to varioin a-t i»liigi<-iit fiiclor*,
and h mo«t comniouly ciicouiiter<.-d ill tin- following groups of cases: (1)
Thow in which tin; cipulsive force* arc ^nlinornial un4 an* iml xull&i-icDiJ,v
slrcng In overeonie the aatural resistance offered to tlie birth of the flbild
by the bonj canal and tlu- niutA^nuil «>ft parts. (3) Those in vrltich, al-
though lh« cxpuhiw fiinvs may lie of nortiiai strength, almormulilu-^ in
the slriictiire or character of the birth caBitl offer an iusuperable mechanical
obstacle to the descent of lli« pnsvuting part. (3) T1io«> in which the
.'fcetus. on account of fttultv prt^scntalion or excertsiTe de%-eIoj>nKftit, cannot
'be oxlrudwl by the via a lert/o. (4) Those cases in whidi accidental com-
plicatiotu, such as eclampaia, hKOiorrbage, or rupture of the uterus, lead tn
rorious irrcgulnrilics wliicli interfere with the normal projn«se of labour.
Dystaoift due to Anomalies of the Expnlsive Forces. — The expulsion nf
the fti'tus h brought about by the (»mraction.t of the uterus. nMiiforwii
towards llic hitter half of the »\.-ond stage of labour bv the action of itie
iniiMclei' of the ulHlomimil wiill. Kith<T of thcM* factors may bo lacking in
force or intensity, while occa.-<ionally they may be abnormally )>trong.
ITnforliinately, Ihcrc is no absolute standord by which tlie ch»r«cl(T
of the labour pain* can lie gauged. Thus, in many mnltiparous women
a rapid and happy termination of labour not uncommonly follows a fi-w
relstiTcly «light pains, which in primipani> would prove quite tnadtn|natc
to bring almut the dcslml result. Clinically the' efficiency of the uterine
contractions may be measured by tlicir <-fTiX:l upon llie course and duration
of labour, provided there is no serious mechanical obstacle to be overconw,
so Uiat. other things being H]ual, prolonged or precipitate labour occnrs as
a Rvult of abnormalities in their fri>(|uency and intcn«ilT.
Prohnijed Labour. — formally, in the early stages of labour, the uterine
contractions occur at infrii^itcnt intervals, and grndually increase in fro-
quency, intensity, and duration as its temiiHalion i* approached. Moi^
over, a proper altcniation Iwtweon the contraction and relaxation of the
ntorus is a very important rviguii^ite for the sucwiwfid aecomplishmcfll of
delivery.
Anomalies ar« often not«<d in the first sti^ of labour, the contmclioiH
romirring in aumv patients nt fnijuent inlerveis and being eramp-tike in
f DVSrroClA DirE to ANOaULIES OF THE EXPULSIVE FORt^ES 650
durai-ter and n>ry ]>aioful. hut esertinfc very little iiiniMncc upon tbi^ diU-
latioo »f the cpTvix mmJ Hut vxpulnoii of (lu* child. \* a nvtilt, obUtera-
Uon of Um.- <iTvicjil onnal U hmught about v<^n' Mlawiy. and the oxlprual <m
andergoei linl little Lhangv. Ait a rule. «uch couditiotts do not Rin> rise to
H-rioiu coniplic-iitiuiw, «iiiw timlitr uppmpriatr- In-almcnl liiv pains assumo
a niun: ncirninl <'haracter, atfter which tli« tonnination of lalxmr ik «j>cediiy
ac€onipIiflh«d.
U'irv fn.-<]uently. however, the firet-fita)^ |>aius recur at lont; inter-
val* and air feeble in charaeler. »o Hiat l«lK>iir, in!<t«>ad of Vting Ivnul-
□ated wittiin Hw usual period, may dra^ on for dnyi>. If the membranea
are unruptured ami the patient ix in ;p>od condition, the delay may be
n-garditl with i-qtiuDimity. nineo in tliv t;rent majority of in^tnnce* th«
pains ei-eniually tK^onif stronger and more frequent, wlwm the birth of tlw
chdd i« effected without interference. For this reason, the ob«tetriciiin
Hhonld not interfere too haAtily, but should encourage the juitiept tn bear
her Eufferin^ patiently by a plain ittatement of the facts of the ease, and
the asfimmtv that u furourabk- outcome may be expecliil not only for her
hut aim for the child.
Again, labour sometimee begins in a perfectly typical manner and give*
rfwry promise of on ordinarily «|»eedy terroiuHtiou, and yet ofler a certain
lapse of time, without anv appreciable eaus^. the pains l>ecome leas fre-
qontt ami le>« iut<:-n>H^'. altiiough giriiig riiH- lo quite us much or even morA
sufferini; than pro'iou^ly. At the same time, ti>e cervix, irhich was becom-
ing obliterated and dilated in a satisfactory manner, ceases to make farther
jinigrces. and labour apparently comes lu a »tandstdl. Such a <K>ndilioii is
fniiui-olly due to what i* termed tnrrlia uUri.
In all of these ca««s, the prolongation of labour is coroinouiy attributed
to the imperfifl dilatation of the ccn'ix. which is suppoM-<l to l>c du« to
kta abnormal rigidity of ita tissues. Ordinarily, howercr, the <-onverse is
true, and the <-cniiliii<'m is Hm' direct residt of faulty uterine contractions.
That tliis hitter view i* correct, i* *liowu hy thf fact that the iipjK-»mice of
■tisfactory- coutnic-tions is promptly followed by rapid dilatation of the
oerrtx and a luippy l«rniination of labour. On llic otki^ hand, homn-er,
«pctially in primipane of thirty years of age or over, exceisive rigidity of
tli*> wrrii ai^l its consequi-iit tardy aud imperfect dilatation may be the
BA«eniia) factor in i]h> proiluriion of tl»o dyiilociH, <>9iMvialIy when u fartlicr
''ovB plica tion has heos introduced by the premature rupture of the mem-
Thia Bccideal ooctirs ocauionally in primipanr-. and not inrnH^uently in
'(^ vsJtiparotia women before the onnet of uterine contraction.", and gives rise
'"^ vhat is designated as " dn/ labour," which is usually unduly prolonged
***^ very painful. The delay is due in great part to the ubi««iw of the
by<]nKiatic action of the hag of waterw, in eonMic)uen(« of which t)tc changes
^•> llir itTvii muct lie bronglit about almocl entirely by the direct prw*ure
«' tlx- prcwnling part, which acts m a dilutitig wedge of inijwrfect shape
•nd coiuuitenc^.
This complication ia usually not so serious in maltlpsrous as in priini{^
IIH* women, nince in the former hilxtur, aH a rule, seta in within a short
G60
OBSTETRICS
time after the dUchar^o of the liijiior amuii. Occfisionall;, however, hoon,
dujrs, aod ill rare iiistaiR-i'^ cwti vrit'lc^ iimy t.-la^ before it occurs
Kot uiK-omiiKinlv (itiliierntioii of i\w ci-rvicjil cuiii«l uU-x ('Uci* aitlumi
(litficuUv, while thi> exteriul on ainnc appears to offer the obiilAcle to dilata-
tion. In Bueh cases its luargiDs are oflcn extioinelv thin and ehsrp. and
darin;; a tontracliun may ii'H cxeiW a Ajwi of (Mipi'r in ihickiww:'. On Ihe
other hiimi. i:sjnx'ially when labuiir in unduly prolonged, ihey maj become
thick and cedeitiatous.
In tile ab*i^ncc of any mechanical obstacle, prolongation of the w-cond
iUige of lalKiur is rnrely due to al>iioriiialiti«s Ui the uterine contraeUon^
but rather lo di'ficit'iit action of ibc abtbuiiinal mii»<-li-^. In priinipariu<
wtmifii. e.<jictijilly. thi- lanly litlxiur i.-^ ofh;ii a-MriU-il lo ibe n«i.-danii'
ollered by a ri^id perinwuni and a small va^nal outlet, but in the majority
of case^ thi]^ )» only appiirt-iK. Ihe delay lieing rviilly due to ui iiuuHkimi
viit a irrijo.
.Kt'uiUnjy.—A'ivTiac insufficiency is usually attributcti to one of thrw
cau».'«: faulty development or disoBKod i^mdition^ of tin- uierine muKcuU-
tiire, anomalies in its innervation, or mechanical interference vith \U con-
traction. The first factor \* the one mo*t fritiuenlly concerned in Ibc
eaiisalion of lanly labour, and ir especially likely lo Im; a'^sK-inlcd wiili
ini]«"rfeot general ilcvelopnicnt. being frwjuonlly observed in patients pre-
senting varielies of the juitlivminor pelvis, but only rarely in mitTervrs from
rliacbilic deformities. On the other hand, faulty development of the mit*-
culatnre ik occasionul ly noted in Hfipnrctilly normal women, aud is relatively
common in lafj^c. pale, iiml fnrpiilctit individuaU.
Honiotiini^ tlie faulty action of the uterine muscle is attributable lo
a lo»i of tonicity incident to excessive dii-tention, and is tlierefure fre-
quently met with in wonien who have pasni) lhr<in|ih a numWr of prrg-
nancit?s in rapid sucoession. or in whom tbc uteni.* has l)een *ubjiiri«l in
acute distcniion. a« in certain eaM'i> of multipk- prc^aucy and hydramnio^
Mudi les» commonly the defect \a, dii« to gtmerul weakrutftc folloiriug ex-
liaui;tin<; thWasiv, but that this \i rarely responsible is shown by the I'nm-
mon otiKeniiliiiii tbiit, lln* pninn an' nxually very vlficient even in piilienli<
sufferinf; from adianced srai^res of tuberculosis.
Although direct proof of the existence of abnormalities in the innerra-
tion of the uterine mn^culaturc eannot he adduwd. clinieal observation
affords rtffmg presumptive evidence in favour of thi* vi«w, or at Irwl
indicates cle«rly iho possibility that extraneous causes can interfifi' re-
Hcxly with the activity of the Hloru*. Thu», it is a matter of common
experience that the entrance of the ot>stctrieian into llw lying-in c)iam|jrr
ia freiiuenlly followed by a cessation of the lalxiur pains, which is iteneTally
transient, but sojuetinK-a persists for quite a long whiti'. Moreover, extreme
nervousness, profound mental etnotionit. or i-xorueiuting pain may have a
similar efTwt. In such casea the severe pain ia often due to tl» irn^lar
uclion of the uteni«. and in turn, by acting reflexly. inlorfen.** still furtlK-r
with its function, thus [living rise to a vieious i-irt'le. That n-flex mTVoU»
infiuenee* iirt- respnnsiilile is shown by the fact that the admini.siralion of a
.•«ilutivc is frcijneutly followed by a return of na'isf"' loi-v i-.ii.ir". n^.i,.
I
I
DVOTOCIA DUE TO ANOMAUES OF THE EXPULSn-E FORCES 601
That lilt- action of iIip uttmiii is octwtianally ialtuenteil by mechanical
oinilitinns in xlioui) |iy ihi- i-jimw in wlitrU hitnoiir formHlionK in iU utill,
<»)K-<-iHlly TuyoiiMlii. Iiiin- lai'n ruiiiid to In- n^Mi><itHi)iti' fur fnull} UlKHir
pttiibi. Miu^li tli« same efTccl iu cx«rtci] b_v utt?riD» tliHfi)ftc'<:int!iit.-<, t!s[H>cially
when the organ sags markedly forward in a pendulous aUlonicn. Old
luihtvionM ulwut llw uleniM and npiH'ndagCH. mii) tn.>^h iiitlaminatorr an.-aK
ill ih«- MUiie Inoaiion may act in a similar nianner.
l>i-f«:tKi> alHloniinal contractions may bo du« to a number of cause*.
Stimcttmve the infufiicivnvy nvult* from faulty dcv«l"]mit-nl of tliu ab-
tlominal mu.4cl<^. but more fre<|ueiilly is ilue to a low of mu.«cular ton«
following exn>«»ive diEtention. h> that it is much more common in muttip*
ar>m< than in primiiuirouii w»iiK-n. \iit i[ifni|tii-ntly (lie insiitVii-ieney is
only appareBt, and is due to the fact that for fear of increased pain th«
pativnt w unvilling to bring her abdominal mtwclm into full play, and
makes effortH to restrain tlu>ni. For tliis reaaon th« obstetrician is often
obliged to terminate labour by means of low forceps, although he fee1# Kiire
tiial n fi>w miuuKu' elTtvtive um> of the alidomiiial inuM'le« would lead to
spontaneous delivery. In many such cases the administration "f chloro-
fumi i« altendud by m<wt happy riaiults, ttincr it dulU Iht- Kn^tion of pain
sufficiently to enable the patient to brinf; her abdominal muscles into action.
Trratmfnt of I'ntlon^^d Labour.-^AcUve treatment is rarely demanded
vliMi the tanly laliour U the n.'niilt of infrequeJil [tains of iili^iht inten^ty, as
io the majority of such cases they ^rradually become more severe and e%-entu-
ally bring altoul a fponlancous ddivcri'. If the coiidilion laitt* fnr MTenl
day* it is importani that the patient should sleep well at night, and the ad-
ministration of hyjmotics, or e\en of morphine hypodermically. is indicated.
On titu otlK-r hand, when the pains arv incfficivnl. cramp-like, sad foU
low one anoiher in rapid Mierft«ion without exerting any apprccialtle effect
upon tlw courw of labour, excellent results often follow the administra-
tion iif a hypoilonnic injection of n>nr|)hini* (grain }). (umbintfl with the
eolpbate of atropine (grain lit); of a rectal injection contaiuing 30 grains
of dilnral hydrate in 4 o»ne»i of warm milk may be given, and n-poatcd, if
■eceaaary. in one hour.
When tile dyylix-ia i* due to secondary uterine inertia the problem is
nor^ difTn-ull ; tikough, a^i a rule, if the patient oan obtain Kereml hour* of
flound sleep, mon- satisfactory pains will appear when sIk wakens. For this
Rwnn tile oko of a hypiwtic in often iiidiciled. Some authors recommend
the- adminUtrnliou of <|uininp in this clans of cumok. It would ap[H^r, how>
vVvr, thai tbc oxytocic properties of the drug have been a gi^n) deal ex-
ttggeratrd, nincr in many c«.*eM lflr;ge doM« produce no visible eScct. Occa-
viriiuilly. however, 5 graina of the sulphate given in a frcuhly prepared pill
or in noliilion, and rejieated twice at intervals of one hour, may prove of
gtatt b^tefit. Further repetition is not Decessar>-. for, if the uterus has
not responded to the amount already giren, the farther adminutratton of
tlw drug may be regarded a» uwIcm.
Ergot was formerly used with a free hand Id thia mndition. but this
pnKrticv cannot )»• too strongly reprcliendcd. It is true that its admtnislrft-
tinn i* often follow«d by an inereaae in ihi^intensitv of tlte uterine eontrac-
U
662
OBSTETRKS
tioiw, but i'!(|ioritiK'r Im>' »lH>wn Itial they norm liwe Ih^-ir nnraial dutrao
leristics and Ininnu' tfianir. An a ro^iilt llic iiIphis is liable to rvmsin
firmly rontrailoil u|witi its crmifiitii. iind. no lonprr ulutmuling Im-Iwwii
contraction uiiil n'liixtili'in, Inut^ iU i>.v|>iilKivL! gmwpr, »o that tlie final aetioo
of the tirujT i* tn defeat the very purpoi* for whi<-h it was jjiven. Moro'>v('r,
if ihf c\ ijilcnw of a nuchaiiiciil ol>!<hn;lc liii-^ !•*•■■» ovi'riooktil, tlift xi*v "f
(Tpit in«y kiid to »n pri-iiioiiiiced an oversi retching of the tower nlerine
segment that rupture occurs. From the very llr^t the young phy^idnn
Nltonid make np hix mind nt^vi>r to tMti|itoy t^iyot for itit nsciiiocio pm)M>rIi<:9,
and to uflt> it tmh- as a prophylactic for nterine liiemorrhaRo after the expnl-
«ion of the plneenta.
Aa ha.-> alri-H(!y heen pointed out, almormalitied in the contnuitinn of
the uterus are uiiiislly ai»ocialed with imperfect dilatntion of the ccrrix.
and in t-ldci'ly pri niipara>, and ooraHinnally in youn^r women wlin liave
Buffered from intliimmatory cmditiouK nixiiit llie cervix, ripidity of the tin-
«K'* <tui wmn-timf:* l«? iiiviik«) ii» it-* underlying eaui>c. In mnny can-s lb'
admini-itration of a i;edatiVG U followed hy eatisfactory restilts. The um uf
an OUff^lhctie. although it fropiently load)' to •;ali>'fitctori' diUtstion of tb'
cervix, is generally inadvisable, inasmuch as the patient, having onci' rxpiTi-
enced its soolhiiij^ cfTert. ix-fuv'Oi to di«pL-n!^<.- with it, so that the oI>i>tetneiaD
will often he olilignl to continue itit use throughout t)tv viitirc eccoml
stage, thereby §o prolonging labour that the applicaiion of forcepa bei-oniiH
ncwswry. Occtwionnlly n v)iii<iii» vuginul dmiche of hot sterile salt solu-
tion or a hot full hath is attended by satisfactory resultH,
In i>lher eases, if interference- becomes imperative, the introtlucUon nf
ti liDugie mlij tho utem.*, or the ■■tnplnymcnl nf a emull Champetier ifc
Kibes rubber hag acts tA an ellkient uterine irritant, and hrtng« about
complete diliiljitiim. A« a rule. Imncver. if the condition of the »noil»er or
the child demand^i the prompt termination of labour, rapid diliitstion of lii>'
UTvix if Ixwt elTocted by llurrts's mannal method, provided the internal m
ami cervical canal are already oliliterntod, and the dilatation ia effected
as gra<luully a» po:isihtc. The physician, howe\'er, slioutd rcMrt to tht<
procediiri- only in the prc-iencn of wme prcising indicnlion, and Hhuuld
not attempt it merely for the sake of shorU-ning the litlioiir. That such a
warning iii nKTcsary Ik xhown by IJiu fact that cacti year I see in ontuultalion
several women who die from hieniorrhage or inftvlion following deep ceni-
i-al (t'ur*. wliich have r^^^iiltiil fmm unnecessary or too hasty interfiTiiKr-,
Whim labour is ■■<iniplicttli>d by preniiitiir'- riiplure of the membmtK?.
the patient should be informed ooncerning its probable eirKct. himI sIiouU
be encouraged to henr her KutTcriiigx ax patiently as possible. At the t>ame
time she should I>e most carefnlly watched, and rare should lie taken that
the child'* head is not subjected for too long a lime to iujurions pres'un-
Horeover. Ihe pn-maluri- npniing np of the amnion greatly incrv«su» the
danger of intrapartum infection. Thi* complication may be due to con-
tact inftvtion. or to bacteria making their vi-ay np from the genitalia br
means of Ihe capillary layer nf lluid extending from Ihe interior of the
utenw to Itie vulra. and should be giiardi.Hl ugainKt hy the strictest ohsrrv-
ance of asepsis. Infection of the amniotie fluid is not only scriooi for tlw
CIA DUE TO ANOMALIES OF THE EXPULSIVE POItCES 6fi3
^Bmothcr. I>ul iictx>nliii;; to tlK> ivwarcliM of UclloD<lall inay nlm lead to tho '
^■dvatlt *ir Itu- t'hitil. a» till- iMK-U-riu t-oDluiii'^l in ibi- umniotkr (lui<i, whkh
^■pttiu IM11-JW Id the minitli. iimy ^'ivi- rUt- to n p^'ocrul inrn'tion or a bmncbo
^B |>neumoiiia. which may end fatally s f<"r day* afttT btrlh.
^ Atvord riigly. if Bymptoiiii? nf i-xluiuKtion uiipi-ur. mid nn objcrtiTC oxami*
knalioii ■bi>«> that t\tc nwiiwr ur ohild will ^uftt-r from further delay, inler-
feffsicc is indi<^tcMl. particularly if the temperature bccoiww elovntoJ. or
changiM in thr fn-lAl piil<K^raIf, tW paitKagi? "f nteccmiiim or > marlcedly
mleuMtoiii* eoniltlinn nf thi? eorvix Ix? D(it«). Toder such (.■ireiiiustaiici'*
dilatation may !«■ t-fTtvlctl cither by means of the rubl)rr bag or manualljr,
after whieii di-livery ithoiild lie lirou^ltl ahout a* tuiun ax |xiii(iit>te by the mo^t
i-n-atiw method available. Forceps, howewr. should never bo applied
unit] thn (vrvix iit (omplHclr diluted, nor white tlit- h«a(I is freelj toovable
hove the Kiipinrior strait.
Tiinly Ulifiiir. duv to the pmloiigalion of ttic second e(agt\ is iMually
best treated by tlu^ appliealion of forcepii, except in tbo^ caiteii in which
berv it Home mcchaiiieal obstacle, or wIk-h the patient refus«-s to use her
falidoiriinal muscles. In live hitti-r caM- tht- ncct.'Niity fur instrumental d^liv-
try may often he obviated by the judictou-i ad miniHt ration of chlorafarm.
Pirdpitatf lAxhuur, — In uTiain mntliiwroiis women preeipilaU- labour
lay result from aa ahnorrnally sligilit degree of reiistanec offered by the
ft |>art:< or from id>normally strong uterine and nbdnniinal contractions,
or very oci-a^^ionaliy from the abaence of painful senaationit during the
^^ ntcriw eon trad ions.
^B Gcncmjly s|H'aking. precipitate labour U not attended by Bcrious oon-
^■•»|iiences. allhoiijfh the child t^ sonietim»i eslnidtii :ut rapidly tliat the
^P'pmtrnt is unable to nceurc proper attention. I'nder such cireumstaitce«i
ilct-p \(wi of tbi! ]K-rinii'uin- an- <-oiniMon. Ciiacs are on n'K.xird in which tbv
woman luia been suddenly overtaken by inten.«e labour pain.* and ha^ given
liirth Ut the chihl before she could riaeh her bed. I'nder such circumstances
the child Iiaa someliniea fallen to tite ground and Ku»lalii<tl ru^verc or even
fatal injuries. Occasionally the cord is torn tbrou;;h and the child may-
Uced to death liofore aid if ohtainablc.
If lem{ie.>l uous pains come on while the patient iti under the abitpn,'ation
of a physiriiin, ihey slmuM l»c wntroUiTl by the administration of chloro-
^^rirm. in order that tlie hc^d mar be hebl hack and |>rc-viiiied rnim tiring
^^nrn too bruN]u<-ly. Tin- etfoctc of precipitate latiour liave Itcvn -itudied
^^nrtiiularly tiy Wtnckel.
^* Trlaitit. ('untraelion of lite I'Uru*. — OccaHtonally in the fin-t. and more
^'vatiM.Titly in llic second stii|;e of laltour. the uterus may oi>ase to relax ati
tar in<ervid>, and remain in a condition of ciintinuol or tetanic contrae-
Titiii comlition is usually encountered in prolon^fed labours, in u'hich
mthanical obstacle is oppovocl bo the passage of the child. ]n such caceaj
danger of ntpluro of tlw uteruit hefvmHW imminent, alllmugh now and
in Ihi* accident occurs when everything seems to be going on normally.
So lonjt as the tetanic eondilion ]>ersiftts the extrusion of the conteolfl ;
nt the nlenis is out of the question, while at the same lime the {wtient
«8ot intense pain, and the child is exposed to coiwidi'rablc danger, owing
rtC4
OBSTETRICS
1" iiitorri'rciioi' willi tlip jiUoenltil cirrtiliiiuH). If 1(u- t)(>n<litinii i» not dl
lo till olwlrnclioii, it <an Iw tt'iii|)»riiri!y (ntitmlki] li.v llif iidiiiininlnilidii I
(tetlalivf}^ or an anw^Uivtiv, iiflcr which i1clt\-vry »h«>iihl ite irfftTrtvd as som
us pnclk-jibli;. I
Olcuely related to this fomi of dvHtociit i» that whidi ie somotiiiies attril
uled to a etrit-tnrtt nfulliiig fmrn I<mie coHlnttiwn nf Hiindl'» ring. Cat
Kiilvniblo altt-tilion )uk9 be^n diivete<l to this cnin)iUoation within Uh> laj
fe-w ypar», ami nuaH'rou§ vuikw havf bi-vti di-KcrrilN'*) by Uiulin, IK^nu'lii
Choron. Itoi^^. uiiil ull)i>r^ Tho Frenelt obHervers Intlii'Vt- iliut while tU
Itnrtioiut of the uterus above and b«-Iou- it mnain Kaccld. Uandl's rini; m
nndergo iwtatt^d rrmlniftiiin, nod tlnT«>l>y so xtniiifjly iiimpn^if): tlR' nefl
or Wtnf iitbiT imrlion of Ih« ohiUl as to interfere serioiHly with it.i di-livcn
('heron ha^ reported tnstanccs of traiiRVcrse presentation in which this kin
of fitricturv dvvclofK'd and i-onfiiinl the child lo llie iipi>«r porttttn of IB
Qteriii', at tho same time olTerinji; an almost insuperable obstacle to the
introduction of the hand for tin- performance nf viTtion.
Wit i* probably corr^et in diMiytng thi* t'xistenoe of siich condition
and in believing that the reporti) are due to faally observation. That
contraction shrndd lie confinwl to B]iiidri> rinjf would sp[K-.ur highly in
proliable, and it U much iikh* likely that the entire active portion of
uterua may pa^s into a coiiditiou nf tctnnic ri>;idily. and that under eti
cirrvmittancm iU' lower margin would be felt ti* a mnlrnctcd rinfj;. In »ud
cases the lower uterine segment would be flabby, while the upper portion -
lh« utcr\i» would l»! (ighlly coutractwl. thereliy opposing a svriou^ obeta
to (he expulsion of tin? cliild and In the introduction of the hand or instr
ments into the uterus. In cases of this character the administration of .
anieiilhctic relaxot; the spasmodic contractions, and delivery can th(«i
accomplished by the mosi appropriate pnic'odur&
It is likewise probable that, in a certain number of cases in whicti
dystocia hax b)Tn attributeil to the contraction of Baiidl'^ ring, the eond
tion was n-ally due to more or lesgi rigidity of the inleraal i», whik
cervical canal below it had undergone satisfactory dilatation.
A:i tho result of the misuse of ergot or of cxt«^isire adherence of the
centa, the uttTUfi sometimes umlerKoes such an extreme degree nf n-lnu'tino
durinjf tlie tliint iitiij!;!' thai Ibc latter becomes imprisoned in its cavity. Ii
»uch eases the greater part of the upper Kegmenl of Ih* utcrux i« tightly i
tracted over the retained placenta, while its lower portion undcrjrons sttB
further retraction, and is Ml by the examining finger as a tightly <»li--
traeleti ring below the placenta. The lower ulerine segment and tbewrvix^;
not having rwovcred from the distention to which they have boen subjected. M
are flabby in character, and widen /rotn above downward to the vagiii*^-^
inttertion. Prom the ^hape thus imparted to the u(oru« the oomlilmn i'-^
generally dc-iignalii) »» an " b(iur-gta»* contraction." Its occunvnce UiOKLj
ally necessitates the manual removal of the placenta, which can gometiine^M
be accomplished only under anesthesia. ^^
Mitsfd Labour. — In very exceplimml instances uterine oontrarli«l^^|
come on al or m-ar term. and. after continuing for a variable time. i^i^H
appear without leadinj; to the birth of the cliild. The lattrr then dus. ii^H
DYS^rOClA DUE TO A.^UJ^AI,I^i> OK THE EXPiriJilVK FOKCICS (W5
mft5 be retainocl in nlfro for iiiontlw, iiii<U'rf^>iiig iiiuiniiiiftcation or putru-
faction, nwnrHiiig »» tlm iiteiiihmnf^x have ruplurwl or ii«l. Th'w i" knnwn
a* niiitM-tl UiM)ur. Tbc (enn i^iould not bv applk^l to tliiwa: aut> in «\ikU
A Uvmg cbilil te bom, i« Hm}' are prababl^r only examples of pralonged
hoit
In tl>e njMH ckurrilied hy Monzies and llennig llie rliild had bwn ro
laincd for two hundivd and riglily am) tw«> IiuiidiXH) and (u) diiys nwgiocl-
itvU after full term. In ilii,! formor inAluiicc it urax removed at nutopity,
aud in lite latter after in<-iHion through th« cervix. Krevet hat< recorded
a typical ckm-, in which the fa?tu». which had Ix-'cii n-taini?d for MJxty-lwo
diiy». v»* cxpiTllii) "iHiiHaiK-nii^lr in a jxiriially iruiiniiiilli'd ci)n<liiii>n, while
ibo pUii-nta looked as if it had been pre:«r«'ed in a hardeninf; fltiid.
Nothing is known as (o the etiology of the condition, though in Ih*!
iitMw n■|>or!l^<) hv Lahhardt and Sanger, it uan H>.40('iaI<H) with cancrinonia
iif the cvrvix and iiiyoinn of tlie uterus riwpcctivcly. It may readily bo
enufoundtvl with ihf n-tontioM of the child after the fnl«r lul>our foUow-
iag full-tenu tubal gestation, or with pregnaney in a rudimentary bone of
lite uleni<. liiougti n eareful oxamiuntion Hbmild preclude the pooeibility of
Much a mistake.
Labour «hoidd b<^' induced an ftton at t)K- diagnopix is made, and was
readily umtimplinhi^l hy ttu^ introduction uf h bougie in uik of mV putient!(
two Dionllu after tlH* death of llie fcetus. Krevet. on the contrary, con-
t>rn<l* Ihal inlerfiTeJHr i* indtealMl only after the upj)earaiiee of nymp-
Uiam indicative of putrefaction or infection.
UTKItATI'KK
RpDiK. IVla dj-MoeimiM^ par I'liiiiMaii fid ItMidL L'OtiotHmiue. IMS, iti. 280-310.
Cbkbun. Ite> itiflMniJlAi lis la verrioii EauoAea imu- k rclnKtiua do I'lumeau de Bandl.
Tl»te dt- I^trii, 18S9.
l>nixux. Dv U retruction ui^ina a%-kot la niiMuiv (Idb inemlmuie*. VObMtriqua,
18W. iu. i»-m.
\ Hbluenoau.. Cctwr ()lc noilcutiiRK d** inftxiurtun KrachtwaaHn (Ur MutUr u. IGni,
BciitaiOD nu tlvb. u. iiya.. igOG, x. X»-374.
ilKMXKi. Ueber litliafNictHa intrnuterina. .Vrchjv f. Oyn., HITS, xIU, 30!2-2M.
KkKTrr. RiiMatian«|per In der noinuilen '^•«lu>nnuli«t um riFbligeo Bnde der .Schwaif
Xinrliuft aligBrtorijCDcn Frurhl Inn mm XU Tafcn. .\ri'hiv (. <>yii., IIMW, Ixi,
■l35-*+l.
I.*B)URDT. Ejb Fan vno "Mimed Ij^mmit" hn Canutionaa u(«ii. Bcitnifp) tat Oeb.
n. Oj-n.. too;, vi. 4»7-«».
Rinu. IlM-t^onti^cUonmiigm vincii HeiielMuigcn turUcchaiuk<lcir(>«burl. MuiuU*>
•ehr. t. l>b. iL Qyti. 1900. xii, »7-tl».
' ViTT. I'clM-r dw- Ttfnlnrie dutrb ddi Cunlnwiiauning. Uuoalwchr. f. Oeb. u. Qyii,,
IWJO. xi.*93-SOi.
VnrKW.1. UdMT <Iio Bcduuttinft prjtcipitjrlvr Olnurtm far Hid AvIinJnKic itca Pne^
poral&facta. MikiK-lwn. IHHI.
(TIAI'TKK XXXir
DYSTOt:iA DUE TO ABNOHif.lLlTIES OF THE (IfSEKATIl'li
TRACT
Vulva. — Complete atresia of the ralva or ttie lower |mrliot) of ihe
va^na is UHiially ci)iip*iiilnl, iind iiiiIi'iik I'ttrrwtwl liy ojieraiivi; itn.^^iiruij
wiiiU! f>p(><i** ttn inMJiicralilf obMacle ut conwptioii. Von Sleer has roporud^
an exf^plional lasi- in wliith Uic lower Iw" lliini* of ihi- VH^ua ircrv lack-
ing, uhik' iht> u|>;M'r iliirit roiiiiiiuiiicjiltil witli liit^ Madiler. Oiitux w
»ccouipli»l>»l per urrthram, lhrou|i;)i which a Ibree-inonths' f<ptn» was sub-
sequently expt'llc?!!.
Mnn- fntiiieiitly vulval atresia i^ incomplete, oixi ia <li>c to ailliwioni
and cicatritial changes r<.iiiiilling from injury m in tU minatory procaases.
The (Icftict may ollur a conwdcrable olixtnelv K> Ulmur. but lln- rL-«i#taiu»
is UHUaJlj overcome by the continned pressure exetii.i] by the boail, thougli
frequently only ot the cxp(;ii*c' nf J^i-p ]i»;riiu';il tears.
Cu«* are on rwinl m wliidi an almost imjR^rforatv liyiuioi has remaJDMl
intact until the time of labour, and only ruplun^I when ilUtotided by Ihe
vhildV hvud. In rnre inrttJiDeini, at wa« jwinted mil by Coaster, a thick
septate hymen may fonn a brid^ of tissue opposing lh« advance of tiie
pre^nting part, and fiiay r«q«irc t* bo cut througli before delivery can baj
eonipli'lwl.
In Home women, especially in elderly primipane. the Tulval outlet
very small, rigid, and altogether lot-king in elasticity. Again, as the result
of pressure or renal loitions. Ihe vulva may liet-nme oo mleinaloud ttiat H»\
orificw IB almost oeeludeil. The hitler cimditiun doe§ not neceaarily ^ve
rise to dyKtoiria, but in Iwilh tin* briltlenow of the wfl pari:) predisposes to
perineal laceration. Moreo\-er, when the oedema ha» been «xoeft>ir«^ and halt
[*er»iAteil for wiiwi' time, the tone of the tinsues may l>f so lowered that ihcjj
even become )^n};nmou.« as a n-siill iiT the tnninmlii'ni incident to lalwiur/
Tlie formntiini of thronilii or ha'mnlniiiata ahoul Ihe vulva. althoD
more comujim iluring the puerperinm. occasionally occurs during the latter'
part of pregnancy or at the time of labour, and gives rise to (ilif^it dNiitocia.
Inflammiilnry lesions about the Tulva. a^ vt«\l m. malignant new pmirths,
may have a ^iriiilnr <'fTec-t.
Vagina.— ('oiiipliitc va;.'inal (j^nww is nmrly alvrav* congenital in origin.
and is an effectual imr In [mgiiuncy. Incomplete fomn, on tl:;^ nttwT hand,j
are Hometimcs manifcHtatiom* "f fuiiHy development, but more
result from awiclenliil complications.
aore freiiucntij|^H
DYSTOCIA DUE TO ABSOKMAUTIES OV THE VAGINA
6CT
SonH>tt*)ial rarri; Itu- vnf^iriM i» iliviilul inlo two lialvtv liy n longituiliiml
M.-|tl)ini untcnding from the vulva to the ccnix; mure oHeit the structure i«
iocompletv, being lituilcd In viltivr the upper nr Iowct |H>rlinti of lh<; caual.
Such eomliiiiinx iin- (rii|ueiiily annocialei! with ttbiKtriiialitieii in the dvveiofH
mimt of llw generative Iracl, and their detcetion should always lead to
further earvful euimimilion, with ii vwv,- to delenuinitij; whether tbo
iitcmv and u[>]M4Mtug(» ar« noniiat.
A foinplete loD^il"^'"''! »epnim rarely give* rise lo dylciciu, an Itw!
half of the vagina through uhiuh the ehild deeeend^ gradiuilly umiorjtoes
NttiKfaelory dihitalion. On the olk-r hutid. au incomplete septum oeoa-
itinnaily interfenx with the dax-ent nf tlic lii-nd, hocomtng «trelchcd ovitr
it as a fleshy band of varying thiekoe^'. Sueh HtrnoturM art* usually torn
Ihrougli »poti(am<ou>'ly. hut oci-twioiiully aru to resistant that tbcy mu»t
be itcv<;rei) )iy ihi- olwtetncian.
t)ceasional)y tlic vagina may bi^ ob«trueted by rin^>like strictures or
Imivlf nt foiigi-nital origin. Th<*e, ltow*'wr. rart-ly offer a i^eriou* olwlucle
to laltour. iL- they (uiually yield before the oncoming hiatd, though in t-s-
traiie cafc^ int-ifion may be net^essary.
Somelimi^ Ilw Mp|H*r [Kirlion of iht- vagina is wpsmled from the re-
mainder of the eanal by a diaphragnidike stnicture witli a iinall twntml
'>peniiig. Siteb u condition is occfl»ionally nii>^takeii by inexperienix<il olt-
«ervers for tJie vagimd fon^ix, anil al tbo lime of UWir for the uiidilatcil
external oe. A rsreful examination, however. lihoiilii reveul the pruM^nee of
IIm; ojK-niug, Ihmugb which u finger can bo piusKcd. the cervix tlieu being
dblingui-dietl almn' it After th« exttfrnal w in oomplctcly dilnlnl. the head
impinge* upon the atmnmia! stnieture and causes it to bulge diiwnunrd. If
it (iiiiTi unt yiclil, "iifrht pn»»urr upon it« o()citing will usually b-ad to fur-
tlMT dilatation: but if thU is not effectual crueial inciiitonK mav bu a'«u»>
Miy in onlcr to allow of dolivory,
ArHJfflij} alrexia t* alw«y« itccoiiJary in ori^n. and rt^nltK from the
formation of adlKvioifi following injurie:* or intlammalori' pnwes!tfs. It
not uifnipii'iilly fnllowH wvcre pucrjKral infections, during the courxe of
wliieb the entire lining of the vagina may have olougtMil off, m tliat as
liraling occurs iti^ lumen hart become almmt entirety obliterate)!. A Mmiiar
Tenilt \9 wimetimi'^ no(»i after diphtheria, miall-pox. cholera, and syphilitt;
while in rare inirtanceii, a^i in a ea.'ie re{iortiil by Hehejtk. it may Iw due to
Ihp action of corrosive fluidn injected into the vagina in tlw hope of induc-
ing ibnTtton. That thv most frequent cause of atresita is injury or inflam-
malori- rimdilionn following laliour in nhown by the fact that 2(>9 of the
l.(KK) easrH (ollected In Neugebauer presenteii such a bislory.
Tlie effects of t^ucb conditions varv- gnratly. In tlut majority of kosV*,
owing lo the mftcniiig of tliv ti«tucx incident to pregnancy, ilie obHlruc-
tion in gradually overeome by the pressure eierted by the presenting part ;
low ofii'ti manual or hydro^lalic diliitatiou or inciKiono may berome neoe*-
itry: while In very nin- cost's evtn-iuc dr-'itocta may demand Ca'sarean !*c-
tJon. F'ldl literalur*- roneeming lhi!> complication is to Im found in the
UiirIrK of Wanl and Rrindcim.
Among tlie ran' canseti of »«rious dyxtoeia, rttt/i$tal nevpltumt are worthy
670
fjHSTin-Rirs
the iitt^riis, Imt n« (lie r(«uU nf my "wii Pxpcrivnoo I Iiave Ixwn roliict«nt!T
forced In ailmit iluit it may a\*<i frM'i'jitionallv oii'ur after tni'fKti/iioH nf \\ui
uliTiw, Ill-It whi'ii [R-rf'triiu'd hy tiniii»L-ttnl (ijit-nitor* wilh Itlf nnwl aM
proT«d tccimi(|ui>. llitii*, it may ocoa^ioaally IinpiKtn, a* the reitaU of iofftvl
tion or xnmc other unknown crindilion. that the proposed suiiptwsion bo-
ooincj) Mtn^t-rltil jiiio n fisntioii. ami ii-" n (yiuN(i|iH-[i(v thi^ iiteni* if llniily
altachiil to the anterior abdominal wall hy a thick u<IIw.tiioii, which will
iwilhcr liiviik nor Ktrct<rh during pn-jriiaiicy.
In AUch nn event, tierioux dillkulty may ari^ at the time of latwur, ami
may U- l>rnii)riil nliout in oiif of Itiret.' vnyf: Miwt fr«iHonlly, as the n-^idCl
nf the iidlii-iiioi), llu- anU-Hor wall of the iiteruH la unalile In expand; an Dints
the enlnr<;cment of the organ is ffFpcIfJ sok-ly at the vi:{K-ti><« of ilx po.-te-l
. rior wall, whilv the hy[H?rln>phii'd anterior wall is repreicutcd Ity a lhi<-)(|
vmaBs of miiscle extending from the point of Hsatiou to tJiO'C«rvL\. atijl
more or lei^i' encroaching iijinii the Mi|i<-rii>r strait. A>< the uterti!' cx*l
[wnds, traction is lunde u|jon the cervix, which is gradually drawn uiiwardi
from its normal potitiuii, until tlii^ exttTHnl ■■« i» on n level with thr proni-l
ontory of the naenim, and itoiiietime.i considerahly ahore it, so that in'
extreme vana its po<it«^<rior li|f may be opposite the fM^eottd or third lumbar
verlelira. WnH-u ]nlK)iir *oU in, dilataiioii of the n'rvix \» efr<\-lcd very J
imperfectly, since the baj; of waters and the jirewenting part, iiuttcad of J
impinging upon it. arc- fnn-i'd down upon the IhicVoncd ank-rior utvriiiel
wall. .\t'cor(nn)rfy, the uterine contractions, no matter how iitrong ihey marl
be, are unald^- to cffwl the ccimplilinn nf laliour, and unt<K« suitable oper-l
athe ntil i^i rririhcdining, nipliire of the uterus will occur, tu) in the cik^c'l
reported by Dickinson and others. I
Ijesi frequently, a» in the cum;' reixtrtcd by Lynch, the iinterior wall ofl
' tlw iittTiui dotw not hy|>ertropliy. and in such cases the dystocia rill lieJ
due entirely to the upward di^lwation of tlic wTvix. I
Very i-xeeptionally, aw in the case which 1 reported in ISOft, tlM> anlf*rior,l
as welt an the posterior, wall hypi-rlrophio^, and biK'auw uf the limilod tj)i8cej
aviiilKtilc l)etwf<;ii the area nf ilxatinn and the cervix, the former hui*):lnti
or lieconics folded npon itself, instead of forming u thick ina»;ular pad in
front of the cervix, rndcr »iich conditions the lower part nf lh<- uti^rino
cavity Iwonie.t divided by a cresccntic fold, in front of which a sa<-culatiitii|
is torined. in which jKirtion* of the hvlu* may lie, and thus he inaoci»'ililit|
to the o]«'ratinjr hand. Moreover, the dystocia i^.cvagjferated by ibel
upward displacement of the cervix, as wHI a^ by (he fold il-*elf interforiniu
with the cnjiitigi-mcnt "f the presenting part. I
Noble, in 18!li!, collected the liiKtorien of 177 case* of prognancy occur-J
ring in women who had been xuhjeeted to ventral lixation or ■iiupcn>.iiinJ
while .Andrews, in IflO.i, was able to iDcrca^e Ihe nHTnbcr of ca^vs to 3!tll.l
In the :W!i (iiitii'iits who went lo full term it was neiwssary to rworl tnl
Cesarean section in 20, and to forceps in !J1 in-itanccji. while crariiotoiuy J
was n-quircd m 1 ca*e. Thi*. howevrr. d««« i»i>t ffxhan»t Ihc nntownnll
effects of the operation, as the uterus niptured in 3 other cta^. and"
transviTwt preseiitntions w<Te not<'d in 10 in*laIK<el^ In Deci-mber. l!»Oii. I
van able to increase still further the list of ooniplieations, and roll<^-ltflJ
DYSTftCIA DUE TO \'ENTROFIXATlnX OF THE llTElurs G71
£mni Uip lilt-ratnre 5G i-acK-s nf Cn-mrvitn tHTlutii. n* wHI nt 3 aum nf crnni-
nliimy nol iiivnli<»i*t1 l>y Amlrt^H.
I luivf lU-flvi-n^ a [urge uiihiIm-t of woint'ti after the pcrforniauco of
vrntro-tixnlion or xuAjx^nsiou, btit in only 4 wan gaKrioud <lj-iit(icia okten'od
as IliP rp<<n]t of t\w ofKrHtion. [d 2 iastaaarr doliTerr «>uM he eSecteA
only l<r ('«viir<>ikn »et-li<in, in iin<iT)i(-r a m<>>t diltkuli vtTKtoii uiix inTfoniH-J,
Fh. JII0L — Dtktocia F'mxt>w»n Vi^v lu.t— . .t ._'.~i>.,. .s*ttiiuiTiii)i tin Ahisuuk
ITtehine Wau.. X |.
Ad., Kitlnlna lii>tw««fi utrnu and ■nlrrior alHliinunaJ inO; AJF., kbcliMnilutI WkU: VJf,,
utntiHi wbU: 8., UmMct; F.. foliM MiUriiir uUniw wall ; />., plMvau.
whil(> in ihv fnnrlli cast- rraniotoinr upon 1li<- (Uik) cliild wan noo«esan. In
"ur of my ni.-*eii (In* <ly«1iioiN vfa" <ini> to vtiit roll xat ion liy an unknown
operator, while in tlw? other S it followed wlial were intomleil to be tTpi-
tal ntf^icn^ions, bat in which the uImiu had uofortunali-ly IxMrnu' fimily
Mtherrnl Iw the aDlerior ulalominal wall.
In Tie*- of »ti<h expcricnti-K. Itw; qnt-nlion anR" whether the perfrtrtn-
aait" iif 1h«!*^ operaiionx \* jn:itillabli> in women during tlip i-hilillHMrini^
672
OBSTETRICS
perwd. FoniK-Hv I licUl that, while vcnlmfixntmn vnf (yinira-imlii-alnilfl
^Wfpcusiou waK prHcticallv dovaid of tlftiii^r from an (ilwtrtriral point »M
view. My own i-xjiorii-niT, howi-vci', jiliows tIwI I wjts in i-rror', (is 'i t V-<iiniinl
svL'tiuDH and 1 cramuloiny Itivunie neciv^ary aftor tliv latlvr ojk rational
Ax Uto itui'))L-nMi»ii in thcMi i^aseit had Uh^ii dom^ hy onnipetent opDralon<
after th« most approved twhnique, it follov,-^ that it may occ*ai(>n«lly
give Th»! to nio«t Hcri«u« obKtoIricul coitiptii-aliuns.
A(<ronli[mly, I fee) that neithtT fixation oor sn^ipn^ion i^Wuld b<* vmA
pIojiHl in wonicu durinf; the childbcarinjj [wriod, exwpl when tlio nTaruJ
ani likcwi«u rumurvd. l>uriiig tint piul fi-wr yvan I luivu trcaled u duiiiIht
at cases of relmflpxion of the uterus by Oilliaiu's operaiion with jtTWt
satii-faction sh far as th« inimt-dialo reifult i» conci^rned. but «u ^iniiU »
niiniber of pregnancto^ have followfii lliat it iii as y«t tiapmaiihle In dcter-J
mine its cSkI upon thv coun« of labour. ■
Tlie vtiffinii/iralwn^ nugyi^xied by Otihrsnen and Mackenrodt, in whiHi
the funduH is l!mdy slitched to thi' anterior vaginal wall, has boen followvd
by nucb wricniK dywtoiiH (hat i[ hn* Ikhii prurtiinUy almndouwl durin)! tlie
ehildbearia^ period. Iliihl has colleiHed 9 ca^^n of (!a>4arean section fol-J
lowing thtii ngxTution. uml Riivk ha» liiiggoi^It-d a modifinl vaginal Ciwnmial
nwtiou for the relief nf the reiiulting dystocia. I
Prolapse. — I'n'siuincy cannot go on to full trmi when the uteru<i i»fl
completely pmiapwd, altiioiijih the sixe of the nlertne tumour which ocra-l
sionally projects from the vulva may giv« riw to a belief in it» poeeibility.
In yiich (-41MW, hi)w<;i'or, curoful examination will i^how that the fumlutj
oconpie* it« usual level, uliile the piwtrusion from the vulva is made [X**-!
sible by elongation of the liiwcr uterine segmcnl and hypirlmphic clong«-
tioii of thi> tvrvi.v. .\* a ruh*, the (i>rvi\ liecomes retraoiiii filsmi taliinir
aeto in, though in rare cases it may continue to protrude from the ntlra and
hwomc mnrkcdly a-deniilt^Hi* and no swolli^n as to give riw<' In M-rimn' ilvi- j
toeia. i'ndpr such eircumstanccs multiple incisions of the cervix inayJ
be necessary in order In itTfit ib'livi-rv. I
Dystocia Bne to Tomoan of the OeneratiTe Tract and Felria. — Toivi'l
noma of the Cervix. — The efttvl of this coiidilion upon pregnancy and labourl
and it-* appro|iri«te Irealmenl ha* been cooj'idei'ed in ('hapier XXV'II.
Fihrn-miifitinla uf tJi' i'lfnu. — Myoniata were obwrved hy I'inard in
HI out of Kf.HI.I col incentive cjim-s of liiliour — ".0 pi-r cnit. It \% s inalt'Tl
of general observation that women suffering from this diHCSMe are rdaiivplyl
Klrrile, Thu", -ID of I'inurd'i' patients weru over thirty ynre of agr wheal
pregnancy first oociirrod. I
The obstacle to conception is most marked when tlie tamour isi of thai
yubmucnuN or inlerstitisi variety, and mncli lex* no wlion it i* I'ubM'muil
in origin. Moreover, when pregnancy oecurs, owing to lhe hwinorrhagicl
changes in the endometrium which are frequently associated with tlie pfvs-l
enee of subnuieoun myomata, there is an inereji-ied tendency lowartls ]in*itia-l
ture expulsion of the ovum. On the other hand, pregnancy is not witbonl J
inHiienoe upon the liimoars themselve-*. which frei|tu-n11y increii*** rapidly fn
size, moR! nx n n-xidt of nilema than of uclual hypertrophy. Moreowr.l
owing io the prestiurc to which the)' are subjected hy llie growing ovojuJ
D^'STOCIA Dl'E TO KIBllO-M^OMATA Of THK UTERUS 073
tlw nMftowd luniuum Hiuli*i^> c*liti»gv» in th»]>K imd bcvunii' inarkWlly
flattctuMl. Uccasioiuilly the pedicle of h siitworous iiiToma may become
(wi«tvtl und gingTvuc und poritoniti* muy cnMw; while ti Kubmucoiis tu>
iDoar may soBKtime.-^ b^H^roe (ooaeDed from iU bed and hang down intn
iIr' a1i*rinc iiivity or cervix m* a p<>ljf[niii.
Tlii> dingiKMiK of tlie aiuoeiation of pregnaiMiy and myoiiiala iii not nivaya
ca^y. Hvinorrhage may ou-tir nl iiik'nah uii the n.-?itilt nf etianges in the
endoiiM-'tnuin, Mid lx> iniftiikeii by the [)(itM>iit UorHcIf fnr lluf iiH-iixtruitt How,
ho that tlie idea of prvjniancy may no) eu^geat iUolf for months or until
an idMtrtioi) ncciiri. On l)u* other liJiiid, a stidili-n iticri'Miii' in lii<- nipidity
of the growth of th<r uterine lutnour vhoiilil direct altonlioii to the posii-
hiiily "f pregiMiney. ami Ihe dia)^o»i# Iwconiei* awuixxl wIwtu «in'fiil paljM-
tion rihown tin? presence of soft areas interijpcTsed between th<! firmer
inyoniiiUiii« a<xluk4^. Subperilonvul tiiyouinla ocMyioiuilly tvcupe ob<uTva-
lion, lifinfc niL-Iakeu for iho sumll parUi, or MtuK-ltnies for the tu-iid tif the
ftctue. CO thai a diagiko><i« »t muttipiv pre^nani^'y may be inad<>.
At the tiute of laljniir the efre<-l e):erIio) by the myoitiuU deiwniU Rii-
timir upon Ihcir ><ize and cittuitton. (ipncrul)y epeaking. «iiiiM>n>uii tumours
•rv witliont gn'ai ni^tinlicaiK'c, cxn.'pl wht-n their lar)[e xixe K-ndM to prex*
FUrt* ■yniplonir', lliou-;h a {tcdunculaleil tumour oecasioiially prolaikses into
llio (vlvio cavity an^ giviw rin* In wriou^ JyctiK-'ia. On the "Out bund,
inlcnrtitial myomala, developed in I1m> cervix or lower alcrinv scifinent,
offer i>eri«>iii^ olji^tat'lo lo lalMKir and may co obiitruci IIk- pelvic uivily that
normal delivery will li" i iiipor.fi ible. As a result of the uK-rim' i-ontnieiioiw,
a «uhmui<ou« myoma may btcomt' partially »eparal<<d from it.« beil and
prolruiV from tin- t-ervix a> a ]>(ily[Hiid uni*.*. I'n^cr i>ui'b circumrtanvc*,
stoce it effectively preTentu the deMwnl of the head, it niiu<t lie removed
liy cutting throujth IIm- [Htliclr.
Even wlien the tutnour itoes not interfere with tlH^ couru' of labonf bj*
jta tixn and situation, il frvqiteiitly exor1« a deleleriou!! inHueiiee upon the
jMwitinn of ihtr child. ThuH OUhauMun, in tabuUting the caMui reported iu
the Uteratun*. found only 63 per cent of vertex presentations, a» compared
with 'ii BUi) i9 \fT cent of bnivh and transverse pn-M-nialinn* rt-vpivtivdy.
Moreover, the mere presence of the tumour may so interfere uilh the char-
artrr of th<- iitvriiK <'onlraiiion« B* to I'aiM- dywtona. In not a few coses
the rendition aptifam to predispow towards placenta pra'via, ax wt^ll a.-> lo
favour tlie occurrenoe of pot^'l-parluui Wmorrhage. The latter is due partly
lo tlw fact that Ihr myomaloii'' noduUv intt-rfcrr with the normal »>nlrac-
tion aiui retraction of ilw uteru*. and partly Iw-cau-i' llwy offer moohaninal
obrtaclea to the i«pMntioD and expnUion of the placenta.
In the puerpcrium. myoniata not infmiucntly undergo dcgencratiTe
chaDp<rt, aiul if Ihev have been Auh)ccted to prolonged preni^ure may hecoroe
gangrenous. On the other hand, in not a few cas«s the effect of pregnancy
il heneficent, ax the tumount become smaller after lite birth of the child, and
oceaaionally disappear entirely.
Pnttfitfutu. — In pri'AuliM-jilir timi's llie outlook in iaUmrii t'ompUeated
liy the prawnce «f niyoinalouiii tumours wsm tootit itcriouA. Thus, the
mat^^raal and fwtal mortality was respectivdy 25 and IV per cont in 307
674
OBSTETRICS
cases tuIlecUtl from llu- likTiiluri.- bv Tjufwir i» 188U. At prvscDt, Uiiinki>
to vurlv dittgiiDiiU nnd prompt re»>ur» to operative proc^uree lO suitable
casefl, the prognosis is mutli more favourable. tlioU':li Ht Die isamr linn; llie
cuuditiiiii i>^ siirnct inns' unc nf t.liir muTit iK-riou.i willi whirli tlie uWtetrician
hjis to cope. Pinard reported that labour was epont«neou« in M. and
■jrequirvd op«Talivc uiil in :{tl of hiii i-»M«-s, while tho mutdmal mortality
nras oqIj .l.ti per cent.
Trratmi-nf. — When cxtn-iiic diKli-ulioii. nerious hjpniorrhtip.% or i^ynip-
toinK of inipaclioii ocx-iir before the child hat au«iiu-d (lie period of via-
bility, laparotomy is indii-utitl: btit whcllit-r ivmorul of tlw tumour '<;«n be
bext effwtwi by vxeision, enucleation, Hiipravitt>innl or lolnl hy.-*Iurertimiy
will vary aceording to cLriomstanees and the preilileelinns of tlw individual
i>[H^rulor, (it'Ju-fjiUy ^peakiii;;, i^olnttil subserou* niyonmta nn- hi^l trcalrtl
by excision, and those of ihv iuterstitial variety by fuiK-leaiioii ; whereas.
If niinierouM tumwiir* are presicnt. 3>upr»va^iiuil tl^-l'lere<.■1»lny i» indii^alni
nritbout refereme to the exi^tenee of prejfnaiiev.
f Myoniwtmny uiid I'liin-lwttiin arxr fn-i^in-iitly followisl by nburttun or
ini»carriaj;e. but do not neiis»*arily de-troy all cban™ of Mivinff ihe life of
the eltiid. NotwiiIi>uiidiiig Ihi*. howt-xer, my own inelinatioii i» [oward^
iiuprnva^inal amputation, whenever operaiion is intperaiively demandn), ta
hviDg a less danprroiis prowdure as far a-^ the inolhcr is foncerncd. Thuniin
ha* (v>llit'liil ti'i itiyome>'toiiiif:<. A" eiiii(<l<»iiioii.4, and '.W nuprava^pnul hys-
terectomies performed between the yeans 1885 and 1901, with a mortality
of 10. S, ami ll.a^J pitr cent nvjK^iively,
If Kcrioun siyuiptoins do not supervene dtiring pre^naiiey, n[K-nitlv«
interferenee should bo deferri'd until Iho time of labour, or shortly heforo
i\* t'.v|ii-<'l<i| onM^l, tis the tumour may m> chiitigi; ilii Kh»[H: nr {vosjiion
as to render an operation unnecessary from an obstetrical point of riea.
llii'i*. in oiie nf my piilicnlt", ii tumour the "iw of a fist vriu found in the
upper pari of ilie cervix at the f fth nionlh, and (i*ve every indication nt
offering a M-rtmis oii>1m'!<- tn di-liwry. To my surprise, howovcr. vhen mIw
roturnol !■> ibe hospital at llie end of pr<^ainy fur » C.'a-»an;aii «wli<m,
the tumour had rii<^'n out of the jielvis, and hud become so much f<niall«r
that o;)eriiti()n wa» not thought ne[-e»ary, and a few day* laler an eafv
spoutanii)US delivery occurred.
So fortimuh* an ont»«me, liowevw, cannot alwayji Ik- expt-rte*!, and in
any event the patient should be examined theronfihly under anawtlMsiiH
vjiortly Wfore liiv rxpectt^d dale of eonfinenii<nt. If tlw tuuionr if fovnd
to be firmly impacted in the pelvis, Cwaarean section should be pi^rfomu'd
In-fore tnl>fiiir scls in, follriwi-d by supravai^inal ampulation or enucleation.
Bcconiinjt I" rhe jud];im>nt of llie opernliT. On the other hand, if there i»
apparently no <lan),'er of inipat^iion, and spontaneona delivery is prubaltle,
the patient sboultl be iillnwed to go into labour. But if symptoms of ob-
slructiou occur, (Jn-sareHii section Hboiild be promptly perfornitil in prefflf-
enci! lo nfUmpIs at delivery by the more umml nbsCHrical priK-iilurc*.
Ovarian Tinnmm. — The presence of an ovarian tnmour in nnc of Uic
most serious eompIieation>! of prepnancy. a« it maikedly inercaMK ilie
probability of u)>ortiou and frequently olfers an insuperable obstacle lo
DVtnXICIA DUE TO OVARIAN TUMOURS
fi75
tlelivorj- at lite (Jniu ot lalHitir. SInntnvor, oveu after tt uponuiieiiua lulxnir,
ilB |iR«en<v oecaoioiMlly gives rise to disturbfiocra iluring the puvrperiuni.
Wliilv any vnrit'tv of ovariau tumour may t-oniplivulv [iri-t-'"'"><-'>' and
l^xiiir. iknimid c'y>li> linvii Imvn <liy(Tilnil iinupHrativelv freiiucntly in this
wiDUeclion. Thus, Jn 107 case* cwllwted by McKmron, in which the
nntun- of the tumour was stated, there were 47 cy^tomata, <fi dermoid crsta,
9 oinli^ant tuniouro, j> lihminatA. and 2 enlloid nysto. Swan, io 1898, was
al)le to collect H cA^nen of aolid ovarian tumour.
Of IIm! 'Ml pTvgnanr'n-f (<itniy\\<-tilrii by iivnriiui tumours collected by
Kemy, sponlaoeouH abortion or preniatua- labour oceiirred in 17 [wr cenl.
Fta. Al?. — Drrroeu Dva to Otakun Cm- (Banun),
I
If Ote tnmour oci-uptiH tlic polrie cavity it may f^re ride Io most seriowi
dyntnc-ia. ThiH. Mi-Kcrron. in 72U cjiitea eoIlMtivl from (he lileratun- in
whieh pregnaniy had bcvn allowrd to nm its counte without int«Hrfereiu^,
iuiUh] h mau-runl mortality of il y»r (vM. while mnm than half of th(^ cbil'
dnai wens l«t, 'ITm." majority of these eases, however, were reported prior
tti iW iiilriKliK'liiin tif iiion- ni>ti>Nil "urgit-al mvlhoil''. vry few laparotnmieM
having lHi;n pcrfi)riii«il. am) InttTfercmH- for iIh- niowt pari U'lng limits] to
punc^re or inriHion of cvfts throujfh the vagina. JktAreovcr, the danger to
the patient docs not ond with the birth of the child. a<) in not a few cow*
{Mtriloniii!!' fol|o»> f;an):rtfK< of the tumour re«ultin? from ex«««iv<' pn-SKUn-.
while in othcTii tnriiioii of llti' pdliclc miiv )iiid Io a fata) ti-rininntion.
Ajiain, Ibe eyst may niptun- and extrude ilM eonlentu into ihe peritoneal
Mvitv during a iiiH>iiiaitvou» labour or at thr result of operative interferemv.
67ti
OBSTET1UC8
lliid event U a mailer of mdiffereacv with tbe ordinary cjrstomata. but in
lh«r cHiw of a dcrtiioid i-v»l iit fre(|ueiitly followed by fatal peritonitis. In
Lother infltances rupture of the uterus occui*, or tlic turaonr is forcvd Into
Flhc vagina and Mx.-ukion(Lily oven into tlie rectum.
Diagnosis. — Unfortunately, the presence of an ovarian tumour com-
plicatinf; pregnancy oftt^'n rtnQaini' unKiispvctcd. the coudilion having
l)««n r«vogiu«e<l in only IS of MrKerron'* first scries of ca.4e^ XOT'er-
ihekfts, more careful observation should cerlainly eliminate a largo propor-
tion of th«'w errors, us any <-\ii>Aivi! t;iihirgi;iiii-nt of llic alidoini-u or (Ih-
nppearance of pressure symptoms shouhl always lead one to make a careful
'e\um)iintion. Again, fnilurc nf the pmvnling part In engage, when (Ih^
pelvis is known to be nomial, sug^ta an obstructing mass. On tlte otlu-r
I'liand, if the tumour does not occupy the pelvic cavity, the diagnosis is
rfixtreniely difDcult, and the ahdoniinal enlargement is fr»(|uently aiirihui'il
lo the pre^-nro of twin pregnancy or hydramnio«. and the tmc cnndition
is not recognised until after labour.
Trfiitmtnt. — If the tumour is detected prior to the last month of pr*^
nancy, it should he removeii at onw by lapiiroloitiy. Orgler ha« eollcclml
142 such operations, which Ucil. in 3904, increased lo I8H, with a maiecnal
mortjiliiy of 2.1 jwr cwit.
It has been objected that such a pn^MA^dure increases the ehances of
prcmilturi' tlelivery. which occiirrcii in 19.47 per cent of the ea)ies collcclnl
by Orgler ami Heil. It ubould, however, Iw remembered that a Mmilar
aecidi-nt may lake place even if the patient is not interfi-rud with, having
been noted in 17 per c«nt of Ri-niy's vfxtc*. This difference is so slight that
the chances for the child are little, if at all, impaired by operation, while
thijse of the mother are itinrkedly improved.
On the other hand, when the diagnosis is not mnde until the lant month
of pregnancy, it is usually advisable to postpone the operation until terui.
for the reason that the fresh abdominal eiejitrix is not well adnptetl to tlw
strain of parturition. At the time of labour, if the tumour is impeded in
the pelvis, tinaninious opininn favourx its immciliaie removal by laparotoinv.
Blond Sutton and most authorities advL^e that the abdomen should tluai be
closed and the birth of the- child left to Nature, or at most assisted by
forceps. On the other hand, Hirst i* strongly of the opinion llint a supple-
Lmentavy f'lesarean section should immediately follow, believing thnt the
Fwoman siuiuid not 1h! submitted to the strain of labour immediately after a
Mn'ere operation, and. when all things are considered, the latter aftpears
lo me lo l>e the wisi-r wursi?.
Formn'ly it was advised to attempt the reposition of the ma» untler
anesthesia. This practice, however, is not to be recommended, for Uie
reason that the tumour is very liable to give rise to trouble during the
puerperium. Moreover, since operative interference will be nocewtary
WJoner or later, it would seem far belter to institute radical measuren with-
out delay. Puncture through the vagina, although strongly advocated at
one time, must be considered as a dangerous and extremely reprehensible
practice, injismnch as we possess no iiK^ans of preventing the tumour cod-
tent* from contaminating the peritonofil cavi^.
DYKniClA DUE TO OVARrAN TUMOURS
677
If i>:ponlanv(>ui> Inlxmr h»» vvcurrvd, lh« pativnt sltould bu curvfully
watched during the puerpcriura for ihe apjwarancc of uDtoward syinptoiiu.
Should they ariw. prompt operation i* imperatively deiniiitd<-d. lu any
eveDl. It Hromnii xulTering Tmin an ovarian tuinoiir :>)iouId not Ix^ ili^harfced
from tr«atinent uiiiil the tumour has been removt^, or at IraM uDtil tho
iniportaDpe of operolive prociKltmw have been elnrngly urgpd upon Ikt.
Tumour) of Other Origin.- — Labour i» oocanionally ohntructed by
tumours of various orif-in. which eiwroaeh u|>on lht> cavity of the pelvis tn
siH'h an extent a* lo n-iidcr di.'livery dillimlt or even impfwihlc. In (Ihap-
Ipr XXXVIll reference will be niade to dvitoeia due to luoiours arising
from tin* pc-lvie wullii.
In rare inslaiict^ a normal tint] or rniargeii kidney or upltet* may pro-
Iflpw into the pelvio eavity'and ofTer an obstacle to labour. Blund Siitlon
luL-> adiliil an addiiioniil vhm^ nf dia|ilat'i-il kidnuy i-oni|iHcaltn|f pn-jfiuiitiy to
tliow it^lected by rragin; am) lias also reporlt-il llie removal of a prolapsed
9>plee-n in tl»e smimd month of pn-giinncy, wbivb wnuM luive given ri*e to
aeriood dystocia at the time of laix>ur had it remained iit ailtt.
Kdiinomfcun rg*h an- oeearionally iinplniitiil in IIh- pt-lvie cavity,
Franla. in 19(12, eolleeted 22 cafte* noted dMrinji; pregnancy and di^cuiMed
ihvir eflferl u|)on Itiv couri^.* of labour.
In ('ha|>tcr XXX rcferencv was made to tho^- ctt/tv in which an old
«xtra-ntenne gestation Me tn olMlrncted the )>etvic canal as to interfere
«ith tile delivery id n »ubMe<pient iiitm-ulerim- |ire^'mim-y.
fiHlrrofvIr or hernia tbroU);h ttw- Ta^inal wall>' oeia^iotLally jfivee rise In
ilyHtwia. tliough in the majority nf easea the prolapsed intestine cuin Im
replaeeil and the oliAlacIe temporarily overcome. Where thi.- is not po*-
cilile. C'leurean section if indicated as a more conservative procedure than
f»r<'ilily i)rHju;in;; tin' child over a )ar^ irrwiucible hernia.
In iK-easioual ingtances tumourg of the bladJff may tikevise off«r an
Impvdimcnl to the passage of the diild, though it i* rarely m> mHou* a« to
demaod operatire interference. On the other han^l, cases have been re-
porlM in which it hais boen necessary to remove a large calculus from thv
bladder l)ofore deliver^' eould l)e effected.
A large rtcioeele or ryslocfle, though occasionaJly offering an nhslsde to
Uboiir. can generally be replnoi'd while delivi^y i« Iveing I'fFected.
Tumourit ariiting from the tower part of the rectum or pelvic connMtive
liMine may likewise give ri«e tn m-riou' dy«to<-ia. Ilol/.upfel having collecti-d
a iierir>i of umms in which rarcmoma of the recltim rGndere<l Casamn
wet ion neteuary.
I.1TKRATURE
KmumHu. Zma Kauenrhnitt« wcgen natlnger Vcrengcrang der weJchon Ooburt^
wvga. Milih. aii« d. syn. Ktinik <k<« Prof. F.ll«>rt^-•m■, ItKH. vl. 289-31M.
ARmntws, Tlw ElTect uf V'Miinil Fixuiioti of the Ul«r\u upoo SutMequent Prtgnancy
and Ijiboar. Jour. Otut. and Oyn. Brit. Emp.. 1005, viii, 97-12.1.
Biuxo diiTToN. flio Stintcry ol I'rvKiiaiiry and lAhotii ronijilicaleil with 'Fuouiunt.
Unrat. ItfOI. i. 3S;-31»; 4.W-*.S6; !i29-M3.
HmkdbaV. Ue rmnSaio K«|uiic du vnxin an point do vim otiatAftMla. L'Oba>Mr>((iw,
IDOl, vi. 97-lW.
678
OBSTKTKICS
ConTRH. Ueber Ueburt«limdenii«w <lun>h hyiiHuult) Bolkcn. «tc. I>. 1.. UortnirE.
1900.
CotoiN. Congenita] Pdriir KLdnoy oWnicting (he Parturwat Quial. Amer. Jour.
Oh«t., 1»9S. xxxviii, 3»~tl.
DlCUVsoN. Pirpianry following Vcntmfl nation. Anicr. Joiir.OtMl., 1901, xtiv, 34-15.
FtiAXTi. Leiikysli-»liyiluli<]uiwilut«jiBiiiplderalHloBHMiuupijiiililc vticdcLnlyalocie.
AnnaW rie (un, nt d'olut., 1002. Ivii. Ili.VlOT; 298-308.
0€i>eit, Uvbpr (.ivH'hiviilBtv der Vim^iiu aU Svhwuiijeench&fl*- und GfburtukaniplikB-
tiiwieii, n. I., Hem. I88<l.
Hriu IkitntL' xiir iK'urioioitiiu in ilcr ^'JiwxncHntelMri. MuiH-huuer dmnI. WofImui*
whr„ I'.MM, li. No. 3,
HiRHT. Ovariun Cyan. A Test-Honk of (Mwlctrif-. Third t^lioii, 1901. 515^17.
Houcvt-rEU KauL-nwhiiitt b«i HashLnniikivbtL Uvilra^' xur tieb. u. tiya., IWB, ii,
ai-77.
Hue. Qut-Ii)U*.'s riM-h(MX'he« *iir ruapliatlan du diuphruKiiiv iK'tvim. ulc. Pliru. IfMNL
I.K Dici'TT. tV I'inHiiencvH du c-tuincrDiiypIiililiquc de coldcl'uttiruitmrrMNWUcliMiMnt.
ThAw dB Pari-, l«>».
Li!n>i'n. (Jooti'd I'y OlshutiiKn.
Lvxm. KiiiierM'hniil und m'hnxm nchiirtwtarunR iiifolxo Voncnv.ftxation und 8id>-
pviuion. Muiiutm'hr. I. <iij>. u. Uyii.. 1904, xi\. 521-^538.
HcKkiuuin. The (Ibul ruction «( l^lioiir by Ovarian 'I'umaurii In tbc Pdrja. Traiu.
Und. Ob«t. Sot-.. IWir, xxxix. ;I5I-3H2,
PTRKnanry with Ovnriaii Tuianui. London. lut>ti.
vox Mekr. CoiiMplioii und Almrt diirrh don AiisfuhruiucrcaiiK dvr bUiuc hi-i luifxibor-
cncr IX-fecl dor Vu(riii»- l»i'ilr»«u lur tU;h. u. r.yi>.. 11(00. iii. MW-lil.
KxltoKB.M'Kn. Ziir [jjhro von dtrn Anicebontiir.n unil iirwnrlKnoQ Vurwuch-'iiiijKti iiad
^'cntitn-TutiKcii dur Sclwide. B«rltii, 1895.
NuBu:. SuH|>eiiiuo I'lori witli l{«f«Ton<« to il« liilluonee upon I^«iK>]aiM.-y uiid Labow.
Tmns. Aiuor, tJyn. Hov.. 1896. xxi, a47-20».
Oldham. SAcriiUtioii of tbn I'lcnm. A Que of ItctroDoxion of ibu Gmvid L'tcmai.
Tnuis. Lond. OI>«. Six-., IHOO, i, 317-322.
OiAKAttKKx. Hyum untl Si<hwiuisorsi'baft. Vuit'v Ibuidbiich dcr flyn., 1IIQ7, ii, 765-
814.
Ohglkii. Zur I'ruifiiotK und Indikaliun der l>vitriDtoinio mhrctid der tMiWM^ftraehdt.
Ar<-h, f. Hj-n.. 1901. Ixv. 12tt-l«0.
PiHAHU. KibrumiM «l Krowunw. Annuli-K de fyn. el d'ubst.. 1901, Iv, 16&-I67.
Hruv. 1>c in gTOKwaw nmipliiiii^- dc kyutn ovuriqtic. PAriH. I8HB.
Kjbck. Vupiiiiikur Mnd Geburt. MonatMchr. (. G«b. u. Gyii.. IBDI. xiv. 237-2;M.
Riiiu Kritiichv Bvinerkungca ubi-r (icburtiMtaninstii turh VmttiiuUAxaiiOHiterL
Moiiatmchr. f. Gfih. ii. Gyn., liHII. viv, 477 Mil.
Siuuixorr. ^tiide <iu ihroinbus du lu vulve vl itu vi^nn. .^hiibIci do KVn- «t d'obat.,
1884, \xii. 447-467.
SCHK.NK. Uo('h^r»di^ friM'IiL- .\cliKtvrioiie der Ccrt'ix und do« Fornix in dcr 8Hi«»ntDrr-
HChsft. Zcntmlbi. f. <iyn.. 1900, xxiv, 161-I7(K
ScHROEDBiL Cori^luliuaiio orificii uxtenii. Lehri)ucliilerGebunBli., XilL AuH., 1809,
.Wft-fiB-.'.
SwaX. The Mana^eiiicnl of Solid Tumniirit of the O^'arioHromplk-aliiiic Preenancy. with
Keporl of n SutH^srfiU C&te. liiill. Jolum Hopkiim lluap., 1898, ix. M til.
Tiwmtt. Chlnirgi8cho ringridc iici .Myoincn dcr (;<tl>tniiiitUT in SchwanjeerMJull lUiil
Geburt, Archiv f, Cyn.. 1001. Ixiv. *57-5'i5
Wxiin, AlroniA Vnginn- complimtiitK i.alKiur. (llmti-tricA. IfniV, i, B'JS-A'Ji.
WliJ4AM8. Dystocia following \'cnlnil Suspunsion and Kixaliou o( the I' trni". Tram.
Soutjicm Siir^cul and tiyn., Asiociatian, lOOd, six.
\Vb ociutdcr a pel*is cxMitractvd wlwn il ia shorteDcd to such an extent
in one or more of its ilinntt^iont a» to uffnct iiinit-riuUy tlio mechanism of
labour, bat M-ilbout ii«*s§arily retardiiiK the birth of the child. AitMitlio);
ttn Liixniann Uibi ih tlw (!«m> wbeii tli« conjngaU vera mi.iii^)irM> 9.5 niitlme-
rtnrs or lc«e in B«t. and 10 ccnthiietreM or less in (p>nerall_v contractwl pclvos,
■ ll\*tttnf. — liiNKniucb a» VvKuliiis wag Ihc Sr«l to drwribe thi- normal
pelvis corrocllv. il is dear that tlie roiK'i-ption of t-oiiiraftwi [wlren oould
.not have vxifttctl before his time. His pupil. J. C. Arnntius (1530-15811).
[jiave tiM' lirxt aiintnmieal ilej^-ription nf iin abnormal pelvis, but \\\* A\*fo\-
IcfT e\ertt'd no apprceiaWp t'lTecl upon (tie ohstetrieal art of the period, for
Elhe n^prfiU thill .Xmliroisi; I'lirr •^Iill hi'li) In the old view of tin- gu-jwratinn
lof the pnbie tfones durinf; labour, and pronuilRated it in hin writinRs,
" Duriu^; ll»' wsl ii-nlHry knowlrdgi- of the *nbjwt ndvanet^) but wlnwly.
and we fiml Maiirio-au (l<l.t7-]T0y> i>talin^ that in hi* very large expe-
Lriencw Ite had oWrMil only two instances of eontraeted pelvis. In oik- of
Mbetir- rhariilH-rltri whs |H'rinilttil 1o apjily the forcep* invented by his «nde.
Imt failed to p)Teel a delivery.
Wc are inik'bicrl to Heinrieh van Devcnier for our fir>l kn'iu-lnl)te of
oootraeted pelves from an obittetrieal standpoint. In his New IJf-bl for
L Midwive*. which iip|>i-nred in 17<it, \w di'!'iTilH-il the two m'Ml iiKUal varie'
Itieti — tlte frenerally (•vntrncleil and the Hat — and diseu^^^ed the inllueDeo
Ivhich they trxerti-d ujxm lalmiir. Vnmi (hat time on mention of the subject
lia to lie found in all the teit-ttoolcH, i>e la Motle, Pueo«. and DioniH being
llhe obsletricianK uf tlw first ludf of the ciiihliTnlh eenlurv* who d«-voted
Imosi altiiilvon to it. The lanl-nniriMl ol)si^rvfr wan tiMt fir>t to |K>inl out Ute
ItatLal fetation wliivh rliaeliiti^ii bears to many cases of pelvic defonnity.
I M'Mcl imptiHanl ennlnbutions to the subject were made by Smellie. Id
piL'! trealiM' on The "nM-nri' and Pracliee of Midwiferi', puhliiiheal in 1752,
U* In W found an evcilleut doicriplTon of the normal pelvis, as well as of tlw
Imofii uoual rarictic* of deformity In which it in ^jubjert. lie aino laid down
nraetical nilw for H»e estimation of the degree of contraction, carefully
MeRcrttml tlw mM'hanidni nf lalmur in such cased, ami gave excellent pictures
■ •howinj; the influence exertml by Ihe contracted pelvi<^ upon the fcetal hnd.
I Rnudt-liHipif (ITtfi'lKlll) conlribuleil lur^rly towanl^ the development
lof our knowlojpi' of tlie subject, as he devoted particular attention to the
Idiagnotis of ll>e condition is the living woman, and Hhowiil thai il cQnld
L 879
sso
oBSTtrriucs
be (letectcd by nioaaurui^ Ihe dj^tanoe between rortaiu external bony pans
of Ihv pelvis by mvftii^ of a pair of cnlipen. lU' wiui Ui«:> finft in di^sLTiU*
the exiomal ii>iijii)nt<*, whicli ii> ii'tw generally known by hia namo, mid
taught tliat the lai^h of the conjugsu vera couid be readily and acvu-
niti'ly (vtimsliHl by dixluctin^ 3 iDch» from it.
At the Hfttiu' time G. \V. St«iii, in Oerinany, did good work upon Muno
what similar lines and dcvi«xl a pelrimetcr for the direct nicnsuralion uf
Ihc ('iinjnf;«iu vcni.
The imi foundation, hftwever, for the modem doctrine conceminjr
('CHttriu:t<-d |K'lvi'» uus laid by Mivhaclis und LilzniHiin. Tlic formvr vm*
Frofessor of OhHtetrics in the Tniveraiiy of Kiel from 1843 to 18.10. and
during that tinii- i-arvfiitly nii'astir«l Ihc pclvi* in l.UOO (■on$4>culivi- eaw-*
of labour. Ho dcsigiialt-"! as wintraclid all peltes in whieh the conju;;ata
vura nicn^nn^tl 8.T5 ix-ntimftrt-s or left, und found I'i such cosvs in liU
M>neti, a pcm-nta^ of 7.2. After bin death tie was succeeded by IjilMuann.
who euntinuod the work, und >iix>n ivpnrtid acvruratr mcssuroinents ba^^
upon a second wric* of l,OIHi ca^eA. He aihancixl the definition whii-h was
given at the bcpinniiif; of l\w pri-wnl cliupter. and considorcd as con-
tracted all polvi-ii Imvitiji n conjujnita vera of ID or 9.5 ficnlimetrt** or
Iww, accordinj! as th^y wero generally contractt-d or Bat, reHpectivek.
Judgiil by \\v9K- rrilcria bo found that 11.9 pt?r ct-ril uf bi.-' pelviw wi-n-
abnornjul, and ci'Iimali'd that hud Uiebaclis trniploycd the ^me stan<lanl
hid jHTi'ontJipi- wiiulii have bii'M i;i.l.
Litzmann's definition and criteria have been adopted thrnn;;houl thi-
world, und KJnec Ibo uppL-aruncu of hti' work scivulific nbKlctrtcian^ havr
devoted a lousidi'iabli- niiioiint nf altt-nlion to !be subject. To itK-nlii^n
all who buve added materially to our kiiowledgi- would hv cquivnlcni 1"
writing tlie bi>tory of obiHetrieK for the past fifty years ; but Xaegele. Kitiaii,
Scbaula. nnd Itreus and Kolisko mny be dt<rd us among the most impor-
tant oontrihulor.*.
Frtqurnitj. — In this country and in I^ngland very few hiati^ic:* ar»
available upon which to baae accurati' stateiripntt* as to the fn^ju'iicj of
contracted pelves, but in ((emiuiiy and I-'runce many of the lar^ lying-in
boiipitnlK BiippJy valuable data. Tin- freijuency of pelvic deformity variw
considerably in different countries, and even in various parts of ih* rtjrae
country. Thu». as i* shown by the following lnliU-. a frequency ranging
from 8 to 34 per cent is re|x>ried from the varioun (terman Hinicj'.
Ooonnor (Soort) ..
HeiuHiua (BimUu)
Ifund (Munich)
t^lch« (Krlmixsn)
HiehoAliii (Kiel)
KUtflen (Bonn)
LilstnAno (Kiel), ..
MtUkr (Berne)....
Weiiloniniiller (MMl>iirF!i
Baisch (Tiibinjwn)
Leopold (Unwlen)
oluwrvcd ".
7.U pvr nut
In 3.433
oium.
S.5
*4
" l.ftll
«i
9.h
If
" 1,190
11.43
tl
■• 1.796
13.1
U
" 1.000
I3.4S
U
" 2.000
14.9
tl
'* i.ooa
16
tl
" 1.177
18.7
H
" 3:£M
M
•24
14
" 3,374
41
Z4.3
U
" 2,416
u
FREQl'ENCY OF CONTRACTED PELVES
681
■
Winckel states that conlracleal pc^hm are (iboerTet) in from 10 to lA
)wr i^nt nf all (lerniuin vfoiueti, wIuIp S<-Uaula estimate*^ that l)i« roiiditioii
is mi^t with in ciih' wmnaii out of m-voii. The staliHtics from thv AuMmii
1 Empire aeeax to iodicale a lemer fret|uencjr than in Germany, as is shown
by the fnllowiug table:
Knapp (Pmgue) otwrved 'iM pvr«ent in 4;3BQ nam.
Ludwii! kihI Savor (Vienna) " S.M " " S0.IV2I "
Pkwlik (Prajue).. " 7.» " " a9,515 "
Ijsrfre mtIph of -italiwfiM are not availaltli- for Franco, TIm^ yearly
n^por^ll from Pinard"* ciiiiic. howi-rirr, inittcatt- a fri-qutiicy of about 5 per
cent, white Budin ^res R per cent in 7,68? cases, and Tamier 16 per cent
in Tlfi casiv.
Fancourt |tame«, in 1897, reporletl llinl only 0.5 |ier cent of contraeted
peJvM wre obeem-d in 3S.0CS cafn- of laliour in l»n()on. In view of thi!
fact, hnwpver, that every yi^r a coi»idt-rable number of CirMn-An i>«cUonit
urv pvrfoniiMl in that city for this indication, tt would appear probabk
that hii' TigiirM in no way rejirwiiil the inic miulilion.
]l htt« liwn a matter of ffi-ncral belief that in this country contraoled
[iflvi-* arc tcry rare, am! IVwitw KlaittJ in lua-l that he had ob>icrv«i only
thre^ i-SMii in hiH larjie expericjice. IjUt^k held a similar ojiinion, and uid
thai rhacliitw if nn-ly, and '0Mt<nniul»4'ia nmi-r, obMorvvd among natirv
Amerioan women. Hirst, on the other liand, Males that tltese dii«as<s are
not 'if iiiftxtpH-til ocfiirn'iMre. and that in> one who practi«^ oWlclric* can
fail In niM-l with nrcasional exanipltv.
We owe to KeynoIilK the first stalisti<»l slalement uj>on the suhjeet in
lliiH onuntry. In I8i'<i he reporte<l that In* ha«l oh*en-cd 1.34 per evnt of
coDtrsclrxt pelves in 2.327 women delivered in Bonton. His statemcoita,
liriWM'fr, fnxntl Im- ar<i'j>it-d willi rewnv mid a.* iiiidenwtimatili^ th* fre*
qnenrr of the condition, since be niesKured the pelvis only in those caws
which ni)Hin>l operative inliTfen-npe. atw) Ml «m of TOnifidrralion tivwv in
which labour terminated spontaneously. Had he taken the^e into account
be windd, in all proliability, havo rijMirtid a rr«|grncy of fi.S p«r cent.
Flint iilKierved I.IS per cent of coiiti'acU'tl pek«s in l(t,23S consecutive
niM« deliviTwl in Xew Vnrk: bnl hii" (t}rmv« cannot be eon^idiTcd to rcp-
reMnt the fremiency of the condition in this country, as his material was
rom[¥»rd almoMl cntin-ly of l*oli*h and KitiMian Jcwwcw, only 5i per cent
itf him patients licinjj nalive-lmm Americans,
tllrDrHcn. of St. Iv)uiis, rcimrtf a ff^tguency of 8 per cent, and Davin
*tate» tha^ (bore were 25 per cent nf cnntrocted pdves in l^'ii caM» cle-
livereil uniler his supervision in Fhiladelphia. Tlie tatter's estimates, how-
ever, wen- liax-d alnioni cntin'ly up<>» e.vli'rnal pelvie tnen.'turatinn, whtcli.
as will tie pninlol out later, gives an eiaSRerated idea of (he freqnency ot
tbe condition.
Since the opening of the lying-in department of the John* Hopkin.*
Hospital, it has lieen our rule to measure both externally and inlernally
the pelvif of cvcrv jm-puml woman who come* into our haiid«. In IKI'H
I nqwrlFfl thai wu had met with 131 coutraetitl pelves in the Qrat 1,000
082
OBSTETRICS
wniiipn rlciivprwl. In June. UNll. I !t«ve tlw n«aU» oliuinwl in 1,1931
nilililiiiiiiil I'list-K, mIiu'Ii nhnvttl rxaclly tlio -num.' pcrri'iiliifff tti^ iii Itip pP>-l
viiiiifi ri.'|jort. Thus, n InUI iif 2,I3;i caw?* jravt; n [M-nrtMiIn^* nf lU.l. I
Oil tlie iiiher hand, Rijrfis in the study of iW first 1.5'» caxes d«liT«rvdl
in my hoi^pitul wrvicf foimd ii | «•«•(■« I agi? of SI.Ti. This apparent di*-
cifiuiDev >' [it'iilialily due to thi> fart ihat in my M>rios somewliat (ess tli«u
ono half of Ihe patieDlK wore dolivfrcd in l)w hu>]>ilal, wlijk- in ltip^'«|
«frieii iiidy liiwpitnl cju-iw wn oonitidert'd. A jrreater niindM>r of oflntracirtt*
pelveii umdd naturally l>e I'spi-cU-d in Ihi? latlvr, as !t ik nnr nilr to nttwii|>t
to iridiKi- all dispc-nsan- )>altttnt» to ontnr t)ie Iin^(>i1al if they pn>!wnt anjTJ
abnurniatity. 1
One rf4i*(ni for thf mnrkt-d fn.'i|in'ncy of (Hnilraeiitl jx-lvc^ lu Rultimor^
18 probably <!ue to the fad that a larj-e numlwr of oiii- patients are vol-.
oufwd. Thus, in my wrrii-s H41 VftT« wliin' and l.iH'i hlnvk, !» compnnitl
with i*!f and 731 respwlively in HigRft'.- ^t-ries. In the former series there
were (i.H and lK.8i (ht iH-nl of <iintra»-tiil jR-lvi-s in IIh- twi> raw^, at^ win-
pariH] with 'J.'iH and .1i.8'J per <H'n! in t\w latter. In oilier wonl*, evcrrt
tenth to foiirtwnth white and even- third to fifth hlack woman of Iho poorrra
I'la-tna* of Ralliinore ha.-> an aliunrnml [i<-lvi». From the MatistioH of Rey4
noldi-. ('ro!i?en. and nnx'If — derived from Bo-iton, St. I^rtniis. and ItaltinMrsI
renpeotively— it would ajipeur Ihtil coiilriK't"! pi-lve* (x.riir in from 7 to n
per cent of the while women of this country. Henre, it will be evidenci
t]iat no one van pmctitt- obstetHcK without encounterinj; » certain number^
of such eftses.
Mfthoth of Piagnosis. — It is esKt'nIial Ihal the oiKtotriciaii bo ahlv t<ij
diagDOHe the exii«t<^Rce am) extent of Ihe condition before Uie nanet afl
labour, in order that ho may, a* far if^ po»«ibl«, decide in advance upon
Lthe pro)>er lino of treatment to In? insiitnte<l in twh tyu*e. With this
'object in view accurate [iclvic nicusurntion i^honld conslitule au intej;nl
part of the prcliminnry cxattiinHtion of pie^nanl wonii^n. a»i), in the pr«^
enl stale of our knouUd^. a physician who practiM-s ob«letrics withoull
pelvimetry niti^l be re^rded of no better than one wlu> treaisc tliMWom «fl
the heart and lun-fs without Ihe aid of au«^cultalion and percussion. I
At the jiri'/iminan/ mtminatiun, whii'li iihould he made four lo Std
Wipeks before the expected lime of confincmenl. the physician shouhll
nt^leet no nieanK of ohiaJnini: all possible data he-arinx upon the nml
(Iwierally i^peakint;, large, well-built won;i'n are likely to have nnnnal. amfl
under:>ixed women conlnu-I'd p(■lv(■^; bul Ibis rule by no nieana alwayd
hold^ >!ood, and it i^ not unusual fnr examination lo ilix^loxt «ume abuorJ
malily in Ihe former and piTfectly normal pelves in the latter. I
The ftail of the patieni sliould Im- carefully noted, since Ihe existenwv
of a limp or some jieewliar way in which the fii-l are plact^ upon ihe
floor may sitvc to direct attention to the possibility of a pelvic deformilv.
Marked ahnonnalitier< of the spinal column — kyphosin or lor<]o«is — «re als<L
suggenlivo. and even slipht decrees of spinal eiirvatnre should not be owrfl
looked, as (hey are not infretjuenlly of rhachilic origin. TIip more uran
signs ot rhachitis — deformities of the extremities. Ihe chaTarterMicallyf
shaped liead, and the rhacliiti*? rosary— should aI*o he looked for. Inqairy
METIlons OF DCTBCTIMO Ct^NTRACTED PELVES
6S3
t'lo. SIK. -UttVIX's
PCLVlHETm.
«hnulil alwavH be iiiailc a.- to the n^ at vlikli llic }iatii>nt fin4 li-nrnvH In
walk, und if xlip is found to liavo Wn hBokwsrd in (his rrogMft (he poasj-
hilily of ii rliachilic pt-JviH ii);<mlil he
UiTue in miDtl, even though t\w ukimI
t-xienial »iHUtftvtatii>n]i of iIm' (U«>
«ttM> ma; be laekin^.
If tlH> jMtienI haK nlrrady t)orm-
rhildn^u shi- ^ihouiil Ih- (|iii'>tiiiiitHl a*
l« thi* ooiifM! at previnux lubour-i.
nnil Dm- UiMory uf any wriooK dtllv
vnlty Hkhnuld alwavK imgge«t the po^
liibililT of an abnormal pelvic Ua
thi' other lianil, a ut-^niive hli^tory
is bj no meaofi ra valtiublp. as it is
a tn-II-known fael that in nxMlerate
dQn^<ee of peliie contraction the
fir>l latioiir tintv lie relativt-ly I'MfV,
while oaeh Kuccewiive one beeomes
more diflicult. In priinipHntni'
vnnien a markedly pendulous aMo-
men. or the aljwiicc of cngagi-nieiil
of ttit- iH-iid ill tlie Ia8t mAulh »f
pregnnncT. shotdd always Ik> nv
jlHrdeil ft* midence of the exislence
of a marked dieproporlion hdirccii
(he child's head aud tlu- pdvis until eiin'ful I'JiamiQalinn iihov«
ii not ilie vitxe.
Felvimelry. — VVhil« tlio above-mentiom-d oondilioun an* of vfttiie in tui^-
gnting lite [xNuiibilily of pelvic deformity, aeeiirate information as to il«
existence and extent ran be
olitaiiKx) <mly by iiiea-iurinjc
the pelvis,
Kor lliiM puriKHM* exleroal
or internal pelTimelry may be
■■niployii). according a* Ibe
memurements are taken fmui
Ihe surfnec of the \tttAy ur
through llie Ta^ina. .\i has
already been said. Baude-
ItKfjUc viu the fir*l to in^iiit
ujion the importance and
valiM' nf Ihv fontier, and in-
ri-nled the flr^t |ieirimeter;
which consisted of a pair of
cjiliper* or coiupaisses proviileil
with a scale to indicote the extent lo which tliey are opened. Innnmerablc
initnimentfl of tliis kind tuiv>> aince been dertticd, but, altliou^li mont of
Ifaen gire Mtticfactory rmiltft, before buying one it is always well to s«e
T'ELTIUBTl^n.
Ilia I HUeh
Pw. MO. — UrraoB or liuLoncc PicLvuivntB.
684
OBSTETRICS
Ihal the liUcl«fl are eufflcicntly curvvd lo allun- Uwm tn »pan the lhigl» of
jiloul iwlicnlK. Tliii!<. Itudin'* pelvilneler (Fig. 518), whkh can readily
W cwriwl in Ihe pockel, givee ciAtiflfactorj' rwalts m IJw vmA majority of
cases; but it cannot be uKed to measure fix external conjugntn in stout
wromtn, owing In thr Kliglit ciirvauiro of '\U blailex. Personally, I a*uallT
i-niploy the in-slnitiient d«Tis<>d by E. Itlariin (Fig. 51ft).
In estrrnat pririmrlrtf th« nnlinary meastirvmc-nlK arc four in nnmbif
Thus we ailoerlain atfui-ately Ihe distantn* Ix-tween lh<> ant^ior mipert
^in(^« of tlip ilium, bctwctjn the externa) edg^s of the ctvete of tlw ilinni.
Iiciwrt-n llie IwjiiIm of the I rocliaiilfru, and IflwiH-n tlio <ic|in».*ion Iw-nt-Ht^
the iitiinoiiii prncees of the last lumbar Tertebrs and the anterior «urfac
of the symphysis pubis. Normally the»c RKUuture ZQ, 29, Si, &D<d H cenli-
Fto. SUI. — McucintNu rite DnvrAMcit nvTwxEK itot AMratKut Rvpwuom Srmmi,
itpspwtively. Nafijielft MiKg(>^le(l cctlain otber tnoasuremenU, which"
Jt', bi>wev<T. an- not cnipioywl tmleso one BiUi|wcts (In; cxtetcna of
•a obliquely contracted jidviii.
When the pelvis i? lo lie nieaHnred MlcrnaHy. Ibe patient «1mmiT* '■
upon a Ix-il or tabic with her aMoincn and hips citlicr hnr«! or ii'.
only by a thin chemise. Tlie U'g» and upper portions of the Imdy rfiouk
KXTER.NA1, PELVlMFrritY
68&
Dot be exponed. Thr physician. Bitting on Uh- Hidfl of tlio botl facing iIk:
patient, gr«5p* the tips of the ptlvimeter Iwtwevn the thumb and aecnrnl
finger of each hand, the index fiiip-rs iM-itrj; left frr*. With the latter he
locsllB the outer ed;^ of tho anterior xujierior spini-i. and with Oio other
1 1». :>^',i. !kli.Aii:aix<i lilt IvXTKajiAi. Ciu>ji.t^i^
preiwoa th« tips of ttie peh-imeter upon them as clo^lj* &.4 poMible.
the diftamv brIwiKti tlH-m bt'iiig iiidiraltil on the w^le of tlie inftnimtnil.
In uieasurin); the dislanre betvceo the i7iii<' cresl», the mmt widolv .<e)ia-
rsl«l portion* on; locan-d, and ibc lips of tK- pttlvimvter applied to Ihoir
outer ed^cA. In taking these measurements, it should be JiorDe in mind
that the iliac spine* and crtvts pn-r^mt nn outer and inner lip and an inter-
nediale ridp?. and thai the diMani-e Mwwn Ihe outer lipn of lh<) npino
and <Ti"<t* in 1.5 to 'LH centimetres (;reali>r than that between the inner Ups.
]u dett-rmininif the diftance Iwtween the trochantera, ttie patient's lugx
harinK lieen bron>rbt into close apposition, the examiner carufiiH}' palpate*
upiier jwrtion of the thijihn unlil tlw mo*! protnini-nl fmiiil:- of the
nchanlt'D- arv fi-lt on eitlw-r side. Ilii- tips of iht* [x'lvinieter are then
ly pre^^-d ajfltin?! them. -■«> that they c*>me into the clo*csd jHimihle
iilart with the booe;, aftt^r which lh<: niea^ureotenl in read off on tlw
Ih.
686
OBSTETRICS
Tilt- OMKmai iwDJty^lP, or Baudi'lwrjur'i diameter, csleode from ihc
(k'|ireiifiion \uA bc-m-ulli ihr sjiim- of tin- lart lumbu- vertebra to the antt?-
rioruntl up|HT ninr^iti <if Ihc svtiiphysis pubis. For this Diearturemcnt, Uic
woman sIkiuIiI lie on her side with her back tovmnU ihi- pb}-i>iciui). A«
» rule Ihc «|]im' of the Isxt lumbar vertebra is readii^v found hy palpotinje
lh<' spinouK prncoiiAes fraiii dbovc downwanl. Iht;
hinl Hiid mo§t prominiMit bcin^ usuull^' that of tb«
In^l luiiil<nr viTtcbrn. Immt^ialel)' lieoeath it U a
»li(!hl depression, vhich fonus the postvrior cxtrem-
itj- of Ihc diniiH-fcr to he ni«aKured. Into tlii* one
li|) of the jK'lviineler should be inserted and held
firmiy iii pbtee. while Ihe iHlwr Iwnd seek* I'w
up{H>r iiiar)itii of the it}inphv»iB pubis, and 3nnly
applies the other tip of the pelvimeter to it. 'V\w
diKlaiiet! M^paraling them ia theo read off on the
scale.
In »toul women eoni>idenih)e dilliculty may \k
experieuced in locating the posterior extremity of
the diamcler. owing to tlie fael that the spiimuii
protisw of Ihe Inst lumbar vertebra ennnot tie id<-ii-
lifted. This diHii-ully con w^ually W obviated in
ihi' folUiuin}; nmiiner: A line 'n drawn Wtwivn the
deprcMiions marking the attachment of the fascia
to tile iUjHTiiir |»ix*lerior wpinfw of the ilium, and
which an? uiiiially clearly vinihle. A point S.5 een-
timetrcK above the middle of this line will unually
cnrru>]Kmd to the point rei|uiffd, and will lie at Ibc
*pex of H rhoinboidal tifiure — Michae]i«'a riioinlioiil
— whoM' iippiT inid lower margins nn- formed hy
the tran^virce and sucru-spiiialif and ;^luleu4 luu^-
dft' ri'»i)i'clively.
The Value uf Ktlemal /'f/WiNfffry.— A* was
said alxive, the external eonjugatv was firat de-
scribed by Bau<ieIoc(|Ue, ulio stated tliat fiy dwliirl-
in^ :{ inclu-K from it the IcDglh of the true conjugate
eould be accurately estiniat^^d. He based hi* 'ipinion U|Hin the fiu-l (liat he
had rarely oluu-rvcd u difference of more than 1 or 2 linei between tlte esti-
mated and the netunl <v>njiigata vera in 30 to 'Ah ctsf* wliicb Ite had nieaf-
ureii dnriitj; life and al autopsy. Later experience, however, lias !>h(iwn that
|{aud>>loi>i|uc~.i iiineluKioni^ ncn; erroncou*. and lliat the length of the exter-
nal conjugate gives a very imperfect idea of that of iIm* eonjugatc vera,
since several tnmlifying factoTs may exist. Thus, the amount to he deildcled
varies with the tliiekncs« of the sacrum ami the symphysis pubis, and also
depends, to a great extent, upon the elevation of the promontori- of the
sacrum nnd the length of ihe spinous pmct*' of th« last lumbar vertebni.
Fnfortmiately, lhe»e factors cannot Im* accurately estimated in thi* living
woman, and Skutsch lia^ Awvin Ibnl in UK* \n-\\y* rvamineKl bv him Die
diffewnci- lietween the leuglb of the external and of tltc true eonjufrali^
EXTEllS.U, PELVIMCTRY
687
irarHil from 5.o to 1" ct^litii(!lrc«. Riiitu<i-t tian rvcuitly arrived at similar
k lYiocliiBioiiH after Bliulyin;; 1^0 ilri«<l pvtvtni: and I baw in luy patutraiiioii
Iwo Apeeiuteati wliust! tnu.' (.■<>Djitj;aU>« art' uf Lt|ual length, but wIiom; vx-
iKnul ranjugalm ithuu- a difTuri-tict.- of h i-pDtimcIrc-<.
Hut nllliougli llic miit><iin-im-nl of lln- rxteriisl cnnjugate drxw not f^w
un oct-tiraie infiirmaiinii conwrninj: th« lenj^h of the ctmjugata vem. it
nc?«rtbeJess enables uh to draw c^tain important c>r>nelu>'iotL'<. Tlin», gen-
«ralW speaking, when the former nu-amiri-s tx-twoen 20 and 21 centimotnw.
the ennjugaia vera will rarelv I* found to be shortened; when, however.
I it measures between 18 and 19 cent imel re*. Ifw eonjujrata vera is shortene<l
in almut one half of the eHH-s; and wheii it i.i
below 17 evil ti met rcji ftiUic contraction is almoxt
uniformly present.
Pm. am.— HKjunuNa the PuumcAL OoMiiMaT*.
It waK formerly IxOieTed thai one fould form a fairly accurate estimata
of the lenfith of the trsn«Terse diameter of the suijorior utrait by maldog
ivruui dedarti'HK from the dii>laii<.-ii> between ilie unlcrior su|)erior xpinea
■Ml between the vnsts of the ilium. The ineorreotueM nf thin concliuiou,
bomber, u*a« fir«l demon)'! rated by ScfaefTer. who showed that lb« trana-
twiie diameter of iIh- superior strait may bt- of the ttame length in two
pelnM, while at the name time tlw diittaiwat tietween the iliaw vmtt^ T«ty
by m miKh as 3.3 centimelif^i'. Thi* Miuree of error depends in gn*i part
BprtB ihp angle wbieh thf ilta4> fo*« Tonus with the rest of the innominate
(•me, aiu) (be extiin to whJeli itp. anterior portion is flareil out.
Tin- di^latiee iii-twfi'n the IroehanterK is fhe least valuable nf all the
ntemal [lelvic mwuremenu, n» itn h>n^1h depends, to a great extent, upon
688
OBKrKTlUCS
llio aiiKlf which ihc iiwrk <if the femur lorme wJlJi lU iJwifl ; mhI w a c«iwe-
ijueDce its ahorlenittg, iinlws wry marked, does not indicate a correspond-
ing decrcflM) in tlio tran^ivenw
diameters of the pelvic cav-
ity.
Xererliieleti^, dvHpitt-
many possible inaccuraci*-*,
lli« cxU-rnal moiL%tin'iuHji-
anj of coDiiidt'ralilc valiif, in
lihat Iboy mtvc lo tmltraU*
witJi loItTBlilt- c<>n«inty the
variety of pelvU with which
niH- has to di-al. Xortimll;
Hw! dii'lunw' lM?twwn tli
apines is 3.& to 3 centiininm
!(«» Uiun that Ix'twwn ihe
rrestfl; bul in tlie rhachilir
pelvis, owing lo llw HariD;;
of the iliac bones, thi^ pro-^
poriioa beconUM derail;
am! tli« two nitasun-nients
approximate oni.- anothi-r in
Icnt^h. the foriutr rrt'ijuently heing tvjiifll to, and (M-canionally pxi-wilin;;
the latliT. If, himt'vrr. both nu-Uf^iin-ments are fom^idcrahly Ik'Iow ihe
normal, but preserve tlidr uauat n'latioii to on« anotlier, and at tlm same
Kia ML — MukBcaiKo nnc Ij^moth or Duoohal
k
pm-
ents^
Ha. we. Fi«. 827.
, SQfl, A37.-'l>iAnluiu Miovisn V«BrAnA)C« n> Lknutii op Di«<ii.>n«i. Coyjiiiu'rin
i-KSBKVr I'l'os nil: Ilrinirr AXn Isc-i.iHATlaH or rut StMCKVntH Pi'Ibh.
limo Uie external canju|i;ale is sImi shortened propurliitnali-ly, it U p-rtni^
Hibli- til niiH-lmU' that tin- cnlirv [w-lvis mt-iisun.-« k-litu' norma) in all il>
diaitn'ti^i-', or, in nlher wcird*. i" j-i-ih-mHv cmlriuttil,
GoeiiiH-r, in 1901, dcnir>ni^truu-d ihv fallacy of attempUoj^ >■■ diaffiin^
INTERNAL PEl.VIMETRY
680
I
the exbtlCDne of n nintrartml ]wlviii by nxteriml jx-lvimvlry iilunt-. .Ktler
meofumg th« pslwnal di«invl<>r» in lOO caiJaver». he oonipAred them with
IhoM.* tit the pi^vir raiilv »s rr-vcjilfid ni mitopxy, niiil tnnml thai uh'TOM
the former troitld mviii In indii-ate tiint nearly all of the pelves were eon-
IrftcUtl, thp Inlttrr pnivnl Dial «ucli vmn thp enw in only ^ ijiKtniU'^ ^
own oboervatioDK bear out Goonner's conelu^ionn, particufarlr in cnloiiredj
nmmen. in whom, had vre e«lim«tv<l
11m> frw|iK'iii-y of ft>ntT«clnl |H'lvfti
from pxtt-mal im-asiirt-inenlo alone.
HOT figure* wuuUl haw shown u pwr-
ivQta^ of about T5, wherea* inter-
nal pelvinictri- showed thai in rcnlily
it w«A only IS. 8.
^totvilitHtanding all theiic po««i-
lilv fallariw, exi^rnal iielrimelry it
of eonsiderable raiue to the oWtetri-
eigu uid ohoiild not lie n«^lwted.
In private practice it is my rtile to
<-nipIwj it at tlw pR'liminary exami-
nation four to eix veeks before the
rspiiHrtI datp of mnfinenH'm. If
liie measurement** are approximate-
ly normal, (tie |Mtii^nt iH-iiig a prim-
ipara and the child's head fixed in
the pelvic caritj. internal mensura-
tion is not prnrtiieil. Rut if they are atmornial. and especially if the exter-
nal GonjuKale falU Im'Iob- 18 i-enlimeln.'^. internal pelvic meaKuretiienU
whoiild Iw rtworted lo. no matter aital the piMition of tlie head may be or
how many children the patient may have home pni'iously.
InUrnal I'ftvimrirg. — In the va«t majority of abnormal pclvcd the most
marked deformity afFectH tlie antero-pmterior diameter of Uie superior strait.
Fio. iUS. — DiAuiiAM titii>'vix<i KrrscT or Pi^
MTI'llI or PHOMUKtuHy or tHAOll ■• i'n>H
inn I^CKirraorTNE UtA«uNAj:.C<>NjiiaJkTK.
Vw. MB. — IHviM^ Pn-mncnca.
I
and a* a onniwquenw we are ettfieeially anxiouf In arrive at the Imgrth of
ihe L'nnjugata vera. Unforlunately, thiK eannot be measured direetly in
Ihr living Woman, and in practice it \* cstimaltil by mi^aiiurin^ the diagonal
conjugate — the distance from th« promontory of the eacrum to the lower
690
OBSTETltlCS
iu«i>;ia of the 6yniphjr«is ptiUiij — mid niakiu;; » <'orl8in dmluction from ii
Tlii^ meitiod wa* iulroOiK-txl hy Smcllk- and ulill fiiilher vlalx^ruUri bj
fiaiwteloeque.
Mmnurinii th« Uiagimal Conjugate. — (''or this purpoM' tliv putieot ehouldj
bp placed upait iin examiniri); lable with )i«r knees drawn up. If t^ can- 1
Tto. asft — Mr.Amimxo (Vinivoata Vkra witii Stimctfri PcLrmtrrtm.
iii»t U' ifiiivt-nienlly arrangtti, bIig lihoiild be lii«>ii(;bt to U»e wljte of th<' l*"l
and a (irm piilnw pljit-cd Ijcmwili Iut l>iiiti>ck!i. Two oarofiillv diKinfivlnl
llnj^t-rs nm ititiixluced into the va;,'iDa. anil thi.> anterior surface of lite
SHonim is nii'thodicaUy palpiitt'i] frcmi Ik'1i>h- upward, und its vertical ami
lutirrat (.-urvaturo nottnl. At the .lame litne the mobility of ttw onccyx
chould be twte-d by seiziop it between the finfrers in tlie vaj^na and the
thumb exlerrialty. In ntmiiiil [wives only llic lii»l lhn-c hutaI verti-
l>rif lan )»■ fill witbmil piiHhin>: tip ihe pi'rinirtim. whereas in markedly
contracted variclicn Ihe eiltin.' anterior surfaoe of the Kacnini is ixwlily
ncceiiiiiblc.
In ordinary fuses, in order to mea-mre the diapwal ennjnftate the elbow
mimt U- depressed and the perinieum forcibly pushed upward by Ilip
knuckles cif till' tliirrl juiil fourth finpers, while Ihe index and t<t«i>iMl fin-
giT» arc held iiniily tnjrether and dii'wti-il upward in the diroction of the
umbilicti*. Tin- promontory of the eacrum is soon felt by the lip of the
second fin^rer n* a projecting bony Tnarpin at Ihe lia«c of the -tacnmi. With
the linger closely applied to its most prominent portion, the hand is i4i»-
v»i^ until the radint surface of the index fingiT if broughl into cfcw*-
rontact with the piihie arch. This point i* Ibpn markiil by tlie indc*
finger of Ihe other band, after whieh the finjrP« are wichdrawn fnim the
vagina and Ihe distance between it and the tip of (ho second Bngrr i*
ineasitred (Fi^H. ■'"'21 and .Vi.l). Thi* mennnri'inont give* the diagniuil
conjugate, from whioh the Irui; coDJugate is e«timati-d by dcdiidiag 1.5
INTERNAL PELVIMETRY
o&t
i cmtinwirv*. ni-v«>n)ing Ia t)»> heijilit and iiidiiintinn of lli« 8jriu>
phyeii' pubiii.
Ill tliJK mctlKxi Ihi- pnililiiti niiixii'lH in tvtinuitin^ tlti- lintf^lh nf <>oi!
^Ulc- of s (riangli?, the conjiij^ta vera; llic olhtn iwo^ltu.' diagonal con-
jugstf «ih1 Itir htnglit of tliu svi»phj':it<i pul>b> — being ktiowii. Wftni we
•lile lo measure satisfactorily the an^U' formed bptwcen the ayiophysis and
(x>njiit;ata diagniiali*'. lli<- rxiu-t k-iij^lh of the true lonju^lf could tvadily
la- ftMiTtaini-il l>y lUv urdiniiry rxiU:* of lriy»Dnint-try : liiil iidfortiinalL'^y
thU eannol be done in ilie living woman, and for practiral piirpoiM.>e it
Fuffin« to MlimHtr the tcn^h nf i)m' diii|?onal conjti^tt- as ju»t d<w;ribvd.
di-dui'iin^ l.^i <mitiriiHnv from it if the puliix t* tow and .ilightly inclined,
and 'i ctrntinietrei^ if it i» high and ha.^ a marked inclination. The ratioiule
^^f thi:< w clearly Hho«-n in tigs. 5S6 and Sm. The length of (hs diagonal
^knnjugale aI»o varim a<«fpn1ing to tlie pwitinn of the promontory, being
^■oDg^r when it ia elevated, and t'tVr vfrxo {Fig. j38>.
^P Since live lime of fj. W, Stein {!"T?). numcroiii' in>itrtime«t« liave heeii
deviwd by meam* (if which ihi* conjujrals vera could lje directly measuntd;
^bul anforlnnalely the majority of them, while Ihc-onrlieally nirrcct, are
pru'tirally luwlcm on account of llie dilfictilty of their application. I>c-
criptiooB and illustrations of many of IheM iDstrameiitit arc to be foiuid
Hkutivh'M ejcct^leril monngra)>h.
SInitfch, in I88fi. de«iw?d a pelvimeter by which tlie e<>njiigHla vi*ra
i>uld be indirectly though acciiralely measured (Fig. 530). Uirst more
Pin, KII. — HiMtrVi PKi.riMBTrii.
dMferiboil a Kimplv device for the same purpcw. Both of tbeae
istrumenta give Hatiafactoiy renaltn when properly atvA. but their emplor-
nent i^ UMually xo [tainfiil to the patient as to require the ailmiaixtTation
of an ansstlwtic. Naturally, ihercfnre. they an- ttmployed only in those
nn cases in which accurate information mncerning the length of the cmi-
Bta vera is nrpently called for.
Neumann and Ehrmfest. >d IflOO, descTibod a complicated instrument
^-the pelvigraph — by means of which the contour of the anterior and [ki»-
692
OBSTETIUCS
Ivrior w«lli< of tlip peivi* can be graphically ntillini?)), mid witrnoc (hr rxart
1piij;|!i of the varionti aolcrci-piwlfrior diaiiK'tprfi can b»> mailiiv aM^Tlainpil
This imtninit-iil gi»«w fxccllf-nl result*, tmt in fw r4ni|»li<niltHl tor uw i>ul-
8id« of a «-ell-T«gulalcd hospilul.
Since IHII4 n-ncwwl iiuen-st ha« Iwen iiianifwtH in the dinct mon^u-
ration of the conjugata vera, ami U-ylwk!. Ahlfeld, Zweifel. and other* huvi'
dtriscd nion- ur If-ss ^ii:i|)li? iiotniinfiils for the purpose. In the hand)'
of tlieir inventors such iiisiruments have proven mwt .tatiiifavlnry. Uiil
olhera haw found that (heir miployincnl g\ws no morr accurate resulU
than can be oblaintt] by the old manual ineihod.
In ID05 GaT^yu^ki dt^isod n nioKt in^n-nious apparatna for ineasurin;;
the hcif;ht of the symphysis pubis, as well as tlw- indinalion of thr laltrr
to the diagonal oonJiigAti', wliich theoretical ly should permit the accurate
estimation of the length of the conjugata vera. The &c<;uru-y of the instra-
ment, however. i« d<'p<''nd(!nt upon *o many factors that it cannot be r«cain-
inended for general use,
Mftutiring ihi' TnimvfrM DiiimHcr of thf Superior Strait. — This diam-
eter cannot be measured directly in the living iroman, aiu] a« a nik for
all practical purposes it i» ate-
Oisary only to palpali? tlie linea
tenninali.-i with tJkf (;3(iiminin)t
fln^Krif. and ii> this way rough-
ly estimate the outlinv» of the
superior strait. If, however,
we wish to learn its eiact
length, it can W uiKvrtaimM
indirectly by the employment
of Skuti^V« instrument.
Ijiihlein aitomplM In erti-
mate Iht- size of this diameter
hy adding a " e^n.^lant '* to lhi>
length of what be de.'-ignated
iu> ill** a«'i*nding oMiqiie iliam-
L'ttT, which extend.^ from the
loMer margin of the sympliy-
sis pubis to tlie anterior and
upper margin of the sacro-wi- —
atic notch, and which can \f^
mcHKiinil by Ihe Knger. A«^
the investigations of Stein—
hrecher «how that tlic wie oH'*
the " con-itant " vnriea in thc»
iHTeral varieties of df-fonn't] pelvis, it is apparent that only appnninut^
result* CTin be obtained by this nieanit.
Conirartion* af Ifie Pftvtr OiilteL — Oontractioos of the peMc nullc i
occur much more fretiuently than i* generally IwlievoiJ. and. ni- they m«^
give rise to aeriou* dystocia, should receive more extended consideration lh«i^»
thq- aro usually accorded. The contraction may be liniilwl to cither tb**
i
Flex. &32.— Mkaicmvo TnANsmiLE Diauvtek or
SVPKKIOH SnUIT WITH SkVTaCtlll riLVIMCTE*.
INTERNAL PELVIMETRY
m
atero-poeterior or the tniu»rciw diamoli.'r, or may involvp th« tiro, and lie
fitluT Mm mot will nr irregular in character,
Leariog out of oont-idcration ihv cji.-'ts oxmctata-d with Icypbotlv, o«t«o>
nudaeic, obliqudy contracted, aod other rar« varieties of abnormal pelr^iit.
0.0
I wit
Fki. U3.— P'U'atwmi or Pvaw Am-d.
it frcqiwnll.r happtnu that pronounced deformity of the ontlpt oecnrs in
pdves with otbenviik? ap|iroximitti-lr normal mt'neurcmi'Ut^.
lu -57^ cnnoetruttTp iK-lva', whicb I examined permnally. the di«tUKc
between tbi> lubera i«chii mi?aMirt-d 8 n-ntimi-lnv or li<6S in 49 in^tanoeA.
p«m:DtAgv of S.6, and oecuritd vrilh e<|ual frecfuency in bolli whiti- sod
>Dred woin«n. In 895 white women there were 86 funnel and 17 con*
pelves of other varieties, a percentage of 8,8 and 5.8 respectiTely ;
in 2TT cotoHP-vl women thp fignreti were 83 and 84, a percenta^ of
8.3 and 30.3 rei<|iee!ively. In other words, flO pt*r cent of all abnormal
vt» in white women an; fnnmO shaped, as oomparetl with 21. ,5 per rent
colonml women, .Accordingly. ahnormatitieA of the outlet will be met
'with in every twelfth patient ; and in wliite women occur more frequently
m4
OnsTETRICS
than all other vamtios of contniclfd pptris combinrd. whil? in rolniii
voincn they rnii;<litiilr only fine tlflh of ihi- iolal hiiiiilicr iif ruiilnK'liipni'.
Meamtrln;! lUf Iiiariirt'-ri "f Ihi- I'rlrir (iutUl. — hi vi*?w of the fro-
(luuicjr of abnuntinhliv-'' of lint oulh-l, llit; ((fhTitunaltun iif thi,' >[>h(v
I'iCi. IkH. — PALrATIOM AP 1«|-HI*I. 'I'lIHKRnHITIIW.
alilo tietwooii the tuliera iM-hii »tiouh1 Ik nuuiG 90 ini<!gnil pari of ll
rinitJik? VAU id! lint ion nf tV- jM-lvid,
An approximate Uloa of iho n'lze nf the tranavcrw rlionteter nuiy fmdii
Iw nhlaiin'iJ hy Sdlhcini'* iiirthotl of piilfoitinf! the pubic arch, Kor tl:
purpai«e, thi> woman liavinj; ln'oii plniiil in the dor-^l piiKilton vrilh
hi(w itt th« itliif of till' IhxI or <.>\aniiniii;! table and tlie tega drawn i
the inittoi^kn aiv miJih-iI hy i'ith<>r hand in tiuch « tnaniuT tlwt tlw
of the tlninih t-onu* in cniitact with the iwhial tnlii-nvtity. while '
thlimh fiillmo llic i-niirM- of tho i>;chi<*-piihii- niiTiu* and Uic other fii
grasp the side of the thijth (Fijf. 333). In ihi.* way the nutlines of fM
piiliic ar«h are vory «iti*fHtt«rily indicated by the position of l!ip thnimrTit
fio that with a little i)ractice one can readily determine whether it ia mr-wu/
or con tract wl.
If the pubic arch iit aUnormal, the treiuvertte ditindcr nf the <iiif/«
ehoidd lie acpurately measured, and if it be 8 centimetres or teas in Viigii.
vtill other iiicni'Hrcnii'nt!^ should he miidi^ For Ihi* pnrpow tin- rep'
sbout both tnlxTa isohii are carefiUly palpated with the thumba, and. fJiM
ISTEBSAL P^XVISIETRY
fl05
\\m pointx onnvupnnilinK 1" iI>l' «mU of IIk- iliatnetiT Iistc Wn locatoil.
[IIh* tltainU* itrr brought into ^lK'll « jHifilmt] llijil thi^r miJIs n'pnuvnt the
pro Inn (•at ion of Ihi- inurr MirfHiv '>f cai-h ischial IwDe. An SMHiAtant itifrn
DK-BKunw Ihk- tliiiUincxr Ih-Iwc<ii IIk'Hi I)V nKiini> nf ii Kuiliri or diIht t^uil-
«IJe pelvim^tar {Fi^. ^3'i). If an atwMtant is not available, equally utis-
faclon' results may be obtained by ttsing the nutlet pelvinu'ter whtcli I
liurc (ifviiutil, in whieU the tijw ot Ihu blad^ are aliaehtsi to the thuinl^
liy atljnhtaNe rinR* ( Kig. Mil).
, Dirttl mni'iircm'-iil bv tiir«ii« of lb« pol[nitin^ fingftrii !■ i« 1m> pr*"-
lierrwl to the niethixl ilf>i<TitH>(l by Scliroeiler, in which, after carefully
|>ul|iutin>r the I«lj«'roKili<-K. mark" an- inHile wjirin the nkin by miViiK of *
ikTuialofj'ipl'''^ peneil at points apparently i^nesponding to their inner
marfiinii. aftrr vhich the diMano- belwceti (he twru nuirkt! i* mi'Sfiurcd.
Id view of the ela>ticity nf the .ilcin it iuu»l, however, freijuently tiappen
titut coiitiderable distortion will wvmt a* mon oa the provnre of the ringcm
Lis removed.
P The an tero- posterior diameter, between the lower marftio of the syai-
)ihy«i6 and llw tip of th« sacrutn, is reatiily measured by Brpisky'i* method.
I
Kio. KU.— UitA*ni>»o Twx DwrAMn nxmine mii Tnuiuk Im-mii,
In lhii>. the woman having; }»xn placed on her oide, one end nf a pnlrim-
Hcter 16 introdun'd into tho vugiiia atut nppliii] to the tower margin of
^nhe irnnpliyxic pubin, and the other end applied over the lip of thi; «icrum
^KxtiTDally. A dcdnclion of I.fi centimetres frnm this mesMUrenient will
^bivr n loU-nihlv atx-nrate idea of the len<.'tb of lliic diameter (Fig. 53T).
■^ I'nforlnnali'Iy. liowevcr. tbi>! know led fire i» of but itlighl prarliral tiiliK-
in i)ie c.tu& in which it is particularly desired, for tlto reason that when
lUw tran*v«Tfif diamvti^r i» markedly shorteiMfl, the pubic art-li iMwomci' to
irri'w tital it ia not available for the pa^iuif^e of tin' head, so that in
696
OBSTETRICS
(!.\ln>int> <-iwi inilv a nmill M'giiicnt "f thr occiput ran iMifn;^ brti
llie tuWra i*cbii, Conseriuenlly the possibility of iU birih nill d«p
Vtp. SSO.—MKNHtTttATtoM or Bi»>t«<'KUL ni^MrTKH wini WllJ.I*U»* pRLTIinrtML
I
H
Dot upon the ien^ih of tbc aiitero-postcrior <liami'ler of Ww ouHd. bi^^'
mllH-r ii|)i>ri llif sjiacf nvailnble lietweeii a line joining tlwr tubera ischr^-^
and tbi- tip of tbe Mu-ruin. Tliin »Iianiet_*'i
wai* ttescribec! by Klien a^ tho pontori-i""
-ngitlal of tbe oiiilcl. ami otiuiibl be nui^K=^
iintl in all cam'* \n which t\w Xnatvew^s
(liametpr mea*un* 8 centimetres nr i-— ^"^
■Jlii*. lioii-OTer, r\i]uirn9i tlift ii« of »
cial instrument, an<l will be consideoi
grc-flliT detail under llie heading "f t'
nei Pelves.
Um of X Rays. — After (be Altcar
of the RoenlKon ray ami tlie denwn*'
linn of the varicu'i uso to which it mi
be put, it was Thought pogtiible lh«' '*
might a))T0 afford s Taluable method ^
invi-^ti gating tbe .«bape anil nize af lb»
pi'lviK. Budin and Vurnier, in ItfllTil^
Vta. A!I7. — Brkukv'h Mciaoii or
Meiaciumi Ammo-pDCTmioB I>i-
AMrm or Pai-vto Ovtu^t.
CLASSIUCATIOS UF CONTUACTICU I-KLVEii
cw
porteil tlwir e:^|M.'rieuoL- with it, aiul i>]ti>we() tliat, wliilt> it often givf aa
BcxccllvDl iiUw of iU Klinpc, Dm; ii\ctu- as to 6U!o abtaiaetl b;^ it were
HcrroD«iu& A coiupti-hemivt; review of ihc Ulenture itpon the subject wiu
HfivcD by MitUcrlicicu iu 181tK.
~ Bouohmiiurt, in 1!)00, tiuviMtl u tiicthix] for which ho ctaimoi ex-
oolleut re.-<ullH. Up to that time all ra(liogra[i)t.-> of ilie pt-lvin gave «!itt-
tortet) id«u id nrgur<] to tti^ <liiiiftufiotis, owing to iho fac-t tlut th«
fttcruiti Iii^ miK'li avAivT t\w Miuitive |iliiti> than tho ityph.Vi'iH, and ma-
hi-qufntly the anterior jwrtion of Ihc peltia was enlarRod out of all pro-
§ portion (o the piii^torior. This dt-fcx.) n-iidfixxl out of IIk- <)uc«tlon any <
allMnpt rn Mtilijtc Ihv radiograph for purjiuMw of mcn.iuration. Buuchs*
c-oort nigge»ted that it inigfat be obviated by placing a rectanfnilar metal
frame sbont tltv woman'^ hip«. more or lean corni>pondin^ tu the plane of
tli»e fiuperior ^niit, (-ach sidi- of Ihe frame beiny marked by lieotationfl 1
n'litimi-tri^ apart. ^Vhen the picture wn>. taken lhc»<- would al(io be nepro- j
doccd, and on ironuirling the c<irn-j<pond iug jioinUt upon the four tiidea'
of ll>c pictnrp a definite idea could be obtained aa to the dimensions of
the superior strait. A ximilar meihod ha* bw*n omployiil by Fabrc, of
Lyon», »inn> 18!)9, and aecordiog to Uonnexan has given moiil ealisfaclory
renultH.
• CloMifieclum of fonlracUd Pflvea. — For the first clamificalion of abnor>
Bul (icItm w« are indi-lilitl to f)i^-cnt«r. who dtKtinguii>lM-d tim'e group* :
too lafige. too timatt, and too Hal pelven.
3Io«t nHM'iil fllti-tnjiti' at daiAiricvlinn have been ba«ed upon the ehape
of the pelvi;«, without taking into enn^ideration the ffiitiologica] faetom
which lead to its production. This method was adopted by Miehealis. and
reu-lM^ its grCBi«*i jH-rf eel ion in LitxtuunnV han<U. Tin- former thor^ !
touphlv realized its inherent defects and regretted thai oilier niethoda of
clnuifioaiioii could not \<v employed. Kiiian, Bu»ch. and Siebold had p^^^-
vioiLsly rec-oj.'uiM'd the mTeasity of tatting into account the wtiolngical fac-
tor)' which arv concerned in the pnHluction of pelvic abnonnalitiw, but
their knoaledge wan tnii meaKr*' I" permit of Hueh a courHC.
It was not until ISSfl that Schauta vau able to sugRest a fairly satia-,
factory aittiolofrical claMiticuti'm. whi<'h mkui "btaimxl jieneral aecvptance,
althouffh if was still far from ideal. Tamier and jBwIin. in tlieir treatise
P'^kuikI in 1898. followeil Komcnhat similar liw*. lirt-us and Koli^ko do
oi coiwider that either iit perfectly sati^faetory, and have sujjgeited a
nbsiitute for tlwm.
Owing to the fact that nor knowWge of the fnmlamcntal fart'm nndcr-
lyiiifC Um- prodnelion of many forms of ahnnrnial pelves is still very meagre.
and (Ki-a*i"iiaIIy tTilin'ly lacking, il t« apparent that al Ihr prcwnt time
no a'tiolnjrical classi Ileal ion can l>e perfwily sat irtfaelori-. ihnuKh from a
jiraetirwl point of view (Ik- one eraployetl by TarnitT and Htidin would soeini
to approach more warly to it.
For convfiitcncv »f referenee we thall give the clasHiticalions of Tamier
' mmI Bniliii anal of Sihaulu In parnlb-l iiilumn*: but allliouKli wf nhall geit- ,
ri-rally fnllnw Iho former in di^xribing the iwvrral varieties, we sliall not
[utwnuiarily aiDiere to llie oider in which the dilTrrcnt gmupA an* arranged.
trvft^^
.tfIA'
Ci>a*^
«»*<:
*■««'
>tiP
B«
oiS''
\.
KduW
l-tfi»-
p.-
\
^•' ?<r>>^
o*i<^
peP
A^"
,««ai"'
tn
\1^
BodU
^rifl"
■^^-^
^d
SCO'
1«P'
,bo»"-
^.. "f^'Sv':^-
col"'" \
A'^^^rsoe^'"'
111. ^-^rtioul^r.
ffi')
.o*>*-
xw.<^-o..«y^'^o>
»cK»-'
.va»c
«f*'
(ocej*-
tbi
Spoi-
,^-'»r!SV'
- ^ [T"*" i of ^^ ^
iv.A'^^s-i"^'
.mp"'
IvSP
,W'
,e«*
lio**-
t-l
..\.
\.
ii«
pen'
,ctv'
..^->=^^
CO"'
,tr*c
*5>«-
CI.AS3IHC\Tl«lS OF CUNTRAfTKD PELVES
690
(b) LoaUsod Mwl n^'niUK'lriial:
1. Dbtiqudy conlnulod {NaiVBle)
pdvia.
Localii«d ami qrmtnclrial;
1. IkouMo ublk|ii(F (Kobvrt) iwIvih.
2. gpUt pd\-U.
3. OiriBatUon of arro-lliac joinU.
4. AtfTHt of <loT«ln|>Tn(Mil of the
body of tfac focniin.
.-ttypwnJ fhJarmUint:
SatAtJTA'8 CLjutBincAiioN
V. Aiamatka nmlliitf /rmn Almtrmalitin
vl At StAjaeatt Sktittm:
(a) CoxitiK.
itr) LuxiUiOD of the bMd u( ibv femur,
(r) l^uationot the bcadaiif iiolh firmam.
(rf) rntluliTil nr MlHlml dult-foM.
U) Abmrice ur it<'f»nnity uf raw or bolfa
lower CKtremiUw.
LlTKRATlillK
i(t.nuJ>. Neiicra BonlreburinR) aiil <Imii (lebMv iler vkuuUih UockonniuawDe. Valk-
mann'i itemmL klin. Vortrn^. N. I'.. 1907, No. 413.
AKAKni'H. Sen CliapUr I.
Bunrn. Rcfonnen in tkr Tbenpie <leti ctigcn liocken. I^npiiK. 1007.
Baubr. Ih la niMiHtnUicn oxtwne dii baitiln. Thj«w de I.}r<in, lfN)l.
BAMKm. Internal, (ijnurcdoe. Conpuai, (;«uuivk, 1896. ZentnlU. f. Gyn., 189S,
XX. imo.
»iTi>nx>i:qvic. L'art dcs aHoucbemcnts. N'oiivello M.. I7S9, I. I, 7S-'90.
ncrHACnncr. De b radjosmphic du h«Min d« h fvnimu iuliilt«. I.'(>lMMr{i|ue,
1900. V. 330-3S1.
ET. BcitnifK ^ur itchiiruhidfliplicn IteurihcilimK dcf VcrcaKeniRKBD do* T)«d(en-
aiuixaiew. Wiun. inv<l. Jn)irl>,. IFI7I). xi%.
Bmeiw imd KuuBXu. Die puthi)li>icii<rlicn iterkcnfoniuui. Wicn, IIMX), Th«il I.
BiTMN. SuliMbiUM do U XUivrniii^ •it rnrii. l.'OhMArkiiie, lti»6, iii, 131.
i%olatcnplue par leu nyoiu x d'tui Imuwd d« Naegtle. L'ObalAriqiM). I8s;, U, 400^
Busca. (ieburUkimde. Hcrlin, IMO.
BnjrKi. I'c^r e«n« Me()Hxl«ti dun icetadon Kmkvnoiapinpdtircbmci^r inittcM -
^B oner 8kak von VS'inkcUicbcIn unmiltdb>r as mniKn. Mamtttnchr. (. Ottt. ii.
B n.vn,, lUCM. XX. EttAutnapimh. 441 -IK2.
^VCmuHBSX. I'krtial lioporl of tight Hunditd C^m^ of lAbour. Atner. Uyo. and CMmA.
^ Jour., imo. xiii. .■-.:{.
Prd^uenc^ tuid Jilorlality of Conttnoled Pd%-va. Amer. Jour. {)twl., 1001, sli.
Jour.,
Datis.
l>ei-KVTEii. (>)«mlioiwa dtimrper novimi lumun uxhilwntea obatctrksntibuiS 1701.
Dewed*. A Cumpcndlou* ftyntam of .Uklwifcrj'. rhilaiklplua, 11124.
Diowifk TraluJ gftttni <leii nomui-heinvnlM. eU: Pari*. ITHi
NjfECAM. lie la nii-niniratinti den dianictrcH do dfUutt mifiintur pw la radioKraphio.
Th6w fie Lymi. ItMH.
Fuirr. Dcformcil IVJrvw. Itu|>. of .Sim-, of llw LyUiR-in Uoft., Sum Yori, ISD?, iM-
?7I.
FrcMo. RUtiiitik dar iii ilni lelilcn 10 Jahrvn iii di-r l->lanieDr I'liu-ondUUii-FRUieft-
klinik voriBekonifnenon vniRd ItcnkciL D. I.. \\<tTthuT%, IHS9.
iTKMKt. Zux Uochaiiik dcr Uebiirt. /.votralbl. t. Uyn.. 1003, xxu, 7(it>-7SS.
TtW
(IBSTFTTRICS
CiOK-VMCR. Ziir Slntinlik Hen enxcn UcckciUL Zeitwfar. [. Geb. u. Cjrn^ 1882, vii.3^|
Kill liuiulurl MuMauntroii wcihiicher R«rkon itn der f^lclw. ZoltarJir. f. Ooti. n. G]f^|
inOl. xliv, 308-325. f
IlnxMD*. Die (ichuiicn hnl ohkod Itorkcn in den Jnhniii, 18(M-'97. U. I., Brakti,
180&.
HiKitr. Aitierimn Tcxt-H™k of ObnK^trics. I8B7. 498-A10.
KlLiAN. Iho Huliurtdehn) von S«it«n (l«tr WiiMonwIiaf I iind Kiuiit darKciAfiUt.
htrt. 1 84a
Klikn'. IHe fniburtohViUlichQ nodoutiinK dcr VcreniCFninKcn dcs Bcriuniati
Valkmnnn'« SammlMMK klin. Vonr^ier. ^<■ P- St. 109.
KitArr. Ucricbt uHt IOa Cieliurliut b«i engeii B«oken ausden JtUuvn l88t-'95.
f. Oj-n., iaS6, xl, 4il'.K'i8«.
Kih-ruK-S. Zur Stiitistik dvn i-n|n-ii n«i^kt-iiK, f>. I.. ]tunn, Iflfl.S.
T.IUirnr.n (rmnkol. Knfftix Itorki-n iinrl ■ponUuio (iubtitt. .^rbcitcn uiu d. kooi^
Fniiienktiuik in Itnii'dL-n, iK)n, ii, -Sf-4S.
IitRiiiASV. Die [■■|>rnicn dcs Hcrkfun. l.eipiig, IBfll.
Di* Ciehurl bei ««Koii R«iokcn. I^ipniR, IH84.
Lui>wiu iind S-ivutt. Kliii. Bericbt ubur die Gplmrlvn lici eugco Beckeo to tfcni
raiiin lA7li-'02. Berieht au« dcr II. gob. gyn. Klbik in Wion, IL Chrabok, I
110-3M.
I.vmc. The Sricnre and .^rt of Midwifery. Fourth od.. ISfKV
Maiikicead. Obmrvntiotis hut la RroHwiwe el rftcnoiirhiiRieBt dee (enutieat Ntiuv. <
17.T8.
MirnBii-lB. HsH onira Bocken. ImpxiK. IWil.
HE UJI UuTTi:;. TntiM coinfilc^t den acroucliuiti«nla nalurvls, etc. Nmiv. 6d..
1729.
HCu^B. Zur FMiiuuni luid Aetiologie des Kllsemclnen vureiitcton HerlmuL Archiv|
(}ya., 1880. xvi, ins.
MCu-KRHBiM. Vtirworlfauu^ der ROiitfxn SInhluii iu der LivburUhulfn. Ueut
Died. Woi^bcnaDbr.. 1808, xxtv. 1110-621.
Nakdkij:. Xhm u-oiblicho Benkan. etc, Carlsruho, 1S39.
I)>ui (H'liriiK ^1I^euJI;1« H(-c'kcn.eto. Maint. 18.19.
XKitidANM and I'jniK-xrxitT. Kina ncuo Molhndo dcr iiinarm ReckenmBaMtnc an
l«beuduii Frau. Moiiultwchr. t. Ceb. u. llyn.. I9U0. xi. 237-253.
P»Hfc, Sec Cliupter 1.
Pawi.ir. IrHcrnat. fijit. CVmKTHBH. Oeneva. IB96. 'AeaXnliil. t. Hyn.. ISflS, s», lOWl
PptiMi. AeratL In('?11iin^nil>lu(t. 1895. xxxu. 24T.
I'l.vkitii. Konriloniiicnt. dc iik iiiniann d'ndxxirheiiieiil BAuditiloojue. For ntrkHMfW*
PcKo«. Tmiti* doH ac<'OiichoinuntB. elc. PariB. 1749.
HicrM>i.iM. Tlio KrcquoDcy of Conlr&ctcd Polvt*. Traiw. Am. Qyn, Soc, 1990,1
3fi7-377.
Rioue. A Coinpamtii'v Study of White nnd Neftro Pdvo*. eU*.. JabDs HopkiM Bo
piUl ttoporlH. I!)(M, xii, 421-4.'j4.
Sr>H.«UTA. Diu Buck I'll 1111(1 [mdicn. Miiller'n Hnndbudi der Cicb., IttBO. li,
HctiKmcK. I'cbor dna Vcrliiilliiiw lits* AVixlandM dor Spina* uud Crisla« iUam in ■I"
dcs QiierdtirchiTiowwr dea livrkimoiDioinj^. MooaUwhr. t. Orimrttk., ISM, bA
299-309.
ScLiitnu. Ziir l^bre votti eriKvii Beckeo. Baltrliiec tiir Cleb. u. Oyo.. 1906, U, >^
312,
Skotbch. Die Bockunmopwune. Jena, ISHti.
Die pmkliHcbu VtTwertbunj! ilcr lteckciinio»iuiij(;. l\-utwbo tncd. Woch., fV
Nr. 21. J
SianoLD. Ix-'lirbiirb dtr (IcburiHbiilh, 1854. ^H
CONTRACTED PELVIS 701
Shkllib. Tmtise on the Theory and PiBctice of Midwifery, with Collection of Coaes.
Ej^th ed., London, 1774.
Amu, G. W. Be«cbreibung des kleinen und einfachen Beckanmesser, etc. Ktune
Werice lur prsk. Geburt«b., Harburg, 1708, 135.
Btkinbiiecher. Dia Schatzung der Transversa dea Becken-einganga nach LoUein.
Archiv f. Gya., 1007, Ixxxi, 433-45a
Vaxmieb. £tude anat. et ladiogtaphique de la j^Tnphyse pubienne apres 1« ^mphjT'
■fotomie. Comptes rendus de la soc. d'obst., d« gya. et de paad. de Farig, 1890, i,
208.
WiKDBNMl'LLXii. Zur Ststistik des engen B«k«na. D. I., Harburg, 1805.
WiLUAUa, J. Writridoe. Pelvimetry for the Genenl Practitioner. Medical News,
March 21, 1801.
Frequency of Contracted Pelves in Baltimore. Johns Hopkins Hoap. Bulletin, 1806,
vii. 164.
Frequency of Contracted Pelves in the first One Thousand Women delivered in the
Obstetrical Department of the Johns Hopkins Hospital. Obstetrics, 1800, i, Nos.
Sand 6.
Pelvic Indications for the Performance of Cnaarean Section. Amer. Medicine, 1001,
ii. 4B3-4SS.
Frequency, iCItioIogy and Practical SigDiJicanee of Contractions of the Pelvic Outlet.
Surg. Gyn. and Obat., 1907, v.
ZwEiPEL. E^ neues Inatnunent lUr Messung der Conjugate vera. Zentralbl. f . Gyn.,
1907, xxxi. 408-500.
OIIAITKIt XXXTV
ANOMALIKH liVE Tt) Ml\Ort.UM. MM.LKAHIUrY OF TUB
PF.Lviv msm
Flat Noti-Bhaohitie Felvit.— TIiik i» tin' nuist fivquiiil varictj of pelric
dcfomiilv octurrin}; in whilo women, but it is comparslit'el)' raw in the
black nii'C. ]1 vrfc< iiolwl in 4:! [kt wJit of th(^ Vi cciiitractcd pelves lie-
wribcd by Michealii^. Litxiiiaiin statwl thai its frwjiifuov, as cninparHl
with tbat of Ihv rhiiubitii- (x-lvit^, vi&f ai< T tu 5. In our material at liir
Johns Hopkiod Hospilal it i^m^tituted -111.33 per cent uf llie vnnirncled
polvcK ucciiiTiii(r in white notiii-ii. ao compared with 9.80 of tboee in
ourod wi)riii'n.
Mob't (liTiiian author!> conlinn tht; statements of Micboalis and Li
iiiann a» to Jr* frttim-ncy. On tlm oiImt haiid. Ablfi-lil iliAM^iitit from
view, holding that many of the pplves which havo bwn (toeignaied as
th« fimplo flal varic'tv are really of rhaohilic origin, and Tarnior and Ituiti
stale that only one sixteenth of the sbnormal jjetves with which the*'
(Duld be attribuUxl to oilier causes ihan rhnchilifi.
Thi.t varii'ly is frwiueutlj described as the pelvis plana TV\'eRl«Ti,
mmple fial pelvi». althou^ih it is douMftil whclhcr Doventer diSerentiaii
Itctwt'cn i1 ami the rbnihilic form. It was accurately descril>e»l by Be
ler in 183?, but Michaelis and liilzmaiin were thf lirst lo insiirt a))Oii ii
imjwrlanc*' ntut fR'cjiieiit occurrence.
The charaelerislic feature of the tiat non-rhacliitic pelvis coDsiste ii»
diurtrning of all lh« antcni-poi'tcrior diameters of the [lelric variiy, «li
the transverse measun^nients remain practioatlv nonnal.* This cottdiw"
is due lo the fuel that Ihe entire sacrum approacliw more nearli li«"
Dorniiil lo the syin|ihvsiK pubis. At the same lime it undergoes a ri^ft"
rotation about its transverse axis, since the vontractioa is always ww
SB
* The UluatntlotiH in the <.'luipt«r« on <'i>ntra<'tetl Palnw hare been impanil
tiin KTBuleiit can and unmnu^. The half-tone illuNtratioiui am <ixn«4ljr ono thinl mXX"'
iiiw;. Thonn from Hpvciniuns in wir powi'jwioo wero drawn (mm pbotognfiti* ■*'"
were taken witli the iicU^x as nearly as po.-uililn in the mme pontinn — UMt it. mA I*
tip of thf! coccyx Htid upper itiaritin of the i^iiphysis pubis on (hu Mune boruoatall'''''
AccordinKly. tlie vuriuus illiutrutiona can lie accurately Kntiporrd.
The diaicraoui of the miiwrior fttmit a.nA th« M«iltal se^ioiu UvmitEh ibe P*'^
ouvity art one sivtb luitunil taxe. und una nccaniti; l4> wilhiii one nuUinwitv. Hiri'''''
were made hy mcnni of the i-nment with the plnne of the m)ierii>r nlrait ol r^
angloa to Ibe horixon. Thu latter were inuile from tr«ciiiKs of ctutaof tlie pd*ir a^
obtained fay mtrnm of dental wux, and reduced by the puntoKmph.
-(V.>
A
FLAT XOX-RHACHITIC I'ELVIS
703
marhci] in llio iujtci"-|K»li'iMir ilmnu'lor of IIk- *ujxTi*ir than in that i>f tin'
luU-rutT fitak. The degrw of (ynitractinn is iisu«)lv luit »it_v (ironoum-od.
and it is rare 1i> limi the rouju^HlH rvn iiH-a*uring Iw* tlion S LTDtimutrv*.
lu fact, whenever thii> liniil in pasMHl, tiu> pmbahitity that od4! has to de«li
with a flat rhadiitiv pelris tdwujd iilwDjre bt- borne in miiul.
Piit. aau.
llna. taH-MO.—fufr K«K-lt»*niiTic Puvm.
The <iacniTn doe* not pn»>eDt the etiarneiertxtitr features of rhachilui,
and prtwervet^ its iHiniial rvrtreal aixl eide to Hide coim^Jtv. Oecs^ioDally
it mat a]>)>c«r iwnit^whal more deliealcly dlinped than u»uol. and Ik* nar-
ruiriT traiuvPHM^-ly. I'ndi-r Ktieh eircuiix-tauccs thv transverse diameters of
^ tiie pelvic caril}' are .■<liKhI),v decreasnl.
■ In not a few ))elTw> of thin cliaraclcr the line of o^^ificatian between
Vlh(^ (IrKl and Hiimd -acral vertebra in inon^ ninrkiil lUnn ii>ual. tim* giving
H ri^e to a so-called ^-cond or acee^tnry promnntorv.
B J!tiohgy. — By many it '» Iwtieved thai the approaeh of the <«eruni to
K)hv mnphviii* rewidU from the wirM-ins; of Wavy burdens u(Hin Ihe ba«:k
Hor b^ durinff earlv life, though Kueh an explamttion cannot apply to all
BcasM, especially in this eountry, where it i" iinii«iiu] for litrU to carry heavy
W inadt. In other eaiK> the mn'lilinn ix attributeil to the faet that the child
WW allowed to sit up at too early an aRo and for too long (KTiod».
1^ .Ahlfeld. Tarnier. and Brvu* and KoIiHko think that a part in the pro-
Hdnotion of the defonnily io played by rhaehitis, which, they hold, ma]^ be
^Fprearnl in a liirvnl f'lrm vithoiit ^iviii;; t'im^ (o itj< ii«nid aihl I'liaracteristioJ
K|UDif<^lationii. The latter »tate that Ow j<hor(ening of Die eonjugala T«r
704
OBSTl-TTRIfS
ii^ tiol ."ii rtiiii-li iliii^ t'l :i ivilatian of Hit- rjicriini ih t>> llii' KliortiHiiiig of 1l
iliac portion of the k-nniual k-Dgth of the itmnminnte lioae; and. «6 tbi?;
believe that Ouk i.-< usually th«! reritilt of rliaHiilLi, Ihoy i^onxitlcr that it
iiiaterialiy in dftermiiiinf; ihe sEliology of thi- conditiou.
Ft^hhii^ iiiul Sohlii-jihakc coruider thnt this variety of pi'lvic anomaly i
congenital in a certain numlwr of instances, as they have &1>oim tliai ib
])(-lrt-K n1 m'nlv li»rti ■■liildn.-n mny ixfa>^i'iiiullyi
present a llHlten<ii apin'amn**. In several ear
uttidii-d liy ilietii ihv n-hilioii JMHwuca the onjti
^'ata vera and the tran^eive diameter nl tl
superior strait iriw «» KM) to 145. KM) to IGil,^
nr HID to i:;, insleatl of KH) In Vi'i, ax i« usuall
ilio ca!v. I'ndvr itucli circumstanci'e the m
<'hniii(uil factum aiiovt- alluded to i-ould wrtainl
not have toini' into play.
Ifiagnoti*. — lite prraemc of a fimplc fl
~ • , , ,- ■ pelvis, a£ a ride, is readily delected. By este
r ' . -'.'-.'- ""I pelvinu-lrj- the diiiiancw l»eiw)H«n the »pini'
r: .' -. - ' ^-i ' and crests of the Uium and that between thi
Irneliu.iten' an? found \n be approximately nor
mal. wliereas Baudelooqiie's diameter is more o:
le>^s Khorteni-d. Kin inteinul examination ll
diagonal eiin)u^ti> i» found to be ftharten«l|
thoufih never to an extreme do^^rec. In general,
if it falls JH'low 9 eenlimetnsf Iho pelve* doe*
lif lonjr in thin eatej^nrj'. The eutin- anterior nur-l
faee of the »icrum appears Id Ik- nearer ttH> ^ym-
lihysiH than tmua), hut preM^ntu it* normal etirva
|,-^£|(fc // '*' "'• li^ lures. There is no n-idenitig of the traiuvern^
■ |5c '"'*■ K'-^i diiiiiieter of the pelvic oiitlet, mk in the rhachitic
£• ^ '''i* V*''"'' 'of^i- 'fhe average measurements in i(, of id;
" ' il' %'''S>« •■"""■'* wtre: spine*. Vt.'i : crwls. ?t.8; tro-
■ /il' ** ''' •hanters'. .t0.r>; BaudeloeijuiyV dinmi*tcr, \*; anJ
'Lf^'AV ''i«pt>"at eonjupate, Itl.; centimetres.
The conKiiliTuTioii of Iho eff^•^^ of the flat
[Mflvis upon Ihe eourse of labour, and (he treat
ini'Ut of sueh ea)M>fi, will be deferred nnlil li
flat rhaehiiie polviit to uliidieJ. «» iWre ik t^'*
e>M-nlial differenee in tlie mechanism of the (^«f"
varieties.
Bhachitlo Pelves. — In many parb of Eunr^iv
the most prnmineiit factor in the prodttction. "'
contracted pehes >» an ahnormal Hiftefiiug «'
Ihe hoiH'v in early life restdtin^ from rliaphi *■'■
In thi« country llic disease is obsen-ed comparatively rnn-Iy jn white dxi-
dren, oecaflionally in coloured children inhabitinj;; the country dUtrids.
very frequently in those living in larjrc citte*.
In not a few cases Ihe disease undergoes spontaneous mr*. w> that tti ,
Fjp
Is
'.11. - Bn 1..,.-. .111.1.1 ..11
KoKMAi. KriPitvmaorCirii.v
(SpUlouuin).
en,, noniukl curtilage; ei., nutU
laxt- cpHh airnnafd m immlld
TOwa; ff,, iin-u .if pri-liminnry
criciticaiUoii; rm . iru'dullnry
Hpnoai: 0., iMtiTi)>l(u<U: io,,
oncnuii l&mriliKi «!., iiinmiiT.
H
I
rATUuLOIIV OF HHACIirrW
706
r;
I
I
I
I
tnce at i|» oxi^lriutt <-aii bi! di^^'ovtrcil in laivr life; wliitc in mMiy in-
staaceri permanent i^kcletal ilcfoniiitM'H rfsiilt which are fiv<|iienil_V local-
ix«l in llio iH'lvtK. Again, i( <« al^> mX ui>ii<^ual In imvt with wuniiii who
all appcaraitcea are <|uite norntallr formed, but wtiuw pelvc» npon
rxAinknAliou pti-N:nl rhatliili*: dcfonnitiof. Hix and lifUiii hundredths per
oent 4tf tiw abnoniml pekeg ot-currinje in l)i« while, and 'i'i.al jM-r n-nt
in Ihc I'nlouni] wnni^ii dvlirercl at the JolinH llopkine Uoe-pilal wont rha-
chitic in oripti, thu.'« thawing that evon in tliin tnuotry tlie diivaM! U ol
not a little importaim- from an obtlftTical standpoint.
HaltiTf anil PathoUnjji of fttrtcAi/u.— B<-f<ir>T dt^ribinj; U»C vartoiu
changes in the pelvii- which mav rif-iill from rluichitiii, it will be well tg
OonKiik-r lirivflv Itiv naiun- ami iMilholn^K.V of iIh- dii4-jtM-.
According to Kai^wwitz, Spiilmunu. and others, rhUchitis ijg to be looked
upon as an oaivitiM aNXKialed with an excosKive formation of osteoid liMiie
at the epiphy«w atid bcncatli the j>iriiJtiteun> of tlie long itonea, as well
an in tUv llal l><>n<n> nf ili<- ukuU and ]N.-lvi«. Thii^ prolifi-ration i» acooui-
panied by defective caleitiraiion of tlti- newly foriue<l tiMue, Kweifel iitating
Dial only 18 to '^4 por cvnt of inorRanie Milte are pre#mt in rliachilic, a^
against (13 tn tl2 per cent in nonnal Imne.
It is ruirtomark' to distinguit^h three i^lageH in Dh' discsM': that of con-
pMtion, that of soficning, and lltai of progrt-s^tve dKfonniiy or cnre, ati
tlie ca** may be. In the stage of con-
gtviimi llwrc i* » gnM incniwc in
ra^ularity, which is inoeit marked at
the union of tlii- articular cartilages
wilti lite d)apliyM<9> of line Ion;; bouoH
and aUo beneath the periosteum.
In filudying the ii)ii>Jiy«ej' of a
Iniij; bone at tliin period, we find Itiat
the zone of preliminary ealeiticalton —
Gu^rinV line — ii> iiliglilly thickened.
and its lower portion adjacent to (lie
newly fonncd "pongy V>ne in perfo-
rated by nuDieroufi vascular loop?-. .\
eitnilar condition ntay alxv )k^
Henred beneath the periosteum t^..
ering the long and the flat boitc
< Fig. 543).
In Ihe Mccond stage, while On^rin'»
line ha:: become markedly thickened
od very irregular, the vascular pro-
liferation hati advancnl to a marked
degree, I'nder the microscnpe, the
former i* iten to tie broken up in all
directions by the ra)>iilly growing va?*cii-
lar l(iop« which :<nt>ilivide it into large
numlfers of «mall. irrcguluHv ■■happd calcific area^. Al tht; »ann- lime llie
formation of mweona tissue just beneath il proceeds in on irn^alar man-
Fwt. M2.— Hucnosi tjumjcuh Epu-hi-ib
nuuin).
e*., rartilaflo nlh MTMf^ la pamMj
ivKit; (re.. UM of pnUaniuMf oaleiT
otiuM: c. opIUuy: to., unoMiBd*
iHHTlirr tti^ar.
U
706
0118TETRI0S
oer, ati«if)<-Ation uilher failiug to occur or taking place iniiHrfeolly. Ttic
newly foniic<l tiiwuv i* pi'in;triitiil in all i]ir(%)ioni! by vascular loops wli>di
brt'ak it ufi into ^mall iiias^Gs, bt-'tneen wliidi and tlie marrow ravitie^ ii> a
considerable ToriDation of connective tift^ue, with spindle- and etsr-ehapetl
cell*, which (\w» iiiit bwoiuc oi!i):ified ut all.
To HUmmarize these changes bi'i<.'ttv, atw may nay that thv growing end
iif (h« liiine. instead of underpoinj; normal ossifii-ation, tv>nsiftt« in jrreat
part of dilated cjiiiillHrttv wliicli m-parate im-Riilarly i^hn[>ed m&sM¥ of cal-
cified cnrlilafw from nrvas of connective tissue and imperfectly forme!! bone
4
4
"fPv?;
->— {-'/:-iv-f^T
Flo. 5t3. — Section tnhoi'cik TlnpwTuii in AnvANt^.n SrAorji nr RHACrRm* (SpShDMu).
Ice. >nv of pnjlminiujr akldfiralioti; et., cnlcilicd CBrliUffo; (^> «>p4llarMs:
Ir., cunnFctiv« lump.
(Fig. 643), More or less similar changes take place under the p^mteain
of the long and flat bon«», no that lh<> «haft of the hon« soon bwoai**
converted into n spongy tissue correapondtng closely to that ohiterved &I
the epiphyses.
In the third period IliOHe changes continue until death occur"; or, iJ
recovery ensu«-^the usual outcome — there is a progrewive decreaw in
vascularity, and the normal proc«:** of o*»ification is resumed, so that after
a time the only trace of the discdw! is to be found in a thickening of Uw
bone, not infrequently nsHociated with an increased porosity. It is there-
fore apparent that Hip Viones hecnmc altnormally soft and \'ietdinj> in tht
acute stages "t the disease, so thai if tin? child ««■-* its exiremilies at ih*
time, more or less marked deformilii-s nf the various bonce maiit r««ill.
depending upon the incchanical eonditionii which arc liable to modify the
FLAT RHAfI
Ir PEi.vis
evolultou if Itio infantile jk-Ivih. Krem an<l Kolii^ko ity^ii^t Ih^l practically
00 growlti occurs during the vwurw of ihc diiw.-ai'e. and, i-unM^uviitly, if it
UiD> jHtrKiKlci) for nny Ungtb of time, it must iirevitabljr lead to atrophic
chaogee, »o that aflcr rvcovi^rv Or- rhacltilk' bon<M arc nnall^r and mme-
wrhai lighter than uornial, even thougli tht^y ahow no chantc-tfrieltc eigoA
it deformity.
t'lirmt of BhachUic Pelvf4:. — A« hae already been eaid. the rhachJtic type
in on« of the niotit frequently oliiiervod varieliw of vonlrHctiil pi^lvis, and '
in exin-me eSMct^ pref^eiit^ the nio^l niurked deforniilies will) which ve ant
familiar, with llu* i^-jtcqitioii of llio»^* rvxtiltiiig frrim oi^k-om alalia. Kortu-
liately. however, the dej^iree of ronlraetion lo uttually not v«ry pmnoiinciHl,
'l^imicT having stated that the cntijuf^ta vera nieai^urt^ le^w than A.'i ecnti-
metri'i' in only 14.4 jmt n-iit ii( lln- I.uai) rhwhilii- pi-Ivcs i>liidii-d liy him.
With the exroptiMi of (lie i-aw-rj whii-h are coniplioale^l by abnormalities
^nf the TXTti-bral column, or by defonnitiw P*"'")? '"''* '" " io»rk4'd difFi?r«n(M)
llie length nf the linitis, rhaefaitie pelven are usually classified as foUoire:
I. Mat rhachilic.
i. (renerelly (^nlnutiil. flat rhachttic J
:i. (ieiH-rally ami c()ually t^ntra^^ted rhachilic. I
I. tVuilo-nnicoiiiulAoii-.
J. Flat Rhaehitie Pc/fw,— This variety corresponds wiih Ihe flat, uon-
litic pi'IviK, in m for that llw fin.^Uft coiilniclioti owiir* in Ihc antcro-
Drier diameter of tin' iiUf)«rior strail, while Itte iransverM- diameter ih
M-Idom alftTled, or may rvvu tw idi^hlly longer t)vnn ti^iial. At tiro «amu
^tinie it ditTrnt materially from it in M>veral [>ar1ii<ular«.
B Itenerally i^peakin^. ibc tmoei) are lo^ denw in teslure than UHual. and
Bnot infrei|iii'ntly arr d>-liial«' in forni. though cHviuionally ihfv mav appt-nr
B-clum<y and Mnollcn. timing to tlw marked lordouin which not infrrfjuently
Biaiull.-> from rliachitiii, the pelvic inclination, mh a nUs. u oon»id«rably
Hinue8»«l.
^B Slu<( important cbangm an.* to lie noted in llie sacrum, which diflera
from tile normal in tliat it U hmailer from side to side, thinner from
behind forward, shorter from above downward, and lew concave on il«
Ulterior surface. The Inngitiidtnal axis of the bone in ao altered ait to
form a greater angle with the oonjugata vera, and in extreme cnnw it may
extend horixonially backward. f'oiiM^^m-iilly iW promontory lit* at a
lower level (hail nKiial, approMchm the liymphy^in piihix, and encroaches
markedly opon tI»o area of the superior strait, fsually the entire aierum
iit Mharply bent npon it>rlf in Ihp nHghboiirlmod of iht third vertebra, m
»that it* veriical etincavitv lieooin«i markedly accentuated. Ocrasionally
thin doc« not ocTur. and in i(uch cases the (acmm may In; quite straight
from b«sc to tip. .\t the i>ame tim» tlie bodies of the individual vertebna-
»txtfnA nut bnond tlie level of their aiie, thereby diminishing tho lateral
KOacavitr of the sacrum, and occasionally (^>nverting it into a pronounced
ronvr\ity. In tin- latter evrnl. IIk* Kpinoii« pnicfMifo project h»fi far Ihan
tt*tial lnyond ihe iMKH-rinr >urface. which li-mU to lieomc iiiwa»«.
As the upper part of the acrum becomes displaced downward and in-
nrd, its posterior .turface recedes from t)w jiuperior po«terinr «pine4 of
70S
OBSTI-TRICS
Ihe ilium, wbicb approacit one auother raorc closely than in ttic Donnal
conditiriii. tin llisl the |H>.sli>riiir limit of the "S"**liApcd curvature of the
iliac erects becomcG accvutuati^.
FiR-Mft.
fig.m.
Fio*. AM-MS.— Fmt BnAcaitic Pfs.Ti».
In soint' vanv \h<- aiUfrinr niirfaw> of the Macnini ruav be conrci in both
dircctionit, an<l, whcQ dirE^tcd more vertically than U£ual, it may happen
that the greatest ti>nvexity will corretpond t« ihe region of (he swond and
Flo. ft*T. — AoctxTCAnm of V»iiTic*t
Omccatitt or 8<>CKOi I" KHACnmB.
Fi<t. MS. — HwowDni Opf-ttuunnH or Vi
cu. CcntcAvrrr or S«c«tm d> Rimoutw.
F],AT RIIACHITIC .PELVIS
703
Uiinl ftttcnl vcrtobni'. In this event the ^horteiit diameter of the pclvU
will correspond tu theautero-po»teriorof lite plane of ^reate^t peine (limen-
uoni) iiLiiead of (he conjupita vera. BrL-ua and Kolii>ko have ctaiu^ified
Koeh pelves in a sptieial group and designated ihvm as " middle flat.*' In
»uch nmv iho pntniDntor}' of thv )>ai.'rnm i* nol di:<placed duwtiwordr and
the condition is usually as-^ociaii^l with iiMimilaiion or kyphiv<i>l<Kij».
Oeea«ioaally (he l»dy of the first saeral vertebra is more tnarkedly
displaieetl forward iJian tlnwo Ih*Iow it. o> llial iU lo*-er margin projwts
bevond the general siirfaee, and can be fttlt a^i a fal«e promonluri/. I'niler
Fttm, Stt-ASt- — Klat RHAonrw Pclvh, mnyrnta Dovin.c TmoMoamtrt.
*neh eire«m»tane<!» the distanei- bclwecn it and tli* jiyniphvsis pubis may
l« the shortest antero-poilerior diameter of the pelvis, lu the majority of
cases, bowever. the presence of a false pronnintory 'n indicative of the
amiiDilatioD of an extra vertebra to the sacrum, and its significance will be
discosted when a-iiiiimilation pelves «r« considered.
The iliac bones are sraalter and frequentiy more delicately shaped
than u«nal, vertical height of tht' pclvi* as well as the length of Ihc iliac
nnts l«ing diininiKheal. The iliac fosse are more concavi-. and frwjnently
present a pronounced, Hharp dvprewinn just in front of tl»e saero-iliae joint,
A* a result iIm- ani.-rior margin iif the bone extends more verlieally than
ueoaJ. as is shown bv comparing the slant of the line joining tlte ocetabn-
i
710
OUSTliTKIl.'S
lum and the anterior siii>crior »pimi of tlie ilium. Al llw *amp time the
«ilt4-rior jK)rti<>D at Uie l)one Hares auf at llic expense of the crent, h> that
the dintancu IkIwcch lii« antiTiur su[K-riiir sjiini'!' appnuut)it« that lietirecu
llm croit*, and occasionally even exceeds ii iu len)^h.
The dimioulion in (lie -izi' of the iliac bniM! if jwrhaps best appre-
ciattxl by Htudyin^ the "terminal length" (Figs. 27 and 28), whMi it i«
Found that ihc ptibiL' (mrtion i>i of nonnni length, thu sacral portion nntr
Klightly (ili'irltT tlinti u--<ual, while the ilim^ portion i» greatly shorti-iml. and
occHfiionally presents ouiy a fraction of its normal li-ngth. Breti.-< ami
Kolidko havf laid gmt
ftrefs upon Ihiri condi-
lion, and voncidcr it al-
most palhoj^oinonif tif
rhachitiM. In many
ea^-i the iliac hones
liend just in fmnt of
tilt- Kaem-iltHc synchon-
droeis, tw that tin* iliiv
jHTliiwal line iD§tea<) of
following a grntli^
enrve. forma a pliarp
an^ilo at itwt point. t)iii.<
ad<liD]; n>a(erialli to Ihc
(lalti^iiinic of llic Mipc-
rior Ktrait.
Al IhenatnclinM- ibc
ai'i'lahiila an- displaced
forward, and thn* i-riin'
to lio upon the anterior
in><tead of uptui tin* lal-
rral |>i>rllon of tlw [h^I-
ric ring. TIw pahli-
arch IB somewhat wilier
ilian uioal, and the
tubers ischii arr ^
everted thai the tnutf-
ven« diameter nf the
iwlvtc oiiilH ap|N?ani to
be exa^eraitil, aiMl iip-
caKionally nu-a?unm
more than in tbi- luir-
inal peh-is. In view of
Ihe upward and back-
ward dielocation nt the
Fw. AA3.— Q):ki:iiai.i.v (ViN-ntACtBn ItHitrHrnc Aaatm-
UkllO.V PU.VIH, X 1.
A, mnterior vi«ir: B, mme pcli-i* Bccn from bdow *ho«rit>c
rdktiv* widming of «ut1«4.
tip of the sacnini, lh<- luilrro-postmor diameter of th<? uutlcl i^ also edtber
relatively or ahsolutely increa.'^fd in kngth. ConM-quwitly. in contract with
lli« flattened KupcHor tttrait, (he pelvic outlet appeart wide and jjapin;;. and
in extreme cases is nearly tw-iee a." roomy aa the inlcl (Fig. 55:*, ^1 «od H).
GENERALLY C«XTRAnED RHACHITIC PELVIS
711
Thetie chan)!^ exvrt a docid^l iiitluenci' upon tlie shape of the pelvic
*eavi(_v. iIh- cffwi liciag mml niarkt^l in Ihe ><u|H<ri(tr »trail, whicli may
become oval, retiiform, or cvi?d liiTart-Hliapod in outline, accordiiig to the
ditgnt' of ilirplan^meiit <if ilm jirdtiiiintDry of thv Mcrum. Ttiv conjugala
rera is alirays ehortcued, while the iraasvertu! diameter »t«m>^ In be eo-
lugcd, although ihtK may be only apparent unl«tui Ihp pelvis be of larj^ aixc.
OivinjB to the approach of the anterior and posterior wralln of tlm [telvlK,
|]m> oblique diumelcr;^ of the >-i])ii-rJor titrsit are alwaya fihorieneid, as are
[■Ihci iIk- luurrivrotytoid iliameleni.
In occasional <-aMrr> sharp exoHtoM>!« may make th^r appearanee upon the
Ipubic CTn^, the iliivpcctincal eniineneoi, and in front of IIk> iiat-ro-iliac
Kvni'hondroses — pith-is npinoMi. When »ueh struoiures are not will covered
hy Mift [MftF, they may had \o wriou^ injurit-^ of Ihe uli-rui' at the limv
bof labour.
Gftirntlly CoHtntctrd. Flat Hhachxlic I'tlvi*. — It i* in Ihii' variflty of
pelvifl tliat oiarkui dt'^rnxM of t^vntraotion are often eneouotereil, Ihe con-
rit, U3.
F1S.&55.
F»i», iaa-VM.— <l«Niia4M.T OoMTanotaB, tunr Rhachitic Pn.Ti&
Its tera wimetinies lieing rednrtnl to 3 nr t d-nlimi-trw. Thic ppivis
irre>[Hind>i rbwely to tin- nrdinurj- flat rliochilio type, except that like
yhortenini; applieit to »]l it* diam'-ter? inxli-ad of bein^ limited to the con-
jDfffta v«Ta. Notvithstanding iJie fact that all of the diamcten of the
712
OBtnKTIlICS
inferior utrail fall Im-Idw itic normal limits, tlie nutlet lunially appears abt
mallj Ufge wheu compared «-ilh the generally conlracled iulci (Fig. ^5i
'the decrease is size i» parlicularlv marked in tl)e Hacruin, which mi
present 8 coosidemble dimination in its transverse lueasuremenU. T6
hiriall ytie of lliu pclris io kuoIi vat«s may bu due ritlicr to atrophic I'hanges
in the Ixknes n.iiulting fixim the rliachiti^ it*eU or lo a primarily small
pclriti that ha* become affected with the disease.
8. QrurralUt Kqi'riUif Vnnlfirtrd NhnchUic /'f(rw. — Thin vnricly wl
fln>t dcvcribcil hy Michaolir. and accordii)}; to niot^t aiithnn< it< oliewrved
rarely. Jhliiller, liowwer, coo«iders thai uol u few i'Msk* which were pr
Fif. svr.
Rr. SOS,
Fm*. £S0-^Si8. — GEKotAixr B«VAU.r Ookthaotko RHAc-iimv Felvm.
viouely described an iiistuiicw of simple, j^-lii.Tally conlraL'U!*! ( jniiliv-lBio*''
pelvis, belong' under this eatejeory, and my own experience, partieulad; >" i
the negro race, ha* leiidvd to eonfirm his observation*. _ I
According to Litzmann, this type diHere from the juitto-minor p"*
in its ungainly and angiUor appearance, and in the marked pixwuiaoiW ^
the pubic crcstH, The superior strait appears to be equally shortm'" "
all its diam<^ti>n< instead of merely tlatlened. while the rest of llie p*^'
presents imli^iiiiabte sifmn of a phnI rhailiili*. which is more partif'*''''
marked in the saenim and in llieevcrsion nf the tul>era ischii.
4. l'Mudo-o*Uomnlnt:ir Hhnrliitic Ptirix. — 'Pill* variety if a ma*'^'*'
tion of the wvcreKl forms of rhachitis, and afTonls examples of the i*"^
DIAGXnstS OF ItUACHITlC PEI.VES
713
inrknl iltfi;]^*!* of 4'onlr«cti(iii. lu icuuli cm*v*, ttf Hk nim« implies, Uw
elvia reaembles one d«foniie<i by wlonmataria, the saoruRi nnd littcnl
ralU wppn niching om- niinihcr to at. to givt- rivic to a vnn- flmall triangn-
ir superior litiait, tho lonlraclion al^o o^Uiidiii); li> olhvr portion)' of U»c
IjK^lric cttvity.
l')ib> form of [telvis «-»« finit (Ifscribu] bv Smi'llip, who gave an iUustra-
3D of it in his anatomical plaleH. Moro parlicular attention wit^ ilirecleil
I it by Stein, no'l c^ipdcinllj- by Nki^lf. It it not of frequent occurrence,
FaMhender in 18^8 kb^ abl« to collect 40 cases from the lileratare,
■ few of wUieh occurrMl in Toun)r chiMrvn.
hiagnoti* of Hhufkitic Pche*. — Iiiiporlant iufonnatioii h* to th« pre*>
ncr of rhachili<: may be «liciled by tbi* iii^perlion nnd examination of the
itifiit U'tu'n chnmc-ti-riKlif^ dofnrmilitii may )><* nnlii) ulxiut the head, "nr-
tirsl colninn, and tower exlramili4><t. In not a few casta, the thickened
»iphyM>fl at th« i-oslal ninr^ni> — itw MM-aileil rhaehitic rortry — may iIho
ene to call attention to the existence of the disease.
decidedly |K-ndtiloiiM alxlonien in primiparoii« women i» always 8Ug-
Iveof marked di«prop(irtion ])elw<-en Ihe sixe of Ihc head and the pdvia,
anl Kiwiuld always Hnjyrest a search for rhaeliitic chanRes,
The a^ at whJi^i the patient (ir-t tivrn'-il to walk i* nl»" of conufler-
able importance, as it ir* well known thni i-hildn>u .-ulTennj; from rhachilt«
mrv it'nally hack*wanl in this respect. A^ain, when Dh- diAiiH* apiiears
er tlie tirwl year of life, llie child ustially win** to walk during its acute
and ha« to Icjirn ajrain at a later period.
Ai-cnrate information roneerning the pelvis, however, can Ih' obtained
ily by JM-Ivimeln-. On externa) nien^nrntion llie dii^tances bctueen the
[pines and cresta of the ilium no longer show their normal relation:!, the
/i»rmer approaching and not infrequently exceeding tlv* latter in length.
formally, there is u dilTerenre of 2.5 to 3 centimetres between tltc two. and
^lienever this hemnio- reduced to 1 centimetre or Ic». rhachitts should be
^ns[>ecte(l. The distance between the trochanters will be normal or not,
^^bconling as one ha* to deal with a flat or generally conlracte*! rhachitic
^VpItis. Baiide!or*|Up'B diameter i" always eon-'iiierably shortened. At the
itami: time Micluu.lis'H rhomlmid liwe« itK n-giilar outliiu-M. and in marked
714
OHSTlvTHlCS
Ut Itif sinkitijr ilounwaiil am! foiwanl nf Uw ucntm.
iW
<x>tiveru-<l iiil^i a troiiij^'uliir ar<-u.
Still iiiori! flffiniti' inf'tiiiinlion ihm.v \n- galuM Uy inrornx] |H'lviuii*lr)'.
The dia;;»iial t-onjugaU' i» always EhorU-iicd. I'hc aulmor surfac-e of the
sacrum i# niurh nmn.- rtwdilv n<i«M<il>lv to lh(> oiaiiiiuiiig tiin^'rc. anl on
careful jialjuitinn ite upper portion is fouiiil to lie flatter than iiKual, vrhilf
iu lower jHirlifin is sharpU* Ih-hI fomaril. Slnrmvcr. iiwin<; to tlw pronii-
lu-iHH! of tlic vcrti'hra! Iiodiix, thi- t>arruin in eoiiccx from siilf to !*i(I«*, itii'lrH<l
of {^im-avv, )i)i normnll>. At the 'amc timi- (he- pi'lvic otillvt M Klaliv«l,v
wkleiui).
Thi- average mMU>lircTn(^t!i in ten rliachitif pelrps in white women wero:
Spinas '^5.1 ; i-n>«lv, if^.l ; Imchank'n-. ifll-l ; Ituitth-lcK-quc. 17 ; mid disguual
conjugate, lO.l centimetres; while in 7fl eolouretl women the meKsurements
averaj.i'd: Spiiia*, 2H.7; t^ntU. 24.4; troehanlcru, 28,6; B«iidvlwquc. 17,3;
mid diagonal conjugate. lO.R centimetres.
The liiffiTfiK'i" in Ilw im-axin'mt-nls U'twiH-n lh»> spiiiiii and crests in
the two races is due to the lesser tlarinj; of the iliac bones and tlie gun-
fmily Munller mzc i>f the pelris iu ct^luiinxl women. Thux, in two scries nf
TOT and 470 normal pelv«< res|)CCtivel_r. the spines and crests measurul tJ.'t
atid SS centinn-li-cw in while, a» cnnipan-d witli 24 and S« centiuictr«-s in tol-
oured women.
Thtt Hal rhxchilic pulviK it ordtTiarilv <]iagnnHVfl wlu-n the tranBTi>r<c
external measurements show hat slight diminution, whereas in Ihi- gwwr-
ally contracli'd varii-iy thev nicaKurt' considi-ralilv li-«s than normal. Thf
generally ami eijually eontratrlrti variety U ran-Jy disfnioMil during li(r.
while the characteristic deformity of the pscudo-ostcomalacic form will le
ret-ogni.tc^ an inlcrnal cxariiinalion, and lh«- ihtci^ion ».* to whuthcr it is due
to rhachitis or ostcomatacia will iie determined by the hiMory of itw patieui.
At'iilf of Prt/ilurtion nf lipfvrmitij in Uharhitir Ptirr*, — In (.'hapter 1
wc considered the part playeil in the t ran k form at ion of the fa-Ial iniw tlii>
adult pelvis hy the aetion of the body weight and the ujiward and inwani
A II
I>iu.vM (Sohroeder).
force exerted hy the femora. IM-ior to the work of BrCTis and Kolinko. if
wa« gt^ncrally helievcil ihiit alniormaliticH and variatinn* in llie in<»l<- "f
.
MODE OF PltODUCTIOS OF RHACHITIC PKLVKS 715
arlion "f Ihft* forros upon the mflniKni |iolvis iilM> «'n'iil Ki explain tlie
prixltK-tiitn of iiin»-l nf iW (-li«nKl('ri»tic rluicliitic defurmilieri.
Tlw'w \u-ns nin- itirvi-litjMil in jinut (larl l>y Lilxiimuri and ScIirmiU'r,
ftad \mvv iititjiiucil aliiinsl g<-iK-rul tticcjilaiirc, allhougL Keliling, Freund,
KdirvT. and otiivn take vxccplion to Itiem.
In tlu- aciitt- stajifr* of rliat'liitU the roiiii]); cliili! in tmablr In walk, and
An itn time iti a >iilting or rtt-lininc pn-iiinii, in Kliiili llic upward and
inwnnl fi>ri'i* cxcrliil 1>y llio ri'imirn i^ in iJH-riitKt'. ('i>ii«ipi<'nl1y, w)H-n
it nilp> lip. llie ImxIv wcigiit i* ihe only fotxi' wtii<-tl comts into jitay, and on
tiring tnui]>iiiiti<-d fr«m lh« vcrlelirnl wJiimn In (Im sacnim. it i» n-^mlved
into Ivo forcp!^— OIK! directti! tlownwani and llie otliiT forwaid. As a
rvKult. iIk' Munim mluii-* alioul it* l n«ii*v«rw asix, Ihc pnm ion lory Itvinji;
ptvMwd forwanl Mid downv-ai-i. while the remainder of the bone morea
in llio oppoKilv dirvclion an<l ii-nilf to awitimc » more or Ivm liitrizontal
ponition. The extr*'nie upvanl ilistoc^tiou of its lower end is resisted hy
thf traction vxorltt! upon it and the cwcyx hy Ihv iitinn^ :4rrt>-H-ialio
ligaoK'nts, and eon«^iuently itw softenei! bone l)eeinnei i-harply tiexwl at
in lowtT portinn. wlu'rcby it* vertical cntu-avity i* ocrcnhiMliil. At the
ftarae time, nwini; to the imfieneil rondilinn of the Mieriim and the iiitper-
fwt nnioii Iwlwci-n llu* WliiT ami ala- nf lU verleUrji-. the formiT are
pQiihed out Wyond lite latter, thus convertinf; its normal lateral eonoavity
into a convnuity.
As the promontory in diiiplareil forward ond downward under the inHii-
Fiux of the hody weight, the posH-rinr -iirfaee of iIh- i<«crura n-crdi-ji from
the ^upt-rinr pocIeHor spinf.i of the ilinm, IIiuh Hulijeetinfc the nimu); ilio-
Hocral lif^ainent^ to marked tension. Afi a m-ult the posterior «pine>i are
drawn ni-anT to tlH* miitdlc line. «hil<' at ihi- «ame time the unlerinr |ii>rtioiiH
of tile iliac bcKUw tlan- out, thus aecnuiilin^ for the cban)^ position of thu
Uitt-nor nujM'rior npinos. TluK movement i* resiole*! hy tin- (^lieuirt' fnree
exerted at the symphysis pubis, and a- n eon^ecjiience the softeiMil lionefl
bi^id jiiKt ill front of the Miero-iliiu^ m-nehondriwii'. «n that llx' iliopix'tiiieal
line on either itide. instead of foUowiuf; a ^^tie cnrre, bcivimes sliorply
U-nt al llut point,
Coitu-ident with fboA^ chanfiea, the ptMitiowi of tlie a(«(abiila lieooiue
allercd. hi'iiig i^iluati-d n|H>n llie anterior, iixli'ad of upon Ihi' Inlfral wallii
of (he fielvis, Ai» a reriult, when the ehild ln-^iiit' to walk the foree^ eserted
by Ihe femora aim a<ld bi IIh* Salteninj; of tlH> superior KlraiL On the
other hand, owinfc to tlie previoiiH non-i)>e of tlte lower cxlreniilicf. thei^e
but forceK have not been called into play early enough to counternet the
viilminjc of th? pa'lrir nnlb't av a rc>^iill of pmlon^-d Kitting, and eonsB-
qaently the iiv'hial tulierottitii-^ tieoome ilarei! out.
The ume faetora an> eoneerned in the production of lh<- ^nerally cnn-
traclti] rharhitir pclvin. i(» ^mall »iw hi'inp dm- either to atropliy fotlovinjt
the rhachiltti, or to Ihe effect of llio di^^age upon a pelris altrady abnor-
mally xmall.
Tlie pwwlo-oaler>nialaeie form rf'ult* when the rlia^hitie .wfloninjr of
(In- Wkv IK ifTV tiiiirkeil and th<' child persipils in walking. FndiT sucll
dmim>'tunec;< not only are the eliaraetGrintic clmnpy in tbu sacrum and
rita
rift
OBSTETRICS
ilian creels protiu4;nl, but iil llic- Milium tiitii* Uiu aiilcrtor itnti IuUthI por-
tions of tlic pelvJ!! are pu^ihetl in towards tlie tiacnim, the pelvic cavity
becoming olino^ oblitrratod.
As liiix alrraily btt'n xaiil, tliew vievnt liave not bn^ii imivcrsaily ncocptnl,
Fehiing belie^-inp that tlio characteristic form of the pelvis may result
in vttro, hvtoTV thi->i! fsclnrH can coim* into play. In not A few ca«c» of
fotai pelvic deformity the einl>ryo has sulTerGcl front M-callcd foetal rha-
fhilis, which )ui» U-i'ii Oi'sifiiiiitiil as nrhoniirfiplrnia iiml di'indrtuJif^tlmphki
farlaliJi by Porak an>l Kaiifinanu respect ively. hoih of whom, however, have
shown that it iliffcrw ratJk-nlly from rimchitiif (Fig. Ml). T\ivy agix-o. thurc^
fore, that deformities resulting from this process eannot he compared with
those resulting from true rhachitis.
Freund has atlempie<i lo siton- that in view of the peculiar nature of
the «icro-ili«c joiniK the sacnim ciuinot mlntc bImuU its trannvcnw a\is.
His description of these structures, however, ap|>ear8 to liave been Unvd
in great part tipi>n iM>n<Iitinni> obKcrtH in adult life, and he ^eenis to have
lost sight of thi- farl that the arliculnr surfaces in early life an- almost
entirely curl ihigi nous, and thus readily fx'vniit of iiintKin in any dinwtioii.
Kehn'r iH-Hcves ihat thi- actiuii of ciTiain groups of miiaclcs playa a
most im|>orta]it part in the prwiuction of abnormal pelves. No doultt this
in truit lo a ciTtain extent, but it in hardly prnhaMi- tlwl it i* the only
factor concerned.
On ihc olhcr htiiid, Itri-iiH and K'di>k» I'laim ihitl ihc vtrvK of Liti-
mann and Schroeder arc in great part erroneous. The fomicr hold that
rhachitttt not only givcK tIm to a g<-ncral softening of the ikIvic bones, bnt
manifests itself more particularly in the imperfect dcveiiipment of tlw? ilinin
and sacrum. Cani-t^^ucnlly the Hultcning of the superior strait is in gn-al
pari due to the ini|>erfeet growth of the iliac portion of the innominate
bone, while tho pubic and hu'ts] portions are but little, if at all, affoctMh
Such an almonuality nmst inevilahly lead to the fliortcning of the anteco-
po'-terior diametir. while, as the result of the normal development of tlii*
pubic jHUtion, the transverse diameter will not lie affeeliHl, or may even
be longiT than usual.
Mon-ovor, thev contend that the displacement of the Micrum is not d«ie
to rotation alx>ut ilw transverse uxi)', liut ralher to the fact tliat lite [ad>
of development at tho siicral end of the iliac porlion of th« terminal length
interferes with the normal backward displacement of the sacro-iltuc joint.
At the Kanii^ lime they rnv. willing lo udriiit that tlie chnngra in the cun'a-
tures of the sacrum may be due to the action of purely mechanical factors.
Their invest igatioii>i have thrown gniat light upon llw niixle of prw-
duclion of rhachilic deformities of the pelvis, hut at the sante lime I dii
not ln*lievi* lhat they "hould he nid-pu-d as the only explaiuilion. Acninl-
ingly it would seem that three factors are conoemed in the gtmivis of the$«
di-formitit-j": (I) abnormalities in the development of rhachitie lKtn<«: (i)
(he mechanical aclion of the varioii* forcr* upon the softeneil hftiic<; and
(;[) the Iraiiion or compre^ion everted hy various nnisehi< and ligaincjil^
Osteomalacic Pelvet. — Inasmuch as osteomalacia gives rise to the most
marked pelvic deformities with which w« arc familiar, Et wa* only iialura!
PATHOLOGY OF OBTBOMAi.MTA
717
that ihp attention of o)H^trtricisii» «houl<l Iinvp bvcn dirKtnl lo it ut an
ratiy ilad?. Caoimt pcrfornipd ('w!<arL'au wvlion tnr this condition in 17B8,
but [or i)i« Diitm [iiou<^i.T work we are iDdebtcd to Slcln, Kibwi, and
Lil»D«RD.
A'ature and Clinunl Utstory of Otteomalaeia, — OstMinalacia, halistere-
«», nwltiti*'" oxfiiiin or malncoiUfii) iliymM', ik u rlimiiic inlTamiiiitlor,V Alii-
vaiie of ibe lionps, irhich liecoiue soft, yieWinj;. and occit^ionally hrittle, and
conMfftutil ly nndirrgo niorki-d cliangiv in i>]m|H' ai* Div n»(ilt of the- action
of the variouM mechanical fnroea to which they art- nuhjocted.
TIms diHWM! is oiM! of udidt life, ajid i* very ranrlv invl with in children.
It occurs far niorv froi|ucn(lj' in women than in men. i-rinecialiv iliirin^
pr4>fniHn(-y or t)M.- |mcr|H-rium. I.itxmann. in 18GI, colk-ctt<d 131 cuHcn from
liio literaliirv, Kr> of which wore in pr^pianl or jmcrpi^ral women, 35 in
Don-prcgnant wnmvn. and II in mvn. Since that limp the number of caw*
in women ha* iiiarkcdiv incivascd. whereaa in IftUO Hahn wan able to add
imlr 31 additional in^Ianc*-" in mntp*.
Thi^ diiM-av^ may occur in anv )iart of ihe world, but in i!S)>ifiall_v fre-
quent, and may even be raid to Ik- cndvmic, in certain localities, notably
in Ihe Khim! Valli>y, Iho Er^lz Valley in Switxerland, tlw Olona Valley
and Calubria in Italy, and in the city of Vienna. It is veiy rarely oh-
■iTVrtl in iliiit country, En^dand, or France, Ihick haritig Ixt-n atilo to col-
lect only 10 cases in America up to I89fi. Tarnier, in his large experience,
enoountentl only 3 caws in i'aris. Iliwt hbw 3 in Philadt-lphia, am) up to
the pret^ent time 3 hare come under my ob«>erTalion in Italtiinore.
As yet no Mli»faetnry e\planati"n for ili cndeinie oirurreni-e has been
Bihiu<<Hl, but it Moem^ to be intimately connected with unsanilary (iurround>
tags and inferior food. I'his wa« strikingly illustrated by the experienee
of Winekel, Sr.. in (jummembaeh in tJermany, and of lloelMvke in Sotte-
gvta in Holland. The former performed 13 and the latter 14 L'ssar^-an
Mciiono n|Kin OMti-^imalacic iialii-nlii prior lo 1K-(ii. Sinci' llial time im-
profement in the hygieiiie oouditions of both villogeti. together with more
healthy occtipation for tlicir inhabilantu, luu K^ lo an alino'^t total dtiup-
pearanco of the diseaiw.
Osteomalacia may alTeet any portion of the sk«4eton. but M>ems to
wlect more particularly the pelris, vertebra', and rilw, TIm? fresh bones
are yellowish or yellow isli- brown in appearance, and ver}- loft aitd brittle.
In ad?ancwd ca^es their consifttenee is that of leather or vti\, m> that Ihcy
can readily be cut with a knife. In tlic later stagm of the dis«as« th«
upongy l)Oiu« prex'nt a markiilly areolali^l appearancv on >iei-ti»n, and in
artme instances are so rarefii^ that only the outer layers remain intact.
At the same tinio tlicy become much lighter, tl>e specific gm'ity being
frequently reduced by one half.
t'nder the microK-ope the marrow spacfrs are found lo 1« greatly irn-
large«l, and there ix a itiarkcil ini-rca-c in la^ularily. The nio^t important
dutnge. Iwwevcr, consists in the substitution of osteoid tissuv in plac8 of
the tme bone snrrounding the HaviTsian ramils.
All of the earlier writers npon tin- subject coiuiden'd thai the eliaiige:)
in llic- lione rvaulled from decalctficui ion. which was due lo (ho pn-Mmni* of
718
OBSTKTRICS
lactic or « R'laleil acii] in the drculaliti^ Ijlood. Rut, iiflvr lite c«rr«s-ttif-<«
or this vk'w hml hiTii dfuiwl by Vircliow in 1852. the writers upon the
i«iil>j»:i liet^iiie (iividfd inlu two (ruiiigi:': the one cluiiiiiu); ttuit IIh? tsmcn-
tial resture of the ili>eaM' is ilwdlciliaitinii. uiiil lli<! oilier, a dinlnrbmiw iu
llio relation Itetn'ccu niiorFttion au<l ifopoHition, l>v which nutcoid innlcad
of tKiM-fiiis liwsuv i» formi-d. I'^iU drlAiU of thi» di»cu>^ion ani to be found
Fl)t. M2.
nic.M3.
Fiiw. AAli'MS. — OsraouALACic Pclvu.
*
in the writings «f Cfljike. Rilificrl. Winckel, an<i lAxitcr, in which
I'ntint .-•ulijci't in cari-'fully conj.i(ler«i.
Ono of the iiiof^t iiii|ii)rliiiil i-iitiirihiiti<iii« lo (ho 9!til)j(Vl wAf tiuid ' '
I-V-hl)iig in IHHH, who advancfd the theory tiuit tlic diwattL- was « tm^^r'J'j
ncTurosis of ovarian origin. He Iwlicvoil Ihal etuini(rienstic changca e^^"^
Iw made nut Id the nvarirs. and lliiil llii-se jrnvi- ri.-e lo n'flt'v atinitiiiU"^"™
of till- viisddilalon siipplyinj: llic hones. Although this thwry ePfv^^* *
cKptain thp hrillinni nwilln f-illnwiuf; cahitraliim in lhi>= diseiW. Ilw va'*'™'
aulhoriliea nrt' nol vi-l afrrwtl ri>iu-i'rnin>! Iht- (ImnxtH in the ovario*. ""
HntiiLs. ill ISIIH. sttili-(i (hut tJu>y m-Tc nol ch«r»ftiTinlir,
More ijo|iiirifiiit, from n iiriK-lical flundjioiiit. i> iht' t-ltntml hi.-lorV"/
(lie iilTeciiiiii. Ill il.i earlic-l >la>:i^A It i^ rhnmderiaitl l>y |Kvtiliiir Wft-
cular )iati-ic!=, which more esjieciill.v afTovt lh« ilin-p^was, and wliivli *n
ttnia>MAi.A(^i<r piavis
•ifit'ii iM't'<mi|iiini<-<i liv (■••iitnu'luntii of llit- aliiliii'lnr mii^lt'.-i <>r llii* lliijcli
uiul iiH-n'fl»c<I jMili-llar rL-tlt.-xi.-». A liltk' latter rhcuiuatoMi pains make tbeir
appearaiii« in variotui ponioni' of tlic Ixxlv, and nt tbu wmc time (Im
gn-lvio. rilxi, «ii(l vertebral column lietoiiio v*-n' wnnitivu up<»n imw»uTu.
Ak iIw (liM-u»t- lulvantxv iitiU fiirllivr and llio Ijonm become Mftcr, Tariou!i
deformities ap|H»r, wliicli ««' |iartieuUrly niarl^t-d in the VLTlt-brul t-olunin
ad pelvi*.
11h> hixtury I'f 'wIcnrnatAric paliiiil* i» uMially of Ihlc vhanctor: IIk
"woman lia- tiad one or more normal lalioiirrt. Iliirili;; tlw nvxt prt^naiM'v
*|if! (iimplaini^ of miiKi'tilar M*mptwm« and rlH-urnaloid paint, and grcali-r
dink-iilty iA oxiHTittMixl at the time »f taliour. 'I1ie samo »>m|ttnmt* recur
^i'ltti addiil intt^Dsity in the (^wrvMlinf; pric-f;nai>c>'. and Ibe labour is etill
Hdom- diflicult. pmliably mguiring craoiotomj'. In the nuotweding pn>g-
^pancv the rheumatoid pain)' bixttme «» intence and Ifiotyinol ion in inter-
BT€T«^) with Id Km'h an i-xtenl ihal for iIh- la-^t niont)u IIk- {lalii'ht in obtigwi)
to take to her bed. This lal*our aiw) Rcncrally iwjuirve craniotnmy or
L'a>sarraii ii«'ti<m. After il» tcrmin»li<Mi tUo paiiu' di^app-ar. awd when
tic patient in able to )tet about a^ain ithe miticeti Uiat siie han iieeoiiiG mmo
[■txtrlcr Ihan prcvioui'ly. the dimiDutinu in !<Iatitre bt^ing i^umetinxM
eialei) with kyphotic changes in lb« vertebral folumn.
To Hiim np, ■ hiftoFT of rheumatoid pains and dillicnlt Iwomotion re-
lirin^; rc8t in lird during prvgnancr, a!i.-H>ciate(i with a deereaM? in height.
almoKl palho^'nomonic of o>^teomalacia.
('kati)}ei in thr Skaf- nf ihr I'tlrU. — The extent of llic di-fortnity rwull-
from Oittcomalacia dcpi-nd» entirely upon the de)rm- of froftcning whicli
Kio. aw.— OwrWMiAl.Kir P»-1.»I». Inh;iui>k Htkait.
various pelrie lionet have undergnm-. Accnnling to Ki'lirvr, in the
Iv •lajfi'* of iIm- diMiis* thr ihIvih i^ ^iinph Hatlcmil an the renult of
Ifnrcing doK-tiaan) and foruunl of the promontory of lh<- oaenim. Al
iimi' timt- ihe iHxIim of llu- vcrti-lirw iin- pu»h«Hl out and U-yond thr-
«nd it« loai-r fxlremity lieo-mH"* markedly eurvwl iovrani. Iho cluing*-*
n-iiatly much morv prutmiiiicul Ihatt in the rliiuhilic jwlvi*.
(Ik- laliT stagt^ of the dix-a.-*, when the Iwnw liavc bwonH." very
720
OltoTLTRlCS
iwft, t\w pvlvu \akv» nil a fliarocteritilic i«inpm<t>i>tl n|iiH>nr»n<^. The Imm!?
weight pr«H<ee (be promontory fitill furtUvr dowiiwani und forward, whHi>
tlifi upwni'd and iiiurani forces excrli'd bv tIm; fttiiiora [lush Ihe Uteral wsll«
of the pelvis inward, until in very marki-d i-aws (he superior Hlrmit boconic*
almost cnliri'lv i)Miti'rflii'<L At tl«' koiiht rime ih« iiichio-puhic rami arw
approximated, arid the puliic arch is conrerled into a narrow ^tit into which
it is Kiin«tiiini< impcHtKiblc to in«iniiate the fingnnt. The piihic nuni an
pushed markedly fi>rward. giving ris* to a beak-likG protuberance upon
Ihf anterior wall of llic prlvis. Ooiiictdent with lli>'»i> (■hiiMK<>». tlteri' is u
markifl diminution in the mixe of the pelvie cavity and of the inferior strait.
(hough in not it f<-w caws, owing to cntixlimt silliii]; wjioii iho smfleiiwl
bones, the tubcra ischii are considerably Hared out. In adrariecd caaca thi-
]w}v'» i» very much dcfonncd, and may pr»cRt any one nl an almOHt infi-
nite variety of bizarre shape*.
Diagnijslx, — The iliiiguosis is rtwdily mfidc. fl» enrfful inipiirv will usu-
ally elicit the characleri§tic clinical history of the disease; while examina-
tion of the pelvis will show thai il is ntarki<d1y oompri'S.Hnl in all directinm.
and the ]>Hthi>K'ni'i"'DiP rhaiijje'* in the pubic arch can hanlly e?eape delec-
tiou. Iniieid, tin- nnly form of pelvis wilh which It might Ih' ix>n fouiidvcl
is Ihe very rare transversely contracted Kohert pelvis, but tlie ab-tence of
the chariicterislii' clijiiiul history iiml the lack of anlero-posterior ehorictt-
ing in the latter will usually enable one to differentiate bctwecD them.
I.ITKRATimK
AHLrKL.li. Die I>iAtci">w cIcn rinfach pkiltcn Borketw an Her Lnbonden. Zcttartir. (.
(;«b, u. tiyn., IH05. xxxii, 356-307.
BvTMUiLKK. Aiin.alcn dor kliti. AimtAUcii. Brcaluu. 1832. i. 24-W, it, 31.
BaRus 1111(1 KdLiHKo, Tta<'liiii>i-li«cken. Oio pittbnInKi"''h«n Iteekeofonuai. Lapiic
u. Wien. 1110-1, I, Th«il 2. 433-638.
BruiTB. 0«t«oiiwliicie ii. Kion-tw:!:. lltfBir'i" licitrAKfi, IWft. I, 138.
DtvHNTKH. Nvutui Hubttiiutiunlit'ht, III. Aull,, Jhiu, I7J8. 109,
DdCtK. OnteomnliLoia, with n New Ciun. Atiier. Jour. Med. Rciencoi, ItKUi, rix, 499-
51G.
FAMiKNDtii. t'cbnrdanpiEudo-uiidiluBniohitiscli-osUiaiiiuliHnHcJie licok«ti. 7jcMAa,
i. Gtb. 11. C.yn.. 1S78, H, 332-.3W.
KKMLtso. Wf Eiitdtohuiij^ d«r nu'hitih<rlii-ii Bwkenlonn. Arehiv I. Oyn., 1M7, »i.
17;M83.
Uubvr Kaotniliofi bei C)«teoiruklni-ie. Vwh. d. deiilacJwin fluwHscli. f. Oyn., 1888. ti,
311-318.
FnKtiKt). t'vbvr d»H mmnnnnts kypholiwhe It(icJ<en. iifn. Klinik, 1885. 1-131.
tiELPKE. I>ia 1lHlviiiiudui.'ie iiii Kncolztbulc. BumI. 1891.
IIaii.x. IJobcr Oatconialni-JE lir.im Muiinr., Zinammenfanmidoi Ref«nU: Z«nU>JfcL (.
die (iniiiXK»bii.'1« der Mnit. u. Chir.. IWJO, iii.
HiiwT. A Tcxl-Hook nX Obslotrics. Thifii rditioii. tftV lliilAiklphU, IBOI.
Kajmowitx. V>k iiominle (IsMifi fait ion ilml ilit Krknuikiinitm Wl liix-ltilu uiid Iwrod-
itiiriT Syfihilin. Wirii. IN8'i.
KAitFMAS-N. I'lilcnnii'liiiiiKrii itlirr din HijEOUHKntif Ui\»Xr ItscbitlH. FWriti), 180?.
Kkhhkk. Zur KniwickeliiiD&wwbifliie d™ mi-hiliM<hpii IVi-Li-iis. rVn-tiiv f. iiy«.,
1B73. i. !A-m.
Pc4vis pliiiin <Ml««iniiU>irii^. Zvntntilil. f. Iiyit.. 1D01, xkv, tMO-OINI,
PELVIC ANOHALTB» DUE TO ABNORMAL MALLEABILITY 721
KiLiAN. BcitraKe m eincr p-nauen Kennlnim der allgemeinen Knochenerweichung
der FniiMi. Bonn, IS2fl.
Time halisteretucbe Berken. Bonn, IB57.
Latso. Beitrigc lur DiagDoae und Therapie der OslcomalBcie. Mon*twehr f. Geb.
u. Gyn., 1B97, vi, 571-608.
Lautex. Zut Pftth. u. Therapie der Oateom&Ude dea Weibea. Zentralbl. f. die
Grenigebiete der Med. u. Chir., 1000. iii, Nr. 1.
LrrKMANN. Die Fonnen dea Beckena, nebat einem AnhanitP iiber OHtenmal&He. Beriin,
IMl.
Die Geburt bei engem Becken. Ldpzig, 19S4, 36.
MbcHABUfl. Daa eage Beckea, Leipzig, 1B51.
l(i}u.KH. Zur Frequem und Aetiologie dea allgemein verengtcn Berkena. Archiv f.
Gyn.; 1880, xvi, 155-174.
Masoklk. Dm achrag venogte Becken. Bf&inz, 1839.
PoKAK. Db I'acbondropUaie. Nouvellea archivea d'obst. et degyn., December, 1889.
RiBBEBT. Die OBteomAlacie. Bibliotbeca Medica.
BcHUKraAXj:. Ueber path. Beckeqroimen beim FOfua. _ Archiv f. Gyn., 1882, xx,
435-*54.
Smblul AafttofniMl Tablea, ete. New ediUon, Edinburgh, 1787.
Snujuim. Le Rachitisnie. Th^ae de Nancy, 1900.
amN. Kleine Werke lur prakt. Geburtahiilfe, 1798, 283-340, dazu, Taf. X.
Die LehruiaUlt der GeburtahuUe lu Boon, ElberTeld, 1823, 1. Hert.
Takkhs et BvDiN. Trsit^ de I'art dea accouchementH, 18QS, iii.
ViKCHOw. Archiv f. path. Anat. u. Pbyatol., 1852, iv.
WiLUAiiB, 3. WHrraiDOE. Pelvic Indicationa for the Perfonnance of Cieaarean Section.
American Medicine, 1901, ii, 483.
WixcKXL. Behandlung der Oateomalacie. Pentioldt u. Stutcing. Handbuch der
■pec. Therapie, 1896, Bd. v, Abth. vu. 214-242.
ZirHFEL. Aetiologie, Prophylaxia und Therapie der Kachitia. Leipzig, 1900.
PKLVIC ASOMAUHS OVK TO AHSOKMM. MALI.KABIUTY OF
THE PELViC HONES tC«nli»«ni>
I
EFFECT UPON THE COURSE OF PREGNANCY AND THE
MECHANISM OF LABOUR-TREATMENT M
Maukku (Irjint-^ of pi-)vk- ilcromiit}' i-xrrt n proiivuitcvd influence apoD
the oouriw of progiiaiK-y as well as upon th<i meclianiniii of UlMur. lutli^l.
(o fM' uiUL-rampunKHl b_v ninn- nr li'*x tintowurd i-lTwts IIk- (■ontraction ms*!
ho niiriitiiiil.
Efleot of ContrscUd Pelves upon the Conne of Pnguuicy. — The p,
lion of the Citru». — In the early tiiontlis of prcgitaavj s tninor grade
[)p|vio maironiiulion may exert little or no intlm-noe upon the position
tho utoni*. ijiit ivlicn pix-wnl in any niiirk^-il di-gni- it may inlcrfcn- w
Ihv iinriiiul rJHiii^ up nf thai organ, {mrticiilarty if ihe proiiiiuilory of l^
9ticmm projeots so far into the superior strait as Riwkvcilj- to oi-erlun; tlKj
pelric cavity. In duoh ca«'« tlw! fuinitw iTiipinj!>!>i iip>ii Ihe utlcrinr m
face of the sa<?rum, and m the uterus increases in sixe it assumes a posi
nf more or lc?s pronouiULii rplr<ifli'xion, which Inter may gitc ri» •*
characteristic Kvmploiiis <if incan^eration.
When the ileforiuity is siitliciciu to interfere with tlw descent «f It"
prciiViitiDg part inio the pclvjn, iTinrki-<l alimirimilitiGs in tlie pmilinn '^
the uterus are atiservwi in the later months ol pregnancy. UnJer Hieb'"'
cuTnstanccs. parlicularly in primipanc. tliu fiimUis nciupios a hijtlwrpW"
tion than usual, and tu^riouii respiratory and circuiatory (listurUanew"''^
peeuU, At the same lime, owing to the fact that the lower port ion «( '*'
uterus i* not fixml liy the enjrn)p"(! head, the entire organ U much i"""
freelv niovaljle than usual.
More imporlniil, luiwever, ts the fihar|»ly untctlcxisl position whirfi •"
uterus assumes as a <M)nse([uence of serious disproportion in siie tn""^
the licail and the ix-lvii?. Tin* is cmplini;ized more particularly in '"'"
women suffering fnini ninrVc*! Uimluir h^nWis. in whom the capacity *' '_
ahdomoD is so greatly diminished that the gitiwing uterus ik^Ics t* P""
room hy pushing forward the anterior abdominal walls. The prw*"**
a penduhiis abilomen is a sign of considerahle importance in priraip'''"''
women, and should alwavit cause one to «Uipect the existence of irtfW
pelvic deformity. The converse, however, by no nican» «]way# bnUs p*"'
and its at>sence doca not necessarily indicate that no dis])ropartioD oi'tv
722
RFKfSrr OK PELVIC ANOMALIES IIPON CXlUiaE OF PHEGXAXCY 723
Moreowr. « [M'liiliiliitiK nlxlimmi i* often nliwn'wl in muUiparftu." iiroin«n,
rik] may Iiav« no );ri'ut Hi^jitilK-aiiL-i-, l^'inji: jpinorally tiw to a lotw of tonicity
H 'if itiv uk-riiK- und uMnminiil vm\h ai* tl n^iill nl pm-intts |tn>){iiUDm'K.
^ I'lmitioH unit PrrMnlalinn uf Fi'tuf. — A cMUlrm-liil jh-Ivis pinyx WM im*
jMtrtiint part in llw- |iro(lu<-tiou of alinoruial jirv'si-nlalionn. lu pfiiiiijiamuH
wnm<-n, wliLii lliv pvlvU is normal, l)iv pre^-nting purl, sh a nilc. dcsceiKlx
inlo th« pelvic cATiijr during itio last «ix itesinA of pregnancy: Lnit wlutn Die
superior strait is considcralily conlracted this doe^ not oi-ctir until after
llic iinw't nf Inbonr, «iwl x<>im-time< not at nil. Wrtcv pt\-«>'nUtioni< Htill
prfdnmitiatp : but since the head tionl.t fpifly abim- iIm' Huporiiir slmil, or
^r<9>l» U|M>n unv of tin- dine fossic, very litigbt intlticntva may caUM? the f<Etuit
■to assume other pcwilionx. Avcordinj; tu Mii-liaclie. vertex pivwntntionit
Kara nti-r hy H) per c«nt in contracted than in normal peke*; while face,
H breech, nnd tmmtverMt pitwntution^ occur ;i nr 3 times, and prt^Iapa- of Uio
Hcord and the extremities 4 to i> time^ ninrc frM)iientiy.
™ AI>nomia] prvM*nlulion« iocri-aw in frequency with the degree of con-
traction, a.« id sitovn by the following Shirts of ^Itchaeli», Litxmann. and
Lj^-hwurtz :
Cou)uxtlk v«ni tt.2 — 8..> ciu,
'■ 8.4 — T-S" ,„
" 7.4 cm, or km, M.7%
1)3.1% iwtox iWDMntationB.
«3JKi
Tnmier, in 1,030 eases of laUmr ompliiated Uy itinirncteil fiekc^,
iW:rVMl W<2 vcrti-x (K.i,|;t jx-r <vni iiult-nd of m per n-nt), t'i lirwch
(J ptfr cent iiutead of :{ per cent), S2 fn«> (3 [icr cent instead of ».(> pet
I), and J4 tranitvcnH- pnrcentulions (4.^ per cent instead of 0.5 per
4).
As has been seen, abnormal presentation^ occur more frH|iientlT in,
uUtparoui' itijiii in priiiiiparoiiK urmicn vrcn und*T farourablc cimtitinns,
,nd, a» might be expected, they become still more common when the pelvis
(■onlnicliil. Tbii*. 8<'hatita »timflli-<l lh«t, ihey are 3 timw more fre-
uent in ttie Jiftli than in the first pre^ancy.
Face and trnnstrriK" pr<^^i)tal >on» jiosxirin a pc^vuliar sifnnticanoe in
TiuiipurDu:^ wonxti. and t)u-ir nccurrcncL- is nearly alwayn njwH'iali^ with
rked disproportion between the size of the bead ami the pelTis. ao that
livnerer either variety ns encountered one can fii-l cirHain that tlw head
iinii^iiunr large or tbc pidvis iilinorinnlly ^ininll.
Nil* uf Firttrn. — l,a Torre, Tinard, and ntlter* have staled tluit the chil-
ren of women with ahnormal pelves usaally attain u larger .lixc than usoal.
Pinard attributes this lo the fnet that in unch cases the head docs not b©-
ccunr fngagix! during tin- Inst few w^-ek* of pregnancy, and tlicrcfori' Cannot
ujKiH the lower uteriuc segment, thui doing away with one of the fac-
rs predispoding to the premature termination of pregnancy. Wilcko and
igpif, after carcfnl «lady. have concludeil that such is not the ca*c and that
the children, under such circiim=tanccs. arc gem-rBlly slightly fimaUer than
I, Thiii i* pHrlieidiiHy (hi- case with generally contracted rhnchitie
re*, aK mch women arc iL«uaIly under-»^ixcl and vontd naturally give
iiirlh to Kiiiuller eliihirvn tlian would larger and better formed individual*.
K>rB I
™%igp.
the (
birth
724
OBSTErnKS
Hectianiim of Labour in Simple Flnt und Pint Shachitic Felvet. — Ttid
iJMMibility of the occ-urrenw <if Kpc»iu>intHiiiT. labour in Hal [n-Ivc^-. (ti-jx-jMlf]
^ininanl>' upon llit; i.l(-};n:-(; of <-<)iit ruction, and, v1k-d (lii» is not t-xci'^ir(h'
upon the folloving additional factors: the size, compKsdibilit}-, and malle-
ability of the fa-tnl lii-ad. and the c)tara£t«r of tho espulitivie forces. The
nieaaureiiieate of the peiriit cao be estiinali^ with tolerable tuwrtu:y, bat
tlxMf am no ^iti^^fai-lory iiu.-titodH of detiTmining iu advance the ttiz« and
oilier pri>perti<'^ of the lit^^id. and not until lubniir has cotue uu can uai; ti-U ,
«t nil approximately what the uterus can do.
In our W7 «i«is of lulHiur in eontrat-tod jk-Ivw. rvportwl in 1901, sjhui-
tancous deliTerr occurred in I9!l (71. .IS per ceul), and became leaa fre<|ueDt^
the more marki.>d the jwlvic deformity. Thus, wh«a tb« conjugata Ten
meaeured
10 — 9 on.. ipontBiieoiu deliver)' uecunvd in 77.28%.
8.9 — a •' " " " 61.M%.
7.9 — 7 •■ « « .. S3-i%.
e.ft cm. or leM, " " " ooae.
KTra u-lK>n tlu' c-lijld IS born «pontancnu#1y uud witltout any undnfr'
delay, certain liiaracteristic altnortnalilies can be observed in the mechaoitia
of labour by wiiich tlie cxpcm-mnl oliKlclriciun \* MtMwd to dingDo^p the
presence of a Hat pelvis without resorting to pelvimetry.
Inasmuch as in the vari('ti<» of pelves under consideration, tho coatrtc-
tlon ii» practically limited to the anterior posterior dianu'ler of the >upehiie
strait, while the transversu diameter reniains unchanged, or may even iMt'
slightly enlnr^il. it is evident that the obftaelc (o the passage of the clhld'^
head h offered by the Bhortened conjugata vera; and vhen tlii.* meavurci
Ivss than 9 or 9.5 centimetres it becomes out of the question for the bipari-
etal diameter of the head to paaa tlirough it, unleft.t it undergoes siinie iltiuir
uutiou in size. Accord iiigiy, when iiigajp^'ment occurs, the iR-ad slips tQ
one side so as to bring ihe .ihorler bitemporal diameter in relation witli thi
conjugata vera. As a result, the long arm of the head Icrcr becomes diad
placed to the fide of the oecipul, »<> that the anterior portion of the heai
d^cends under the induence of the uterine contractions, while the (MM^pitai
prirlion rix<w up, Under iIk-ko conditiiinK the large fontanellt- is found to bi
readily accessible to the examining fin^^r on one side of the pel?iH, vhill
the wnnll fontaui-lle 'u reaihtsl with wime difticulty on the othiT, At thj
same time, owing to the fact that the transverse diameter of tin- KUperiofl
strait if not shortenei). the heud teiuU to accommodate ilfelf to it, so tliaH
its long axis, as indicated by the sagittal suture, eomw lo lie transvi-reelfj
More characteristic still is the abnormal attitude which the he»A a«
Humes when the disproportion lit^tween it and the pelvis is at all markf^
so that vre ha^v what is known as an anterior parietal prenenl/itian. In Ihii
the presenting pari, which is the anterior parietal bone, occupies the su]i«
rior strait in such a maoner that the sagittal iiulurc lies ju-it in froni of thi
promontory. TTpder nuch circumstances the anterior ehoutder iit rvndil]
distinguished upon external palpation. .According to the e.v]iUnafion ^>?tiJ
erally acceptiHl, this condition is brought about by tlie abnormal rxiUli'iB
home by (he axis of the antellexed uterus to the plane of the supenor
4
uex;haxism of labour in ooxtracted pelves
lit, ae tbo nwult of which tho posterior portion of the bead is pressed
■gainst the pnoinontnry of th« naerutn, wh<>re il hMmtite* arre»t«d, while iU
uitirrior purtioD i» forced into the pelvic.
Thin prt^c-iiliilioii is «ini})ly Rii cxaggcntion of the so-cnllod Xoegelc's
obliquity, aod the iiM«hani=m of deftcent is rc-adily undfrsttyid when we com-
V tin; pswtagv of llic ht^d through tlic ubnoniial »u)H.Tior strait to tlw
na-iivrc neceaaary t» pass a titick nf a certain Icnj^lh Uirough a ring of a
rhat ebortor diameter. To do to, one must depress one end of the
SW, — SlillWlVO A-MtlUUK fAMETAI.
Fill. SGfl.— StloWINO Ttll: PjUMGE o» A« .V*-
lEKlOn pABIKTitl. l'lll»tKTAnoK tiiauvuu
THE Sl'l*mK» 9TIUtT.
lick M as to allow it to enter the rinj» obliquely, and after it liaii nearly
■K^ed tbroiigh ill' olbt^r eml niu.->t liko<>(M> bt? lou-i-ni).
In order for descent of tlte bead to occur, the posterior parietal bone
lintily pn-«MKl n^ninM the )>ronti>ntor>' of Ihv Mionim, while under the
utluem-e of the uterine contractions the anterior portion of the head i«
rly forced down inln the jwlvis along thi- jHwIerior surface of the sym-
liysi.4 puhis; after thU i» aci^omptiHhed Ihe jMMit^rinr {tortion pnsm orcr
promontory and enters the pelria, tlw sagittal suture at the same time
«ng forwnnl. t'nder mieli circtimftiinceji, when the controction ia
considerable pressure most be exerlwl upon the posterior [mrtioa
the head. Eridciicc of lhi< i* Hnualty nlTonUtl after birth by a moR' or
welMe^nol riirtni depression, jii=l Itehiod the coronal suture, upon
' side of the head which was in eonlad with the promonlorj". After the
lerior pariclul bone ha» p«i>»cd the »u|>enor strait, nil nniinlaiMHt haa
nvereonie, and, owin^ to ilu> fnet ihat the lower portion of the pelvis
is often larger than u^ual, the rc»t of the labour is promplly aceompli^hed.
In a small number — according to Litzmaim about one fnurih of the
oues — the rerer*> condition — the pfttlrrior parittcl preaetttatton — is ob-
■■^■d- The Mgittat »^uture now lies almost in contact with the fymphyiiis
^^^n *bil« tbe posterior parietal lM>ne occupieo tlie HUperior strait, and in
^Ki^ked cases the posterior ear of the child can be folt ju«t above the prom-
^^BBtory. Ko that ihc condition is sometime* ([Kiben of as an tar presfnlalion.
Tbc long axis of tlie child's body fnnns an obtuse angle with itn Iwad, and
726
OBSTETRICS
upon palpation the anterior )>ortion of the 1atl«rcan be felt as a prominenl
tumour lying aiiorv tho »jniph>>is,
Jn order for the head to i'nt«r tht- pelvis, ita posterior pnrcion mntHi
be puiiiicil tiowii past llic promontory of the Mioruiii. u(t«r which its anterior
Pm. 907.— finnv-Txa Postkhiob Pjuuctai.
Pmimoctatiom.
8vi'i;Hiun Snuir.
portion descends alon); Uio eymphyeis pubi^, whili- at tlte same Unw the
eaRillul siilTini ii|ijiroaohp.* the middli^ line of Ihe peh'i*. After lliia h»
(Kicurrtil lattour takes place in the usual manner.
The mode of jiniihiction of tlii» MliDoriimlitv is not definitely understMd,
oltbon^h il I* obnerverl nia^t frequently wfien thi' grade of cnntraelion i*
marked, the pelvic inclination considerably inrreased. and the abtlonun
not pendulous. The pnwt'iitiilion i* generally eonwdcmd ti» very unfaroor-
able by Ihe (lermans, as the line alon;; which the uterine conlmctMU
are transmitted if given unothrr direction Kt Ibo neck and is much hw
advantageonei than when the spinal column and head form it onntinwHis
osis. TuniiiT and Vuruier, on the olhtr hand, hold Ltuil il ocx'urs much
more frequently
than th« antenor
parietal prc««iU-_
tion. and is withou
ominons prognnslt
eigsificance. In-
doed. thoy belie
that it is merely
exu^rrelion of ti
procoB obi>«rved in
tbc normal mechan-
ism of labour. U
my erperienw. hov
ever, il has occurred
far Ii-^ fre[|uentir than the anterior parietal presentation, although ii
many cases it has not bei-n atwocialcd with d particularly dinicull labou
Fio. SCO. — EMOAOCur.sT OF Head in HEKimui KirpnaKw Snuir
CrkrnlcF).
MECIUNISH OF LABOIIR L\ CONTRACTED PELVES
727
Wbea th« promontory of the iiacnitQ protrudes into the superior xtrait
tia etidi « way as to render il renifurm in outline, it is impMsihte for the
rtiead to iis<mnie its luusl IranaverM) jKjaitioii, nnd lh« Mgiltal sutarv mmt
i oct-upy an oblique diamotvr (Fig. ft69).
In mre in*liinoft« tlie pmiiKinlory nmy proji-cl «> far forvrard ns to mako
the superior strait rceemhle the figure 8. Under utu-ti ■■imini'iance* only
|onv tide of it >» availatik- for tliv pa»#agio of the hvad, snd Breisky has
'dttiignaltil the oonditiim Si* rjlra-meJ'mn rnyixgfmrttt. It i«, hiive%'er, of
VL-ry ran- oecurrpnoy, and ni-ed uot be coDRidcntl further. '
Wlwn the pi-lvic wntrat-lion li compticntt-d by tin; existcnou of a faw
DtitalioD, tlH- pro^Dofis becomes more dubious, an it ia more difficult for
fact) tlian for Die va-rti-x to paw the ooiitrai-lcd eupirrior strait, and
' accordingly the course of lalmur ia unduly prolougi'd.
Iltnifli proi-Diiitioiix liki-wiw (■iiiiplimtf uialkTs to some extent, 18
they are veiy frequently acvompaninl by prolapse «(f the cord or of one orl
niorr of the extreinili(«, oning to the imi>erfect adaptalioo of the breed!
t/j the superior strait. Under audi cir-
cu instil nn>^, although tint prognosis for
the niotlier remains favourable, the
child's life is endangered. This is
expetrially trm' w)u-ii Iho roiilraotion
ia marked, as considerable diHiculty
niay bo cxpcrieiutici in extracting I)k^
^^after-coming Itead, and if this lie not
^■promptly accomplished the child vrill
^BlDevitalily |><-rii>h.
^f The afitr-tominR head, in passing
through till! conlrack'd «uiH'rior utraii,
follows a meclLaniiim analogous to that
obserrtd in animor iwirivtal preseii-
taliona. In othiT wont><, its posterior
^ portion is arrwtcd at the prrtmonti)ry, while its anterior portion passes down
^B hvhind the eynipliyiiii', after which its posterior [wrtioii d^'«-«-n<ls.
^ Kechaninn of Labour in Qenerally Contraot«d Flat and Generally
Equally Contracted Bhachitio Pelvea. — Tlit^ mechanism of lalxmr in gener*
ally (xinUacled flat ptivt-s varies acmrding to ihc extent uf tlw- deformity
uiul the shape of llw pclvin — that is. nt'<-"riliiig «s it approaches more
i!liK(>]y to Ihv flat or to Die generally contracted type. In the former csM^
pn>«ide(l the contraction be not too marked, the m<>cltaniam of labour will
I be identical with that ju«t dt.vcrilx'd [or flat peh-es, whereas in tJie latter
tbo h<«d will lieeome sharply flexed and be bom by the m<rliani-'m whii-h
ke ahall consider in detail «1k>ii wc study thi; gmicnlly oontraoled or justo-
tniDor pelris.
In Die gctieratly and equally contracted rhachittc pelTts the niecbaniam
cnrrespond-1 to that observed in lh« justo-minor pejvis.
In the pwudiMistciiniiiiwio fonii.i the contraction is ui'ually m marked
a* In preclude tlie potuibility of the Iwad entering the superior atrait, aitd
ttiB child caiuwt be bom per viat naturaiea.
Do. fiTO. — Itiiovixii f AMiAon op ArrH
COM IK a UiuD TiiHiiiini lii'mioR
BTiu,rri Dakkch Unii-o LAiir.
728
OBSTETRICS
Coone of Labour in Contracted Pelves. — \Vlii-ii l)w jK-lric dc-formit^l
sullicii'iU i_v rnwrk<it in pri'vi-nl lin- head from entering ihc Buperior strain
duriu^' tilt' Isini few v!>xk» of ;)nij;iiiii)cy »r nl (be onitcl of utiTim- mii-
tractiuuii. the course of lalwur is usually iindulv proion^nl. In Uic fim
istafK l\n* i* due 1u irii|H.*rff<.-l dilutiiliuu of Ihu cervix, untl in ttic setnnd
to the ttim- rt-<)iiin?d lo so mould and t'oniifiure the head as U> render iku"
Hible il« cnlraiu-e inio tht.' pelvic cnvity.
Al/nrirmalitifs in ftilalation of Cirrix. — Xonnully. dilatation of tlic wr-
rix is ItrouKht aliont bv tbe unruptiin-d metnbranea actiu); as a hvdroflUlie
wi'diti", and after their ruplnre by the direct action of tii« prc9entin<! part.
!n contrai'liil |k>1vi-s, oh the oilier hand, when the head is arrested ai ilie
superior strait, the entire force exerted by the ulems act? directly Upon
tlie portion wf int^-mbramM in eonlart with the internal n«. mul ronM>qui*ntly,
ae its force i« not broken by the iuteneninK head, as in normal labour,
prrmalurr ntpturr' (n'liuenlly resiill*. iKriiirTiiij:. uwonting to Lilzmann. in
26 per cent of tlie ca.ws.
After rupture of the nicmbraww. further dilstation cannot take place
until the preiienliny part U able to exert a direct preHHnre upon the cervia.
and tht(i IS out of the quo-tion until a long i-uccc^sion of stronj^ paiui; bare
mnuhbil the Iu-aiI Millicicntly to pi-niiit its <lev.'t.'nt. In not a few insland-^.
however, a fiipul succtilanfum fornix upon the mot^t dependent portion of
tin; jirewnting purl, and aids niHteriidly in the dilalatiim of the wrvix.
Even after the cervix is completely dilated considerable delay may
occur, and it ^onieliinc!* rojuire* hour* lo mould (hi: bead to the pelvis;
but in Itnl pi-1v<'.'' l)u- laliour is pnnnptly tertninateil a;* ^M>on a>i the con-
tracted superior strait is passed. In the ;ienerally contracted varielie*. how-
cviT, thi« is not Itiv caw, ituismuvh ii» Iho hindrumir |H'n<i»t« throughout tli«
entire |>t>!vio c^nal.
AbnortRulilirK in rti-rinf Coniractinnn. — Not infrequently the courae iil
labour i* -■•lill rurlher pmlnngeil owing to faulty uterine i-onimctinn?'. Tlii;
ie rarely the case in rhochitic primipane, iu whoui the pains an* usually
Ytiry ellieieni; hut in niulli{>ani-, in mhnm previous diffimlt laboiim lia^e
weakened the uterine nni^c-ulatiirc. Hecondary titt^riiie invrtia Dot infn$!
qncntly nccun' a» tbe nwnlt of exhaustion.
In a .■'mail numinn' of cases tbe uterus, instead of presenting ftignxnf kmj^
ondary inertia. may become IftnnicnUij ctmlmrtrd. Tliin !» nn extremely seri-
ous cnndilion, hk il eannoi lead to the K-nnination of labour, am) at ibe muiv
time markedly increases the danfjer of uterine rupture. If Xhw coiu plication
dom not yield pronipltv to the adiiiinistration of siilatives, it aiTord^ an im-
perative indicntion for tbe termination of lal)our by one means or anoihet^
Danger of Uierine Rupture. — Ahnonual conditions in tlw lover uteri
jw-ginenl not infr<'([uenlly constitute a very serious danper. ospecinlly w
the disjirojiiirtion lietwii-n the bead and the jiclvis is pronounced.
I'oder such eireum stance". aft'T a |irii)onged second sta^c, with llw
head still at the superior strait, the lower uterine eiffinent become* mark-
edly stretched, so that the dan^T of rupture bocnmM imminent. In t-iKb
cases, the contraction rinj;; can lie felt as a traiisveme or ohliqui- i '
tending acroM the uterus a short distance below thu umbilicus and ■
im-
'4
.1..,
COURSE OF 1-ABOUR IS CONTRACTED HELVES 729
My ol it» Irvfl, vrliile in aut a («w instances it^ position i^ clearly vjsibit?.
Thitmin;; of the lower utoriin? I'l.'^mt'nt i" purtk-nlarlr Iial>lu U> nrcur in (lie
gcncmllj' CK>ntru^'icd variety of rhiu-hilic pt-lTi^H, ?in<« the lower end of
the cervix may be caught betwevu Ihv child's lM.-ad and llie pelvic brim,
and llius he pri.>Ti'iit('d from rotrm-tinjt, tln-n-liv fai'ilitatin;; ihe Ktn-tcliing
tjf the lower uterine segment. Whenever this condition is noted prompt
delivery i« urgvntty indirati-*! ; hiii at the «nie lime grt^ut raiition is m\*»-
sary un the part of the phy^ieian li»t bin niUKVuvreii give rhii- to traumatic
niptiirv,
frodurtiiin 'if Fi'tuliT.—ViXwM llie pri^tu-'ultnjc part i» (irmly wedj^etl into
tlie AQperior Htrail. but inaliCB no advnn<v for a long tinie. [tortious of llie
grnerativc lmi;l lyin^' Wtwccn it uiid llie jiirlviir wall may he auhj[!clnl
to iindae presnure for a ron^ideraijle length of time. As a result the circu-
lation i« ioterfvr^'il with and niTn)i»i» followi', which may tnanifuKt itM-lf a
few ilayt* after lali-^iir hy the npfiearnnce <if vesieo-va^inal. vesico-cervieal.
or recto- vaginal li>tul», dejn'ndnig u|Hin the part sulij't-lwl to pre*Min'.
ThtM^ (^>ndttion.4 arc not to be feaml «a lonj; a^ the nieinhrancs remain
inta^^'t, but are liable to follow a ver}' prolonged ect'ond vXage.
Inira-piirtam /n/cWtun.— Iiiferlinn is another M-riou* danger to whiell
llie patient U expo!*i| in prolonged labours coniplieuloj by oontraeted
pelv», iMrttcularly wlieii »lie i» examin<^-d rejic^ittxily by a pliyi^ician who
doea not oheerve Ihe nio^t dtringent aseptic teohniqiie. Tha amniotic fluid
may become infceU-d and give riH- to febrile ninptoniM during labnur. while
iu itol a few ea-^ei tlK' iiiiinMirKaniMiui may |Kt.-<.H ibrougU tin- fu-tal niem-
lirann and invade (he uterine walU. giving rise to the diaraetcriittie maoi-
f»tation» of infix-tion during llie puerpcrium.
Id other imtanow, ^a»-prodti<'ing bacteria may be intrtnluivd into the
Btenif. which eoim becomes difitcndt-d with gafi a- a rcMilt of their activity
— Igmjianite* vt^rt or fihtiKumflra. Tlii* conditiim uviinlly follow)! iiifec<
tion with iMeJttiid aerogeues capt<ulatit<i, particularly when llie ehild is dead.
It wa* formerly atlribiittil to llw? enlninw of uir into the uterus, but at
pretient such an explanation must be reganlcii with sccptieUm. l-'or fur-
ther iletaiU. the reader in refrrreil lo the eliapter upon I'uerperul Infci-tion.
Ittiplitre of Ihf I'fh-ie Jointn. — In rani! iii.->liinei-H, iwrliculnrly when llie
pelvis is contracted in ils lower portion, xpnutanoous rupture of the syin-
plijn>i>i pubis or of one or both oacro-iliac joints lia* bi-cu observed. Such
cases have been reported by Ahlfeld, Kchauta, Braun-Ferawalil, nudoux,
Ih- \av, Kn){ntriim, and olbcri', though in the majority tbc injury is pro-
duced by injudicious methods of ilclii-ery,
Effret of Labour upon thf Child. — So long aa the membranes nmtain
intact tlic child suffers but Hllte fmin the prolonged labour; but after their
rupture freijuent awl |irotongt><J ulirrine conlraelion.'* evert a dejeterious
influence upon iL This is dne in great part to interference with the pla-
cental circulation, owing lo which the child receive* imperfectly aomt«d
blood, which sooner or later leadfi to manifestations of asphyxiation. Now
and a^ain pnTnuturo s«p<iration of the placenta occurs, causing certain
death tn the child.
After tlMJ oHtnbranes have ruptuicd. and particularly during thesewmd
730
OBSTETRICS
stage of iabour, prolonged pressure pxerted upon the head is not without'
inflii«ii<.-u np<>n tliv vliild. in eomv cilm'k lt-«ding In v»ga» ^limiiUlion nidi
its reatiltin;; slow pulse aiui oons«|ueiit grntiual asphyxiation.
{'rolafif of Ikf Cord. — A niuuh nii>ri' wrious anil fR-qucnl complication'!
for the ohilil i.-" pmlajist^ of the wril, the oi«urrenpe of which is facilitaliil
hy jjnperfecl adaptation bc-twceo the pn'senting part and the pelvic inlet.|
The rondilioii cxctU iio >n(1ui.-iic« upon the KWima of Inlwur, but in Ihu
majority of cases death of the child results from rompreiisioii of the cord
bftwoeu the prcsoiitiiifi part and the pelvic wall, unless prompt deliver)'
ata be seooniph>hed. Tliis iiiii-tt lH^ regnrded on one of (ho nioxl fm|acnt
causes of fa-lal death in ^imntaDeous laltour in contracted pelves.
Ckanget in Scalfi nnd SK-iiU. — As hti» aln-adv Ix-eii Ktuted. a marknlj
caput is frv<nieDtIy developed \i]i(m tli<- most depindent jiart of the hejwi In
prolonged labour, and allusion has been inade to the part which it some-
times plays in th« dilatation of the eervix. In many inslaoectf it may ncsunivj
very considerable proportions, but is without siiHiifloanee so far as the life
of the child is <«mrriud, usually diKuppouriug within a few day* aftCT
birth. When it is well marked it may lead to serious dia}niostic error*, a^
it may projwt well down into the pelvic cavily while the head is «till above
the hriin, so lluit an inexj>erienee<l physician may mistake it for the head
and ibu? be templed to rcs()rt to ill-tinied opcrtilivo measuriw,
Wh(!U ihc di>pr(>pi>rti»n iH-iween the sixe of the bead and the iH-lvic is
considerable, it is apparent tliat the former can only pass through after
yt^^^^ "■ proct»« of moulditig and acponiuiodatioH.
y'^^^^^^^ which is usually spoken of as ettttfiffuratUm.
^j^^^^^^^^py In very cxccplionul eases iIh' head may de-
^^^^^H^^HJL J *cQad at a compuratively early p(.>rtrHl into
^^^^^^^^ Iho pelvic cavity, and as it cannot rcadUy
^^^B^K \ estrape it undergoes further dc^elopmcnl in
^^^|LJ jU the pelvic cavity, and in consecjuencp pre-
~~^^l^^^ AmV •■'^''-'' charaeUTUtie deformilif!' al birth, llie
lj// V^^H^V part within the pelvis being markedly flal-
!x-\ \^^^^^ lened, while that almvc it it unusually large^.|
as shown in Vig. 571,
tTn<lcr lh<' inllueuci? of iho strong uterine
i-ontranliono. the variouw Umes (■oinprisini;
llic skull come to overlap one another at iho
various sutures. As a rule the median mar-
gin of the parietal bone, which is iii contact
with Ihrt pniiTumtory. becflme'i overlap|xd by
that of its fellow, and Iho wmic occurs with]
the frontal Iwne*. The occipital bone, on the other hand, lieeomw sIiovl-<1J
under the parietal bones, so tliat the posterior margin* of Uic latter fre-j
Huently overlap it. These change* arc usually aeeompIiHhed without detri-
nicnt to the child, though when the distortion is market) lliev ooca*ion-!
ally h-ad to rupture of the longitudinal sinus, followwi by fatal lia-m-
orrhage.
-At the same time the head also beconwe moulded, aitd the ptrie
Kio, (171. — 8ii'iwt!«i Moin-niNQ or
lllui) fx « Gr.NEniLI.¥ i'ait-
tnxiTTKD KiiAoiinc PblvMl
COURSE OF LABOUR IX CONTRACTED PELVES
731
hoae, which was in contaot with
liaviiig beoD subjected to marked
^llt-Dvd. This prooen iit morv
the lieaii are imperfectly oeaified,
that it >-i«lds to pressure ae rvatllly
^
^
the promontory, imually shows sign* of
prvwiuro, somrtimus biicoRiiD^ very mueh
readily 8n-<>i»pli#licd whcD Ibe buni'» of
in rare instances tlie skull being ao soft
a» the #lwll of a soft crab. This property
U of marked inijuirlauce. aiu] tern* In
explain th« diSercnce in the course of.
fla. £72. — OvKMJimiia or Bivtta
or SsvtJ. <T»mwr).
Flo. 973. — Omu.Apnsa of tkiMt
or Sstnj. (Tarakr).
labour in two npparc-nlly similar cases in which the pelvis and the head
pre^i-ut idi-nliral mea^uremenls. In the one (he head in wft and readily
moulded, so that spontaneous labour can result; in the other the more
resiilnnt head retainn it« orifcinal iihape, and a radicnl operative pmoeduro
befoiiieti necessarii' for its delivery.
We hare ain.'ady n-ferred to llie pretmre maris upon the scalp coTcring
the portion of Die liead which fu**^ orcr Ui« promoulory of ihu Mcmin.
These are fre<)uently very characteristic in appearance, and frnni their
course enable one to detenninc 1h«
imivetiienu which tlte head has nn-
derjione in passing through the
Miperior i^trait. Much more rarely
similar marks appear on Ihe portion
of the bend which has Ijiien in
contact with the symphysis puhis.
Thrve markx liave im tnllucmi-
upon the wcll-tioins of the child,
oDi) usually disappear a few days
afliT birth, although in exivpiion-
a! in>tanc«s tlu! iicalp may have
been subjected to such severe pre^
*ure ax to lead to neeroHLt and
sloughing.
In a nriall niimlxT of c«sv^
frarlurex of ihe tinill arc met with.
This acctdont usually follows rio-
Ival attempt) at delivery, though
iHCumoally it may ocrur spoolaneously. Tl>eite fractures arc o( two
TEfk-lic*. appearing either aa a shallow, gntter<lilce groove or as a
tta, 674. — Cnii.li I»o*»i 8»oktjuikh™j.T
■nlKniiaii OcKEajtiJ.T I'lPHtD^i^ZO Kil*-
«xn I>>:n>KiuioN or Skci-u
732
oaSTETIUCS
tipoon-sh«p<!d dtpriJNiiion ju.4t po^Eerior to the coroiuU nuturc. The for-j
nier U relatively common, and ns it involres only the external plate «I
the bone is mil very (iaajtemiis ; wherea* ths lattt-r. according t" Schrocdcr.
IcaiU to the death of tlK> child in about 50 per cent of ibe casi», rfin«! il
Kmj. B73. — I'lii -I 1.1 MsJiKii mou
PiKiti»:cTanT.
Flo. STB.
SUtru. (Tttdtt).
extends ihritiigh llie i-ntire ihickness of the skull and ^:i^■c* rL-<« Irt pro-
jections u|Jon it* interior, irhich «xert hii injurious pn-jwure upon the bmin.
In such cnsc:* it in advisable to operate upon the ehild a.* soon a* foJi-
renient after labnur, when the deprcwrd portion of the *l;all ii- elevated or
emoved. a* iniiy I"? indicated, in the hope of prevent ing ilie otit-urrenoe
of pre*Bure syniplonis,
frognonh for Ihe Mothrr, — Thv progno»i« i»s to tlic oulcoinc of la-
hour nimplicfltiil by eomraoled pelves depends noi only upon tho ile-
gree of contraction but bIko npon the other factors lo which ve hv^
alrcndy alluded, il may he said, howfver, that siKintani-oust delivery of
a fully developed cliild cannot oecur wlwn the coiijugata vera measun» .
7 cciitinu'ln's or les*. Above this limit it will tx-eiir in n varying pro-
portion of eases, and becomes more frcfiucnt the less marked ibe pelvic
distortion.
In our 2rs cases, n?ported in 1901, Tl,58 per cent of Ihe children wen-
delivered spontaneously, as oompaR-d with C8.C per (»nl rcporlwl tiy (llaser,
69 per eent hy Vahiscy, 76.5 per cent by Bar, 78.48 per cent liy Krviiig.
and 80 per cent by Baisch. L'pon deducting the casc« in which delivery
wa.* effected by nii-«ii* of Ion- forci-|i«. in which the operation liud nalti-
rally noticing to do with the pelvic deformity, 78 per eent of our ant*
ended .^jiONlnntiinsly. which compares very favourably witli Baincb's
figures in which a liinilar dednclion was made. The prohahility of spon-
taneous labour dccnascs with the degree of pelvic contraction. Thn».
in onr material a spontaneous tenninnlion nceurred in T7.5!8 per cent of]
the ca*c« when Ihe eonjugata vera mcasurwl betwieen 10 an<l !* renti-
metres; in tJI.M per cent lM?tween 8.!> and S eentiinetn* ; in SS^ per cent
lK^wcl•n 7.y and 7 wnlimetrt-s. and in not one with a mea^urentent Ixjov
t centimetre.'^. The experience of Ludwig and Savor is .shown bj the
lowing tabic:
PROGNOSIS OF LABOUR IN CONTRACTED PELVES
733
■^
fc:
^^^^^K Conj«i^ta vem 9.5 c. m., 75.4% (iianUnoixiii labours. j
^^^H " fl " A&7%
^^^H " 0.5 " 49.7%
^^^V •> "
^V •■ 7 " no "
Generally Bpeaking, ihe proliabilify of aponioneou^ lalKiiir i» leas in ffia-^
erally CMitracttil Umn in f\a\ jirhi-i pre^i-nlirig Ihv iiume ronjugata vera,
it beiD^ customarv to calculate ihat half a cenlimetre must be added to the
ninjugiiu vera of IIm> fornn-r to n.-iiiicc it to lorm* of the lattvr. This,
however, is denjoti by Ilaisch, in whwe material »pontftne<>u.4 laitotir oc-
rrcd «ltgli(ly niorv rmfuoully in (lie forraer than in the latter.
The dan^r to the mother depends upon the cwurse of lahonr. the ptl^-
fection with which a^ptic tcchni(|U(.> is obwm-d. and Ihe treatment pnr^
u«l in njitrative com:*. S|>eftkinf; I>ro«dly. the riiat<-riia! morulity after
ntAoeous labonr Ehould be hardly greater than tiiat observed with nor-
al p^'InM, if the i;a«c i» conducleil properly and tlie patient is among good
rroundings. On the other hand, if spontaneous labmir doc^ not occur,
d thi! patient i» left U> licntclf. ebc will almost alirny* die undelivered,
atber from hii^morrhago resultini; fnnu uterine rupture nr from infection.
D operative cases the proguui^is depends entirely upon the ehoiee of the
iperation, the surroundings of the patient, and the degrw; of perfection
of the technique,
Tn nur 278 tutv* ot labour compliraled by contracted pelves, tliero wore
maternal deaths (3.BS per cent). It should be said, how<>Ter, that 6 of
lei'C pflliente were profoundly infected when Urst seen, as the result of
ttem[>ls at delireri' outside of the htntpiul, and l-uIIurm taken from the
uterine cavity immediately after the expulsion of the ptaeenta demon-
•Irati-d thf pn-^enn! i>f the niicP>-or)n>ni*)ii.'' which niUM*il Ihi- fatal infec*
ion. leaTing only two cases whose death can bt* fairly attributed to ua — •
mortality of W.T'i p«T cent.
Bar had one maternal death in 166 eases and Baiseh four deaths ia
ca«», a mortality of ci.sn and 0.50 per cent rotipoctircly. Ludwig and
ror reported a luortatity of 0.8 per eent in 706 eases of spontaneous
>nr complicated by contracted pelves, as compared with 5.3 per cent
.591 optfalive cases. All these n^uKii. however, wt-re obtained within
last few years — after the perfection of asept'c technique. Previously,
li nyullK were impi«il>lo. as Michndis and I.ilxmauii rvjMrtvil a mor*
of 10 per cent and 7.3 per eent respectively.
A TCTy instructive comparison between tlta conditions existing tbeo
now wnK rtimiKtii-d by Tarnier, who iitated that tht- maternal mortality
28 per cent in 334 cases occurring in the Maternity in Paris between
years ISOO and 1S69, Bi* compaml with l,»I |ier cent in 1.036 eases '
urring between 1884 and 1893, In the latter series 764 lalmurs were
if>ntani>on«, with a mortality of 0.78 p<T ecot. and 37? were operative with
mtirtaliiy of .^.15 per cent.
Prognosis for the Child. — The prognosis for the ftettis is always mora
gn in ooDtractcd than in normal pelves, even though labour oceun
734
OBSTETRKS
»{KinUini>riii«ly. Il likcwwts dcpcixls in « gn-at <.'xU<ul npon the nu-tbods
chosen for delivery; sad, broadly epeakio^, it may beMaiil that Utc tiMtl
mortality iocwast'S with the degree of pelvic conlraetion. utileHs CieaamiD
sTOtioii is freqiiwitly iMtrfuriintl. This ii* cleorly whown hy the followu
table of Micbaeti^, Litsiuanii. and Schwartz :
ConjiijtatA wen fl.2S — 8.5 em., ttntiil mortality ftcj,.
^ '■ " 8.4 _7.5 •' " ■' l&.9%-
H "7.4—7 " " «2.(>?i.
Accordiof; to Ludwig and Savor the mortnlity woe 9.4 pur cent in
spontaiieniiii InliouT^ as compatvd with Jfi.S per cent in .191 operative ci
Bar reports a mortality of 11 per eetit in 137 trpoiitaneous. aitd 23 per
in .ly opitr«ti\<' Ultourn. ami Baisch one of 3.3 and ift.S per cent in 605
ttpantaneous and ll>^ operative luboun reitpoctively. The difference between
the rCf'ultH obtained by Tjiidwig and Savor, aiitl Bar and Batadi is due to
the fact the former resorted to craniotomy in the difficult ca«c«, while the
latter performed Cawarcan *ee(ion and piiliiotomy frtHpiently.
In iHir S7H ai*f* Hti ehililren were iiorn dead, a moriaJiiy of 12.90
cent. One half of these, however, died from causes not connected with t
condition of the pelvis, being macerated or having diod from wlamps
The other half — ii.r» per eent^howi^ver, dietl i1i«>eily from lite effect* of
pelvic deformity or from operations performed for its relief. Of tb
ehildren. however. 7 wcrt? dead when first *fvn, having *neciinii«Hl h> a
pro!on>red labour or to operative measures undertaken outside of the
pital: leaving 11. or 4 per cent, who died in our bauds. a# compared wi
BaiM'h's corri'i-lii! morliilitv nf l,,'i jier (■■■nl in T-Vi cft.-fs.
Treatment of Labour complicated by Contracted Felret. — The treat
meut (if InlKiur (H>nij)li<-ateii by c(tntruct«<] p^-lven varies u-cording to
degree of eonlraetion and the iwssibilily of the occurrence of apont
Inbour. generally "peaking, a nonnnlly dcvebipi'd full-tcnn child ouuii
be l>orn Hjumtaneousiy when the onnjunala vera mea^iurca lesw than
centimetres In flat, and 7.5 eiMilimetre« in generally mntracted pdm
wltereev, interference is rarely required when it nieasnrea 9 and y,5 ceni
metres, in the two groups of pelves respectively,
Wc have thenfore to coni*idi-r in the first place the treatutcnt of l«o
great groups of pelvic deformities — those below jind (hose above the liialf
just mentioiie<l. In the first group the problem i* wm para lively simpl
whereas in the latter it ia ofttiineii extremely eomples and roquirei
utmost nicety of judgment for its proper solution.
Ctmjuijdln VfiT'i 7 ffitHmftrfs or Lfx* in Flnt, nr 7." Cmtimelret •»
Otneralli/ t'antraettd pflvfx.—Vilu-n Ihe pelvie eonlraetion falls withiti
thwe limits the treatment will vary according as tlie child is alive or ilo*J|
and al^ depends upon the physical condition of the m<)llH>r and her fvti
roundings. j
If the deformity he diagnnseil during prcgnaney. Ihe iiatient sImwu
bo *enl fo a well-regulated hospital for the performance of Oicaama sim
tion within ■ few day* of Iho expected date of confincnionl or at ih« OTntm
of labour pains, as the operator deems best. Such a prooetlure will yij
TREATMENT OF I^BOUR IN CONTRACTED PEH-ES
7.i&
HalmoNl icl«al rvHulU, ami all of Ilw diUdrHi anil nciirly all of llic motliftni
should bo savixl. tiuu^niueh as tlio mntiTtial morliilitv followiuf; Ca-warniii
Mvlion, wlicti {Mrfoniiml liy comiH'tcnl ii|)vrutore ii])<ni lifallliv wornvn. ms-d
barcUj' exccwl that following the remoTal of ovarian <!yiitoniata.
On llii- (itlwr hand, if tiw otnditiou of thv fsWis is not dia^owd until
the woman lias fallen into lalxiiir, llu! treatment 1» be pur^mxl will xary
with cirrutnstancce. If the patient is uniofectvd, has not been exaQiiiiod
r^>cau<(lly liT tlw nigina, «ud i» among «uit»l>h> Miirrouoding*, Cfl.vnri-an
«ection will offer erery prcspect for saring both mother and child, pro-
vided the latler it. in gfnid condition and a conijicu-nt opiTalor i« pnx-urublc.
^£ut if the patient is itifected or the child is diiad or dying, th« line of
HirvatjiM-nt lo be pvirvui-i! will be Jptcrmtned by llw dcgnii of pelvic conlrac-
Htion. If the eonjugata vora bo above 5 ccnlitnctrM, iTaniiitoiny should \>c
V'p<^forn>cd : bul with a mra^^urvmvnt holow thie limit wi< hare to deal wilh
the ab»olute indication for ('if^arenn section, no mwitt^r wluit the rontU-
tion of Die child or Iho moth«r. as under such cireuinstanoee the ilelivery of
a mutilaiMl i-hild through the natural pmsMignt will lio imp<Hvible. or al
st more dangerous to the mother thnn Ihe porformanw of Oaesarean
^•rction, fvrn under unxaliKfiulory Kimlilioii*. If ihi- jwlient ii* infcck-d. tlw
dcli?erT of the child should be followed by a total hysterectomy, whereas
thv c-la»xt(al miiM-rvativv opcralton should Ik- choM-n if div is in good con-
dition. Puhioioiny should not be thought of here, as its field of usefulness
tis limili>d to tlK>M! ca»cc in which the conjugnta vera measures 7 centim«tn«
or more.
• Conjtigata Vera above 7 Centimelreg in Flat, and 7.5 Cffttimetrf* in
Oenmtli) Contracted Pelvfg. — Here the que«lion an to the proper treatment
canitoi In: so reftdily disposed of, sin<t^ ileRnite rules cannot l)e laid down for
the entire group, and each caiw mu^t be eon^itlercd ujwu its own merits.
We know in gi.iierai that KiHintati4s>us laWir will occur in many of
roses, antl Iliat its frequency increasea with a lessening degree of
contnrtion. Bul at the Mme lime it is very diUicult to predict
ii will occur in an individual case, as we have lo re<-kon not only wilh the
w of pelvic deformity, hut also with the xiie of llie child's head,
^the extent to which it may lieentne niouhhvl and cniiipr<9>M'd, aiid tin* char-
acter of tlw lalmur paius. Moreover, although we <-aD determine the siw of
.till* js-lii* wilh lohrrable accuracy, unfortnuntely we can form only a very
|Muj>i-rfe<'t estimnle coin-erning the other fiii-torx; and unlil >nmc mellnMl is
"d by which this Iiecomos po«Mihle, the treatment of tatioiir complicated
'nodcrutc degrees of contraction will remain a very difHeult prolilem.
ileOiotix of Dfltrminittg (he Sizr vf Ufaii. — pn-spile the ejtistence of
DumeroQs methods devise«l for aocuratoly determining tlie siw of llw Iteud,
^wc air ettll without one that is thoroughly satisfactory,
^b In mnltiparous women, important information can occasionally be
^TEHined from the character of lite heads of previous childrm of the name
mother; and if they were large and firmly owifM-d, it \* extremely pn>)»able
that the child in lue^lion will jkikmw* a liead showing similar eharact<Ti»-
liee, which may even be somewhat larger, iw il \* well known that the
is liable to increase willi KU(«c«siTe pregnancies. j
736
OBSTETRICS
Afjaiu. in some instances. MHIItr'^ viethod of imprrgston mi
mftk-riiil uii). In making tiM- i>f thi» |iriH'i>(hii«. tlir |iiiti<?nl h«v
ana^Hthetized, the obelL'triciaii seixes the brow and oecipiit of the C
his tiiigur* tlirougli llio abtlominitl wiill iinil niaki*> linn pr«K»v
w«ni in the asis of the superior strait, the effect of which ma ^
trolled hv the tiitfifrs of an iisAi^luiil in Iht- va^iiin. If thi-re ^-^
proportiini, llii' lii-Aii u'JIl roadilj luilcr lUv |H?lvi> »n<l M|ionUDt.'
may \>e pivdicted. On the other hand, the fact that the bi,
be forcwl into the suporior strait doe* not nwessurily itii
iipontaiKH>iiA labour h oul nf tho ipiesiion, as wo have no in«i
tellin;; the extent to which moulding and conli^ntton will '
time of Inliiiur.
A somewhat similar method is employed by Finard — le fnlj
Iciir. In this prwt-duri'. \)w brow and wciput having been gi
two hand:!, the head is ni"ved from side to side, so as to briti^
contact with the pelvic brim. When lhi>- h accomptiEhed,
placiil U|Nin ti)(! i-bild'c neck and llut head pushed xlmnj
and backward no aa to briuji its posterior portion in dose co
pronionlnry. An nltompl is then made to in>iniiali< (lt«
other hand lu-twei'n the anterior siirfai'e of the hi-nd and
If this cau be done it indicates that there i^i no disproporU'
impoicible, and the anterior ]ionion of tbi- bead f<>nii!< a prr
over the pymphysii^ pidii*. the probobiliticf are that cn;;4f
occur.
Ahlfeld ithownl that the Uiparielat dinni<>t(T of tlic )i«m'
relation to the length of the child, and cuftjiestcd atteinptin
!utti.T in utfrii. To i|<i tins, one hliide of lbi> pclvirncIfT b
abdomen over the breech of l!u- ibilil. while the other is in
Lva^tna and applii-)| lo the vertex. Tbc mrii-iiromt'nt Hiua
"(o represent one half the len^fth of the child, ami from UJ
head is calcidalcd, as «howu by the following table:
For a cbild SOitm. InuK, bipnrkfail diiuncl«r9.G
" 4fl " " " " a.7
■' " 48 " 8.5
TbeM' fipins. however, represent only the av«ra^ obttl
itrcmeiits of a number nf children, but do not nec«sMri|
^iven KUite.
PftiTct. in 1899, and McDonald, in 190C, rocorani'
fron to-occipital iliaiiiiler of the head llirough Die atido
ertiraatin^ fnun \\ the U-uglh of the bipiirielal diAh
a special cephalomeier for the purixisc. while MeDf>
of an ordinary pelvimeter to the index and seoMH
Klrip* of adhesive plaster. The former c^inut
hiparietal hy sublractinR 'i.Tt ceulirnelre.* from tli
lamed, wMe the latter contends that the amount t>
ACTED I-ELVEa
739
'•/M» <
,ijti
■I cxamttiAlion sliould bo
id character of the head
i)f rnj^iif^TiK-nt "ci'wrriiig,
in olh^-r ou*^ it should lie i
t!iu!ittc»t liouwi and rcfu»G8
tli« phreiciao cannot c»m-
■r on iiM'|»tii: o[ii^r)ilii)n, UiO,
til the appearance of signs
Occaifioiially tpontunvoiui
ailinx surh a fortunate out*
to the hrad and a Iw trac-
idTancf-, they slniuld hi- por-
-.-movwl and craniotomy per-
•0 cmploytil otdy t^nlalirely,
uerally contn-indicati-d, and
f exlruction «n> not pvrmiK-
•ntvly 1ml a» by craniotomr,
'tdangCTcd.
Iiolic, the well-knnwD viewa^
- rKf>pni'*d. and the physi-
, or ('n*9«rt-ai) MXtion wlinn,
jtutiHabilily might be opvD
■9, craoiotoniy ithould always
larM^of labonr. a« any otliiT
lUger for tite purely senti-
td.
tiiU far advaiU'ed in labour,
Dnt ekillfM) in atNrptiv tcch-
«f a hojcinning infiKtion.
'«! on acciunt of Iht'ir very
tativi- aitriiiplK at il^liTi-ry
craniotomy should be per-
< livint; child and i* willing
ieurean «e4:lion after thetf.
In »uch caws thr entirt'
(tie* adris^ ayuipliviieolomy
npinion lliv rvxtdti- obtaini-d
d riiik to vhicli the patient
'itliiiftl for tM)H])tt«] practice
ftetal mortality will hardly
iiih; Ihc mnlL-rnul mortality
ir hattd, when the forceps ts
imy in imsiii-cwwfHl ca«e», tbSj
>4lt tlR* danger to the mother
738
OBsn-TTHlCS
hiiwl will ItRcrjtne inoiililGd KuHicicnlljr to pai« throngh Uie oonlnu'tcd t>npo-
rior strait. AccordiiiKlv, in p«>1vM of tliU charider Hii> course o( labour
should lie left In Kaliiiv as lanf! 8s possible, awl ind-rffirein* itworlH to
only w!i«n abwlutvlv newsiiarv. In motit (.■««•(■ llio bead l»(?coin«s cui^ajp-'d
arij jpMii^ralij de»uen<is into Ihi- (H'IvU afu-r it few hour* of socoiHi-stngf
pains, or St least bccoint* suflicioiilly uioutded to permit Ihc safe applica-
tion of high or mill forc«;|>r^
On ibr iithtT band, if I'n^jap-'iiu'nt fails lo nwiir aftiT caiii|)lnto (lilala-
tiuu of till' citrrix, thv pnlii-iit should W plucvd m \Valchi->r'ii poeitiou for &s
long a iinie as aim will bear i1. In many I'asi-:! This pn)ct.-<]inv will bring
about a k-n^tbiiiing of the an I ito- posterior diameter of the superior strait
siillicriMit lo p(>rinil engage niwit. A* won a>t the bend litw duKcendcd into
the pelvis the patient kIiouIiI lie plaeeii upon her baek, a« the hanging
poHitioii teiidi' Ui eonlrin'l the pelvjp nullel and Ihiis retards dvlivcry.
If the child should die during Ihc i-oursc of labour, craniotomy should
be rei^orted lo without hesitation, as it is far safer for the mother than
the application of forcirp^, unlcnx the greatest diameter of the head has
already pansed the contraeti-d portion of the pelvis,
Cimjnijnia V'-ni 'J t'l 7.'i and S.'i to 7 fVnd'nii'fr**,— II \» in pcl»w« ooB-
tracted within these limits, which 1 have def^ifinated as " border-line case*,"
that IIh- gn'«te#l diiriculty i» v.\i«Tini«ti in pri'dictiiig the courw of labonr
and in layinj; doim rules for trealmenl. Store ihan one half of the |Mlients
will be dclivertJ sponlaniimi^ly. Ilie number decreasing Hf the lower limit
is approaehinl ; but at tlie g;anie time it i» impoTsible to foretell what will
occur in a given case. Accordingly, the labour should be left to Nature
a* far a* possible, in Ih*- hope that :>|Hiiitari(iiiiH ddiverj- will rwult. unlcs*
the history of previous labours or the excessive siie of tlte childV liead
rcndem it aluioi'l certain thnl I'lich a termination it out of the question.
The. mnut rigorouii a^'piit: Ieehni(|ue should Ih^ einplovcd. and tin- c<vu»e
of labour foltowtd by external palpittion, internal examination being re-
striclwl as far as possible. If llie iiHidition of Ihir [m-Ivis 1ms I»-cn a*«T-
tained befoie lalwur. a vaginal exaininalion should not t>e made until after
niplure of the mcmbnine-''. iw there is no jjos^ibility of Hw hi-ad descending
before its occurrence. The fo'lal heart, of course, should be auflcultati,>l al
fix'quenl iiUervaU.
In a large number of castas sitontniii-ous delivery will oc<riir nflrr a
longer or fhiirler Ktvom] stage; but if the head shows no tendency to
de»w>nd after several limir* of fllieient weoiid-»lBgi? p«iit«. a spontaneous
termination can scarcely be hoped for, and it then remains to determine
what will be the most desirable method of delivery.
If the patient is in a well-regulsteil hospiiiil, or can he surrounded by
every wnvenicnce in her ovm home, the second stage of labour should )>e
allowed to go on for one or two hours before the internal examination is
made. If at that time the head is found to lie well mouhled but *till above
the superior strnil, and shows no sign of adviinee, (he jiaius having lieen
ellicient, pubiotomv or C'lesarean section should l>e considered, aix^nlinii
to the preference of the operator. The neowsory pn-paralioos for the
operation shotdd then be made and (he patient aiwiitheliznL But
■
TREATMENT OF LABOUR IN OONTRACTEI) PELVES
739
lH>fore pnteeedinfT to operate, a tboron^b vaginal examination nhonld be
nindi- wiDi tin.- cnlin- bniii], bikI the »izv nnd character of thu lieud
e'ilimatc'd. If ihi'T^ !«<.'tiii< to \je no likelihood of eng^j^meiit oocurring,
l)w opunition hIiouIcI be ptrfuruicd at on(«, but in other ctuv* it should be
deferred ,
Od the other hand, if the patient be in • tenement house ioi refiutes
to <riiter a l»n«piliil, or is in Iht- cnuntrr when; tlif phvcician cannot com-
mand the neccssan' assisiasce and applianceb for an aseptic operation, tlie
MWond tlagc Hhonid be allowed to continue until lh« appcarnnoi! of sigiu
of dan^r on tlie part of the mother or ehild. Oceasionallir iipontuwous
Uhnur will occur conlrari- to all expectslion. Failing such a fortunate out-
come, high foreepi^ >houhl be applied obliquely to the head and a few trae-
tions made. If tli« head fhovrs a tendency to advance, they should bo pcr-
»i»ted in, hut if not. the inHtrunn^t nhould tie reinovul and craniotomy jwr-
fonnetl at once. In euch rascK forceps tihould l>o employed only lenlalivelg,
it being tindcn'tixKl that Ihi-ir employment ii^ generally contm-indicsteil, and
that prolonged traction and brutal methods of extraction are not permis-
sible, a* by their means the child is almo*l as surely lo«t as by craniotomy,
vhile (lie life of |]m> mother iii unneceR-iartiy endangert^d.
Of courHc if the patient is a dcvoul Catholic, the well-knoim views
of that fhiirch comiTning craniotomy must Im? ns-ogniw^il. and the plmi-
cian may feel ealkxl upon to perform pubiotomy or ('ie«arean section wlien,
from a puMy proft'Hxional ]>nint of vU-w, lU juslillahtlity might be open
to criticism.
In all griid<-f of moderulely oiritniclrd privi?. craniotomy diunld always
lie perfoDiKil if the child has dial during ihe ixiume of labour, aa any other
operation subjects the mother to increased danger for tlve purely senti-
mtiital con.4ideration of not mutilating the child.
Likewise, if the patient har« not ))ecn seen until far advanced in labour,
and has l>een repeatedly cxamim^l by [KTMrnn not xkilUil in uM'ptic tech-
nique; or if she praseats symptomB indicative of a beginning infection,
pubiotomy or CsMrvan section is cnntrn-indicatrd on arrount of thvir very
higli uoiiality tuider such circumstances. Tentative attempt.'^ al delivery
with forceps shoitld be made, and if these fail craniotomy should be per-
formi-M unlc^ tlie patient i» very anxious for a living child and t* willing
to undergo the markedly increased risks of CiesarBan section after theac
bavv Utt) clearly set before iK'r and Iwr family. In Much vjim'm the entire
uterus should l>e remnved. Not a few authorities advise symphvseotomy
or pubiotomy under iIh?<i! condition*, but in itiy ofiinioti the ri'Kultn obtmiM^d
ar« by no mean^ commensurate with the added risk to which the psticnt
is sabjectcd.
If the line of treatment which we hare outliood for hospital practiee
be rigoroiifly carried out. t feci »itrc that the foetal mortality will hardly
vxcvetl that occurring in normal lalmur, while the maternal mortality
will be r<>duced lo « minimum. On the other hand, when the foroepa is
employed Iwitatively and followed hy craniotomy in uiwuceem'fiil i^m», the
fuital mortality will approach £0 per cent, but the danger to the mother
will bv only slightly iiH-reosml.
740
OBSTETRICS
Bneek and Face PrMentatiotw in Conineted Pelvea. — ^The cxbtence of
a bn-Lfh [ircsfiUHlinn In ino<Utriit>' ilegivt^ of polvic deformity sltoiilO lie
roganliHl h-^ a coin jtH cat ion especiullv unfavourable for lh« chikl, imiMiiudi
a6 in lilt; I'arty gtujroH uf lubour prulufKrc of lht> cord is fadlitatnl and in
the Ifttcr ^l&f^ei aeTiOiis ilelay may lie eiicmintereil in tin; delirery of liw
after-comiiig h«id, which is foilouej by almost uniformly fatal nsulU.
On tlie olliur liniid, w fur tw Ihv mother is coiiccniwl it i« rather favourable,
for the soft breech does Dot subject her soft parts to such injurioux pn^H^ure
a» ihc Iiiird hi-ud ; and if delivery becouira impiTativo. t-xlrartion can usually
be aocompli^heil without frreat difliculty, unl&uk the {lolvic contrarlitm i»
TOO' mnrki-d. In most of tlii-jre cases, bowi-vor, the child is sacrificed.
In frank hreenh presenialionA, wlien there in reason to bolicv« thst
operative interference will become necessary and the pelvis ia but slightly
cuntncii'tl, it is advisable, as a jirophy lactic nie^siirc, to bring dnwii one
fotrt soon after rupture of the membranes, bo that prompt delivery can be
effeclHl when iildiralerl.
Face and brow preeentations should be retarded as tiiiich more M<rioiiii
com plica I ions, ii* llu-ir evistence u*u«lly indicale* a marki-d degree of din-
proporlion ami an inireascd probahilily of ihe necessity for operative inter-
ference. If the j)elvie contraction ii* at all serious, too much should net
he eipi!cted from Nature, and nutieal measures should Itc promptly om-
ployed. On the other hand, when one feels fairly eatietted that the dis-
proportion U not exccssixe and ean be overcome, an ettempl should be
made to convert the presentation into o rcrtei: by one of the recojjnirfil
procedures.
C'se of Fori^epa in ContniHtd Pelves. — IJenerally xpeakiiig, the employ-
ment of high forceps is contra -indicated in contracted pelves, es]>crially
Then the head is fr(*ly movable above Ihe superior strait. The pcr^^istencv
of the condition after seveml hours of eilieient second-slaRe pains giMiemlly
indicates that tlie disproportion between the hrad and pelvis is too gretA to
bo overcome. In such cai^cs forcible attempts to drag the head through thi"
pt^lvis will lead to fatal injury of the child, and not infrcfjucnlly to tJie d>Mtb
of the moiluT or to serious legions on her part. Too many Knnx in hospital
and eon^ittlation practice abundantly bear out the truth of thta ajisvrtiot).
On the other hand, the tentative application of forcepa, after th« head has
become well moulded and is fixed at the pelvic brim. Is a ]ii£iillal>l« pin-
eedure, providwl brutal traction is not made.
When the grentest circumference of the head haa passed the (^itrrior
atrait, the employment of forcepv is ^remed by the same rules as in nor-
mal pcK-es, [or in such cases the operation is not perfomied on account of
the contracted pelvis, hnt for one of the unutl indications.
Vcntion in Conlractrd Pelves. — Version is frecjuently reeomnivnded as a
satisraetory mclhod in ddiveri- in contracted p»'lve.-(, and many auilwritie*
compare its advantages with those obtained with tlie forcetu.
Sir James Y, Simpson pointed out that the after-coming head of^rvH
more favourable conditions than the vertex for passing through the nm
tncted superior strait, as smaller diameters are the first lo en(*>uuter anij
overcome the resistance ofTered hy the pelvis. But although wnion on-
TBEATMENT OP LABOUR IX OONTRAtTKD PELVtS 741
(luiiljl^Iy prcM-iiIi' wtno iidvan(»^» «> far a« the itiotlKr if ■.'oiKi^roi'd,
ihvM- arv more Ihau i-'miiIt'ri)a!ain.'Kl l>v iln- tlaiiR^-m Id whifli it ej;)jii»es the
I'liilil. Tliu« Lu-liU'ii>^li-iii *iati-- lli»t the ru-liil iiiurlulih ■» \^A »p<-rjili(ni»
|H.Tf(>riiM»d in I>t^>}wli)'s I'liilil! (niiii I'.Nll to llHiii vita '^41.112 jht it-nL More-
over, the advanlaKi-'ii of versiou are markcilli- diininixbed by Uic fact that
it tuu»t be [tcrfnniit-d k(h>ii ufU-r rupture nf ibi; mcmbraiuss if Mliefuclory
niHlernal results are to be obtained. This liniiU coiiHidcrabty itit range of
D»cfuli>VM, a« one ■» romjH-ili'il to n|H-riitu lii-fnn; tbi- uliTini- con(racli(in«
bavv had an o{i|K>rtii[iity to exert their full effect in moulding the head,
aud cx>nMf|iicntly wnion is doue in many cuw«, which if Id alone would
have li'niiinjited H)i(>ntnneau«ly.
Voniicrly many of Itie (lerman autboriti»< recommended the ])erfomi-
ancv wf Mt-(«lkil firtifihglarlic rfrWwit— turning a1 (be ouh-i of tbu wfund
sta^e — in all cases of moderate disproportion. This practice, however,
tHHlhl Dot up]x:nr jutltfuiblo for Kcvi-ral n-aMinn. In the fir^t plaM, It duos
away wiib ll»e possibilily of fiponianeouit labuur and converts all into npera-
tiva (-»»(■<>: aitd, on iIm other hand, wlw-n thv o)>enilion ik jierfiiniuil nl ihe
niwt favourable time, juat after tlic rupture of the nicmbrane:!, tlie head
has had no chancit of bocoming moulded, and accordingly must be dragged
l)iriiu||:b the |M-lvtA with only »ueh diminution tu nixc a^ rcT^ullx from a few
niiniiti->' traction. )1orrovcr, ihu death of Dm.- child is iiH'vitablc if any
M-nuii* oliKtacli: to extraction id exiH'riem-t-il, as only a few utinuivM oin
elapue between tlie birth of (be umbilicus and the delivery of the Iiead, and
■ uthcient time i* not available to jx^iuit of any other 0|H;rAttou being per-
fi<ruie<l in the hope of Having the child. For tlie^e reaiions a mistake in
like Lvliiiiation of ttui dc^gnv of d ii^ pro portion alwavH results in fietal death.
InituclioR of Prt'tntiturr jMbuur. — In iiioderaie di'groi-s of ju-lvie d«f-
rormity, many autboriliea reicommcnd the iiiductioD of premature labour at
llie thirty-fourth or Ihirty-xixlh week of pn^nancy, in the bop thai llw
•mailer and softer head will be born more readily than at term. This is
uniloubl'Hily lite caw, and llie op«-ration. if proju-rly jMirfonned, should nut
have a maternal mortality of more than 1 per cent. Personally. I have
never induced labour for this iudicntion and do not recommend (he pro*
r«dure. It la applieahle only to very moderate decrees of eontmction, and
lite children not infn-queiitly succumb to Ihe o{>rration. or. wben Imrn
alivv, ere in i«^ imi>erfivt a »ilale of devdopment that even wi(h the most
careful attention hardly more than 50 per cent sunriro the first year.
Leopold and Konrad. in M*t)1, reporled a primary mnrtalily of 31 pur
iidil in 81 eases, and stated that one fourth of the survivors died within
lliu finsi yi-ar — « net mortality of ^.'i jwr cent ; while Voorbei.'S reportwl. lO
I9(r.'>, a prinmry mortalily of 21 per cent from C'regin's clinic. Tl>e«e
results, to my mind, arc not to good as thwc following thv expectant treat-
nieiil at full term, and are far inferior to tbo:« following llie more general
(wrformance of pubiotomy or Cxsareao section in the da™ of cases under
disctiMion. Indeed, Ihe fa>lal morlnlily, direct and indirect, attending Ihe
hMlnrtinn of premature laltour i.'i m great that it appears to be ineroly a
i|iHSl»on of degree between its employment and bringing about artificial
abortion in thi- early nionlh* of pregnancy.
40
:
742
OltoTKTHICS
Tlitf eshauBtivo etudjr of Baiscli has dearly dentniuitrated thn great
vhIik! of oxpecltnt treatment in conlractiil pelves, and ha^ ahoim thai Ihe
reeulte for thi- cliild inipmw nucorrlinj: an the iiiie of high foroeps, pmphy-
laelio vi'rsion, and the iiiiluctiou of lalwur is pioro and more r«8tricted, whUe
at the ^mc liniu llu- tiiiili^Tniil inortality )» not iDcn«»ed. Thu«. in the
cliuiei^ of Frit^h, tJhrobak, and Braua, in vhicb there operations were
freely employed, iho fu-tal mortality waa I3.S, 18.3. and 34.3 per cent
ixwpwtivvly, as compared with J,4 jht cent reporteil hy Bai^ch from Doder-
lein's clinic. Moreover, the onipioyment of theec operations leads to a great
dml "if tinin'(*KUiry in1i-rferenii>. ok I* olmrly demonstrated by the facC
that in the clinics of l-'ritscb, tJhrobak, and Jlraun the peroenta^ of spon-
taueouK lalwiirH u-s^' 6(1, 54.5, and 37. restpcetively, U;* coinpanxl with the
7S or 80 per cent observed in the hands of thoee employing expectant
trenlmenl.
I->om my own e.vperienee, and that of others wlio hold simitar vil-u-*,
it would appi;ur that a sponlanvouii oiilcnme may bo expected in from 15
to 80 per cent of all eaM» nf contracted pelvic, and that radtcal surgical
intiTfcrencc will be necL-ssary in only about one third of the operative caseti.
while the other twi> ihirds may be i-ndi^i by forcops or vcr»iiin, or eraninl-
oniy ii|«>n the dead child.
That the e)aini.'> of the ailvin-ult^^ nf the induction of pntmature labour
are untenable is demonstrated by the fact tliat equally goo<l results eonlil
be ohl»iiitHl, n* far n» the child i.-< ennwnu'd, by pi-rformiiig craniotomy in
cveiy cas^e in which spontaneous lalmur docs not iHcur, which U nHlurally
an absurd propositiott In many of the cases belonging in thia cati^ry
the pelvic oinlraition i* so pronotimed tlint rsdieat surgical inlerfprenee
is imperative and the induction of labour out of the question. Awonlingly,
it mii^l )h- ii<ltiiiltcd, if Utv latTcr cipi-rtitioii ix fnijucntly employed, that it
must in many instances be resorted to unnecessarily, mid consetpiently can-
not fail lo increuxe nialc^riidly the fa-tal mortality.
In conclusion, it cannot be too forcibly impn'.v'eil upnn the general
practitioner and the student that the repealed delivery of dead children
in cases of contracted pelw.* in aWolutely unJiLitifieblc. The loss of a
child is fn-queutly perfectly excusable in a single prt^ancy, but tt» re-
peated nw'urrence indicati^ n ncglecl of human life which should not be
tolerated, and physicians should learn that it i^ their duty, if Ihey do not
feel (■oruju-ti-ni to co]te "uciTMfully with such cases, to e«nd them to a well-
regulated hospital or lo conllde them to the care of a ennipetttnt speculi>t
for appri)priiiii* in-iilnient.
Treatment of Labour romplualfd hg Oslfomalacte Petra. — ^The coarse
of labour in wlioinatacic pelves varit.-s according to the stage of the dis-
ease and the de^n,^- of contraction. Ulieu the deformity is slight its infto-
cnce upwi llie labour is minimal, but when marked it not infrefiueatly gireg
the aliaoluie indication for fWarean section.
Some idea of the obstacles otTcred to labour hy thin clisx of pelves may
lie gaioKl fnuu ibc figures of Litznmnn, who in 18B1 collectctl from llw
literature and lalmlaiwl 7!' caws. He rfniiid that the following opera-
tioa« hud buun performed: 40 Cie«arcan sectioaa, 16 perforations, 1 »ym-
TltKATMI-:NT OF LABUUR IN OONTRACTKD PELVES
743
pb^rcvutntDV. i in4liiL-liiini> of pn-tnntarv lalwur; vbUc 7 vomi^ Imd suc-
cambcd to rupture of the ulcru^, nnd t others had died undfllivcrcd.
Lutzo. iu 1897. cwusidt-rfd the I'ffcct of osteomalacia upon the coutw
of labour to 85 paltenttt who canip iiudfr lii# oWnatioD. Th*- wonwii id
qaeetion had 459 laboun-, 230 of which occuned before and Ifi9 aft«r
tite appearniicc' of ihi.- diK--a»e. Tn the Rrft ^>»p. opi-ralivp interfurcDce
was neceeeary once in every 48 ca»ei, and in the seoond once in every
•i.9 eiues, lhu» showing that lalKnir liad become about lu timvs mvrv diffi-
cult.
If ihc {»ticn( i« nn-a durin<: lli« cnrly aionths of prcpnancy and is suf-
fering fmin lh<^ diu^ase in ils arule fta^t-, fhi- f^limiid Ik- at oik'C rvimivi^l to
a hospital where she can live tinder tlie best hvRienic surronndingH and
be mppiiei) with an Nliiitiduncv of suitable food. I'h'Mphonui in doM-JH uf
2.4 to 4 milligram 111 eH per day in pill form or combinwJ with cod-liver oil
or almood oil should be given, as Latzo, Wincki-I. and others claim tliat
many caaen ean be penuancntly cured by iB adnuni.-itratiun.
On the other hand, if the patient is not wm until the end of pregnancy
or Iho tini« of labour, the treatment tn be pufHued d<>pond« nllo^thor
upon the degree of pelvic contraction. In such caset> attention should
bf pwid not only to the len^rth of the cionjupita vera, hut nuin* ptirtiiiiliirly
to the dimenirionA of the inferior strait, as die pelvic outlet is usually very
markedly coutravled.
In florid oa^s the hone^ may be 90 soft as to re.-i4^)ii))le li-all>er in coa-
Hisleiicy. and the pt'lvts readily aesiunes varidus forui^ Thi^ affords an
e:ip)«naii<>n for the fact tliat one is occaxionally »urpri»«l to i<cc delivery
accomplished through a pelvU whidi at firal glance appears to offer no
poMihility of such an occurrence. Quite a number of such eases arv re-
ferred til in Schroeder's text-latok, but such an outeonie slioutd bo regarded
as very exceptional, and should not lead us to expect too much of Nature.
If (hi; )H']vii> IN markedly conlradcd CiF^iiarean ww-tion nltould t;e per*
formed without hesitation, followed by the removal of the uterus and
ovar><<)t or by eautraiion alone. Fehling lias shown that ciither of theiw
operation? leads to the permanent cure of the di.4eai« in al>oui 80 per cent
of lltv ca«-3>, and lii* n-kntlK have been confirmi'd by Loblein, Schauta,
I.^t20, and niany other ob-iener:-. On tike other haiMl, if delivery occurs
sponluH-ously. or has been effected by forceps or version, castration should
be perforninl soon after the pucrperiwm in the hopr of chwking tlw dijteaM!.
Exactly why this operation should have such a marked effect has not
a* yet been dcHnitely determined. As was said in tlte preceding cliapter,
Fehling comiidora the diw«i«c u a troplionciimitig of ovarian origin, and
believes that the removal of the ovaries does away with the reflex stimulation
of (he vaKn-i|i1aton>. which he cm^idcrs plays iio im|NtrIant a part in the
pmdacti<m of llie bone changes.
Caratulo and TaniJh made careful studies of the mvtAhoUsm oorarrtng
in doga before and after oantration, and showed that the excretion of lime
■•Its and phnvphorii- acids was markedly diminished after it. Ileiu-f tliey
U][ue that Dk' pri^enre of the ovaries in some way either favours decal-
cification or prevents calcification of the newly formud osteoid tifsue.
744
OBSTETRICS
Tlittir I'ditduAioDa, huwcver, have lately iH-en denied by Falk, luul iiannot Iw
a<-r'ej)te'l n-itliniit r<.>»vrv« until furlhvr rniifirTnaliun is sappHfd by the work
, of "llii-r ciliwrvers.
I LITICILATIJRK
Am.nsi.ii. I'clier diu ZomuiuiiK der Sduimfugc uiihreml dcr (ielMirt. V). I., LeipolSi
18GH.
BMtJnunungen dec Ur(>aw uuO <l«ii Alt«ni <ler Frucht vor der Ueburl. Archiv (. OfB.,
1871. It. 353-3T2.
Baiacu. Itefoniien in der Tlkerupiu il«ti eiu^u llorken. Leipxig, 1907.
Bar. Ldc^h* <ic pathologio abM^lricnJc. Pnru, IIMXI.
BxAOX voK Fkrwwaui. Uobar Synijili.viwiilookvniiix uud SyinphyBenruplur. ArrJuv
f. Gyn., IWH. xlvii. I0t-I2B.
Brkoxt. Kxtramcduno Finitcllung den KtmJMkopfM, vtc. Arcfalv (. Gyn.. ]S70i L
17^174,
CARAnri.a ct TAUin.u. Commont In nutrntjon giUait roMmnialacw. Aanalwa ^ ITU.
«( d'obst,. 1SB7. xivii, SSt-mi).
Db Lke. Two Ouan of Kujiiurc uf the Symphyn* I'lilria during LabiNir. Aswr. Jovr.
Obnl.. ims. xxn-iii, 4!*»-4(l9; aim 1901. xlUl, 630-633.
Falk. Ejq Ikitms lur KHrmisiiM des StutTweoboels nadi Entfemung dur Ovnrfeti.
Archiv f. r.yn,, !H1«». U-iii, .Vt** -.'iTll.
Feuuko. I'eber W«9«ii uiid Buhundluiig dvi pucqioriilou (>Kt«<iniitlBFie. .\iwUr L
nyn., ISni. xxxix. 17I-1(«-
L'«b«r DsWoiiiHiacw, Zeitoclir. t. lieh. u. fiyii.. 1894. xxx, 471-476.
Wcat«Ri Beitrii^c :iur Lohro von ilor Onlcomulacic. ArcMv f. Gyn.. IKU, xlviii, 472-
4»8.
Glakkh. I'eber sponiaiie Oeburt«n bei ongED B«:ck«n. 1>. I.. Muncfacn. 1800.
Kr^ikio. TAe Thenpie hei cutcen Dnki-ti. LeipiiK. IM)1.
La Tuhhk. Did ilerdoppi-meiil dti fii-tus chex las fumriMu ft biuHQ ricH. Pari*, 1M7.
Lathix lloilrtiRo xiir Dintinan; und Tlicmpin dor Oatoonudncio. Monalaiac-hr. (. OeK u.
Gyii.. 1897, vi, 571-608.
Ijtavin.o II. KovnAD. Ziir IterccbtigiiDKiifRigc der kiuutildicn Krufagoburt. Aivhiv
f. t;y».. 1907. Uxxi. ft42-iHil,
LiarrKNBTEiN. Ucber die liociiiiluieninj dcr Inilication (iir Wenduog u. KstnuttjoA
duroh die H«tM}U>i»i«. .\rrlitv t. (lyn., 1007, Ixxxi, ftaWH".
LrrxuANN. Die Konntiii den Ut)ck«iiB uebsl «iu«iii Aahaugt &b«r <li« <>BtconukUde.
IScrlin, laet.
Uelxir die hiiil«ra ^rheitelbeindnMlolltmg. Arrhir I. (iyn., 1871, H, i33~4W.
Die (ioburt but en^ui Hotketi. Leii>iig. 18K1.
LUHLBK. ICrffthnuijn" >ib«r den Wcrib dor Caatntion lici Ontomnftlnde. ZeJlAlir.
r. Oeb. ti. (iyii.. 1804.. lutix. lS-47.
Ltniwti) iind Savoii. Klin, licrirbt ulier die (ictiurUiit IiciiD eii^n Bcckca. Ilottcht mm
der H (wb.-Kyii. Klii.ik in Wi«ii, Wi.-n, 1807. I2U-M3-
UvDoN-AU). McnaiiraticiTi nf the (.'hild in tlie l-lerus with N«w.\I«thodL J.Am. U*d.
A»«i., UMW. xliii, H17Q-19H.1.
MicHAXLiH. Diui cii^ Hetkeii. Loii^JK. 18.^1.
Mi^LKiL. Uebcr die I'mgntmo dor Ct-burt lici cngem Hd-ltcti. .\f«hlv f, Gyn.. 11186.
xxvii. 311.
FKntter. Ln cdphitlonieiric extcnic. etc. L'Obstt^lrique. IS09, iv, M2-AM.
PiiAHTi, Du palpM monmuntoir. Tmitt! de pnlpcr abdnminiLle, 2nM id., Pmu, IKS.
2CK-222.
Nnt« pour acrrir A ThUioitc de In pit^t^llure pcndatit In grawnwc. AmimIcm de jQ-it.
: ct d'obitU. 1898. 1. S(i-sg.
■ '"'Aft^
EFFECT OF PELVIC ANOMALIES UPON PREGNANCY AND LABOUR 745
RiooB. A Comparative Study of White and Negro Pelvea. Johns Hopkins Hospital
Reports, 1904, xit. 422-454.
RtroAvx. De la rupture de 1& syrophyse puhienne au cours de 1 'accouchement. Thiab
de Paris, 1898.
ScBADTA. Allg, Pathologie der Beclcenanomalien. Hiiller's Handbuch der Geb.,
1BS9, ii, 265-284 (full Uterature).
Die Castration bei Oateomalacie. Wiener med. Wochenachr., 1900.
ScBoBDEL. Erfahrungen iiber kiiustliche Friihgeburt, etc. Archiv f. Gyn., 1901, Ixiv,
151-164.
ScHBOEDEB-OLSHAUSEN-VBrr. Lehrbuch der GeburtshuUe, 1899, XIII. Aufl., 659.
ScHWABTZ. Ueber die Haufigkeit des engen Beckens. Honataschr, f. Geburtak.,
1865, Mvi, 437-442.
StuPBON. Memoir on Turning, as an Alt«Tnative (or Craniotomy and High Forceps,
etc., 1S50.
Selected Obstetrical and Gynipcological Works. Edinburgh, 1871, i, 393.
Tarnieb et BuDiN. Traits de I'art dea acoouchements. 1898, t. iii, 70-135 (CiiU lit-
erature).
VAI.E.VCT. De 1 'accouchement spontan£ dans les basans rdtr^s rachitiques. ThAse
de Paris, 1900.
Vaknieb. Accommodation de la lite fcatale au bassiD maternal. L'obstdtrique jour-
nali£re, Paris, 1900, 131-149.
VooKHEM. A Report of Sevan Csaaraan Sections. Am. J. Obst., 1905, iii, 161-100.
WiLCKE. Das Geburtsgewicht der Kinder bei engsm Beckon. Beitrage lur Geb. u.
Gyn., 1901. iv, 291-302.
WiLLiAiiH, J. W. Pelvic Indicatbns for the Performance of Ctesarean Section. Amer-
ican Modicine, 1901 ii, 483.
WiNCKBL. Behandlung der Usleoraalade. Penioldt u. Stintiing's Handbuch der spec.
Therapie, v. Abth., 1896, vii, 214-242 (tuU Uterature).
Ueber die Erfolge der Kastration bei der Ost«omalacie, Volkraann's Sammlung klin.
Vorttage. N. F., Nr. 28.
CHAPTER SXXVI
ABNORMAL PELVES BHSULTINO *'flO.W PRIMARY AXO.VALIBS
IN DEVBLOPMUNr
TiiRBR ticpnrnte ^croupti of (■a^es are differentiated aeoordin^ as the
altnormalitiee arc: (a) Gcm^ralizul aitd itvmnHitricnl ; (b) locnliMil >ucl
nByminetrical; (r) locitlii^ed and iiyni metrical.
1. Generalized and Symmetrical Anomalies in Development. — Abnormal
dovdopiiiern m«,v iii»njfe"t iu%eif iti «(i f.\(v_v> nr in a luti; of the gcoerxl
growth of tiie pelvia. In the former case we have to do with th« peaerallj
ffularppd or jiwto-raajor pelvic, and in Uie latter witli one of ncTersl van-
etit»— the generally fontra^ted (jusio-minor) pelvis, the infantile. Hit
oaseuliiie, or the dwarf type.
Til)- Oenrralh/ Enlnrijcd [jvato-mnjor) Pelirit. — -Thia variety of prfria
is symmetrically ailargcd in all its parte, and differs from the normal only
by it« increasixl #iz«. It iif usually i>b»<Tvi'd in ^tanti>s.HCH, and ocea^ionallr
in women of normal Klatim-i iiiilt^d. if the external measurements alono
are taken as a oriterion, it is of quite frequent oceurronco in the- tattvr.
According to Sfhawtn. the variou* dinmelet* in this type rareJy exceed
the normal by more than 2 centimetres, though he refers to Dc la Tountite'*
(•hth', iu which the antcro-iioeterior and tranrt'crw! diawKtiTi* of lhi> *u]wrior
and inferior straits mt'ftsiiri'd 1-1.9. 17, and 14.9, 14.9 ccutimetrfs respect-
ively. In not a few cases the greatest increase ic in the an(t'ro-iKiKl»trior
diameter, while the othcrx rcmnin practically normal. Occasionally tiie
enlargement may be limited to the superior strait, while the lower por-
tions of the [M-lvic- eamil retain their UMial prop"rtions, thus producing a
funnel-shaped pelvis. In rare instances excessive trnnsvenw' e\l<Tual tma.'*-
uri'inents may Iw due to the fnct that the fowsm join the main liody of the
iliac bones at a less obtuse angle than usual.
This variety of pelvis has no effect upon the Cfturw of labour, except
that its excessive siie now and again obviates the necenBity for the ofual
mechaniiini, and the head may be Iioni so rajiidly and suddenly tluit o-riouK
perinea! tears resolt.
The Orneralli/ Conlraeled (justo-minor) P'lvh. — ^Tliis tyiie was fir*t
described bv Deventer as the pi'lri* nirais parva, while Stein later applied
to it the d'^ignution justo-minor. All of it* mi-a«ureinentj' are morn or
less proportionately sliortened, so that at first glance Uw pelvis api>ears
perf<M*t1y normal, the narrowing being discovered only after carofol mra-
8U ration.
746
OENER-VLLY CONTRACTED PELVIS
As » rale, tbo gciM;ralt,v L-oiitrnoted pelvU in ligliter in test
componenl parU are nton- delicately fomiod tlion usitol. TIm; mc
Mtualler, an*) the alnt fira]>ort innately tihorlcr tUuii lliv liodieH of its
bne. AL the same timi> it» vvrlical concaTity is not iofroqui^ntly inc
On carufu! osamination it is found that the dccTea«c in nute is not ui
=!-
f^' Kif . iTS,
Fig-STPt
h>..\
.%-1/f.
Floi^ C7A-SS0.— OK!i>HAU.r CoXTVACTiiii Pui.vai.
Ad occasionally the conju^ta vera is relatively ^liurter tlum tlic tra
diariK-t>T of liH-wu[K'ri(>r vtruit, and v^tccpl ion ally the inferior la n
sntalliT Uian the superior strait, so that we hare a type ap|>roaelt
simple flat or ftinud-'^hupod pvlvio rwpcctively. Michaclis nmsider
ll>c an tiTD -posterior shorlcnin^ in thin elaM nf [lelve* rarely exce
ctsilintetres; and, although thix appi'srs Ui Ix- ton (conservative a flj
may be »aid that uhenever the ronjugnta vera measures leas than f
nietrrji, rhnohitie chanp-s should be suspected.
This pelvis is usually met with in Hmall women, althoujEh one i
sionally «arpri»ed to find it in thoi^e of Innn; stature. It has (^neral
said to occur but rarely in (li-niiany and I-'rani«, altlMu^ih it was ol
In 37 and 28 per ocnt of the contracted pelves reported by UtkQ
748
OBSTETRICS
fui. SSI, — CnuxuBOuisTiioivu Fixtum.
Gonu^r rt«poetivelj ; and Biclielet staler tliat it is much more cominoD
in t'rance than lias geutTHlly IwcD bclimed. vOiir own pbacn'atioiM Hhof
that it ii> by no monns unuMial in llalttmnri', as it was noted in ooe thii
ol the coQtxacted polvcii oLTurriiig iu uhito, aiul in two thirds of tho"
I'Occurriug in block wumon. Id 1)i« latlirr it is uncttiubuxlly a Mgu ot de-
"^gcneration, aod U a maaifeetatioa of the imperfect physical developnifnl
which charackTixCH ntigroe* li\iiig in larfce citicit.
Miiller cousiilt^rod that its froijiiency iu Berne was probably due to tba
prm-ak-nw of cri'liiiisiii in Ibal burulity, but tlm ftii-t llinl Goiinvr ol>s«Tvti
it almost ad frequently in Basel^
vhcru the l«ll«r discuw; occur
but rarely, militates against suclij
a vivu". It i* qiiilf powiblc Unit
not a few so-called justo-minor
pi'lvxw arc really of rliuchitic wri-j
gin, especially in nej^roes. and
lliat in such stsmx the otlivi
more characteriBtic changes ar
lucking.
Iliv liiiiijnosia is readily madi-. The esistcnce of a genertlly contracrt
pelvis should always be susportcd in STtinll women, and wipcicially in poorly]
dCTfliijurd working vrdmi-n. ultlmiigh it should not im forgotten that il niaj
occur in larp? and a[jparently wi'Il-fornii-d individuHl:(. Awurale informa-]
tion cjui bi' obtained by im^un» of pulvimetry. ^Vll of the external tnemDr
ni«nta are coDHid«rahiy and uniformly vliortcoed. Internal esaminatioD
ehows a shortoned coujugata vera, uiih general iiniallno-.-(.-t of ihc jk-IvIm
eatity, typical rhiichitic chiingc* being aliMut. The average measuremeDtaJ
in 'iij white women in my clinic presentinj; pelves of tlii> ohariwUT wi-re:
Spini», a.'f.as, crwU, 25.J. troi-haiitcr*. 'iM.'i. Bauddo«|«t>, 17.9, and diag-
onal conjugate, 11.1 centimetres, while in 167 coloured women each nM»>>'
urvmvnl wni? a few milliriictrtw shorter.
The effii't nf tiie generally contracted pelvis upon labour la rurv eharj
ncleristio. Owing to ihi- fiict that all the diamfU-rs of tltc enperior strait
are shortened, inslead of only the conjuRata vera as in flat pi'lvi-s, tlw
head «iicounti.<iK nion^ nr \\-t» <s{aal riutii<^lan(H- from all »idce of the pelvid
inlet, and consequently enters it in a sharply fli'xed position, *o tliat onl
vaginal exuminiition the liiuall fontanclli* is readily felt, whereas tin' I^Ht^j
fontanelle is almost or (^iiile out of reach. Moreover, a* tlie contraction!
involves alt portions of the pelvic canal, labour ia not rapidly tromplffti-dl
afn-r the head has pa««'d the »u[>erior stniil, but a* a rule is considerolily
prolonged. This is due partly lo Ibe resistance offered by the pi-lvis. ami]
partly to the faulty character of the nlerinti contractionit incident \a tb
imperfect development of the uteruH^ which frequently chanu-teriMs au
cawn,
.\a has already been said, a generally contracted pelvis wiiJi a tonjngala
viTH of a pivrn b-ngth "fTi-rs n gn'iifer oKttaeV (n lattour than a flat prlri?!
offering a similar iiieasureuient, and for practical purpi>sefi half a centimetre
mnHt Iw added to tW latter lo reduce it lo terms of tho fnrmer.
DWARF PELVIS
749
Thf UofrultHf I'eltnt. — MU-liai>li8 (iirecti>d alt^ntion to the fact thit
Konerallv conirapteiJ jjolvw iire iX'C4Ki<iiuilly wicoiinli^nid in wliJoh llw t>on«fl
■re (hick«r and clunukT thau usual and approach ihe male type, Telvea
of this claaa are not of infnviucDt (K^tirri'iK'L', ami tiavr thi^ mititt etToct iipoo
labour as the ordinary iicnerally contracted variety, thouj^i in exceptioual
ini>tan«r)i IIk; r<^luliv« <-on1rui'linu ut llw; iiiforinr »lrait luny giw Hw to
»erioi)fi dV!<iocia.
The JnftintHe Pflcu. — In ran* iiwtanrp^, as tlte recalt of difva«!, vrliich
haa caufted the individual to sp&td her entire life in tiod witlmut attempt-
ing to wit up or vrnlk. Ihv pcKi« r<.-tainH the charactcriKtic iufuntilc form to
which refennt'e was made in Chapter I. Kxampi<» of thia abnormality
Itavv lM.vn i)r«cn)>cd by Xac^-li'. l^^i^infriT. BiitliK-r, and Ourlt, but nata-
rally it pas6CSM« no ob.'^tctrical .ligniili'Ance.
The Dwarf Pelm». — Accoidiiig to Brcuit and Koii^ko, several varieti«B
of dwarfi* ninst be distinguished — i.e., the chtKidrody-'^tropbio, Ihe "Irw,"
till- cretin, llic rhachitic. and tliv hvpoplaslic
dwarf.
in the firHt-raenlioned variety the deform-
n»ult» from chnndrody atrophia fii'talia
Kaufmann). achondroplairia ( I'arrot and I'o-
k), or fu'tnl rliactiili', a> the di^f^-u: han been
variousty de^if^atcd. The affection is not al-
lied t» rhachiliA, but i-t chantcU'rizo] by wetl-
marked chancres in tlw epiphyrieal carlilagi-
which lead to imperfect dt.-M'Iopiiictit of the
idiaft* of |)i« lon^ lH>n<s, sa that the individual
may pr^wnt a vdl-formed head and body, while
th« extremities are short and «tiinipy. HerrKott
haa ithown that the condition is somflinxw he-
nililnry. and ihiit person* sufferioR from it are
fretiucnily exceptionally fertile, and thit* in
marked contract to cretin dwarfs, in vhom
sterility is the rule.
Id the " tnie " dwarf there U a propor^
tionate lack of jrcneral devetnpmeut, which is
particularly charactiTiwHl by Uie fact that (he
varimut epiphywes do not undergo owilicatinn,
't remain carlilnK' '■"'"' nntil an advanced ago.
In the cretin dv^rf the lack of di'%'>Hopment
general. The bimy clmnjir*-* are allied to
oljMrred in the true dwarf, but are lera
marked.
Thi- tf^rm rharhitif dti'arf shoidd not lie ap-
plied to individual)' whose short Ktalure is d<w
to ckc^cta) defonnilic-'*. hot should l»e i«-lricl«l
_ (a Ovuf who would fall far lwlo«v iIm- normal height even if tlte drformitin
Hftere strai;rhtntci] oui and cnni|>en.-4ted for.
^K Id Ihr hgpoplaittic dwarf the c)uing«!ii an ijuantitative instead of qnaU-
Pra. 883. -I'nitxvmauTimtomw
DwABr < limit uid Knlkko).
750
OBSTBTHICS
tative, fo Ibat tbe individual diScn froni the nomu) only in its miniature
8}}j>caraiK'i-.
Eacli ot these varieties of dwarF« h&» a rharactt'ri^e«]ly shaped pelvis.
wlii«.'h i« nioro or lutH ji;i--niT£lly tDiitrni^ttKl.
The Chondrodi/slrophic Dwarf i'ftvis. — Fig. 581 repixwinis a cliondro-
tmphio (tifuiil, and Kig. 582 a «hondrod}'str»phic dwarf, nlwiMt {loIviK
is ivpnMJurecl in Kig. 583). This specimen was d«fcribcd by Bnms and
Kolisko. an<I wax oblaiimi frnin a wmtian twenty-»e^'en years old and 123
(«nLii>ielrc.4 tall, who ili«l after a Ca«arvan stiction.
This varifly of pelvis i* <-haracteri»Hl by an exirMiie ant«ra-]>o<>'lirrinr
flalu^ning. m that an first glance one might believe that one had to deal
vrith a rhaehitic pt'lriii. On crlo:M;r vxuniiniitiaii. hovrowr. it is »oco thnl tli«
HftlTcning in rlui> to Iho iiti[ierfi>i-t de^clojimcnl of the portion of the iliac
bone euteriog into the formatmn of the ilio-pectincal lim-. owing to whii-li
tlic «acral articulation >» brought much noiirer the pul>i<! hone than (uiul.
In fi pelves of this character described by Breus and KolUko, the conjupila
vom varit-d fmrn I to 7 rttilinietn'w, wrhile tlie transverse diameter of tbe
superior strait wae but slightly shortened, varying from 11 to 12 centi-
nii-lrc*. ^^fc.
!■■■«. M* Fig. S84.
Fiait. SS3, A84. — CBUKnxnPVBmorMic Pklvm (ItinuBBil Ki41f4o).
The Trut thri/rf I'vtvU {l*ehU Sana). — This variety of pelvis is ei-
treuiitly rare, only 4 ucil I -marked I'lnviincni- being in exiittpno.' — thivc i!c-
scribed by Nacgclo and Boeekh, Schauta, Pnltaiif. and Breus and Kolisk.i,
two of uliich Vi-vc in fvmuliv. The pelvis is generally oontnartt^ ami
fends towards the infantile type, hut its most chanctoristie fojiturc is tlu*
persistentf of cartilage at all the epiphyMo. Thii», in Bocckh's iMJvia,
tt-hich belonged to a thirty-onc-yenr-olil woman. 108 ct>ntimetn>t tail, tin-
Y-shiiped cartilage at the acetabulum waa eleariy marki'd and the aaiTal
vertebra' wen- not fnscil lugvUnT (Fig. 585).
The Crftin tfwarf i'elvis. — 'I'his is a ^neraJly (^ntmc-tcd pelvi* with
poorly developed and imperfectly formM bones. Unlike that of tlw true
XABGEI,E PELVIS
751
iwarf, it do» not prewiil infantile chaneleriflicit, but aiwm. »\gn» of a
ieady thouRh imperfect Riwuih throuRliout early life. tfiiowiGwl curtilage
Duy be pn»mt bcrc ud(1 iJicn- in jttunji; ^uliiM-tti, but it disappear!! with.
ric. w,v F%. 080.
Mlvanciug age and t» nvver fouixl in ult thp epiphj-Mw a^ in the true
|wii'ia.
jTA*^ Ukarhitic I>tctirf Petriti. — TrtH- rlischittc tlwarfs are rare, and pos-
gencrally contracted. Hat rhachitic [wlvew, which ilo mil dillei fmm
tboec diveribvd it) iht- pn-viouit o)iapt<T oxivpt bv Divir extremely Nmall sixe.
Tkt l/ffpofihtntu- Dwarf l'tivi». — A<»»nl)ng tn Hivun and Kolinko tbic
riety of pulviK i« nbNTVul in very cniall individuals, and tn simply a
Simtial jH-lviH in ininiatore. It dilToni materially from thai uf Ok- Lruo
^varf in that it w <x)ii)pletely o^sitinl.
II. Lo«alited and AsTmmetrical Anomalies in Development. — The
iblitjurly I'unlraftiii or Stuijrlf PrlcU. — Nat^jtle, in iKU.t, ua.* the firat
m-o^ise the >ii^iificance of this ranety of pclvts. and in \&'i9 pnb-
i«b(-ii n innnojfnipli itfHiii thv hiiIijitI ba-ai] njioii lb<' i<tii(ly of HH it]>ccinMn*,
up of which bar] U-en oltlaini'd from an Kt^plian mummy.
The Naep'l<? pelrin prcH>nt>i the following charactiriktieji : The ntie of
nrral ?<'r1eliiw an* either lacking or imperfectly develo[»ed upon ono
ie, wbilo the eom^|)oiidin(; sacral foramina ore Munlk-r than thoKC on
normal ^ide. In tho great majority of ca.4e« tlH> Kacrum and the
Qominate bone are finnly eynostowd on the affected side. At the wimc
ne the latter is pntihed upward and haclcward aa wvil aa inward fmin
he refn<in of the aci-tabulnm. and il« cn»t in at a biglivr Iei,-cl than that
(if ilj> ftlluw. The i 1 10- pectineal line U Uwh cnrrcd than noritially, being
almost straight whvii thv dvformity is marfcecl, while upon tlic oppo«ite
752
OBSTETRICS
Hide its curvature is acccutuuu^, [lurticulitrly iu ihe auUrior portion. Cor-
responding with the chaiijK in position of tbe innotninste botw, tlie »cliial
luberoaitv and spine are displaced inward, upvrard. and backward, tbereb?
approaching tlic outer murgiii of i\k Micruui and iiurn>wiiig tlic ^acru-
M:iatic iiot<'h. Tlit^ sytnphj'sia pubia U dinplai't-d tuwards tJie well aide, whik*
the pubic arch instmd ot looking dinvlly forward ii- directed towards
abnoriiin! fidn of the sanruin. Tbe Kacrum itM^lf is dinplaoed tnu-a
the aiikrtoricd side, while it« anterior surface i« dircclod more or I
obliijuolv liiwanU iL
Ae a result of these changes the pclvi* Wroine« obli<)uely contracled.
the anpitrior Htrait. hcin^ ovale in iiha]io. with its !«Tna)) pole dinvleil toward*
the abnormal Hacra-iliac joiut and iU larger end towards the horizontal
ramu» of ihi- |iiil>is on ihe woll nido. Us ohlitjuit diameii-rM nr<- of umituiil
Icnsih. the shorter extending from the i^iicra-iliac M-nciiondrosis of tbe
well iiid» Id till! ilin-pe(^tin«al cinini'mr on Ihe diMmT^-d sidt\ whik- llir
€oajugata vera is ut-ually Honiewliat lengthened and is dirocted oblitjuet.v-
Diie
t W- 587. liK. S88.
Flofc SBT, WW.— Antkbiob Vik« <■»■ Otitittato.-r Cotmutiiat Pei,vib (Nmc***),
The duitanccB from ihc jnoinontory of the f^cnnn to tbe acotjilmlti
and from the tip of the sacrum lo the ischial spine are markedly dimioif
on the dineased side. Al Ihc »«nic time llio difitance between On- IiiIm
iwhii of the dii^eased side and tlie opjwsite potiu-rior *ii[>frior spine i> lo
than that iM^iuecn the ttdwr i»cliii nf the well and the correit|iODding spioo
of the diseased aide, lloreover, ihe tip of Iho spinous pra<«sa of the
lumbar vertebra in nt!arer Ihe anterior superior spine of the ilinin on III
diicnjred than on the well side, whili; the distance from tlie lower murgii
of the syiiiphy»i» lo the posterior superior spinn is les^ upon ttie well siil
The walls of the pelvis converge below, eu that tlio contraction iqvoIt
SAEGELE TELVIS
753
liw entire pclTic cavity but is reUtivelr greater io th« plane of least pelvic
dimvasions und iu the inferior struit lluin at tlio »u{K.T)or strait. Tbt- ace-
tabulum on llMt ili^^-41.-^ side ix iJirM-UtI man- natiinorly, wliilc that o<n ttu
well !>i(Ie lookn aliiioKt directly outward.
Modf of I'roducliott. — The jjenesis of this variety of [wiTie deformity
hiw giviti ri«: to a great deal of diMniaeion, mtav writvrH claiming that
Via. *80. — Po«TR«to« View *■» Oim-iovklt Coxtkaoted I^i.t» (NMg*l«)> .
tiie drfwt Id the Mi-ruin i» primary and tlto xyacMtJMi* MMondnrvi ollter«,
tlial llie gytio^toHifi nt^nlto primardy from cban;^ vhicli Imnj; about more
or lis* dr-'l nii'l mn of the «U'nil tin". Tin* foriniT vii-w iiil> aiU'tK-aiiii
particularly by ('ana, llohl, Litzmann, Olshaueen, and Hchauta. aitd the
latlCT by BelJchler, E. Martin, Tliomnv, mtu\ oUm-m,
It i§ now (^'iM^raliy admitted that the first -mentioned vie* ia correct,
llnhl and otlxTK hnviii^ ](lH>wn (but tbi- cnliiv- Micral aliv mii^ht I>e tacking
witliout a aI^ of ^ynofliosis. Moreover, Thomas and Kundrat. anions other
nbeervcT!, hav« clcmon»lrat(^ that tin- aln* of one or mow sacra) rcrtebnc
may be ab«eut or imperfectly developt-d while the others are norma!.
Accordingly, while the ^yooi^lo^iii tU'UHlly occurf at ttic affected fiacn>iliac
frrDchondniiiiti, it is not a nerfw^ry clinnicieristic of ihi* variety of pelvis.
The merbanisRi by whieh the deformity is produced is as follows:
(Iwinjc to llto asyiamelry of the Mcrum tbore in oninpenjutitnry acolions
of the liimlMr portion nf the rertcbral column with itii ronrexlty on th«
dii>e«><e<l oide. This cauM^ the pi^Ivis In aiiMimi; an anKl'' with the horizon.
tl>eTieby brinpin;; about s lowprin;; of the acetabulum on the di<«a^ aide.
A* a prtiiwfiueiice greater preit^urc i* exerted by the fcnmr on that side,
which gradually brings about an upward, backward, antl inward di«plsce-
nu-nl nf (bi; mnr^^pinding innominate Sonc. Owing to the inen-a^ed
ptwHore. the synovial merabraoe at the aacro-iliae {tynchondrotiis gradually
uodpreoci> prcivnre nwrrvio, nod «yDo«tosu> eventually mull*.
754
OBSTETRICS
' frcquencif. — Tbomas, tn J86I, was able to collect from the literature
II (liKcriptiDD of 50 pelvM of thi» clmrot-ior. SitHv I1m>i) adJilioiul
catwi) have ixvn deecribed, but at pretent the entire number does noti
vxmihI Iiiii. I
Oiai/iumii. — (Jenerallj speaking, the conditiou is readilj rcco;^ig«bk^|
pruvidi-d tliat oiie'e KtUmlioii is dircct^nl U> the puMibk* L-x>»tf-iict! of iiadl|
a deforinitv. I'nforlUDatcly, since the cusuinary external nieaeurenKntll
give no el<!W to it» pnuieuce. the diHgnosU is u^iiallj not mude until liUxiiia
in fnr ndviuii^-d, when the <-vident dj'stocin totves one to look for die oiL^
The patientj) do not linip. and a.e a ride give no histun,' suggestive d(
trouble Ht the .-ijicro- iliac joint. On the oilier hand, the oxistenee of »co-^
lioets, a variation in the height of (he hips, or a differeuce in th« distance
betwiTii the Bjiine of tlie \nA liiinliar vertebra and Uie posterior f>n|>erinn
■epioe&, should cause one to suHjwet its possibility. I
Nwgi^U' Htiggi'»ti>d live mwiwuri^nient)* wliieh iihoiild lie made in micM
cases: (1) From the tuber iscliii of one side to the opposite posterior supeJ
rior spine; {'i) from tlie anterior itupcrtor i<pine of n»« iiide to the o{)poMtd
posterior superior spine; (3) from the spine of the last luni}>ar vorleh™
to the anlerior superior spine on either side; (■!) from the IniehHUter lo
the opposite posterior superior spine; (5) from the lowrer margin of tliM
symphysis pubis to llie posterior superior spimw on either side, Noriiially,]
tht?>e various nieasureincnts should be the same on both siden, but diffol
considerably in ohti(]Uely c-ontrutled fH'lve«. ■
Owing to liie dilTieulty of definilt'Iy Inonting their end points, the lir*d
fourth, and fifth nieasiiremontB are rarely employed; but the infonnatiod]
ohtuiiR-d fnmi Ihe seeiHid and thinl is of very considerable valnc. A differ*'
ence of mon- than 1 centimetre between t]i«ie measurennHits on the two
»idi-» imlieiitiw nil oblifpiely eontraeteil pelvis, but is not sufficient to enulrfe
one to differentiate between the Naegele and the other varieties On in-
t<TUul examination the conjugata vera is not shortened, but on measurinn
the diagonal eonjutiEate it is found that tlie »yinphysis pubis, imetead oil
being siltiiileil directly iu front of the promontory, lies considerably tfl
one side of it. t)n palpation it in found that the lab-ral wall of the pelfii^
as well m the ischial spine and tuberosity, approaches the sacrum muehl
more closely on the diseased lliun on the opposite ^dfi, whilt; lite UmJ
pcctin<-al line is markedly tiattened. At the same time the distance betweoa
the tubera isehii is markedly diniiniKhiil.
Elf'^ct uptm Labour. — Wlien the deformity is at all pronounetxl. Ihc iidnJ
of the pelvis corresponding to the small i-nd of the oval is so contracted am
to be of no practical value tor the poe^age of the child, so thai 'fingagementa
if it is to oeeur at all. must take place on Iho opjHwite side. In elTtvt. thfl
pelvic iiilel becomes converted into one of the (tcnerally oontraeti.il varirln
, and an idea of ita availnlile spnce is gained by measuring not tl»e conjiH
gata vera, but the distance between the symphysi^ pubis and the sucru-ilin
synchondrosis on the ninmal side. If cngag«'mont is possible, labour wilB
progrcKJ! more favourably when the occiput is directed io«,-ards the iliiJ
pettineal eniinenei- of tlif disivist'd than towards that of the well side. f'J
the reason that in the first instance the biparietal diameter lies in tfaq
NAEOELE PKLVIS
765
loD]; obl>i]u«' in^ti'sd of in tho «hort obliqtu^ diumetor of Ihv i>uperi4>r
Btrail.
Owiiijr to tlio stvfldv incn'ttet- of tliu coutravtion in llii- lowi-r portion
of thi' pclviiK, luarliMl (liflieuU}' ih tixpuricooed when tlie head nttcinpta to
pass betwwn the iwhial spines and lulH-roxitii-s. und tlw possibility of
^^jdiTi'ry (l«p(!ud.t ujmn lh« diiitiuu'e Ix-Iwi-eji Iho* |«»int«,
^B Prognont. — If tlu.* dofonnity is marked tite pri>gtiotfi» is liad. unli^x
^'Cnitiaran wetioii 1% pi>rfori»cd. Liuinann Blatot iliat ii nul of 28 itiotlwni
I died ill the first labour, aiid that only H labours cndvd ^pontaocuuely out
I of tliv 41 making uj) lii.t (tntin' tteries.
^^ OeneraJly t))>eakiii};, spontaawus labour La oat of the question nnlesa
^Hiho elmrt obliqa« diinivlvr mcoifunM H.5 iHiitinR-tiut. When lbi« limit \*
reached, ('a>tiarcan 9«<-tion is the only rational method of treatment if the
child ie alive and the {mtient in good condition. I'inard in nw. uixo
gainiil fUlTjcicnl room for the dHiv<ry of the Wiild by aawing tlirough
the horizontal ramus of the pubis and the ascending raoio^ of the i«cbiuin
on the diftaMxl Midi- — iwrhio-pnbiotomy. The operation a atmn^y con-
deniDcd by Budin, and it^ perforiiiancio is not to be recommended, for the
FV teu.
Kin- Ml.
f^OH. GPO. fiSI. — TiuK>nnDHii.T tVHrtn.u7m> Homekt I^kutm (Riibfrt).
Iliat the anchylnttiti at one sacrn-iliac joint may prevent mfficifint
rxpanpion of the p('lvij>^.
CtnarlkrolititUeiie Pelvu. — TTudcr tliia nonie Rppingcr, in IftOS, div
scribed a transversely contract<.<d pelvid, ubotrc cavity was eneroached upon
by ■ pr(>lni.->ion arixin^ from the portion of the Ul«ntl wall mrrvspondiug
to the base of the acetabulum. In 3 eai>ea the cnntraetion vra." tinilatt^ral,
iriiilF in a fourth case it wa* prwent on each ?ido. He allributpx the de-
fnnnity to deRi-iint and dt-tayi-d i)H.'>iriraliun of tbv ha«e of Ibv iteetabidum.
In etich cases the cartila^nous struelHre yields to th*> pressure exerted by
the luiw) of the fnrniir. and projects to a varying extent into the pelvic
cavity. At a later period o.-u;i(icalion oceur«, *o that the projection ia even-
tually repKt-enled by a thin cap<uIo of bone.
756
OBSTETRICS
III. Localised Kad Synusetrical Anomalies in DeTcIopmcDt. — These
may bu of »«n*urul elmniolerH : (a) Imperfect du^flopmcnt of both eacral
alip; (fr) liu'k "f union ni the j^ymphysis pubis: (c) look of dt-%-clopmonl
of the vertehral bodies of the eacrum; (rf) m^iimilntion of the liul lumW
vertebra vritli tlie nai^ruiii, or of the first eacral vertebra with the Itunlnr
mltinin.
The TrttHavtrselii Contracted or Rnhert Ptivui. — Irapcrfect developineni
of tlie sacral alte on Ijoth sides produces a pelvi« which Lt niarke<lly
PioL W2, sua.— 8put Pklvu (Bfcntaikd Kolbka).
^aetLt] transversely. an<i is sometimes deseribed as tlio thublr ,Vi
pelris. This vuriely i* (txfrcnidv run-, Tariiicr elutinfr lltut only 10 cas
liiid been il.-M-ribcd up to 1898 ("Fip. 590).
In the pelvis de^tribcti by Itobert Die ahv on both sides of U>e sa
were lackiii;:, and tlie innominate bones firmly synaitoHed with the rudi-
mentary siicnim. Tlie anterior surface of the latter was convei in both
dii-ection.-. Owinjr to tin- iiuperfeet development of the sacrum, the pd»i*
wits ninrkcdly contracted trausversclr, and only slijjhtly antero-prwli-riorly.
the antei-(>-po*tmor and transvi>T»c diameters of the eiijwrior and inferior
straits incusiiring 9.7 and I, and 10.6 and 5.1 centimetres nwpixTtiYelr.
Just a.* in the Nuegelc pelvis, bony union between the saoruni mi
innominate Imnes is not an I'^isentiid irlianielenstic, and is nceasionalh
lackin^C. "omi'limrs on one, mueh more rardy on Imth sides. WTm-tc I1««*
is a difference in the de\elopmi-u( of fhi; nlip on the two sidea it can rmdilv
be undenftood bow an asymmetrical ly transveiscly i-nntrueted pelris n»;
result.
Th« diagnosis is readily made, all of the transver:<« external measnr
ments being markedly nliortcnt-d whils the extenial conjugate
gPLlT PELVIS
757
I
practtcollj' normal. lutcrnal Mamination showi* the conjugata vera to be
unl^ >lixhtly cbaii^, while it is hardly pwsiblc for the marked approach
of the Uchisl ^piiMM aud tubi-rofitii.-* lo one- aiiotlivr to <^'iipe rocoj^riition.
lu all auvf thus fur n-porti^d tl)e traimver^ narrowing of Uto pdviit wan
Ml great as al)solut«l>' to preclude the possibility of the birth of a liring
child, and accordingly Ca.-«an.-au nvctiou i* tltfi only rational metltod of
treatment.
Split Pelvis. — In rare instances union between tho pubic bones at tho
vyniphyiiii <]ot* not noiMir, and the anterior porcionx of tbi' ])vivi* gape widely
( Fig. &9'i). This condition is ustutlly a»$ociated with ectopia of the blad-
der and impcrf«!t dexelnptnunt of Ihe h>w«-r piirtifin of the anterior nhdoin-
ioal wall. It has been ob^rved in adults, but iiuturally is more common
in young ehildrt'ii. W« are iiub-hkil to i.itxinniui for the fimt aivurale
deiwription of a pclviH of this ebaractcr from an obstetrical point of view.
In the *plil pcUw. owing to lU^so'iit of tho proinoiitory of the nacrum
tho absence of union at the aymphysia, there is marked transrcrec
ing of Ur- pOKtcrior purtiim of the pi-lvi*. while ilji anterior portion*
more or lees parallel. Kxternai exauiinatiou in such caeea ehowe a
-4 — ,
Tta. M4. — OoKTBjU'm) Pr.vm I>rit to Aanamne ar Bomb* or Sjtciui. Vaarrans
(IJtBIUlIB).
def<
Vfiii«
marked flariRg of t)u> anterior iinpermr fpinc* of the tliam, and were the
defectire condition of th^ anterior portion of the pelris not clearly evident
rhadittie pirlviH might bv unitpected.
The dUtaace between the extremitieii of tlie pubic bones varioa conaider-
dy, and ocranionallj ie> as great a^ 14 ccntimetrcfi. TIik space if usually
'filled by a Gbrinoiui Iwod. Sehiekele hun Inli-ly n-portod a case of labour in
a pelvis of thb character, and statefi that S others are to be found in the
^^teratora. In only t of them was labonr perfectly spontancona, bat in
L:
758
OBSTETRICS
none of tiicm <n» grwit difficull}' experienced ; coDiiei|ueDl)i,' for practkiii
purpoaes the pelvis may Iw catistder<>d as ^DeruUj intlar)^, the d^tmia
being due to abuorniulitii''^ nf inix-liaiiHm rt-vultin^ from l)i» abccnnr of
rcH<i:<iant anterior ;H']vii' xall. Itn-iis and Kolinkn gtvi> an vxccllcnl i)i>sc-nf
tion of several hitheno undeseribed cases, and discuss fully tlie mechanitil
ttcMn conccrnod in their proiluctiuii.
imperfeet Devetopmenl of the Vertebral Hodieg of Ihf 4S(imiiii.— Ii«M
mum \m* described u rcmarkabtf pelriit, in wliieli almoot tlie entire sacnin
r»wo.
Fkm. iSJ-MT, — ntan Aunwu.ATiort Pm.vm.
■Wit, lacking. Thii- defect wa^t associated witli oonxtdenble tranArerse oon-
traction, which in<:reased iw the iufurior strait was approaclMid. the tnub^i
verne diameter of the superior stmit iTiea«urin|S 10.5 renlimetmi, while IhaT
distance between tln^ iiML'hiat spines and ischial tuljeruintitv was G.Tt and 8,11
CCTittnietns respectively (Fig. o9\).
ASSIMILATION PELVIS
7fi9
Axnmilalion Prlvui.—Qniu: rpw|aently the IraiMvcm; proccwc* of Uw
Bsl lumbar viTlHirn iiiuy W transfonuecl mto structures similar to liie
f^latfrnl mftj**» ot Uu; sacral vcrtubr«\ Hvucc the former aBsunws tin- func-
t'iK. son. till. Q!K>.
Ficml MS, AM. — TkuiBTnHiKi.T CbKrHAcnn Ah*ihilatkix Pei.m (Hrau* anil Koliiiut).
tions of thi> lirst eaenl vftivitn. tlio sacrum bomg noir composed of 6
ioxu^d of .1 [»in«M. Id otlter Iniktaixes tbo Itnil «iTal verlcliru niny take
oa lbi> cKaractvriiilice uf « lumbar wrt«tira and Ik sssiioilatid witli tlw
FM. 000. — t^w AjMiMii.ATiaM Pklvw <ltnnu Bad KdIUd),
»1nmbar ralumii. ■» that Ui«re are R lumlMU* and <niW 4 saoral v«rt«bni>.
Ocx-aiiioiislly the first coccygtvl vertebra mar become assimilat^t] with the
acmm. but thin hafi no effect upnn tlie chnracicr of the pelvis.
760
OBSTETRICS
TTnlvsa tbc vntin- rcrk-bral column U availtiUe for study, it is tn-
qnentlj tlillU-ult to detonnine wiih u-hkh rarifitv of aititiinilation nniy has
to dcml, Ri- it i» itnprji;«ibki to aKrcrtain wlu'lher wliHt <^om^potifle to the
first saiiral vcrttfbra in the twenty-fifUi vertebra, at) nortiiiil, or U Uie iw-ftnty-
fourtli or twvtity-sisth vertebra, as the caw may be. In tho dt^vclopmcnt
iif lh« [M'lvis, The limt piirtion iif the ncTUm Ici enlt-r into llu- fomiMton
of the sacro-iliac joiot is tlic twentv-eistli vertebra, which oomiaUy cor-
rwpoml* to the «Triiui ^crid. tUo lufnty-fiftli vertebra not lunng tiicolvol
until laltT. Apiwrdin^iy, a ^eruin wit!> only four vcrtehrK niay indicatfl
the persiKtcnw of a tielal type, while the pnwi'iiw of *ix vert«hnii *ho«»
that ihe normal process of articulation haa been exaggerated.
V^a, flOl • — At.TMumi(ii:Ai. AjiuuiLjtTUii* 1'kt.riit (Hnnw anil KolwkoV
AwimilatioQ i* Ihe mwl roinmon of all pelvic abnormal itioa, and i*
noted in at least every fifth or sintli pe!vi-i. Indeed, it freipietitly bapji-^n.'
tliat pelves' u-liirh have h>i'n demointrnleil for ji?ar* as tvpically norma'
present one or other type of this ahnonnalily- 5lor»«vor, the conditi«a
may Ixf nswictuted with rhnrhitis or penerol imperfect development, so tiat
one frequently has to deal with rhnehitic or generally contracted assimiU-
tion pelves (FiR, 55?). More commnnly, however, such an asKOcinlMin i-*
lacking, hut tho mere existeni-n of Mssimilntiou may, m-^ertbolcss, give ri*f
to marked changes in the shape of the pelvi*.
When the last lumbar is ai'i-imilated with the 6rst sacral vertebrs— iit^
aesimilation — mi that lht> sacrum conxiiiU of 6 pii-c<w. important chan^
in the shape of the pelvis result, whieh depend in great part npoo the
manner in which tho naenim and innominate bonw articulate, At well as
upon the width of the former. In donie ca«» tli« condition gives rise
FUNNEL PELVIS
761
tu It |H-Iviit which i» very hi^h in ibi pMtcrior portion, and whose superior
strait 16 almost round, the u-silit of its tiifvrior portion conriM^ging, thtu pm-
jducing H funwV^linpttl yuhl^ (stt- Ki^. USh). In other t'nM>s thi? condition
i^ves rise lo a somcwhul IruHsvcrwIy otnuraclcd pulvifl (mi- Fif.'. 5flS),
On tliL- ollivr hamt, when t)iv tir^t Hacml vortv^tra i* axMiinilaloul tritli the
j IuiuImu- colnnm — lov assimilation — a peWU reeulta which is very Bhallow
I in ito poelvrior jiortion, but which oftan no particular oUtaclo to labour
(see Hg. fiOO).
Oci-a*i'>na1)y tlw asKiinilntctd vertebra may undcr^ only a partial change,
' uiu> Mde ot it rttlaining the characteristics of a lumbar or sacral vertebra,
I as tbo ca»? may bo, uhjlu the other s'vio un<lcr;gow ronMiilcrable modificu-
tion. ITnder Nuch circuinalaivecH asyrn metrical p^vcs result which are not
linfrs^ncntly obli'indy com tr acted (wt- Fig. COl),
Funttfl Prlri/i. — Whih; llw tinwi tyji!<ral e.vniuplo of funnel-sha))e<I pelvig
is S)^«)ciatcd with lumlx>-6acrat kj'phovis^ contractions of thv pelvic outlet
art! atHO nolcd in i^jKindylolisthetic, oaleomalHcio, obliijudy contracted, and
other rare tyjies of abnormal pelves. These, however, occur so rarely Uiat
tiwy arc of wii-nirfic rather than (imctical iniiii)rtitmT.
()a llie other hand, niDclerate degrees of outlet contraction ore frequently
nott-d under oDmt coDdilion«. Tliiu, in the gcni>nilly coutraclvd or ju«to-
minor polviB, the inferior strait may be so diminished in size as a part of
the j^-ticm) hypoplu'ia as to give rtw to dystocia. In mich caw*, Imwcvcr,
the diacnoii.4 of ^-eiuTat contraction shonlil inevilabty direct one's atten-
tion to the possibility of lln! cxi»lenco of such an abnnnnalily. lai tha( it
1$ not li)i«ly to p«sM unnoticed.
rnfortunalely, in a much laffiier class of cases mor<^ or lens serionaj
contrnction of the onllrt niiiy t>cciir in pelves which appear to be ix-rfectly'
normal as far as tlte unual external and internal nvea.-<iireiii<-nts are con-
cerned. In such cs«C!i tlK' condition may not be #itM|NX-tud until terious
d}vti>ci« arisen, when Uie phyiiician may And himself in the enibarraaMng
position of being obliged (o report to a imriouBoperalinn in order lo saw the
child, after havtU); a.viiinil the (lalient that tier [lelviM \hl-< perfectly mmnal.
Aa Muted in Chapter XXXII I. pelves presenting a transverse diameter
; nf S wniimrtrw or l«:*» were iiotitl in 8.(1 jwr ci-nl of a wrics of 578
[ennsecative patients whom 1 examined. Huch contractions occur c<|uaUy
rmpK-Rlly in botli white anil coloiin-d women; and wt titc incidence of
Iho onlinary tv'pes of (■ontraetixl pelvis \i five timea greater in iltc col-
I ourcd than in thv white women of the same series, it is evident that outlet
.i-jintrartinns muHt hi; due to (mine other factor tlian rhachilj* or imperfect
; general development, which are so pn>\-alcnt in the coloured race.
Formerly it wa* liclievi-d tluit the itmdition was a mnnifestation of thii
' existence of a masculine or an infantile type of pelvi.-i, but itij observation*
have tauglit mc that «uch ix not the case, and 1 now beltc^-c tliat the great
majority of outlet contractions are a^woeiated with high assimilation, name-
ly, th« presence of six vertebne in the f^crnin. This may so alter the rela-
tions at the t>acrf»-ilinc joint-i that the wall* of the lower portion of the
, jmHvic cavity converge, while tlie npper portion retains approximately its
uormal proportion*. . I
762
OBSTETRICS
The correctness of such a viow is iliriiion*lni1e<l by the fact that I
abk^ to pulpatii iix naural vertebra? in a iiuoiber of my cases, and in many
Fla. n02. — UiAiiHAU Siiowisii nit SmsirKTAJtrii: or tjik Di-
UEKKIO.VH Ul> Tilt: ANTEnion AXD PfMTXHIOIt Ha»ittal
DiAurtEiu. X ).
SpontAnnnw IslHiiir ia njiilo of h Imiwvmi! (liaiiit<t«r of
S.& cm.
more to deli-cl the cxiKtciKf of n false or
(Wfiiml icornonlory. Tiint dtfiniie proof
eostd not be udducvd iu all cases is not
uTirpri-^mfT, a.* lli« r-arrnl vertebrie can
be counted aoourately on vaginal or rw-
lal palfintion in only a c-omparativoly
(irnall proportion of cases. Accordingly,
the dt-monfltrstion of the cxi^lifucc of
higli a^iiiiiilation in n small number
of living women justifies the awumf>-
liou thai it n-ally ixtui-* mucb moro
frequently. Thus far my investigations
tend to show that approximately one
fowrtb of all funnel pHve.i are associated
with imperfect general development,
vrliilc lite remaining llirw ijuarter* are
probably dependent upon higb assimila-
tion.
ShorUiiing miiy occur in either Ibe
Iransverse or antero-posterior diameter
yia. 6fO. — DiAOHAU or PctTii'
un' av 8ahe Cake. li.i.t-!>nuT
PoHtiiiiurT or SroKTAKiotv
uoint; OwtHu to Ioko tVwnmna
t)A<lnTA^ ntAUBTtLK. X ).
FUNNEL PELVIS
76a
of the pdric outlet, or in both Bimultaueously. In the great majority of
cases the distouce between the lubera iitdtii varic« betvrceu 8 aixl 7 centi-
Tta. WW. — l>iAuiiJtM Smtwixo rur, SioKirK-AXOE or T»K DitfCnjONH or niB A>TKRinit
^^ A!i(ti PiUrTUlinR t<xaiTtAI. DuHLYKM. X 1.
^■^ CWMirwn fcction in qrite ol k inancrac tUamriOT of 6,5 era.
Fki. 000. — DiAOKAN or Pm.vm; Ofn.tn'
OP S*li« Cimx, ItunrntATiwa Nbcik.
MTTrmiCKMnMKBKcnux. x 1.
metres, but Id eorpral instances it waa
)(««. ami in ont> csiBe measured only 5.5
oentijnetres (Kigs. «0S and BOS).
Thai coMt riKtionti of this uhnravler
may serioiislj- alTeet the course of
labour is hIwwh by the fact tliat in 40
cascf, which vent to rerni, ihe f<dlow-
iuf; operations were necessary to effect
ih-liwrv : nanioly. !> fonx-jw, a Ca's^n'siii
sections, 1 pubiotoniy, and 1 eraniot-
omy upon tho after-coming hoad.
liorvoTer, even vhen the disproportion
is not sufficiently great to pTc rise to
niurki-d dyi'tocin. tl may play an im-
poriani part in the production of peri-
neal leare. In such ca«e«, vith in-
cn«Jting narrou-ing of tlic pubic arch,
the occiput cannot emerge directly un-
der Die symphysis pubis, and aecnrd-
ipfrly inui'l stem l(if#lf furllw*!- and fur-
ther down upon the ischio-puhio rami,
and in extreme eases must rotate
764
OBSTETRICS
JKrounil u linv joining tlie ischiol tubcirmities. roriM^iionfly fh« poHiiirnnil
ftnuet become iimre and more lii^lvinifd. iiml thus cxptiM-d lo gr*a«l dtingi.Tj
or fixt<!iisivi> nipturtf.
In view of ttifl frequency auil pnu-ticul siffnilicanw of outlet cwBlrB^rtions.^
palpation of the pubic arch, as de.tcril>ed in Chapter XXXIl!, nlmuld form
an iutfgral part of the prclimiiiary ciainination of every pregnant vroman^
If any abnormality liv ddrt^loil, tiii' t ram'Vi.T.'*' ami aiiu-rii-piisicriur diaiih
etera of (he outlet lihould he measured, and a shortening of the former to]
8 vcntitnttres or lii;s ehotild be regardt^'i] »» a danger sij^al.
Unfortutiali-ly, ai> Klifn ^minted out in 1896, the li-ngth of cither of
I these diamoten^ Aoa Dot afford a BUttieient ba«ifi for llie fomiQlation of
an inti'lligt-ut prognosis. And it may hap|H-n that eerioiiK dy:<tocia may
sometimes arise with a trsnHrerse diameter of 7.5 contimeties, while oa|
I the othrr haud spontaneous labour inny occur when it i» reduced to 5.S
fcentiiiietn-s, «.■■ in one tif my ca^os (Kijt^. fiO2-605).
The decrt'asc in leiiglh of the transverse diameter is asHJciatt-d with a
progressive narrowinji of the |)ul)ic arch, no that only a smUh^r and smaller ,
segment of the head can pass bencnth it, and in extreme casw! only thsj
.portion of the nutlet imstenor to a lino joining' the iM^hial tuherooitins in
^BVftilable for its pas^ia^re. !n mich cases it is evident that the [KWrsibility
of delivery will dejicnd not upon the actual K'njk'lh of the nntero-iMWlerior
diameter, but rather u|»u the space available between the transverse diam-
eter and the tip of Ihe sncrum.
Klicn has deiiijcnalH this distance as the posterior sa^'itlal diameter of
the outlet, and has devised a Bpecially constructed pelvimeter for its men-
eurutimi. In practice it may tw determined as follov»; After eU^atinj;
the bullocks by means of a hard cushion, the eml points of the transverw ,
diameter are located, and a piece of load pencil pressed between them untilf
it <'orri'sj)(juds wilh the level of the iliameter; Ilun. by mean* nf a jw-l-
vimcter, the distance is measured helwecn the centre of the pencil and tlie
^posterior surface of the (ipof tliusaeniin. By subtracting 1 oenlimvtre frofn
this measurement, the length of the posterior sagittal diameter is ohtainetL
If it falls below 8.5 ecniimctres and is associated wilh a contracted trans-
verse diameter, spontancdus ialmnr is out of the ()ue--.tion, and piibiolomr wj
Cesarean section is indicated. Above this limit spontiineouH labour inByl
occur, Klthough forceps will frequently he necessary. Below It, howpvrr,)
forceps should never be employed, as in such c«ses evtraction can I>e elTectcdl
only by brute foixe, and may lead In frailiire of Ihe f<etal skull, nipt
of the symphysis pnbb, or other grave injury to the mother.
LITERATimK
HLER. Kuuo ZnHacht. i. Gob.. IS40. ix. 121.
-Dofcotii. llcber Zwurgbofkun. Arehiv 1. Gyn„ IH93. xliil, Mr-472.
DnEOD iind Kot.tBXo. Die path, llcpkenfomieii. IfiOO. i. Spallbwlcon, 107-139. A»-
riraiktioiisbi-i-keii. 1(itt''2.>«, Znergbockiai, 25!) »(»l.
BoDiK. RRchetphcn cxfX-runHiilaliw i. propo« de I'iMrhiivpuhiotoniiu. FanmM »
couobes et noin-oau-ciCc. 1897. 468-^82.
rniMARY A.V0UAUB8 IN PELVIC »E\'KLoPMENT
765
BOrrXBH. BcKbreilnuif; tia innena WaHwriopfii und den fttuea UeinkAriNirs uiner
vmnihrorfinbiman hJitiRi vll. JiJtfknmkf^wcaencnPvnMnirciblu'iioD Goaciifeclita.
KfiiiiicabCTK. 1K73.
DBt-EXTKK. N'ciicM lU-hanuncnlirhl. 11. Auft.. 17JS. IM.
FrpiNOEK. P*lvis-C'hri>tittk, C<ixanhro)b)lbvm»-ncckDn. MeiUAna uir n«b. U. Qyn.
(CbrobiJc'ii F«Wchri£l), Wicn. 1903. ii, 176-235.
nustsrn. Zur St«li)rtik der engen llcckcn. Zcil«chr. f. Ucl>. u. Gfti., 1S82, vii, 314-
331.
<(V)u.T. U«ber tinige Mi>M|[««titltiingQn dim mnMbhcn Itcrkaia. Berlui. IBM.
HmiUKiTT. Ih) luuiume uu poiut dtt vui obaMtrickle. AunAlea de gro. «( d'obtt.,
IDOe. 2lDe .S, iii, 1-18.
noRi.. Dm whriK veronfrtv Beokeo. iMptig, 18S2.
KAUrVjixN. [.'ntcrntichuti^n ubur die ni^nntiatc Ktale Rndiitw. Berlin, 1992.
KuKX. Dio geliurUliiilflirhc lindculiins ilrr Vorenetfungcn del 13ock«iii>ungM)tik
\'olktiuan's Saminl. kliu. Vortnigu. IWCi, N. F. No. IGO.
Kv.tDiUT. Quot«d ia full by Bn-ui and KuUidio. Die paitli. Ikrkcnfomicn, 1000, i,
MT-I.^3.
l.tJMMiEJt. Anal. tlRDcbreibuiiit ciiicK kimllichDn Beokciu. D. I., Tubbigim, 1M7.
LmuA.VK. I>Hji wJiri^pvale Iteckwi. Kiel, IH53.
Ihu gi-q>altcii« Bccl^en. .^rrhiv f. (iyn., 1872. iv, 280-384.
Eia durcJi manj[DUiA((e Entwickoliin|[ de* KTMiibelnM i]iUTrvoit»gi«* IWvkon, Arcliiv
I. Uj'D., 18B5, xxT. 31-39.
Hastix, R. De polvi oMiqu« <it'«i«. Jena, IMl.
MOllbb. Zur Frvijutuii u. Acl(ulo|p« Am uUg. vereiigUn BMlwna. Archlv (. Oya.,
1B80, xvi. 155-173.
N'aikiele. Dm aekrig wrencU BedEeo. Ukiti*. 1H39.
OtAHAUHCN. SdingveKfigtea Bockcoi, ot*. Monnlwcbr. I. Udiurtak., 18S3, xix, 161—
18&.
pALTAttr. Quol«d in fuD by nreuii and KdIimIu).
PiNABi). It* l'twlito-pubii>tutuiu ou op^fatiou d» Fanbeuf. AnnalM (b jQ^. trt d'obat.,
1803. xxxix. 139-1-13:.
Potux. tit IWJiondmplMJo. Nouv. krdiivM d'obnt. «l do Ryn., d^ramhrt;, 1880.
RtcMttiXT. Du bwNin gfatnlement rMrfoi. elc. Th^tc ile PHria, IHUC.
RoBUcr. BMchmbuni mr» im bch-JuUoi Gndc qucrvcnugtcii Bcckiuu, etc. Kiiii»
rulw u. FrvlUiix. IM2.
Sm^irTA. Diu UvckvnanoinBlion. UiiIIct'h tliuidhitwJi dcr <>eb.. ISfO, ii. 33(M08.
Doa durch nianiRlhaft* Fjitwlckeluugciniui Ktiiuil«iiifluiKJ«M-hrA4[votis«i|ct«n Itockcn.
MuUer'H HiUidbudi dcr (M>.. 1889. ii. 319-331.
Dit Bcrkcnfcirmm Iwi RVnimctriivhcn iind luynuncIriwJuiD AMamilAtion. MiiUct'b
Hu>dbuc-li d«r (iub., 1880. ii. 447-UK.
SonncKMt. Bcitnix ^tur Ixhrr dci nonnakn und gnipaltoncii BcckcniL BeitniKe eut
Gtb. u. Oyn.. 1001, iv, 'iAS-'iri.
9ms. Lehn dcr CMHtrliliiiUe. vie., 1825. t, 78.
Takximi ot Bi'niN. TraiM df I'Krt dn* anmif-Iwincnta, 1898, iii, 314-31K.
TkmhaisS, Dah artiragti-cTaijAv tWkeii. uti-. l^pxig, 1861.
(Jkka. Ziir (iencM dm w-linucvcKiifitea Bcckcn*. HanUirgcr Zcitadir. (. die ;«•■
Ued., 1M3, xxiu. 281.
l!:n xxxvn
PELVIC ASOUAUKS tiVH TO UlSEASf OF THE VEltTHBHAL
COLUMN
Kyphotic Pelvis. — Ki'phosis or humpback. Ihe reetilt i>f npinal caries,
plavK nil imporiHiii pari in iho prniiuclion of |>elvic abnormal it iei>, fa
when aitaated ia the lower portion of the verlebral column it is ni
olwnvif ii«iuK-iiilcd ntlh a cbitnii'li-rixtic-jill)' ftniiK'l-itliajit-d pi-htii.
We are indebted ro Uokitanf^kv for the fust accurate work upon tl
(iubjwTt. although ii.'' larlv aii KSli Mndutiic Bouwier dc Coudnij' rcporhnl
Osearean section performed upon a patient havinp a pelvis of this characie
Krpnoai* (Bn-uit and Koluko).
The most important contribution to our knowledge concerning
kyphotic ohanpcji was made by Breisky (iSfiS). who clearlv hH forth if
mechanical fattors by which the ultcration in shape wa* brought about.!
IaU-v Chttntrcuil, ("hampneys, BaHionr, Treub. and particularly Brvofi «dI]
Kolisko, added materially lo our knowledge of the subject.
760
KITHOTIC PELVIS
767
The effect exerted apoD the pelvic bv kyphmin differc according to its
locklioii. When ihe gibbii^ or hiimj) if situated iu the dortial region it
usual]}* compcti»ted for bv marked lordo^U k-niMth it, ho that the pelvia
Haelt in but little flMU]g«.>d. On the other hund. when Bitiuled al the jui
tioD of the doreal and lumbar portiouf of (he vertebral column iu elTeet'
Dpofl (he pelvb bi'vumo- niaDife»t, and is Btill further aeeeutuated wlu-n
the kyphoMiH U lower down, bein(( moot marked whcu it U at the lumba
Mierul juiictioii.
Klien analyzed «1> i-a^es reported in tlie lit*'rature, and found that the
kjrphom wu» dor«o-lutnbar in 24, lumbar in 17, ood lumlio-oaeml in 37
I
•07. — Ktwiot*! PKbrn, snovmu BuraaAriu.N or Ook/Oimta Tnu.
FaAO!<. while in 7 other ea.«!« Ihe vi-rlelirnl »iliimn «i OTerliung the superior
(trail ai» to produrt- a '■ ptlrt* obtetta '' ( Fiji. i>08).
[ The characteristic featun* of the kyphotic pdi-i* is a retropuUion and
Mtaliriii nt tW Jtaentin. by which the promontory beeonie.i diitplnei'd bnek-
ward and tite tip fonrard. At the Kume time lite euliro tmne hocomeij
doiif^tt-d vertically, aiid narrowed from side to side. Tliwe ohaii^f
SMOciated with a rotation of each innominate bone altout an axis, which'
extendi throuf^h the symphysis pubis and the aacro-iliac articulstioo, m
that the iliac foftw become flared nutwarr! while the lower portion* of the
iiwhial bones are turned towaril the middle line.
Wlwn llu- kypIwMix in in tliv dorwi-lnmbar region, marked lordodi* bdow
it indicates an attempt at compensation, but as this is imperfect, the body
weight i» Inuii'mittnl to the sacnim in »ueh a manitcr that tint latter be*
cornea markedly retroposed and lenntbened, its promontory beiuf; farther
768
OIWTETRIC-S
flo. 0l».— PKLvn OinwcTA (Kchllng).
backvnni aiut »t » hi^lier Wol than iiniial. Al Itif i^iiiio tunc Us nnrma
\«rtical concavitj- is replaced bv k elraighl or etva conTeic snrfBCP, whill
it* Itteml oiiriojivily bit-nmis ■tliliti-rati*'! tiv IIkt pmjwiion of the venoliral
bodies beyond their alK. '1'1m> bodies themfielves are coiwidcrably narniwc
than usual, uvxi the alif of Oic fir*t »«cral vtrUtbra apjwar to be drftwn out
and to extend obliquelj' upward to tho promontory,
Owing to itt bueJiwnrd difiplm-einviit, l\»: ]>0*tffrior «urfACC of the
crum approachen the superior posterior spines, thorebr relaxing the iUo-l
mcrot HgaitiontH. At th<'
same time the posterior
cxtrciniltey of the innom-
inate bonee are pushed
apart, ami a$ a eonx^-
quonee tlieir upper por-^
tionn tf:aA to mlalv out
ward and the lower por-j
lionn invani. m thai die
eresi"i are flared out and^
an> iiitiialed nt m loworj
level than usual, while
iho iMoliial «pine« audi
tiiberosilie^ approach !h«^
DiiililU- liwe. This move-
nicut of roration igi itiU
further ar(^i-utiiali>d I>v the inereoiicd teiininn exerted by the ilto-fen>araI
Ugatnents resulting from a diminution of the pelvic im-linatioi). Tlii^H
acetabula ni.-x> an- Khifti-il Kliifhtly and louk num.- to iW front than usual. ^^
Coincident with the displaecment of the Kacrum, the ilio-pecliiK-al lim
hwiime.'' longer, purl ten In rlv iu iu iliac porliou.
The^e chan^eii pive rise to a funnel-«haped pelvis, in whioh, as the result
of the niarki.'d iiicreai^c in the I<-ngth of the eonjugata vera, tite »u{)friar
strait bwiinn--» round or oval in Nhape, with the long diameter runnii
a ntero- posteriorly, while the transverw diameter remains unehan^'ed nr rnayj
even be somewhat shorter than iiKunl, lliore 'a also a gradnul diminulionf
of all the antero-poslerior diameters of the pelvis ImjIow il>e su))i>rior strait,]
but the iTKwl ihii met eristic ehniiKe is Iho shortening of the various lran=-j
verse diaiiicttrs, e.-pei-ially between the ischial spineif. anil to a WHiiewlmt-f
less estent lietwi'en the ischial tuberosities. The pelvic inclination is ura-j
ally deereax-d, though in iwiiie vaMisi it is only wlightly allrtrcd.
In 18 kypiintie pelves described by Ilreiia and Kolisko, the cruijugata
vera variwl from 111.7 to 1(5.5 centimetres in length, the distance beiw«o
Iho lupines from B.2 to 8.2 oentimetri's, and that tvelween the iwhial tulwr-
ositie-t from K to IS.l centimetres. At the same time it shoulcl be retncni-
hored that in not a few raiW-i the entire curily is smaller than usnal. Klien
having pointi^l out that :iO per cent of all the kyphotie peh-c* described
were also generally contraclod. «i that « conjugatn rem which at first
glance apjicurs noniiul may in reality be relatively increased in length,
When the kyphosU is situated al the junction between the last lunilwr
KYPHOTIC PELVIS
769
and the first sacral vertebrte, the pelvic changes are generally more marked
than those just described, as the promontory of the sacrum ie usually cari-
ous and takes part in the formation of the gibbus. In such cases there
can be no attempt at compeusation, as the body weight la tiansmitted
oi--:.._
FlO. 609. — DlAQKAM BHOWINQ FOBCES CONC'ERSED IS TBI FttODCCTtOX OF KTPBOTIC PeLTU
(Tftniicr).
directly to the anterior enrfarc of llin .aarniin. so that its upper part is
pushed far backward. It is nnt lengthened, and its alee are usually very
small. In such cases the transverse contraction Iweomes still more marked,
80 that the distance between the ischial spine.^; may be reduced to 3 or 4 cen-
timetres, as in the cases described l>y Schrocdcr and Doktor. The pelvic
inclination is always diminished, and in some eases is entirely obliterated.
When the kyphosis is very marked, the lumbar vertebne may so over-
hang the superior strait as effectively to prevent the child's head from
770
OBSTETRICS
cntcriug it. Tliis condition was dewribod liv Fehling fl» pelvis wMfcJn, td
iiw i^pwiiiK'ii the (iisUiDcf iK'tux-eo the iiyniphy.->ia jjubic ami the iiwirv^^I jxiint
on Ilie v<-rt4-lirul column was 3.6 ccntiraetrcB. The pelvta Abiectn waa
noted in 8 pur cent of tlie vtuw* atM\ya.i\ by Klii-n. A eimilar condition wa»
dtKcribed by llerrpott as xpiituifiiiztme,
Modt of i'roduduin.~A ky[>hosi& in the dorsal region is luually com-
pensDted for by a iiiaikwl l<ir<liii'ii' l.eJfiw il, m Ihiit tbu body wuighl is
tiniLfintitted to the sacniiii in ttie luiual manner. On the other hand, aad
Rreiiiky poinlwl out, whi-n lliv bump is i^ituatcd towx-r down the bodji
weight is transmitted throii;;h tis upper Hiiih, and on reaching the gthbiu
bccomiM H'solvi'd into two wmprmwits. one of which is directed down-
ward and ihe other backward. Thi.-< latter force drawn the promontory of
thv sacniDi backward urid upward, thus leading to rotatitHt of thi' eatirej
bone (Kig. BO'J), '
Brcus and Kolisko hare shown tliat, owing to the necroeis of one or
more of Ihi; vertciiml iiodics forming ihu giltbiis, the Unly wvight i» mrt
tranemitted directly tlirousb the vertebral bodies below it, bat t]irough
their archcit and xpiiiouK procewM. A* a nwult the latter cone into close
contact, while Ihe aniorior portions of the vertehr* become widely Mpa-
rated, thus lr»i|iiig lo marki'ii lijr>li»i.v K'nejiiii the gibbus. lliis eaiues
Ian upward draj: ujion the IxHlies of the ^airal vertehra', which lieconie i
'etretcht'd and elongated. Coincident with tbiTfrU changu; the innominate '
bone.-i likewiiie undergo rotation, which bringiA almut a narroving of Uie
lower portioi] of the pclvi;^. and is dtic partly to Ihe backward displace-
ment of the Kucnim and partly to increu'Xrd mn^ioii exiTied by the ilio-
femoral liganunts. ■
Frr 5 w'-wn/.— According lo Klicn's statistical study a kyphotic pelvis km
met with once In evary ti.Ult! laboum, iiUhough he himself bttlicvwK tltatl
this esliuiale is too low, in view of the fact that hunipbackol women are
relHtivdy niirinnnin. On the whole, it i.i probable thai any one who tiat
much olistetric practice 1^ liable to meet with one or more caseti complicated
by this Hbnorniality. .
Diai/no.ii!'. — The diagnosis is usually easy, aa the external defonnity in
•Tcadily detected and ifhould at once )>iiggiwl thu postiiblv vxisteDce of al
Ffunnel-.-<ha|HHl [K'lvr^. 1
Kstenial pelvimetry is of great value, as it shows that the distance
iK'twwn the ilin<' crests is eqtia] to or cx<reeds that between the tmchantcr<, i
whereas noiniatly Ihe ro-erse is true. In a patient sutfcring from this ^
defoniiity, lim-s dniwii ihroiigh Ilie iliac crest.* and I i-orJianterK will mi-ct
somewhere in the neighbourhood of the feet, instead of near tJie bead «s_
is generally the Ktne. I
On int'inal exaniinatiou the transverjc narrowing of the peNic ftHlirtl
should lie nok'd, as well a^ the antcro-iJoslcrior lengthening of llie coojugatal
vera. In the liimbo-Micni! varii^ty the promontory no longer exists, and tlinl
bodies of the lower lumbar vertebra overhang the superior xlniil. Acwrd-"
ingly. particular attention should be di'%otc<] to estimating the length of the
" pseudo-conjugate " — the di-tfini'e from the Hp|N-r murgiu of the symphy-
fiifi pubis to the nearest portion of the vertebral column. Occasionally
KYPHOTIC PELVIS
tbe coudition may he confonodod irtth spondyloliethesis, aod the differ*
Liilial diK^u»i» will b« con^idcrts] undvr Ihv hiltt-r beading.
Efffd upon Labour. — Owing li> llw cdlnpH: «f tilt vcrtfbml voluiniif|
tlw ritw apprMcJ) the pelvic brim and mark<,>dljr le»w.-n Iho uipucily of the
abdomen, which in contwqiwnce becomes markedly pendulous at an earl]
period of pregnancy, these mechaniml conditions favouring the occurr
of t-crlain abiiormul pmilion^ of llio tn-uii,. Thun Klien, in 103 caaee,.]
found 100 longitudinal aitd 3 obli^ut^ presentations. Of the fonnvr 96|
won; vertex, 4 fare, and U hnxili pn^ventalion*.
It ia ini«rc»titig to note that left ocei pi tt> anterior presentations occurj
mnch laB6 frequently than usual, being noted in only onv Uiird of \\w c««c«k
Pml AIOl— KaoiTT juio fcna. View o9 Paticwt vim LirniMi-iucmu. Kipriui* rHin*).
while the remainder were eqiially divided between right anterior and pos-
terior pre^MiIatiniiK. Il i« difficult lo ^xv- ■ >«ti«favtory explanation for
the unusual frei]m'ney of the K, O. A. position, but llie pmdurtinu of po:i|o-
rior poattioni' i> dni' In itii- pciiilulmiK aMomni. a> tind«T such circumstances
the cnncave anK-rior surface of the i-hild ti^ud^ In apply il>elf to the convex
anterior anrfaee of the utenia.
At the time of labour the presenting part exjxrienwf no difBcuIty in
entering the sup'.'Hnr olrait. and uo oh-iiaele is nu-l with until il reachea
the lo»-er part of th<> (wlvis, particularly between the iKchial spines. If the
ti»n«wr«e contraction he iwt loo markvd to prevent the panage of tlie
bead, further difficulty i» encountered when tbe latter atteinpta to
I
3
772
OBaTFTTRICS
beneath the pubic arrh, which, nuin^ Ici the approach of thfi tubera ischii, '
has become more angiiltir tliun usital. *><> that lh« hcnd is prctcDtol from i
coming in tinimd with Ihe lowor margin of ihe Hvinphysii< pubis and mu-t
descend lower than usual in order to bt> bom. This fact readily cxpUiiiii ,
the dtxp ptrrin<uil tean> ao frequently »b»erved, J
(■enerallj speaking, it Diuy be said that when th« distance bctvMn thm
ischial ^piiu-K is liw> than H cenlimotres, lal)nur t>ecoiiicii difficult or inipoan*^
b!e, accordinp to the dcgri-e of contraction of the trunsvorw.', but more par- ]
ticulurly of tl)c priotcrinr naji;iltal dianioter of the oulli>t (see page 7iM).
Owing to thy narrowinf; of the pubic arch. Gccipilo-anlcrior arc less favour-
able than Accipito-pofUTiiir iin-u>iiliition.i, lu in the former tln' uidc bijiari-
etal diameter haa to accommodale ilwlf to the narrow pwbic arch, witemtt
in the latter it* i)Iaci> i* taken by the brow. According: to Klien, facB.
presenlationa are still more favourable for the same reason.
I'rwjntms. — If the contrsclion \* ut all marktxlr tlio prognosis i» bad
unleiw (litsarean section ia resorted to. Ktien has analiied the histories
of 175 labours occurring in 95 women, und foiind tlint 4ii per ctmt of tbft
eJiildron died. Thp maternal mortality varied according to the degree of:
coutmction; when the disproportion between the bi]>ariv(al diameter of Ihc
child's head and the di.'^tance Iwtween the spines was slight it was 6.2 per
cent, as coraparcd with 17 per cent in marked casei;.
Neugi'baupr has likewise analyzed Ibo histories of 1H9 lah«iuni occurring
in 118 women, und found that only 44 ended spontaneously, Tlie matental
mortality waii 'i\.A jkt ctmt, nnd ti) per cent of the fo-tusn:* AwA.
Treatment. — When Ihe distances between the epines and tubcmiiiti^w (if 1
the ischium do not foil below S centimetres, gpontaiieom: labour, or at teaet
a probalile delivery with foroej>*, can be looked for, but when the meaa- ,
nrementx fall below this limit, operative interference nsuuUy becomea neces- 1
[*ary. If Ihe ease be seen in the later weckji of pregnancy, Ihe propriety «f
the induction of premature labour may be considered. As a rule, however.
Ca-.tarwin sectt'in bI iti-tii is far pn'ferabU' tinlo-^ the child U very smalt.
Symphyseotomy is urped by many as an appropriate operation in this daas
of deformity, and wilt vcrlninly give n sufficient incrcaw in Ihe size of lb*
pelvic outlet to permit the passage of the heail, providwl the diAtiuicc bft- '
twei-n tlie spint^ does not fall below 6 centimetres. If the child is already
dead, craniotomy is the operation of election.
Eypho-Rhachitio PeMi. — Kj-phosis is nearly always of cations origin,
but when due to rhachitia it is usiuiliy n<"<ociaI(^ with n greater or lw«cr
dcgriio of scoliosis. In the rare casee of pure rhachitic kyphosis, how-
ever, the pelvic changes are slight, %* the etTeit of the kyplnuis is counter-
balanced to a great extent by those of the rhscbitis, the former lejiding to
an «tongation and the lattor to a shortening of llw conjngala vera,
while tending rt»|)eetively to narrow and widen the inferior strait. Thus
it may happen that a woman ])ri-»i'ntinp a markedly deformed verlebtal
column of this character may still have a practirally normal [vlvis. The
two proce-wes. however, do nol always conntcrael one another, and, as a
rule, when the kyphosis is high up the pelvic changes are prtxlgnitnoiilly
rhachitic
BrXJLIOTIC PELVIS
778
Seoliotio Pelvis. — Prononnoed acoliofiJSL, <iT UlPral nirvnture a{ (he xpine,
is UBttallr of rhacliitic ortgiD ; but. on tin' other hand, mioor d«gTc«s of lh«
xlttfonnity nn- nftcti nlismnl which have no connocltoD with rJuketii. When
the Bcolio<iiH jmotviti ihc iippi-r portion of the Tcrlobra] column it is amaHly
ronipvnutvd for by a c«rr<w|ionding ourvulnrt; ill tlii; oppO«it« dirtvlion
lower down, thiu giving rise to a double or Sshaped curve. In such cases
thp body weight i» lransnutt<Ml to tliv Micnim in the uMual nunnur. But
when thescoliocvin i^ lowor <Ii>wu and involve^ the lunihur n'gion, the DaeruiaJ
lakei part in tlio oomponnatory [imcwB and accordin^iy asMUiiK-!; an abnor-l
tnal position which leads to slight ii^ymnictry of Iht- pt^lviw.
llrctiii nnd KnlUkn hare devi>1i>il piartirular attention to the pelvic anom-
aUvs re«allini; from non-rhachitit- iicoliofii«. but th<- chan^^ in nhap- are
u^iinlly -m ■.ti;;hl a» 1" have litt!i> or no elfwl upon ihc four**' of labour.
\yhva due to rhacbitis, the wolioHis niiiy be very {in>n<iunc(>il, and
give riM! lo nuirkitl pekic deformity, in which the eharactcristio chaogeflj
FiK-ftll. 1^ 012. ^
'. 61), 0lft— OaLiiQCitLT CairntACTED Prlvm, Dpe ii> NoM-Riu(«fnc Scouixn (Unas
MidKoUiko).
lAm to the anomaly of the verlebral column are HiiH^nuhlnd to Ihow rnnilt-
I in|i from rliachitig. In l^ueh atf^ei the scolmtic convexity i» usualtv directed
lo the rij^hl liido, At wa» nottnl in 7 out nf tlic a ixmv diiitcribfd by lywpold.
tJDder snch cireuroi'tance)! tlic iiacrum takea ]iart in 1Im< i'nm|H>nKatoTy
' *oolioi*i>'. one fide being compn>i^-d and (Ih- otlwr olon^taletl. w> that its
limi; avis* becoititr' dirocttil i>J)li<(uely Inward.t one xidc. At the Mmf. tiinc
it undergoes a partial rotation about its vertical axis, Ibe spinous pro-
Si
774
OBSTETRICS
ccssw bfins ilirectcti towards ilie oolJlp^e-t^el^ side, s result which indicatM
t)ic fiWtrniiil ilirt-clion along which ihu bu«ly weight \* trHn^iiiit.twl to t)ir
itini' Ihiik-, iiml ihciK'i- tu llx: fi-inur. Oniii^ ti> ihi> iitinormal [trcssun-
«.verted upon one side, the pehis becomes obliquely contracted, usually
upon the fiAii oorrvKpou(]iug tu Ihc lumbar coiiv«xit}'; but, (wing to the
coexi^itt-nce at rhachitie changes, the contraction U in great part limited
to Ihv liuperiar ^Irail.
Fig. BU,
Kin*, 019, 614.— Scior.to>nitAninnc Pckru (Taniia).
i)wing In llio prfttftiire omtIwI upon the (rmii]>r4HuM><) f'n\i^ of the «)cram.
ankylo^i!^ al the Muru-iliac arliculatiouti often occurs. At tk« miiu» time
the iniKimiiuito lione on iht- nfTwtttJ ?i(i>- is lii^jilmrd itpward. inwan), and
bacliward, while its acetabulum looks more forward ibftu u.-xiul. Thr sym-
phyM* pubis i» hrou^Iit soiiiowhal ncaror to the oppasito Bide, and aviag
to the rharhitic chanj.'e^ the pubic arch i* wiitinnd, while the tubcra
iKihii arc tlirpctcd outward iii8t<-ad of inward as in the Naegeio pt>lvi)^ In
marked easns the HU)M>rior strait a.vMiin<v nii obliquely ovHlf appearance, and
oeea«ionalIy the acetabiilun) on the atfected side may cutne aJmnut in am-
tact with the promontory.
The location of the contraction I'an lie deiermlnwl by <')it(.'mal examina-
tion, as it always lies upon the side towards which the convexity of the
scoliosis is directed. The contnieted side is valueless from an obstetrical
standpoint, and (or prucileal purpose* the tiuperior strait becomes Keocnllt
narrowed. If, however, the Iiead inanagCM to pn*' through it, no fgrtlier
difliciilly is experieneed in its dovQwanl course, owing to Ihc rhacbittc
viideninj; nf Ihe lower }H>rtiou of the pelvis.
KYPH0^«X)L10-RHACHrnC PELVIS
775
Eypho-Sooliotic Felris. — Th& dUlorlion of the peUie will vry accord-
ing m» the kyplimls or the »iMtio«i8 U the pralomiuant factor id the dc-
fnniiity «' Ihe Mpinal <'nhimu. WTn-n tbu forinvr is mon- pronowiiwd, the
jnHviit wit) |>artake of tltc kvplioiii; cUiini<'t<-r, nnd riir rt-tv/t, Wlntn tlio
two di'formities aro upproximatflv cqiml. however, the kyphotic changes
in Die (iclvi^ prcdnminntv, allhou);h Itiv iiiflui-iitr nf the ocoliiwis intAt
to counteract, to a curtatQ extent, the transverse narroirinn of the inferior
rtrait.
Eypho-Soolio-Rhachitic Pelvit. — T!ii# variety n( pt'lriu dcformily hii>
been Bludit-d more particularly by l^eopold and Barbonr. As bmt already
iMH-n |)oinl<.>d out. u kyphosiii dtie to rluiehilti^ i» m-urW nlvrnyv eomplicst«<l
by a scoliotiiH, and the latter nearly always predominates in the production
of pelvic deformity, for the reu>'m that the kyphovif and the rhuchiti« tend
Imuiiially to cniinterai't one »ti<ilticr in their ctTeot ii|M>n ibe irnlviH. Ac-
eordingly, the resulting pclria does not diQer materially from that observed
in Hotio-rhachitis. except that the tvndinicy to antero-poKli'rior flitttening
if> [mrtially coiinleracted by the adinn of the k>-]>hotic veriebral column.
Nevnibelees, owing to llie pmrence of the HcolioKts, the oblti)tie deformity of
»'«. «iA. »-«. nil.
VUm. At£, 616. — KTmO-SrouOTI<vitHJW'HITIV PKLTIIt (LMpotlt).
the superior «trait i^ itxually fjiiilc- markiHl. Generally speakinR, Itowever,
thii) class of (telvifi \6 more favourable from an ob^lclricul »Uindpoint than
that due to wolio-rfuiehili:* alone.
Spondylolisthetic Pelris. — The term iipon(Iyl)ilt>ilhi.-sU {tmaairiv&vKaf,
wrti-tini, aii'i oXiVft^c**, i^lipping or sliding) was inlroductil by Kilian in
1853, in dewribinfi; a pelvis in which the la^t lumbar vertebra had become
displaced downward over the anterior surface of the sacnim.
The d<^Te(! of displacement may vary greatly. Wlien the deformity U
776
OBSTEnWOB
lum-
3
slight tfw anterior inferior niar;:in of the last lumbar vtrichra mort'ly'
j«l* a short di»UliCv t^vond \hv unlL-riiir iiiiir);iii nf the promontory of I!
Mioruni. nliilo in pniiinunroi iamv iho eotin* liixiy of Itio vi-rtt-tiro ii^ ilil
filaced downward and forwani into the pelvic csvity, so tlmt its inferior si
fuw conii-s in contact with and morv or Iii>k c-onipletely mvure tbv body
the first, and occaBionatly ihat of the seeoiwl Mora! vertebra. Ar a w»n«
qucncc, a greater or Icj^cr jwrtion of the luinhur column comos to oecuf
tlie upper portion of lh« pelvic cavity, the itujM>rior titrait assuming a 71%
form rihapi'.
Tin- lower lunihar verlelinB may overhang the pelvic iuki to «uch
extent Ihat the ohi^telrical or pwudo-conjugstc will be represented by
line dranti fi-oni (he iijipi-f margin of itit- tymphysiN t<> the lower margin
the foarth. third, or even second lumbar %-ertebr8, as the case mar be.
llie i^ijtjcimen dwcrik-d by mc
ie:)9 the ptieudo-oonjiigate extend'
t» llif iowi-r mnrgin of tbc ibird lum
bar vertebra and meajsured *>.'» cent
metres, as compared vrilh a diati
of T.fi <N^niiiiintn.>s lo the lower a
gin of the fourth lumbsr.
The displaci'meni of the Iml lam
bar vertebra is dne not to tuxatio:
but to the lengthening hikI bendi
of its interarticular portions. I
inferior articniar processes still
lain their normal relniinn In tlx- «i
pcrior articular proeesws of the 6:
nacral vertebra, whereaw ito liody a]
it« superior articular processes, t
^Tiller with the rol of the vertebi
column, become displaced forward
tmd eventually downward. As a
suit of the new portion aitsurnvd
the binly of the last himhiir verteh
the superior ami anterior i<urfnci*
the promontory become more or lew worn away by friction, the defect hi
not infrequently followed by ankylosis which dellniiely eheekx further di
placement. In advanced cases llie inferior articular processes of tlw> I
lumbar and the superior articular proce.ise.H of the fir«t s«ora1 vertebra
usually (irmly synostoncd logetber, as an* nl-w the inferior articular prof
of the fourth and Uie superior articular pmce-»«e« of the fifth lumbar
tehra.
Owing to the collapve of the vertebral colninn into the pelvic cavi'
the centre of gravity falls in front of in^t^ad of ju>t lichind the ncctabnl
and conw^nently the pelvis must be tilted backward in order Dtal II
individual niay retain an upright po«ilian. Tn olhur words^ tlie pd
inclination must \k: diminislicd, and when the deformity i« mark'xl t
plane of the superior strait l>eo<>nies jiarallel In tlie horizon. This is niB'
Fra.eiT. — VcinicAi. HurnoM THanttuii Si^N-
iiTU>usnwTic Pkilvi* (KUImi].
SPONDVUJUSTHSrriC PELVIS
777
dereil poe»iblc hv chiiD^w in the iUn-fentorHl li^^iiw-nU, which are nuini-
fLi>hil DD thr one liaocl by a markei) rouffhcniti); of the portions of the
polvif (<> wliii-U tlwv «R- allHehod. und on the oIIkt hy cUunwUTii-t if i-liHiigc>i
fit- 1110. Ptg. sao.
»
^
in Ihr |^it of Ihf [iRtinit. In niv "un c«w iIk- pi-lvic iiiclinution vrsn olilitcr-
■ImI; liiit, hail i( rGinained normal, the vi?rtetir8l ciihiiiin wmild liave fnnintl
« right anglv with tho trg«, iii-c««ntating I1m> {Mtiont's going apon All-fouTH.
wbcteMH, ail a matter nf fact, »iw vrtw Me tn irolk i^rrct.
Aa Ute interior eurfac*- of the lat^t lumbar rertebra is in contairt with
thp anli-rior tnMOfl<l of the miiitTirtr siirfiui- "f Hm; firtit »acrnl vertebra, thfl
action of the botlv weight tc-uds (o force the pramontorj of lite mcmm
backward, thcrehy causing it to rotate about it* transrem ajcis, while its
tip approaoh'-H tlwt anti-rinr j»-lvic wall. The retrnjiutninn and rotatioo of
the sacnim. toji^^thcr with the increared traction exerted by the ilio-fenioTal
ligamcnti:. raiws each innominate l»nu to rotait^ ahoiii an axis extdndiiig
froRi the >'ymphy»t.i to tiie imcm- iliac joint, and temld to give the pclviit
a fntutel shape, jnrt a* in k.rpl)oei>^. tho inferior atrait becoming consider-
ahl^ cciutractMl Iraniiverwly and the pnhic arch narrowed.
778
OBgrrETRics
j£tiohifg. — Kiliftn considprcd
TOrtebra was rendered jKH-silile by
Fio. 1131. — BroNi>Ti«Lintittinn; Vam-
mu. Skitiok tmruuuh J.*ar TMMr.r
Lvuiian Vemikiikj! axu Sac»vm.
X*.
Fio. 022. — Kni'Hi-)) xrto FietH I.(-mii«ii
VaRrcanjt man uv Cimk ov 8n>N-
WI.Ut.BTirKBU. X |.
A, miptiriur articular prootai; B, Inwks-
winw |imw«»; C, iiiftTiornrtJnilnr prno-
Oh; /', lAintruL i^f fdiurlh tiiiiiljnr viTli.*-
bm; t^r iiU|H*i'iijr nrlirtjlfir prtKvw^ F,
Infmcirnnlciilariiniruiui: CV, tnm"i-i-n«t
procnn: //, /. J. fixniiH in Inltrarticii-
lar portioD of Uot lumbal nrU'bnt.
thai the diiiplaceinent of the \»»i lumbar
inUaromaton,- soIteniDg of the interverte-
bral disk. Later, rnriuuti h^'potlK'sea we
a(lvtitici.'d iii< to ilK niudi'^ of production
Jlobort, l^mlil, and Kiint^tein fihowc
lliat the dicplsrement could not tall
place so long as tho inferior articular pr
iv*in-A n( Ui<! la*t luinWr were nonnftl at:
in contact wiUi the superior articular pr
cp*w» of lli« fin'l suursl vertebra. uiik-!W
the entire Tcrtebrn became lengtbencd. ^^
Neuf^ebauer devoted thirieen jeai^f
Oft82~So) to ttn- wludy of tbi« mhyvt^
and during that jicriod published 15
journnl ariick-s and 3 inniio^raphii upon
it, covering nearly 900 pages, not
incntiou tho dii^cuoiioDF and deraoostr
tion* in which he toi)k part. He i^howe
contlu lively that in the vast majority
<■««•* lh« deformity wan rendert^d pru
blc hy a lengtheniD); aiid thinning oii|
of lh<- intcrartictilflr ]M>rlions of the Ittf
lumbar vertebra, by whirh its supia'io
and iufi'rior arliculnr procc»L*t« borora^
separate) hy a Umg, thiit Umimi of bnti
ioHtead of being almottt in the aanw v«
ticai liui- (Fig. fi22>.
This condition lie aitrllmted to no
[HTfcft dfvelo]»incDl of the interariicu
lar portion (spondylolysis) or to iU* fr
hiri', with Kubsoqufnt strclching of Ih
callus. Ho wm-idcn^i that tti« fonn«
wan the more frequent cuu»e, an i>e wa
able 1(1 <]vnii>n:>lTHU^ it in niuny vcr
bne wliich presented no signs of spondji
lotiKllii:^!!!;. Wlien the di«placentenl
marked the intcrartit-ular portion ic M
only l<-nj*t ))(.'» cd and Ibinncd out, bu
also ln-cojiHw Ik-uI orer tltv promontoi;
of the sacnini. thus forming a dididii
ky rlii-phtii-fpondt/liu,
to op{)o^!li(in to Neugeliauer's stat^
mont that the deformity alwavs nsalt
from chan^'v In the inlcrariicnlar
tion, Chiari definitely nhowed, in on
cane at loa^l, that it can follow fraotut
of Ihe arlirular [mxi-w'e*' without
cliaructerii^tie rttatigvs in the rertcbnL
SPONDYLOLISTHETIC PELVIS
779
Arbnthnot Lane Ftatud llmt tlio diecKst- ii^ mora common ihan ia getier-
aliy Bupposod, AS he ob»«rv«tl M.-vvral v];u[nplo!> »f il in <Mut-hun\'or)i. He
consider that in sucfa m**x, ut kw»l, tht* L-hungi^ in tbu uitrrurtk-ular por-
tion are duo not to abnormal itii.-« in dovolopnii-nt but to uxctisetve pn^wure,
which nwulu from (virrying h«a\y biir^MM, Onmplote lileralure ii|)on
the xubject will \)c found in my on'n article and in that of Breus and
Kolisko.
Frequency. — NcngvbatuT. in 18i»a. wo* ahic to rollftcl 115 casea of apon-
dylolistbciiifi, moat of which wore clinical obtiervationfi. In 1889. T
collected 123 cases, 6.5 pur cent of which occurred in malu». Accord-
Fra. 833. — FauiKT *>ii> Kal-s ViawR or WnoiAN «nM SroMUtuNJaniKMii (AklMd).
injf to Breus aod KoliKkn only W indisputable anatomical spocimeiu
tif Uiix (y>ndition are in exiatenoo, 2 of whicli thay described for the
fimt time.
Effrrt upon Itdbtmr. — \C\«m ihc cciinlitioii \* but i>lijfhtly marked it4
i-ffvct upon labour is .similar to that of a Hat pclviH, as the fcroatoHt con-
traction is in the evnjuguta vera, ultliotigh it «liould be remembered that
it ia likcv)«c aitmciatol with <-onKid(Tnl>l'' ('•tntraition of the jnfi^Hor xirait.
When the deformity i.* prouomin-ii anil tin- Idwot Uimliar vertebra' over-
ttanfi the superior xlrait, the decree of contraction, from an obstetrical
point of view, is to be reckoned not by tlic diKlanev betwivn tlw i»ym-
phvHtB pubift and tin- aniRrtor jviriioti of t)te laiit lumlur vertebra, but by the
lics^i of tlic pseudo-con ju^te, whoso posterior extremity may bo at the
7S0
OBSTETRICS
fonrih, tliiitl, or even nccntul lumbar vertebra, and m many cases in bo'
i<>lH>rt as abmlutoly to prucludu the po«>iJl>iUtj^ ot tho hv»A uuloruig the
pelvis.
DiagHons. — In typical cases, Di«ro inBpwliou o{ the patient ehouW lead
Eon« to :^it>{Ksct t1ii> exifltitxi' of Ihin ili'fnniiiiy. iDa.tmudi m there U always
narkwl luiiiiiar lordoais and tho entire trunk seems to hare caved in, so
that the rilis conic iilnK)»l id eoiilact with the iliuc crC6t«. When vicirvd
from iho front, the abdominal walln appear redundant out of all prapor-i
tiOQ. Such patients have a pLculiar duck-like walk or waddling K"'^> ^|
which Nmigi-baufT (ir*t dinsti-d alien- 1
lion. Since the poflterior portion of tho»
last lundiar Tcrtvbra rclainx its normal
position while the real of the vertebral
coUinm i«inks fom'ard, the «pino of th«
loi^I luniLiHr vertelira will sometimes
form a marked prominence just aborv
tlw facniin. The oooditiou, Itoweror,]
should not be mistajcen for a deep-|
m-auvl kv[ili«»i«.
On internal examination the diagno-
»\f,a» a ruk-.i« nadily inadtt, aa the body
of the lai^t lumbar vertebra will be found
lyinj; in front of the anterior and Upper
portion of the Mtcnini and will be ie-'
tected when one attemptii to mensure tbe
diogonal eonjugate. At tlie same time
the i!iM-]XH-tin4Hi! line eod« abruptly at
thy margins of the overhanging vert^ral
Ixxly IntU-Ad of continuing unintempt-
edly to the proniontorj- of tin: »icnun.
Owing to the marked lordosis, which
frtHjuently accompanie* tlio oondilien. ■
the bodies of the lower lumbar vertebw
can roadily he polpuCfd and counted, sad
ihe bifurcation of the aorta, or at lewtj
lli<^ comnion iliac arteries, are not infre-
queuily rea<Uly accessible to the cjiain-
ining finger.
Occattionaliy pronoonccd riiaehttic '
changes in the aacnim may aitnulate \
t«pondyloIisthe«is, but a correct dia^iosiii can OKuully be arrived at. If
ach patients he anar«lh<ttiztil. on careful palpation the ilio-pcetineal line*
will be found to terminate at Ihe promontory of the sacrum instead of at|
the flidt» of the prolapsed body of tlie la«t lumbar vertebra.
A somewliat similar condition is pteseuted in marked cases of Inmbo-
ral kyphosis, particularly in iho pi-lvis obtecta. Tnder surli circuni-
Bces the promontory of the sacrum in destroyed, but a eomect diagnosis
can QHually be nuido by carefully |utlpa(injf the anterior surface of tbe
Jjpk BW.— Side Vrew o» n'muAN wmi
ltUTLl>LJIfTKr»tn.Bllon'IXU PlUUETT-
' IMO SviKB OP hjun LvuuAa VisutKniu.
SPOXDVLOLISTHETIC PiXVlS
781
acrum and tradng the nlw to the body of tiw firnt saxnl rcrtvbra, nhkh, ot
t>urw, is iinpoMtiblc iii tpoiidvloli^lbesis.
Prognosis. — GentTally .-[H^akiiig, ^jiDnliuieotw laboar can occur only
Iwhf-n the deformitv is Jiiinimal, and miordingly, in jironounctHl cst*w, the
EOuUook is uniformly bad for both mother and child iiiil««s ra<lical opera-
jlivv meamires bt; undi-riuki/n. Other thing)' bving t^iuil. n itpoudyloli^thctic
elvifl ofTers a wor«e ])ro;i|^oitii thmi s rhachitic one vilh ihe itaine antenf-
[jKMtcrior ni^a^urrmciit!-, for the reason that in the former the inferior strait
lis contr>i<'t<-d, whilt- in the latter it \i usually onlarfCM).
In considcriog the prolrable oatcoine of lal>our, one should not only
ftnoa^urr ihi' diNtancr bctuitcn thv i>ymphy>iii> jiubis and the lai^t lumbar
vi?rtebra, but should alM> estimato tlw piteudo-conju^ate, inasmuch as the
latter mnch more fmiucntly than the antcro-poi^tvrior diameter of the supe-
rior strait oKen tb« gn-jile»t obstacle I« latjtiiir. Tljt- fml thai u patient with
BpondyloIiBthcsia has bad one or more apnotaDeous latiours does not neces-
trily itn)dy that Ihir labour in qut^tioii will Ih- uneventful, for Ihti rmmn
bat the deRfee of deformity frti]iienlly increases with age, as was clearly
■on.<lral<i) in my ovrn ease.
' Trtatment. — With a pM^udo-con jugate of 8 cflntiin«trc« »r over, tlic po*-
■ibility of Epontancous labour, or delivery hy forceps or version, Ehoold he
ome in mind; but when it falli' Iwhrn that limit C'w«ttrt?an *«tir>n ^ibonhl
done at iImj onset of lalnur. Syuiphyseoiomy does not seem applicable
1" the condition. It certainly proi-ed incffeeluiil in Morisani'i" «i«*. a* well
^fts in my own, having been retried to in tlie latter only after the jMtient
had persuleotty declined to submit to (;»ear«an section.
IJTKRATUHK
BBDDn. Spioal Detormity iu ttttlaiiun la ObcWirics. Edinl»i^, 1K83.
unMEK Dr CiirDiLJkT. Iyi>i;[sx. Abr^ de I'art dra arnnichmM-nlii. I^ru. 175{l.
iHEiaKT. I'obor iten KinftiM* tt«r Kypbmw auf die BoektnguUalt. ZelUchr. dor <■'•>-
der Aenle ia Vi'iea, i, lUa.
\WMV* und K(»j*K<i. Die path. Bcclccnfonncn. I90Q. M. ill. I. Thnl, Spondvlcitw-
thMiM, 17-159. Kyphrmn- Reckon. 103-W7. 8lKillaseii-Deolc«n, 311-302.' Ky-
pbMkoliaaEn Becken, .LU-SM.
CHAMrVETK. Tb» Ob«totri«a oi tha Kyplmttc Pelvit. Trans. Ixukd. Ohal. $nc, IIIS3,
XXV. 166-194.
CVAinSKVlU fituds »ur lea AHonaaXiaa* du bsiMii cfact leu eyphnliquo^ TlWae •!»
Parii. IB«g.
Warl Dm Aetiologic uod r«nciw der Migeiimantcn SpomlyMirthMii lonibo-mcmlia.
ZmtEwfar. f. H«lkuBdB, Il«3.
DdK-mK. iVai FoU too eonauvativea Kaiaeracbiiitt. Zcntralbl.i. iifIL,, XWi, xvv,
630-633.
FaMUKO. Fdri« obtoeta. Arehiv f. Oya.. 1872. iv, 1-33.
HaaBOOTT. D<i xpoRilylis^tae. .\niliivMi de tooologic, 1B77 (F£v.-U>n1.
X. Ds spODdyloii'tbiMi pavWtD» palvaagiMlv caum nupar dauela. Bonn,
IS53.
Die Qrburt bcJm kypbotiarben Beekea. .\reUv t. Oyo., IWM. I. 1-128.
K&HloanDi. I^tateb-ungnvdaa iffondylolutlietiacber Becken. D. I., IttaHmrf. 1K7I.
amnan
782 OBSTETRICS
Laubl. Das Wesen und die Entstehung der SpondylolisthesiB. Scanzoni's Beitrage,
1955, iii, 1-77.
Lane. Some of the Changes which are produced by Preaaure in the Lower Fart of the
Spinal Column; Spondylolisthesla, etc. Trans. Lond. Path. Soc., 18S5, vxxvi, 364-
378.
Leopold. Daa skoliotische und kypho-skol. rachitiscbe Becken. Leipzig, 1879.
Wratere Untersuchungen iiber das akoUotiache und kypho-akol. racbitische Becken-
Archiv f. Gyn., 1880. xvi. 1-23.
MoiUBANI. Ancora delta Sinfisiotomia. Annali di oat. e gin., 1B86, viu, 345-391.
Neuobbaubu. Zur E&twickelvmsgeBcliicbt« dea Bpondyloliatbetuehen Beeksua und
seiner Diagnose. Halle u. Dorpat, 1882.
Spondyioiistbena et apondyliiime. Paris, 1892.
Die heutige Statistik der Qeburten bei BeckenverengeruDg infolge von Ruckgrata-
kyphoae. Monataachr. I. Geb. u. Gyn., 1895, 1, 317-347.
Robert. Eine eigenthiimliche angeborene Lordose, etc. Monataachr. f. Geburtak.,
1855, V, 81-94.
RoKiTANSKv. AnomaUen der Gestalt des Riickgriits und seiner Tbeile. Lehibuch der
path. Anat., IIL AuR., 1856, ii, 162-172.
Scbhubdbr-Olskauben-Veit. Lehrbuch der Geb., XIII. Aufl., 1899, 649.
Treub, Kecherchea aur le baaain cyphotique. Leyden, 1889.
WiLUAUS, J. Whitriihie. a Case of Spondyloliathesis, nith Description of the Pelvis.
Amer. Jour. Obst., 1899, xl, 145-171.
TAI'TKH XXXVIH
PELYW ASOMAUES RK.fVLTIMO FROM THE ABXORMM. DIREC-
TSOIV OF TUF. FORCE BXF.RTF.D BY THE FEMORA— ATYPICAL
1>FF0HMITIBS
XoMUALLY, Ju tbe cafle of an indiTiiluid xunding erccl, Uiv iipvtiril un<l
inward force viurkHl bv the fcmnra i« of ctjuul iDtcnsity on either side,
UD<I i» lfan«niitli-(i to iIm pclvt.-i through t)it- iKitinbiilu. Iti vrtlking ur
running, Uie entire bod; vcight is transmitted altemately first to one uul
Uivii to \\w oXUvT \Ki. On Die olher ttand, iii a pvDon i^uircriug from
diiwflHC AfTit^ting nan Ic^, the iioiin<l one Iia.^ to \te*T moro than it.i tiliare
nf the body weight, und conxxiucDily the upward and inward force ex-
t-rtixi bj the femur i«. tu a rule, grvutcr upon tliat itide of the petvix.
To thate mechanical factors are due the chao^ in »hape which accom-
pany certain form» of lamcfUJM, provided that the lo-ion, which givus T\fc
to tlH' lattor, appears at an eartjr period of life while the pekic bones are
still in a formative i^tate.
The defect may be eith«r anilaleral or bilateral ; in the formtT case
it 18 usually due to coxalgia, luxation of the femur, tnfunlile paralysis.
I^. ASA.— A. DuaiLui ■ikiwuki Oixauuc Pklvm ncniwt rati IHBUVDMrai. itu Wam(K(».
B. DiAUOAu HiowiMO tJMuuiM: pRLvn *mM tn iMoivnrvAi. HAS Waucri (TMDiur).
or iihortening of one le^ from varioDH cauMio, while the most common
canscf of the latter an^ luxation of both femora and double clulvfoot.
Thew conditions have been studied in detail by Prouvost, in vhoae article.
M wdl a« in the chapter of Tamier and Budin opon the subject, foil
lileratare U to be found.
784
OBsrETTRICS
f elvie Dcfonuitiei Dne to TToilatertl Lameness. — Coxatgia occnrrmg in
early lifo iK-urly ulwavft give* rirt? to an olilicim-ly contracted pclviH. If tl»
ili»«n»c makes itn npiionrnnct- iH^furc tin* |>n(k-ni Ic^inis lo wiilk, or if the
child ifl ohliged to keep to its bed for a prolonged period, definite clianfies
occur in ihe pelvis a» a direct result of tim dii!«iidu. Th4»c ura in grcst part
F1K.6Z7.
yiOK fl20-<i2II.-
l^g. OS.
t'oxtiatc fKl.riH. vim Anktixhicii ("kmck.
alropliic, and Hre iiiiinife!<ted liy imperfect devfilopment of (Ih! dtsmsed
aidu of the pehi^, the iniicimiDitti- bone bi-tng smaller thtin its fellow and
the ilio-pwliiicul liiH' rej)reBeiiU'd l>y the are of a circle having a smaller
ndiua than upon the well side. At the same time, th« sacral alie are Itet
developed upon the afTtHrkil Kide. and the entire bone i^i somewhat rotated
about its verticil] axis, no that iU anterior surface looks toward.'^ the veil
flid« (Fig. din, A and Bl.
When the individual begins to etaud. owing to the actual shorting of
the diwnsed leg or to fear of placing it firnily npon tlie ground, the body
weight is (ransmiitcil In great part I« fJie well leg. A* a result tlte pdvis
'becomes oblifjiiely lilted, being higher on the well side, and n c(>rnpen*atOTT
seoliosis appears. At the same time the upward and inward forrc ritertetl
by the fomnr tend.* to push the well side of the pelvi* upward, inward,
and backward, whereby the ilio-pccliueul line is markodl; flattened and
PEL\1C ANOSULIKS DUE TO UMLATEKAL LAMENESS 785
I
the aiyumetrj of the sacrum still furtlwr increased, thus giving rise to
in o1}li<)uel]r contractnl pclvin. The (»ntniction iit not limited to the supe-
rior strait, tiut invoUe.1 the lovrer portion of the pelvis as well, the spine
and tuberosity of the iK:hiuni b«ing dis]>luccd towards tlw middle line.
Not uncommonly lhc*c chnngu» arc aoconigwiiw) hv in-itmivi! procecie*
mt the aacro-iliac artii^utaltons, w)tic}i erratually lend to anki'tosis. Aa a
general rule, the obli<iue contraction is to be found on the well side of the
pelvic, bttt, according to Tamtcr. tlic rcvereo it, the raiu; whvn the affected
1^ is ankyloseil in a position of aildiiction and intcniAl rotation ( Fig. GiS).
Similur though l«#« marked chsngps take place in tiw pelvis wh«n
uniUitrral liiiatiitn of Uie fentuT occurs in enrlv life. tJnder such circum-
E-'ig. 031.
Fioa. 839-6S1. — Oinjgim.T CbXTULrTEc PiiL*n. Dw to i;K(i^Tiaui.Xvx*TiOK or ('^chvk.
■tancCH the ticad of Uic bone is displaced backward and upward upon the
outer surface of the ilium, where a n^w joint nurfiire tnay occa^ioniilly be
formed. Tl»; affii'irtl lig iHtinmw wii-*ii1enil»ly chorloni'd. and act-ordingly
an undue share of the body veigfat ia transmitted through the well leg,
786
OBSTETRICS
which forc« the carn.-s]x>nding »i(le of l)i« iielriK upwont. inward, SDd
bnt^kward, »n(l loud.i 1» an oblique contmctton, just as tu coxalgia.
lu unilateral infantile panlysvi, find iu tiiotx> (ul>(s. in nltich <lta«aae at
t]itt kii4>e- or ankle-joint, or amputation tias csusod eliortoniiig of od« 1^.
unless the patient ha* liad llw iH^u-lit "f pr«|j<-r orthopipilio treatint'nl,
einiittir i.liiing<« iKrur in liie pelvis, though it rarely awiumea the eitrenic
degree of obliquity which chnnictcTixe» lh« (Mijittlgic Tnrioly,
Piagnwi/i. — A limping gait at onne Fuggeatt) an obliquely contract^
I pelvic, and when, upon quii^tioniDg tho patient, it i« found lltat tlio condi-
tion his Ihtii |)ri-srnt since early ehildhooii, ilie I'xisienCT nf pelvio deform-
ity npon tlie side corrffipouding to the pound leg botonies highly prot>abli;.
More ac-ciirutt! iiifnrmatiun ean he ohtainal !iy eareful examination and
noticing the relative position of the iliac cre»'t* and the presence or absence
of i-oiii[H-iisatory Mi>ii(Mis. and finally an absolute diagnosis can tho arrived
at by the employment of tlie nicaKureiricnls siiggi-jitcii iiy Xnegcle for the
(it-livliiiti "f till* ohliquely contracted jwlvi-i due to imiiorfecl dcvclopini-iit
of t!ie sacral alae. An accurate conception concerning the degree of con-
trnetiim. linweTcr. can l>c olitainod only by onrcfiil exploration of the
interior of the pelvis, preferably with the patient under the intUience of
an nnn-sthilii', although in mimy coxulgii; palientji thi» may be extremely
diUtctdl on account of tlie ankylosifi of one leg.
Effefl upon Ijabour.~~The effect of thim clas» of pclvwt ujwn Inboor
varies with the extent and position of the deformity. If the affected side
h so contrui-lrd an In prevent its being occupied by » |Mirtion of the
presenting jiarl. ae have for all prai'lical purpose^; a generally contracted
])elviH, and engagement, if it can occur at all. will take place more readily
wlion the hiparietnl diameter of (he limd i» in relation with the long
oblique diameter of the superior strait. But ex'en after descent haa oc-
curred, III! olwlMclfs to Inbriur Imve by no means been overcome, sinci- in
many cas#^ the inward projection of the ischium may lead to almormalitie^
in rotation, (lonernlly speaking, the.*i' pcivc»i are not c)ccc*«ively contraclod,
I'rouvost reporting that 40 out of the .>0 cases of labour complicated by
Ihcni etiilcd sptiiUfincously.
Trmiiucnf. — As the pelvic contraction i.i usnally not %*ery pronounoed.
("a'.*nronn »-ction is rarely indicated, unlc«i the f<etus is very Urge, or the
histoiy of previous lal)ourit ha* «hown that the hlrlh of a living child if
out of the question. When the oiistacle to the engagement of the head v
not Bcrions, vornion givm iHtli-r ^■»u!t* tiian forcep*. This t* esptxHally
true in coxalgic pelves when the ankylosed !^ and the asymmetry of the
puhic arch may make il« proper application practically impossible.
Symphvseotomy or piibiotomy is never a jnatiilahlc npcratioi) in these
oases, particularly in those due to coxalgia. as wo have no ineana ot
determining in advance whether the sacro-iiiac syiichondrose* are syno*-
tosed; and if .lueb bo the case the operation cannot lead to an increafc
in the capacity of the pelvic canal.
Pelvic Deformity Ihie to Bilateral lameneu. — Occasionally cJuldren
are Imni with luxat'wn of holh ffmiira. the liiiuls of the l>"nc« lying, at ■
rule, upon the outer surfaces of the iliac liones, abore and posterior to
PELVIC ANOMALIES DUK TO BILATERAL LAMENESS
787
il ejliuitjou. Id tome cases the acctabula are i-utirdy sbMnit,
l«it more friiim^ntly the.v art- jmx-Dt in a rudiiiipntary ondition, new
but iiiii>erfi'ct substitutes bciog formed liigla-r up. Siraiigi' to *»y, Uic
condition iIw-k ni>t usually iioriously mtcTfeno with the iodividoal in the
□lutter of Icaniin^ to walk at the uaual np>, though tli« gait ie iiivro or
l<wji wal>|}|y.
TImj pelric changes r(-«u!tin(r from tlii:< <widitiini liav« bceu ^todiod
particnlarljr by Klcinwiichter, Srlauta, and Kaiumaiin, ilit* latn-r wriii-r
haTiDg collected 27 caaeA from the lilcratiirv; Oirtng to the fact that the
upward and inward force
cx^rtetl l>y the femora in
Dot applied in its ufiiial
direction tlirough the uci-
tabula, the pelvis becomes
uniluly wide, aiu) mom or
IcfS DatteQed antero-jK»-
•ieriorly. TIkj transviTM,-
videniDg is partieularlj
markftl at tiw inferior
strait, while th« Hatien-
ing, as a rule, is not very
pronounced, llmi, lite
ooDJugata vera usually
iMAsarffi between 9 and
10 rontimetrcs, and in
only 3 of llic v»*v* col-
lected by Sassniann was
it as short as 7 cmtiaie-
trea. Hence, as might
be expected, this pelvis
rart'ly offer* any serious
obstacle to labour.
Tlie intient prescntu a
characteristic appearance,
which is Ku^'/estivc of that
.obsened in spondylolis-
\tt*i*. Owing to tlie dis-
plftcenienl of the femora
trochanters are more
>niincnt than usual, and the width of the hiitti>cks is increasal. At the
«n)c time, owing to the incrwise in Uie pelvic indiiuition, ihi're in marked
ardosis, the back of t)R- pati«fit appearing considerably shortened and
inventing a markerl saddle-shafted depre»aion just abovi- tlM saemni.
According to Schauta. Clever described a pelvis obtained from an intli-
tdual who had d-iuhlr rluh-f"ol, and found tliat it was niarke>lly funnt^l-
aped. This condition he attributed to the sl»sc»ee of the usual spring
11 tiw foot and ankle-joints, awl to the fact Uiat the knees were Iidd Axed
luring watldng. AocordiDgly, with each step a distinct shock was imparted
Vta. 032. — Oiiia akp Riua View nv Patikmt wttm
BOjtnUtAL Lt-XATIOH or i-'OKNtA.
788
OBSTETRICS
to the acutabuld, instoftd of the mora gentle force vhicli is eseiied under
ordinary' circunifilancf?.
Atypical SefomiitieB of the Felria. — In rare instancea the pelvis may
be more or leas (Iffonntd by tht- pmseucc of Lony outgrowths at Tarious
points, aiitl K-<^x frvqti«nt)y by tumour formations. Nxogiosts are iiiuaI
fn%)u<.'it<ly ohiiencd upon the jK>st(!rtor nurfaoc of th« sympli_\'Mis, in front
of tlie sacro-ilini.- Joini-t, or u{Kin the anterior Hurface of the sacrum, tlioiigli
in ocoaAJojial canes th«y may be foroK^d aloug tho coune of the ilio-]>ec-
tiiieo) lino.
Kilian, in 1854, dirttfted attention to tho fact that sud» strncttin** may
form sharp, more or Ics^s knifc-likf pnjjcclioiiN. He deeiguated the condi-
tion as taanthnpe.lifi or jieU-is xptnoxii. Such forinationit arc rarfsly «ufii-
ciciitly lar^ to olTcr any obstacle to labour, but owing to Uwir peculiar
structure may do consiilcraUle injure* to tb«> iiinternal Moft partn. in fiKt,
in several of the cuew reported, they harp cut through the lower portion
of the uterus.
In rare instances callus formation, resulting from inflammatory pio-
€!ef»e» within the p«!vi.i, niny iittAin »uch )>n>iiortions a« to lead to serioiH
pelvic ob*tniction, as in a case reported by Ahtfeld.
Tumour fnrmatUinii of viiriou* kind* may spring from the walls of tbc
true or false jiclvis and so obstruct the pelvic cavity as to render labour
impoesible. Fibromata, osteom-
ala, enchondroniala, carcinomala.
and oBteosarcomala of the pdvis
have bocn described, and sonwv
timea asaume very (<oni<id<'nih1e
proportions, and occasionally bc-
eonie cystic. Slailfi-ld wan able
to collect 49 such cases in 1S79,
and Coder HI cftts in 1K9$.
Knchflni]romata occur mon- fre-
quently than other varieties of
tumour formation. SchoppineWiiif
■[.^^^■^■^^■^■^ \ able in 1007 to collect 3.1 well-
v^H^^^^^T^H^Hv fc_- de.-^<'ri)H>d caxt-jt from the literatan',
^' "™ '^■^^■l* ^^to- ^ u^, poinjej (,|j( that sneli tumours
^row (s^pecifllly rapidly daring
prefrnancy and give rise to wrioii*
dv'^loiia: 31 Cesarean sections
and 3 destructive operations bein^
n«cc»«ar}' in his series of (tasN.
The prognosis !s very gnm-
when the pelvis is ol>stni<:t<il by
tumours from its wallg,50 per cent
of the toothers and 8ft per cent of the children having perished in tho c««»
collected bv RtadMd, while in only U cases was labour terminated by spon-
tanenus delivery, forceps, or version.
In rare instances, healed fractures of the pelviii may oiler an imnipcmbli
FlO, B33..^<luBTmit-noK or Pki.vic Panai. iit
Onru: ENcnoh-DiiowA <Zi»lf(il).
ATYPIC.U. PELVIC ANOMALIES
786
do to the hirth of the <'hilti, nwing cither lo «ii eiccesfiiT« formatkin of
ralluK f>r i'> ihi- jinijwluHi nt the bmken I'mii* of tlm bi>rn» into IIk- ptivic
cavity. This condiii"!!. liowvYcr. if rvry rMrc, a» it is staled that ouly 0.8
per iiiit of all fractures
i]iv<flve the pelvisi, aiii) in
such caiKM the internal
»ilijuri«!t art! ii»ii»llj- w>
Pia. 034.— FM;u.-nwKO Pu.tib (Man).
eevere as to lea*! to the
itvftih of Ihc patiflDt, M
tliai only a unall propor-
lion ot Kuch women sur-
[■ri^'e, ami very few of
liein bvKioiiitt pregnant.
The efTent upon la-
iiir i1<-prn(Li tipon tlio
aliun of the frat'lurc
11(1 it» manner of hoal-
ig. Fig. t^t4 iihowK a
Iris (leticrihed by Mars, and Kices an idea of the extent of the clumge^
which Miriii'liiiif'' r[r*i]11. In a cjw n'|Mirii-<I liy X>-ii(;i'lmuiT. in which Hmto
was a transverse fracture of the seconil Haeral vertebra, the vertebral cotuinn
pmUjiMil into Ihc pelvic cavity and gave riw to a dt-formily suggestive of
^pondyloliritbesiji. Kor further details the reader ia referred to the articles
f Sciiauta, Taniivr, and Mcun-rv.
LITKR.MirRR
Dm dnreh Knociwiuiuawiiirtun vcnmxte BMkcEit. Ijehrfaunb dec Oeburte-
buUa, II. Aiill.. lItH8. 33ii.
aoKB. Vmi deal B«<fcen aiu^ehende Tumanin aJu (^btirtahiwImiiiMk D. L, UaUei, IS95.
(lUkM. Du .StnrJicilwrlMi (Akwltliopalrii) 1 Arhitdeniiicui Muar Bock«idaniwR, <tte.
Maniihvira. 1KS4. .IV-llt.
^JCuuxvAnrrxK. t>tui l.»u(Btiianiibcclcen, etc Prager Viertcljalnwcbr. f. Hcilkuixfe,
osvlU, rxix.
SehrDgverciigtaa Beekcn in/olge einer t'roietm. .ArcUv (. Gyju, IB80. uutvi,
i;aKH». BdbBS nir eeb. Bedoutung lUr Fmkturt>»rfcen. I>. L. R<«dalIierK. IMt.
■iwT. f:nid« Mr Un baMiui rjeW* par boltwi*. ThIW de l>>riii. IKIl.
B.uMUANH. Ilttn Itwiien bei anptioruiior doppcJoNltgvr llafl^lcnLiduxation. Arobiv
f. r.yn.. 1S73. v. 241-287.
BauUTh. Mriller', >Ii>iiil1>urh d. Ovh.. ISm. ii.
Di« Rocluinfnmicii bi-i <)u)ipi:lH-i tiger Luxation dor S«fannkelk0]4e, 160-472.
Die Beckwdotm b« KluinpfiM, 472-irj.
IBcNorPiMj. !>■« Bockm-oni^bniidrom. bcMindent al* Gebucttliitwlcniia*. Muuat^Bchr.
I t. Ocb. u. G>ii. 1907. XXV. Sl&-fr74.
^u>TOji. Die (hibort bed Gewfairubtiea dea Beckeiu. ZeatndbL L Gyn., IBflO, iv,
I 4I7-42U.
Takxiks «t BVMS. TniU de I'art dea accoti«lietiMnl& Pui*. ISIM, Ul.
MaUonaalioaii ilu tiawiin itan* la daudicalkm 229-27B>.
Dtf anaaliana atrpilUM du buein, 33ft-3&2
S2
ciiArncK xxxTX
DYSTOCIA Dl'F. TO MiNOnMAUTIKS Iff liKVKWPMEST OR
PRKSEXTAriOX OF TIIK Fif:TVS
Exceuive Development. — \i^ waa elukt] in C'tiaplor V. tins t-liili] at birlh
rarely e\Li't-ti.-> 12 jioiinil-i (ri.tiOO grnmimv) in weight, tliougli auiheniic
accounts of mtic-h larger infaut:^ arc to bo found in iho litcnilura.
Provi(i«i ihf [K-lvi* is mil (••HilrHitt'il, it i* very s.vi-epliontil for a niir-
mally formed child. neiiihiiiK t»s than 101 pounds (J.OOO grammeii^), to
give ri*c to dv^twiu bv it>i nifn.- sini.'. In oTi'nU-vvInjji'd diiMroa llie diflV-
culty is gfinprally iIup to the faet th*l the heati tends to be«>mc not aaU
1argi<r but hardiT. and conw^sjufnlly kns iniilU-ublo with infn-aKinjr weight;
although it -■.oineliriii'.-' Iiiippiiis thiil iifler the ht^nd ha^ juasned lUrougfU the
pelvic eanal without dilliciiliy the dystocis may be dut- to llio arrest of the
unuxtially lurp- rfiouldcrs eilht-r ftt Uie pelvic brim or outlet. On tlie othei
hand, when the pelvis is abnormal, great difliculty may be eiperieo«d io
delivering even moderately siwd children.
Kxcf>'»iv« d('vili)imu'iil iif Iho fu-Ius ean usually be traeed In one of
four cauries: prolon^'ation t^f pre^aniry. large eizu of onv or l>oth parental
advancing ag<:. or mullifjurity (if tlic mother.
t'ases in wliidi thr<^ hundred days or more elapse between iHe Uti
men^tnml jx^rioil and Ihe onset nf lulmiir arv not uiiLMtimton, hut in tbt
majority of thcsi' the prohmgation of pregnancy is only apparent. ««!
merely meanB that fertilisation of the nvum look placi; just Ijcforc llw first
)N>rini1 mii>si-<l, iu«t<-n(l of Kliortly nf ler ihi- IhM menstnial flovr. On the Other
hand, actual pi-olongalion is ortasionally ob.Hcned. and is liable to ex«rt a
seriomi influence njwn the course of laijour. inn^much a* the chihl inirea.**
Bleadilr in size for every additional day it ri'mains in the nterus. ArcorO-
ingly, whenever it seems prohahle that gestation has gone on lieyonil ihf
normal h-rm. the patient should Iw carefully ciamiiuil ai fn-4)n4-nl inli^Ttals,
so that labour may he imlmiil a» si«>n hs there io any sign of disproporttcai
ln?twirn the kIkl' of the head and the pelvis.
More fr«]\ientlY the eJtoe»«iTc thv of Ihe child ix dne to the fact thai
one or both of its parents are unusually large; moreover, it is a matter of
common observntitm llial Ihe fcrtal head in many instanc*" rt-semlilc» lh*t
of its fatlKT. large-headw! men usually proilueing children with similar
characleriitic-*. The n^.t- of the mother has likewise an imporlAnl influ-
ence upon tho ftetal developmenl. Thus, the chihlren of elderly priruipane
often exceed the onlinary uvcr^gr, and in multipara' tlio children are ofluD
7fK)
DYSTOCIA DUE TO EXCESSIVE DEVELOPStENT OF FXETUS 791
»r||(4>r with each «ucuc««ir« prcgnancjr, provided th^ do Dol follnv in ton
rapid HncvvMKiafL
A« n rtik-, Inrf^'-lipadcd ohildron Iiatc liurd iiid wdl (Hi6iri4>d )i(mii1>;.
Tbia in inon- j>iirli<-ularly irm- f>>r iiisUrH, in uhom (li<> biptirmsl diaiiielvr
t« u^tully ramovrhal f^ri-atcr lliao in ft-mulc clntdrvn of Ihc tame vrei^ht. In
auvh fwet the inability' of ihc houd Id bflcvnie iiiinildi^d iii>t oiil^' iiiierferei
villi itfi eof^fiomeni, but predi^posen ta ccrlaio injiirim, siicli an upoon-
dtapcd dcpr»«j'ioi»it of iliir i^ktdl, wlicii artifitrinl delivery Ihtoiik* noc-
eatmty.
Althnugh in lh« raiip of a normal p<?-lvig a modoraCc incronsi^ in tho s\ns
1 the rhild is usually williout gmt jiractieal .iij^niliciuiiw, whttn any dc>EnH>
of cnnlraclinn exi«U inich a condition may make all thi' dillcrenoE) between
an caiy and a ditticull laltoiir. At tb« sain<' lime, it mii^t In- ritincndiL'ivd
llinl in m)illiparoii>- uonicu the dystocia is often dne in Rreat part to the
lotw (if liitK? iif lii4- titorint- inuM?utature incidont tn rvpt-ali'd cIiiliDx-nring.
Inasmuch an we poiwees no perfectly Hatisfaeton' nteana of determining
iV xize of tl>e child, and parlii-iilarly of its hoad. the di^;n««ii! of cxciiwirv
development ii*. as a rule, not estahli.^hixl until after fmillew atlempls at
iWivwy Imivo Ix-cn made. \cv«;rthclc»i<, a careful routine examination will
often enable the obstetrician to arrive at fairly aoeuratfi concluflions ami
inrparc him to nirvl thin complication.
(ienerally iipeakin^, if the pt^lvin in normal, tho failure of enfragnment
■4hp la»t wevki; of pregnancy in a primipara. or the existence of a face,
', or tr«nxv«rM> preHeiilaiion xhoithl ^un^*t the pnthnbility of an ex-
cessively lariie bead. Accurate bimanual palpation fre()uently conflnns
mcli u "uxpicinn, (VfRx-ially ulieu Miillcr's niiHhod of inipTUfKion failt tn
cauAc the hemi to enter tlH> pelviii.
Trrtitmrnt. — Owing to the diflicuity of clinching the diagnosis, tho
liiient is usually very un^a I is factory. If the ]>atient ha^ gone Mreral
peke beii'ond term, and examination kIiowb that the bend is probably exoes-
ively Inrjfe. llx'n- sboiild U' no lu^ilancy in llitt imnioliali^ iudixtion of
labonr. tl»o operation being particularly indicated in mnlliparotii- vomen
hfhW history kIiowk ihal cxf-pwive fwlal dcu-lopment W0» tin' caune of lh«
ireviom ditlieult labours. Ou tlu> other hand, if the pregnancy U not pro-
lyl, the condition is rarely mspected at the outlet of labour, and llw
iagnosts i^ maile only after Xature ha» kIiowh thai she i-* unable to effect
elivery. In snrh cnsw il is nflen very difliciill to detcrmiite upon llic
>t method of denlinK vith Ihe complication. If can-ful c.vaminaiion
'lows that the head is excessively large and well iic«ineil, tlie advisability
if Pa-san'an section or puhiolomy may Iw eonsidcreil if the patient is in-
meely desirAi* i>f offspring; tlnui^b il ihoidd be remcml"-rftl that, owing
the manipulation): which have U'^ualty precedeil il, the pro^"***''^ '* i*"*! *"
vouralde as in frank nwe^. and a<'eordingly the operation has only a lira-
ti-d fii-ld of nM>fulnc<4s. In moiit case*, however, wlien delivery appear*
pcrative. better results are ohtainn) by version than by llw employment
if foreeps npnn titp freely morahle brad.
When llitr iiliKiaele In delivery i* dtic to encewiye size of th** sbnutden
rartwT than of UwlK-ad. labour can often readily Ik^ terminated after dimio-
792
OBSTETRICS
i#hiiig l{i<> Kixo '>f tlii> it1iou)<liT jtinllc by rnttin;; tlmitigh ttw plnviclo^ with
a pair of ln'xw seiiwor* — cMttolomy.
HAlfonnatioDs of the Tains.— OmibU .Uiiin^tfrx. — Knr jirHi-(i<-iil pur])nMS
il group)i of <limijlc t[i')tisUTK iiisy Ix.' ijistin^iuhed: (I) incomplete dcuMe
f<>rmiitiim« ut tho upper or lun-tfr h«lf of lliv bodj (dijirotmpus, dipajrus);
(2) twins whirti are unitnl tOigether at llio iipi'M'r or loWer ond of th« body
(craniopiij^*. i§rhiopapi6, or pygopagus) ; (3) double luonsters which am
liniltHl bv (Ih- tniiik (tliornvnpHgiis ai)d (lici^pKalun).
The diaguo^ia of any one of these coiiditiomi is not made nntil the seri-
otis ctiffieully vX|KTifiic(<d in utlrniplin^ dflivery hnc ktl to earefut L<^xplorfl-
tion nnder amesthcsia with the entire hjind, allhoiij;!i in many cases the
existfncfof » multiplf prcfrnaitcy may hnw l»wn nuspwlcl. A* i:»ch moo-
stro^iiie-H fr»-<iuently present minor deformities as well, the deleetion of a
rlub-foot, hurt'-lip, etc., should alwayis dirivt oiifV utlcnlion (o (he posnibb
exisleD<« of ftoine stilt more serioiix abnonuatity.
t'orlniiately lh« delivi-ry of many monnlroKttiw I* miich more readily
arcoiii|ili-l3'il ilmii wdiili) ap)H-ar ]>OK'^ilile at first si^lit. In the fir^ii plrnv,
«icti prepiaticicw rarely go on to full term, fo Ihiil IIk- nxm^itroeity PiMy
(•xcfeil* II normiil child in sixe. Jq tiie Heeond place, the t^nnwtion be-
tween the two halves is often of such a characttT a^ to permit of Enflkicnt
motility Ki^Iwecn the component parts as to make their auccesstvo dclivm
possible.
On tin- "IIht liuiid, in the flr»l, group Iho large sia> of the douhlnl pir-
tion of llie nioneter may lead to serious mechanical ob«t«cU-s at the time of
delivery. .I'hc fuiHil head in a diprosopus i». no a rule, much more rendily
lii'litcml wht-n it forms tin* after-coming part than when it prt?wnL« pri-
marily. In the sucond ^nxt)). a craninpagu* prciwnting hy the head u.-uallr
«iiu*><« only^ a nioihTale amount of iliiliculty; wbi'reait, on the i>lh«>r hand.
iarhxopagl and fiygopagi. aii a rule, call fur coniplicatctl and dilltcult maniTu-
vrOB before (h-liv<-ry I'jiii bi- oITci'IihI.
In the third group, the liclivcrv of direplialic mon'tent is fai'ililalcil
when Ihcy present by the bri.Hith. us in miiny caMst fiml om- uml ihMi tlw
other head can Iw estractcd. On the other hand, in cephalic pres<mtalioo*
the two hoodit may mutuully intcrfitre with one another ami tliui< pm-«»
engagement imlil one has been diminished in size by craniotimiy. VTbra
engagement of one h<-jiil iM'<iirs. di'livi-ry can In- partiuUy effi-i-ji'd hy forwf.
but as a rule the bead cannot Ix! delivered beyond the pubie an-h, (or tbf
rca»M>n thul further de^'ccnl in prevented by tho Brnut of the sevond hiwl
at the superior strait, Tnder such circumstances it is advisable to ampa-
tato the first head. afdT which delivery of ttie rwst of the monster is, w a
rule, bast aecomplishod by version.
Thomcopagi usually otlcr a Iom serious obstacle' to delivery, (or (he
reason that they are fn^picntly «o loo«ely conne<-ted with one nnotbcr thai
considerable motility is possible. Indeed, it is not unu!-ual for the two rfail-
dren to present in a dilTerent manner. ftTien possible, it if ndvisable tn
bring down all ^our feet at the >uime lime, ami to elFccI extr«ctinn in kiicIi a
way tjiat the posterior head is first delivereil. In cephalic prcs^-nlatinns,
tho head and body of the first child aro t'speUed, and the second child i»
mtmX^lA DUE TO DEFX>RM1T1ES OF FffiTUS
798
<rn very niiii'ti a» iu an nnlinary twin [iregnaikvy. If, however, the
latlKT prwuDU transt-vnwly, iU dcUirery can be eSecled only by version and
B Defomities of Fatns. — In thi» pla<>c attention will W direoted only
lo tho6C atiuornialitii'« iu fa>tal development which may f;ivc ri^e to diiS-
cuit labour. An amrdiacu)' is a monsli-r which i« Homplim<»' di^vulopwl in
iiin^l<!-a\-aDi twin prcjinancies as the result of in<w)ualities in the cornmu-
nivaling placfntul irircuUtion. Oin- twin i» wHI developed ai>d normal,
while the other is imperfectly formed and lacks a heart. The way in which
lIitK is brought about wa:< concidrrvil on page 3*y-i.
The moiit (Munmon variety of acanliac monster is the acephaficm or
hcvdlcss f<FtaB. Ltva common is thv amor/Aotia nioneter, whi^ poeeeeees
neither a head nor extremiiicn, hut i» round in «liape and prewnts upon
its FurfaoG a number of small noduloe. which repref«nt the rudimentary
oxtremitictt. Tiie umbilical ronl may lit nttHob<-d to any portiou of it*
Gurfacv. Tfao interior of the moofitrogity containn a rudimentary intestinal
tract, «.78lic nvitiM, vertebne, etc., but no trace of a heart. The rarmt
variety of acardiaeus is the ac«rtnva or tniokleea monatcr, which consists of
an imp<'rfwtly divclojicd h«od and a ludi-
uieiilary l>ody, the umhilieat cord being
^altucht.'d to ihc <Tn*ioal region.
M a rule sueh monsters do not attain
ny notable «izc, allb<tu)ih i-xci'ptiomilly,
tlie result of obstruction in the umbilical
cia, tliey may become a'demaloua and
ive rifv In dyxtotin.
The aneMc^phaliu or hemicfpkatw is a
aouvter jWwCMing a trunk, but only an
1 perfectly developed head, from which
lar);r part of ihv brain and i>kull i» lack'
nj;. tinlinarily. 6uch tiein^s are of moder-
ito "ize, but occasionally Dw shoulders may
M i>i(t4uivt-Iy ilevcbiiHii as lo give rise
serious dystocia.
Owinji; lo the nliM-ntf of tlH> cranial vault, tite face is very prominent
and somewhat extended, the eyes often prulnKle markedly from their
rket*. an<l tht- luii^ue haiig" from the mouth. The brain is in a rudi-
meolary condition, and the ba»e of the skull i^ lu-nvoible to ihc examining
inp-r, w tliat the sella turcica can be disiinguii-hed. Owing to the ex-
eondition of the base of the brain and the upper part of the medulla,
here i« frequently a marked increase in tlte amount of amniotic fluid, its
lirtxluction being aiin!ogou.4 to that noted in the picikre experiments of the
physiologists.
In view of the abnormal shape of the head, face prewntations ar« tre-
quently ohservail, whilf tho«>e of tlie vertex are \iss common than with
niirninl f<etUH. TraiisrerBO and foot preitcnialion* arc likewise not
iniviijil.
Wlien the monittroeiily prcsentd tiv the face or Iwad, a correct diagncsis .
Fill. S3S.-~A!i):»iKPHJtt.t«
794
OBSTETRICS
U fn-qitfutly m0<lr hv vnginal toiKh, tho eiuirflvterititic bulgins of tin^
eyfs he'mf: noted in Ihc former, nnd tliv absence of th« craDJal vault nnil Die
presoiici! of the nolla tuRriea in the latter premintatton.
Delivery, as a rule, occurs much more readily when the monster pre-
acnU hy the hrccch, for llic ri'aciii Ifuil thi* iinjicrfeelly dMcIopcii lnyi'l
in not «n cHioient dilating agt^nt. though in ninny caws rapid and npun-
tancoua delivery is obscned. Even when the enlarged shoulders give na
to dystocia, delivery can luually be aoeonipli»hed hy meanii of version will
out any ([roat difti<rnlty.
Hydrocephaly. — in this not very rare eondition, IhcwrchrBl vcntrick
are <lisii'ml>'i| hy an ewc»«ivo amount nf rerehro-spinal fluid (Fis. (^*i]
As a result the skull l>ecomes much increased in eixe. frequently altainm^'
M-vi-ral liine--> itit normal dimenHionn, vihiU
the brain sulwlance forms a layer only a fc"
niillimetn-* thick iMMK-nth it. A1 lite witivf
time cranial imnes are inipcrfectly (IcvetopcJ.
(he ^ititurw and fi>nlan«llc9 being muuk
wiikr than usual.
^^^^^
Fio. Mft. — DywTOft* Dob to HroHovKniAtAv illunuiil.
If the enliirtictl lii?iiii is not tensely filled willi fluid. uikW iIm* inllui-ii<'
of the uterine i-i>nli'ai'tion,«. it may undergo fufh chiin^'es in shape lliat rt*"
spontaneous expulsinn k-c-omes possible. This, however, h so nirp n ii"»-
itihilily (hut it should no] Im- nrckoniiil with in lii'termininjr the trt'aiiii'-nt
to lie purMicii in a givi'ti caw. Still lfli« fi'<i[iifiitlv, nwin;; to Ihe pnv><iir
to which the head is subjected at the time of labour, the tisaucK T'lnniiif; i
fonlancllu or suture may {jive way, so that the cerebro-spinal lluid can
cape, after which the head cfillapse-s and spnntau<^^nt deliverv' tiecomes
aihle. In the vast majority of cases, however, the eomlition gives rin: ti'
serious dystocia, which if not promptly relieved will lead to nipturc of lli
uleruM and the death of the palienl from intra-abdominal liieniorrliaf^r.
In hulroiephnlic ehitdren, althouj-h eeptialie preNHitntiomc pmlnn
mite. owiiiK In llio lack of aecommoilalJiin U'twi-cn the hcnd nnd IIih [itiv
canal tlie hixixrh is often substituted. "^
DYHrroCIA HUE TO HVtiHoCKPHAIXS
795
Hi Dlafiiuuii^-Jiii u rule Ihr condilton is npl ntxf^aisd iiDtjl -ifTeral hours
^■of fruitless s«con<l-ittaj!<.' pninn linvi- il<'iii»n.>IrHl'ii] the c\iii>'-iK-f n( nil oli*
Vvtiiclv lo (Idivcry. Un tlip niher liuud, can'ful I'.uiiiiiiuilioti bIkhiIiI ordi-
narily lead to • correct dio^wix in thi; last we«ks of pregnancy or soon
uftcr tlie onsvl of labnur. In many casa-j [he d^'fonnilv can W doietitod
tiv exlirrnal piiI{iation. l)ic iiniDPniM?l_v Inr^o ninl movahle head Iwin;; iso-
Inirtl aUtvf ibe sii|»crior »tniil or in lh« fniiduK of tlw; utcru*. Furlh<!nn«re,
»llie ciamincr ehould alvnyn be on lite lookout for t|i<: pre^eiiixi of fluctua-
lion, whilv ■ peculiar crackling E«n»ation can be cUciti'd by pressure upon
the akiill. I bai'i> made a jxMilive dlagnoMA in tbiH manner upon Mvcral
(>cca«ton(t without an internal examination.
».\» *oon ai" ibe wrt-iit is diliiUHl, vaj;iniil vxatnination will rcv«id a larp;
head wrilli uiddy gaping sutures, through vhirh fluctuation can 1>e obtained
by appropriate inaiui-iivrVK. Of course this dovti not ho]tl good in llio«o
caKO) in vhich the child pre^ienlw bv the breeoh, but hero alKtominal pal-
]>aii»n will rvrcal ihv pni^-nct- of the large Hucluaut lnwl in ibc- fumliii; of
the uterus, or jusi above the superior strait. Id ca«e atteinpti at «slraetion
^. bavv been inadc.
B Prognot'u. — For the «rhild the outJook i* uwiforirdy liad, for even if
iMtm alive it usnally Kuccunib« trilhin a few days, and in the rare case;: in
which it fun'ivfs, ^rows up a hoiM-lext tdinl. Tbu innli-nial pnynonii
depends largely upon the obstetrician. If left lo Nature, the usual ter-
mination of labour cninplicatitl by hydnH'cphalu:' in niptun^ of (he uterus;
irhercas. if the condition be detected antl proper treatment instituted, the
nvults arc nlmont nnivcr<ally favourabte.
Trraimrttt. — As wion a.* tbr ivrvi\ ban Iteeouic c<>inplcl('ly ililatofl. the
Bfaead should be perforated, in onter Ihat the ccrcbro-spinal Huid can escape
and tlw! >4iull vollagtM.*, after which deliver)' can U^ elTiH-liil by (he unai<k>d
efforts of XatUPe, or itini Ijc accelerated by tlic employment of Ihc cranio-
cIhi'I. On Dceniinl nf IIk- nature of ibe diwuii:- and its elf'Vt u|>»n the child,
liic operation may bt- uwlertaken willmut hesitancy, even by those who
ofdinarily do not coiisidcr craniotomy a juiftiliuble procedure 1
In evacuatinj; llw- b\dnHi'p)udic Iti-ud it :<bould be Ixtme in mind (hat,
owing lo the e\lTi?ine ihinnc^'i of the brain, mere perforation is not always
tyiionymouH witli firlal dentb. For ibix ftviHin the perfornlur i-ImiuM bn
irried to tW base of the skull and vigorously manipulalnl in onler to
3o>'trr>y (he m<vlullii. mt nothing could lie more horrible than tht^ vxtraelion
Itf a li^iti;; tliiM iifior Koch an «|H'ritti<ii).
Enlargement of the Abdomen of the Fcetni. — Knlargcmcnl of tlte alidiv
m-n Kutlk'tt-nt lo chuso grave dy,"tni-in is usually the nwull of ascites, a
cry mu<;h distentli-il bladder, or of ttmiours of the kidneys or liver.
Whenever the aMominal distention ia marked, spontaneous labuar \*
"«mt of Ihr (|nc*tinn: but unforlunatdy the comlition u.->uiilly escapes detec-
tion until fruitI<--« utii-nipb' n1 deliver)' have demonstraleci the existence
Hbf some obstrnetion and have led the nhsletrieian to inlrodiwc hi^ entire
^T^and into tlw* uleruK in tin* hope of diwovering its nalnre.
f><'i-asionally a fa-luK affivtii! with yi-n^mf ilropsg may attain sucti
ironiciiM) proportions Ihat spontaneous delivery is impoMiblc. A ntiinber
vl
796
OBSTETRlCa
of such «i«w nrc rectirdeil in Bullsiiiyiie'it vnlunblc nrnnngrapli. Id venf
rare instances the asoiteB aseocintGd with fetial peritoititu may have a sim-
itar result, arul i-xa'pti'iilHlly a fcrlii* siilToring from ehondroilfffimphia W
ftrlal rhiKhitii' iiKiy lic'corno »n (ndematoiii^ as to give rise to dystocia.
As Iho rc-ult of 1Ik> diUtutiou of thv ^mpurlicinl 1yiiiphatio» UH»)>cialL<d
with icdfiina of lli« fiulK!UtHnt>nus tiiwucii, the fcctu^ may asiiuniR inimciuc
proj)arttntis an<I take on a bizarre shape. Thi« oondition. which is desig-
nated ait tiUphatttiajtis ran-
g^ita cytlica, ha& been uttid-
ied in detail hy Ballanlynu,
and is a reiy rare eause of dif-
ficidl lolioiir (Fig. 631 (.
Defect ive develop men I nf
th« lower portion of Ih« nri*
nary tract may lead to the f»-
(ention of urine aocompaDicd
liy dii<teotion of tlw Hlnloim-n
KUllicinit to render normal de-
livery inipoMtlilft (Fig. A.!-'*).
ICxaniples of this condition
have Ix'-en reported by W«l-
llier. Schwyzer, and other=,
wiw kIho give details u to tb
a;Iiolo)jy.
A much more frequent
cnuHc of aMomiuHt tMiJarp^
ment is the presence of fnn-
grnital c^Kiic kidnriffi. Tin-
growth, which is hii«loIi>gical-
ly an adenocystoma, may in-
volve one or botlt organ*, nni!
givv rti^? to tuuiourii of iiB'
nieneie i>iie. The condition i*
frt-quentty associateK) with dila-
lation of the ureters, ami with
dropsical eirosionii into the v»-
riouK iMxIy cavitiw. Fig. 1139 gives an idea nt the cstcnt of the at«biminal
enlargement in a ohild which 7 delivered.
Lynch, in IWfi. cHrefiilly dpsi.rilM'd the anatomical fimlingi« in my ai*-
and analysed nearly .10 other eases reported in the literature.
In r«R' eases the abdomimd enlnrgcmoni may be dw to tttmann of Ihi
tiver, Porak and Couvctaire bflvtng reported a ease of congenital ci-riie
liver fli-soeiated with a similar condiliofi of the kidneys. Mokovit, large
tumourf. arising from any of the aMominal organs, may give risp to dv»-
tocia. Tliiis, liogers has di'scriljcd an immense fibrr,-rifs(ic trstu-h. and
Phiienomennw lui aortic iinciirism so Inrgi- a* to interfere with delivery. In
ran; instances fcetal inchisiouN, such as the ajw^alliil firtu* in fcrlit. niay
he responsible. Oecanionally the invasion by Itacillus aeixigenm npsu-
Via. 6S7. — ICi.i^i'iiA.i'i'iA-iN CoKuKxrrA Cnric*
(tluIluilyiiH).
D^-RTOCU DUE TO OtSEASES OF FTETCS
797
latm maj be followed by such an oxlcnsive production of gas
fwltiK IiMiiniw mo?Y* IliAii dowbli* Iho nnnnal i^iic,
u'bou (iponWnooun delivery is iin-
ponwibtp.
In all of ilivMi c<>Ddition«. if
Iho di-stocia is marked, delir-
iTV am Ix' iu;r»iiipli>'lM,Hl
ouly after npenititc the
ImhIv iif tbi' fii'his aitd
allowing ltM> fluid In e<-
c«|)c, or ri'tnoviitg a )Kir-
lioR, »I le«»l, of the
offeiidiog tumour for-
marion. Tito latter op-
eralion is not alvajr«
m»y. f«r. owing to the
rorirlTaiiH^ po>^itiou of
lh>* h«(»l in ul^o and
the dense coDsidlencr of PKi.«sa.— Fivmwnu lUHCKmn-Y ttamxxiai
that tlte
B<-AM>Ka
I tic growth Id many
cmeB, great ditlictilty is
cxppfivnw.'d in oomptet-
Tiimoun of the Body
of thf Ftetus. — In rare
iDAtaoces, aboarniaL
grottiliA arising fnim n-
riann portions of the
body of the fcvtas may
Miriounly interfere with
delivery. Cases are on
Twonl in whieh lipom-
aia. earcinomata. an-
gioma ta. and V a r i o u #
oiher tumours have
liven riw In iqteh an en-
nent that sponta-
ntis deliren' bvcamv
of (he ijiuwtion. Kx-
fptionally, dermoid
rifts and U-ratmnalono
imnuni al>oul iIh* peH-
i-iim and wicnini may
a scrions obHtade.
i. ?J.i n-pn-w-nt* a fn--
A* in which an adenoma
of th« thyroid gland ne-
»iitate<I a dMtructive
(Hcdur).
tlO. last— (■'Mi:- wrm I^MlVltHIT*), CtBTlC KlI'NIit*
798
onsTtrrmcs
opcralinn. In raro iitstancps parnj^itic ftptal tiimoum. n \nrgp tirnl>ilical
hernia, n Apiiiii iiilida, niui ixliur ^rowllis, ^i\e Hkc In ilillicuh lalioiir.
DyiUicU Dae to Aboonnal Pretentatioiu of the Foetiu. — Transrfrfr
t*resfnlali'jin.—la tliis c nut i I ion tin- l.tn-; asis of l\w hvlns oroBm.'w llinl
of tUi.^ moihor u1 aluiut a riglit iiii},'li'-. VVIumi it rnniLt un scute iiD^le ire
apeak of an uhlii(uif. presentation. The latter, however, is u^uully oiik
transitury, btToiiiinf; ronvortt-d into a loiigitiiiJiiml {in-siinlHtioii vhen laUtur
8Upervt;iii>:i.
In transverse presentations the shoulder a^ually occupies the eapofior
stnit. thi; \\vaA lying in om^ nni] thir liri'itih in thi> other iliac fossa (Fi^.
640 and (111). A«M>rdinBly, such a condition is commonly spokrn of a* t
shouldrr. nufl lew* frwjiii'nlly ai* a lalrral phitir. prrxsNtatUin. As the acro-
mion process is one of the most characteristic features of the shoulder, thtM!
■re usually dvsignatud ii» acrumiun prttenlntiuns, the jtoiiiion bein^ right
or left according to the aide of the niotJier toH-ard« which the sbouldef
Fio. a<D. — DiACiHAW HMowisi) (.Bi-r Acao-
HIltN Ul>IUM>-FOI>miOR PKRHDrTATION.
Fio. (Ml. — DtAQ&AM iaowtMO RtwrT Ana-
is diiwtt'd. Moreover, in either position, the hack may be direeted either
anteriorly or posteriorly, and accordingly it is eustotnary lo distinf;iii>h
hi'tim-n ihf dor.io-iinlTuir and ihritQ-puft(Ti"r variclios. The n«o^ition
of the position of the back is of very consideriibW iniportAiK>e in coniwction
with (he propiT piTfonnam* of version — Iho treatment par eie^Utnn in
Ihb condition.
Aecfiiding to Srhroeder, the shoulder is directed toirardx IIjc left «de
of the mother 2.ti linii-s nion* fni|iii'ntly than towards the ri};bt, while
the hack looks anteriorly S.S times more frequently than posieriorly,
JEtiohgg. — The exi^lencc of a trniisvenv prraenlation in a primipamns
woman is prima fnrir evidence of a lack of accornitKHlation, usually thi;
result of dixpm[Hirlion U'liteen the size of the Iniid and the pi?lvi*. In
ran- instnnci>8 it may be duo to hydrainnion. In miiltipanc, on t)te other
hand, the nioi^t frequent leliolopical factor is an abnormal relaxation of llw
abdominal and uterine walls, tin? ri-Bult of repealed chiMhearinff, wliirfi
may \»; slill further cnmpiieated hy any of the causi\« ainiidy enuinenici.
Aecordinjfly, trHncverw pwwentfiliou* are much more frcquenlly ubserA'ed in
women who have liornu a niimt>er of children, and in tlicni, aa a rule, tlie
DYSTOCIA DLTE TO TRANSVERSE PRESENTATION OF FUiTUS 799
^
^
^
conditiDD U Dot so .toriou^ ns in prinii|>in<v, fnr tW Tmimn thut in the former
iiponUiu.'ou» rvpoHilioQ fix-quonlly ensues afler the onset of labour pajna,
the diild asdiitiiin);; » loii};irii<]iiiaI prv^'iiUliun, whcrvas such an occurrence
ifi exceptional in th« latter. 1
This (tponluncoiH (•onversiun into a longitudinal presentation is ren-
dered more diflk-ult hy premature niptiirc of iht- miMnl>rnn«9^ an well »»
by any condition which interferes with the d^'scenc or enga^nient of the
liejul; fur exiiinple, a enntnicind pelvi«, placenln jinrvia, n pt-ivic tumour,
or twin pregnancy. In rare inittancea lonffitudinol may t>econte conrertcd
into Moondnry tran^vurie prcMintatinnK at the time of labour, although
such an occurrence is exceptional, and is always indicative of diqiroportion
l)cl«*ecn Ihp size of the child and ihw pclviit.
Diai/natU. — The (lin;;ii<>-i)i of a traiisTcrse preM^ntation is tu^ually readilyJ
made, in>fp(H-lion ahmc fn'i|Ut'nlly cauxing otic to Kti^pccl its existvnviv'
The abdomen is i>eeii to be unii.''iially wide from side lo nide, while the
fundus of the nlcru^ frefitirnlly diip« not extend above the umbilicus.
On ]inlpalion the flr.->t uuiDiruvre n-vcalK the alisem-e of the h<.'«d or lh«
bnrch fnim the fu»dui:. l»n the wx-imd mana-uvn> a ballotlable head will
lie found in ono and Iho breach in tho uilicr iliac fo:>Mt, whilii the Uiird.
and fourth manwuvrc* are negatirc, unle^ labtmr has i»een in progreflfl
for M>me time aitd the >houl<b-r ha" iK-conu' impurlcil in Ihe pelvic
Al IIm? saitiE time the position of the back i;* readily dia^o-«d. When
it i» niluaitil anteriorly, a hard ri'^ii'tant plane will bt- fell cxt«nding-|
across the front of the abdomen; when it lies posteriorly, irre^lar nodo-'
latioos, representing the small parts, will be felt in the same location
(Plafft XV).
On vaginal touch in the early stages of labour, the side of the thorax,
rewlily nvngnisabU- by llw "gridiron" m-miution allonK'd l>y the ribs, can
be made out at the superior strait. When dilatation is further advanced,
the M'Hpula can U* di<tiugui)>hcd on one Biid the clavicJo on the other sido
of the thorait, while the position of the axilla will indicate towards which
»ide the shoulder is directed. Later in labour the i>houldcr be<»me8 wedgod
down in the pelvie canal, and a hand and arm not infre<)uent]y prolapse
into the vagina; whether il is the right or left can bu readily determined j
by AMicrtaiDiDg to which one of tlie obstetrician's it correspond.n, just aM\
in shaking hands.
CoNfM of Labour. — With very rare exeeptioiu, irpontaneoua labour is
impossible in persistent transverse presentations, since expulsion cannot
be effected unless both the head and trunk of the child enter the (tetviii atj
the aame time, a manifestly impossible event when both arc of normal^
[■roporlions. Accordingly, both the fu'tus and mother roust inevitably
perish if appropriate measures are not instituted.
After rupture of the membranes, if the patient is left to herself on arm
usually prolapM-K and the i>l»outd<'r bivomeji forced down into the pelvioJ
cavity, but can desct-nd for only a certain distance, being arrested by thcd
head and trunk at the superior strait. The uterus tlwn contractit vigorousln
in the attempt lo overooine the oWade. but in vain. After a certain timA*
the contraction ring rises higher and higticr, the lover uterine segment
OBSlPn-RICS
Ix-coimte more ami inore elrctchinl und i-iiTitually give* w«y, whii)
or the whole of the product of conceptioa ciicapeii into the abilamiDal cavity.
Undtrr such circutnotanccb tliu patiunt ui^uully (lui.-cuiiilv nilhiii a short
Iiin4> to intriiiKTitoneal hwiiiorrlui^t^, while in other ini^iaiicce death occun
after a longiT or sliortcr pt-iiod fiYim iufectiou.
I'OKnibly once in many IhoiL^ni) cum^ tl>o nierui' womh' to contract Ix-fo:
rupture occurs, sih! the Hiild. heiiig rciaioed within the uterus, may eventu-
ally bwome mtiniinilled <ir i.ii»v<.-i1wl into u lilhopatlion, lo In- linnlly oist
off by snppiiralivo propesrtca, Sneh an oecurr«nee i^ described at initted
Inbour, and i» very rare in human bcing:<. though it in wdl kuown to tlw
veturinariatis. (Sci* page tUW.)
In trun^verw pn«en tot ions, now and again. t'lMintniKous dtdivcry
»\iP*. itarttiotin. in Iho lievintti-mh i-(^tiiry, jiointetl out that a child whv
has lain transwrBoly during the Inter months of pregnancy may xpontaueJ
uu^ly aivnnie a longitudinal jirctteninlion at ttie time of lalmur. Thi* m^
called sfinntanrous termin ii' a not infrc<)ucnt occnrrunce; Its mode
prtHltKrtioil lia» oiri-«<iy liecn rv'ftTn-il to,
A century later. Kocderer pointed onl that in very rare instances, if
the child va* Mnall and tliv pelvi« large, dcliTcry might oocaxioiiully
accomplished in spile of the persiiitenee of the abnormal prcwntaitoi
Tliif [inwi** he designated fiwnltnmus evitlulinn, Tho mnnogniph
Payer U n-pleto with historical aliiL^ion* to the sLd>ieet.
Sponliincoiis version ocvur*! only in the early «tag(« of labour, and it.
occurrence siionid not be lookeil for after the rupture of the uiemb
'M
FMl. Stf . — PaOIKH SXtmOft TKHOVflH tVoHAH I>TIK<I IN (.AHOVK irim « XKOLffCmTlUK
Spoiitimenu* i-voltilion, on fill' ollur Iwuid, is pofHible oidy late in lalHiit^
afler the membranes have ruptured ami the shoulder has tH^^time wwljl
down into Iho pelvic cavity. This, however, is met with so rarely, dun
DYSTOCIA DUE TO TRANSVEUSE PRiaENTATION OF Rl-ITLS 801
Htii'h {H^cnliar cotulitionii, noil h attoiittol by mich rUVs to the iiiolhcr, Uiut
^■ita occurMscc should never bo countnt upon in actual practice.
H When, hon-vvi-r, Itic pelvU i.* noniml nntl lli<> child uiidcrctxcd. and par-
^P iNMiliirlv if i( iti marernted, fipontnnoou-i evolution may be effected in one
of itt-n ways proTided the pains arc siiHicipiitly slmns;. Thus, (he imparted
• vhrtulder after being driven dwi)er and dtvper into llie pelvin may c\'CHtually
rotate to the front and emerge from the tuItb, its expulsion being followedl
by ihc n-st of Ihe Ihnniji and thiii by lh<- feol, vthih llie hejid ctij] romainsJ
aitovo the superior strait (l-'ig. tH3). Lees fre<jueutlr, particularly ii tbail
¥io. M3.— Duomjui nxtamutiKO Mu-iuHiiai or BPOMTAHsoctt EraLVrinM (Jsncmsnn).
child ii maevrated, tlie shoulder may tie farced dnvn Ihrougli Ihe pclvix,
while iIm- body i* «> bent upon it«elf that the bead and tliorax come into
rhfse a|i]>(Kiitiou and eti-ntually enter iIn- |u-lr)s togvtlHT. The birth of the
fhoolder is follow«-d by that of the head and thorai, which emer^ simulta-
nt^u^ly from tin- vulra, and are followod by ibe breech and lower eitremi'
lie». This mechanism is descrilted af partus condnplicalo itirpfire [Vig. fit 1).
In verj' ran- im^tancew f^ponlancou^ evolution may occur even when Ihu
[child had atlain4>d eoaiidetiiblc pmj>orti«ii«. Thu^i. Pai'cr has reported Uic
[ ea«e of a child weij;hing 2,6SO grammes and mcHMunn^ SO centimetres in
lenjilh. M'hirli wa> iu> l>nrn. and give^ a li't of lU Kimilnr inKtance* from tlte
literature in wbicb (lie obiliiren wen> of an otjuiil or greater weight, one
among Ihcm — Champion's case — being bom alive.
PfugH'iKin. — If K|Htn(antt>UH version do*-* not i'>c<'ur n-ilhiD t!w (ir*t few
hours after the onM?1 of labour, and operative proivdures are not inslituled,
ibr- ••uiiiiTiic for l»')lh mother and child Ls almo>i( uniformly falnl. the child
sutvumbing to asphyxia and the mother lo hwinorrhage or infection, as *
of rupture of the uterus. On Ihe other hand, if appropriate lucu-
802
OBSTL-riUCS
nrcs are instilated at the proper tim«. the prognosis fnr tlie duld U fair,
while for ttio iiiol)i«r it i^ oxc-cllenu In ilui< cIium of iMt*» pn>l«pde iif Die
cord 18 one of the most frequent causes of ftetal death.
7'reatinfnl. — IT lh« dingnnsiM lm>^ IxN.-ii made in Iho lust month of prcfi^
nancy and the pelris is approximately normal, cephalic version should be
iitffocied by vxicTiml inanipulations, and ihu child held in its new position
by means of a pro))erIy nttin^ bandage. On the other hand, if the pelvis
is inorlii'dly cnntraeled. such a proceiJure is not advisabl*. as Cieeareun sec-
tion will pnilmlily Ih' the operation of choice.
If tile patient is not >et;n unTil after hil>onr haH set in, cxlcmjil cephalic
veriion i^umld likewise iw attempted, provided the membrane!' have not
Fio. $U. — Rark Fcikm ur S'mrtA-
^
ruptnred. As a matter of fact,
will iisuully pmve uiisikhvs.*-
it is better to wait until the cer-
Itited. and then, after riiplur-
intenial podnlie version, fol-
On the other hand, if the
well aciviiiiiod in labour and
the treatment will vary ae-
tation of the cervix, the con-
as that of the fn-tu* and
partially dilated, while the child is alive and freely movahh^ in the utcru«.
bipolar viTsion nmy he attempted. After a foot has been brought down
the cervix should be allotred lo dilate Ktill further before extraction is com-
pleted. Oti tho other hand, if the mndition ia complicated hj prolapw of
the eord, the lervix should be dilated manuallr, and the child rapidly
^itrueted after internal podalic version.
Whenever the i-nrvix i» fully dilated, internal podalie verBioo iihouM be
performi'd at once, according to the rule* already given, and follnwwl by
immediate e.\trnetion, provided the uterus ie not so tightly contracted do«n
however, sndi manipulations
ful. Under thn^- eireuinstaiii'^
\'ix U almost completely di-
ing the nieiid>nuic«. perform
lowed by prompt extraetimi.
patient be not f*xn until slw is
the iiiemhranw have ruplnrrd,
cording to the degree of dila-
dition of the patient, as weJl
uter«*. If the ccr\'ix is only
DYSTOCIA DUE TO COMPOUND PRESENTATIONS OF flKrilS 803
nvnr th« child and tlie lomr utdrinv ^cgmnit eo thiniHid out that tiu<-h a pn>>
c«dnrv Bpp«are synoni-mom willi rupture. Id sudi caM». uitip^thvsiu mme-
tiniiw an rt-lnxirf. llic orgnn that
vursion may be safely effeoieti,
vvi-n tlmu^h at lir*t glaDcv
it had appeaT«<) to be
nal of thv ijuvatioa.
Via. 645.— HKitKH Sacnox TmMtraN Woham DriHa at Khd or PuHnkMcr.
P«X)IKKTATt>»x (Mnuiii-).
CoMromiB
When wnion uppi-am to be eotiira-indicalixl. draipitation becomes the
npcrnuon of choice, even if the child ia alive, allhou>;h vory exccplionally
Oi<an?an iKTlioii nii^bt be tliought of uiuler thu circtuuiilaiices. The Istter
should iioi. liowev«r, be umioriaki'n
vxcppt at the vxpiwe wish of the
pati<-nt aiui bor family, and then
only after tliey have been made
faliy conrcniant with ili^ inlHirnt
ilun^riT in itiu caiw of » patient who
ID all probability isalrcttdy infected.
Compound Prrgrnlali'»v. — By
this term iv uwliTAlood the pro-
lapse ol an eitreinity alonpidc of
thv presentiDji part, both entering
the pelvic dinal simultoneouslr.
It in not an infrequent occurrcnoc.
being observed abont onc« in every
250 cases (Pig. 64A>.
An a rule, a liand or an arm
(-nm<-« down with the head; much less cnmutonly both arms, or a hand and
a foot, or both fwl miiy prv«-nt lotErtlier. Hahl has reported a vxf-e in
which the iKTk of tin- child wa* girdled by iu leg.*, so that the icrolum and
head were felt upon vaginal examination (Figr 646).
S8
I^Q. MO.— COWrOCKD pKMnCTATION (lUU).
SM ^^^^^ OBSTETRICS
Hornv i<t«a of tlic rvlalivv fri^iiciicy nf the ililTt-noil coruliiutioiic may]
he gaiiti^l fn>ni tlx- fullnwing table, taken from Penucc:
lIoBil nn<l lutnd "Mamm
UoMlKudami 8 "
Ilaut, bkad, and card. >> 5 "
Head and Imtli tuuidn. 4 "
Head, i»ic luuid, and ouu fool. It "
Ilend, tnii hftndii, one (out, anil oord 1 1
ftxv, Iiaud, and cord 1
Swnli a wMMiition U fn'^pifnily aasoeiateii with a tltsprnportion IfctwHtrn
Uio size of the hvuii iind the ]K'lvii!. owing To which O-uHy i;ngti^-mvnt ha*
liM"!! inlfi'fpn^l with, and a» a rcBiilt om or more of the c\tr«initie6 ha»«
prolupwod K'forf Ihc pnc'scriliiig part idilonil thi.' |i«-!vtii,
Trmlmrnt. — Whenovor, during the first utagf of lahour, a hand is di>lin-
|rtii»hcd nloup'ido «>f the hv«d. it should bi- put^hcd up if po^^iblp; but if
it be firnilj- fixi'd Mwei-n lh« Ueai nnd thu* pelvic wall it ^liouKI Iw left
alone, since it fl ill usually not interfere with labour. On Ihe other hand,
if llic onii™ arm hiii' proln(wed alongiiide of Ihe head, an energetic effort
should \ie made lo replace it. If this iit nm poMiithlc, version «houl<l he
porfoniiiil, i>imv if Ihv arm rctfliiif itii )>o«-ition it may give ri»e to serioas
dy^toeia, inon' wpi-cially if it e.\tt'nc]» nroutid the iliild'x nwk. (-uni^tiliiting
llw eo-cnlli-'d nurh'il pofUion.
When, an happeiiH only ruit'ly, Ihe frHit prnluftsi>M, atleiiipt« should lie
made to replace it; if thee>c fail, version iihould be resorted U>.
IdTKltATURK
Balukttmb. Cionrml F<rtAl t^^-xtic Klcphanl.iaiUH. The tlJiwaRCR ot tb« Fcotuo, Edin-
brlfKh. lf»J. i. IH2-:il«.
n«t<Tiiiit.i\. t^Molvd by l^ycr.
Bahl. Striclitr do* <m mtemiun aU OobiirtKhmdomi^it. Archiv L Qyn,, tMI, IxlB,
Lvien. Dystocia duo toCv"'''' Kidney. Surgery. Gyn, and OtwI., ItMl, w. a'JH-ii37.
FaTBr. Zur Lehre voti der tMI)iit«iitwiek«lUD^ VolkinBiui'* Sanunhmg ktio. Vor-
trAgD, N. F., mot. Nr. 3H.
{■EBmcE. Die Gebiirt mlt Vorfall d»r ExtrmnltfiUn noben dem Kopfe. Leipaie, I85& <
I'uAKNouKNow. lioitRig 4ur Cuiuiiiiik der dturb die Fruebt tivdiagt«o (ieburt«l]diKler--l
aitm. Arcliit- (. Qya.. I8HI. xvii. 13:^139.
ToftAK et CouvKi.AiRC. Foic polykyiCiquii eaum do dystocie. Coinfi<«a Rmdiu toe.
d'obst., de gyn. et da pa^. do Parut, 1901, iii, 2a-.17.
RoEoeHKR. Quoted by P&yer.
SoiitOBnKR, OuMAiTHEX iiod Veit. I«hrliiirh der (laburlilmltc, Xlll. Aufl., 1RS9. 73T. '
ScBWVtKn. I'libcr einun Fall vnn (icbiinxbindcniwi, tiv>)iii|Ct duK'li boehgndijct
EicrwvilnninK der frtluli-ii Hamblaw. Ardiiv I, fiyn.. IBOIt. xliii. :t3.1-a4B.
Waltbkk. Il>'iilnki(! iafnltic uhnrmiiksisi^r AundehnuiiK der [fitulcni llambUiv. Zd(>
iichr. f. Gab. u. Gyii.. 1893. xxvii. 33S-347.
CllAPTKK XL
U .K»tiHRH AGR
PREMATURE
PLANTED
SEPARATION OF THE
PLACENTA- PLACENTA
NORMALLY IM-
PRiCVl A -POST-
PARTUM H/CMORRHAGE-INVERSION OF THE UTERUS
A PROFUSE haMtiorriw^ occurring prior to or vhortly after (he birth
of thi- i-liiltl i« iilwiii-'' H itBD^r^mK uml not rnfntiiHiitlr a fHtal romplimlinn.
Praclically all clm'oi.'s uf aiiir-fMrlum hirmnrrliifjr, witli ihc cxvi'plioR of
ihoM; originating from Isceratiottit of Iho genilal (^anal, arc due In a partial
or ruinplfU' si-iiorntiou of the placi-nta from iU attachment to tho ntcrino
wall. This am4)eDt in an inevitahio ari-onipaniini'nt of lalKHir wheo thf
plovt-nta is implanted in llic ncightKiurti'KHl of lliv inli-rnal >iv — plocvnU
previa — I>ut o(vasion»Il_v o<mirs when ih*? organ occupies its normal site
io Ihr upper portion of the uterus.
Prematore Sepantioii of the Normally ImpUntad Flaoenta. — From the
time of Hip[>o(Tat<* it had \nvn cunlomary to atferil* all cai-es of ante-
partum lia-morrhngc to thi» aieideiit, Inil « ttli tlie nx.'OK"i<i"R of the nature
of placenta previa and the knowle<lge lliat its separation is uoaToidably
aMociatMl with ha-niorrhago. Ihv nrlicr vi«ir wa« abandoned and the fornicr
accident eant« to he rtyarded a^ of rare incidence.
Ooodell, in lHtl9. rolk-etcd l<>(! instanees from the literature, whilo
Holmcii, in isn], vas able to find 200 additional eases'. Tlu^ tatter writer,
liowevcr, belicvcjt tliat th(«« ligrirnt give a very inadequate idea of the
frequcDcy of the accident, and he liini^lf c^nitidcrs titat it occum about
once in every 500 )aboiir»i. His contention is eontirmcl by Lyle's statie-
lio>. which nhow that 40 cai^cs were nlgeu-niil in ihe Itoliinda Hospital of
Uiiblin during the ten yean; ending with 1K99. My own experience leads
UK to believe that llolmt^'M c«tiniate It appntxiniHti-li- <;urm-t.
.£tiologi/. — Unfortunately, the primary cause of the premature sepa-
ration of the placenta is impirrfiKtly uiMh-ratood, allliongh a number of
t)i«ories have Iteen advanced i-onceming it. In fi" of Holnifti'ii cane* there
WIS a history of a preceding traumatism which, according to Coe, i« the
mo«t common nptrologioal factor. Mo«>t German authorities attribute the
am-ident to inftammatory r)iaag<« in th^ dtvidiia, which were present in
every one of the S vstM-.i examined Ity \Vfi». although in S of them the
pmloniinant lesion wa.t a suppurative metritis. Schickde. on the other
hand, fonnd no ifigns of endometritis, but de*cnbe«l n pronounced dcgenera-
tion of the decidua in the 8 ca««« which he studied.
805
806
OBSrETRlCS
Winter bdievce that a do!^ relationship exists betvcen n«pbrttiB andi
prcmnture «eparati(>ii of (Ik- pliicoJUii, and tnuny iiiiilinnt haw ^ubwribcd)
to tliis opinion. Weiss, on the other haud. vas abic to demoniitratG albu-
mtniiriu in oiilv 5 out uf \u* a cn»v», auil it would appear prubnblu lliat in
many instances, at least, such a combination is purely accidental ; for, i£
renal Iniions played anything like the prOmioiiit part aiwigitcd to them
hy Wiiilt-r and h\* followers, prt'inalure reparation of the placenta would
be frequently ohserred, eince nephritis complicating pregnancy is by no
means uniiimmon.
Muhiparity would appear to be a prediKpo^ing c&uae, only 19.2 per cent
of the cnw< colk'flcd by Iloltne* having bevu noted in primipanp. Morr-
over, the frequency of the aoeident inereases direetly with the number of
prvgiiancitv, and Die advocate*: of the endometritis theory bvlicrv tlist tliesc
facte add to the forei- of their ar^ineut^.
Atiy of tlieiic conditioni^ may come into ]>lay during pregnancy or at
the time of labour. On the otlier hand, certain letiological facton cannot
Hb- 647.
Mr. MS.
t'raB. M7, 648.— PRKUATDKR Shpjumtton or Placenta wtni CsrciMAt ({.cuofiKiLiiiii
(Wiauc).
become operative until labour has »ct in. Among: these may tic mcution<iii
traetion i-!i<;rt<.-d by nil abnormally short umbilical cord, as well ai^ a nuddea'
diminution in the bulk of the uterine uontentit following the birth nf tJie
Urst child in a twin pregnancy or the too rapid expulsion of a large amount
of amniotic fluid in hydramnios.
Pathology. — .An thf result of the scpfiration of the placenta the
traver>ing the decidua semtina or* font through, and since the utwns.^
which is fltill <]i--<leiHlcd by the product of conception, is unable to retrv-t
in the umal manner and coiiipn.ws thc-m. haemorrhage must inevitably
result The blood may make ite way to the exterior or be retained within
PREMATltRF: SEPAriATIOS' OF THK PI.ACKNTA
807
the utcniB. Acconlin^ to (loodoll, lli« latter condition, which contititutes
whut iit Iprmcd cimcealvd ktimurrhagf, \- lialilc lo cxxur (I) wlim Wwre is
an cfTuKton of Itlooil iK'himl the |itiK'i?ntti, IIm iiiar^in^ kIIII reiniiiiiini,' ad-
iHTcni; {i) whuii Dk- plntvntu is ramplflvly M-pftrolcd, wliilv the incm-
branat retaia their attachment to tlit; uterine wall; (It] w)ton iho t>t<M>il
gninx itccvm to thp amnioUc cavity alter brvaking tlirough itie memhrainGti ;
am) (-1) wflieit llif lnwl i» w> ini'uratflv apgiiiiil lo ihi* lowt-r uli-rinc M'^mx-nt
that llic blood r-jiinot make its way post it. In about two thirds of the
cuM-ii. howrcTcr. (In* im-mbraiii-* are diomTUnl np and tV- Wood i-vr-nltially
t^icapcM from tlie wrvix, 'I'Iiuh, in a iwries of liOti eaiwti coIImioiI iiy (ioMlell
and llotnHW, the hirmorrtiu^- wa« vxlernal in l!l<t and m»LTaIcd in 1i:t.
Kigby, in K80, directed particular attention to this condition, and d«»-
ignatcd the lupmorrtiago rv^nlting frou it as accidental, as contrasted with
tlie vnantidabh it»niorrha^ fallowing the partial «eparation of a plaivnta
prvTia. In many iDstancM tliv prematurely tvparated orf^an may be sen-
qunIv dania|;n] by the hiviiiorHia^o ; and eHpecially in llic (%»£» coinplica.ti^l
by albuminuria, s lar^ part of Ha bulk is ofteti found oivupit'd by fresh
Kd infarctsi or plni.'eiilal a)M>plexics. In ollivr ra»e:<. Iiowcrvr. the only
anatomical indication of th« condition visible in the placenta will be a few
blftod-otnts npon its maternal surfacK* or about one of its margins.
t'tmica! tlUtory. — Premature separation of the placenta may occur
danng tJie later months of pn.-gn«m-y or at llm (imo of labonr. In llic
former case, the nsiilling external or concealed tucmorrhafie is soon fol-
lowed by tliG onset vt uterine eonirnctions. In either event, if the lo4S
of blood is marked, the palient presents sipis of acute aniemia, and passes
into a condition of profound shock 'which may end fatally if delivery is
not i-fTected proniptiy. Wrichl <'ontends that tin; ^hock Is mor<! often tlie
result of traumatism than that of actual hemorrhage, and may pass off
under appKipriau^ moclicinal treatment.
In concealed luemorrhs^ the uterus Kradually becomes of a size con-
i>id«nibly larjcer tlmn would normully (iim?*|>ond to the duration of tlw
pre);tiancy, awl awiumes an almost li^niMus consistency, so that the retiults
of pMlpaliou become VLTy indelinite. At the same time ibe paltont eoin-
plains of intense pain. <)n the other hand, when the hjciitorrbace is cx-
t«-nml, there is little or no rnlarf^-ment of the nlcras. and the pain is less
Revere. In ll>e former ea»e the pain and ihock are often attribuli'd to
otiier conditions, and the patient is sometimcef left to die undelivvred.
When ttie premature M-|Kinit>on of tlie placenta oceun at the time of
labour as the result of traction upon an abnormally short cord, or of the
sudden purtiiil iviiptviiig "f the iili-rine cavily in twin pntgiiawv or hy-
drainnins, eijternal iiiHiiorrhajte ji'''neral!y occurs, and in llie former case
thv fcetal heart sounds become impercvptible.
In very etccptional instaiiei-^ the placenta may Itncome «>parated from
its attachment durinj: the course of an otherwise normal labour, and bo
•■»tnide<l in front of the child. No doubt most of Ibe rft(^)nlei! cjwes were
really instanccn of placenta prtevia. although now and aj^ain. as in the cose
n^rted by iliinchmeyer. sueh an acvidenl may oocnr even vlien the plt-
centa m tiu«rted normally — prolap*e of the pUtcfnUt.
LJb
S08
OBfO'ETKICS
•
DiagnofU. — The appearance of acutv anemia, vith nmnifc-statioiu: if
KluH'k, ill n patient in l)i>' IiiIit ihodIIi* nT prf^iinncy hIuiiiIiI »lwiitii -iiiKK^i^t
Uie [jossilnlilv tit com-esieil inlra-literiDe harmnrrliage, t(ii>upii Hiniliir "vmp-
lotiiit may follow lh« niplure «f an wlvniii-wl i^xtra^ulerinv |»nvn«ncy, op
tlie vfiry (■xit-'ptioiial (;a*es uf tipuntiU3(»u» rupture of Uif uteni*. Iti many
jtn^taDcv^ tlif diuin^cwis is plaun) Ik-voiuI doulit by Uie l&t)p- sJKe of ihe
uterui and iu ItyneouA mnaUlenee, (Jiouf^b uaually it is srrivn] at luainlr
by exclusion.
When, huurever. the hiPitiorrhairc^ i<) external, the diaRnoAifi is rendctwt
practically potiitive hy tho fnlliire l" liciiionnlrati' llu- priTw-iuv iif a plaCT'nIa
pneviii, llmiigh. of wiiirx!, it is iiiipowilile tn difTert-Dtinie the ran? ea>«-a
of rupture of the circultir einuii of tlio placenta to whiHi Bwliit has dini-l>-<l
our alleiitioii. ^Vheii the aecidi^t ooeurii durinj; labour and is attendi-d
by some lo^s of blood, the syniptonni are siig^t-Klivf of Uw)M^ fnlloving
riiptuR- of iW utiTUs, though ihti Inttor accident rarely oecurH except after
a ])rala»i;cd lieciind stugv, wliile preiiialurL> fcparatioii may oticnr lit any
periiMl.
In the exceptional instances in which the hjeniorrhage is entirely retn>-
placi^nlal. a lociitiKcd elevation of tlie i-onxw|M)ndin(( portion of tJie utRTine
wall ran oeoa*ionally l>e dctectiJ on palpation.
Vrognofif. — Accidi-iilul luiinorrhagf. whelhtfr Mtemal or «»n««ile«|. in
one of :he inont serioiw complications of preunancy and labour, practically
nil of tlic children and mniiy of the molhiT>: [M-ri«hing. Tliu-^, OnodeU and
ijolijiM re|»ort a malcmal and fo-tal mortality of 50.9 per cent and 114.1
per cent, and of 'i'i.'i \niT cent ami 85. S per cent respectively.
Treatrnfril. — -In the nmn- ninrked form* the life of tlifl mother can be
saved only by pi-ompt evacuation of the ufenis. On the other hand, when
the wparatioR in partial iind the lois of blood hut flight, the ar^^idenl may
be without serious si(;nifiennce. In the latter claM of eases an expectant
Ircalmetit )ihou1d Ih- purKuc<|. and lalwinr allowrd to luki- \\s natural ooiir*e,
interfereiK* tieing indicated only when tlie symptoms become urgent. On
the other hand, if tlw patient presents sigOK of acute hitmorrlia^. whether
of the concealed or external variety, the Uterus should be emptiinl with iIm-
Icn^it posKibh* delay, in onler that it may n-traci and thiw coin])r(s« the
bleeding vessels.
If labour has not yet set in. th« cervix should be dilated inFtrumentally
to a sufhcienl. extent to |»ermit the introduction of a Champetier de Bib(«
hnlh'on. iiTiil. as soon as Ihe inti-rnal os has become ohlilenilitl. furilier
dilatatiun should Im! elTtvled by Harrin's methotl. On the oihi-r hand, it
the condition of the cervix permits, manual dilatation should be employed
from the outlet and the child promptly delivered by version or forerp*. as
appears most advisable. In the rare caaea in which the aymptoms are
urjjent and the cervix m rigid that dilatation cannot he pmniptly accnm-
plinjiii], vaginal Ca?sarean section will afford a most satisfactory means of
delivery.
Xot uncommonly the tonicity of the uterus ha* fieen so impaired by (he
loss of blood and the distention to which it ha* W'n Milijitfliyl that it faiU
to contract and retract during; the third stage of labour, and as a lesolt
PI^CENTA PILEVIA
S09
profiiM! pOHt-parinm ha?mnrrha|^ ina; follow. Thut prwihtlity Bhoalil
a)wii}v bv iHiriic in iiiiii<). iin<) I)k- ojxi'riilur lOiouttI liave in readinu^tt t\w
lUK^i-wiiry iiiaI>TiaU (or [iiwkin}: llic merus at n iii<iniciit*s iii>li<M?.
Plaoenta Prnvu. — 'IIh- movt cainiuon vati^ of aiito-inrtuni harinorriiBgo
is Uh- parital M^jnirulMD nf u friacnnta iiiiplunliil in the Deigliliaufhoo<1 of
thf iDlprnal o*— plawmta pnefia.
(Iiir iiinnr!til>n' iiiiic-niriig lliin oknonnalitv may In" laiil lo ilaU- from
the eDil uf thi* sexpRti'enlh antl ilie Ix^jtinninji; of Itie ei);hlei?ntli oi-nturies,
ParUl. in lOHS, antl Schachn*. in ITOO, having acciirntvl; divcribi'd tho
condition fmin a clinicjil and ao anatnniioa] point of vIaw. \o4with)itaiid-
in^ iIh* fact that Snu-tlic. William lIuntiT. and lligtiv wcrvwvtl acquiiintMi
with placenta prsria ami itu dan^rs, rery little advance was made in our
f-iK-ftW.
FicflM
Cl'.:,^,
Piml M>, (tSn. — Sivwtxo r>irnc«tc)tT Moac* or PLA<ncxTU. iKianiinr.
(Holikd tram AmcricwB Tbxi-Boak.)
knowledge connrnin}; it until Barnm promulgated his vit-ini as to its mod*
iif pmduclion and tlw mL'lhodn iif (t>nlr»l)iii^ tin; )ia-morrh«g« arising from
it. Hiact: then utanv invest igators have buRieil them»ie1ve« in (leatThing for
its mode of origin and i)k- ninut iiiitaMc limlmeDt. An excellent hii^torical
rhumr i* contained in von HerfTii mon(^rap)i.
In this condition, the placenta, instead of bein^ implanted !ii|^i up upon
the anterior or the poKlerior wall of the utoruR, overlajM tlte internal ob
til a gfPatiT (ir litwr extent, tlierchv Vx'oniin)^ acturwibU' hi tW exam-
ining finger. Orilinarilv, threi- varieties are diAtingui:>he<l: Plarenfa
previa crnlnlU, lalrrali* or pttrtutlu. and inarginalia. In the lirtit the
inlenial (m i« coiiifdetelr enrore'I by pla<N>ntal tinxne. whieti in aitln'tiMil tn
ilM marxiofl; in the M-rond (he placvnta enenuu^hefi niorv ur law upon the
S12
OBSTETRICS
pUtc^nUt gniwally brtdgod orer Iho inturnal tu and et-entu«]ljr came in
cnnltM^l ninl {mm-A uitli llio dtwiduii vera, utter which rascnlar ixfflncciioiifl
with the uWriin; will became eswblUhed (Fig. 652).
This view at once met with very favourablo oon^idorBtion, and at Uic
1887 meeting of tlic German Gyniecological ('ansn'-'U was a^in aiTungt?
advocated by llofnifior, M ih<!
mint- (iit)c, while Mating that he
had e\amin«d Dumcrotis spuci*
meiiM U'hioh apjiiurcd to Ruli^n-
liate this mode of origin, hi*
udmitlcil that it wts not the
only manner in which a pla(?cnta
pnpria might ori(tinaIi'; iiias-
itiuch a» ill <«rtain instanecs the
i'.i[li*Ui<ii>n o( tlirt pla-
Scrotina cL-ntal area niiKht in'
niiderwl posiiiblv hy
a process of rleavsg^
in the decidua v-ra,
as the rp»iilt of wUieh
the margin of thi-
or^'an would extend
RcdcM hc-yond the Ecrotina.
Should Kiu-h a prm-
csH extend ilowiiwanl, it was read-
ily conceivable that the placenta
might grow on eillier siiv of the
internal o«, and. a^; the latter tw-
tame ohlilcraliil, (roil) pU>lely4»viT
it. At thai time I'eteni's orum
had not Ih'cm dewrilK-d, w that
Hofmeier waw not aware that an nnalof^oug process probably occnrs in every
prcfrnancy at tin- tiorriial phiceiilal site, Ablfcid and Ax'hoff, in lil(l4,
admilliil llie i^orreetnewi of this explanation, and i^tated tlial llie eloitva^
mij;ht e.xlend •^o far a>: !•> give the impnjj^«ion that a part of the plocinila,
nl lea.-'t. Iiiwl developed in the wall of the cervit.
8traM6Ti)ann. in IflOl. pointed out that one of (he most important facton
in tin- dcvfhipmeiit of placenta pruvia was |o ht' found in defective va^ii-
IsriERtioi) of the dcctdim. the result of inHammatory or atrophic changes
the Inlli-r licing favniin-d hy ri'[N'«ti!d and closely following: pre^aneusc
Such conditions, he maintained, limit the amount of Mood going to Uw
plaiTnta, fo that in order to obtain its retiuinitc supply of nutriment it
becomes necessary for it to spread over a greater area of attachment, and
in Ko doing its lowr portion occafionnlly approHchc!' llic region of tli**
internal f>*, completely or purtiiilly overlapping it a.-* the caw may be.
PlauKibility is lent to such a rit^w by the fact that the placenta in tht*
ahnormality \* xpreiid over a greater arm of the iiterud than unnal. whih>
•t Uu eatne time it Is often conaiderabty thinner. Thua, in one of my
, 6fi2. — IM»(in*M ii.i,t-"TKATrs>i H(>r»it:ir.it''t
HEiint <ir me Foumaihik "r Pi^utiuita
PLACENTA PR.EVIA SIS
MM*, which etmti to autopAv, ibe iilaoeDtat Mte occiipiml four Gfllu of
the interior of tbe uterus.
Id view, thcrefon;, of I'pters'a work upon the normal implantation of
the ovum. (M wHI ILK .Strii>i>maiutV thi-orclk-u! ilixluctionx, ii appitnt prob-
ahle Dial in moHi cane^ plaii'iiin pnt'via n'sulls rmin the pririiarv Jinplanla-
tJoD of Itii' ornm in tho lower portion of ttii; iitcni^. a-ioL-iBtexl with e.vtvii-
Hive cli'avnjrc of tlio <)i?ct<)ua vt-ra. liy nliit-h the exu-iixiiiii of iht- plact'nta to
tlK' nv'on of Ihv tnlrrnal os is facilitated. At lh« tamv lime the posfti-
liility of itit occaiiional dcvolopiiicnt fn>ni a n-tlcxa jilat-iiiia niuiit be
ad mi I ted.
Very McfplionaUv, ■» reported bv ton Woii*. Kvilmaan. Ponfieit, and
Kermaancr, a part of the placenta is developed upon the upper portion
of the cervix. Tlw" pnwibilitv of «ioh an owunvm-c mu^t b« admitted,
althouf;!) Alitfeld and Aechoff have Hhown that it is more apparent than
K-al. a* ibv condition Ik not due to a primarv implanlalion, liul rather to
a ftcooiidary ciiavajte of the cenix bv llie exicDsion of a placenta which
had been primariiv implanted above it.
St/mploma. — The mont characlerisitic nvmptom of plarenia prx'Tia ia
lupinorrhage, which tufiiHllv d'H« not appear nnlil after the seventh month
"f ptt-^.Tiancv. At the same time it in |)roliaiili* that not a few i-aiws of
abortion are due to lhi« condition, although tlw true ^tatc of sfTain usually
Mcapee obwrvation. I hare wen wveral abortiona in tlie tliird month
which wcn> ck-arlv due to tht« abnonnality.
Tlu- hanmirrlinne fn>i)iu-nlly eotnc!' on without warning; in a pr^nant
woman who had previously ennsidered lu-r^lf in perfect health. Occa-
iiionally it mako it» fin>t appeunmet' while Uk patient if. u>le<'p, to that
nn awakeninK and feeling the bedclothes moJEl, site is surprised to find that
nW w lying in a pivil "f liloiid. Onlimirily. iIm- initial hliHiling t«aa(!S
fponlaneously, to reiur aftain when lea^t expected, th»ii^h in rare instanoea
the firi't hwm^rrluiKe may be f» profui* a" to prove fatjd. In other ca*(»i
tlie Iilotsling dt»ett not cease entirely, there being a continuous disf^harge of
»niall quantities of a bl<HH)>»taiiHi:l lluid, which eventually ki ni-akcnx the
woman thai a comparaiiveK flight acute hemorrhage may \m- »nflicient to
caure death. In a ci-riain pnijwrtion of chm-*. particulHrty when the imwr-
tinn tt> marginal, the bleeding t\ot* in>l ap|iear until the lime nf labour,
wlum it may vari- from a flight, hlood-Ktain^-d dim-harge In a profuse or
even fatal ha>ti)orrhage. A» a rule, it is Ichs copious in this than in the
other vnri^'tiii'.
The tu'xie of pnxluction nf the ha-niorrhage is readily uiMlerKimN] when
line recalls the rhang<« which take place in tl»e lower uterine si-gment and
in the cervix in the later weeks of pregnancy and at the time of lalHiur.
When the placenta is irurrted centrally, it i» evident that as the formation
of the lower uterine ^eginiTt an<I the dilatation of the internal m progreMCa
t)ie plaeental attachment'! muct iiievjiably l>e torn through, the rupture
)>eing neeetearily followed by lupmorrhagc from tlw inlflrritlotiH s|ncvt; and
from the vr^^x-U of the di>eidua. MurnriviT. ax i1h> lower uterine N-gm«nt
lievoines developed, it is impostiible for the ovam to follow its retraction,
and eomtc^iuctitly the conneetioii betwet'n it and the phiceuta mutt of neces*
814
OBSTETRICS
•ity be more or lei« completely severed and Iwmorrhaxe reenlt. At the
tomtit! tiiiii', tlk- blttxliii); is favnuroi) hv the fait Hiat It i^ impOti^it>lc for
the stretched libre^ of the lower utt-iino ^fginiMit to compress tlie torn
vcitMclit, AS i» the «uh: vhvn Uiv phici-titA tHvomes Miparated during tlie Uiird
stage of a Dormal labour.
A« tho plnci'iiiii pni'viii ooeiipitv Uwj lowvr portion of the iitwOK, it
interferes wiih the accoin modal ion of the ficlal head, aiid eoifc!«|ueatly
Abiiormal prc^culutiooK nrc uiiusiiAlly fre«)in'iit. Miiller Imviug ni»tt-d '-Ji'i
tran-sverin* and 107 breech presentations in 1.1 tS cases.
In normal lubonr uU danger w ortJinnrily piisl with thtt <i>mpk>tion of
the second tita^e; but in placenta prn?via, as a I'e-ult of ai>norntal adKttiions
or an oxccwivdy lnr|r« an-a of utluchmciit. the |»rnti.*< of wpuration i»
ttoiriotinitti intfirfered with, while in other caiws thei-e ii> proDounci>d tend-
ency to atony of IIm; iik'rutf. v\s a result. profu*f hwinorrhagc infrivjitcnlly
iuriir> kfti^r iho birth of the diitd. and except ional I r the manual rcmoiral
of the jilacctiitt becfuncs ncfcjssary.
fiiagno^ui. — I'lact-ntii pnevia should always lie suspected in patients suf-
fering from uterine htpmorrliagc in the second lialf of pri^naiirj, and iti<
pi^ibility ."houhl hit lH>rn<- in iiiiiid until a careful examination has rertnled
80m« other satisfactory e.\p!anatioQ for its origin. In the gn;'-ut majority
of cjiM^ tin- cvrvix \it (Miftor and more succulent tlian usual, and its «anal
is more or less patuloufl, eo that but little difficulty U vxperienn^ in carry-
ing Ihc TingiT through the internal os and feeling the characteristic sponge-
like placental tissue, or at least making out a sogg^v, thick subetance'lying
bfftwi-cn the Qngcr iind the pri-scnting port. When, however, Iht' cervix
is not patulous it should be dilated, uniler anivsiiicsia if necessary*, stilfi-
cicntty to permit the introduction of the linger, which is then pwiMd
through the internal os and swept around ibe adjacent jwrtion of the lower
atcrioc segment, when the presenee or absence of the abnormality can be
positively dctcmiinwl. It is true that such a procodure oivasion^ly re-
sults in the induction of premature lalmur: but thi; risk i» nc^'erthelcsi
()uile justifiable, sinct* we )iossc«s no othfir me^na of arriring at a definite
diagnosis, which should be made at any cost on account of the very eerioiu
menace which the existence of the condition offers to the life of the
patient.
/'roynojtin. — The piogiioois is always serious. According to Mttller,
under ejipcctant treuluicnt the maternal mortality varied from 3C to 44
per cflnt, while for the children it was about 6(1 [>cr wait, one lialf of thoiw
which are boni alive [tcri>^hing within the first ten days following deliver)-.
The daiipr to the mother arises primarily from hjcmorrhage. which t»
iixually the direct result of the condition, though frequently it may he in-
creased by di-ep oervicnl tears rcsutling from too hasty artiReial dilatation
or the extraction of the child through an iuiperfecily dilated cervix. More-
over, snch pnlifTits an;- particularly prone to puerperal infection, which is
favoured by the presence of the thniml>oi'cd sinuse« in the lowpr uterine
segment.
Tlie ta-\a\ mortality i< due in great part (o (he fact that many of the
cbildreu are honi some wv^ks or montha prematurely. In many uistaDces
:
thry pOTieh from ospliyxlutiou. tlif it»iiU nT placc'nUl liipmorrhftge, while
(MM-nMUiDally Uioy t^iiccuiub during attenipU nt e:klra(.'1ioD thiTiu);h hd Im*
Nowada)^, tlie niati-'riiiti morulin i1qM>ni].-> )i|ion tlie variety of (he
placenta pntriu, tho method of di^livery, anil Itio <M>ndition of ibe patient
wtieo first tii^D. TtiuH, id liS auti« rejHirliil liv Ilufnit'.ior, Be)im. aiid
[xinxrr, and Ircntnl by tl diff^vnt obeU'triciaus by combined rereion by
the Bnixtoi) Hickii mnnti-iivn^, tho iiiatvrmi] morlality waji 4.S pt-r l\*ii(,
whcrcui^ H.'i ca^c« Ireali'd by the three operntorti niiiitiontxl i^howed fl mor-
tality of only 1 per c<<nt. Koblaiick n-iHirtM a •Wth-riit<- of li.S per cunt
in -m? catoi 1reat«'d in the I'rauenklinik in Iterlin, and Htir<;er and Graf
onne ^f S.HH per cent in '.H'i c«»i>h <>h<TTi-d in
SctiaulaV clinic up to 1905. Of tlie 30 deaths
in tlw lairi'r «'rii-s, 7 wm due primarily to
lueiiiorrha;^, 4 to laecmlionF of the cervix and
hivfor titi-rtnc m^fnii'-nl. 1 In [iulin»iiurr wn-
Mism, aitd 8 to infection. Acconlin}; t'> their
fijturcji, iIm- pmgiiiisit i* fn>m S to H lime* more
serious in central placenta pnevia than in the
Dtlwr TariflieM. JUircovcr. the mortulily de-
pends n|ian llic condition uf the patient wlien
fir^t MK-n. it bein^ evident that women w)to
liavG Kiifrered from profuse ami re|)eaied blct-d-
ing have tar liim cluincr of rocovcn,- tlian lliow
wIh> come undtw oWrvaliun after lh« firxt
pli^jht haroorrhajte.
riiforiumitely. the fu'lal mortaUtr has
Mhflwn eomparativety little decrease in recent
war*, Kiii'tni'r. Biirgi-r mid (.inif. ami Slra*i»-
inann ^rin|; pcrcentaffes of 36, &S, and i>1.23
re*|M?ctively. A vi-ri' )cnttt improvement in
tins resjiect is hardly to l»e anticipated on ae-
ciiunt of till- lar^f number of prcmalure chil-
dren with which one has to deal.
TrmimcHi. — On (kccmint of the danger of
pmfuiie and oiie.xpt'cted hemorrhage, pre^*
nuiKV or lulKiiir, a» IIh- caM* may W. should
In- temitiuiiiil in the moHt eonaervatiie man.
ner as soon as possible after a placvitia previa
1ia# been powilirely diagnosed. There i» no
le melboit of tr^'almcnt applicable to all
L>^ and the nbNletriciiili who umhrmiandst
how to differentiate his eaaee will obtain the
b»>t rMult^.
If the din^Txt^i* '** made dnrinfc prefoiancy. the cervis should he dilated
by means of the fin^r or by the Goodcll nr TT<^ar iii*tri]ment sufficiently
to permit the introduction of two tiniferx. This having been attained,
further treatment will depend upon whethvr the child is viable or not
Fm. 0S3. — Focrim PurTuu.T
BXT«A(-TSII mint A pATtEXr
l>Ti9ia itr Pi-ti-rnTA Pd*-
VIA. UIDWINO 1UW IT Jtcn
AH A Tamkim (Laopold),
816
OBSTETRICS
In the formfir c«fe th« liwt ni^ulu an- ohtaiiiod bj the intrmjuotion iif a
f')uiiti[>i-ti<-r ill' Itiks iKiltniiii sflor nt|>liii(! of tlio iiiotnliramv or |KTforn-
tion of till-' [iliifenlii, antii'iliti^ a^ ouc has to deal with H laUTal or central
inmrtioii. ililatalion Wmg huxtomil hy iiltufhitig a ;S-|Hiiinil iri-ight to tliu
end of the tube by a Hiring and su8|>e]u)ing it over the foot of Uie bed.
Oil llic other luind, if the child h not viable, niually good mutvrtial re&u1t«
are more nwlily obtainod bv brin;;ini; down a foot hv Braxton llifliV*
mantpuvin- ami ii'inj; thi' liKri-h of lln- cbiM a* a tHtii|K>ii to control further
bleeding. If liie lia-niorrhajie ceajiSH after the font has li«-n bniujtbt down,
Ihu GxpiiUion of Ihv child may be left to Nattirv; but if the onzing con-
tiniies. ^I'Utlf traoiion should he made upon tlie teji; r^n a-t to Kiinjin^* the
placcnlH with Ibv chtldV botlock*. Whichmir mvlhotl is einployfd, oxtrao'
lion i>l)Okil<I not be attenipie<l until the oi'ri'ix U ct>iii[iletely dilati-<l. or at
least sufhrifDlly so «>> to jK-nnit the ready passage of the ItL-ad. Too jjreat
baale is liable to eaune deep eervlral Icttr*, giving riw to )in)fu»i- ha-mor-
rhage nnd rcipiiring tho application of isutiires, while in other iiuitancita ,
serioiia diftieully may be eneounien-i] in delivering the ohilii.
GMK-rally speaking. In-tler ri^iilts will be obtnimxi in private practice
by the employment of Braxton Hiek^'.i bipolar version, no mailer what
may be the cnridition of the child, for the rea-^n that the average practi-
tioner will rarely be e<]uippeil with a xuitahle biilhioii and the iKwKsar>'
paraphernalia for its introduction. In hospital practice, however, its
ctiiploynient baa undoubtedly ai<le<l materially in diminishing tliu fa'lal
mortality.
In verA- exceptional instances in priiniparons women, the cervix may bo
so rigid that it in impossible to dilate it suffleiently li> pennit ihe employ-
niiiit of eitlK-r of the a lii>ve- mentions] prwc<iurc». I'nder siieb cireura-
atances, in the hand^ of an expert, aiidominal or vaginal <'irtan-an evctinn
may bo indicated, but in general practice a tigtit cervical and vaginal pack
of sterilixeil gaiii'.e hiinitap* shnuhl In* applied. After n-maining in place
for a few hour)' this will usually bring alKiut suilicient dilatation to penuit
the employment of whatever itinnieuvrm may U^ dii-iniil neci-»«ry. The.
USD of tlie pack, however, should be reeiricted as far as pnsaible, and
sliould he. regiinleil merely as a teniiwrary exix-ilient, ]>arllr on areoiint
of the dimmer of infection, but particularly Ijecaii** it may give rise to
a false sense of security.
At the time of labour, the treatment depends upon the deftree of dilata-
tion and the etindition of the patient. If lh« cervix i» oldili^ratnl. imme-
dinlf delivery by version or forceps ia indicated. (In the other hand, if the
dilatation is only partial, the biemnrrhage slight, and tlMt placenta insertnl
marginally, good results frequently follow nipttire of the merabrane:*, sinra
the plat-enla is thin nlile to follow the relriicling uterine wall. In all
other eases, provideil the child ia alive, I prefer to complete tlw^ dilata-
tion hy means of a large Ohanipetier dc Rihes ballonn. Kor this piirpnse
it should lie intmdiiceii inln ibe amniotic cavity after rupturing the mi'm-
brancc or perforalinit the plaeenta aii'oniing a* one ha.* to deal with a
partial or eoiiipleie plaei-nla pm'via. and gentle traction exerteil hy
the hand or a weigbt altacheil to llie end of the tube. After dilalallou
w
^
I
Kre{
I «(1
■fth
PLA(E.VTA PRjBVIA 817
V(>in|>lvlcicl. <li>liv«ry is luually bcKt vfTocU'd by n^raion and ex-
trarlion.
If, hoM'tnirr. Die rliiM i* AcaA. or ■ bflllnnn is trnt avatUbIt*. equnlly
lUfac'torj nwalb umy be iilitaliied by Krii\l(tii Il^'k"'* iit(-lliO(l of bipolar
Tvrsion. proridnl L-xlntdion is oot alteniptcd until t\ve cervix ia fully
dilalii].
TUe practitioner in eam«<tlr wampcl a^rainM the emplayni^Yit of rapi^I
DMiniuil or iuKtrtiiiM^ntsI ililuutioii. In l)ii« cln>^ of cilm"' tliv c^vix is
piirtioiilarly prone to iHiMrration. awl do matter how tcraibially iihil care-
fully llw ililninttDn may Ix- vffi'iTt^-d, dwp tcjir* fni|iifi)tly rwMlt. 'Iliiiw
may cileii<l far out inlo the ba^ of the brrwil lipiiiicnt or tip into the
lowi'j-' uUrlno w^mi^it, and occuoioiially entirely through tiic uterine wall.
I recall one of my own ame^ in which ih-ath ri-Miltt<<l from a lar^'
bmad lignmitit laeeralion following: a tear through the lower uteriuv
M-ifineiil. whieh I thonitht hail Ihi-h >ali>>riu'torily n-paJiitl, an well a^
M-f'eml vonKultatton cufcs in whieh laparotomy and amputation of the
titenin wax DeettMary lo ehoek Wniorrhi^Et! following coniplflv nt«riii<(
nipt u re.
Arrt>nlingiy, this ni<>tho(! of tlilnUtion Hhonlit l»e n>«Tv«l for very
ffxi-<-pl)onal ctt>*«. and then the physician should ln> |irt>parc^t for ati occa-
ional tnifrie endinji.
As alrvady indicated, alt dan^rer baa not patwed with the delivery of
thtr child, and great rare oliould Ixr i^xereiKftl in ili*.* I'lmduit of tin: tliird
sta^' of labour. If there is no h»n>orrha^. enprmi^ion should Dot be
Itiinpled until t)tc placcntA hn* been expelled into the vagina: but )f
blee<lin>! is profuse, IVeiWH method of expreiwion flhould lie immediately
renorlnl to, and, if not effective, tlie plac<;nta Hhonbl Ih' rcmovetl manually.
Oeca^ionallr ll»e lo^s of liloiid cYinlinuw afior Iho i-ompletiim of the third
filagc. hi »urh cafc« the eervix fhould be inspected, aitd immediately
paired if lacerated; but if no leaioitit are priM-Jit, an inlra-uterine pack
rlxiulil be inlroiluccd.
Whenever the hii-niorrhage ban l>cen pnifuwe, ami the patient pretents
the subjective symptoms of on acute anemia, il l>eoome* nece«sari' to resort
to llie constitutional nieannriM outlined uiidiT ihe tivatmcni of ]-ist-partum
harmorrhattc. Ocrwionally, when the patient ih innrkedly exiianjpiinated
whi>n fint ^leon, but x* tooint! little or no bl'xxl at the tinH', it U better
to devote one's attention to improving her ^'Ocral condition ratlwr than
|o atli-mpl inimittiutc di-livcry.
In view of ihe danger to the mother, and particularly that many cbil-
dpcn are wM-rifiw-d by Itraxton llick»'s niHhiH.1 of vi^wion. or by extraction
Ihrou^h an im perfectly dilaliil rtTvix, Tail, l>»QO|;hue. I'almer Dudley, and
others have recommended tlw jierfonnance of ('a.»kan<«U »vlion, provided
<e child ix viable kihI the {Mtit-nt in ^ml condiiiim.
.\ii tJw retiultD obtained by the metliods of treatnimt outliiiMl above
are quite ftatiafactory ro far as the mother i* concemi.>d, it seem!) doabtful
whether (iamre-an wction will come into very jjeneral une. particularly aa
the a)MTatioD is applicable only to patient« who arc in ■ liospital. or tliu
rich, who can be iiiirruunded bv every convenience and fiafegiuird. If such
.
81S
IIBSTETHICS
a liue of Inwdm-nt wxirc »tlmiii>li!>l anion;; ihe pnonr diviM-i' in tlwHr iivii
hoRiee, tlie <Iciath-rHtc, I ain iiaro, woulit lie much grealer lluui Ihat oblai»»l
by th« UHiial muthod?. M<>n<i>vor, as bin; Ixun mJd. thu fii^'liil miirtnlily in
any c»*e in nut ituxvptilil^ uf any iiiiitiTial rciiuelioQ, far tlte rea-wn lliat
Iho prc;niin<^y ■>' generally terminated before term, wlicn ttie chuum uf
i>xlra-iiI(;riiio life nnt n^latively inifavimraltlfi. Khreufi^t and llnlmcs,
after carefully coDKideriut; the subject, have arrived al tbe mmc i»n-
el UK ion.
At the same time, I am prepared to admit that Cssarcan eection may be
[)k- (i|u-i'ii1Jiiii at (■h(ii<t? in a vm' gimuU numhi'i' nf ca^s, m, for inAlaiife.
vihea a primipara with a very rigid cervix and a living child is overtaken
by profiifft lia-niorrhago. Hueh conditiom:. liowcvc^r, am m> exoeptiunal that
it appears to mo that the field of u»«fiilnc« for th? operation is very
limitL-d, and ihat lU widi^prt^d oiiiploymcnl woidd he pnidiiolivo of far
inoro harm than good. Biimm, in l!)OS, atrongly repnmmended vagina)
Cteswrean xivlion in »iich citntw, l>»t our (^|><;ri<!D(« with it i* ^» yet toa
iimitcxl to piTmit a judgment a* to its value.
The mmle of prmlnction and »igiiificun<« of ultglit unU-parliim Iitrnior-
rhage, uhich sonietimes follon's intra-uterine rupture of Ihe cord or tbe
tearing <if lii« vftwel!< of the vclamentously inwrled umhilical oord, have
already liecn considered in Chapter XXVllI.
Poit<parttim Haimorrhage. — With the exception of tl>c very rare cajw*
incident to invtrgion of the uterus, a seriouit bleeiJing following the birtlU
<if thi! ihild is twually due to one of three causes. Of Ih«»e ihv mo»ti
common i* retention of the partially jteparat*^ placenta or of iiKlividiial
cotyledons; lc«8 often it is due to deep tears involving th« tii^sues of tho
birth canal, and in very rare ini<tanc«M to defective funetJoninf; at Uic uter-
ine muHcnlaturt' — atony.
Ailioliigtf. — .Kt. long a* the plnoenta remains firmly altaehwl to il*e uler-
ine wall the possibility of hemorrhage is slight, but when it hax become
partially ^epnrnti'd. the norma! action of the uterine muKculatxirc is inter-
fered with. As a rreult, thf torn vettsels at the partially dejiudeil placental
»it<J are Mot collet ricli-d, ami Hcciirdiiigly more or leM profuwc hH-morrhagftJ
occurs. Imperfect separation of the placenta ean usually be attributed ta*
improper management of the third stage of lalwur. partieularty tbe ton
early and emrgelic employment of ('rede's mameuiTe. Exceptionally, it
may nsiill from an Mliruirmaliy iutiiiinte atlachmint of IIk- placenta, ihir
to a decidual endometritis or some other morbid oondilton. TW n-tenliou
of imilated cotyledoiui or of a i^mall succenturiate lobe inlerferea with ihc
normal oontraetion and retraction of the uterus in preci^y the same
manner as the partially wpiirutcd placenta.
The part played hy deep tiiirs uf the gc-nerntive tract \% perfectly obrl-
oa«, and will be considered in detail in the followiog chapter. J
In very rare tnntanetw wrious lia-morrhnge may iwhII from rupture oP
large varicose veins, of an aneurism of the uterine artery, or the dis-
turbance of areas of thrombosis in the cenix.
Formerly, alony of the puerpernl uterus was considered llie most fre-
quent cause of {x>«t-par1um liwmorrhage, bwt mam careful nb<<erration Uas
POST-PAHTUM ILEilvHtRHAOK
819
sImvd that Biieh a oomlition is wltioni (trimarv ; for, vtilU the raccplion u(
lh« nxv i»#t«)Ktf» lit wlik-tt il fiillowii vx<-<w«ivf iliHtention of the uti-rud
iiKid«nt to twin pivjtnanfv or hviirainiii'w, noriouii ahiinniiatilies in Iho
coiitraotiltf fuiK-tinn of IIk- ut'Tiiii- miiMulHtuR- tin- ukiihIIv u-«<i(-in(ixl witli
Home nie(-tianii>«l iiiit--^^ »m-)i h.i ri'Ieiitiuii of [xirlionA nf \he pluLvjita, th«
pn-M-iKv uf tDyoraalu. or iD ran- la-wi^ liK> i>xi»ti>iiro of wllwsitiii.^ iK-twtvii
till- utrrui* ami iIh: niHToiimliiix nrgam. Ocitutiniully alony may Itc iua»>
ciaUil with 4)i>^ncrati<(ii of th^ mii^clo filtrvs n-^ultin^ froii) un Hlrnqmial
iti vail inn nf fn>liil rlcnn'nt*. ii» iIcxcrilHil liv Ku'iimotuiiKky, Murliii, and
otWn. It ia pn>lMil>l«, bawcTpr. tlial Veit goes too far in dvnyin;; in tola
lliv ptiisibilily of a primary vtony, ultlmugli t\w guncra) tcotK'ncy lo ovcr-
etiiimale its frequency muat be ftdniiltid.
niiL' rur<! cuM-x uf bii-ntorr)iii^- fnllnning ]iirxilti*U at Ihf pJiiccnM sxtt,
in which the re«t of the or^^n lemainA firmly contTacted, aii in tbe cases
roporivd by Cliiuri, Itniun and 8pn<-tlt. OUhaitn-n, and nlben, point to
(lie possibility of a partial atony, while tlie oceanional instances in which
putieulM l>l(i>d profuM-ly aflor each lulwur withmtt dcmonslratikt ciiiii<e,
likiruirie afford corroborative i-i' idi'tice. At the same lime Ibt- po^ible
fixiHlvntv of hn'mopliilia Klmiild rtlnaj* In- Ixirnu in mind in Hich w<Hn«n,
as in a case rvpart«d by Wehle.
ffinieal Hulary. — Ha-[nnrrhngi> may ixvur either during or aftw tlie
third stage of labour. In the liriit dans of cases, as a rule, it is the result
of tear* or uf partial w-|iaralii>n of lh« plaoenla. Fortunab'ly, liiciiiorrluigc
dependent upon tiie latter cause is usually not serious, for the reason that
ia the vast majority of atich cases the conditton is only transitorj'. complete
separation nci-urrinj|f spontancou.ity an the r^ull of uterina> contraction,
when satiKfactory rt'traction chocks t)ie Inxs of blood. Exceptionally the
bl(<n)iii]{ ni»y {HTiint ev4-n after the pliutiila liaii liecome completely sepa-
rated and lieii frw in tlie uterine cavity. In such cases, howciTr, it is duo
either to tcant or to im)>erfcct functioning of the uterus.
tjeocratly speakinf;, partial wparation occurrint; duriflf; the course of
iJacn-nlnl rvpuUmn by lUv St-hidl/c mtvluinii'tii i» nut aix»rii|>an>u(t by
external ha-morrhage until the placenta escapes from the vulva, when the
lurgt^ anionnt of blood c<>ll«cti-d Miind it i* ituddttnly ditchargcd. In
[luncanV mechanism, on Die oilier hand, the loss of blood continues
Ihnnighuut the nitirc plno-iitiil ix-riinl.
A ba^iiiorrhape which (legists after the extrusion of (lie placenta may
be dup to tears, rrlrntinn of placental n-mnanlo. or lo atony. lu the first
tkure is a steady flow of bright-red blood, which liepins immediately after
tlw delivery of the child. When the hsrmorrhaiR! i* due to n.>(>nitk>n, thu
blood eHca)>es in pushoi, which are apt to lie synchronous with the uterine
contractions, and fn-«jucntly in \argc clots', whcrt^s in cases due (o primaTy
atony t)icn> i.i a continuouit tlnw of blood, which may be so abundant as to
cause death within a very few minutes.
In rare instances, crcit after the discliar^' of the placenta, (he hspmor-
rhag^ may lie conrfaUd. several litres of blond sometimes accumulating in
the nterine cavity.
TIte amount of hlood lo«t during n |KHt-|Mrtum hwinnrrliage may vary
■
I
S20
OUCTETiacS
Jtroni 500 t? 3.500 or 4.000 nihic renliinfltns. the lattor pxtre-mc. Immrver.
baioj; ii)V»mli!.v inpom|>atilili' wiili life, lifnwiilly six-akiiij;, lliw woiiinn
ill lalxmr can lirar with iiiiii|mnt(ivi- iiiipuikil) (hy los. iif »n nriinuiil ii(
blo'iil uhii'h Hiiulii M-rioiLilv pi]ilaD^'<>r lliv lifi- nf n wdlrilfvHoiiiil man.
ulthoD^'li it* c-fTix-t urill il(r[H-ii<l iii<ii\' iiimii lit-r ;triu'riil I'ltiHlilimi lliaii ujiuu
the ac-iiml tjuantity lost. Thus, a woman who U already cxliani^tcil by a
[irolongtil labour or wcokcjiwl by mid-ttfli-nl (liM3a>u>, may succumb afb-r
a loss of from 1,000 tn 1,.500 cubic ccntiniL>trv». whidi aliivrit »uIIi't willi
im|ninily. As u niU-, ibv Iosk uf m muhII Hiiuitiiil of blood is not «IUiiil<ii
by si'rioii.-. syiiipUmtA: but when the hipmnrrhasc i* profu.-* the pulw? bc-
comt» rapiti niiJ rompn.-Ksiblc, tlic fan' biH.f>»n^ jiaJlitl ami awumoj* a drawn
appt-araooc, while at tlie same time the woman may coiqplain of disturbed
vision. i'liil1iiiir<s, and uliorlncj^i of brvfllh. In twlnrmo tM*C* itj'mpliimi'
of air bimger ajipear, and the patient usually passes into unconsciouimcAe
iM'fort? thi- faini termination.
Oiagiio/ii».—'l'iw diagnosis otTers do difficulty, esccpt in the rate in-
ittancut in which the ha^inorrhngc haii tfikvii plaiM* into tlie uu>rin« i.-avily
and does not appear exterunUy. It must, hoirever. be distinetly stated
Uiat ooni'Cidnl liiiiiiiirrhii^i- slioiilil never oi'cur if the rmidilinit iif the
uterus is eonst-ientiouily waleheil. altboti^li. if routine preeautions air
weylefleii. llii- lin'T iriilii-atinn of the c'lmdilmn may Inr alTordnd by the pale
and liajoiard apjK'arance of the patient. On examination the pulse-nite
will Iw riHiml {.'n-iitly ai-eelerali-d, the utenui markedly ini'n'a«sl in si»',
and pre-eniiu}; a doughy eonsi^itenee inf<lead of tlte chu^aele^i^tie lirni.
hard I'l^nsaliun offcrt'd by (lie iionniil jinerperal or^n. I'rcwsuru upon it
is followed by a copious flow of blood fruni the vaxioa.
.MlhoHgii thi; source of Ui« lia'rn<irrhagc is sometimes »ory bard t"
trace, yet inasmuch as the deeision as to the proper treaiunuit of ibc
(Mtit'lit friHjuenlly depends upon i|!< reeognilion, a ditTerential diagnoti^
is of the utnitBt importance. (lenerally spesikinji:, if the ha-niorrhage cam-
meuces imniediutely after the birth of IIk- eliild. it is due either to tear*
of the >;eoital traet or lo partial separation of the plaeejita. In tiic latter
ease it usindly tvas"'" lempirarily after enerjrr'tie kni-ading of the.uteni'.
but recurs as soon as it is allowed to ivlax. If nianipuUtinns of the uleni.-
prove of no avail, it is probable that the hipmorrha^- comes from a t«r.
allhouKh this i- not a universal rule, since in a I'ertain numlierof in'taive^
tlie Iftjw of lilnml will miiiinuc until the pliiitiita is expressed by Crede'»
method or i- reuiovini mamuilly.
Agiijn, II h»'HnirrbaKe persisling after the nteriis Iiiis lieen emptieii, while
abdominal |ial|intion shows thai the nrjian itself is firmly contntelvd, <u^-
gMts a wrinus tear of the birth canal, which should Iw sought for. and ei.tr«l
with sutures when found. In order to accomplish this, tin) pHli(*i)l having'
laiai brotiirht lo tbo edj!e of the bed. the external ^nitafia an.' carefully
inspected. If the [lerinirum is intact, the ecTvix should be forced down
toward* Die vnlra by premure ujxtn the fundus, and if thiit bilk to haog il
into view, it should he examined by the fingers in the vagina. If a cemeal
Insion cannot be delected, the vaginal nails should he spn-ad apart by nn'ans
of a apecnluiii and thoroughly inspected. A Iwniorrhage which does not
POST-PARTUM H.KMORRHAGE
S21
come on until ten or fiflwn minutw afU-r the Mrili nf tlw ehiM onn lianjlj*
be dur to a U-flr.
On the olher Uari<l, if lt».' uIitiic iiiMa< nor lYicitrat-t and n'trwt lirtiily
afU-r iliv i-xptiUion of (lit- jiliut-iibi. or if it ritiuiins u» only k<> Iuiii; a»
knea<lin|; is kept up, the cause of the hjemorrhaRe must \>e soujjhl (or t-iiher
iu tin; reu-utioii of a jilmi'iiu) cipljinloa or in »tc)Hy. (.)i!rt»uiil)' with n-gunl
to t}ie former point in usually ohtainiid liy careful inHpcetioii of thr after*
I'trlh. a Inrgc fk-fwt up.iii itc malt-rna] Kurfafv itniicnting Iht- retention of
a cotyledon, white a ntore or !(>» ciixular defwl in tin- iiii-iiilinUKv u Miort
di)>tiin(v from the placunlul murifiii nhows that n ^uecenturiate lolx; ha^ been
left behind. At the sanie lime oav shotihl bi> careful not to confound mere
fiiiiiiurni with defMrtif due to los» of ttnfue. TIk- diaguoHiB of primary atony
sboidd be made only in those caa^ in which ev«ry other vicplanalion liaa
Imi-u Mclwioii.
Treatmenl. — With proper niana^ment. bifinorrhn^- during and imnio
ilialWy following! Un- third Ktagv of latiour should t>p extremely rare. The
m<«t important prophylaetic measures t'onsidt in walrhing the roiMlition of
the ut>.TU» aftwr the birtli of the child, and not rcwirting to Crmie's mamen-
ne nntil the ritiin^ up of the fundus inilit-at«.-> that tJie giluicnia has )N-com«
compMdy di-luchfid. Pn-matun- att(*mptii at exproismn arc a frerguent
caus^ of imperfect ^paratioo. A;:ain, owin^ to tlif tendency towardi* to-
laxalion following tlic tiirlh of twittf. a» well a« in hydrumuios, concealed
tuemoirha^, and placenta pra^via. tiie condition of the uterus xhotild bfi
mwl carefully watchcii for Ihe few uiinuUv immctlialcly follouiiig th«
birth of tlH- child, and i>nt-r}i;ctic knciuling tbmugh the ulKjominal walltt
promptly resorted to uj>on the fir#t si)^ of failing! contraction.
Tbt' plai-i'nin Hbnulil lie carffully oitainineil after its expuUion, for liie
purpo-te of ascertaining whether it i? intact or not. If it Hbitws any seriouB
dffi^t, immtilifltv pn-)iarati»ns shmiM In- made for the renwtal of llw
retained portion in caw symptomB supcT^ene,
In thf jirts^^H-e nf adua] Iwi'morrhagi', ttie treatment rnriw arcording
the placenta is still within the uterus or has aln«dy bet-n expelltHl. In
Ihc fiirtner cnw- ihf iiteru» sluiubl ut ooci' In- ^hl-iimiI thntugh the uMnm-
inal wall and firmly kneaded. If firm contractions come on, all is well, but
if ihr lucmorrhug^ cnntintHi' and Dw ulerun relaxes an mmu o* the ktu-juiing
is ^-topped, the placenta sbtnld he exprcAnod by Oretl^'o mctho<l : and if
lhi» cannot !»■ ui-<iitiiplL«hii] and ibe patienlV cmtililidn i» ulurming,
tiianiuil removal may liecomc neceBwir}-, This latter procedure, however,
iiliould Ix- n-juirted to only in wriou* casci', and tlw dinx^^tioim given for
itit performance in f'luipter \XIV should be motit conscientiously followed.
If the hwmorrhagi' dnrn not cease after the dt'lirery nf the placenta,
ttir cauw should W BHc^^riaim-d imd .<uiljd)l>' ln-jilni*-nt iiiotiiuti-d. Tear:!
»houId t»e located and llwir edges brought together by suturM. On tlie
uihor hand, if the Itannorrhagp in tlie n»ult of lite retention of placental
tiiMUc. the carefully di.«infected hand »boald be carried up into the nterua
in order to seek for and rmnove the n-taincd cotyledon. I'ndcr such cir-
cunutancAi tlie haml actn an a most eini^ient irritator, causing tlte uteruii
to contract energetically. After «rparating the retained {wrtion of {riaccnta.
823
oagrrCTRics
the Imnil Ahntild not ho wilhilrnwn nt oiin-. iiiit t^lioiiU] bo alloved to recflfl
gradually as it in fort-eti down liy the (Niiilr.icliuii of (he (uudu.'i. 1
ir till- hn'tiiurrhtigf is iliio to aloiiv, the uterus should )» rigornuHln
kueadfii, mid from ■!•> t" ttO minims of vT^yl or of erjfotol udmini'^U-a'dl
hypoderiiiically. A'fter careful [li^mfecUoit of ttiv ^in, the needle should
be jduii}j^'d di'i-p dovn into (ht- Iiki^ik^ of the lhi>;h. ut ri^it Hn<!k-« lo Ihd
surface, sime in Ihi* way tlii! cliaiH'i'" "f at)scvj« fDrinutinii ate grt'nlti^
dimini^litt). The PAperinicots of KiirdinoUMky indicate that adrenalin
han an ewii imire [xHHit Hrtvl tluin i>r}ia(. iqam llu; uterine iiiiim'ulatur
but as yet no data are available coiireming its ubo at tW bedside.
If Ibtwi' iiK'a*int?' an' iii'l iilli'iiih'il with the diwinil rt-sult. a vi'ry U
Ultra-Uterine douelie of tievi'ral litres of sterile !«lt solution should he vm4
|(loveii. In many caww Itiii* arU a* u mn*l vlTiciriit hii-miMtatic, i-iTectivetr
irritating the uterus and causinR it to contract forcibly and perraancntlyj
If the hicitiorrlni^'i' {H-rsint:' in spile of the d»ui'hi\ nur only hope
controlling it i« by packin;; llie utenni lightly with sterile gauxe. whicli'
kIiouIi) Ik- inlnidui'i-d aii-onling lo thi- dini lioiu given in Cliapli^r XXIV
{aee KiR. 4-11). Before resortinR to the use of the pack it is ffllways advi*
uhlf to [>iiI|iHli' the inlrrior nf IW utem". iu> nciiiH tonally a portion of tin
placenta njay have iK-en retained, even thoiif;h immeiliutcly after expiilKHtB
the i>rgnn may have appari'ntiy litren entire.
Koriiierly it was customary to recommend the introduction into ibf^
utcni^ of ict^ or ^olutiontt containing Tinegnr, the perchloride nf iron,
other astrinj.'ent B>ib?tances. Their emptoy^nent, however, is not advisable,'
since ice and ordinari- vinepir arc hitit »terile. wliih- lite inm solulinn
acfomi'lisliis its pur(}ose by the formation of deu«? coa^^ula, which arr
later separated from the titcru* hy !inii|)u native pmrt^uo*. Al«>ve all, none.
<tt Uiein set 118 pniniplly or eDlciently as the pack, tl»e emplojuicot
which, altbougli coniparatiruly rarely indieal'^d. in eaiwptional caw.-* offen
the only reliiiiile meiins of coping with the condition. For thia reason th
obstetrieian should always curry in hi* hug the niaterinls lu'oeswary for
m* Ihcy cannot u.-<ually be obtained promptly in an emergency.
Too fjreat stroHi cannot bif laid upiJii the importance of ubw^rrini; Ihc
most rigiiriius nH^ptic li^chniiiue in every intra-uterine manipulation under-
taken for tbe purjvnie of clicikiiig pri*l-parHiin hietiiorilinge. TIk- natural
tendency of the physician is to forget all other risks in hia attempts
ciieck the lilewiing at once. Such negli-eU howter, in fritpiently sttendv
by nioKt (tiTiouM «nnw<iueiices, the pntient being iiaved from (leath fron
hiemoirhage merely to prri»ih of infivlion n few dnyn liiit<T. For this i«t«oa
Ihen-fore. the obsli-lriciun will u.-unlly liest Bul>her\-e the interests of hia
patient by taking the time ni'ccKitary for cari'fuUy d lit infecting his haniU
bcfort: beginning any mnnipulations. In fact, the only esception iai ofTcroL
by the very rare ca^^N of atonic hitmonhagu in which it appcftra piobalM
that a delay even of a feu' minuli« inciin^ inevitable death.
After the actual lOTmonhajje has bixn cheokeiL attention must be di-
reeled to the general condition of ihi- pntient. \Vlii'n thi; shock in ndfl
piiifound BUil the pul^' not parlieolarly rapid, elevation of Itw foot ofl
the IkiI and the applimljoii of Ih'I iHittles: or bricLt lo the extremities wd
INVERSION OF THE liTERUS
S23
be all lh«t IK neitleil. In mon> soven- raws, the ailiiiinUtrAtian i>f ^g grain
of strvchniiK- hv(>oilrrinically. .'i it<>*i.¥ bting given in prompt Mic«-**ion. if
Iiociwitorv, i» attttiidtil b_v irxccIK-nl rt-nalU, whi<-h inav be ati{i]>lt;>u<TnI).-i| by
lliy]Mi4temiic injei-iinna of wbjaky or etiter. Hot rvcia) eoemata of equal
I parte of black ofTve and pall solution arc att'o rahiablo.
Whtn the piitti-iir in [iroroundly Klxtikitl. nH-rili? norma) Mit aolutloD in
llargo i|itantitio9— .'>U0 culiic eentimptrts bi'ing injectwl nmicr each brMfit,
laiiil nixiatiyl on itoiin b» absorption has occurred — will prnv« tlie U»l ns
[storativf. When Um> con<!itian is verr sorinus and a Huitablo canula ia
Favxillalili-. L-vcu morr Ktrikiiig rc«ull> niu}' bu obtainttl by ui) ministering it
'inlravynously. Occasionally, wli*n iho Iom of blood ha;* been very jB^rcal,
tifiH' iii4tL»nrM may be siipplenieiit^'^l by liglitly bandaging tliv i-xtrcniitin
or compri?s«int; (lie aoriA, in the bope of n'taininK as lar^ a <}uantity of
[blooil as [MKuiblc in tbc opficr jwrl of tliQ body,
Invcnion of the Uterus. — This condiiion is a vt>r>' rare, but important
iuh; of jH>:>|-parluin lui-iiiorrhagc. According to Itcckmaun, not a siuglv
Fm. am. — 0>Mi-i.«tr Ihvkkhiuk or D-rmi'a (Baiiiin>.
caw orcarrod in SAO.HOO lalmurs in the St. P<>t«rsburg Lying-tn Hospital,
hvhilo Madden nnlwl it only once in ISrt.S.t.'t tMiveriiM in Dublin. Many
■lir'lrtriciani' in liirge praelire Uav<- ni-ver seen a caxe. or have met with
Miy A fow tfinnipb-s of (lie iwindiijon. Oh (In- otWr hand, it i* much more
lfm{iiently noted in the praetice of igitorant midwives. The biiitorical and
834
OHSTKrHK*8
(>tuti?'Ucsl BKpcct« of the subject an^ (My dealt witii in thv lu-ticic* of
Bcckiniuin, BroH'ne, Hnlints, and Vogcl.
Now and agAin tlie fiindiD!' of lliu ijU*rtu bccoincA inviTk^) and fMmv*
into citwe wiUncl «'il!i nr may protrude through the exu'mal os; while
in ran- iiislmuvH tlio entire organ ap]>cars uut«idu »( ttio vulva, the cou-
dition being rcspoctiTcly d«»igiisliHl a* inaimplete aud compltte invmion,
aud prolaptf of ihe iitvtrtfd uteru» (Fig. 624). In not a few came Uie
placenta n^maiufl nttaehnl to thv invfrUxl organ.
tjiliologi/. — For lint prrHliiilion of the aecident three fatitnrs are neccs-
Mrv: iiiarked laxity or thinne»> of the utpriDC valU, particularly at \\w-
pliu-cvitul sito. pn-sfiire Tmin uhove nr tmction on the cord or pUoenta, and
a pululouii ccrricnl i-aiial. Inversion may occur spoutaiimuxly as the rwvH
of the inlru-abilorniiiiil pniwHri- or fnmi ihc men- weight nf tlifi intf.-liiiej,
but in iiiodt eases it is attributable to violence resulting from the tno
vigorouK employ 111 en I of t'rciie'* maniruvru or tn trurtion n[Kin tlw eord.
In one of tJie cawea which I saw in consultation, it followed the mannal
removal of the plucentu. vehAv lu two others it wa* Auv to too vigorou*
expresxion. Occasionally, inver&ion may recur in the eanie patient, fVitfich
haTing obwrvctl il in tlirce successive prcgnaiicicx.
Itei-kriiann, who has carefully nna]y»Hl 100 ca^^^ rciiortwi in the litera-
ture, believes that in the iiiBJorlty of instances the accident occurs epon-
lani-ouiily, while Vo^-1, In » Kiinllar n-vicw, liohU thai nio--it ea.'U^ are <liie
to violence. His contention appears to bo conRnned by Bcckmann's »tatt^
tiw, as only 3 of thv If'U cif«,'« occ-urn-d in hospiUl practice. la<W-d, it is
highly probabh- that the accident is exoesuiiTcly rare when labour is properly
conducted, but that it occure more frci^uently und«r the unfavourable
ciimlitioiis exiiLtiiig in private practice, particnlarly a» conducted hy mid-
wives.
The eoniplication usually follows a full-lerm labour, alUiough a number
of cawa are recorded in which it waa noted after abortion. It is aim an
intcn^ting fiurt that nion- ilian M |ht cent of the c&wfl recorded by both
llecliiiiann and Vogel were in primiparous women.
Symplotnif. — A* a rule, inversion of the utt-n» is promptly followed liy
alarming !iym|i[j)iiiii, the patient presenting marked evidences of shock, with
a rapid pulse and a tendency to syncope. In other cases conrulsions oontr
and priifii«' ha-niorrhage is not infreijuentty noted. On tlw other lund,
the sjTnptoms are wimetimc* very iliglit. and the condition may continue
for wvcnil days without causing any nerinu.-i annovanre to Ihc fkalient.
In ran- imtlanc^.'^ the cervix may so retract almut the completely in-
verted uterus that strangulation occur*, folhiwcd hy gangrene. In othiT
case.-, this doc-ii not take ])lacc, but the condition becomes chrmic, netra-
sitating operative priH'i-<iiirt's later.
Progntms. — If the condition is detected promptly, and the uterus re-
placed inimtnl lately, the prngnOHtu is fair, Beckmann reporting a mortality
of 14 per cent. On the other hand, if strangidal ion or gangrene occur, the
ontlnok is ominou*.
T'rrd/m !■«/.— In verv recent cii.*i>* ii-posilion i-^n usually 1k> effedfll
without difficulty hy pressure exerted by se^'eral fingers in the vagina, it
{|.EM<ilUUIA(JE
825
lH.-in}( iriiporttnt to rcinctnlttir lii«t Uu: force hIiohIiI be directed iij>vrnrd ia
the a.\io of thu superior Ktruit. N<>];!ect of Uii--^ [irecautioii undoubtcilly
luifiuutH for a i-urluiu miiiiber nf tailiiriM. As the pnx.-v(luA; U g<:m>rally
IMinful, ona^lltGHia liliould ))e etiipln^ed.
If the platxrtitii is still attached to the uteruH, it iw gent-rally adviHiililc
to ik-fvr ilf M-pantion unli) rupwitioii lias bwii t.-f[<x-li'd, bvcsuM) tbu von-
tractile fiiiwtiiiti n( the Jnvirrli.-il hUi-um being in aU-yuncu Uivrc is alv-ny«
the rt«k of prnfii^ ha>inorrha){i?. On the otJier hatui, if tlte patient i» not
M«n until .*i'v«nil thy* aftt-r Intmiir. the (rrvix iitav be no contracted that
tnanual reposition cannot Ih' ait>oiii|iIisIit.>d, and operative prooeiliim* will
iH-eomc ncvi^^jirv. Full pHrtieiilars voUcvruiug tli«iW vriU bv found iu the
current worka on gynteoolog;^.
^jCh&i
i,itkrati;re
^
■^
HLflei.i>. t'diEV Ilacvnta pm-^b. Vvrh. <l. ik-iiltrlH-n f^unlL t. (ij-n., 1807, 2W-'n7.
Aiu.rKLi) u. AH-iiorr, N'cuo ikilmxn i. CiciiuM: ilcr Pliuxaibi pnrvn. ZeiUchr. I.
tith. u. Gyi... IWM. li. 544-55tt.
Dahxkh. The I'byi'ialiig)' mi'l TroiinicTil of riuccota tVn-via. IxiiMlon, 1858.
tiaccnu Pn-viii, l^cCunaoti Oli-lvlric ' >|K^ntlinii>., Itli cd. t.<in<tnn, IftNH. :t!HI-l'J*2.
Bechmamm. Zur Actiologii: dur Invomiu uteri pust ^.uirtaiu. %nU>ciu. (. (itih. u. 'iyn.,
I8SA. xx\i. 371-101.
Rcflii. Vie nunbiairt* Watulung b«l Ilatwita pnrrviH. Zoltadir. f. Glib. u. 0<fii„ IMI3,
ix, 373-^10.
BiuvH, Cmi«ri iukI Spakth. T^nlym; iliM rt«nia. Klinih der <iob. \i. Qyn., Erloapai,
18.W, a02-2M.
Kaowns. Intt-mioii i"( Ihe I'lenn, Atucr <iyii. aiul Oti«i. Jmir., 1H99. itv, II>V-12(l.
BviHX. Ili^niorrluptui ut^rincii ct ru|>lurv (Iu iiiiiuii cimiiairv. Kununtu en niurfiuK irt
nmiv-ewu n^. lADT. lU-lftl.
BuMH. 7.IIT t'roKL- Aa biiioplaiilalion tiilf dem iniit-ro:i Miillrrniuiid. Zcnintlbl.
f. liyn., im*., xrii, 1-7.
Uvbur die Mcthuden dcrr kiiiiBlUchen I^iwojIuniBic den M-hvnui|a>rcn u. kivumnilan
t'tMiM. Verb. d. dcaUrben (iiwU. f. Hya.. 1906. xi. &M1K.
L'tKiKK U. Oraf. Zur t>l«tiatUf d«r Pliuvnta pni-via. MoointMchr. f. (kit. u. <>]m.,
I90T. XXV. Vt-n.
Odk. A«ciili-nUil lln-mnrrhiMK diiritix the Fint SUjW irf Full-term labour. Tnuu.
AiDcr. <J>ii. S<w.. 1801, xvi. 35-30.
DniRV. I>D U riiLiiAtinn mAnitclfe du nil ui^fin doju lua ■i-FOticboniuatic aver hfiimnrha-
jDW plu«fiUin.-ii Rnv<»- TUnr ile Nann', IWKi.
DoviHiiiVK. CH'mmui Ao-timi fur I'lun-nta Pra-vh. ItoHtoti Klwt. and Surg. Juur..
I>i!«nnber B, 1900. cxliii. .Wl.
KAVTH. SuiiMliiK-hn >il*r rUrcutu jirwvin. ChrabBk'i ItcrirhU- »ii» d*r ^tcn Rrif.
Syn. KUiiik iti Wicii. 1807. i. 77-1 19.
I)et>;,i:Y. Tho Mnderii Cnoutan Scctimi »n Mial Method of Tnslnwnt fo* Pbninla
Vt»\». tiev Viak Mcil. Jniir., 1000, Uxii. 7.H 7IW.
RF.vnKT. TIh- Iiiipropriclj- o( CinartJUi Section in l1iu«fiU Pnrvut, rlo, Aroer.
Med., 19(«, ili. «4-<tH,
FurW'Ti. Ziir AcHulojae dur iKiunuMwIcn IltcniiaiiwrMOfi. Zuiilnllil. t. Hj-ii,, 1907,
i««i ■tW-fO.
hkia. Coiiccnlal Atridunial n>nnnnlia«e «l ibe dravld UUfiu. Aniar. Joar.
Olni., 1870, U, 2a)-»M.
OBSTETRICS
UaRKI*. a Method of pcrformittK Rapid Manunl PiUtation nl the On Ut«ri. and iU
L Advmalage in Uie TreattiiBEit of PtucenU Pnrviu. Anier. Jwir. Ubvl., IBM, xxix,
' 37-«.
ItKurr. Ziir Lulint von dur Pktraiita prwviu. Zeilnchr. f. Ucb. u. (Jyn,, 1S0B, xxxv,
lIuniKiEK. /.iir IliThanilliinK dur PltiixtnlK prwvta. ZelXtehr. t. Oeb. U. Oya,, 18SS,
viii. 80-11)1.
Uetwr Plftcwnt* prsrvi*. Vorh- 4. doutM-hcn <JciwIL f. *<jti., IMB. IfiO-IKL
Ziir ICntatuhuuK •lur I'buwMila pni-vui. Zeilitrlir. (. lj(^b. u. (ijrn.. 1804. xxidx. 1-17.
Udlwr Pla.i!nlji pnrvia. Verb. d. (kutK-hcn <h^U. f. <!}•».. I8fl7, 2tH-J2IV.
UiiLMKH. liivL-rnm I'teri ixiiiipli«»tiiic Plarantu PrH'^-in, ObHlvtrim. IWS, i, 297-311.
A()kti<i Pliipentii-. AiDcr. Jour. Obat,. 1901, xJiv. 75S-78*.
HQMnrciiii .Sorlinii fi>r Plai-vnta Prtrvin, an Impmpor rmcedtirc:. Joiir. Am. Hwl.
BPAn».. miT.. xliv. \M4-I6fa.
lIi'NTKK. Annlomipid Dcarription of t.hi^ Hiimnii fintvid I'ltiriiH. IlirrninKluuit, 1774.
KALTKxnActr. Ziir PalboBeitCM; dur PbcunU pni-vm. Kvilnchr. f. Uul>. ii. Gj-ii., IBW, ,
xviU. 1-7.
KmufAMX. l-Tino CorvixpUccnt-i, Ztutmlhl, f, (iyn., 18',I7, xiri, HAT-tUW.
Kermaukek. Plai-enta pnrriu (irrt'ictiliH. Bvitriigv b. Uvb. u. Ujni,, 190(1. x. ?'(l.
KovLANOc. Placuntn prwvin. Biingcr-Heitf, luicj-klopodie dor Gob. u. O)^., IWO, G,
180-lftI.
KuRDi!iow»Ky, Adroutiib aU cin UebiumiillfnnUtel. Arcbiv f. <iyn.. ItKH. Ixxiii.
4i1-l37.
t KIWtkkh. ll«ber PlanirUa pni-via. Verb. d. ilviilntlicn tluwIL 1. <lyii.. 1807. 277-JM.
KwoBcrTAKBKV. Ucbor AnBloniic und Palholo)^!: tier Pkrvnta, ct*. .\rrhiv. (. (Jyn.,
19W, Ixx. 1i:i lU->.
Louxn. Ou ("otii billed 'I'liming; in lire Trenlniciil of Pl&cvnlii I'mvin. .4tnor. Jour.
ObM.. 18S4. xvii, ]233-12(i6,
Ltue. Tbe Treatment of Accidental Hs-iiiorrhago. Tins Itij-idcmn wi"! .SurgDon,
Ijondon, April 12, 11)00.
Uauukn. IJuoIimI by llrowiie.
MAitriN. Zur Aetiolatno IcthnJer Atonien poat jMrtuin. .MmutiMchr. I, (leh. u.
lij-H,. IWXl. xxili, aj7-J17.
Mi'u.KH. W. PlucantB pm-vla. Sluligarl. 1877,
Ml'MrntiKTmL tieber den Vorfall dor Na«bgoburt boj rcKrJniiUMgein Sltsc di-ni«ll«n.
Arcbiv I. riyii., 18H8. wxiii, 4»li-4!>r.
OtjMiAfHK.N. I'aritlyiB der l'liMwiitar-iii3vrtiun»ti)Uc. Kchrtwder'it Lehrlmrh dordeb.,
Xni. Anft., IHlW, 77.V
Pktbra. U«b«r die Einliellung Job numMliltclwn I-job. Wiuii, 1809.
PiNAitt). tin la niptiirc prAmatiinie, dite njtanbuite, den tncmlmuieB, ct4!. Annalu
d'obal. M du yyu.. m)«l, xxv, 171-1711; 32I~3*J>.
Pi>s«< n. Zur Aiiatomif der PLiiynil« prjrvlu. Arcbiv t. <Syji., 1000, Ix, Nt-I?a.
pDiiTAL. Iji pmti'inc dcH ncrniK-hotiicntt, olr. PnriH, IRSTi.
Riuny. An Lsaay ou tbe llterine Ilii'm»rrlui|j;e wbich PrecedfiH tb« Ltelivery of the fufl'
ftrown F<ptii)!. London. 177fi. '
> SnuCHER. I*B plnMiitiP iiturinii- morbiK. I.ip'iutt, I7(K).
Sc'iDL-KKt-ic. l>io vDr»oiti)9 {.oming dcr nomial nitieiideu Ilarentit. Beilrage mr (Mi.
u. (iyn., ISH)4, viii. :»7-364.
Si>iKu.iE. A TreatiiM on tbe Theory and I'ructico of Midwifwy, I7.S3,
SriiuiKLiiKRii. t)j« Inverainn der 1 iel'iirinutur. l^brburJt der (ieb., 1891, ni. Au8.,
51KM5()7.
9rHA»HUANS. lletier I'larcnta prn>vi]i. Z«itiu-lir. f. (ieb. u. (lyii., 1901, xliv, S2!^4M.
PlaronU propvui. Archiv (. Gyii., 190^, xxvii, II2-27&.
H^HORRHAQE 827
Tut. On tlw Traatment of Uoavcndabte HtPmorrh&ge by R«movBl of the Ut«rus.
Had. Recotd, 1809, Iv, No. 9.
Tasnier et BcDiN. H&noirbagie par iiiaertioa vicieuse du placenta. Traits de Van
dei accouchements, 1B98, iii, sri-SJig.
Vbt. Usber die Behandlung tier Blutungtao uumittelbar lutch der Ueburt. Zeitachr.
f. Geb. u. Gyn., 1895, ixxi, 214-225.
VooBL. Beitmg lur Lehre vod der laveraio uteri. Zeitachr. f. Geb. u. Gyn., 19U0,
xlii, 490-525.
WBm.B. Ueber Hamopbilie bei einer Gebarenden. Zentralbl. f, Gyn., 1S93, xvji,
672-fi7S.
Wems. Ueber vorieitige Losung der normal sitienden PUcenla. Archiv f. Gyn.,
1897, xlvi, 255-291.
Zur Kaeuistik der Placenta prsvia centr&Ua. Zentnlbl. f. Gyn., 1897, xxi, 641-649.
WtUJAMa. Deddu&l Fonn&tioa throughout the Ut«rine Muscularia. Trana. Southern
Su^. and Gyn. Am., 1904, xvii, 119-132.
Induction of Premature labour and Acoouchenient Forci, etc. Trans. Am. Gyn.
8oc., 1906, xxxi, 316-333.
WiNTEK. Zur Lebre von der Toneitigeo PlacentarlCaung bei Nephritia. Zeitachr. f.
Geb. u. Gyn., 1885, xi, 398-408.
Wrioht. Some Points m the Diagnoaii and Treatment of Accidental Ilirmorrhage.
Am. Jour. Obat., 190«, liv, No. 5.
rrTAPTKR \t.T
iNjriiHiH ro run biktii canal
Injnriu to the Vulval Outlet. — In ilii> chapter upon t)i« Co>»luct of
Nornis) Labour ref«mic« was nmile to llie frequency of perineal tacen-
tioiiH, and emphasis vas laid upon the niiceaaity for repairing tbem imme-
^■Iciy ftfUT thf birth of tin- child.
More rarely tears ocair almut Ihi- antoHor porlinn i>f ihe vuK'a. Id
ppODtanL'outi lalMur thceu x-ldoin amount lo more than fiil;jht abrasions upon
the inner iturfaceit of thi; labia niinnrii, but in oporatitv (li-lir«Tiei!. P«pe>
cially when the handles of the forccpi^ have been unduly elevated, serioui
lesion:* may he producftl a» a re.-.HU of ctimprt-wion of ibu lt»sui-:s Ix'twivn
the pubic arch and the blades of the instmment. Now and a^in the labia
minora arc cnmpletely (M-'verfd aiid torn Iomm; from their coiinoclion)'. or
deep tears occur on either side of the urethra implic-atinK the ve»s«lh sup-
plyiufT (he eliloris and ^ivin|r Hue to profuse ha'itiorrhagi'.
Injuries to the Vapna. — With llie (^xoeption of the ma>>t «up«riloial
varieties, which are limited lo Ihe mucous membrane of the fourchette, aJI
[HTinenl laeerationK are aecoinpanied iiy more or Ie«» injury l» tlie lower
portion of the vajiina. Such Icars rarely occur in the median line, but ei-
leod a varialilc iliNtntiee up one or both va;i:innl sulci, iH'iufc altuoxl alway
sufficiently deep to invnive some lilires of the levator uni mU!^le. Bilateral
lacerations of Ihis variety are usually um-qual in length and are srparaled
from one another hy a longue-shaped portion of mucosa which repreaeott
ihe lower end of the posterior i-olutnn of llie vagina ( Fijr- 315).
I'he.-e injuries* should always l« looked for. and their repair sliouM form
H part of cverv' operation for the rt-storation of a lacerated periiia^uin. If
this precaution ia negrlceled and the c;ctemal wound alone ii attendisd to,
tlie patient will eventually present srmptoins due to retajation of thf rcg-
inal outlet, even ihoujrh the pcrinseum proper may he in pfrrwt wmdilino.
Isolnted tears invoicing the middle third of the vagina, and uni>»n^^|
ciated with lui-eralions of the pcrinipum or ccrvii. are very rarely oIw«rvp*"
Tfaej are usually longitudinal, and result from injuries !>ustain«>d ilurine
a forcep* ofirnilion. tliouph now and aj.'ain they follow spontaneous deliv-
vry. They freijuenlly extend d<fply into the uuderlyinp lt«sa«s and mav
give rise (o a copioun tuemorrhage, which, however, is readily conlrollnJ
by a few suture*. Tln^ir pr<?seitee is usiibIIv riverlookwl, inasmuch as iber
ean he recognised only after the va^nal walls have been spread apart Iit
means of a spoculum.
S28
IXJimiKS TO THE VAOISA 829
Mnm important it* tli« in/wnV* to ibe. levator ani musrle, whiHi are
nol SMwcUleil with tears tlirnu];h Iho vHKiiul luucMft and llM-refim- (!!toji)>e
imm^^iiito ilvlivtjon. Ah lln- rx^ull nf ovt-nlintcnlinn of llic- birlli canal,
tl>cre may occur a submucous t^sratioii of certain libres of (be inu^wlo. or
al IvMiil no gn-nl n diuiiiiution in iu tonkily that it can no loiifrt-r prop-
eTly fulfil its function as the pelric diaphraj(nt. In the^te ca^es (he patient
tooan or latiT ^ufTcT* just a* iKxun-iy from symptouis of rrla.xattoD sa if
a deeply lacexateil ijcrinipum had l«>en left uniepnirod. Altlmu^b ihi» a«;i-
drnt 'iin «imotinti-s 1* ttvuided hy an intclhp-iit use of forceps when the
aecond ftaf^; of lalwur U unduly pndonirwi, indi('iitiou.-> fur prtiphylaelie
inMwurOK are iml nluayo at hand, xincc it not infrequently lotions spon-
taneons and Tspid delivery,
Letionii of the upper third of the va^na arc extremely uncommon
nnless they nfprp>«-nt (he extension of deep cenical learK inui the fornix.
In rvry rare inNtnnce^. hoKe\'(Tr, the cervix may be enlirely or partially
torn loose from iU vajpnal attachment, rupture in (itlH-r oiiti-* oceurriog
in either the anterior, posterior, or lateral fornix. Ilugcnberjfer. in 18Tft«
collected 40 raie:^ of llii.t accident from the literature, and (h'signated it
as cttlpaporrhfiU. Schtschotkin. in 1801, pub)i>ibed 40 additional instances,
while Kftufmann, in IKOl, estimated that inmethin^ more than 100 eases
have been recorded altof^ther.
The aeci<k-nt in itomewhat analo^uK (o nipture of the lover uterine
segment, and follows energetic efforts on the part of (he uterus to over-
come fxnne oUttaeli' to die )Mwtage of the child. .\s a n^ult of the re-
traction of Randl's rinn. so ^reat a strain may be exerted upon tlw cen-ix
that it it torn Uxmr from it" va^nnl attachment. It iK (commonly tau^it
that colpaporrhexis is possible only in tho^ cases in which (he lips
of iho eiMrii are nol comprctsril iM-twiiii the pWH-nting pari and the
pelvic wall, but are free to follow ihe retracting uterus. Ii sometimes
ot:curs iipontanpously. but more fnvjueiitly follow* i)U-honen operative
procrtJures.
The nympioms are identical with those following niplare of the ntern*,
and will lie eonnidercd under ihat heading, hnincdiately followinj; the
rupture, the child may escape into the pf^riloucal cavity, aUvT which th«
int«9itiDe« may prolrutle into the vaginal canal, as in a case reported by
Uosa.
T)i« diagniiti* in nia<le soldy hy llic ttenw of touch, as the clinical symp-
toms do not differ from those following rupture of the uterus. *rhe prog-
nosis is cxtrrmcly unfavnurahle, f>(i to iS per oeot of the cases reported
in the literature haring ended fatally.
Most authorities recommend in-aling tlie condition l>y means of a Tag-
inal pa<-k. » pmciHiHn- which probably explain* in part the high mortality.
Rverke recommends repairing the rupture through the vagina after ex-
tracting Ihe child. I agn.v with Schick that laparotomy olIcr« the best
chance for sncccssfuUy coping with this emergenci,-, since in this way one
ran obtain an sty-uratc idi« of thf extent of tht- injur>'. when it may sotoe-
times lie pcBwible to unite the torn surfaces by sutures, or, failing Ihat,
to rrmove thi- tilerus.
■
830
ODSTETRrCS
Lnions of the Cerrut.— SI ipht dcjjrees nf ts^rvical lacvraiion munn!?
regardt'd ii- on iii<.'vii}il>ii' ticciiiiijMiiiiiiK'iit of Llitlitljirtii. Such ivat^, ttow-
evvr. ht-fl] rajiidlv uiid nirel^v givv riR> lo i^.vmplwmti. in iH-atiiig the}' caufe
S niateriiii tliniigc iu the >lia}H- of tho exii'rnil on, nrul llwnOiv ulTunl uk a
means of di'ttnuiniDg uhetlitT a nomaa has born« children or iiol.
In filhiT (-j|»iT> liif tiiirs an- (Jccprr. iint iiifrt-qiii-iilty implicating one
or bolli side-> o( the m-rvis and o\U-iidin({ a* far ti;>wiinl a.* ihe vafcinal
junction. In ran>r inKlanci-A \]\v lacfration iiiny pxlciid avrosA Iho vaginal
fornix or into llii- lower iil(<rim- ioj;ii)cnl, and iKcaxioiijilly oiM^n tip tlio ha^
of tlif l>r(Wil lii^jmcnl. Such i-sti-nvivfl li'iiions usually involve v<«wls of con-
Kiderablo .■<in>. and ari> nt'arly always a^Miciati-d willi pmfti^e liii-niorrlmi^c.
Deep cervical tears occasionally occur during the coiu^e of Epontaneom
Itbogr, end under tnich oiiviintiiiancvii ilicir xi'iiuxis is not atu-ayii readily
explainable. M'tro iK^ually, howcviT, they follow attempts at rapid manual
or iiiKtri)iiii,'niai dilaialion, i-s|>ectally in foIniniKiii. jiliiii-nia pni'via, and iu
vomeii liuffcring from gei)eral tcdcma- ilort'over. Ihey are apt lo result
from atli^mptx at ileliv<-ry through an imi><-rf<->T!v ililattil ctTTix, no matti»r
whether forceps or verfion he enTploye<l.
Oetns ion ally, v\^n in Hpontaiicoui' InlnnirK. Die anti-rior lip of th(> r>-r%'i\
may lie caught Iwlween the bead and the !i\niipliysia puliis and eomprewed
until it nndiTj;ot-s nirrfilic clwmj^-s and ni'jniralion <M'(riir*. In stilt rarw
instances the entire vaginal jiortion may Ite torn looiie from the real of
(ho cervix. According to Uoudrt-au, Ihi* »io-e«]lMl cirruUr <Ularhmeni ttf
the cervix usually oecnrn in elderly primipara* when IIk' pains are stroo);
and a i^eriouw ohctaelc to delivery is offcn-d by an inijHrffctly dilnti>) iw
fxicrniim.
Hynipiomi'. — In all leaionsi involving the cervix there is n'^ually no ciivapo
of hloiHl until aftiT till- hirlh of Ih^ eliild, nlk-n the Iwiu'irrhajce inay be
profuHK In many ca»ieu, however, the bli>ed!ng is ^^o sli^it that the con-
dition would jiiiM unrii'ogni.>i'd wore it )iiii dcKi-Iiil upon an t^xami nation
made for wome other indication. When one lip of tlw; entiw vaginal por-
tion of the cervix is t<irn oil iWre i.* uitnally very little Iwniorrlin^. for
the reason that the tissues have lieen ho compreirseii Ix'tore tire oceurrenof
of llie neiidi'iit lliiil the vcswIk hiivo nnder^ne tliiomhodis: likewi>e, cir-
cular dftai'luntnl of ihe ceriix ie oflrn not followed by bleeding.
Most eirvical team heal «poniiineou»ly, pnividitl lh« jMlient nnnalni
lininfi'C'lecl ; hul the deep wonnd alfordw to any pathogenie.niiero-organi.Binf
which may he presenl a n-ndy j«>ri "f <-ntry into Ilii- lytophalii^ at the \mx
of Ihe linmil li^iini<-nt.
IMagito»it>.~~\ difp i-crvical fear should alwnw W sMsp^ctwl in ea<K
of profuMo hn'niorrhage coming an during the Uiird stage of labour, if ibn
hand applied over the lower slKlonicn ran fevi that the ntt-nts is firmly
con tract) -I I. For a positive diagno.ii.i, however, a vaginal o\amiiuttion is
necessary, while the extent of the injury can be fully apprrrialed only
after drawing the wrvix down to the vulva and subjecting it tn ilinvt
iniipeetion.
Tears unaccompaiiii'd by hiemorrhagp usually ^-ja-ape dfliilion unless
they are aeeidenlally discovered during a vaginal cxaminalion nuidc fnr
Botne olher nason. Annulur ilvtaclimunl nt the vsginat porliou<
u-nix should be diiigi>n>Md wheitmvr an im-gular ta&.*it of linMUfi hi
1 circular oiicning in <--a--t off l)efoi% or after the birth of the child.
Trcaimcnt. — IJwp eervii-al tears aceom|ianipd by hsntorrhagi* shmil
imnK-diuti-ly n'|Miir(ii, ihu iulrixJuclioii ot a fi-w «utiirc» rv^idily chit
the ^ow of blood. On Uw othor hand, if lite condition is not kamw
with hiDniorrlui^i.'. it is adriNiblv tu Ictivc th« patient alonv ralhcr
fulijivt her to the miini|iiiIiiti'iUH iiiirs!>Hry for iU n:)Kiir, which iiitrvj
e\p(>i-e her to additional rifjis of infection. Moreover, in the iiiajoril
filch tvnrn opuntani-oiiK hiiiliiig on>:ue:<, and in Ui« vxcoptional cttm
which this does not occur, lielter results are ui^uallj obtained by a Bogtm
operation performnl in the liiiler part of the imirptTinm, f
TIh^ treatment of cvrvieal tears a^^eoeiated with lueiiiorrha);^ raries
,tbe ulent iif the Itaiion. Whtai Uie lawralion i» liiniltii lo the ii;
833
OllsriLTKlCS
cervix, tLc VKgiunl u-alU, if neccuftary. lieing hM apart Uy mcnoit of HuiUtilu
retractors (Fi^. tj55). As the hamorrliaije u^uallr coinci^ from the upper
angle of the w»uiii], il i* advisable to apply tlii^ lirxt iiiitun- in this eilua-
lioii, »inc« if the suturing U bej^uii al the free eni) of the tear, a dead
space is oftt^ h'fl (awurd;i il« upper Liid from which Eub^cqucut htemor-
rliBgo mav nn-ur. Kither Hilkworiii »r catgut ^uturcii may be employed,
though the latter are preferable, as they do not have to be removed. The
bcgiiimr J* (-aulioncd again:tt ton gn«t a regard for appfnrunci» and
attempting to give the cervix too norpial a look, iuaaiiiucb as the retrao
lion ocrurring within tli« next few d«y» may I<«d to such constriction of
its lumen a^ to eaii«! retention of the joehial discharge.
Many autbori1i<-» ri-coniniriKl n light vaginitl ptK^k in thi« cla»» of c«w».
Thia will iinually Hieck the hivinorrhage and may be employed in an emer-
gency, but il« cinploynirnt doi^ nut compare id cDicieucy with repair by
suture. Tn the rare eaiwH in uhieh the wound extends through the broad
Jiganieiit inb) llic periUnu'al cavity, a light puck may U- tnlroduwd. pn»-
\i<led ibeii- i^ no >erioui htemorrhage ; but in all other oaw-- tl>e only .iati>-
faclury iiii'lb<«t of iknting with the lomlilinn is by laparotomy.
The treatmint of leant of the up|M-T 5«r1 of the cervix which involve
Ui« lower uterine iiegmejil will bo considcreii when wu take up the treatraent
of rupture of iln- iiTeru".
Bnpture of the Uterus^ — Thi» accident, which i» one of ihu mo«t E«rt-
I OUH with which the obiilelrieian ran bi: confronted, seldom occurs except
in prolonged labours, although instances of spontaneous rupture during
pri'gnancy lisvu Ini-n reported.
(a) Oiirinij frfjuannj. — While this accident fjccurs more fre()nenily
in the last month.*, it may Ik' niH with nt any pitiod of prc^ancy.
Thus 31 out of ?8 cas-es collected by liaiscb occurred in the first five
months. In the first half of gewtatinn Kpontaiicous rupture ix usually due
lo in.«1er»litial pregnancy or excessive invasion of the nlerino wall Ity
f<Gtal elcnicntfi on Ihc one liand. or pregnancy in a blcornalc or infanlilc
uterui' on IIht <irlK'r. hi the latter tu<mtlis the condition i* usually
associated with the presence of sear tissue in the uterine wall, which
yields gradually with the increasing distention of the organ. Accord-
ingly it occasionally occurs after (Ta'sarean stwlion, or in women wIkisc
uteri bad Ih-ch previously perforaUd or olhcrwise injured during currt-
tage or some oilier opi-ralivc proci^dun-. In other easi-s the accident
may be attributed to faulty hypi'rlropby of the uterine wall xt the
fundal region. AIcvanrlroiT. Jellinghaiw, and others are inclinefl to
allribute cerlain ca»es to inbcn'nt wcaknew of the uterine walU rcwill-
ing fix)m Ihe excessive fonnatinn of connective tissue following the re-
moval of an adherent" placenta in previous pregnancies. Porosehin con-
siders that he was able In demonstrate in certain cmso' a faulty devel-
opmeiil or relative absence nf the e!a.stic fibres of tin' ulerini' walk
Haiseh. liowevi-r, eonb-niU ibut this i* not the case. In other in-^IaowN
K* in the two cases occurring in my service, no satisfarlonr cause can hn
discoverwl.
In spontaneous rupture occurring during prugnaucy, the loutMi b sbnosl
UlIITLKK Of TUB rrEHUS
833
I
I
I
I
tnMvuUy situated in the npper portion of tbe uleruti. Thu Jft in marked
coDtnut to tbt.* conditioDri otiM-ncd ul the linH- of lubour, when tko tu{>-
ture U ui^uAllv Hmiln] t» Ihe lower iegiuenl, ami Hearlj indicates thai
radically different leliolu^ical FiK.-tar» mu«l l>f coiic-iTnud in Ihe produclion
of tlte Iwo proecBOM, Conlrary lo llttf .'itaU-ment of Bltiul iliiil the ru|f-
ture nearly always occurs in the neighbourhood of the fundus, Baisch
found thai it waK xituslcd upon Ditt anli'Hor or i)Oiilerior wall iu 3'i out of
56 txscn in wliioh Ihe locslion of tlit- rupture had been accurately described.
Thf ■ymplum", dtiigini>is. |>n»j.'iiii>ii«. «nd ItvalnKiit of this condition
are i^Ienlieal vilh tho-te foUowin;; rupture of the uterus occurring; at the
time of labour. 11 should bo nol«-d, how<.'\-cr, tliut in a number of the cuhm
reported iu the literature the luiMnorrhaf^ following the accident B'a<< ho
relight ai^ not lo give riw to »yniptiMU!<. the condition escaping rccognilinn
until 0|>tTative [irociiliin^ii l<er»iiie n«eeaiar%' for the removal of the f^tu»
lying frev in the abdominal cavity.
In very i>iieepii<)niil iui-taRi'e^it, as in Itie v*»t^ reporleil by Ljii)[>')td, and
llL-urotin, llie plarenta rciiiatncd in the nlerus. while Ihe f<etuii, surrounded
Itr il:> im-iubranes, i>kidi|niI into The pcriioni-al iravity. vht-n- il went im In
furthi'r devftnpmciil — \iUr»i-abdnminal ftrcjuancy. Such an •x.'currvncu i«
Usually synftiiyirious with firlal d«lh.
(6) ICtiplitre of the VUrvn at (Am Time of Labotir, — This not very infre.
i|ni.<nt Accidcul is one of llw ni<i>t >u.'riou» coitiplicaltoii<^ of lubour, as il
irly aluaj-s lemlH to the death of the fietu^, and fre<)uently to that of tlie
Ukt us well.
.Utiohgy. — rrarticolly we ant irulcbU'd lo Baiidl for ll»e first dear ex-
planation as to iiM mo<te of production, its lelioloKV beinK ii^cparahly
twnnectitl with iIm* dociriue of ib>- lower uttTine segun-ni uud (he fornin-
tion of the contraction rinj;.
Xonnally. under Ihc influence of labour piainH the ulerut; bocomos tUi-
ferentiaied into two portions, iicparated by a eireular ridge nf ttmie, tn
which tliv term amlrailion ring in usually applied. The upper, by its coa-
Iractiony, .■u>rve« lo e.\]M-l Ihe child, while Ihe lower under^ocM dilatation
and merely fornix part of the canal throu^ which the contents of the
ut4^et are forced. On the other hand, when a iwrious obstacle is oppoMvl
to the passage of ihe child, tlie adivf (lortion of tlie uterus is stimulated
lo more forcible effori-i. As it contracts it likewii^ i-Iowly Ixn-ome* re-
Iracted. iu lower margin — (he contraction ring — cvenlually iK-eupying a
much higher len-l than nsiial. As a result, porlteiilarly if the lips of
Ihe cervix are caueht between the pre»enling part and tlte superior strait,
powerful upward traction is exerted upon the pas«iTc poHion of llie uterus,
which Ix-comw more and more stretched, and thinner and thinner. At tbe
same time the rontraclion rtogsepamtintr the- two portions liecomes llitcker
and more prominent, so that it can readily be distinguished as a trvurerse
or oblique ridge c^lcnding across the abdomen juKt below or perhaps on
a level with tlie umbilicus. Tlie round ligaments, likewise, arc subjectnl
In an abnormul otrain and remain tense even in the intervals lietweeji the
uterine contractions.
Aa the process goc: on the lower segment bemmct) extremely wnsitive
834 ^^^P UOSTKTKICS ^^^^^B
to proMum, tile uterine contractiomi incn^aite prngrewtivdy in frnjucncy
nud inteofiiU', and cati^c tlic putK-nl gn-utcr j^utTerin^. Ttiv pulse bpcumra
more rBpid, the palii'nt prewnu a worn and haggard appearance, and the
coatraction ring bcctune^ marc prominent on palpation. Such a condition
itidicntc^'K that ruptim* i" iiiimitii-iit mid will occur unl<%» delivvr)- is prompllv
ttTrtilwi iti a tiiiiMirvat ivc iiiaiincr.
licncrally speaking, rupliirc is more apt to take piait wlien one eidc of
the lover uteriiii; w^mi-nt \* Kiihjw-U'd lo grcaliT i>tn'ti')iin^ ihan ihv iilhiir.
In transvcrr* presonlal ions this condition is »io«t markixl on the side of
Ihv ultruf octnpivd liv tin- iK-ad. A similar danger thnyiii-ns the pfisli-rior
wall when the child prcrfnis by the head and the psiieul has a inarkedlv
pendulous abdomen.
Kxce^ive strelchin^r of ihe lower uterine w,B;ment, and consequent dan-
ger of niptiire, i* farourcd bv aiiv factor which interfere* with tlic birth
of the child, and mon> parlirnlarly with thi^ entrance of the ppe-'i^ntinj!
part into the pelvic Such conditions are most frequently afforded by con>
Iracted pelves, neglecried- tran»verae prct«n(ationii, hydrocephalus, excesaivc
site of the child, and. in fact, by any obstacle to labour. The following'
analysis by Merz show^ the ictiolo^ical factors concerned in the produc-j
tion of IGO en^es of rupture of the utvnw:
Coiilnotwt pclvi* .70
Neglectwl IruiiBVL-nNT prensntttltOn '1&
tlydroraphnlu* , . IB
l.mrt;u child nr uiilaroiirahic prvswiiUlimi 10
StciiiHix of hirth moal 0
TrnumH 3
I'clvk tumour. i li
AiH.-ilc« ,, 1
Opemtive procedureB ... 'Jl
It i* KencrHliy held that exccsaive -itreichiug of the lower uterine t*^-
niMit can occur only after n prolonged second »lage. but Goldner. in I'JIKJ,
reported liP iiiKlnniTs in which rupture appeared iniuiinent Iiefore Ihecwape
of the amniotic fluid, in thi* i>cries of vHrua (be condition wnn ajwKiatol
with oligoliydrntiiiiio*, vi^ry resintajit membranes, or a rigid cervi.v.
It. ia customary to distinguish between spontanrous and violent ruptum
of the «toru». In llic former the aceidi-nt mcnr* npontaneously. while in
the latter it iii usually the result of ill-judged manipulations on the p»rt of
the obsletrician in a uterus whoM> lower segment is so thinned out and dn-
lended that the idightciit riok-nce proves too much for it* rcslxting i)owim^
In other ease* it may result from the upward extension of corneal tears,
following rapid manual or instrumental dilatation of the oervis.
Violent rupture occurs relatively frequently when versioD is attemptnl
in neglected lrun*vcrsc prescntalion*. The proper treatment of this cl«*»
of oa^es requires the ntuioiit nieety of judgment, a* it i* ofliime* entrMnfW
difficult to detemnne whether the lower nterine segment is SO thinnni onl
Hf (o con I rii -indicate iiltemiit* at version, the operation having been readily
accomplished under amesthesia in some eases in which, nt fir«t ifighl. It
had appenred impraclicnble; whereas in others, in which it seemed that the
Rl'PTL'RE OP THK UTERIS
S35
I
I
noctXMTj inani[>itInli<Hi>< mmM be vritliAul <ianp.'r, rupture fnltnvrt>d Hw
mere introduction of llw han<l. Mori'nvcr, (here if> a niark^vl diQinvn
III the nipidilv vritli wlikh ouT^irtu-hing of the lower ulcniii' Mgnieat
comes about, Ibe oondition Bupervenin); very rapidlj iu c<nn« c«ses, while
in others man]' hours of Btroug, twcond'Slu]{i; pains nuiy be DCC<M»ar)' for
itd prmitH'tion.
Ccrtmn women si.>«iii to posectw u prodi!'{)oi-ition towards tuplunr of the
uliTu*. this uwumpiion being »np]Mirteil liy the fiu^l that n<ii a fvir cafleii
of rp|>cate<) rupture ap)>ear in tbc lileralnre. Thus, Mlkhine found records
"f 13 patii-nti^. G of wbom di«i a* u n'siilt of a MVnind rupturr. iiikI IVliaiuJ
bsii likewise reported similar instanww. It is rjuite likelv (hat under endil
ctrcumi'lancvs ihu second rupture oecurs id liscnes nlrundy wcvkeni-d by the
preTiouf accidenL
Pathology. — Ituplure of thv utcrui: occurring at tltr timv of labour i»
limited almmt entirely to the lower uterine segment, the rent usually pur-
^
Flo. U6. — UiiNiniTtipcAt. tiKcnoM mRoroii Wamah tirura mm Riimntr. nr thk I^vmic
mini;; an oblique direelinn ; althou;;h when it is in the immeilinle vicinity
of tbo cerrix it frnjumliy extends transversely. On the other hand, it u
usually lon^fitudinal when it occurs in the portion of the uteruH uljocent
to the broad ligament.
It is customar)' to di^itinguish between ompUte and inmmpItU rupture,
according a« the laeeration commuaicate<i directly with the abdoininal cav-
ity or is »eparated from it by the peritoneal ooverinjr of the utenifl or brood
ligament. The former is apparently the more common. XUrx having; col-
lected lis complete a^ a^in"! 4<i inonipletc ruplitrcr*. Koblunck notird
S8 and 24 respectively in 80 castas orrurring in the Berlin Francnklinlk.
Incomplete nipture^ not infHy)iienlly extend into the bniad )i^ment;i
nnder >ueh eireumi^tances the ha>morrhaee often oceun« Ie(» rapidly than'
hi the complete varietv. the blood »low]y acoumnlattng between the leaflets
S3
am
fiBS^lETRlCS
and Inuliiifc Ui llio iH.-]>itra1iiiii (ir thi^ pcritoiupunt from the siirroundiii;;
vUci'ra, with the tousequent fontiatiou of a larp? nubpfrilontal httmaioma.
Occasionally, n lifpmorrliagi- (iuHk-icntlr copious lo cause <)ie death of the
patient niav remain inetostti IhIwwii the Mtriicluriv. ilorw frequently,
however, the fatal ifSUQ does not oeenr unli) rupture of (he )ta>maioina into
the pcritoTu-al t-avi(y n-Iic^cs thir pru#j^iii'v which had pivrtously, to Mimo
ejctent. reslrainetl the blrt^ling.
Althoujjh the ruphiro occurs primarily in the lower uterine segment,
it i» not uiiii^uul for thi- laivraiion to i-Mcrid further upward into Ih*- Wly
of the uterns or downwanl through the cctvix into the vagina, primnr>-
l»iniiji of tho utertiift \iinly. iw n riilc, tieinjj ohwrvwl only in Ihc cui»«-* nf
sptmlaiifous nipture occurring during pregnancy. The tear itself usually
pnweiH--' jiiggi'd, irrcj^iilur imirginK which arc "laintil wilti blood.
Following complete rupture, the uterine contenirt may eieape into the
pvrilonml mvity. whil« in Ihc inc/)inpMc tariety ihcy may oonip to Ito
beneath the !-eroui^ covering of the utenia or hetween t!w leaRetn of tJm
brand lignnu-nl. In a n-rluin number of *'as^^8 of either variety, however,
particularly when the presenting pari is firmly engageil at the tim« i>f
rupture, only a p<irlioii "f llw fartu^ csit-ap"-*, iIh- n-t remaining in lli«
uterine cavity.
Symjil'ittis. — The Mini)!"!!!* of iii-ln«! niphire vary considerably. If it
occurs during the later months of pregnancy the patient usually experi-
enw* sharp abilnnitiuil jxiiti following some unu^^nal exertion, a fall or
BODie other traurnatii'iii. In some cases marked .lymptnms nf mllapiBe im-
mediately supervene, hut in many instaiKcs the patient merely compIaiBs
of mulniM', gravit :<ytiip1<>iris only oit^urriiig later A* ihir n-xult of inftwlion
or of putrefaction of the fietus. Thus, in one of my eases, luo weeks elaji'iiil
hi-twwn \hv mrurri-nce iif ruptui* and the nppt-ttrunce nf alarming symp-
toms. In thi^ earlier months, on the other hand, profuse luemorrha^ i^
the rnie, and the patient rapidly sucK^nmlis to acute aiuemia if not oper-
ated UfX>U.
If the accident nt'furx at the time of UtKiur. the patit-tit. after pre- '
aenting for some time the premonitoiy signs of the accident, suddenly, at
the height of nn intense uterine contraction or during an intra- utennc
manipulation, complains of a sharp, shooting pain in tlw lower ahdonicn,
and fn'(|iiintly cries nut that wonielhing has jjiven way in*idi' of her. At
tlie same time the lower uterine segment becomes much more sjciwiliv^ to
proMure, Ininnitialely following thl•.'M^ »ympt»mi' there te an absolute
ceaeation of the uterine contractions, and the patient, who baa prevtnunlr
been in intense agony, suddenly expt-rii-nw.* marked relief. At iho samt^
time there is usually more or less external haemorrhage, though not un-
commonly it is rery slight in amount.
Palpation or vaginal examination ahow« that the presenting pvrt bu
slipped away from the superior strait and has become morable, while a
bard, murul bodv. which represent* the firmlv contracleil ulerus>. can hi'
felt alongsidi' nf ilie fivtus. Naturally, if tin' uterine content!^ haw ix-aptii
into the abdominal cavity, Oic pr«weiiting part cuuDOt be fdt on vaginal
ejtainination.
KliPTL'HE OF THE LTKIIUS
S37
Ah a Tutp, Bbiirllv after ihe oocurrerK* of noinplelv raptarc, Ihc pstivnt
presents eymptonis of collapse, the ]m\fe incmaee markedly in rapidilj,
li>sH>« Inn*', ami inki'^ on u filiform i-Uarador. iW fact- U-conK-s pallid, fl»«utae«
s drawn appearBiiiir, and U ofit-n ctiveml with ticadi> of KWfnt. If ibe
hsDmorrlisgv )ia« I>i-<-d enpiouK, ^ho may coiuplain of chilUoeK, di.iturbances
of vL-iion, and air liim^T, and (-vt-ntiiully pAnn into uii ui)coii*cion» slate.
Symptoms of rollap^, bo«wer, do not always a))pear immediately, but
iin' Kom^'limi-" ili-fi-rnil for m'vituI Imurs afliT ruplurv. bt-ing 1(^ niarkcil
when Ihe child rpiiiains partially williin llit? ulerii!-. Af((T in(-i>iii)il<-lo nip-
tun', on lh« olhtT hand, the immrdinic symptoms are i^ometimcs rery ^li^ht.
but iocreai^ in severity an Ihe ttutiperitniii-al hu*malonm liecomes lar^'f,
whilrnctiial (n,-mploniK of collapse frc<iucnlly do not Bpi)ear unlit secondary
rupture into tbe [leriton^'a) mvily has taken pla<«.
In a tvTtain niimlH-r of raH-^ of incomplete rupture. cmph>'$cmatous
eraeklinc can tie eliciteil in tbe tisHuet of Ihe anterior abilutiihtid wall, II
cnn^ of ihis chararli-r tiaving Ihvh collected )>y Dii^ebler. It wonlil appear
protubte tliat the condition n usually dne to ttu- invaMon of ttie iiubpcri-
loiienl connective tiuiie by Itacillnif nerojrencs eap«iitulut>. It i» Iruc tliat
liaoleriolo^Eica! proof )!».■> not In-eji addnciil in supiiort of this staii-itient,
lirtt Ihe fact that ttio women liad Ifceii in laitour for many houro, and tliat
many of tbe children woie more or Ie*s putrelitit, i>|ieHkii strongly in favour
»r Miieli a view.
/'ufi^N'jKU. — In rases of i<|N)nlaneouii niplure during prf(fnan<y. Uie
(tia^ioi^is is not always vn*y. If ncconipamed )iy profutH.- tiieniorriia^.
tlie profound collattHO kIiouM at once lend lo a pruriiiional dingiMuii', tmt
in other ca*es ttie condition usually ewapes deteetion iinlil tite appearaneo
of pcritouilii- symptoms, (ienerally Hpt-jik inji;. it may he >aid Itial a rapid
put«e, slight iHevatioD of temperature, and alHtnmiiinl dif^tt'ntion av>ioeiaIed
with vi-ry dixtinot iwlgialion of tbe firhn. ^Iiouh) always la- n^urdt'd with
grave suspicion, particularly when preceded by a history of tmiiniatism.
On tbe otlier tiand. lfi« dia;;n(Miii i* usually eiL*y when iIm' aeri<h>nt
occurs at the time of labour, ej^pwialty if the patient has been under super-
vision durinj; its cinirse. If »lie is not swn until laler. ihe eharaeleriotic
histofy and tbe collajiije are almost patho];nomonic, the only oiber condi-
titina in which t)K> latter is noted before delirojy being the case* of Incinor-
rbft)^ following the rupture of an advanced extra-uterine pregnancy, or-
Ihe premature wparation of tlu" nonnally implantetl placenta.
If the child has csca))ed into ihe alxlominal eavity, it is much more
readily felt on palpation than luual. while on one side of it tl»e hard)
munibH] body of Ihe uteruH can l>e delected. Moreover, vaginal examina-
tion frequently reveals tlte exivicnce of a tear in the uterine wall through
which tbe fingers can \n- pa»(-d into tlw abdominal cavity. wl»ere ibey
eonte in contact with Ihe intestines. .Again, the fact thai the presenting
pari can no longer lie fell is conclusive evidenoc tluit the ftrtUK lia« escaped
ifroni Ihe uterus.
ProgHwii*. — The chanc<w for Ihe child are almost nnifonnly Wd. since
it frcqnenlly flKi-uml" l>efori' Ihe tK-t-Hrn'oco of the ai-tident. On the
oUier hand, if it bas stirvived up to that time, its only cfaaocv of living is
S38
OBCTKTItlCS
iiff»r(li.ii !>>- iniiiintiale exiraction, asphyxia, llic result of the separation
of the placenta, b«iiig oDivrwis^ 'IneTiUble. If left to tlieiDMilvea, the vsitt
nwjftrilv lif th« moitwrH die from hiMiorrhflpe or infcicttOD, although spon-
taneous rocov*Ty hti* liiTii tioloij in ex«;)iii<mal laiies.
Dcalh fn>iii hu-inoiTha^ UI^ually occunt vithin the first few Iiours,
though occasionally it may bo doftm-d for forty-eight hours; la iofoctlou
the fatal tfriiiinalion tioex not occur for some daya.
Spnntaiii'oiiti rcrorery is lca»-t likely to occur when the child lias ivcapw]
into Ihr al'dnniiniil i-aviiy, tttou^di iKolaU'd iiutaticix aro on n^i-ord in whii-h
the patient lias survived even such an aceidcnl. lender such circumstances
Ihc child ii* ur^ually »urrounded hy fcial imrtnfirauw. and afler iu dc*Ui
may undergtt any one of the several evenluatilies mentioned in the chapter
on Extra- I'lvriiiv Pregnancy. So ftir a» liic woim-H are convernrtl. «-\if«
if they are properly treated, the mortality is very high, at least one third
(uccumbing.
TrfatmeNt. — (a) I'rophylartic. — Intelligent care of the lying-in woman
idiould alnioi'l entirely do away wilh iIitk accident. \Vhene%vr theri- is a
pawibilily of ihe exi.-'ltnce of an obstacle to the birth of llie ehihl. llie
ebstotriciau i^huuld aUnys be on tbc ahrl for »ympt"m» indii-ntivc of im-
paidiu^ ruj>tnr& Transverfto pre^enlalion^^ slmuld be promptly ileliveivd
by vcn-inii a« soon as Ihc (Tnix ix fidly ditatctl; in head prest^nta lions fail-
ure of ell^;n)^>lm-■«t after one hour of strong aecond-iitagc ]>ain$ should W
regarded uilli sui^plcton. and if the conlnicllon ring risc» up labour rbnuldj
U) promptly U'riiiiiiflU-d by the niont con-«'n'nlivo jiroctHliire, In m-gb-cted
cases, decapitation in transverse and craniotomy in head prcMentatiniui vflcn
promiw llie bcU rcsidl". Such pnKS-diin's arc the more juslitiablo under
ibe cinumi'tani'i?:', as Ibir i-liildren are usually eiiher aln-ndy dcjid or cximwl
to such danger tbat Ibeir cbanccs of being dclivcrc"! alive an; very slight
(b) Vnmliri'.—l( the (iiild is xtill within the uterus, delivery should be
promptly effBcted by the natural paKsagi;s in the most conser^-ativo mannur
poiwiblc. On tlw other hand, if it has already ■.•icapiHl into the abdonnnal
cavity, no attempt sliould be made lo extract it per vayinam, hut laparot-
omy should be iniriieilialoly jierfornied, and followed, after removal of tlic
child, liy whatever oijcrative proctslures may be deemed neri»isary — »uture
of the tear, supravaginal amputation, or total remot-al of the ut«riis.
On the other band, in the cases which are not !*en until the child luu
already been dcliveml prr vaijinam. and in which tite uterine rupture wat
not recognised until after its birth, various procedure? have b«en su^csled
by ditTcrenl authorities.
PerKonally, I believe that th« b^J"! rcultd will follow laparotomy, nu
matter what the cliaracter of the tear or whether the patient i« suffering
from bn'iMorrbagi' or mil, for the rt'ason that it is ofttimns ditlkult to de-
tennine the extent of the laceration, and alM> that il \* abKolutety imposaiblf
to forelell whether the hxmorrha;;e can l>e ebenked by *imple proralurs:
and. even if Ibt-se nuweed, wbelher Ihc result will be iiermancnl. Fritsch i«
twri-ct in staling that Ibe only iiiethud by which we can a^surft onr«4ves
against all fuillier risk of liDcniorrbagc is by opening the abdomen. Vtr-
nier, Ivauoff, and Zweifel take a similar view. Tltv latter does not soturo
LNJURIES TO THE BIHTH CANAL
S39
llio mii^l<>. Iiat »implv Mirorn iht- wouiui by periloniniin itftcr liaving timt-
oujilily cleansed tlw periloiH-al cavily o( blood.
On IheotlHT liuul, ccrlnm uullmrilifv iirvu*- lliiit, ituuiiituch a* 1h«> dui-
to Ik apprt-iieDdcd in it]n>i!i)ileli.> ni[j;ur(- is Imin Ititmorrhs^e rallutr
ttiail M'p^i)', lupnroluiiiy i<ti<itild )■■-• {nTforiiiuil imiv in ihfm' ciihv iti which
the loeii of blood in profui*, and UiAt id all others oiuatly >^hn1, if not
br'tliT. results may bt- obtained by drsininf; or pockin); the rupture from
iTi*" vagina. 8iii-h » pniciMtin\ lioum-iT. d'HV nol apixiiT rutioiial. for
nut infn-qupiitly women, who ai>' a|iparei)lly in t-xwUent condilimi T<hortly
after tl»e utvuirerxv nf tW nii'ttirv. Iiejpii to bliti] [)rofiiK«-lv wiini* boun'
later, and are then in danj^r of dying before operative procedure can be
itiiitituli<i].
Schmit reports S3 canes treated by packing or drainap', and .1"J by lapa-
rtiliiiny, wilU a morialily of 4S and 15 percent ns'pi'elively ; wtiik- Klicn
haji colloetid a eoriea of Vi& and Hi* cajen, with a rf)pi.>cii\'e mortality of
39 and 11 jht crnl. 'V\w latter »lat«'» tlwt lite mortality was only IT per
ceat in Ihe caws which were treated exeluBively by drainage, lie ibetA-
fun- c"nchid» thai hii>ariil«>my i« j list i liable only in thtwc ca-^s in which
tuemorrhafire is peniiHtent and cannot be checkcil liy other nii>a''iireA. Var-
ni^r, on tlic contrary, ^taie.'' tlial nut of 11 caws in his experience which
were treated by packinj^. HI died ; wl«?ie«H 3 of the C patients operaied upon
rwivrn-d. fi othsr* dyin)i l»ef<>re ofurative prjcirliin-jt could be imflitiiled.
The statiMlicM thus far adduewl can liardly be re;;ardfii n^i i-oixlnfiiTe, inas*
much a* no di'tiucltini wax madi* Wtwwn compleic and iiK-onipU-te rnp-
tur^ b)il partictilarly because many of the aagoi were »ee» aiH) npcrateil
Dpm nnty aK a lai^l rcwirt.
Instrumental Perforation of the Utertu. — ItcfiTcnce ha* alnwly bei-n
made lo perforation of tlie iileriis ff>llowinj; attempts at criminal abortion
fir in IIh* effort In n>m»vc placental. tiwui- by mcaR« of tlR> ciin-tlc or poly-
pus forceps, after an incomplete aljortinn. Similar aceidenlii) likewiw occa-
iionally occur nn the ri-Kult of want of rtkill on (In- part of the obi^lctrictan
in full-t^rm lalioiir. As bax aln-ad> iH'i-n jMiinliHl oni. in can-M of this
character, loopH of interline fm|umlly prolap.^ through the rupture.
Uiulcr »u<*h circiiniHlannu la|uir»tnnty ii" tlw itU»l treatnaiil. thnufch. iu
the absence of prolajw of tite inlestinvM, cases are recorded in wliidi recov-
ery ncctim-d »pontanw)u*ly under what were ap|uin'ntly mwt imravourahlv
circumsianrt's.
Perforation of the Genital Tract following Necrotia. — In obxtmctM
labour (be ti^HiM'H in varioitx jiortioiiK nf the ^fuilal tract may be forcibly
compresoed between the Itead and Ihe l>ony canal. If tin- pruscure is trand-
tory it in wilbout sijinificanci* ; but if it la long continueil, neerorti^ nstutts,
and after a few days the area implicated lilougb^ away fO that perforation
fnllowK.
In most caiw« of thui cliaracter the perforatiim occurs between tlw
vagina and the bladder, giving rii* lo a r«iro-rii;/tna/ finluh. \/V» fre-
qncnllr Ibn anterior lip of llie cervix is compressed again^tt the symphysis
pubis, and an abnormal communication k eventually c^tubliKbtil )K-twe«ui
lbs rervtcal iraiul ami the bladiler — cervitv-vriiicat fiatnla.
840
OBSTETBICS
ir llw jwtH-nt iR iiol infwtwi. Ihct fiMtilouit tract fr«tiiMilIy Iwaii* with-
out ftirtliei' tii-aliiieiil. In other caw*, however, it rnav |tersiiil, wiicii a
»iibM't|U<;tit (ilu^tkr (i| II -ml ion l'fi'«iim> iit-t-f-wsiiry for its <-iirv.
Oct^asionallv. the posterior «aH n[ the uterus niaj- be subjected to so
omch pivesuro nguin^l iht* jimiiiontory at l)ie ^acruin (hat necrocti^ rfvults.
and a ronneciion is established with Uougla^'x cul-de-sac. It infection
oreuri', the accident li^ usually followc<l by M'pltc jicfilonittM. Fortunalely.
r>\'i>vtTy UKimllv rollnw* wilbmit fmlht^r i-onijilirfllionK. iimKmiirli ns a Irioal-
JKed |H-rilonilif Ifad* to ibe foniialion of adUosions iN-tureen ihe jMisU'rior
wall of tUi- utvi'UK and llic pt'lvif [HTilonii-iim. thereby floin^ away with thr
posfiihiUty of a (jeoeral peritoneal infcelion. It slmutd l>e remenihoreil thai
similar It-sicmj' may iinur in the ran* cuM^ in whii-li v,xi«lii»^--s or bony
spiciitcx protrude from the wallit of the birth canal, a-i in pehix Hptntma.
LITKRATITKE
AtXXA?ll>ii<)Fr. Fill Fullvoii ttluniAni)>tiir wiLlintiid<]erKr)iiniD)a'rwlmfl. McicMlKwJir.
f. (loll. II. (lyii., ISMKl, xii, ■IIT-I.'sr,
ItAjacH. Uetiur Z«TruiBim^ iler ( Ivl>iiriiiuttur iii der ScbwaiisenehafU Iteilra^ i.
deb. It. Cyn., 1903, vii, ■ii»-2»a.
Bandl. Uebor KiiplUT lics trieruH iitnl ilire Mechuiiik. Wien. 1875.
Buxo. Uuittug lur .\«ti(]|ogio iler Utcnianigitur wahnmci dcr Scbwiuif;crwh>fl iiad
\uiter Hor rrtjlnirt, D, I,, I^lrumliiirK. IW-i.
BuuuuEAu. L'urnidiutnmil cimUiuiv dii txA uc^riii iwadunt I'aTOuui^bement. Tti#«D
do Toulouse. 1002.
DiBCHLKH. l.'c-tivr nibpvritoneiilca EniphysKra tuph Huptun uttoi. Ari^hiv (. Ctyn.,
1898. Ivi, l«>-217.
KvEUKK, Uuljer Kulpupurriicidii in ilerCeburt. Monotasmhr. f. (ieb. u. Cjtt., tSSft, w,
23,t-239.
Kritcch. Uelwr dio Betiandlun^iler llt«ruiuniptur. V«rh. (L<louUcben CleiriL f. (JjriL,
Xma. 1-10.
OoLnNKK. I)«hniiiu( <le« unloren UterinMitrmentA bal stahmnilor RImo. Monatwdtf. f.
ti«b. u. Uyn.. 1003. Tviii. 4S]-i>1:J.
HK.MumK. r tern-abdominal CiciAiition. The Pnu-lirc of (thnlctriai Iiy Amerkwli
Aulhnnt. I89U, ,186.
HiTiiE-suiLKiiKn. l.'«ber Kolpnpnnhexio in dcr (kburt. . rotcriibitrK(!r mod. ifoittchf..
IVANOPF. Etiulu^u, piophyluxit^ i^t Imitroeiil iltu nq>turcs <le I'uUmn pundaiil lea
ooucJicji. AnnaliiH ilc nya. ct d'clut., l'M\S. lix. 341 '3M.
JKLi.iKofuvs. L'eber L'terusmptureu wahnud <Ier StrliwauKcnchaft. Ardilv f. Qyn.,
I81>7. tiv. 1(B-Hfi.
KAimiANH. Ucljerdiu ZitmTiiHninK den ,Si-hdd<niKew6lb«» nahrend iter Oaburt. Mo-
liubtH-br. f. t^ub. u. «yii., 1001, xiii. 4IH--t7o.
Ki.iK-v, Ilif apor»t4i'v uiid iiii-ht ojnTnliif Bvhiuidliin); ifcr l't«niiimp*«r. ArcUv f.
<;yii.. 1000. Uii. Hott 3.
KoBUNCK. lit-iirHK Kiir Ulire von dcr litiptuni uteri. Htullgnrt, IBM.
I.roroi.n, Aus^lrueLTui •nninHAiT .\hdoiiiinHlH(->iK'an|Rrivhitfl iweh TtuiMum ulcri
IruuiDntkn. «t<-. Arcbiv f. Gyii.. IHW. iii. H7fl-388.
Mkm. Ziir Bchaiidluinj; der t ' UniRntptur. Awhiv f. Ojrn., }tOA. xlv, 181-271.
MiKRtNE. Vix ciu dc ri^cidivc dc nipturo itli^rinc. AnnalM do gya. vt d'otart.. :90I.
Ivii. iai-tia
INJURIES TO THE BlRTH CANAL 841
Peham. Ueber Utenurupturen in Narben. Zcntralbl. t. Gyn., 1902, xvi, 87-04.
PoROHCHiN. Zur AetidoKie der Bpontanen Uterusniptur wahreDd Sc-hwangeniphaft
und Geburt. Zentralbl. (. Cya., 1808, xxii, 1S3.
Roes. Lacerated and Piinrlured Wounds of tbe Genital Tract. Amcr. Jour. Ubet.,
1898, xxxvii, 440-469.
Sanqer. Buptura ut«ri. Verb, der deutscheD Gesell. f. Gyn., ISO.'i, 19-86.
Soiioi. ZerreiBSung des ScfaeideDgewiUbeH wiihreiid d«r <i«burt. PniKtr med. Wo-
fheDBchr., 1893. xxiii, 3S5, 367.
9<MMIT. Ein Beitrsg zur Therapie der Utenmnipliir. MonalAsrhr. f. Gel), u. Gyn.,
1900, jtii, 325-342.
SmTurHOTXiN. Quoted by Kaufmann.
Varnieb. Du trait«inent dex nipturen de I'ul^nis. AnnaloH de iiyn. et d'obiit., 1901,
Ivi, 249-279.
ZwRiFEL. Ueber die BehandlunK der Ulenisruptur. Beitra^ x. Geb. u. Gyn,, 1903,
\ni, 1-27.
CHAI»TEK XLII
PROLAPSE OP THE VMBlUCAt. COMi— ASPHYXIA NBOSATORViS
—SVOtiBS DHATH VVRIXO LABOVH
Prolapse of the UmbilicRl Cord. — It is customarj to distinguieh between
prrsrntatiiin nixl fruidftnf iif thr funlf nr uitiUilioal oord. In tlie former tli«
cord can U? juilpated tliroii;^h the intact membranes, while in tKe latter a
Dop of il prolrudvs tliniugh tht! wri'w iuto the vagina, and exoeptioiiallv
^emergeti fn>ni the vulva.
Mtialog^. — 1q gvnvral il may bu said that nny factor which int«rfen-8
with the aci'urale adaptation of the presenting part to the lower uterine
segmont pri-diipoww to prolapsy of llie cord. Accordingly, tin- an!iden(
oi^cura nioit ooiiiiiionly in tranoverAL- and foot, and lesii often in' frauli.'
breech preecn tat ions. Ou the other liand. it U rarely observed when the
child prcMrnU hy tho ht-jul, utiles aiooniinnilation it* inierfereil with ai> a
result of a coniractcd pelvis, excessive development of llic fu'tus, hydram-
nios, or abnormal flaccidily of Ihe lower iiti-riii« segment. Fur this n-a^uin
it U much more eonimnn in multtparouM than in primiparou-i women.
Symptoms. — Prolapse of the cord Is without approciublu dlwrt upon the
eonr»e of labour no far tt* the inoilier ia com^mod. I>n the other tiaiul,
[■it 18 one of the most froiuenl causes of ftplnl death, comprcwion between
'the presenting part aixi the pelvic wall inlerferin^ with the cirx^'idaiitiQ
lo each an extent that asphyxia and inevitable death often follow unieM
pn>mpt delivery i* I'lrMli-'l. The danger in grtwler in vi-rtfs thun in other
presentations, for the reason that ihere is leas likelihood that the cord
will e-*(0|je eompniij'iori when the ]K'lvic canal ii! fitlwl <mt by the hard,
rounded liead tlum by the softer and more irre>;ularlr shaped part in other ^
prcM-ntntton^.
/>ia(/iio*i>.— Prefientftlion of the funis is dia^<Med when on pAlp«tIaB a '
soft, pulsating cord-like liody can be felt tlirough the nieinbrunea. In many
instancei^, however, il.^ reeOjU^nilioii is only poiaihie when tlie cord is in direct
contact with tho presenting part.
I'rulap^e of the wnl, nn the oHkt hand, it readily reeogni^vd. nince
on vaginal examination the finger* eome directly in contact with a loop.
while exL-eptionally the structure may protrude from the vulva. Mi^takc^
are hardly |i(iKKil>le if the fcetus is alive, as distinct pulsation* at* felt,
although in their absence th(> eondition is Mineliniea overlooked on snper-
fieial examination.
I'he possitiility of pr»la)>»e of the cord should he p«rticuUrl; borne in
84'2
tk
PROLAPSE OP THK UMBILICAL CORD
843
N
»
■
■
mind in mnltiparouii vrnmen in w|>om (h^ meinbraiies rupture irhil« tho
head in i^liU freelv inoTat>|p a\in\i- (ho ^uix^rinr ulniit. In out^ti vivtei tlie
suddvn crt««lii>n ol tlii? fu'lul h(.-iart-b(u( raid«rs the diagnosis almost ccr-
lain, c%-efi without vaginal txamination.
Trralmtnt. — The treatment to be punu«d in any pvea cue d^wnds
m»inly upon Um- dcgroo to which lix* cervix is <lilai(,il, irnd In » )«Mer ex*
lent upon the prctiuntatioD of the child. So lon^; as iIk mcnibranra renuin
inliK-i Ihrrt- it iiu imnivtliaK: daogvr of ixiinpri'M>i»n, and for lhi» rcaw>i]
every precaution ehoul<] be taken to avoid their premature rnptare, ra^nal
(-xiimiiiiilionx tii-ing made wilh tin- utni'Ml p'»tleti<aw. Al Ihe Kiinie time the
nln^letrician should hold himself in rcudineMa to effect delivery as soon as
(Ih> L-iTvix i» »uflK-ientIy dilated.
If the nM?Ribraneti have already ruptured, provided dilatation iti corn*
pkte and the child pro^cnU br the livad, its' life can often Ik- Mvod by
prompt delivery, vhieh can usually be effected more rapidly by version
than hy fonx-p. unleM the hmd it already deep down in the pelvic canal.
In bret-x^h preM>ntationjB, a foot i<hnuhl be brouf;hl down and followed imme-
diately by extraction. In trun»ver»« prvMiitalioiu vcr»i<m i» indicated.
On the oilier hand, wlkcn tlu! cervix i» only partially dilated. Die ehancea
of a favourable outcome for the child arc markedly dimiuiKhed. If tho
)M-ad IK not dvi^ply en^^ed llie pntieal iihouhl Ih' plait>d in the knee-vhext
poeilton, the entire hand introduced into the va^na, and an attempt madit
lo pu»li the cord up into the uteru* nnd, if pocMible, to carry it over some
projecting portion of l)i« childV body. If the cord rvmainu in the uterus
(lie puticnl »liiniM be mud« lo lie uptm I)m- wide towards which the child's
back if dirot-ted in Ibe hope of avoiding eompreaiiion.
In the majority of csm-k. however, the pn>Ia])«v revure again a» «k>u m
the hand i» removed. Under, such cireumtftances an improvi?ted rcpoeitor
will ramelimcs senc ub in good stead, nltliougb tbi- n^ult;> slletidiiig the
»M! of nuch devici's are oflim un.-Hlisfaolory. A piece of bobbin is Itnnly
alUchcd to the free end of a sterile bougie or eutbetcr in itueb a manner
w to teave • loop Hcreral inches long. Thi« in then paxsed around the pro-
lapsed cord and lilipjK'd over the tip of the bougie. By this mean* Ihc cord
can rmdtly )m- cJirriitl up into the uteru.-, after which it may Ik- frv^ from
the repositor by bringing the loop in contact with a portion of the child
and making tntction ujHin it «o a^ to rflnm it to «lip off from Die tip of tlte
liongie. In the gn^at majority of cases the condition recurs an soon as tho
rej>o»ilor is rcmovtil; to in^inr against any risk of Kuch an aoetd«Dt, tlw
iMugie may be left in the uterus.
Occasionally the tendency to prolapse may Iw ovrrcomc by placing the
pnticnl in the knce-chciit {lOfiition until enga||:ement of the presenting part
occurs, when the cord cannot get put it. In moHl cascv. however, Iltise
manu-nvrrs prove ini>fTi.f'iiial, and tbtt death of tlto child beromeji almost
iw^viiable in vertex, and only somewhat less so in breech and Iransverw
presentations.
In exceptional vuM-a, if the child is in good oottdition. excellent reeull*
may lie obtained by manual dilatation of Ihi- n-rvix, folton-iil Ijr prompt
veriion and extraction. On tlie other hand, if Uw pulsations in the cord
SM
OlteTElKK*
are wvuk or hmv <wnMM] nltt^tlier, siii-h a jiroccriure h1h>uI(1 never be
adoptitl. iiioisiiiuc-li a^ the child has either already pL'riiilieil or will die
befon; ili/livcri' tuiii In- eirwtwi. If, h'twuver, ilii- itrvix in fullv tiiialed, *iivh
limitntioiiK ilo mX tiold ^ootl, &i (Hi^a^ioiially a child that is apparently
hopelessly \<rr-i may be rescued,
Aspfayxia. — Nnnnolly, ihc h'Uif while it retnain^ in ihe utenii' tit in a
c<>nditi'>ti of apiKi-a, liein^ sati.'iraclorily supplied with oxyjiien by mean!! of
the plawnijil cinulation. As soon ax dolivcty occ-iirs. owinj; to the Bcpa-
ration of Iliv pliK^'iita or In a great diminution in itx ari*a "f «t1iiobin<fnl.
this source of oxygen is entirely cut o9, or so fpvtatly rcdaced that the
ncottwity fnr K-livc nvpiralion uriiew. GcncTBlIy speaking, iinper/wt oity-
gcnation should be considen^d as the primary factor in the estsblishment
of thii^ funclioti. although nuinvnui* ncrt^wory cuu«ec com« into play during
the act of ddivery and juAt afler birth.
Exceptionally, as llic n-»u11 of Ihc death of th« mother, compieesioa of
Uie pmlnpMHl cnnl, prt'malure H\>parati(>n of the placenta, or much lata
commonly of tetanic contraction of llio uterus, the normal supply of prop--
eriy aerated blfiod llinmgh the uitiliillcal vei*seU may Iw cut off or intorftTod
with while the child is still within the uterus. Occasionally. « similar
condition niny In; hr()nglii oIkiuI by compreiwioii a^inut the «^yn)pliy«is of
B cord which is wrapiwd around the net^k of Ihe child, while now and a^in
asphyxia and even dwitli nmy nwiiH when iIk- hoad i» on ihi; pcrina-um,
owing to excessive retraction of the active segment of the uterus, with a
conM<t]UcnL dimiiiulion in the area of placental attAchnienl.
Alt a nyull of the action of any of thew factow, lh« ehiW may lake ita
first breath while still in the nteroa or in the lower portion of the birth
canal. In the former v^w it drawic a certain quanlily of ninniotie fluid into
ita lungs, unless such an eventuality is rendered impossible by the fact that
the moiitli and iioso arc t-Uisely applii-d to the uterine wall or are covered
hy the fu-tal mi'mbranc.v When respiration liegins while the head is in the
vagina, a certain amount of tnucux is liable to be aspirated. In cillter event
the ^el^)l'<l i>\y)^-n i-'> ui>t olnaiiunl, and the resulting sir hunger leatU to
increased respiratory efforts, which arc nevertheless of no avail. Gradually
thi! accumulation of c«rbon diovide and other excrementitiou* niKieriaU
in the fo'tal orjcanism leads to such a pronounced decrease in the irritability
of the medulla, that cii-ntunlly llie attempts at respirntiim ci««\ Ihc inlrr-
vals between the pulsations oi the heart become longer and lon^, and Ihe
child dies from asphy.via.
A^'ain, pressure cxertivt upon the brain in dilTlcuU labours and o[H-ntlivu
procedures may Icail In vagus irritation and consequent slowing of the heart.
As a R'siill of Ihe inter fern lie with the fu-tal eireulnliou, the bbyxl bcconiw
poorer in oxygen and richer in exereuientitious material; this goe* on until
at laKt the irritability of the medulla l>ecomes so lowered that the u^al
stimuli full fi) call fiirlh the first rc-f^piratory movenifiit and asphyxia results.
'riu- must friHpient i-aast's of ivrebral coiii;)n-»ioii lire iittemptt^ '«> the
part of the uterus to force the head through a ciHitractetl superior strait,
excessive pressure everlnl by the lilaih'.-: of the fore*-(w. and intra-cramni
hn-niorrhagt-. When limited to the cerebral hemispheres, a very cuusider-
.\SPHV.\IA
S45
alilti i-ffiifiion af blomi may occur wilhoul cJivrtni^ it tlclttbtriniiA effect tipoti
tJic fuiloe; but if tbu baw of (he brain is implicalul a uiutih nni«ller ainouut
may jp\M ri«<i- lu fVitMu (listurbancfe.
OiaynMiji. — T(i<^ iiiiiHirtiiiicc of wnli-liing for luanifetttalionM [toinling
ta tfareateiKxl inlra-uterinc iL->f>)i}'.\iu t-aiiimt \n- ovcnutti muled, itiaiiinurb oa
their recognitioo freigueotty aQordij the indication for oiwratiii] dvlivcry.
without tthi^h the life of th« ebild in inevitably lost.
The niostt clKiracli^rixtir iiytii])l«iii i» ■ffordi'd by chn»gv« in lh« f«etal
puLw-rale. At first, u^ a result of monieDtary roiiipression of th« brain or
intrrfvivDcv with lh<- placental eirvuialioii, it becoma!< slower with each
uterine contraction, but ri'^'ainii it» normal fr«<i(uency in tho intcrvnN be-
tween Iho pains. As the eondilioii heroines more serious the remisHions
fail to (Ki-nr, aii<! the piil.ie becomes siowt^r anil slowiir ami t-vinitually tlir
heart ceH!«H to beat. For practical purposes it is wdl to assume that a
piiU!-nt« of I(H> or leM i* iiiiiimpatilite with pmlonjcvd life for th« fcctus,
and under such oircumsianoes rapid delivery is indicated, provided it cati be
accompliKhi-d wirlwut Iimi gmit ri*k for the mollicr. Kxwplionally, the
first sign of asphyxia i>i n marked increase in the fra)uenoy of the fieial
pulw. which may vary from 100 to 300. Tlw acceleration, howOTcr. is only
ti-onsicnt, and, as a rule, soon giVMi place to a marked nlowin^, which
hoconK-« still nioT« pom.'ptiblc as tito fatal termination is appniHched.
In vertex prc»cntation!t another* characterUtic m^ of iiii|H'nding a.'-
phyxia is the escape of niL-conium. This Is due lo rdaiiation of the sphinc-
ter ani muscle indui-ed by faulty aeration of ilie blomi. In brecdi presen-
tations, of coarse, this symptom is without «i||[nificance, and is to be
rr^rdi-cl as a purely nuTlianieal rt-siilt of p^c^*»un• applied to tlw abdoiiKii
of tl>e fietus. Acconiinjtiy, whenever tJie amniotic lluid in a vertex prewpiita-
tion pnR>cnt8 a >-el tow ish -green appearance and contains flakes of meconium,
we may eonoluile that the child in in danger, and that tin- only hope for its
safety lies in prompt delivery,
E»p«f-ial!y in dtlTicutl brx-ei'h (•KlrBctiim*. wbi-n iHmv is experienced in
dehveriiig the head, signs of aephysia may appear in a rhild which was
appan-ntly in cievlk-nt condition hcforo IW o|>enitlon. L'nder nuch eir-
cumstances the fiujccr in the child's mouth can readily appreciate the fact
that vifforous inspiratory movein'-nti^ ar<! U-ing made. A Mniilar phcnoin-
<-tnin may nCTflstxiiuiily !«■ ol>*erved in vertex pr^-sen tat ions, when the head is
arresl«-d on tite piHvic tloor, the movem«tits of the mouth l»-ing fell or
seen through the Ihinnml-out p<-nniciim.
ViTV cxceplionally the child may not only make inspiratory efforts, but
aclually give ulttrance to sotmds in Hirro — mgiliv ulerinus. For the pro-
duction of this pbi-nomcnou it t.-> ■wtpntial that air gain access lo ^hc fmtua,
it* iinlranw into tin? uterus sometimes tesulling from the introduction of
tile baiMl or instruments. A rory charaetoristic examplo of this phenome-
non ha« iHvn nvonhil by Hucura. who has collated the Jiteraturv bearing
ufwn ihi* !*ubi«'t u|> to 1!I04.
After delivery, the a>phyxiot"l cbtM may pr«*nt one of two appcar-
Aocefl — atpht/zia ftnUida or anjihvria Urida. In Irath rc^'^piraliim i* in ahey-
aoce or occors only in gas[)is, while the heart lieati iilowly aiKl feeblj. In
■
M6
ORSlETRlCa
tite former the surface of the body i» pcle and cold, the cxtremitiM hug'
limp, and tlic t-hilii fails to rt)!ipoii<I to the usual external Rtimnli. 1b the
latter, on tlii> oilwr haml. it proocnt^ a coiigKtcd or livid appearance, which
is usually sttributeil to orcrdist^ntlon o( llift right lieari a»<i iho inferior
viiitt cava. Thi* form of asphyxia is o^ually more amenable to treattneot
than tl>e pallid variety.
Prognosis. — Aepliyxia oeoDatomin is always serious. The prognosis ia
relatively favourable wln-n the comlilion in du« to mwluiniwil interfer-
ence with the placental circulation, but is far less so when it results from
injuries to the brain, kucH •» inlra-craiiial hurmorrhagc, friicturos, or de*
preit<ii»n» of Ihe ekuH.
Treatmrnl. — Normally, the child eltonld rankc it* firxl inspiratory move-
ment a few iiioiiicntd after it emcrfiot from tiio vulva. If this doM not
occur, the feet beini; grn^pi'd by the fingers of nne hand and the child fus-
pcndcil with itit head downward, it.i bo<ly should lie nlapped vig(irou.-(ly with
the other. If this manoeuvre does not prove iinnicdiaCuly successful, and
partk'ulHrty if utt<^niptH at re-^piration are a«-v>ciauiil with a gurgling Kouod,
a Hnger should be passed to the back of the phan-nx for the purpo^ of
removing any hm-ign iiiiitt^risl which may interfcn- willi Ihe free accc« of
air to the larvngeal opening. Ordinarily, if the child is not deeply aaphys-
iatcd, thcso tncmiurcs will bring about the desired nvutl": but if (hey fait,
artificial respiration should at once be instituted, the child's thorax beiitg
compressed 5 or <i timw to thi; minute.
In some instances, however, more radical measures will lie found oeoe^
aary. In such cases the cord shofild be ligatcd and cut through, and the
child immi'r.*cd in hot and cnld water altemalcly, with only it* head pro-
trading, and rublrtd vigorously. If there is any reason to believe that the
bronchial IuIwk conluiii nnicu» or amniotic fluid, a »mnll, sofi-rublK^ cathe-
ter should be introduced into the larjDx and the otlending material rciiioTcd
by suction exerted by tho obstetrician, or by the emplojinvnt of a Bilie-
monl-DessaignM insuHlator.
If these ni<-HsuTcs do not lead to the establish ment of respiration, thi!
child ohoiild lie wrapiMH) in a piece of blanket or flannel, to prevent tno
rapid cooling, and laid upon a table or chair, tho Iwad being allowed to
hang over thu tilgc, Tlic tip of the tongue is then grasped by a small
pair of artcr>' forceps and drawn forward n* far as possible and then allowed
to recede, the inaiiu-iivn! being rcpeatn] at regular inlervels 10 or 15 tiiBW
to the minute. After the first few tractions, an inspiratory moveniejit usa-
ally follows, after which respiration goes on regularly. This procodnrc,
known as Lnborde'a melhudi/f restucitalwn, is based U|»n the principle that
traction upon the t'inguc irritates the fibres of the superior laryngeal, gioaso-
pliarynge'al and lingual niTvc.->, which in turn give ri« to a reflex «tiniD-
lation of the phrenic nerves with consequent contraction of tho diapbragni
and the inteniistal mu«cle!<, Oeneruily !i|>eaking, it is tlie most effwtiw
measure at our disposal, and the prognosis becomes extremely gloomy if
its emplovmcnt i" not ath-ncltil by Kalitfnctory resull* within a few minitlrs.
Occasionally il^ edlciency may Ik* heightened by practising it wilh ttie child
immcrsiil in a hnl bnlh,
:
ASPHYXU
847
Before, howcrer, despairitiff of saring thp child'it life, recnunte may be
had to Schulttf's mflhotL In this inancouiro, sh shown :o Fitp«. (i^? and
|<.'>H, llif vhili) ii m'iim] liy Ix'lh liiind" in kiicIi
a maomT that the indvi iinji^Ts of tliu opern*
tor lio under its axilla-, thv tliumbs over the
tliorai. while the jialnisr nurfaees of the re-
maining 6ngpr8 arc ajiplii-d to its back, thv
bt'ud at (be Mime time iH^iiijtr fi^iil !■>' Il)i> ball»
of tho thumbs. Tlw olx^li^tricjaii xtiiiKls with
hi« 1(^ apart and at rimt allnu* the f<i-lu9 to
bang down between tbom, lii.- thtrn hIowIv car-
rier Ihi! child over hi.H )i«ad in siurli a mnnner
that the I<^e fall towards its face, bo that the
bod/ bec-ooiea sliarply flexed, after whieh he
bringa it b«ck to its origiQal poititioo. The
RiHiiu-inn; is repealed -I or S timiit a niinule.
The mtionalf of the methKHi is readily appre-
ciati\l: lti« thorax is markedly comptiiMed
wtien the ehild is elevaleti, and expanded when
it is lowered, the two pw^itions favouring ex*
ptration and inspiration respectiTcly.
Some iditi of it« oHicicDcy may be gained
by the fact that, when it ia praelifwd upon a
dead child, air can l>i> distinctlr heard to enter
and leave tlw \uag» with each mot-einenl. Th«
procedure, however, is not without peculiar
dihadranlages. In the first place, it« employ-
ment Mmtetimea pvt& rise to fracture of the
clavicles or ribs, and occa«ionalty to nipturo
of the liver or oilier terioun lesioiu of the in-
ternal organs. Moreover, in view of the ao
Ninall dcrgree of violeni-e aviorialed with tta
use, the manceuvie is coDtTS-indicated in llio?e
naex ill which ibo elavicle or buim-ruM ha.^
been fractured during a dilHcult extraction.
inaHmtirli aif the free e«d« of thtr homw are
liable to cause Rerinos injury to the soft parts.
Byrd, in 1874. raggenta-d a conrenteni sub-
■ititute for Schultze's nu-ihod. He recom-
mended lluit tlH^ bsck of Die child be allowed
to reet upon the palmar surface of both hands,
(he ulnar margins being almost in apposition,
while ll»c thumb of one hand is applied over
the etemum and the otlier orer the thighs.
By approximating the radial margino of the
liand", the operator can tlien bring the child's
liead and feet closely together, therehy eom-
pret^ing thv thorax and causing expiration.
fit-we.
Fi«
WIT, RW. — Jkuvi.riK'm
UnHuu or ttciuiiH'riAnriM.
fclfi
rVKJ
OB«Tl-mil(S
vhik- .1 iiKivi'iiH'jit in llii> npiMk.-ijtP dueRlini) brinpi nlHtuI eilreun! cx|Min»i4i]
nnd faviiuTs iaK]Hriitinii.
Ill ob'^hnuU- rnff*. In nc lie pal n-Mtills i'w»it'tinH» follow lliu h>l»oilerniic
iujt^'lion of a f<'w ilri>|is <>( wluNky or <'llirr. *
When Ihv asphyxia is the remll aS a ilepres^d fracture of tli* ^liull,
H iMnall |K'rf«ration v^houlil Ih- niailo ihroii^li whicti lti« Itlado of a pair
fit M^i»orH nr koiI)i> otluT .'>uilali]i- in^lruinont it intm«hK-ml. niiil utt rtTorl
nimle to rcplaw Ihf ili'|in.-v-i?(l |>ortiiiii aiiii ifitis ri'tnovc Ihi" ■<<iiir»'i' of ciipii-
prt**i<Hi, Such mi iip<Tiiti<'ii. tmw^vcr, ^^liniilii lic ntlcinpltil only «clu-n
other procednrfiii Imrc fniUKl, and prorided that the heart atill continues
to bent stroiigl)', though t-lowlr.
EfTortH nl rosusoltiitinn should he pcri»T(!red in aii long ai> Um; h<-nrt
continues to boat, one method afUT «nollKT being given a trial. The neous-
^ity for persistence is shown by (ho fact that »ui;i'ei&ful n'.tidtit uiv noi^
unusual after trials lasting for thirty to Bixtr niinulvs. or even lonjier.
Sudden Death daring: or ihortly after Labour. — Onlinnrily, dt>nlh wenr-'
riDg during lalHUir. or in t!iL- fir^l few hfiur* iiiiinedifltwlv following tl, in
the resull "f Kimii' iinc nf the sbnonniilitios to whieh alluvion has alreailr
lieon iiiadi'. pari leu I a rly pultiionarv eitilnilisni, niulo ath-nia of the liin^s.
Mpuplexy cAmpIieutiiig eelunipsio, or acute nna>mia thv result of pot;t-partimi
hemorrhage, [ilaeinta pra^via. prenialiire ^t-jia rtil inn nf the nonimlly iin-
plHnt<^sl pliiet-iitti, iir rupture of the genital eanal. This subject wa^ dis-
eUH»t?d in detail by K. 1*. I^nvU in IWi, tn who^ article th« atud«nt is
refcrriHl for un e.\tensiie bibliography.
In rare inKlnnceii, inooniplelir rupture of tho utcDu is imaltendeil by
symptoms at the time of its oiciirrenoe, the blood sliiwly Heiutniibiing
bi'twivn lin- folilii of Ibe broiid lignmenl with a gradual di'AolopraeDt nf
Bjrmptoms of shock. A subperitoneal tucniatnina formed in lhi:t way is
liable to rupture into Ihe periloucal cavity nl any time within the Gr»t
forty-eight hours after deliver)' and lead to tuilden d«Mth.
Moreover. » woman in latwur. nr during Ihe piierperinm. may die sud-
denly from the «^fTei!ts of any eondilifni which would give rise to a similar
outcome under other cireu instances. Thus, ca^u have been reported in
which the fatal tenuinalion wn^i due tn rupture of an aortic or cardiac
arieuri'^m. ha'morrliagc from a gastric ulcer, or other aet.'ideuts. Van lier
Vwlde bail n-porled a ciw of a fatal n-tm- peri to nt-al hn-morrhage compli-
cating an acute panereatiti><. while Node and lliues ohierved auddea death
during InlHiiir follnwing the ruptnre nf an anitiristn of Ow splenic artm'.
In the chapter liealtng with the Pathoing)' nf PfL^aiicj' refen-nce va
made to theccui»ifpieiiMs<if laUmr in women suffering from valvular lesion*
of the heart, pariiiularly sleiiosis of ibe mitral orilU«. l^e** fn-fpitmily.
sudden death inuy be due to fatly degeneration or to change*! in the mio-
cardium. Such accidents are to be partientariy dreaded in dderly and
corpulent women.
Shock-- — Formerly it was customary to attribute u certain number of
deaths follfiwiiig laliitiir to shw-k. whii^i was stippr»si.-d to oecur in certain
individuals after prolonged and very painful Inbonnt. the irwidmiat Umm
of rft<t, imperfect nutrition, and mental excitement being looked upon ad
81IDDI:N death DURIXO or 8HORT!.y AFTER U\DOUR 849
■
l»retlii')»M>iiig <-aaMS<. In IIm; |>rc'«nt MaU of niir kn<twlt'il]i^>, ImnCTtT, lliia
<>xplaDiition U hardlv |>pri»i^iiil>li>. ^inw in the inajority of i^ih-Ii i:)u«» *
carefully piTforiuv)] NHtojw^jr will rvvv^] llio <r\i<iU-mv nt wine condition
»uflk'i('iilly Mtriiitin Ut nciinmUfnr tint iiiifiivitiinilil*- iitiUT>in<% (liv ui'xt wiii-
nton l)einj|; lueniorrliaee following ^»»o n-wre iiijurv to iIm' ){cnilal tract.
S^top*. — F«intm«» i» not an uocommoa result of exhautitiou following
[tniloii^tl lilmur. aiul in neuropallilc indiviilitHls niny 04-inir vTvn nfti'r nn
easy anil rapit] delivery. In rare in^tanoofl it may )»e due ta oen-Iirnl anaemia
resulting from lack <t( btood in Ihu nervous cirtitnui following Ihv »udd(;il
dimiuulion in t)M> intra-alxluniinal pn;s:«uru incident to tlw rapid decreai>e
in tlte siie of the uterus.
Till' faintnixt u:iimlly ]m*w* "IT raiiitlly and <Wft* not l<md to tinlnwiird
result*. On the other hand, it occasionally gives cause for serious alann,
the piiiNT lioiTiniin^ wenkt-r and niiir>! ru|iid ami tW palieni rt-niaining in A
eandition of profound priwlration. 1 have ucrer i-ecn a death from this
caiiM!, tiul nn reenil one pati«*nt who cauM'd niv tlu: ^ri-atest potwihle
anxiety, and who was in imminent danjjer for more ihan twelve houru.
Ilaig l-'ergitwm reports 3 «!«■* of wrious exhnu*lii>n rulloving lalvour
in vbieh lie wa^ iiiolined to atlritnite the condition to reflex irritation
a«utting from pncvwun; upon the ovnrivs incident lu the improjH^r employ-
ntent of C'n-d^V method of exprus^in^ the placenta, the organ being grasped
laterally instead of antero-poTitcnorly.
I'r'ifound Jdtnlat Dtfireiaiun. — In rare in.-<Iaiirv.-> the only apparent es-
pUnation for dcutli, or for a profound collaji**- which eventuat<s4 in nn»v-
rry, i« tu be found in Ihv mentid condition of the paliciit, Minvc the inunt
careful examination, boih at tlie bedside and at autopsy, may fail to reveal
ihr i'lifchu-1't flbnonnalily.
I recall a case in my own praciict? which apparently lielonjr* in this
category. The palieiii. who wa» unhappily uiurncd, hud nln.-ady jMiwu'd
through two very dinicult labours. When 1 saw lier, in the latter part
of th« fifyt Klage of lier third ln)>oiir. «hc wa* about \\w room, .lu^l Wforv
^ling to bed at tlw beginning of ihe »ei?ond ntage nhe ai>kiil the nur^ and
rnvM-lf In vilnf«e her will, as eho said she felt »unr >ihe would not recover.
The labour was rajiid anA uneventful, the placenta vomiui^ away xpon-
taneously, and everything appearing to be most saliitfactory. On approach-
ing the Ih.iI to take h-nve of t)u> {Mlii-nt half an linur hili*r, I wil" nirwk
with her haggard appcaranc*. Kearin]* llie jMRrsiliility of Iia-morrhage. 1
at onco applictl my blind over It>e uieruo and found it lightly i-onlrailed.
while the pulse wait of e.vccllent quality. Without any appiircni rea^n,
and in «pil4> of em-rgctie stimulation and tlio subcutaneous administration
of salt aolulinn, Ihe patient grew mIowIv nor^, iIm' pulM! Winining rapid
and weak, the en's sinking back in their sockets, and Die face assuming S
drawn and Ilippncrutic expression.
The moitl careful examination faileil to reveal the slightest cause for
tbo condition. The hand introduced into tlw uleni» could find no lrac«
of rupture. Eight ViourM after delivery I re<|iiO->Ieii a. eol league to see her
in cooauitatinn, hut be also was unable to offer any explanation. It ttiea
Dcmrrcd lu mv that llie condition might jwti^ibly be tlw result of her moi^
850
OBSTETRICS
bid forcboditip;. niid acliii); )i{h)|i rliis inippoHition I adminieitcrtil n Urge
do*c of iii"riiliin« bviio<lt?niii<:aily, nliieb was proiupdy followvd by enuoil
ilci'p, H marked iinjtrovcinent in tli<.' chartiokT i>f Ihu pnltf. iin<l ii rapiil
chanp- for the lu'lliT in llii- gii»Tn! it|)|Hiiniti<t-. I'lKili awnking n fi-*
l)our» tator, Uie [katieDt felt very comfortable untl made an uuinterniptnl
reeoviiT,',
Piiltnonart/ ^mto/wiw.^ThU apcid<'nt, UiUially noted only later in tlw
piicrperiiiiii. but otcanionally wcurrinjt (ibortly afli-r liiboiir, is due to thv
di'tacliiiiriil »f n Mimll [nirtirle nf ibniiDlms ."itiialiil in a uterine or |M-Ki4-
vein or elsewhere, which is carried to the right side of the henrt and lead'
to more or le.^ itunpli-le ncWiision of tlu- pulmonur}' artttry. It ik umiaIIv
aiwociated with inftwtive or thrombotic pmcesdea el-wirberc in the bo<ly.
though il may occur in women who wi-rc npjmn-ntly jwrfwlly w«ll. Oan*
coD^iders it the most frei|uenl cau#e of sudden death in tb« abwnxi; u(
definite <liM'a»e. UntWr such circuni«tance); thv patient cumpiainii of intense
and sudden pre<»rdial pain, bei'ome^ livid in appearance, and ptv«r-ut^
sytuploni); of profound dy>^pn<va and eventually of air hungt-r. Thc^-
eniboltKin!!, bowe>'er, are not always fatal, a small pi-oportion of the |>atiriili
recovering.
The trctitnieiit i>i purely paliiatit-e. The vomau nhoutd lie plaeud in llu*
recumbent poiiition. ^tiniulnnt' by the mouth and »alt solution ^ulxutam;
oiixly sliotdd be administered. Inlialutimis of oxygen, if obluiiiablv, an
aho indicated.
Knlnnur vf Air into Ihr Vlfrinr SinuMs. — Certain ca*** of death f
lowing intra-uierine manipulations in women sulTering from plaeenta pre-ria
or nifiture of the uterui^, are iillribul<^t] by mauy autlvorities to the enirann-
of air itilo till- uterine xitiusi-s. whence it i* <-arrii^l to ihe heart. Tlu'
exact cause of death is not understood, some holding that the air ImblJc-i
enter the coromiry nrtcrie*, and othfnf that the njthl litMirt. Ix'ing unabk
to rid itself of tbeni. becomes paralyzed as a result of its {mitlesii effoTt'.
The symptoms an- anulngou): to lliosi* following pulnionury vmlioli
Cases of this ehiiraeter have been reported by Olsliauseu, Lowe, Perki
Hoger, and others.
That ^uch a condition oecasionally occurs is clear from the foot t
several ea«e« have Iktii reporli'd in which I'tidden death followed the pu
tug of air iniii the pregnant uterus for the purpiist> of priHluring aliortiiii
On the other hand, it is probable that its frequency has been inucli ov
Mlimatcd. and thai mont of lh« va»c* whioh have tonw In autopsy, aiul
which were supposed to demonstrate ^uch a possibility, are open to auoihr
and fur more rean" liable csplaiiulioii. Thus, (!. W. Itohbin. in my dintc.
was able to demonslrale the presence of RncilUis iienigenes capMnlatuit in
tlic tiMtues from one of I'crkins's cases, in which the presence of air bubbtff
in Ihe blood-vessels had Umi regarded as sali^faclory evidence as to tk*
rauxe of death. Wendeier had a similar experienee. and it would (h>-n-
fore sii'm permissible to n-gard with scepticism all cvscs of sup)KV4tii nif
embolism in which death did not iXTur almost instantaneously, or in whiA
careful baclerlologii-ul iuveetignlion demonslraled the prcseiRv uf ^'
bacilli.
II n: I
SUDDEN DEATH DURISG OR SHORTLY AfTER LABOUR 851
pati-morlfm Prlirrri/. — ia the litcniiun^ wtiii^h hns litwii (Mirvfully
.rehed hy Avelin;; arid lU'imann, a number nf nmei are rcmrdKl in
wliiHi iipi>iitanooUK hirth uf llur I'hilt] tonk plnci.* some haur^ or (Ihv^ after
th« (li'Mtli of tlif iiiuIIrt. MorvotiT. dvlivvry suuit-tiiiK't oct-urs afli-r burial,
id, wIh-u the b<xly hn« liet-u uxliumi-d for M>iu<t niiwtii, lir» iiidividaalx
iii^lead of 4>i)e li^ve liewn founil in ilic cotTm. T1u!m> arc imtanci?!) of the
ao-called " coffin birth." The pht-nonienon is nsually obwncd in mnltip*
»Ton6 wninen in whinn thw vii)^iiiul mitU-t in nuirki-iUy iflaxwl, imd is sup-
poMs] to he due ti> a niarkt--d incieaHc* in the intra-abdoniiuat prvH8ur« pro-
du€i<d by pulrvfactivir c-IiaDgcs, Ihwugli it^ain BUlliorJliiM nri; inclined 10
attribute isolalet] niwH to rii^or mortis of the uteriuc musculature.
w
T.ITKRATURE
Avnjim. On Past-innrl«m l^rturilian, wilb Rcfcrsnco* to Forty-four Ciurai. Tniw.
Umlon Obrt. Soc- 1B73, xiv. -iMt-im.
Bircuiu. VaKiliM ulcriniia. Zentnlbl. f. <;yn.. tOOl, xxviii. 129-138.
Btso. a Spoodj- Mcihod in Aapbyxla. Th« OImi. Jmir. at 0ml Rnuua *od Iroland,
^B^ 1W4. >• 05-^9. AiniT. Suppkmenl.
^^HDavm. Suddon Dmlh iIuHiik or JouniHliatGly itdcr Ibe Tornuoalion of rr^piaocy.
^B' Tmnti. Am. Oyn, Soi-., !!»», xxx. »45-3U6.
^^buBiuN. RcnKT/kuii^n lu dca ArMti-n von Srhnrll, Wcodelor und Oonbctl: Uidwr
^H einc-n Full ^-on t^^ilawui im nitil^cioeriim-hTynii^tfiiaiiWrt^MturlwwwiPQerpgni.
^H Moaalcivlir. f. I>1». u. Oyn.. 1B»7. vi. 375-378.
^^VKit»iMi<>K. On a V»n(Tty nf Po«t-p«irUini Shock, ItM Xalura, Cauav, and Pruwulkm.
^™ ^:diIllnlr1■;h -Wed. Jour.. 1889. xxxv. 32-11.
Lahomdk. !«■ intcitonn rfaythm^e* de In liuiffiiA, moyvn mUohimJ ot puimnt da nuil-
mar h fooction rwpiraluin «i la vi«. Parlih 1804.
LbmL Bin weitarer Fall von Lutlcoibolie tici I'liuxnla pncvin. Zeitwihr. f. Oeb. n.
Oyn.. laOft. XXXV. IM-191.
XoDH and Hiiren. Falsi Rupttire of aa Aneurymi al tbe Spluiiic .\rtcr)- imiaodiately
after Labour. Trsiiii. Loadon l>l»t. Roc.. i'JOa, xlji, m'V 3)fl.
I Ou>H*nni:74. Udter Liiflvinlritl in <!•« Ulvnuvmien. Monatoschr. I. liutmrUk., ISSl,
H^ ixir. 350-371.
VpcKXiNH. .Kit l'::rol>otinii, olc. Iio«lon Had. and Silrit. Jour., 1807. cxxxvi. I54-I56l
RKHiitifH. Uabar Oalnjrten nach dam Toil« der Mutter. Anhiv t. <>yR., 1B77, xi, 2IJ^
2.M.
RoGKIt. lUilda cbnlqtie tnir U pbtinoiii^ie de I'aulr^ d« I'air pai Im Mnila Ul^riiu dan*
r^tat puerpi^rd. tWim de t'ari.'>, 1890.
ScnrLnc. t'cber dio twitto MciIumIc der WitxlubeMHiBK achaiiitodi locJioranur Kimkr.
Jauocha ZpilHchr f. Med. u. NaturviHwiucfa., 188(1, iii. Itcft 4.
D«r Sdicialnd .\eiifftbon»Gr. Jcnn. 1871.
'am I>«H Vblob. Kin Fall von tAdUirhcr PaacnadihituiN;. eic. Itef. Kronimal'a
JalHai«)crMhl. 1808. 784.
WnnnuiL Uatwr uinan Fall too Oaabkuan iiu Bbil« finer nadi Tympaiiia ul«ri gi»>
atoriMdco !*ucrpcnu Uonatavhr. f. Gcb. u. Oyn., 18S0, iv, Ut-&&3.
56
PATHOLOGY OP THE PUERPERIUM
CHAITKU XMM
PVKRPmAh INFKCTIOS
T'kpfr t)i<- general headin>r "f '' pu«r{KTHl iiifcrlion " arr now includtid
all the variouK morbid coiiditioiii? wliic-ti iv'xiill from thL> i-utrance, during
Ubour or ihe puerperium, af iuftvtivi? iiiicro-Drganiyitiii iiilo Ui« fviiiule
gniOTitivi] tract. TTit- older lerm, " imtrperal turvT," is at once too voKoe
and mi.ik'ailiiig, aii<l for niajiy reasongi i^liuuld \k- diuiinlnl. tn (h<- ^rxl
place, it «iif;K"^^»^ts the old idea of the es^cntialitv of tlu- aftpctioD 60 stroD;{ly
urgiHl in tlu:> <.-<>uDtrj- bv thi; late Fonlvi-u' Barker, aiid uki^s iid Hcx-oitlit
of the various itt iala(;ical factors which may he conct?rc«l. Moreover, it
cin{)ha-'i»-> thi> ft'tirik- |)lioiutmena of ihe alTi-ctton, inrttxid of laying etrw*
upOD its itifeclimis nature and the eon^etiiient ret^pon^iihilitr of the nk^lelri-
cian and hi." iLvti>1ant.i. A^ain, " jUKTix-ial !<e|>tieii-iiiia" and " pi)er|K-rHl
iwpsis," whii-h are often used as synonymous terms, are hardly le** «ti*-
factory, inasmueh as iit many instanciv Ihv iiifvclinii rtiiultK in perfectly
loealixeil inllanimalory prr)cei««s, to which such terms cannot be appliui
without violating the estabiixhcd ride* of diction.
It is proliaiili' that put-rjieral infection has oceurrwi almost «»> Wng as
children have I>cen bom, and p&)tt«giv in the work:^ of Elippocratce, (ialen.
AricMina. aiid many of the old writers, clearly have n-fiirt-ncH- to il. A*
early as lUTfi. Willis wrote on the subject of frbfi» puerprranm, but the
Rnglikh term "puerperal fever" prohahly was first employed l>y Stroth'r
in ni8.
The ancient* n-ganled the alTeetion a* the rtyullnf nrtenlinn of thi-
lochia, and for centuries this explanation was nniwrsally accepted. In
the enrly l»«rt of Ihe Kcventin-nth century Plater ^^honfl that it was c«wi-
tially a metritis, and was followed in the next centoiy hy I'uxos wilh bis
milk mctastaiiis tlK-ory. From the time of Plater, until Scmmelireisi
proved its identity with wound infection, and IJsler doinonAlraled Iha
value of antiseptic methods, all sorts of llvcories wprc suggested conceni*
iug ilH origin and nature, which are ciinipri'lionitivclr dealt with in the
monojirnph- of Kisenmann. Silhersehmidt, and Burtennhaw.
Or^niami Causing: Puerperal Infection. — Allhoiigh Charles White
(17S8-1813) and many other English observers had vague idea* as In ihf
eontngiiins niititre "f puerperal infection, it was not until the middle of
llie nineteenth cenfury thiil sueh views were strongly urgml. In 1S(3,'
Oliver Wendell llc)]nies R'ud a paper before the Boston Society for Medical
832
PITERPEKAL INFECnON 853
iBiprovi'im-nt, fntillol "The Conta^ioiiDnf^u ftt I'lwrporal Fever," in which
\iv fU-«rl_v Hr^txl Dial itt Imsl (Ik- i'|>iil<.'mic fonii* "f IIk- olT^'i-li'tii couM
alwsvA bo Iraci.'d lo the lat'k of pi'^iwr piwaiitioDs <iu the purl of the physi-
i-iati or nitrM-. Four jtiirs Inter Svinnivlwi-i^', Ihen hii mwitliinl iii the
Vienna I.vin)i;>in Hoiipiial, \itptn a careful inquiry into the catiees of the
fri^'hlfiil ni'irliility atlcndiu^ labour tu that institution, an cnmpar»d with
IIk' (iiiiipnralivi-ly :'iiiitli iiiitnlM-r »f u-iiiuen »u(ruiiil)in^ lo |)U«T)>t>rHl infec-
tion wlien (IHiverei) in iheir nwii hornet. As n re-ult of hift oliivrvalious, tiv
fnnc'ln<i<il iImiI tUr niortiid priKtjw wa> iiwnTiiilly a winiml inf<-(.'lti)n, and
wiu due to the ioInMluclion of septic matmal by the examining linger,
Actiiijf upon Ihi* id« lie iMUfd «lringcnl orc]i*r» thai the physidniDt, i^lu-
ilent^, and niidwives should disiiifeet their haiidri with I'lilnriue water
bvfori! examining jinrluriciil wonii-ii. In vpiie of altuoit inimt-dtalr iiurpri:!-
ing reBiilts — the mortality falling from over It) to about I {ler eent— hb
work, ax well ax tlinl nt llolntni, wai^ M'uirtt) nt by many of tite moet
pmniinent inen of the time, and his discoTery reinained nimppniialti) until
Ihe iiiflurnw of I.intfrV liticlitu);* and the <te>-i'loppni-iit of biurli-rniliigA- had
bmnshi abont a revolution in the treatment of wonnd».
Among ihr princijMl organiNniK whivh haiT btrn proved to be caiuee of
puerperal infeetion an^ the following :
(a) Strrplwiurvii. — Thr St rt-ptixroecus pyogenes Is llie most fre(|Uent
I'Bu.ie of ttK> epidemic and fatal foniiii of puerperal infi.Ttion. Ao ivrly
as 18G5 this organism vras ubxerved in tbe litMuc« of women who bad died
during the pneqienum, liy Mayrhofer, who!«> tindingx wvrn conrinnei] hy
Coxe and Feltz. Keckiinghausen, Waldi-yer, Klebs, Orth, IU-il)erg, and I,.an-
dan, I'aslcur. in IsKll. howwer. Vphk thr tirxt to cultivale stneptot-occi from
rOM-i of puerperal infoi-tion. and he called them '' e)tnpi-let.i i-n grains." 11o
was astisled in this work by DoU-iHs, who carried it etill further, and showed
tluit the Rtrcptnonccun wa« generally the inf<H-ttniu agent, but tlial xtaphy-
lococci, and ocwasionally haeilU, weiv mmt-tiniM responsible for the iiifec-
tion. n»p!te researchi* wt-n* mkmi (iinllnncd liy l/imvr, Bumm, DiidcHein,
Winter, Widal, and by a!) aub^uent obseiTors.
{h) Slapliyloeocctw. — Furtlivr invMtigatiwn gradually demon#traled the
faet that the htrcptoeoems is not necessarily the only organism which may
U* (fmccniH, bnl Ihal most of the pu» protluccTn, which give ri**- lo wound
infection in other parts of llie ))ody, may likewiw at timce be the exciting
factors,
Rriegcr, in I8ft8. reported aulnpi>i(« upon 7 women wlio had i\'i«A after
a febrile puerperium, in 5 of which he ilemonsirated Staphylococcus aureus,
DoU-riif, in hi* thisiiii of IH14<>, Ktnli-d that lie had lioen able in similar
eases to cultivate in pnre cullnre cocci arranged in groups or bnnchee,
bnt it wiu twt until 11494 iliat h« stated definitely Uiat they were Htaphy-
locoeci.
The statement made by Kchling and Ilaeglcr lliat staphylococci nxttally
give riise (o mild form" of inflation, luw not lieen borne out by the obserra-
tioBB of other investigators. Occasionally roixt-d infections with stophy-
loooccus and etreplfx-occus are olmerwil. a* reported by T>iiderlein, and Bar
and Tissier. It appears that Siaphyloooccus aureus is the variely obwned
SS4
OBOTETRICS
ill pii'T|H'riiI infecOnn^nfe nlliii:< arnl liln^iw {ilnying litilu or no part in its
))ro«liK-lion.
(r) G'mur'/rritn. — AKliough clinicians had !on^ siisjKvteii timt gonur-
rivxa ont infn.'i]uoiiUy pluvn » part in tlio jiniduotion of pi)or[K-nl infec-
tion, Kriini^ wns lh« first to adduce bactcriotopcal proof of iu atrtion. In
18!J3 he reporlnl 9 ca*es« of inik! infiTlioH, in all of which he wag ahte to
ohtain pure c-iiltures of gonoiocci from the uterine IiK'hin. In i> hiU-r
I'oiiniiuniciiliiiii hi- wluli'd that liv van nble to cultivtttc the same or^niiiTn
from tV* dhsciiaixcH of !H) out of 179 jialientii pn-sunting fdirilii pmT}MTia.
None uf t\n-W viifvt vtidcd filially, most n{ tlie patients recoverinj; ft]x>u-
^lanconsly.
' KToiug** experirnce ha* bet-n coiilinm'd hy ail subsequent invest i^alors,
and Tau^i^, and Stone and Mi^Donald stale renpis'lively tliat probably
one t^ixlb to one teiitli of all ri»c» of tomppralure in Hie pucrperiuin are the
resMll '>f ijonorrhn-al infection. As far a.t I arti awan\ Fouli-rton and
IBoniH-y ore llic only rcwnt writers who have not had a similar experienci?,
^ being unable 1o dcninn^tnite the goiujciHTii-' in a. writ* of 6fi eatv* of puer-
peral infection. Maslowsky and Neumann state that they were ahle to
di-iiionstrnlf Ihc pincKticcui' in the linyucv <tf cainw of (U-cidunl endometritis
and 1 have repeatedly made similar observations. As a nile, goiiorT)i<i-aI
infection in the pmrfHTium pur»tK-4 a faviiurable course, but occasionally
fatal septiciemia may result, aa in one of my cases reported by ITnrrix aud
Dabncy.
[d) liadtlua CoU Comtimniii. — In my article (1893) upon puerp^To!
infection from a bacteriological point of view, it was slaitil that »on
Fxanqu^ had cultivuU'd Hie colon lineillus fr»mi ft caw* of piier|K-ra1 infec-
tion, and ibe belief wati expresiied that it would be deinoniilnited more
frc(|ui'nliy in the future. Time h«» amply vwritw-d this prediction, ami
^there are now on record a long series of cases due to this organinm. A
Jpriori, this is what would Ik- expected when one lakes into consideration
the proximity of the genital tract to the rectum, and the ease with which
■ conlamiimtioii uiu iRiiir when the ob^tHricimi fuits to obs^rrc the strictest
^Mpais.
Some idea of the enormous numbers of colon bacilli pre^nt in tlie
human lindy imiy 1h! gained from the consideration of the figure* of several
Krench observers. Thus, Vigoal slates that 1 decigramme of faeces cnnuins
about atl.OOU.ODa. and (iilhtrt and Dominici wtimale that from 1^.000,(Kifl.-
000 to lA.dOO.OUO.OUO are daily excreted. It is therefore evident that tlic
e.vaminin^ lingir can Imrdly avoid con t ami nation with \\t«ea organisms it
it comes in contact witli a nnn-di.-'infected perinseuin.
Gcbhard demonstrated their presence in 7 cases of tympania uteri.
^tber alone or in combinution with other organism.*, and Gnllier ^tnles
that it is the organism most frequently concerned in tho prodaction of this
cnndilion. i
Not uncommonly it is associated with the streptococcus, aa in caas
reported by Jlurnmrek. Charpentier, Bar and Tissier, and myself. Somii
oliM^rvers have thought that ihi.t combination augments tlte vinilejuw of
tJic streptococcus and gives ri*« to very intensu inrcctions.
p
PUERPERAL INFEC-nON 855
(e) liaeiUua Dipilktria. — Until rcry rnvtitly it was bvlicvt-d llul ihc
tliphlherilic <lcp<MitK ti[Ki» lliv mgiua nnd ihti interior of tlie puerperal
uteni^ were duo to the stroplococeus alone and were in no way connected
with true diphtlicriu. l*hut ihtH U not slway:^ lliv i-ofc. hnwi'\'cr, U»* \)Ctia
Hlmwn \i\ tlw) otKipn'sIinnft nf Nism. Bumip, T»|>, niVM-'lf, uud others, wlio
repgrtc-d iQEtancea in which the Klebe-Loeflkr bacilhis was cnltivalcd fnmi
tlw diptitbcritic mombnintf lu th« ngina, the aifection yielding promptly
to the use of the anti-<liphth«ritic acrum.
(f) Bacillut Mrogrnrt CitjamlatHS (Gas BacilliiH). — 'llw go* bMcillun of
Welch is occasionally concerned in pucr|>cral inf«!iion, lu 189(1 tlio writer
oliMTwd an Initluncv of this kind, which was ni>i>rli'd by Dc>l>tiin. Briefly
stated, the ntic was as follows; An outdoor patient, a Bohemian woman,
wilh a generally contracted pelris, hud been in labour for invwi three to
four dav9 under the care of a midwife. Wlten tihe came into our hands
tlw liuul of a tnaecrated child was found firmly ciiffBgixl in tlie tiupcrior
strait, l)ie uleruM being in a. »tate of tetanic conlraciion. A fit-tid, dark-
colouml diiicharge, which contained many gas bubbles, was e*cnpi»g from
i1m> vagina vrilh a crailcling nuind. Owing to the iioflentid mndltion of
the diilil'ti head delivery with forcepii was out of the quciition, and was
«fr«x'li>d hy nieiin* of TarnicrV hasiolrilie. The mother wa» profoundly
infected at the time and died the next day. Within a few hours after
death her b»dy had nearly doubled its original size, us titc result of the
development of gas in the ^iilicutaRcoiL'i tiuues. Similar changes were
obscni'd in the ftetus and in ihe plueenlu, nnd we were able lo demon-
Ktrato the prewcnec of Ihe ga.t luicilliis in the liw>ti<» uf both, a.* well a^
in the tilerine lochia, t'nfortunately no autopsy was allo«-ed upon the
motlnT. nnd we were therefore unable to tay to wluit extent the (irganism.-i
bad penetrated into her tiii'^ues.
Well-uallienlirnli-d iiixlancvs of infection with this organistn have been
reported by Htcwart, Kraat, Norris, Wood, Hallwn, and others, and tlie
entire literature uj>on tli« subject waa exhaustively rrvieu-ed by Welch
in I9<K) and Fraenkel in 1!N)4.
Little, in |!>ri5, reported ten cases in which iho gas bacillus had l>ecn
iM>la[ed in tlic Obcttethi^ DtijianineDt of the Johns Hopkins Koopiial,
and pointed out that in all probability it was identical with (he " vibrion
M>|>tii{»i'" of Paxieur and r>oIvriK, un well u* with the bncilltis {HTfringenn
and other bacteria deseTil>ed by various writers. In only one of our cases
did llie liMcilUi.-i occur in purt^ cullnre, while in all Ihe others it was ason-
ciatcd with other bacteria — ]Mirticularly the wlreptococcu*.
As a rule, llie gas bacillus exists merdy as sapbrophyte upon dead
material, and does not in\'ade tl>c deeper tiHtues until vhorlly lH>fore or
just after death. Accordingly, (he prognosis is favourable when it occurs
in pure eullure, but becomes very x^rious when il is associated with thi>
streptococcus, as it would ieem that audi an aitMK-iation tends to augment
(be virulence of the latter organixm. According to Welch, its presence
in (he pucrjx'nil uti-riw may givf riw to empbyseM)a of the fa-tut, i*ud«ine-
trili*. iihyKiinielRi, eiopliy»ema »( llie iitfritit' wall or ga* M-jwi:'. More-
orer, it is important to rx-imitilnT, as was lirst pointed out by Welch aivil
sm
OBi?n,TKlCS
Dobbin, tliat th« gas bubbles found in tiw blood -vcM>c1if »f vroimat vtipponcd
Id huve {H'ri^lied from " air enibolisni," are fretjuenlly the product of the
bacillnci in <|ueetion. Therpfore such a dingnoiiii^ iif not justifiable unless
careful buvlvriological exaniinaiiou iuti demons irated tlve absence of the
ga^ bacillus.
(3) ItaciUni Tjiphosm. — In IHW, Dobbin and I i>M>1alMl Biicillue
t,vphoi)Ufl, streptococcus, staphylococcus aureus, and an uoideutificd anae-
robic j^amproducing bucilluK fnmi the iilt-riiie Iinhiu »»f a Bohemian
uxiinan who was admitted to the Johns Hopkins Hoi^pital on the fifth day
of Iht' pm-rpcnum with high ffvcr. Her bloi>d ginv the c)uinu:Iemtic
Wiilal rf-aciion, but all the usual symptoms of typhoid fever were absent.
Th« IcniperaturD fell to normal on thu tliirtconlh day, and did not rise
again. We were inclined to Mieve that the typhoid badllt were inlnMluced
into iicr hUtiis hv the iiiidwif..-, alonj; with other orguniMn*, since she
was. delivered u]i"ii the name twd u[Hin which her htL■^l■and had died of
lyp}ioid fever a ffw day* previously. ,\ somewhat siiiiilur case has been
rejMrted by Blumer, in irhich the auto]i!(y revealed an unsiLtpeeted typhoid
fe\-er.
(/t) Barillari/ /n/'^Wioa.— Perkin*, Charhii, and other* have reported
esses in which they bclic'\'e that the bacillus pyocyaneus was the infcetioos
agent. Moreover, isolated ca.*** rt-jwrleil by Fruiiiki*l, Doleris, Widal,
Mixius, (loldsehcidcr, and othcTs, tend to show that certain casee of fats)
inf(-<'tir)ii luny bi^ duit lo Iwi-illi with whiisi- ])ropcrtie« wc are ii* yet unac-
quainted. Hut the baclerioloBicnl work upon wiiich tht^se .■jialements are
based is i.ot of a, character to enable us to identify the organisms in ques-
tion, much less to ckflsify them. At the same lime, bacteriological eiami-
uation of the uterine lochia in all cases of fever in the puerperium, as
ttirrini out by Kriinig and mywlf, ch-arly kIkiw that many bacleria wilh
which we arc tis yet unfamiliar may lake part in the proct*;;, 1 have re-
cently fwn a ease of plilegma^ia alba doleiis in which Uie infectious ag^it
was apparently a short, thick, anaerobic hacllIiLx.
(i) Siifinfmin. — Uesides the ca»r» in which the infection is due to the
growih and cxtennion of niicro-organisnis within ihc hiMly, then; is a large
group in which the syuiptoins are due to the absorption of tosinea produced
within the uterus or elsewhere in the generative tract by organismc which
do not inviidc the (issues deeply nor make their way into the blood enrreiit.
To this form of infection Miillhi-WN hiiriciin Hmie \v»rtf ugn applied the
liTUi " miini-Mut." It JK usually thought to be due lo the invasion of the
uterus by putrefactive organiHiii.-' with wbow properties we are as yet almost
totally unromiltar.
No doubt the term has Iji-cri greatly abuH-d. and many caseu hare been
included under ii which were really due to infection with the ordinary
l>yogcnie organiMO^. This stal.-ment has been borne out by the olxier-
rations of Kumm. who found st rvpt'x'iicei in K oiil of 11 casi^s whirii
wn' thought to preM-nl ibe ilinical picture of sapra'^iia. Von Fnimiue
also iibtaiiKHl Miinrwhat wiiuilar ri>ull^, and tiuicl udeil that ^apnemic
Tcver iu the pufr|ii-riiim is cxtriiufly ran% and t«tioutd Ih- diagmiHixl tmly
iiflcr an accurate Imeleriologiiiil cvaminatioo of Ihc iitcrino lochia ha^
PUEUPERAL INKECTIUN
867
il«niotiKlmt'il lln; aliM'iKt^ ■>[ iiHlli<>gi.iiii: and lliv |in>vnc« uf M|iro|»tiyti«
organisms.
The causative organisms in sapnnnia are mostlr of an anaerobic n«tiire,
uul coitM.-q unfitly do not gmw on the iikusI i-iilturc mt-diu. Many of them
are pis produecni. and oausu ibe frothy, il!-nme!ljng i^et-retion whioh in *o
diaracterifilic of thi-sc casvs. Many diffwrwil varieties are undoubtediy
(tMK^nicd in itit production, thoujch only a. tew have oj« x-et bccu iiiolated.
nius. Buiiim cullirated from one case an anaerobic bacillus, which decom-
posed aJhumin and produced pni^onoui! vubi<IaiK'>.*», while DcklcHcin imlatcd
an aniuTobic gaM-prixItii-in^ cooK^Ui< from a woman who preM^nteil a frothy,
purulent vapnal dischar^. Kronig. in 43 abnormal pucrpcria. found
nrfniii'^ms whi<rh did not fcrow ou tin' u.tuiil ntvdia, ami in 3i of them
obtained varieties which were pure anaeroJKw,
Hiwteri<rfo(fical evaminalion «( th« uU'Him^ loehia in a weric* nf 3M
CB!*es of my OYrn. in which the temperature rofe to 101° F., or higlter. daring
the first ten days of Ihc puvrpurium, gave the fuUouing r\»utti>:
StivptoMiccuii alooie
and IweilluH «<ili ...
" " 1 tiiiduti tilled iNM-tlli
" " lapilluH iii.T«Keiwii otpoilatu*
" " i^nocoocufl
" " bacilhu aMogetiM capMilatu«aBd bacilliu etdi .
S4iv|>t(H-(K'(ntii, anai-n>l]«o v»riii(y
" iitaphylococoiiii, ga* and tf pboid twdlliti.
■' •• ■' '• cnJwi liwriUm
Sl«]Jiylnn>Poaii aitrviM.
and gv> (««illUK. .
" albtMMMlKuUcUhHk.
altiux
HanlliMcoli mnnnunU. .......
" " and ^D btKiUui . . .
" " " gnaonocGiiM
tiatia(mi.Tiu ...
" anil fff (nmUu* .
" ba«iUuK(al>.
*■ " unidmtilicd liocUlua.
ooccu.
llaciUiia anvgenca mpmibtiu . .
Untdentifioil anni-rnliir larWriH
Mttibic lau-turia
ButlltM dipblharVT'
(jrpboma -, ,.
Ikcterw OB eovar dip, rallitronncpitiro .
8»«rilo
Cooloininiitcd
Besides the organisnK already nicnlioneil. it i^ not unlikely ttvat furlhrr
researth will show »lill others which nuiy piny u part in tho pmdiii-tion nf
wolated caMM of pucrjicral infection; bul In Humnturixe, it may be said that
858
OBSTETRICS
thoiie moflt commonly conoeroed are the well-kDown pyo^^enic organi«n>>
( strep lococcne, staphylococcus, bacillus coli, aud gniiococcus) and (he vari-
oa» pulrefactive vnriistiea. .
Some idea of the relatirc fn\{ucncy with whtcli the (CTCral organisnu'
occur in pm-riii^ral infections may bo feathered from tlie work of Kriinij:,
nrho ejcaniioed IT!) coses of puerperal endometritis bact^^'riologicatly, and as
a rvjiiiU of his (iliw-naTiftnn divitli>d them into 3 ^roiipn — pyogenic, gonwr-
rha?al. and saprieniie. Tlie pyosei'i*" ftroup comprisotl "9 catiefi, in Jj of
nhieh the infeclivt; agHit wiik the ntn-plm-ociiis, Biid in 4 Dw utaphyloooceod.
In &0 cased tlic gonococeus was ii»laled, while in J3 of the 30 sapni'iiilc
OK'w the organ ivms did not gniv on the \ifnal culture mediu, 3ii of them
being (Hire anaerobes.
Fftthologfical Anatomy. — The lesioms may vary widely even in eases clin-
ically .HJiitiUii'. iiixl ilie.Hi^ variations afford a pnibahie explanation for tlio
failure of the older authors to appreciate the true nature of th« afteetion.
Thti^, ilicre may lio an almost infinite ^erieH of j^datioiu from a :<l)ght
membrane eowrlng n sniall peritieal tear to au indamniaton' prooo^ invnlr-
ing the f'niire ^i^ncrativo tract, or extending beyond jt to tiu>, pariiTnelriiim
or ptTilouffiuin, and sometimes rvsultin^ in a systemic infcttiou. In
other USMM the infedioust dementei pawi rhrongh th« port of entr}- with
Biieh rapidity that they do not e.tcite local Ici^ions, but produce a spptica'mia
which is rapidly fata! — the .i-fwi/t {itfuirnyanlf. of ihc French uiilhors. In
the majority of cases of puerperal infection, hoircver, the endomi^lriiiio
i» the portion aiTectod, and the morbid procew:* docs uoi paw beyond it. Die
condition being termed a septic or putrid endomctritiii, acconling as it
hoe resulted from tJic invasion of pyogenic or putrefactive ai;ganisins re-
spect ively.
In other cases the Unions may be situated in any jmrt of the gt>nenilivc
tract, inoro tlinn one region being frcvjuently implicattsl. Thiiw. at dilfer-
cnt times we hare to deal with a puerperal vaginitis, endometritiB, metritid,
pHnmirlri(i«. iiietrr)lytnphangiti)>, ttietrophlebilrti, Kalpingitii'. oopbaritiis
peritonitis pwmia. or phlegmasia alba dolens resprcli voly.
Lcsiona of tke Vuha and Vagina. — In former lime* tti« puerpfral uh.tr
WW of very common oeeiirrencc, but with the intn)dnclion of atteptic meth-
ods into midwifery its frequency has bei-onie markedly diminished, so that
now it i» only rnn-ly encountered.
These ulcers appi^ar on the .^urfane of tears about the vulva and peri-
nicum, soon take on a <liriy, greenish-yellow sppearsnci- which is due Iti
necrosis, and are biitlied in ii frtu!-*nielliiip wccrelion. In iwrne ca*e» they
■ro covcrc<i bv a jfra_\ish-wiiite membrane, and on this account were for-
merly di'signatiHl H)' ■' diphtheritic ulcers." Careful harterioln(;ical osarai-
nation, however, lias {>hown that, except for their exti^mal appearance, they
have nothing in common with diphtheria. As a rule these give rise to very
little systemic disttirlianci:', and weuM frwiuently pSHs unnoticed were it
not for oeular inspection.
I'urii'rnil I'liijinitU — Of lliis tlicR' are two formn. the nne Iteing ohar-
aclerized by jjeni-ml iiiilamrnaliun. Ihe iiiueoc>a li(>eiiiuin)( Ihickennl. wft,
leddened, and batliiil with an ubiimhirit purulent, svcretion. Iii tin* ulhir
PUERPERAI. IXFECTION
SS9
»
t
h'lw. PBjwcially wlnni torn mirfwi'x mv pniwijl, i1m' vii)pit»l WJilI« nuiy Ui
the M>«l iif H |:)seDi|<Mli|iht)i(!rili<' iiii-iiitiranf. wliicli may vnrr in oxii-iit from
a Hiinll |uiU-h f-ntmng u ■■■ar to h dimplHr nwt of Ihr mlint vaginiil cutHil.
I'litil n-t^iitly it wa* boiievt^ti lluil none of iJie ah^allctl vaitvA i>f itipif
Ihrria of the va^na wuri' dm- to Ihc invsKion of llw Klt-btf-boeffltr bot^'illtt'':
liHt Utc recent uW'nutionii of Biitiini, Ktxit, m.\-self, ajul »t]iiti> t^wv \hitl
in a few cases that orfraniHin is nndoubtedly the etiotogin) faetor.
EndomelrHin. — The iii<wt coiiinioii K<«itm in ptwrpoml infivtion i^ An
indammatioQ of ihf pndonietrium. When one rct-alk thu rondition of tlw
ut4*rti» imtiK^liati-lv tif(>-r dfliviTv, ntlh iU btwctiii);, niw mirfacu* and liv:
\ai^, frapin^, thronibooed placental siniiees, it becomes apparent that anj
vintlcDt material wliidi lias bt^n iiitrodncod into the cavity during lahour
can easily find entry into its walls. Afcaio, when one cnnsiders the iitix'han-
inu by which Xhv ilraidua i» normally rcmoriM, onv mi n-adily jtoc tliat on
ideal cultnre medium i^ prepared liy Nature for the reception and propaga-
tion of organisnii! iutr»d;iced from without.
In puer^teral endometritis the infection may be limited to the placental
site, or mar exti-nd ovi-r Ihv cnlinr tnULXi«a. WIxii tht- former alone is
implii-alud. the organiEtnu ari> mually found growinj; into the thmuihi and
producing comparatively little local rt-aclion. On the other hand, when
tlie entire internal iiurface of the ulerun U affectiil, the endometrium may
become converted into a Htinking. sloughinfr area made up of necrotic mate-
rial and decidual drbru, and hulltoil with a blocxly, piiruli-ni diN-hiirgi'. Titc
necrotic material soon takes on a dirty yellowish-prcen appearance, and in
many in^tancot ulcoratod HurfacM appear, coated with fibrin and presenting
the clinical picture of diphtheria. This t}'pe wai> formerly di>9igna(i>d n»
dt^thrritic rndnmrlriiU. but jiixt as in tlie case of the vagina, the con-
dition, an a rule, is not a tnie diphtberiii. hut pimply n-prtwiii.-i a llbrinou*
exudation, the result of an inteuw necrofiin following llie invasion of
the uaual pyogenic orgarusiiis. Infectionn duD to clrept'xroiH^ii^ or Mtaphy*
Idcoccus are usually associated with ver)' little odour: whereaf! in thoae
exeilixl by bacillun eoli or any of the varioii* puin-faftivi; organifimf llw
interior of the utenis is bathed with a profuse foul ■smelling discharge
which fri^iurntly containn giw bubble^, Tliv amount of necrotic inat^^rial
produced i^ often eaormotts, and may recur with great rapidity after curet-
ting. Fig. 65» rcprf«ent* the uicruit from a ca« of puerperal infection
due to iitreptoooocn.4 and bacillus cnli. The woman surcuinlxnl ten dayA
after the birth of t)K' child, having (wen curettnl thrc« or four days before
di-alh. th<' uteru* at tliat time havin^c been swrapMl [ierfeclly th^m. A
glance at the drawing, howerer. shows that the entire cavity is filled with
necrotic material, which in all probability had IxH-ii reproduei'd in tlw inter-
val daptiing between thu (mrctlage and llie time of death.
Although thi> infection generally remains limited to the Gndomctriom,
in not a few cases it mar progress berond it, giving rise to a ntotriti«, «
lymphangitis, a phlebitio, or a peritonitis, as the «ul- may be. This exten-
sion usually o<\'urH through the lymphatics, and in snch cases areas of
inHammation can l>c traced along their coutw oxlcnding In the poritoocal
anrface of the aterus. At other times, especially when the infection baa
F»n
onSTKTRlCS
kvn limited lo Um pliici-ntiil mIc, tin- llircmibi inii>' Ije in^-«d«l liy llw mipni-
iirgniiiMiiH, aad Uufri' ^e^^Ils a phlehitus wliicb inav reiimiu limited lo tli«
iitcnaL> null or iiinv rajiiillv «'Xh-iiil ln>>'oii(l it uiid givu riiu Uj lb« ruxiotui
llirumlxitk- ruriiii' i>( ]>m!r{H>rnl iiiU'clioii.
The le^iona pi-oiiuwd in the ciKloiiietrium rary coru>iderablv nvuonlin^
to th« iDicro-orj^anismii coiiofrni^d. und Mtill morp according to their viru-
hmcc. In the c'ii>h-» in whii-h i>n« hat To <li!nl uilh * virulent ^tn^ptocm--
run or dlaphylopiwL'Ua infcclion. the local cliiiiigts are camparativelv t^lighl.
the proot'f^ rapidly T'pixuiOiiig tbrough the tymptuiliM or vviiiit past Ihc
uteruf, and ^ivinj; rise to a peritonitis or a general systetnic infection. On
the other hand, in tlic cof&- duo to putivfa^^'tivc organum);. lo tlie colon
Ixiciltiix, uiiil CO the ordinary pu»-or^aiii.'imH of le*«r virulen<-e, thi- prncrss
reiD&ins more or le^ liinilcd to the endometrium nnd c«ti«ies marked local
l4«ton.'<. Fi>r. K(>ii repn-.vt-iit.i flu- iiTc-rii.-< fmiii a woman dying nf h virub'iil
streptococcic infection. 'I'lie wa)U of its cavity ar« seen to be almost per-
Pw.ASg. — t!ns«cis ntQM WuutM mtKnTsH llATaarran I.ABoUKmow a Mixed iKmimx,
wm> HTiuimii.i.>i.-cuti axd B>iciu.ini Oou. x {.
fwtly nmoolh, and nothing iw pniwnt which could have been remoTod by
means of the curette. In fhia reiipect the ca*e stand* in marked contrajit to
the one representeil in Fig. 059, in which the infectious agents were strep-
tococcus and bacillus colL
Fm. 000.— DfMi<n rooH Woua.v l>nHa Tch D*n AnKa Lahopn t»n^ SriwrninvmB
lHrat-T«Mi. X J.
dilTereDcefl lietvcen (lie putrid ami »«pt)c formn. Acoordin^ to Buinm, in
MvticHiK Ihmugli llw Willi iif a uteruH the m-at i»f n putrid end'/mtlriti*. a
thick Uver nf necrotic- material ir found liniii;; thv utvritic cavity, ctiilN-ilili^)
in which iro Inrjtt' nuinliern nf llw oiteiidiiitc mirro-'irftuiiixin*. Ikoeath titis
i» « tliiitk U,Tor of liiuall-t.'ell mtUtnition — the «hk of reactinn — and under
this again, more or leM nomuil tissni;. CareftU xtodj of the sections
^K sbowK (hat the mtcra^r^nixmi' »ri> limi(e<] almoMt cnlinrly In the tmpcriicial
^V sermtic InTVr ; nnd alihoii^h a few mar be pn;si>Dt in the reaction zon»,
I DoDP can be made out in the tiB*ue» beni^tb it, thiiit iiliowing Nature's
I mode of pm'^nting the LDVa^ion of the ImmIt by the micnMjrgaJDisnu (Figs.
I fifil awl tMW).
Tlipno pioturcK an* olwprved not only in th« cawa duo to infoclion witli
the piitrffRclivo lincU'riH. bii( »1*" in lluw in uhifli IIh- pycgciiic nrgan-
inm* |Kl^.M■».■l unly a nlifjlit dt-nrw of viruleiKP. Oii tlie oIIht liKiiii, in cjumw
of siplic vtidvmtlritw, unti tupKiiillv ivlitrn- tlii: ijrg»]ii«ius nrv virulent, a
TD C0L4MC Ismcjuix. MioviNa Uaiixkd
DisTBiiamEJi'r or L^wwcmc Wam.
^*IU. 003. PimSPKHAl. KKOVHrTMCro UlTK
TO t^rnKiiainitx'iK iMfu-iioM, lUKtw-
ata tiuanT IliiVKUirHXNT or Lctioo-
cmc Wall.
totally (lifTcrcnt uppe>uraiice is noted. Allbough heri? also « layer of necialk
nmti-riiil lonlatning DrganixniK i* f«iin<l udjcituiiig Ihtt utcrino cavitj, it is
usually thinni^r than in the preceding va»e. The zone of ^mall-cell infil-
tniliiin i» eitliiT lacking or very i rii]H-rrcctly dervlopcil. and tht- micro-organ-
iama can he observeil mskin>; their nay down ihroiigh the dividua and
iil'iug ihc lytnplwlie)' through the muscular wall of the utenLi out tovard^
its peritonea! Aurfara ( Fi^ RGS and (Ifil). I hare been able to shundantly
L-onlinn Ihe ubserTation»< of Bumni, whoM conclui^ionK uro otnplr justified
(I'lateXVn.
The effect prndiKH-il by various miero-organi^nia was strildniily demon-
strated in one of my own oa»fs— » douhk' infwtion with rtrepIococcuB and
bacillu.* poli. On making sections through the uterine irall diaraetrristic
ni.'crotio tUsue wa* n.fH-n lininj: (he cavily of the uterus, and in it appvaivd
Imth forma of micrf>-flrj;ani»m«. Bi-iiwith this the xoiw of small-cell iafll-
Inition was fairly well ileveloped, and in its tipper part both forma of
organisms were rwojirnisatili'. In its lower portion, however, there were
only s(rt-ptococci. which had continued to pa-'W through the ulcriiR' wall bj
^^^^^^^^^^ P[, A TE ^^I^^^^^^^^^^^^^l
g
1
1
■
J
^^^^^1
1 ^^^^1
^^^^H
^^^^B
1
1
1
^^^ SKCTIOS THimrdll ESr>n«KTBII'H IS 8TKKPT(>W>cnt; PUERPKBAL |
■
IKP>X-Tir>N. X IKW. I
^^^^^^1
PUERPERAL INFECTION
X«3
vny of the 1,nii[)hatics, and oa r««cbii]g the peiipheral surface had given
rise to a peritonitw.
It would ajipear, therefore, that Natiire endeavours to eonfine the micro-
organisms to l)ie inner inirfaco of thu iiluruit bv ink'^rpoisinf; WlwwD tlu;
m-rrotio layer and the deeper portiom a barrier of small-cell inflliration,
which acts us an cfliei«nt Ultor when tlw toicro-orf^nism)' are attenuated,
but fail« to restrain Ihvin when Ihey piwHiw* a marknl dt-grcc of virulence.
Faranflr{lv.—ODe of the more fr«|nent complications of Ihc uterine
infection iit ]uirariietri1ii>, which in uAually due f> the trani'inii:di(>n of the
micro-organisms thrnujih the lymphalicK to th*- peri-iit^rine connective tis-
sue. Ttiv firvt etrpct of their invasion is a marked iiiflnrnmatorr tptlema.
with very little or no ouppurution. In mild cawM the procesH fK>e« no fur-
ther, hut in the w?verer types it rapidly tipmds to (he surrounding conmw
tiv^- tissue and eventuates in abscess formation. Tlie infM'lioui' ngentti in
M-v4>n- cau^ follow the enun>« of the Iyniplia1ii<i>, iind sonie4iincs pane
behind the peritonieum and jbito ri»e to retroperitonrai phlegmons, which
Fm. Mt. — CoixiM B«),iij.uB Endom rmtiiM.
Unxwcmc Wam. ttar lMVAiit:i> nr Hao
n»u. xtoa.
FM. S64. — ^nmnttcopcic EsitMiiiivnn-
riH, mawuMi InvunoN or I.KticxKrvnc
Waij.. X 800.
v#i
may extend an high as the posterior niediaslinuin. On the other liand,
wh«i they are tranAmilted atoiij; IImbw which pi In tin? anli^inr portion
of the pelvic, inllamuiatory phenomena occur about the inguinal canal.
FUEllPERAL INFM-TION
ma
-C
^.^ -..
x^J.
v'^>-
r^ ^
Flo. 665. — Si;crt£>N nmoi'iiii 'l'iimJUB<ni.i> I'u.tic V«in,
luiowiMo SnuirTOCorci. X «»0.
Bnd arc cairipd bv tin* blood currenl in variouN dir«c(Jnii», giving riM- to
efHlot-nnlitiit an<l tiirliutialic atu-cMse*. from u'liich no portion of the Ih>(1,v
ii|i|K«i> to Ik- <.'Xt'mpt. In IIiim form of )iiHT)HTitl infwli'>n xiit-ti abweMW
mitv Ik- found in any of the lUttToal organs, the HviH>viaJ HurfacM alim bung
fraiui'iitly implicatoci and giving tiwt to nwvUings ahoal the jointit, which,
if not promptly trvntvd,
may Itwl to tbeir coin- p^
|>l)-ltt (U-^trnotion. In
other caiK^ blelxi or bul' , "'
la-, due to the eame
cause, appoar on vari-
nti« portions of ihv body,
and in their conicnu itiu
(iffrnding niicro-orpin-
isnis are readily denwD-
Htrable. Ii»8 frequent-
ly, delat^hed pailiHc* of
thimnbi may be arrt«tcd
in one of the Urgt^r vo-
mJs of the luQgs and
givi^ t'Xft- III piilnionary
embuli«m and almo-^t instaataneouK death. When Hniatler Tetuwls are in-
volvrtl, till* reoiilt" \vtv not «> wHihik, though the portion of lung snpplksl
by them becomes infarcted and gives ritte to a secondary pleurisy or pneu-
monia, which may nltimatc^'ly lead to death. It would appear from the
obwrvalionit of Mahler, Bn-uer, and Kiehler that a tiirgcf pari of the pulmo-
Dar>' nSections ocvurring in puerperal women originate in this manner, and
Id not H fiw inotance* th« apjK-flnuHT of a loinltzi-d idmriHy may be tlio
firitt man if ratal ion of a eerioti^ thnmliotie proee^g. Moist caHot of pyipnita
preKlit very lillle uterine inrolvemrnl. and divilh. when it occurs, is due lo
general e.vhauHiion following a prolonged suppurative proceiw, rather than
to peritonitis, which is llie usual cause of death in the other forms of
)nfi>ction.
t'tiUgmeuia Alba Oolrtu. — As was pointed out when the qaesiion of
piarametrilU wan eonniderml. this affi-ctton i» Minetimwi du« lo tite rxteiwion
of a parain«lriti.-> through the lymphatics to the tissuoi surrounding the
great v«Me of the thigh. As a rule. how«'%'VT, it nwults from the vxtciKinn
of » thmuiliotic prorexs from the pdvit; reins ; and in several of my autopsy
nseti it could be traci'd from the uteniH lo the common iliac vein, whenov
il I'nteiidi-i) upwani lo iIh- vi-nu lava and downwanl lo Die vesm^U of Ihe ri>ot.
Oet-asionally, in cases whith recover, the phlegmasia appears to be an
isolated process, though it is probably only u part of a much more extcn-
aive throroboais. Moreover, it should be home in mind that even vide-
spn>ad thrombosis may givi- rise to but slight clinical man i festal tons, »»
in oiH* of Hiy cam^, in which at autujmy tlie femoral vein and all its
brsDches were completely occluded, though carcfal mensuration was nvoes-
Muy (o detod any dilfi-ri-nrr in the si»' of tlie legs.
Phlegroaitia din dolcns should always be regarded clinically as a ntani-
866
OBflTTETRICS
festation of infection; aithougli ii oiav- po«»il>ljr be «f otWr origin. Thus,
my a»iii!ttaRt, F. 0. (}oldsbaroitgh, described a cate of complete occlaaion
of the common ilinc. cxu-rnnl ilin«. «ii^ feiDorat vmn*, which wk» cicnrly
ttic rrwiili of preisure. Buch an inference, houex-cr, is not peniiiasible
unless ilie cate comes to autopsy, aiul cnrefitl baclcriologicul cxuoiination
dcmouKlrnlc* tin- nl)i«enr« of luacteria.
An excettent ides of the frequency of the various lesions in fatal casm
of pui.T['rral tnfi-clion iimy he ^ine<I from the statement of Kneimi, who
cludied the autopsy rcporu from 89 cases in Halle, uilh the following
results :
P«ritaniti« .
ThromlfO-fiUclit lis.
PjTrtuia , . -
I^ninuMrilU
Sepn« (oudro.vkuhi
4r( r]i>oH,
M "
1- "
7 "
JEtiolo^. — 'Careful invi»tigation has dvmonslraUil that Ihe baelorin
coDcenied in puerperal infection are identittal with those with which we are
familiar at causing wouikI ii)f<!L'ti<>u. In fact, puerperal infection must he
regarded as a wound infection caused hy the introduction of pathogenic
organisms into Ihc gcnerulivc tract either heforr. during, or immediately
after labour. In other words, we Iinvc to deal with a direct infcf^tion from
without, the offending buctcritt being brought to the woman by the bands,
instrumenbt, or an; other object whiih may coui« id contact with licr gen-
erative organs.
Puerperal infection, then, is contact infection, this conception haring
been firr>t definitely enunciated by 8eiitniclweis3 in the followin]^ wordii:
" 1 consider puerperal fever, not a single caae excepted, as a resorption
fever, cuuhhI hy Uie rfri.orption of a decompo»ed animal-organic material.
The first result of the absorption is a change in the blood, and the exods-
tion>^ arc (Im rwiiH of ihis change. TIjc decompo»«d animat-orjpiuic ma-
terial, whiih when re^irbed causes childbed fever, is brought to the indi-
vidual fnim witlifiiii in ihe great majority nf caMcs. and this is infection
from without. These are the casc^ which represent the epidemics of child-
bed fever. Thcw are the ca><» which can be prevented.'*
In the latlc-r pari of the eighteenth n^ntury piierpcnd fever Iwgan lo
be considered as a eontn^lous malady in Kugland. This conception appar-
ently originated with Thomas Kirkland. of Ashby, in 1771, but was firet
clearly enunciated in 1795 by Oordon, of Aberdeen, in his treatise "On
the Kpideniic of PueriMrral Fever, as it prevailed in Aberdeen from Derem-
lier 1789 to lllareh 179S," in which he gave a table of 77 cuea which he had
attended himself.
In this country we are mainly imichtiil lo Oliver Wtaidell HolmeK for
introducing the conception of the infectious nature of the affectioiL In
an article entitled Puerperal Fcvi-r as a Private Pestili-uw, fii>t publisbnl
in 1S43, he cle«rly showed Ilml it was a preventable alTection, and ow«l its
origin cither to the accoucheur or midwife. His teachings, however, did not
exert the tnfltienct; wliidi miglit hava been expected, mainly because ihtgr
PUERPKRAI, INFBOnON
867
vme oppoeed by the trading olwlrtricinnx of the coviDtn*, noUbly M«igH and
Hod^ Uw fonner ^talin^ that he preferred to considtT IIms ili^u^ as due
to the working of I'mvidviicf. uliteh hv cm\d iindi-rstand. rutlH-r Ibaa to
&a unknonn ii)fi>ciion of which lie oould form no ooDivption.
For many ycara the prcraleiit th^-ory in Europe ts to the cau£«tJon of
purriicrAl fever wa.i lliai it wiis due to nitagmsli^^, li-lliiric, or utin'Mplmric
intliKrtiMv. This view ht-'ld its ftround for years after the Hppearaace of
S«tnifH'lwi-i!»!«'* Iwok in l»*H ; a]lhoii;i;h in 18fi4, llirwh, nfu-r xtudying tlie
matter from an historical standpoint, came to th« conclusion tliat the
Dinhidy wm* of infvctiou« rallic-r than of miMmalic origin.
It wa.-i not. however, until Lintcr h»d introdmt^l anli^t-ptio iiiethoda into
rurgery, and tilndfcld. of (.'openhagen. hnd ro-omriicndct) Ihe atv of bichlo-
riile of niertury in obsieiri<^. that ilic groat niaiw of tlie profession lM'jj;an
to underhand Diat puerperal fever was due to eotilaet infoeti'^n. and could
hi! prevenliil hi a vi-ry ffrval dv^rve. The hiR-tcriolo)cinil work of Patiteur
and his sueocssors, and the almost enti-^tant presence of slrt-ploeocei in fatal
nM«, ihH'idcd ihv ([Utvlion. and at pn-^'iit tio one doubt.'' tW infecliouit
nature of the diseaw.
Mwits of Exlrmat infrctioH.~—Thc mo»t u«ual niodv of infi-ction i» by
tho hands of the olisletrician or the midwife, and no one who has ohservcd
the way in which many medrcnl men conduct labours can wonder that
puerj«i-ral fe»er occasionally occurs. The eroployuwnt of dirty instrumenta,
OS well as of dirty hands, aim play« an important part.
Sourtm of infection, much rarer, it is true, hut ^nernlly overiooked,
ar« copulation during the later days of pregnancy, and, «spci:ially among
lltv lower clasw$. self-inoeulalion hy the patient fingering her genitalia or
even making internal examinations. Id my out-psticut de|iartmi'iii I iiave
seen two women dib, who had not been examined internally : but upon seek-
ing an explaitalion for lh« infivtion, 1 found that Ihey liad copulated during
tlte first stage of labour. Contact with secretions from wounds of any
kind al«o pltiys an important part in iU |)roduclii>n, and whclber (Ih- punt-
lent material bo from an external wouiul or elsewhere within the body,
the result will be the same, ll i« only nectsary to rcvalt in this connec-
tion tlie case of Dr. Itutler. of Philadelphia, who was followe.1 wherever
)>e went by an cpidenite of pni-rjivral fever, while his brother practitioners
were practically free from it. It appeared later that the iiource of infec-
tion was an ozsna from which he was constantly contaminating his liand^.
Woundi> on tin! liaud.-< of Ihe nurw, bone felons, anil ollwr alTeclion* of tint
liners, ami not infrct|ueuily a pustular ec^cema, are soiuctinie^ n-s)>oitsili|e.
For many years it has Ijccn known that puerpnal fever often occurred
vtlvea ft woman in lal>our was car«d for by a physician who at the awne
time WAS attending a case of erysipelas. As has already been said, one of
till! old idiw« eoiK-erniiig the affirtion liHd it lo U? idi^nlical with the former
disease, hut it wiu* not until bacterinlogy had proved lliat ery*ii()ela» and
modt of the serious c^ase^ of puerperal inflation an.' due to the strepto-
oH-citi llutt thin relation «ra» umlerstoo*!. M tlie prewnt lime tlie majority
»f obserrers bdieve that there is no c^^ntial difference Ix-twoen tlH- strep-
tococeus eryaipelalua of Fehleiscn ami the ordinary streplococens pyogeoee.
1 ST
*
PUBRPKHA1. INFRTlitN
pn-^nsut w(>mi-it, iiml Dial Divm; mi)flit Im.- iiitnxtiKt'il into the titcriu^ by a
finger which wan jwrlwliy slerile before bring )i»kmi) iigi lh« i-iiiiul, Of
courw lh(w« wniilii uiit be iiuUuci.'K of ttuti>-inf(<cti<>n in th« ittrict senaa
of tlie word, and much coafu»ian iiiijibt have bciii uvoiijul had i\w Ivrm
" iitdinrl infection " bm-n 6ub(-litatL<d for it. iiin«e the uiiernH>rKaui>ims
must have )>ei!U inlToduoed into tUc vii^^iui at wtiic pcnod 'if life, and the
question simply resolves itself into one of limi;. Many obM-m-ra n<iw hold
that auto- infection, f-ivn in thii* modified scusi.-, is not {H>ssib)c. iind that all
(nneH of puerperal infection arc due U> the i ii t roil uct ion from without of
pallwfrcnic micro-organisms at the time of labour.
AftiT all. till" quwlion can l»e linally d<-<.'idin) only by ihi- n-siill.* of the
Iractcrio logical eiaiuiuaiion of the i;enerative tract tu the prEynant and non>
prvgnaiit conditioiu. Vnfortunulety. t)ic tnvtwti^ilious which have been
umlertaken in the ho|w of settling the <)Q^tion have noi jfiveu uniform
rvsull)'. and consequently we an- nearly as far from a scientilir solution of
tho pitihlcm an when it v&i first brofti'lwtd ; although in a<'1uai practice a.
constantly increasing number of obstetricians act as if the possibilitjf of
•Hto-inft«tion had tteen definitely dUproved. A
I'mctically all inveetigators are united in claiming that the trgvlty at
the normal ulenis i» free from micnMirgHtii»ms both in the pn-gnant and
n»n-pregnani condition. This fact haw lieen amply dcmon^straicd hy the
work of (louner, Dodcrlcin. and Wiulcrnilx in wom«ii, and tbal of StniitM,
Sanchei -Toledo, and Denzler in the tower animalA.
Prior to 1898 it was generally believed that th« cavity of IIk' normal
puerperal uterus wa* irrv from bacteria, ami thai their prescan-c nlT<'r<i<ii
iixlubilable evidence of infection. In that year, however, Franx tilated
that bacteria could frc(|ucntly be found ufter the tlr>it few days of the pucr-
{HTtuiM in wnmt>n, wlm hm) preHcntcd no clinical iiignD of infecti<Ki. His
results were siK>n cinfirmcd by Uurckbardt. and pmuiptty denied hy I*oder-
h-in hik) Wintcniitz, .M fir«i it wa* Ik-IicviiI that ibc Inu-tcria in 'pu^tiou
were merely sapro|)hylcs, but other invest iga tore, such as Stolic, Sclienk and
Scheih found streptococci in fmm 30 to 118 per cent of Iheir ca«es. On the
otlicr liand, Fnult-rton an<) Bonner, Hrownlee, and other* Htated that Htrep*
tococcj were never present in the normal puerperal uterus.
In view of thesR- ci>nlrt(dictorr ■laleinenlji, I re(]ue3<tetl my awiiflant,
H. M. IJttle, to invetitigate the question. For this purpose he attidied the
nterine lochia obtained from 50 consecutive women delivcn'd in my clinic
in IHrtl. In each case eultureK wert- taken immediately afler ihe expul-
sion of the placenta, and aj^in on the third and ninth day of the piH-r-
perinm. Not eountint; the gonococvn^ tlic uteruH wsa fouiMl to )m- Htcrile
in 96, 85, and }0 per cent of the cases on the three days r^pectirelj,
■nd in none of tlw 150 examination" were utreplocodi found.
The«e nbaervations, therefore, clearly indicate that the normal puer-
peral titeruft at no time contains Dm; unual pyogenic liaeteria; but, on the
other hand, it cannot Ih! re^nlcil as fterile except iinmclialely afler deliv-
err. and becomes progressively more and more ty>ntumimilnl w the puer>
perium advunt^s. Ilie bacteria pn-.-"'nl an- u:<tially saprophytic in charac-
ter, and while they may give n»e to sli(;bl fvbrilv disturiiaiKe* dui'^ig the
870 ^^^ OBSTETllICS ^^^^^^^^^
puerperium, thcr cannot bo hold ntaponsiblc tvr tlui proclaction of tlic grn^e
formii of inTeciion.
As onr investigations show tliat thu normal piwrporal iilvnix ilix-x not
contain xtn^plooHX'i, Ihe que^tioo aa to tlie po^ibilitv nf auto-ind-clion inuet
stand or fall with the dwnonstrDtion of sucb bacteria in tl>c vs^nul wcn^
tion of )i<-altlir iircfcnani nonien. If iher are e\'en occasionallr present, it
mUHt be ndmittoil that they may be airrl^^K) tip iulo the ukTu» by tho »lvrilc
exKHiiiiing tingtir, and ^ivo ru>e to inffotion; vrhervari if lh<\v i<«nmtl be
demon-^tratcd, each a comteatiou must bo di»uii»«L'<l a» imfouudt^l.
E\'(Ty otlv udinitK Uiat th(^ vaginal secretion during pregiutntij- nor-
mallj contains large numbi>r3 of bacteria, mostly bacillary in character.
although cix-d are fn-qui-ntly *wn. I'nforliinatoly. Iho baclrhological
investigations whi<ih Iiave l»een undertaken In dt-toniiinc Ihe nature of the
laltvr have served rather lu coiiipliaitc than to settle tfae question : one
set of observers claiming that strcptooo(vi are freqnently prcAcnt. and the
other eoiitcnding that, witli the vxecjition of t)ic ^tnococcus, pyogenic bac-
teria are alwaytt la<-king,
Dbderlcin's studiee on the vapinal secretion, published in 1S92, proraiiicil
for a time to rectmcil* the conflifling rutulls, hut aat tli^v have nut bet-n
confirmed by fubficquent investigators, the qaestion still eniains an open
one; nlliuiiijih T finrily hclii'V<' that pvngi'nic Iweleria an> in-vrr present,
and that tiie contrary Iwlief is ha:reil \i\wn the employment of a faulty tech-
nique in obtaining the »ecr«-tion for examination. Diiderleiu ><tali-<l thai the
vaginal secretion might occur jn one of two foniia, vhich he dec^ignated
a« normal and pathological. The former was a thick, dry. choo««-like mato-J
rinl of H whilii^h colour and a distinctly acid renetion. Mimirs-opically it
showerl epithelial celln, a puri> culture of toleral>ly hmg, thin bacilli, and
occasionally a few yeai-t fungi. The pathological weeretion, on Ihe othiT
hand, was fluid, generally "f a yfllowish lotour, t<n(n;e>iing pus. and *>m«-
timo; eontaini-d ga^i bubbles. Ili^ reaction was \e^ acid than that of tho
normal wi-crelion, occasionally miilral, iind very rarely even alkaline. In
it were found large numbers of leucocytes and many micro-organisnts of
variouit kinds, both Iwcilli and cocci. Fifty-five pur wnt of his paticnlii
presented a normal and 4o per cent a pathological secretion. As pyo-
genic bacteria wen* never pri'.*<'nt in the former, w}iile streptococci wpra
noted in 10 per cent of the latter, he held thai Biiio-infectitm was i>ut
of the ipieiciun vrhcu the Msnxiliou was iiorniat. but might oeca^ionallr
occur when it was pathological. I
The following fable given an idea of the frequenev- w^ith which plrej*-
tocowi have been demonstrated in the vaginal secretion by certain iuve>-
tigutors: i
, Burckhardl 4% Wiiit«r 1S% I
I StdTocli 4% WiUiam* nsaS) 20?i,
I DiKbrleiii . 4.1% Vahlu . 25% 1
I llurKiJliiiri. , K.r>% \\alllnr.l. , 37% I
I Kohlaiid. g .«% atolx. .. .. 30>;i ]
I Vdble 10^^ BumniaiulSixwatt 7i% '
I Will* i-j..5% Natwig . lOO^i
PUERPERAL ijn^ixrnoN
871
*
This grwil di*pBn'ly in tho iiuiili'itw "f stroplococci wmilj spcoi to
tiidirali- Hint ofiinc nt llic invi-ilij-alor!'. nl ka^t, in'rtr in i-rrtiT, »e il Im
Bciinrlv iintewiviibU- llml ftn-iilmoni mtilil iN.n(-iir "JS limes minx- rFn[UCDtl}'
ill ijiif H.>t uf woiiieii titan in another. Miircover, if tltey mx'tinvd o* fre-
quently as some obwrrors state, it wouli] appear remarkable that relatircty
so few {vnliitntt Kiiffer fr»i» «lr(>pt»0occie tnf<vti<iti. Tn rivi>i\i>mi! Uua
oltjwlioii. it viLi first SHsmiied llml the vaKitial wtroptococci were of a dif-
ferent strain frcim tluiM* which f^ice rise In severe infections, or nl Inisl
pi)iui-!i»ni only a very flight <Iejn«e of virulence. The cnrnparinon of
streplncocei of their biological ehsruclvristio with Diom derived from
iiiff'i-liniiK pnxH^MW, however, faiieil to Hiinlaiii »u<'h a conti'niion. Ae-
coiilin^fly. Waithanl and lli-ber attempted to esea|H.' from the dilemma
by assuming Ihnt the women liecame immuni! to the action of their own
sin'ptoeotxri, and therefore could be infected only by those coming from
some extraneous source: This apiK-ars to ma to be n rrdnclio ad absvrdum,
aiul it would seem far more probable that the es: pi an at ion for the hi^
percentage of strrptocooei i" I" he *nHf;lit in some error of Iithiiii}ue.
On tho other hand, the work of Cionner. Thomen, Samsehin, Kri)nig
and Menge, Bensis. Itcrgholm, and niym^lf e^liows tluil pyogenic bacteria,
villi the t-x^t-ption of the gonocoecus, cannot \ic found in tlia vAj^tnid
secretion of healthy pregnant women.
Kritnig. in IKt'T, iitateil that in the Tuginal secretion of J67 pr«gnant
women he had been unable to dvmosstrate tho presence of typical strepto-
cocci or any Oliver pyogenic hafteria. with tlic exeeplion of tJie gonoooccus.
M"nnver, }i<: ^Ikowcd that it va.^ decidedly antagonistic to streptoiHuvJ intro-
ducc-d from without, all trace of which usually disappeared in tho course
of twelve hours. He therefore e<>nclu<lwl lliat tlie raginal secretion should
be considered as practically sterUe, and that it did not offer the slightest
evidence in iIh' «tup{>ort of the doetrimt of auto-infection. He obtained
the .■'ecretion for examination hy means of a tmiall tulic, whicli could be
introdut^^ed into IIh^ vagina under the guidance of the eye without coming
in contAi't with the labia minora or llu: niargins of the hymen, as hr sur-
mi^ that wlien a sterile speculum was introducetl liaeteria niu^t inevitablj
be curriiii up fnun tin? vulva by its moans.
In l)4U.s I coiifinued Krunig*^ findinjcs, wtien I n-ported to the Ameri-
can Uyna-Tologicul Society the results of the bacteriological examination
of llie vaginal MTn-lion of 33 pregnant women. The secretion wn* obtained
by meand of a tube niuiilar to tluit employeil by Kriinig ami ^hmge. and
m no invtance could the strc]>tococca^ or stapbylooocciN aureus be demon-
slruKil. In view of this fact I concluded that auto-infeetion from these
micro-organisms vna impossible, and when tliej' were demonstrated in the
puerperal literufi. that they had been introaluced from without. At the
HRnii* time 1 admilt"d that certain cases of puerperal rndomelritls might
occasionally Im> iUw to autn-infi'otiou from other haeteria.
These conclusions were abMluIely contradictory to those at which I
had arrivwl five years previously, wlien I fouixl stn-plocooci in 20 per cent
of the fflises which I examinetl. In the two series of ob^iervalions, the work
Via condueusl under identically tlui same conditions, cxcvpt that in (lie
872
OBSTI-rrHKS
firitt the secretion wat iihlniiml ti.v iiinmii' (>r a vtvrile j;lain sjxKrnlHin,
whcrtTw in iln* m-ukkI .Menj^i''^ tpbe vns em)>luyed. The cotM^lui^ini). tlwrw-
Utn;. npfieaivil iiievit«l)k- Ihnt in iho (ir«t wiriisi luurlcria liail bocn (.-jirrirH
into the vMjiiiiii hv llu; Hpi-itiliirii fniiii lh«- itmrgiiii' nf lUv hritii'ti nr
the iiitKT MirfunCA ikf the labia mioora; vher«aa, AUoh (lontAcI hariiig Ix^it
avnided in the iccond i-i>rivf« hv the ura uf Munge's tube, lh« secretion
ohtflimtl w«« «l»m)hiidy fi»* twm <-i>nlnnitnii(i4>a.
The «'onvrIne?« of ihi^ explanation u-aa placed lievon<! all reasonahle
doulil In* (Ik- <'\ttiiiinHlton of 2."i ii>l<lit'iiinil rawM, !t wt* of culture)' Ix-ing
made fnmi each. The first waa taken from the hvinen and inner wurfaces
of llif labia minora. Ihn «s-<itid from the Tuginul Mjun^lion obtained by a
Menge tulw. and the thin! from the vaifinal secretion obtained ibrou^ji a
stcrilizwl sjiivuliim. Pyojivnic cocci or colon bacilli were dcmoni^trati'd in
80 [)er cent of the iirsi, in none of the sivonii, and in 18 i>cr ncnl of th«
Uiird Kcl of <.-nltun-)«, tlu*rcby ehnvtiig conctustvcly that thu Ta);iiia) secre-
tion of healthy women is free from [»yop-nio cocci, wlien olitaiiied wiihi>ut
coQtaininulioTi, but that since bacteria usually are pre^nt Upon the hymen
rond labia niimira, it In inipiwiiible to inlmdiicc U M{Hvuhim into the vaginit
. vitliout carrying them along with it in at least one half of such ca^s.
Thig cxplunalinn apjMirciitly settled the nialUT tor a few yusrs, but
in 1904 Bumin and Sijjwart stated thut it was nm «li»fa^tory, am) thnt
my nt'giitive results were to be attributcil to the employment of unMiiliible
cnltiire media, so tluit stn^plot-occi ei(-ji|H>il dt-tedion. Tlu;y thou n?|(Orli-d
the n'^ults obtained in the examiuatioti of the vaginal secretion of HfS
prx^iant wotneii. &tcn^-'s tube vros not vmplnycd, but inKtcad a speculum
, was intmdnct'd and the se<'retion obtaineil from a portion of lh« vaginal
wall, which prcnmnbly had not come in L'onlact with it, and then inocu-
lattHl into lioniiloii. Streploctnci were dcm oust rate* 1 in from !iH Ut 74 jicr
omt of their vatn». according an cultures were taken upon one or several
occuxionA.
These results were at such variance with mv own that I reipii'slt'd my
a)MiKtarit, .John H, Bei^lanii. to n'|K-iit Honim's cKiKTimcnt!^. employing
exactly the same technique and culture mwlia, and at the same time to t«t
my ])rc%iou» work. For this ]>urpo«f cuUmv?* wi-rc taken from 50 cunsecii-
tive nonnal pregnant women, in li'Oti, as follows:
1. l-'nim Ihc vulva before disinfiftion.
^^8. From the vaj?ina by itieaiH of Men^V tHbc,
^Hpi, Prom t\w vugina by means of a speculum, following BnoimV iivb'
^rfne. In each fj;iiiup oultun^ were made in bouillon, following Bunun's
recommendation, as well as tipon solid media.
In group I tho cidtun-* were nearly always positi\'o. in group 2 always
negative, as far as pyoj^ii-nic cocci wert* concerned, while in group ;i posittt-e
roultx were obtained in more than one half of the ea-tes in which badcrta
had bw-n dcmnn»lryt«-d upon the vulva.
Tliesc ol»wrvatioii«. which hare not yet been published, confirm in toto
my previous work, and dcmonntrato conclusively to my mind lliat the vagi-
nal jiecrction. when properly obtnined. is sterile so far as pyogenic haderia
are concerned, and also that a speculum cannot W intri>Jiioeil into the
primrHttAi. isfixtio\
S73
TKgiiift px(vpt u( n i-DiijUlmlilv rUk of cairjjug np iMctrria rinin tlie
vulva, ,
ll IK iiii|Hirli«iiI l>i iiiilf Dial 1-n'n witi-ti R^rtflund "Itliiiiivrl |i>i.-itivc tv-
Mill.i ^In'jitiH-ucvi were found )iut rari'lv, llieir piutx' iH'in;; Inkt'ti tiv »ilu]Oij'lo-
ratxri atii) culoli bacilli. 1< would. thiTt-forv. W inlvnv-lin^ to riixl tin i'xpln-
niitinii for thie difTvifiiif. »» it i" iin|Ktw<ilile to Mievo lliat mi ti>ii)pt>tent
a inacteriolotnat af Bnnnn could Imve conrotindod otlivr Imctrria with iitrv|v
titoifci; whitv at (Itc '«im- timr it Ik lianlly {)nil)iil>lo lliiit tin- )ini-li-nii1 Dnra
of Iho fidva tiiidd van* lui jfivatly in Italtinuiri- fiv>iii llial i>l>-<.>rvL<d in
Ik-rliii and JIatlo.
Ai II nvull *)/ iiur own wnrk, as well us that of Kri>nig and Menj^, I
coiwidiT that it han bwn fairly MHitfuttorily d<-iii(iiiKtrat<il that pyogiiiic
^Mi-i an: not prentiit in ihf la^'inal sLvMioD of pn-Kiiant women, and that,
Ihfn'foif, there is no possiljiiity of aiiln-infcs-tioii a« far a* tiwy arc cou-
c«ni<^. Consequently, whenever they an> dfinonvt ratal in the uterine
lochia of puerperal women, they should be rrpirded as di^'ttiiet cvidmcc
of cxlcnml inftH-lion. At tlie mnie tinitr it in poHniUle in rart> in-itaneea t]ut
auto-inf(«iioD may occur from other orptni-niH. which are found in the
vaginal Mx-Mion, and plau^ihility w h-nl tu Kuch a Hupixviitiim hy the
inereasiog frequency with which bacteria are found in the utenu with
ttiT tdvanw of the piw-rperinm ; but (gUisfnctori' cvidi-ncv cannot be aildncwl
in BOpport of such an oceurrt-nce until methods have hwn devised which
will viial»ltt UK to i»olal« and cullivalv in puru ntltun- thf organii^ni* in quL'it-
tion, many of which am anacral>es which will not ^row upon the ui^ual' media.
The ^nococcus forms an exception id this regard, as it w the only
pyogifiic copcuK which ean lin> and tJiHve in the va^cinu) m-cri'l inn. A^
already indicated, it i^ fntiuently (he cauw of an elevation of temperature
during th« pufr[K-rium. Siich ni*v*, Iiowpvit. kliontd not In- conKid^rvd
aa Hupportinjj the doctrine of a a to- in feet ion. for the reanon that the women
vtVTV infix-K^d before (imeeplinn or in the firvt tw.- mouths of pnynancy,
after which the Konocoeci persist in the cri'ptu of tin? corvinal canal, where
they live u» parM^it<4. and Mmply find nmrv snitabk' ii>nd)tionK for deix-t-
opnient in the tirat few days of tl>e puerperiuni, wlien t)u-y make llieir
way up into the uterine mvily and manifest Uidr presence by tlie produc-
tion of fever and an inc-reAscd dixrharfte.
Likewise, oik> nhould not repinl an auto- infection, in the Htricl «enae
of the word, thuM- i-amx In which ihe iMtttcria an- limughl In |)ht ulerru
from distant foci of disease by nteatis of the blood current, itor those in
which tlw procvnt renult* fmm sonir prC'CxiKting affection of tlK genvrativt.
tract, such as an old pyosalpini.
An inliTeKtin<; fact in connection with tlie (guestion of auto-infection
ix that ihnsv who In-lievc m<Hl firmly in its possibility, and who arc in
the habit of employing pn>]>hylacltc va)i;inal dnuchvt' for the dtwtruetion
of the organisms in the vagina, have tlius far \tetm al>K- to pn-M^nt for leas
favourable stnti^tic^ than tltoir opponents. Thu«i. Ahlfeld finds that 38
per «■«{ of his patients hare a ri?e of temperature durinj; the puerperium,
evm after the n*e of the prophylactic douche. Again. Kultt-nNich. while
chief of the Lying-in Clinic at fialle, always resorted to its routine em-
874
OBSTETRICS
ploymcnt. but llio nlfllislirs show a very mnterial iniprorcmfiil since hi*
surcessor, Fehlinu, discoiilinwd Ihw prnt-lii-f. Fiirtlifniiore. lh« rmnlU of
Ijeupotd ii7iil MiTmiinn. who <!ii m>l u.-o: thv iloiii-lii' ai all, hIimw it i.itii.-'tnut
improvoiiieiit corrcsiinmlin;; with tht- incmasiiig pri.-c-i«iou with which oIj-
Jective aeep^i? is carrii-d out.
Tlio vftliio of the prophylactic va^oal douche has i>i»n investigate-d
hy Kronig aiid l{rut«;'!inci<UT. Ilic latter fnllowfO 2.3J*» num in llw l^uip-
Kig liiiiic, every ahernau- wmiian IwiiiR doiifhetL Tlio |m«-r)wriiiin was ,
febrile in 4Ii.ld pt-r cc-iit of tho cauvs in which the itouchu wns nx-d. as
c»in[ian^l with 3G.78 per t^ent nf tht^ e&»e* in which it wa^i oniitKHl, while
a atill more pronounced difference was reported by Norris in 190J.
Jftwctt quotes the opinion* of n niinilH'r «f Ameritdn oliKtelricians upon
the eub]«ct, and it would appear that llie majority of tiiem do not employ
the prophylactio ilourhe, and that, wliile a certain number tlicoreticnlly
believe la auto-infvdion, they practically aot aa if ita occurrence were
iinpossihle.
Freqaency. — It ia very difficult to make acnirate iKtatementx aa to the
frequency of puerperal iiifectifln, Pi-p'ciaHy when it occurs outride of bo9-j
pilal practice. Concerning this condition liic vital Atatinticii of tlie health
officers of the various cities are of no value, inasmuch ae the vast majority
of deaths from this diHCane are reported m being due to malaria, typhoid
fk'vcr, pneumonia, or other causes.
Thu[i, Reynoldii, in 1SD;1. wrote an urtii-lc iiiwin the prevalence of puer-
peral fever in Jloston. In that year he himself had seen 28 cases in htupital
prBcticc^ with 7 deaths; but, in looking over the statistics fumislied by the
health olTice. he found tliat. ^ntnlin)^ the n-portw of the dcparlmc-nt to Iw
accurate, this number represented more than one fourth of all the ca»ei
of thin character in BoMton— a conclusion which would oortuinly appear
incredible.
Since the introduction of anti«>ptic methods into midwifery, the mor-
tality from puerperal infection has liwreased very iiiarkcitly in hospital
practice^ In the old Maternity of Paris, and in the l.ying-in tiospital in
Vienna, in some years the mortality from thi.'t uffitction van<^ from 10 to
ITi per cent of all the women admitted, bo that finally it attractod Ihft
Btlention of the piihliir at large, and steps were being taken to aboU&b
such instiluiions as a menace to public liealih. With the intnHhidioD of
aseptic methods, luiwcvcr. all this wa« chau^<d, so that at pnyenl in welU
ragiilated lying-in hospitaU the Tnortftlily from iiifeetion is usually only a
pniall fraction of 1 per cent. Hence it happens that at the pre^tent time,
in the discussions upon the subject, at leant *o far as hospitals are con-
ccrnt-d, the question is not so much one of mortality, but mainly one
of morbidity, and deals wilh the percentage ot patients whose temperature
ri*** niMvo 38" C. or 100.4° F. during the puerpcriuin.
On tiie other hand, in private practice it is doubtful wlwtllier llw
results are materially better to-diiy than Iboy were before the introduc-
tion of antiseptic methods, for ihe reiison that the doctrines of asepsis haw 1
not yet permeated tho rank and file of medical men, much Icsw of mid-
wives, to who«c care is cammitte<] a vwy large proportion of obstetrical
rilEHPERAL INFKCnON 875
CMM. Tlvnugli, nt tti« t>nme lime, it nnut be •dmiltm] that wo rarely hear
of outbreak;^ ol puerperal infection such as are meotianed in the histori-
cal work of lliim-h. who giiii:-*; u« tim particulan of Slfi cpidomict occurring
bftwvett the ycAts UUti and 1862.
liacon, io an srtici*! based upon the records of the health department
of Chicago for tlio forlj yvare prior to 189ti, ahowi that pnerpcral infoc-
tioo Htill plavM a very prominent part in the deatli list, being tiie cauab of
death aaaij^ed in 12.75 per cent of the women dying between the age* of
twenty a»d fifty ywin;. In 18T3, SO per cent of all women dying in Chicago
between these ORea succumbed to puerperal sepsis. Happily, ihe mortality
has gradually fallen, reaching G per c^nt in 18t)3. and Iwing ri.vji:irded at
7.3 p(rr <-ent in 1895, Thew results are substantiated by those of In^erslev,
who stated that, eien at the prewiit time in Denmark, with the single ex-
cvpliou of tu^K•^(^lIlwi)^, puerfieral infwtion i* the mint frcKjuent eanM of
death in women beiwei'n the ages of twenty and fifty years.
The involigations of Knxall and Hyt>K i>how a similar condition in Eng-
land, where it may be »ai<l chat outnide of tlte lying-in hoMpilala this prc-
Tciitible wourge claims aj; many and perhape more victims than it did
twt'nty or oven forty ji-arsi agii.
Monmrer, in trying to deleraiine the fretiucncy of puerperal infection,
onv cantiot ho guidtn] iilto^tiber by the mortality iftatiKticv, inai>much as the
largest proportion of these casea do not end fatally. On the otiter hand,
any oik- who deal* mainly wiih gyiia?cological work cannot fail to bo
impressed with the very large proportion of patienUi whooe trouble* have
originated from febrile affections during Ihe puerperium, which in many
eoitc* wore cliinrly due to the m^lvct of awptic prvotutiona on the part of
the ob^lolrieian or midwife.
Symptoms. — .\n wft« i>tnli<il when concidcring the pathological anatomy
of puiTjH'ral infection, the eommon leiion ia an endomelriti.-<. Thin may be
either of Ihe wptie or putrid variety, each typo prewnling a K*^"? ^^
more or Iwa charaeteristie nymptomn.
In the ca»c>i of septic eMdnmctriti!«, after everything haa gone smoothly
for tlw! (irst thnxf or four daw of ihe pwrja-rium, llie patient suddenly
experiences some malaii»e, and may complain of headache and a filing of
chitlincMf. or she may have a welUdi-liniil chill, thv trmperalurc soon rising
to 10:i' F. or higher. (leneraUy, one rigor occurs, after wliii-h the tem-
pi-raturo remains «Tnislant!y eb'^olitl. At the Mime time there is some ten-
deniesa in the lower part of the aWomcn, Ihe uterui* in hirpT and niorp
dou;:hy js consistency than it should be, and is sensitive on preaiiure:. The
lochial discharge i.t mmetimcH inen-axeil in quantity, aiu) is partly bloody,
partly purulent in character, although in the purely septic forma it is
practically devoid of odour. If tlw; temperature is very high, the secretion
U not infra|u«ntly diminiMhed in amount, and otx-juionally disappears
almost entirely.
The chiiracter of ihe uterim- discharge* in these rascM often leada to a
mistake in dingiiosi". for the average practitioner asMMiac-s put-rjicml infec-
tion with profuiA- and foul-smelling lochia; whereas, in reality in Ihe moat
Tirukiit caccit, and u»i>ecially in Ihoae due to a pure slreptocoocna infec-
1
S76
ODSTLTUKS
lion, tlii^rt! in v«ry IKtIe, if niiy, odour lu be noticed, ami On absence. thero4
fore, IK not mw#)iaril.v a favoiirabk indicatiou. but rnlh«r the rt-vcnw.
Anolhvr point of importaaw is tbt- /iiiilly involution of th« uli>riu.
This nivi«l be tookvd upiin ns tin im^torlanl factor in the further spread of
llwr (li««w. for, a.- lia* already been flaid, the micro-nrganismB make their
way through the museidar walls of the uIitU!* by iiican^ o( the lymphatics,
and when tlie orgiin '» markedly relaxed these cbannela are morf> patent
and offer far lees reeiftauco to the outward paange of the bacteria than
when firm, normal pout nut ion is preiWMii.
The further history of septic endnmctrititi varies according «/f the pro^
ceiui remain" limited to tho cavity of the uterus or e:(ten<)s beyond it. In'
the foniier ease the tempcraturu gradually falls, the Kixirctton becomes lese
ood \v». and tbu' patii^nl i« f^lowly restored to health. In the majority of
casoH, however, the mucosa is not restored to its aonnal oondition at
onocv but for a long tJTiio remainit the »(-jil of m ^tibactite or chronic inllatn-
nialioo. When the process has extendwi beyond the uterus, the symptoms
will vnry aeconling Id tho or^an^ involved, and thow Monging to a para-
metritis, peritonitis, or pyemia, as the ease may l>e. are snperaddetl.
The clinical picture presented by a putrid endometritis difft-rs somewhat
from that ehanietPriKin)j: llie septic form. Here we lil(ewiM> luivc lite initial
chill and the high lemjicrature, hut the patient's eondition does not usu-
ally apiHrar m) M^rioiiK. The main difTrrt^nec, however. iH'tween tlw two
vurieties is to be noted in the character of the uterine diseliarife, which il
(he putrid ca.-ies i.* ahiiiidHiit. vi-ry fout-smdiing, and fn-quently has a frolhj
appearance on account of the larjtc number of gus bubblcK ninlnimtl in it.
TbcM- cumv- usually eventuate in recovery, and only in rare instsuees termi-
nate fatally.
Helwn.'n these two well-markrd classes of rases, however, then; e\):it
all }{radalion-s and not uncotnmonly we luive to deal with a miuil infcctiaa^
due to pyogenic as well as putrefactive orKanisms.
At liH* aln^udy Iwcn mu\. the chill and rise of temperature are occasion-
ally asHociatpd with loialLy..-.! ulceration uIhmiI Uie vulva or .■>oi tie where in Ihi'
vagina. In the vaj^t uiajority of cases, however, the puerperal uli-er or
va^iinitiM dixw not iKcnr ulone. but is nccompnniiHl by an widometriti*.
The extension of the process from the uterine cavity or from uIcvtb
about the cervix to the parametrium pnxluccji an array of more or In**
eharactcrist ic m an i festal tons. In many ca--tw the inilia! rwe of u-m)ii'ra-
tun; lasts only fnr a chort time, and we are eongnitulatiug ourselves thai
our patient has eseaiied so easily when widdctdy another chill tti-\ir>, the
fever rises again, to pnrjtue a more or Iws irregular course, usually mailed
by e^■eninp exacerbations. This may eontinue for winie time without niiv
local nianifc.-lnfiou: but. sooner or later, careful abdominal palpation will
n-vi-ul llu; presence oT a inasK oit one or both oides of tbi' uterus, due lA
pus funiialion williin tlie folds uf the limml ligament. Ttu? atineeM may
be limili-d to the biciad lipimcnt itmdf, or may extend along the connective
tissue n)ioii thi- anterior portinu of ihc [lelvis up to the nei);hbourhoo>l ••(
l*oii|iiii'l's li^anienl ; in other cases ajpiin, it extt-nds liackwnnl towiirdn tlic
retmperitonoal n-gion. The fever etintiniit* until tlie »be««8 rupturce upon-
rUi-^KI'UUL INKECTION 877
Unrou^ly or has bcvn opened, except in ■• f«w aucs, in whidi it uii(lcr);oc«
gndusl n»orplinii. li.-aviiig a tofiss of cicalririal lissue to mark its fonner
oiluftlion. If not op<.THtO() upon, n paramelrilic ahBcosH may burst liponta-
nmuHty into the rectum or blatldor, hckI (xvaxtnoaUy througli Iliv abdominal
wall in lb* rcpon of the injniin^ canaJ. I'oleaa it ruptura> into the pi-rito*
m-al uitily t)io putif-nt uvuaDy rocoTvrs.
In certain instancra thi> inf<%(ion extc>uli< from Ihv ulvrinc cavity to
the p'flllopian tubes, and there pvee rise to a salpioKitiii wiih its acconi-
panytng nyinpJonm. A l«rg»r proportion of ib<f vutv* of ptyualpinx, which
come to operation mouths or years later, have orij^nated in this manner,
particularly aftt-r infec-tion following abortions.
t'n fortunately, it »ninetini<M hiippettii that tlie procesw t\nn» not remain
limile'l to the uterus or to the parametrium, but tho mier<>-ori;anJ^ms make
their way throuj^h t)ie lymphatic.)! of Iho muxt-ulnr wall of lh<> utcniK In l)i«
p<Titonvum, and there excite a periloititif; though in excepti<Mial instaiieeM
it may n-^ult fn>ni an laleHxiftn of thv inflammation from tliu tubM, and
oceafionally from the rupture of a parauielritie, ovarian, or tubal ahsoeas.
Somcdhat ranrly, the peritom-al implication is limited to thv portion
lininji; the jH-lvio eavjtj- — pi'lvic perilontti^i. If ihi' jhw^ikm dotw nn\ i^pri-ad,
the diancM arc that the patient wiil recover, but if the peritoniFiim be
invatli'd to any ^rvat extent diwth iii alnnut tnovltablM. TIk* <')uiractfrii>tic
ayniptom^ of peritonitis may make their appearaniie at almost any time
during tlw- piii-rjit-riuni, but ran-lv iH-fore llii? lliinl or fourth duv, or later
than the end of the first week, nnletw they are due to the rupture of an
ab»«c8B.
Witen the patient i.« infe<-ted with very virulent ylreptnuHvi. tlM^ endo-
motritic implication i-^ usually very "lij^ht, and practically the lin^t H^n of
infi-rtion a)>[iCArs from thf iti<le <>f ihc pi-rit'>n»-um. ,\ mnrkiil rjji^r (Hvurx,
the temperature rises rapidly and remains constantly elevated, the pulse
Ixicomoi tHpid, and ]at<^ nn wry vvak and timwdy in charactor. I'hu
patient eomplaiDH of intense pain, which is at first limited to (he lower
portion hut graduully cxti-iid* over the entin^ alHlom<-n. At tlw "ami' tinn;
there is marked tymjianitt*, am! the a)>dominal walls are rendered tense
by the dintvndcd inli-:«tini^w. If a fatal isi^iie eusunf. death usually oecure
within the flr^t ten da.vs of tlie puerperinm, tlie patient gradually sinking,
although slw may remain consrtouF to the la^t. In rare ctMS th« tompvra-
lure tH htit liillir i-li-vated and the pain sltm'hl. the wrinuii rharaeter of
the condition l>einff indtcatc<l only by tlw rapid and roniprrwible pulne, and
tht! drawn and luijcganl Im-w.
In llie eases of pgirmia. on the other haivd, the clinical pictare i« very
different. Jlerv the initial chill dm-!* mit iwcur w> early, ami tlw temjiera-
tun- doe* not remain eonstantly eleraled. but inslea*! we have a typical
lu<c1ie fever, willi the chill, high teinpcraturr. awl n-miKHion nxiirrlng In
socceeaion. Tlw nympt(un« of ptieriiiB vary very loniiiderably. according
an it i* the result of tlw di-lodjiment of a single Ihrnmbu* or of tlw
constant I'nlrv into tlw MoimI of Kmall infti-tis! jiarticbs. In the first
invtiinci- »i- liavt' a metastasis pmdunit at some cnw i">int, tin- Krmplom*
depending upon the organ involved. On lite otlter hand, if thrombi are
87S
OB.fTKrKK'S
iH-ing constantly dislodged wc may Jiaw »ympt(>mi> referable in varinas
oi^gaiu.
One of Ute mo^t constant mantfL<6tiitinns of jiyieiiiiu it no tnfvtctiouit
broDchu-pDCiimoDiit, which ctmiributeii to the fatal termination. In other
cascw swellinjEB occur at the varii)ii» joints, which frequently e%rntu«lo in
suppuration and leuil to tolnl d<-.-> I ruction of the tia.'^uei intpticated. Ab-
»«*:** may also doveiop in the internal orpans or appear upon the surface,
and in ao^eral instance I have nvn them lead to llie df«truction of ihc
eye. Tbe i/ninw of pyieinia varies very materially according to the or^ns
attacked and the rcsi^liii)^ powers <>( the patient, but it la Dothiug like
«i ttnifornily falal as the pi?ritonitic form of infection.
In a certain number uf cskcs lh<- infection is eo virulent that the organ-
1*018 do not ha\e e. chance to become localised in any one orjpui. and Iniih
they and their toxim-e are found in abundance in the circulating Wood,
with very slight itnplioation of the uterus. Thi» )uip|ion8 in ca-^B* of
BO-catled xepiirifmia. which represents the most rapidly fatal form of in-
fection, the paticnitt ocea.4ionally dying on the second or third day of tlie
pucrpcrium in a condition of shock, and without the development of local
symptom.*. A ca.**- of streptoco<Tii* wplica'mia, oli*«Hn,'nd recently in our
out-patient d<?|>arti)ieiit, ended fatally within eighteen hours after the in-
itial rise of tcmpi-rature.
In a small number of cases the thrombotic process involving the pelvic
veins may l.■^t<■tl<l to tlie femoral vein on one or botli sidw, giving risi' l»
phlegmasia allta iliilen». This accident, as a rule, does not make its apjwar-
ancc until some lime in the socomi week of the puerjicrium, or oven later,
the tlrst .-lyitiplom Inting pain along the cinir»t! of th<- femoral Vi»w)s, which
in thin individuals may be felt as hard, wositivo cords. At the same time
'I'demn uppi-iirs in liic feel and srvon extendx upward, Ihniijfh ocfA-''i<>iittlly
it may appear lirst in the thigh. This swelling is aMociaii>d with severe
pain, and usually lasts for a coii*iderable time, months sometimes elapsing
before tlit' patient can walk with comfort, .\t the same time the conditioa
is rarely fatal unless some cmiplication occur*. At th^i onset of oertaii
fasftt of plilt^gniBsia the patients complain of severe pain aliout the i-lie^t.
This sympfom is attribiiU-d by Pinard and Wallich h> Uie arrt-st of minuta^
emboli in thti smaller vessels of the lung, with subsequent infarction and
the development of isolated areas of pleurisy.
In a cerliiiii niimlHT of cases infection may occur l)eforc tlie birth of
the child. This is designated a» intrn-pnrlum infrrtinn. and usually occurs
in slow lalwiurs in which the membrano-s have ruptured at an early period,
I'nder such cireunistances tlte temperature may be markedly otevatu) and
the patient present a profoundly septic appearance even before delivery.
When the tempiTatiirr during labour rises nI)ovc lfl0..1° F., we vhonid alwaw
think of this romplicatinn. and at once institute procedures to bast«n the
evacuation of flic uterus.
Diagnosis. — Tii*- diagnosis of puerperal fever is usually niadv vithnut
difficutly. a* the clinical hi-^tory is very significant.
If a patii-iit, who lia.t \y,vn doing well afl<-r delivery, has a chill and a
rise uf tetniicrature on lite third or fourth day, we may he practically sure
m
tafl
PUERPERAL INFECTION 879
that wc Iiavr lo dent wilh an infcolion, unk'ss we can apcoiint for the
eymptoins by some other natififactory cause- In many cases the initial
chill does not occur, and the first indication of the condition ia a rise
of temperature. In general, a temperature exceeding 100.4° F. (38° C),
and persisting for more than twenty-four hours, shuuld be regarded as an
a priori evidence of infection.
In the old limes it was believed that the onset of the lacteal secretion
was accompanied by fever, and the older observers were always ready to
attribute a rise of temperature on the third or fourth day to this cause.
At the present time, however, this eo-callcd "milk fevrr" is no longer
regarded a^ a morbid entity, as we know that the normal puerperium
should be absolutely afebrile.
After the infection has become well established, either as an endome-
tritia, peritonitis, or one of the other forms, the diagnosis is generally easy.
In uncomplicated cases of puerperal endometritis usually very little pain
ifl complained of, and it sometimes becomes a difficult matter to decide
positively whether the temperature is due to a uterine infection or some
other cause.
In a certain num1>er of instances a febrile movement may occur on the
third or fourth day, which may justifiably be ascribed to emotional causes,
such as excitement, fright, or grief. The temperature may rise suddenly,
and after reaching a considerable height promptly fall to normal within a
few hours. At first we should alwaj-s suspect a beginning infection, and
it is only after the rapid subsidence of the symptoms that such a diagnosis
is penuissihle.
Now and again a post-partum rise of temperature is caused by auto-
intoxication from the inlenlinal tract. Special attention has been devoted
to this subject by Budin and Galtier, who state that in some instances
such a condition may closely simulate puerperal infection. The diagnosis,
however, is readily arrived at by the administration of a purgative, for
after a copious movement of the bowels the temperature falls rapidly and
remains normal.
Again, fever occurring in the early part of the puerperium is not
tincommonly due to inflammatory troubles about the breasts, but the sub-
sequent historj- of the case readily clears up the question of diagnosis.
In addition to the more usual causes of fever during the puerperium
not due to infection, many intercurrent diseases may be accompanied by a,
chill and high temperature which for a short time may make one suspect a
puerperal infection, although the subsequent history of the case may show
that one's fears have been groundless. This is froiuently so in angina
and acute pulmonary affections which may occur at any time during the
pnerperium.
Occasionally, prolonged suppurative processes in the pelvis may be
accompanied hy symptoms which may readily Iw; confounded with one or
other of these diseases, but in the present state of our knowledge there is
no reason why we should long remain in doulit as to the cause and origin
of the fever in a given case.
There are two diseases, however — malaria and typhoid fever — that are
880
0K*TETRIC3
fro<|i)i*nlIv I'm! fouodei] wilh pueriHTul iitfiTltoii. ai»1 ituit aiv oftpn iuikIi?
the M'H I ».■);■ >iit III Klitflil l)i<- |ii'iii'litii>iK'r uli't hiu> m-^Ui^liil iix'^tlio {>ru(.-Hii'
lnjii» ill Till- iiJiiduct of hi-i cii«i. Whilv Hktc is iio doubt that eilher uf
these aSoctioii» iiwy o«ur iluring tlie piieriwral period, in llie vast imijority
of CMe* Uie diagnosia is opon to qiieslioti.
If tho Hvmptom* In- dw tn rmihiriu. ■iiii- shmdil, lie alile io di*nioii«tra1«
the pr«ne»rP of the flpt-oilic or};anLsmH; und in default of a positive exam-
ination of till.' blood mw jk nut juKtifitHl in n-^iinliR); an «-tcvnt«l tvmperM
mrt- and an occasionni diil! ocirurrinji diirin}; liie puerperiurn as iif iiialariaF
ciri(!in. Indtwd. it wmitd b<' fur bt'ttir tn f;i> still furthiT untl make it a rule
lluit out- \* m-viri' ju!ititii*<l in ftJiohidinK a ptierperal infection mi n pmbable
causative failor uhIpkc cultural nii-thocbi have demonstrated that tho uter-
ine cavity if frw from all patliogi-nic organ ti> mt ; for it if po>wiWe in wxcq)-
tional Pases that a pm-ipcral infivlion may W associated with malarial ptii-
Honinp. and without the bactt-Tiolof^t-nt cvaniinatiou of the ulerinf lochia,
after tindin;; tho s|M>i-iflc ]iIa.->ni>Kli8 in ilu- hhxHl, one mijiht he satisfied
of the exfhi.'ive nialarJHl origin of the sjniptoras, whereas, in reality thov
are ))artia[lv due to infet^tion. Judgnd hy thtvo criteria, a malarial fever
complicating Ihc puerperiurn will appear in healtli statiatics far la*, fsv-
tliicnlly lliiin ai prcsi-nt.
At the sauii- time, there is no, doubt that occasionally a latent malarial
inffction may siuldenly hurst nut again during lliv puerpcriuni. Thus, in
aeveral of our eases the women had chilis followed by fever, and we were
able to demonstrate the pnwcnw of tertian mnlarial nrgnnistni' in Uiv hlmxl,
and at the same time to make sure of the absohite sterility of the uter-
ine Inchin.
The diaifnosis i)f tjphoid ferer h T«rj- frequently made in prolongud
cvjivs of puerperal iiifecliort, being basitl br the average obeeri'er on the
long-con linufd fever and the general prostration of the patient. Xo doubt
typhoid fever may be an occat^ionnl complication, but every one. who will
make a point of imjiiiring fully into the many instanceii of which he ti«ar«,
will eoon he convinced that only a small proportion of the cascn so de§ig-
nate<l an- really typ)uiid in origin, and thai most of tliein depcnil upon an
infection of the genital tract. In tho pre^ieiit state of our knowledge, ospe-
eiaily iiince Widal's disci'ivcrv of ihi- iifrgluliniilivt' atrtion of tin- hlnoil lU^rum
of typhoid patients up<m cultures of typhoid haeilli. we are not justified
in making a diagnosrK tif typhoid fever nnltw* this specific n.nction f«» In-
demonstrated.
On the other hand, typhoid fever complicating the puerperiurn may
simulate very closely a puerperal inflation. Jung has recently dft*cribtJ
several ott*o* in which this mistaVe was made, the true nature of the
malady not being discovered until autnjMyj and I have had a similar
esperienco.
Likewise, an anilt- miliary tuberculofiis, or tho flaring up of a chronie
process during the puerperiurn, may occasionally simulate an infection,
op may mask its xvmplonis. Recently. I tn-atcd a patient with a typical
pyipmia following a brutal deliveiy. Streptococci were demonsimliil.
in the blood and uterine lodita. and Ke^-cral superficial absce««es develop
PUERPKRAL ISFEtTlOS
S81
tiUter, pulmonale RTmptoina appeared, aod for a tiin« it vae thought that
WL' liuii to diwl wilh u ini-tjii'lutic proct-xr'. itnltl Ihu iltrtiKiii.'>trat)<in of
tulicrvlf Ixtcilli in tin- fpiiiuin clfaml up ail doubt.
To sam up, it may Im.- safely i^uitl thai i-vvry riiw of bmipi-ntiire ob-
tierved in a put^rperal wouian should he regarded ai> due to iiift.>clion until
it boo been clearly demonstrated that »»rae other exciting cmife is respon-
eible. Uvnce it follow* thai ui making a diagnowin of any alTfctioii com-
plicttliii){ ihc ptivr)i(-riuni, an accural)* iin<) ciiinpli'ti' jihyKii-al t-xa mi nation
of the patient is ucL-ei^^^ry, and at the same time all the aida which the
rMvnt advaiK-c* in tnicrowopy and li4iet«rto)ogy have ptai-n) at our «otn-
mand should )>e utitiiied.
Badfriotoi/ical Examination of the lochia. — As Itie moi^t n>mn»ni Ic^iion
in puerperal infection is an endometrittH, it is a matter of Mimt- impnrtanee
to dvcidv whc^'ther one lum to divl wilh the wptic or putrid ranctr: but
although to many caHea the clinical Hvinptoiiu will give tolerably definite
indication!!, a positive i-ondusion can be arrived at only after a buvtii-
riologioiil i-iamirialiori of the uti>rini- Im'hia. In |iiini>rrh(iial infeciion:! the
(Icvt'lnpnicnt of 11 jiunilent opIithnUiiia on ihe part of the child afTordi^ an
almoHt [HMitivf (lia^cutui*. hut i-veii in auch vawn one i^i not sunt that other
iirganiitmH may not be concerned.
Cullum' may lie taken frtmi tht- intftrior of tlw ulcni* wilh compaia-
tively little diflieulty by meaoa of a (iimpli! device first iniroduced by
[><idfrlein ami iiioditivd by H. M. Little. TliU cunKiulK of n gla^ tuhe
30 to 35 centimetres in length and 3 to 4 millimetres in diameter, with
a «lighl l>cud at one end »o am to conform to tlic antdtrxcd vondilion of
the uleruH. Ir U then throwlcd with a pteei* of stning i«ilk, to one
cn<) of which a folded rubber band in altacW-d. wliicli exerts cuetiun
when traction t* iiiadc upon the freecxiremily, which pnitrudex from
the other cml of tlie tube.
tio. (HWi. — Lim.B^ Tvss ri>H hkmoviko Iitkhihs 1<(kwia.
Whm cnlturftf are to l>e miidt* fr>)m the uterus, the inMnimentii and
lochia] tube are .olerilized by boilinj;. and the handD of the operator and th«
eittnual genitalia having been thoroughly disinfected, the patient is placed
in the Sinid'ii or dontal position and tlw eervix eiptMed by a suitable
speculum. It is then spixed with a voWllum forceps, and its vaginal
portion having been carefnily cleanfled with a bit of sterilized cotton, tha
Ini^hial tnlio ix introduce a» far as possible into the uteni*. ntrr boing
taken to avoid touching the external genitalia with it during the manipu-
882
OBSTETRICS
lutioit. On making trn<rti«>n upon l)io thruD<1 prntrmli nj; tvnm the free
end of thv liili>-. n c^rt^n aiiwtuiit ut iili-rine Wliia in drawn up, iifWr
which Iht- tulie is removed from l!ic uU-ni* and i)*" i-tuU hermclically
cloticd Willi MulitijK VAX. It is thi-n tiiken In thi> hilioriiiorji', wlw^n- it is
liroken in ite middle portiun and cuUunM madv from the cooteats (Fig.
ThiA method. althoUKh it may appear to be somewhat oomplicnletl, can
W re«dl)y nirriifl out Uy nny Jirnx-Jitioin^r who is c'oiivi'i'Hniit witli Iho
ordioai;y rules of sar^cal tt<clini(iue. and if Ihe lube he eent to a C4>m|)eteut
bai'tvriulogiMt for exoti" nation, it cjin be dclcrminiHl witliin twirutj-four
hours whether the infection is due to pyogenic or putrefactive luaoteria,
and wfiethdr one hm to i|^l with a dangerouti or a c»iii[iitnktivt-1y )uirm]i^!s»
conditjoii.
In mj practice avclt ft procedure form* a pitrl of Uw routiiii; i-xitmi'
oetion in crt-ry case presenting a rise of tcmperalure alrave 101° F. Tlw
Had^factioQ of knowing exactly willi what form nf inft-otion wi? hovi?
to di'ul amply repays for the trouble taken, and at the same time llie
recognition of tike infective orient givtnt important indicationit a» to
treatment.
Hirst heliiiVM that the examination nf the utL-rine Whia muy Ituid to
orroneous coiiclugionii, as it may give uejrntivp results, white at the same
time bacteria can lnt cultivated fituii tin- hlomi. In my «;.\i>cri«netf. how-
ever, this ie not the case during the first ten days of the piierpcrium, but
after UMt period, and cupecialty in certain ]>n>loii)f(!d v»m^ nf pyn-inia. h'u
contention may be eorreot. Moreover, if n-lianee were placed anlely upon
blood culUire*!. pradiiully all of the mild iiFid some of the wvero eases-of
jnffvlion would escape ililTereutiatiim. In the foruur, l>acleria rurely gain
HCPUK to thv circulation, while in the loiter the reverse ui-ual)y bold*
good; although 1 have i^ecn several women die fmm infection in whom
n-p<-Ht«d exuriiination of Ihe blond gave nogotivo n«ults both during lifv
and at ntitop^y.
In my opinion, tbereforr, the bacteriologieal examination of tlie blood
is of secondary importance from a diagnostic point of view, olthoitgli it
may be of great prognoNiii- value, a;* the dtnn oust ration of streptococci
always adds to the gravity of the caM-. At the same timt-, it does mit
necessarily indicttte a fatal liTinination. a* I have rqitwliiilly s't'o unA^
cases recover, and in seyera! innlajice* they np)H«ni) lo Im? but dightlyl
»iek. I
Aft(>r n-moving the lochia for bacteriological examination, provid^VI Ihe
cervix is sullicicntly puluious. it i» vrell to introduce the sterile finger into
the iiteniB and feel its interior, after which a douche of several Uln^ nf
nunnul salt wlutiun should Ihi given. Palpation of the cavity of the utonu
enables us in many cases to predict in advance the result of tlic bactmo-
logical oxaminalion, and, what if of more practical value, give« w im-
portant information as to Oie line of InTilmcnl to be pursued. Thns, iu
putrid ('Uilomctritis and iiifoctions due to the colon bacillui^ we u«ualW
find the interior of the ut«rimi cavity rough and cnvenal with .shi^dji nf
broken-down tissue; while in the septic forma it is often perfM-lly smnnlh.
PUERPERAL ISFBt-TION
883
»
^B^Sm iiia«riD>r»]>io a]t|H.'«r«»>(-i- nt llin lochia U a\ta of ^^tt^idcraiilu vhIiiv.
fur in n putrid etutoriiRtritis the diwUargp » frothy ami fTi-c|Hi'iitlj- very
ofTensivc Id wlour, while in pure (^tn-ptucxvic iiifi-('Ii<>iiK it ih v<fri' lillte
vluingm) from thv nuniiHl. Thiit distinction D(nm)s to be cK[Mwialiy nnpba-
tiL»x), Bince t]w Rr^t question which tho practitioner ii>^(ially nfkf the nur«v
in thf pw-sciici- of fever during thv p«i'r|HTium. i* whi-ther thv linliia are
foul-siiM^linK «r not, awl if he receives a negative answer he ia too apt to
think that tltv fever is of otIiiTr than uterine origin. \* a matter «f fiu^,
the revi-ne i» almoctt onOAtantly true, antl, w* a rule, the foiilnefH of the
odour i)r in invrr«<r progwrtion to thp danger to whivh tlu^ patii-'nl 14
exp0M.1l.
When the process has extended beyond the utcnu the diagnosis is much
more n«dily ina<le. and, provideil that malarial or typhoid fever and tutute
miliary tuberculosis have \wvn poiiitivcly excluded, it is harxlly possible (o
niiiitake tlie symptom* pr^xiiioi'd by a piTilonili." or liy a pviemia. In ihe
caM.-s of parametritis and suppurative atTectious of the tubes and ovaries,
bimanual examination will demonstrate the prewnce of a inaws <>n oiu) or
other side of the uterus, if the tumour has not already made its«lf evideut
to aixlAminal pal|>«tii)n.
Prophylactic Treatment.— In considering the treatment of piier|icral
fever, jiropliylaxis should (wX'upy tliif nKMt iinixirtatit place. As Ivus hvvn
repeateilly insisted, puerperal infection H wound-infection, and in due to
the introduction of pyogenic miorn-nr^'anism* by ihr hamis or instrn-
mcnte of Ihe doctor or nur!«. Hence it naturally folloirs that the most
senipulou* asepwii? immiilialclT iM-fore ami during lalxtur is the means
upon which we have mainly to rely tn limit iU oceurrence. Kvery phy.^i-
rian who conducts a labour caso cannot feel tou strongly his pcrsmuil
respoaiihility in tlus connection, and he fails to do hi* full duly to httt
patient unless lie regards the ruh« of aR-|isis as carefully as when per-
foniiin^' a capital surgieal operation. Thi^ i|»esiit>n in all itit vartnua
phases lias been fully dealt with In the appropriate chapters.
All tliat has lieen said concerning the neceMily of chnnlini-iis and
asepsis on (he part of the physirinn applies etgually well to the nurse,
and in all her manipulations about Ihe |iii(ient she should nev<T forgrt
her n-iponsibilily in this respect. Moreover, she sliould lie strictly for-
hidd'^n to make rajiinal examinational or give dom'tx^ except at the direct
request of the physician in charge.
A» long OS vaginal e\aniinnlions an- made, infi-etioti will on-a^ionally
occnr, even though the carefully disinfected liand lie covered by a sterde
rubber glove. As it ts im)>ossihlr to distnfeil iIm^ vulva tboraiighly, il
mnot ineviuUy happen that bacteria are carried up into the vagina from
it with each examination, and il is tlicrefore not tiurpritiing that titey
occasionally give rise to infection. For this reason vaginal examinationa
dhould be dispi'a-ied with as far as possible, and with this end in view
the accouehcttr should ncn-r lose an opportunity of perfecting bimeelf in
Uie methods of external examination.
In view of what lias already boen said oonceming the bacterial con-
tent* of the vagina, and the reiiulls of tliu experiments of l^opohl nnd
SB
884
OBSTETUKS
ntbem, which hove been confirmed Ity my OWB poraoiuil expcrienc«, I
ftrorifrlv mWiw njffiiiKt (lie wiipl«vment of the propiii/lactii- duuclte. a» n
nuitim- [>n>ii-<liiii.', ht-Iiminn Unit it t<li<>itM Ik' n'Korlal In only nli«i tlw
vaginal si>crc-tlou pirM-n1« inark<-d iiiilunecv uf nlimknualttr.
Diirliifi; Uw ii«?i)nii »tnj;e of !aliour it is iroll to have tire vulva ooverwl
wit]i au a5v[itic pnd in lh« form uf a Uiwi'i Minkiil in hit-hloridv ivtliitinn.
Tliii' i" (liitK- not Ml iiitK'h for (tnr <■[ jnfi-ciion fn>in th« air, «a to prvvent
i\k poiHittilitj' of conlaminatioa from the putiitit's hands.
Tlie Uiird xlnfco of Inbotir likewUc olTfira many fm-iliti» fnr infection,
and too niui-h KtrKs ouniiot W laid upon il« proper coniliiol. Speaking
broHdly, tliu (^■lUTalive trad aflt-r ilie hirth of ilie child nhotilil bi- n:-
forded as a noli Hif tanfj'ye. unices an omvrgifncv, ciich as a hiEinorrtia^
or an adhcn^t pla<t'nta, neic^^ilatcs the intrmtuition of tlie hiuid.
The rcc-omiiiendation that a routine raftinal examination in calln) for at
the cond vision of the thini xt«^ of liilmiir in onhT to ilelwt ivnicjil li-nw
with a viiL'vr to thoir inimt'diaie rt'jwir. oaiinot lie too stronply <lepr«'ated.
nod lltij-v who fotliiw it will inevitulily i-ixiiunlt-r a iiiui-h larger jx-rct-jita^
of ahiionnal pm-rperia thau vlicD va^final e:( am mat ions ate rL>M!rv(>d far
exceptional and iir);i.-nl vatv*.
AnotliLT point in the prophylaxis of puerperal infection is \o clost- with
autiires iniimiliiiti'ly after Iho eoiirtui'ioii of hiliour any perinejit vroumi that
extends kyond the nineoda, udIcas the proci.<diire is eontra-indieatifd hr
profound exhnu>lion on llw pari of the pulient, or by a vurr wdetnalouf
cowlition of the tiKsuos implicated. To save time, it is my praetiee to
introdiK-f the ^utiireti irninciliatily after Iht! birth of thcr chiM, aod while
nailing for lh« cxpiiltion of Ihc plaii'iila.
To rtenpilulate, the liability to puerperal infection will he nuitenally
li'wened by the olHct olnerranrt! of Uie following: (1) llur mainlenani^-
of a*v^\i by tire obntetrician and niiree before, during, and after deliver)-;
('i) the rent rict ion of va^'inal exaniinalionA within the iiurrowt!:*! limi
powihie; (3) the omisBioii of vnf:inal douches escept in certain rare ea.*es?
(■1) the imnit^iate repair of perinenl laeorationit which miphl otherwise
offer foci for infection; and (5) repirdinp the genital canal of Iho puer-
[M-ral wouian ah u nnH mi: tringfre, into whicti iw-ilher fingtfr nor instm-
meiit whoiihl lie inlrmlnced except in emergencies.
Curative TreatmeDt. — The ninitivv triHtnu-nt of pnerperal iof»ction yi
a qiie<ition concerning which there is a f^rvat deal of dispute, and it i» proV
ahli- that what is said here may be directly up]KN>ed to the usual practice
of iniiny physieiaiis.
If n puerperal nicer is sitnatcd about the vulva or on the lower por-
tion of the vagina, it should be occasionally touched wiih piin^ carbolic aicid
or tincture of iodine, and Iho parts kept as clean at possible. If the
n>)tair)H] [wrinietini hn^^iks doun and siippnrativ, the itlitelicie sboold be
removed in order that, free drainage may be piovided.
.\s ha.< liren "aid. ptii-rfWrral endometritis is tlw fonn of infection mo^i
fit»(]iiently encountered, and unforlnnateiy the direetionit for iU treatmcBt
differ widely and arc often contradictory.
As .tooit as tlie patient's tcn)))erature reaches 103" F., nulen b n
PIERPEBAL L^■K^rTION
SST)
inrectioD OiiD be exclatlcd with a fair amount n( certaiotv, the uterine lochia
sllould be HtibDiiltvii lo a bii('tmotn];ical i.-j(fliuiiialiau. Wheu fejutibk-, iai-
iiicditili-lv lifter litivinff withdrawti the tulw, Uio itilcrior <if the iilcrus
Hhiiultl be (.-ikn-fiilly i^xiiloixti by Um; sterile iodex finger, iifter w)iM!lt, by
meaDN of nreful bimanual exaiuinntjun, the wimliliun »f the n{)|>ondages
and llie bm«d hf^ments is determined. If the uterine aivity is perfectly
rTiinotb, liM-al ImuliiiKnt xlioiild lie limilvd in n iloiiehc of ii^rvcnii litns*
of Itotliil mili-r or normal sail miution. On ihe otber tiaud. if it'i interior
in rough and juji^^ and vfintainM uiore or \v*» drbrin, it xltoubl lie ttior*
ou^hly eleaned out witii the fin^r, after whieh an abundani valine doudte
«Ii()uh] W iniiidoyifd.
Cureltatjf as a routine uica.iure in all caHoa of puerperal endontetritia
i« Rut tu h» n.vi>ui in ended, for tlw n-SKon that in Ihe tno«t ivverv cafws
ttierc usually a ali^duu-ly notliing in liie uterine cavity vhioh ran be
rumavv<l, and it)> i;iii[doyincnt can only do hann by brraking down tlio
leueoeytif wall wtiit-h «>rTi« lo jirevitit the invasion of the <b?p|M>r layer*
of tlH^ uU-ruK by 1)h- offendinj; bacteria. On Ihv oilier band. wiM-n tlw
uteriid contains iniieli tlfhrit, iu removal is more readily effected by means
of tliv linger tluin by tho curette.
llib teaching iit directly euntrary to that of many American and
French UTitcr«, who ciithiiFiiaKticiilly nr'ommend the aso of the euretle
in all i>aN-i> of |nier}>(<ral infnlion, although Tiuanl, in 1iH)r), ailniittiit tiiat
it did more harm than good. Kritseh, wlio^ Tieu-s represent the con-
ner^'alitv tienuon d<Nrtrin<<!< on tlie suhjevt, would rou^rve itji use for rx-
eeplional cases, and ct^rtoinly the writer's experience lioa convinced liim
•'f Die iidvrsiihilily of ibix rmtriction.
Tile routine um.' of tiichlur'ui* or ratitolic intra-utrrine dotuhrs in the
Irtvtiwiil of thu>c i^ofct m cvntro- indicated on Hncral grounds. In casM
due to virulent fltn?|iIoeoeci, a hUtologieol examination mIiowi* that Dte or-
gani»m« have peiH-trut«-d d<vp down into the tinnicM by tlie time tlie initial
chill and ri*e of ii-tn|H.Tature Oivur*. I'nder tlw»i- i'ircuin>lui)i-tr* the
employnienl of an anti^plie douehe is not rational, inn»uiurh a" Mte ger-
micidal Huid eaunot {lOiisitily peiittrate ilie uti:Tine wall iiulllcicjitly <U<ep
to reach the bacteria, which are giving riM> to the KVinptuiufi and upon
which Iht! furtlii^r ii])ri'ftd of lliv dlw-^Mf i^i di-fx-ndeni.
Moreover, it has U'vn «hown eiperimcntully by Buram that hiehloride
injcctiun* pwictriitc iW tisMie* only to a very ulight extent. He I<«k the
Ur«r of an animal dead of authrax, and after nutking it for tliirtr inioutea
in a l-li>-l,iitw) bicbloridd wlutiou plmwl it ujion a frfwiing microtntnt' and
cut thick sections from it. After cutting oil about i*, of a millimetre,
he inoculatt^Hl the next w-ction into anothrr animal, which »hccuih1ii?<I to
anthrax, tliuA showing that tlie germicidal action of the bichloride had been
eiuirted only upon lite surface. If this Iw Hie case In the labonlury after
the tiuiii* luivv Ui-n iuimiTiu'd in ihi^ auti>mptic xilulion. wbnl cITmH eon
we expH'l ujiou organimiis emlHildiil in the muscular wall of tlu- Utem«
from the transitory application to the surface of a fcrw litre* of a weak
hichloridi- I'olulion^ Itumm liki*wi»c idtoww) thai the "In-plocncci make
tlieir way through the uterus with groat rapidity, travelling 2 centimetrai
^^^^^r OBSTETRICS ^^^^^^^^
jir more in tlic (^pace ot h« lioiir^. What Iia» U'eil tau\ coQcemiog Ck-UU*-
n<lc iipplii.'s (^jiinlly well tn ttw ntlii-r i)i»inrivtttiitj>.
On the other hauti, Ihoir eniplimm-nt in law^ of puUu! i-jidometritin is
evuu k«8 iiitioDal. lu ihL' vuif^t majority of »ui-h C8i'c« dimply di-uiiing out
the utcriiii with tlu* fln^r. fi>|]nvn-<l by a ilouchc of Merite fmh Aoliilinn,
will lead to a rapiil fall of teinpcraluro and the ameUnration of tinlowanl
^yitiploniK, Till'! otijn:i in giving a U»iichv in thtM- <.■««» i> siniply l«i wttsli
away the lUhrin which has been left MiimI hy lhL> finder, and for this
porpofii! (iterik- »oll H>lul)na t» far supcriur lo uuy ajilirx.-plic HuiiL
In additioa to lhi»e ^Amevhat theoretical objflctiona, Maen is this rvtj
practical one: lliat the cuipioyiurnt of antii^i;ptic)i may do un imiiK^ii^
amount of hjirm. Not a few ea>e.i of iudden eollapM- foUowinn the use of
carWic-ucid doiichi« are on uncord, whik- in wiiiii! iii>'tHnrt> intr«-iilvriiu>
injecItoQ!* of bichloride have been prnvwl to have been thi,- direct cause of
dratli. Svtfrul ycarv ago, at Uic autopt'y npon a wnman who wu« ttupp(>«(H)
to have died from puerfjeral *ejini», I fmind all the anatomical lesion* of
bichloride poitroning. tn that, to say the tcai^l. it remained doubtful nbclhcr
tlie infeetion or the treatment inj^tituuxl for ita relief waa respomible for
the fatal iwue.
On refereiK'e tn the literature at that time, I mlleeted »omo 4G
in u'hicli death had followed the employment of biehloridv douches during
tlio pueqieriiitn. In many in.->1an<'4v. In Im vure, excetoive quuntitii* had
been employed, hut in i>everal a single injection of several litres of a l-to-
4,tKH) Mihition hud n-sulti.si in fatal niureiiriul [Miinoning. When tlu*e fwU
are taken intn eons id era t ion, along nttb the llieon'tieal ohjeetious to the
umploynicnt of antisepticii under ihcso rirciimf^tauces. it would appear that
the benelll In 1m> expivlwl from iht-ir empIoMnent is at leant very proh-
lentatieal. while the dangers are very real.
The Kanu- onnKiderulion.-' likewtKi^ ■it'I''>' '" ^^'^ varioiu^ other antuieplir
agents which have been recommended from timi) to time. Kor am 1
inclined lo phiii- gn-at oonl'idi-mv in (In- ilisinftitant properties of injec-
tions of alcohol, as reconi mended hy Wethi-riil, Sitsinsky, and othew-
At )h<! sanw lime it must \tv admiili'd that thi; uniform suneeaH ohiained
by the latter in %AG ca»«« of infection speaks in it» favour: although tlic
ahvi^mv of haclcriid»gi<'al tbita Honiewliul weaken^t hiit oaM.
The reiiuU^ following the method of tn-almeiit jiu^t outlimil are igutt?
as gi»)i) u:* tlioiH.' ubtiiiiied with tlic various antiseptic ttouch&i, and thut
contention U sustained by the experience of Itumm, and ICronig. Hy this
niean« 1 have trvulinl !)2 rasen of »(re|>toeo('«ic endonietritiii, wiih 14 deatlu
— a mortality of 13 per cent. In til cases I had to deal with a pure
«(r(fptococcic' inffvtion, while in .'tl cnnw it wan a»sociat<>il with the cnl'ia
bacillus or other organisms. After deducting 5 cases from the former ana
4 from thv latter group, iu which the pati«nt» were admitleil nnlltring
from general peritonitis or severe pyemia and manifestly beyond hope of
recovery, tlien- were .only 5 deaths in 83 cases — 0 J>er cent, Tliere it*in i
deaths in the Hi c«>e* of pur^ streptococcic infection, as compared with
3 in the 87 eases of mixed infection — a mortality of 3.5 and 11 per cent,
respectively. Ilieite flgure" apparently Itrar out the contentions "f Bar
Pl'ERI'EHAL INFtXrriON
887
iDii Tiwirr, that nmiljiiicd iafvctiuii^ witli StM-plnomirn* pvogitivw and
BacilluH coli are inmh more dangerous than infections due to either otxan-
um aloiw. At (hi; miiio tiniu it i» not <l(«ir>-d U> giro l)i« iniprcwion tluit
pure 8lrei>tococeic infectionii are devoid of dao^r, as they are alway» seri-
ous and ofli-u fatal, and I ht'liuvu thai otir farouniblv re^ ull» are prubaUy
attriliutcd to th« fa*;! tiutt many mild chm^ are includ«d in our seriea,
which would hare e»t-«pcd detection excfpt for the bactcciolof^ical exam-
inalinn of the lochia in all fi^brile wiAeK. X«>^'ttrl]u!lit<>', our rxvulti' would
appear to indicate Uiat too ciKT)?etic treatment may be harmful, and that
an equally good or Iwtler outcome van ho obtained by Mafer and more
conservative measurm.
To nvapiliilaU', in di-nling with a ai*r of puiTprrnl onilomi-trilio after
having removed B»me of the uterinv lochia for oulturet*. tlie tarity ftlwuld
tie fxplonil by the «t«ritt* fiiigi-r and clrtw*! out or not a<x.-»rding to lit
condition. The nlenis should then lie doufht^i with twveral litres «f sterile
nail «ilulinu. If the bjiclirioliipral examination chown the prwcncv of
streptoc»K-oi, all Ioc«l tn-almeDl !<hould at once Ik* oiiiiH<ii. If, na the
ulluT hand, one Imi» to (leal with a putrid ondomelriliH. and the aymptoma
do not yi44d to Ihf fimi injit-tinn, additional dotieho ntay )h* given. WImvi
the infection ha>: extPndi'd beyond the uleruc local treatment should not
Im> tH'Mi^rnl in. N» it will do tuon- harm ihnn good.
Bumm oljMrrvcd tliat in many inetanei.ii involuiiou had taken place very
)n<»mpletely, and he tlierafore mwntm«niU<d thi; employment of «fgat to
secure better contraction, thereby occluding to a greater degree the lym-
phatic* in the atcrinc wall. My own pxperience ic in uccord with thitf
view, ami in ctsea tn whii^h the uli-nis in larger than it should lie at a given
period of the piierpenum the employnnml of the drag would certainly
ap)>ear to Iw iiidivatM).
In gonorrlMeal endometritis arlive treatment i» not required at tlie time,
sin<i- in the vaM ntHJnriiy of (itM-9. Ihe flight riw of tf-ui[i(-ratun- AiwH'iated
with tlte otifel of the dit4-aiie »oon falls tn normal, and tlie patients recover
"pontarn'ounly or are left with a chronic i>»dometri(ii> and diM>am9< of the
ap|)endage». which can be treated much more advantageously at a later
)teri»d.
In all severe eases, general tonic measumi that will serw to keep up fbe
■trength of the putiC'Ut and incnuiM: her rmiMam-c to tin,- inf*x-tive Tinii
are mMt valuable. The most reliable drugs are strychnine and alcohol,
and it i<< a matter of r-tjuTiv-nw tluil i\vM!- patientf can bear much larger
quantities of the latter than when in heiillh. High fever should not bo
cumlwteil with aiitipyrelic«. the exlcrnal application of cold, either In the
form of spongings or oold baths, being far preforabte. Hydrotl»er»peutic
mnuurce have b<^n enthiuiai'ticHlly advocated by Mac^, Rnngc. aiK) Da»-
temes, and in their liaiidA tvave given very satisfactory results.
If the prortiw ha» extended heyoiMl the uterus, and wc Imve to deal with
a iwnimetriii'i or a [H-lvic peritoniltx, dry or nioisi heat to the lower
portion of tlte abd<Hnen in the fonn of poultice* or other Itot application^,
ii> to In? re«-otnmeudiil.
(Ktasionally. <'iir|trifiiiigly gnml results are oltLained in profoundly scptio
88S
oiiwTi-rntics
ciiinlilionH liy repoatfJ i^ulieiifni»T>ii-« injirtiouK of ntfrili* i*aU mfav!^
Atlcnliou »ii» tirftl directixi to tliis method of imatuit-'iit l»y Bosc, and
suWquent experience hits in great purt jii^ttifivd liiic pmlic^UoRH.
Of lite u great donl Itaa been written on th« operative invhufnt o{
puerperal infection, neartv every prominent obritvtriciui and g^'nffioologi<t
hiiviiig Ttmdi' ■vomft oonlriIiuti')D to tln^ siitijecL Ktcpj- one in agreed as to
the sdvii-abilily of opi-nin^ paranR-tridc abwi'.<«cs as Mon ae fiuctiiation
^•Ppotrs ratlier llian alloving them to rnplnre iiponiancously. Xoi un*
commonly, in cascs of paranu-triti^, ou palpaljon a »?mi-t1uctnant eonsntion
ia (MDvi-veti to liie examining finger wliieh may !i?«d odo to mippiBto thai
one has to deal with pus, whcn-as upon opening tho suppoi^pd absce^
through tl)i> VHgtna or abdominal wall, asi the ra!M> may W, the tumour
turns out to be a mnt* of inflammatory exudate without pus formation,
and only a »mall amount of seroti* fluid eacapes when ii is cut into. For-
lunati'ly. inoii'ion into thc^c iiis»h.'s fn.-qurntly gives us good results as
if a ions ill i-rahlo quantity of pii> had Ix'cn evainialrtl. jii.it as happonH in
ordinary cases of cellulitis in olher portions of the body.
When pus tiihen or ovarian BhstrraHnii can be made out by bimaniuU pal-
pation, their roniovul is urgently indicated, for as long as they remain
the patient will continue in a scptie condition. Whether these should lie
dmlt with by I«pnrfitomy or by puncturo through the vagina will depend
upon the particular oai^e. If they are freely tiiovable, laparotomy should
bo performed; whereas if they aro adherent and readily acn-fisible from
below, vaginal puncture with t)uh»eqnent packing of tlift nbMMS cavity
with gauze is to be preferred.
The chief point of disnimon coiici^niing Uie oiR-rativo treatment of
puerperal infection has been as to tlie advisability of removing Ums in-
ftwtwl «tvni» at an curly [MTio<l. Hi*re the various «urg<M>ns take quite
opposite views, the more radical adrocating its prompt removal, while the
more conM-rvaltvi- do not «-g«fil this uti-jj with favour.
For two n^anons it wouhi appear that li t/strnrttimti h usually rontra-
indieati-d in puerpiTal infi-ction. In Ihu first platv, if mk operatm at a
period eufticieutly early to prevent the extension of the process to other
orgaiiH, a 1arg(' numlior of ijlen will undouhtMly lie n-UKivi-ci immxH-ssarily;
on the other hand, if one waits until a later periixl, when other organs have
become im)>lii-at<-d, the operation will nlso he ui^olres. NevertheK-w. tliere>
is a restricted lield for bysfcrecloniy in those cases in which the procnu
ha^ not extended meterially tn'Vond tho uti-ruc hut luix given rise to
abscess formation within its walls. Again, in a putrid eudometritis. whi-n
ail fither atlejiipis to check the diseano have proved futile, llie operation
would apjwar to be justifiable.
Lusk siiggOKted thai hysten'cfomy may jiomeLimes bo uneful in the castv
of p}'a?mia in which infected thrombi are carried from the uterus to varioui
portions of the btMly. giving ri*e to a hectic condition. Xo douht in
exceiitionul cases this may Ih> true, but as a rule Ihe thnimltovin lian
extwided fur licwml Ihi- nliTun Ity the tiioe the pyu-iriii- sympl'iniA make
their np|>eamiice, and the n|>er»lii>n woidil have to lio done Ihniugh septic
tissue. Much more pnirlicjd is the *uggtwtiou ut Kre»ind, Tivndelvnburj;,
•
PUERPERAL INFECTION KS9
and Biiitim, that the throiiilHised veswls l>o i-xposiMi |jy la{>an)tiimv. and
fxcieed or ligiit4.>d distal to the thrombus, as may fii-cm most expedient,
just as has been done for some time in the case of infected thrombi com-
plicating niasloid ditwase. Both Bumm and Trendelenburg have reported
successful operations of this character, and in two cases of my own, the
outcome was most satisfactory.
Until very recently, the devetopment of general peritonitis was con-
sidered almost necessarily fatal, and ia such cases the treatment was usually
perfunctory. But in the past few year*, Sourdilie, Kownatski, Leopold,
and others have shown that recovery may occasionally follow after freely
opening and draining the abdominal cavity. Cragin, on the other hand,
reports that his results were not encouraging. In view, however, of the
almost certainly fatal outcome of e.vpectant treatment, such interference
would seem justifiable in appropriate cases, at least until more extended
experience has demonstrated its value.
In certain ca,ses of infection following criminal alwrtion, Prvor, Robb,
Sourdillo, and others have reported encouraging results following wide
incision of the posterior fornix, and packing Douglas's cul-de-sac with
gauze. In many such cases serous or purulent fluid escapes from the
incision, so that it would appear that such a procedure may be of value
in preventing a pelvic peritonitis from becoming generalized. In my lim-
ited experience, this procedure has not appeared to exert an appreciable
influence upon the course of the disease, but in view of the high standing
of its sponsors it is worthy of trial.
The prosijccfs of coping more succeswfully with puerperal infection
were greatly brightened in 1835 by Marmorck's announcement of the
discovery of an antutlrfptacaccic serum. Unfortunately, up to the pro-'^ent
time the results of siTum therapy have not proved more satisfactory than
other methods of treatment. In May, 18»!l, a committee of the American
(iynji-cological Society, of which I was chairman, madi- an exhaustive re-
port upon this subjirt. giving the complete literature and eolUrling all
the ca>es treatcsl by serum reported up to that time. They found that_
352 eases of puerjwral infection had been so treateil, with 73 deaths — a
mortality of 21). T4 per cent. In a large numlwr of cases the lochia were
not e.vaminod baeteriologlcally, and there was therefore considerable doubt
as to whether the infections were due to the streploeoecus ; but in 101
cases in which its presence was demonstrated there were 33 deaths — a mor-
tality of 32. G9 per cent.
This is a very discouraging showing, especially when compannl to the
results obtaineil bv Kriinig and myself without serum therapy. The ques-
tion therefore arises, Was the high mortalilv attending the use of the anti-
streptococcic serum due to its employment or to other causes? Our
investigations having indieatefl that the serum was practically harmless,
the poor results following it- use can pmbnbly be explained in one of
two ways; first, tliiit onlv exceptionally severe ca-'i's were trcntiil by it;
and secondly, that a large numlier of the eases s.. tn'at<-<l bad iiln-ady been
curetted — a pro<-i.ilure wliicli is often rolliiwnl by unlownrd results. In
Tiew of these facts, the committee rejwrted that there was no evidence in
890
OBSTICTRICB
favour 'if lhi< ihorapMidc vnluo of tlie Fioruiti. Htllinii^h il »|>|itiric'ntly ilul'
not LXcTi H (li-lrl'Tiini* cIT.tl upon \\u: ]wtii-iil, xtul llii-ir-fon- mif^lil Ixj
eiiipldjeii if the piivHtcian ra ilo^innl. J
Following; the rcjiort of our commi !(*•«•, tlw.- ^;vtiLTal wtiwnifUH of opin-
ion has iHt'ii thai Marniorok'ii i«cniin hm) failetl to nuhmantiati* Ua valw, anil
i* praclk-ally usele*^ as a tlifrajwutic uffpiit. Ucccntly. the work of Amn-
s«hn, Tate), Jk-najur, SK-yvr, iirnl othir* ha» tVirt^tnl r<:n*-wiii alttintion i«
the ftibject. Ah the result of their ioTeetifiationa it bna lieen shovm that
Marmorok'M oii^thoiU wi^re fuiitlamfnlnlly wrong, an«i. in onler to produw
an effectivG serum for use in human bein^, tliat the Atroptococnu."! t*hould
not bi: giHKM'il througli lowi-r Hniriitils. hut lliat n* mnriv r^lrnini' a< pot^iblc
of virulent battcria, obtained from various human sources, should he em-
plojvd for inimunixing the utiimul fnim which tliu »enini ia to In:
obtained.
It WHO then shown thiit the ixTuni did not iirutralinr the loxiiMV. as is tlie
caw with anti-diphlheritii' and anli-li'Ianii- werum. nor act din-otly npon
liui htttrtcriu, hut inciTly gavv ri»i; Ui condilionis whit-h favouml phaj^M-ytoiiiti
—in other uonls, increase*! the opw>nic pouer of the hinod. Mortsivcr. ex-
IKTJnientBl work Ims dcni»n«( rated that while the iseniin might potixei*^
niark^il pn)|iliyiai-iit' vahio and if ahle to proli-cl an animal a){ain»l inocu-
lation with many time the unlinarlly fatal doiw of KtrvptncotTci. it was
lackin); in curalivi' |ini|H-rtie.->, and at moHt wai* of vahif? only in lln- inilini
etagcb of infection, being without apparent eHeet when the proceiis Itad
bo««iio ftilly I'stahli-'hcii. Ac the sini* timi- Il ««■< found to eu-rl no dele-
tcriou>i effiH-t U|Jon the patient and actwrdingly mi({ht he aduiiDi.-<icn-4) with
impunity.
Therefore, it may \te said that the prospect of cure is very ulijiht wln-n
the Mfrum is adniiiii>'l'-ri'd to ven' viek patients, though if giTou prior to
the onset of serious symptoms to those who have ln^'n enposcil to Ihi'
IKi^sibility of infection, it may harv itotni.< prophylactic value. Modem
aiitistreptocixvic serum has lieen employed in lar^> >x>riw of fJiMv \n
Itumm. Waltharrl. I'ehani. Raw, and othore. but does not appear to have
exerted an apprtviahli- cfTin*! upon the counn- of the di*rtiM*.
It is always ditficull to arrive at compel concluiiions as to the value ofi
any given thi-iapeuiic agent, unless largi* nnnilicni of a\M* are u«J as
basin, and this is particularly true iu the nITection under consideration, for
the reason that lis clinical course in ko very varinhle. TFius. it is not at all
rare in cases of streptococcic infection to hci> the temperature rise rapidly
lo lOS'-lort" F.. remain there for a day or so. and then fall as rapidly as
il hud risen. This may occur without the employment of any treatment,
and had the specific xerum been cin]>lo,v(td in such cases it is more than
probable that thv rapid amelioration of gymptoma would have been attrib-
uted to its use.
That we as yet jxvjsess no satUfactory treatment for all cMKex of puer-i
peral infection is indicated by the vast number of mcUiods advoeattnt from
time to time. In tfii^ place only a few of the more nx-enl nc^ be men-
tioned.
Hofbaiier, in IH'MI, ri-j^ortiil M>vend catet nf piKT)N.'rid septus in whii-h
PUERPEHAL INFE3CT10N*
S9t
he protlucnl an artificial l<?iRf»Miwis Uy the em|>loyiiMiuL iif tiiioloiii. In
*omv of hin i'uwM iIik ItMiiperatiirv Ml Uy ■ l.vt^i* and in others Uy iTieiit,
mill )h- hi'lii'Vi-') that lh<- Irvatimiil jiliitiil ii iimrkiil jMrl in Ihrir t-iiiv,
Hf uiaik' a wfuni! L-oiiiiiuniii.'atioii in l'JO:t. and i-lainii tlwl tixlutiUil <>lM>r-
vfliion ha* cmtinmid hi» origiiinl »U1vnK^nls.
Ueference notnl soarcwiy be mode lo the einploymonl of inlniTutiouii
JDJivtions of fonnaliii. u« advomuil by Itarrow. in 190.1, as Ku1i6e()ueat
imt~<ii^iition Iiak nhown tlut they an* not only of no valiu^, Itut an' hIj<(o-
luifly haniiful.
A coiuidi;niblo litpruturr hait ac«umulati.tl upon tlM.* omployment of
Credo's ointment, and the iotraTenoua injection of coIUrf^it or a Mlution
of tilrvr nitrate in puerperal infi-ctton. The report of Oiiterlok, liovcwr,
clearly hIiow-i that they arc of but Hlight value, and act only by proinoliug
phagucylOFL!,
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VcirlHtiflm MiubuiluMK olwr K-«it«ro IwkteriolaiEi'whir UnUrHiichunKtn do« Schelden-
■wkrelvB. !!«iitiull>L t. <iyti,. IBM, xviii. 779,
Die IkxiehimKcn dcr Kixloinctritji xu den FortpflanEunffiiTorcAnjecn. V»rh. d.
d0Ul>ichoti <:<)«. f. (;>ii.. 1895, T2^-2K.
VhniKU.vr.is und Wistkii-Mtt.. Die UukUtriuJuKie dur puerpcndcn Sekmlc. llellniiV
xur (wb. u. V.yn., iniH), iii. Ilil 174
DoLfcitiM. F.wsi »ur la |ml)iOK<^iii« 1.-1 lu lb£r>poillii|tio dua accid«aU infcriieux dca
■uilvxdi; ctiuchco. TIi^bv Ac Puriii. IHSIO.
Innaiiiriiation |ini«4pfir&lo. Nonv. uroliivea d'obsl. vl de t^.. 1894, ix, 97-122, ^^2-
161.
Ei"i:.vuANX. Witnd- und Kiadbettneber. ErknKvu. 1S37.
KnKn. I'obcr taaaa eisUldoiidon .\nnrobvii jtn tuciwelilictHin Ki^wr uml mjmi !)»•
xiehiinK mir Sc^liauinlclier. Virchow'* Archiv, rxxxii), iMi 'J.
^^^^^■F rUEKPEHA]. INFtXTION S93
FKiiLiXfl. TetwrSdlMiinrekiiun. Vert.d.<leutM-bt9ii<;uM>IlMr]kf.(iyn.. Preitmn;. I8W>
I'fliur ><ic J'j'kruilLiiDipBiiflrni ICntliini)inigi4iiiiMfr. Ilnilwho iinn). Wiirlivitwlif,,
IKW. ia->.
FouuiNtu.N and Itu-iMit. Au luvwilipLiiui iiitu ibe t.'uuAiliuii of I'ucrt'o'o' lofui'Uou.
Jour. <MM«t, and llj-o. Brit. I'JnpL. IJWS. vii. l2■^-\^M.
FiL\K.-<KKU L'etwr dw Ai*tii)4ugie u. Utmew der Gus-ptileicinoncn. LuljanH-J>4>*«cn.ait,
F^rgfflmian der nllg. J'ath. u. pntb. Aiut., IWH. viit. 403-471.
V. FiiA.SML'it. nuktofioloffUi'lM ('ntcrMirbiinguci Iwi iiomiiUcui tind Ikiicrluftetii
WochenlHill- Zcilrffir. t. (;rl>. u. »i,vu,. lWt3, xxv, 277.
Fhakx. llakUiriolniciM-lHi und kliiiisrhi- riitcnairhtinxeii ulwr leklttv Kielivntdecrun-
fcn im Wuciuinbcltc. Ileilratw lur <ieb. u, (iyn., iii. lEHXI, .11-100.
PaXDNit. I'etief die Melhodun mul Indikotitmun ilcr 1'(iMlBX>>ltrp*li(ui dea Ut«nui.
Ueitngcc «iir Gcb. u. Uj'».. IB98, J, S+HW.
Fritsch. I'ober AuHknlnuifE dea t'tcrua tiad nittai Gcbti/tsn. ZidUcbr. I, Qeb. U.
0)-n.. lael.xu. 4Gfi.
Ciu.TTKK. Dc nnfoclUm piriuutivc <Iu tiquidc amnioiiqno »piH niptuK prtmtttoie dM
iiHiRilifanM dc Fa'ur huiiwin. Tbtee do Faria, 1HU5.
tiAiuuuuKH. INicqiend Infoclion. Amcr.Texl^Moofc crfOlMtetriM, ISO-t. lUt.1-73t.
-GciuiAitn. HkcMmiin ooli coninmiMSUH Frillan von TVinptLDia Ul«ri cviurhUl. Vorh.
<]. doubKibeii UcoeUKti. f. Gyn.. 189». 305.
Cin.iiKnT cL DoMiKrr. Redwrdwa mir le nombrc dea mirmlicii du lubo dIgMtif. 8»-
iiuune Ri&l., \mi, 70.
(■(ii.oniuviuxrciti. ThmmbMia o( ihc Internal Uiiu^ ^'cin during I'tcgnMuy. Bullettn
ol Uw Juhiu Ho[iki>iB IIiMpital. IWM. xv, IHS-IOO.
(iiiLBatcMKtoKit. Kliniicbc luid bkktenologiiidM; UiUbcUungiHi iiber Sepw puerpcMlU.
CtMrit^-AniMtkn, IMI3, xvjii. 164-242.
Ou-yNxa. Leber Mjkrooiv>ni>anon im :tekn-U- der weiUichcn Ccnitalien wihrvnd der
S<-liw«aioif«clu((i mill lin joiorpenlen F-rknuikiiiiccii. ?.viilnUI'l I. Gyn.. IKKT. 444.
llAiaiLtx. iiiMtd by Feliluig. Pfayidolupe und Fath. dea WucfatsnLeKa. Stuit^rt.
IIalkam. L'tctuwRiphyaefii uad Oaawpgia. .^loiiatsKlir. (, Gob. u. Oy>u, IDUO, xi,
8S-122.
IIarhih and Dabkrt. Report of a Csao of C!«no<Ttia«l FjidpmrdiiU in n Pniirat XfyUig
in thi! Puetperiuni. liuU. Jabn* Hopkioa lloap.. 1001, xu. 6S-76.
flRHKIBo. l>iu punn'onlcQ und pytimiachcn ProoMae, 1873.
iliiincM. IliMwiairViNtthologiitcihe L'nUraiMthungau liber PuMpenlfieber. Eriauf^i,
Ihnm. Mcxtem MMboda <4 TraMment of Pudipera] Infection, and llMlf CompMSlIva
Worth. Amer. Jour. (MmL. 1896. xxxiv. IBO-184.
SonM Probleiiu ill ihe DuHcmMiii ind Trealmont of I'lirrpctid Inrortkin. Amor.
Medicine. 1606, xl. 121-123.
MomM-KK. Ziir S'rmirrtUimtt oiner kiuiatljciicD ixrtikorytoMi bd der Behttodlung
BoptiM-lwr Fiicr}wr»l|>ni<7VTMti. lUailmUil, (. (•yii., 1890, xx. 441— Mil.
Die .N'unlcin-KodiMli llcluuidluiu; der puefpemJen HepMi. Ardiiv (. Ujm., 1903.
Iksviii, 3u9'375.
HituinL l*ticrporal Fcnr &* k Private l^tutilenw. Borton. 1905.
In<ie«si.ki'. IHe Hlerbliohkcit an Wocbenlieliiieber In Diuiomari und die Bcdeutung
der .Vmtin]Kik (ur doMcIbe. ZciUdir. f. (Mi. U. Cyc IffiS, xxvl.-443.
JmwKTT. TliH (^leaiion of Puerperal SolMii fact inn. Amer. (ijii. ami ObM. Jour., ISM,
^■ui. 417-^2fl.
Kaltbvrach. Zur Anluepei* in der GeburtefaOU*. VnlkRi»nn'i 8aininlun« kitn.
Vertraflc. St. 2ft5.
t^ber ScllMinfokttnn. Vorh. d. <leiit«hon OcMlbeh. f. Hyn.. Imbut^. Ifm9,
fm
OBSTETllICS
Kjhkukd. Trmtiw on Childhed Pevor. 1774. ~
Knkihk. Zur Kcnnluiiui det niactx :<eptiknmie. ArcJnr f, (tyn., IIIOI, IxxiJi, ^S-SAO.
KoHi.ANrK. Ziir piierpoRtWn Infol^linn. XciUvla. I. ('t:h. ii. G.Vii., 1«IW. xi, M-{K2.
KiiTTMAKN. Bciing nur Haktcriolo^' dur VsKiK"- AtrUv I. (lyn., 1808, Iv, QIA.
KowvATHKi. Ziir RwhaiidlunjE <ier (raien ])tii)r|iorHl<;n IVritonlCis niil LAparotontle u.
DnLUingc. Hcrliner Idtn. Wochoudbr.. 190.i, No. 20.
Kkoniu. Varlaiifim AlittJiBlluaK i>l>«r nonnrrhfio ini WofhoolMtl. lianlnlhl. t. Oyn.,
I«03. XV. IflT.
KctuiitlBii-vkrvlimU'ivilrliimtccn Ini nin Iliimlt^rt Si'hwanKnren. .VscfiCIk in ilcr ficlnirts-
h.iUc. Zumtallil. t. t:.vfi., IWH. xviii. 3- 10.
Vwlwr Fiohcr liilr»-|airtum. Zvutrnlbl. (. <iyn.. IfKH. 7411.
UtKcuoiHuu ubor KodiHiwU-itis. Vorh. d. doubMihw) GcaoUwIi. (. Qpx., 1B05. 49»-
802.
Kliiuivhu Vurmifhv <tl>cr >I«n l-!:inf)tiw (l«r SrhcMonxp^dDnjnii iriLhrand dor (Mxirt
Auf den Wuchciilwttsverluuf. .MiiiirliuiiUT [iiwl. Wocliciiiichr.. 1900, Nr. I.
Kr^xm ui>(J Mrvi-K. ltftkt«:rii>to|[ic Acn licnit«Jk»nnlca <1ct itphwanncren, krctoucnden-
uud [Hiuqvrnlvii Fniu. Ixiyxiii' 1807.
l.AKDAi'. t'clicr piicrpciuli: KrkniiikmiRcn. .\rphiv f. lijii., 1*174, ri, 147
LiMPULn, Uvtwr <lii> WiX'htMit>v(lvii vnn iiictit iiiilcnucliUiD und nirlil uu>i)^i<|iiilMin
Gitbrircudeii. Vi-rli. d. duutopbcii (icirlUrh. f, (!yn.. Fmibun!, 1880.
I>TiU«r Dcllmji HUT VcrbittuDK do« KiadboitfWburv. Archir f. Oyn., IBBO, xxxv,
146-162.
trnb«r die FjitSchrlirhkoit dor Srhctdnnaiimprihuimn uid AwiwMchuiiKea Iwi rtg^-
liiunwn (!iol>iirt«i luid iiber die i^r^iixlaiA^iilie Vcnrertliuug tier liiUHctvn THrer-
■nicbung in dar (MiurUbiilfi!. Archiv (. Cryn., IMI, x\, 3411,
Vcrv^lrhendo nnU;riiiirhiiti|rgu ulwr diu F^iittNtbrlicbkoit der ikbeidcnauMpuluiiiccn
I bei Kitnx minintlon (ielnirtoii und iilwr dk toKcnannlc SeUwIinfcktinii. Archiv f.
' Cyn., ISM. nlvii. .^H0-«:i5.
Z»r »pvnitit-(ui licliandhmK der piicrpemlon PctilonitlH i). T^ra««nlo. Artihlv f, tijm.,
1906, Ixxvii. 1 33.
L*:oiKit.i> und Ohd. Die l«itun)i Knnt normnlcr (ichun«n niir diireh :^uiiMra I'tiur-
Mirhiiiig. ArrJiiv [. Gyti., IHan. xlviii. :iI>4-323.
LmruLi) uad SiKiHUNu. Vi« l«ituiig der niEulmiuwiKcn ficburlen nur (lurch Ai
!'ni«riiui-hunecn. .Archiv f. (lyn.. xiv, 33(H37I.
I.nTLK. A 8ini|)lo MethiKJ of Obluiiniijc I'loriuH Ltwhiu l<ir Uiii!t«noloK<rml Knmt-
nntiom. HrdL Johnu Hiipkiii* llmpitut. IWM. \v, 2.W-251.
I'lit' lUi'LUiiH ArroKenciH ChiwuIhIiih in ruurjivrHl IittoPtlon. ItilU. Jotuu Hopkiiu
Hr)«piul. IW)5. Kvi, 1.30-140.
Tht? HmU!riiilti(t>' of llin Piicr|«Tal I'lcnlB. Amcrioin Jotir. Obut., IBOT.. Hi. SI5-M7.
liiiMKti. I^clvr dvn hiTUtitn-'ti Slaiid d»r I.i-hrv voii dvri InrukUonKtraicwn Iwi tHmpei
fiehcr. Zt^ilM-hr. (. (^ch. ii. t!j-n., ISHl, x, 3lS<i.
I.uHX. Ktcviit Hui-iT-riuloKiiiii InveHtiKHiiuitacunfwniii>Klh))N»tiiiv<>(l*tiFrprnJ Krvrr,
Ampr. Jour- Olmt.. IWMt, sxxiii, 3.17-M7.
h^cfe. Tmitpriivnl de lu wptintfiiiv puerp^rulv pnr la r^rniptrntiMt ei nn psflinulipr
pnrlrn hnini iniiih. r.ai. dou HAp., IH!)4. l:trj.
Mahlkic. Tlirtmibuw. Liiiip>ui-iiiliulit< ii. pli'itntiehnr Tod. AriiMtMi mix tlor Fniiii*!'
klinik. in Drcxlpn. lH»'i. iii, 7-J-12U.
M^RHOKKK. S<1r k- Ktreptocwiue. Cuni|4«« Rtndiia A« In •oc. An biol., ISn.S. lllni>,
rfrip, ii, 123-
TjC (itni|it4iciK|iiL- rt \e sfrum iuiliatniptOt'Wi'lgi)i>. AitiaU* do I'lnMilul PMlaair,
1905. ix. .in.1 «20.
MAftL(>wflKY. Zur AvrioldEiiedtir vnnteitijnn AhlitauuK dtr Pliu«iiUi vnni nnnunlen Hiu.
Btmdw. f. (Job. u.>.yn., ISM. Iv. 212-218.
PU^RI'l^KAL IXFWJTION
S»5
SUnnonK. Zur Fn^ nsrli \tt ioiogic der I'urrpvralprufuoo. Hoitiliwrto. f . OaborU-J
kuade,18e5. »v, I12-I»4. \
Mboi. On Childbod Fvviir. PbibdalphU, IftM.
Mkiorh. Itea AntUui:pUik<ikk«tuenin> iind i«iii«< Anweiuluiii; b«an MeaMcbsn.
MunchDiier Me<l. W<irbni3i-hr.. 1903. 1057-1001 mnil 1125-1121>. i
ME)im.\,v>. Ziir AiitM>|iwi in iler i luliurlshiil/e. Zon(i>)bl. t. <>yn.. lf)87, ;<i. 439.
Die ICnttichrlK-hkcit uimI (tcfahrcn inncfcr Dewnfcktjoii hci nornutlcD (ielHtrU!n. Vcrh.
(i. ileiilM-lwu (^escUM-li. I. CSyii,. Knritiunt. 1889.
KunfUir Itvriebt lilicr *vni ilundort (icburlcn ohno Uuieru Dcianfokliiin. ZcntmU)!.
f. flyn.. IBttI, xviii. 7«6.
MKrKS. Teiwr AntUlreptokflkkeiMcruni. Zvitwhr. f. klin. Moil.. I9<xt. t. 145-153.
MiMtio. IUkt<iHolnKtM-ho linroniirhiinxoii einiK«r F:Ute puctpcnJcr Srpnii. D. I.,
H«rliii. lS9i.
Natwiu. |{alfl«rlola(i«a'ho VorhAltniHto mi irailil, C^vDiUlivkrHo. An-hiv f. Ciyii.,
l9Ck>, [xx\i. TOI-asg.
NutiiiiJixK. t'cbcr ptierpcmlc rienwKonorrlUic. Mdiulurhr. I. (Mi. u. tiyn^ ISM,
iv, lOP-Iie,
NltKiT. INpbthi^rio ragina-uMrinc pucrp^ralc. Sirolb^rapiv, piAriBon. Adi»Im <le
tya.. Gt d'nW.. IWIi, xlv. 259.
KoaiM*. A Keporl of SixOuMtn which ihv Hni-illiiB.XMiiiteiitti)Uai>inil*ltisws8iKiliil«il.
Anier. Jour. Med. Sricnnen. Koi)niary. 1S8!).
The I'revuiitioti imaj Tit«Uiivnt of I*iicniBriil Infcrtinn. Aiiior. Ucd., HHM, vii, 2J56-
OOTH. VirciMnr'« Archiv. IviU, 441.
OvTKKUKI. Bettrag lur BchanilUutK <Im t*uerp«rallictx:fn niit intnVL-D»Miii.
CollM|CcluiMpntninK«n. DoiUorlmt ArHiir I. kUn. Mccl.. IWK. Uxsv. '227-2:33.
Fastbvh. Stiplit^niie pucrpdrale. Bull. <te Vncsui. Ae tiiM.. 1870. 'XO-Vl.
PuuM. I'abar SeratnlxliUMllunj beim I'UcrpenUficlier. Arcfaiv I. ilytt., lOOA, Isxiv,
47-W.
PMUUMt. ncpnrt fiC Nioo Cbikh of InfiM^tion wiih UAciUuii f^Mynneiu. Joor. Med.
R«nwrh. IW)I. vi. iM An.
PlNAKu. DUciiiHiniii Hir irt indimtioiiii dii rur^lnxc pDndaiil lea Kiiitm de fourbol J
(■il]mli>jD<|iii;H. IVimptm rnid. de Ia "h-. d'olut.. dc xyi' ct dc pird. dc rariar]
!«». vii. 134-1.31.
PiNiiiD pl Wd.ijtni. TniiUtnicDt dc rtiifcdion ptterpfnie. IVrin. IMH.
Pkvoii. TreHlitiiml of Puuqwnl HlrpplvrtxTiu lofwlkn )>}' UiuvllaiR, (Iw 4>il-<U^4ub
liuiMon, Gir. Amur. Jour. <>M.. ISM), xxsix. .SB4-5(W.
Raw. Puenxiral lltvptimini* with 8|>e<-ia1 Rofvrvnro to Um Vatiw of Anliclreptcroccio
Rnum. iour. Otwl. and (Jyn. Brit, JJnp., I9IM. *-, .52.(-.'V26.
RKon.tNcitiAnBKS-. Zontralltl, f. mcd. Wiivwnivhnflon, Ih7I, 713.
RxTNOLMt. The Vnmiicney of I'utvpvnl Infvrlion in Mtuatrhiuods. etc. BosUin U«d.
mudSnrt- io»T., Fxx-a, 1A9-1M.
RlorrvB. Tfarainttow) n. Cmbidia im U'o(-hciii)<c4l. An;liir (. Hyv., lOOS, Ixxev.
I23-H2.
RiiKii. Thr Vaitinnl Indalan In Sepda (ollowiiiit Abortion. Arim. Oyn., 1903, fi,
5S4-530.
RcKfiE. I>in Allccmcinbelinndlmi( d«r pucrpcnJan Scptu. ArMt f. (>yn., I88H,
xxxiii, 3B-^'2,
8*MM-M1X. Ucber dw Vnrknmnicn vnn EitcfsUphvlonoccen in den tienitnlien von
geawnden FrauMi. Drtiltrehe mud. Wodionsrlir., IHSO, i, 233.
fliniXMX nnd ScVKm. Din i^tdhmg ii. Ekdcutimg dc* BIrcplooocriM pj-oKcmi* in der
, Bakt4vio)iope dcr I'lvniNhirlaeii iKmitabr Wocbcncrrinnon. ZQilntht. I. (ivh, u,
Gyn., I1W6, In. 325-330.
890
UfitrrtTKH^S
BcBHiDuccnNKii. Qatieraciia utvd pitcrpotnlU (Molrilbi ilcjMcnnii). .^rchiv f. (lyn.,
1900. Ixxviii. AS^tSlt.
Skmmblwkiwi, Die ActinloKic, dcf Ucgriff u. die Prophytusui do* KuidbiittfielicrK.
Pujtl, Wwu II. U'ipxic, ItHil.
SlLBBBSCHMiDT. Uutoriscb-kritiiichc DaratcUtuig der nttiiolagie dcs Kiiidbe1tfi«l)«s,
Odcrutilv PfvUHThrlfl. I->biijtoo. JHS9.
SiTfirKKXV. Diu Uvhnndlutifg dtu niitiwhcii VVodicriiliciu-iknuiktitigen. MunulioK-hr.
f. Gob. u, Gjn., »MM, xi. Kfjcinx.iiishclt. «■!<» fi77.
SounniLLK. 'rniil«invDt du rinfit'liun pu(Tr|M^rul<< eravu par la bptrotntiiia 4M (mt 1»
ralpotimtic innii hyi>ri<r(«-l«ii»c. H^vuc de gya., IM)A, ix, 8X7-800.
STKmtlX. BakterioloKiHi-hc Dccnindunii (l«r SallMtiltrtiktloa. Z«itachr. f. (lob. u.
Tij-n., 1800, XX. am.
SncwAST aiid 1}ai.i>wix. DariUus AcroEPiiM Cajwiilatuii. Columbiw Med. Jour.,
.\ug., 1803.
Srou. Stiidicn lur Baklcrici1«|tiR dc* (icnilitlknnalea in dcr ScliwuiKenK-liatl u. ba
Wocbuiibelt. Heitriiiw «, Crl.. ». (i>ii„ 1!HB. vil, 400-121.
RniKK Dtid U<.*])uNAt.i>. Tbt CiODiHiH-mu ill ihu Puurpurium. Siinc- (.*ti^ atml Gjm.i
IMS, U. IA1-1«2.
SroAVfla vl 8ju«uiKt-T<ii.ei]o. Svptic^mie puorp&ale oxpArimenUtc. Nouv. Hrchivm
d'obnt. «t dc Kyti.. lim, cv, 377-205.
Stbothkr. Critiiul FtMty on Fevers. I^indnn, 1718.
Txvtma. (ianiinh<r»l i'liMpcnt) Infectum. Amcr. Cyn.. lOOX. ii. 334-345.
Tavki- nx|>. u. k1iiii8<'hc« iibor cLui AotiBlrcptokokkciuGmni. Dcutoabe med. Wochca*
sclir.. 1903. .No. 50.
T»nwK\. BaktcrioloKiM'hc fntrrmchuaKcn noniinlcr l^rhien und dcr Vb^im uod
Cen-ix ^!l'h1•]|nK(^^VT. Archiv f. Gyo.. 1880. xxxvi, ;!31.
TiucsuKi.xHiittiiu. A Review of Kurgicol I'mitnun. Jour. Am. M«id. Amii.. 1906. xlvti.
81-83.
Vahle. U«ber dna Vorkommm von Strrpiorocccn in iter Srlioide Uiiliitntnder. Zeit-
srir. (. 0«b. 11. Gyii.. IfWS, xxxv. ig'J-21.V
ViuNjU. Sut I'ftction (leu niivnf-oTiciLniiiiiu dv k bourho ct dea inali^reB fi
(ViinplxM n-n<hi* de In hoc. dc bid., anilt, 1887.
Walurvi^r, Ui-Imt dua Wirkmiiinoii vuii Baktrrii-ii Iwi der dijililheriliitchvn Form dtgi
Pucrpvrallipbcn. Arrhlv f. Gj-n.. t«72. iii. 293,
Walthard. lUkl^rJilnKifirhtr r>iTrTMich<iti|[>.>tt titv wviblldiNi Oeidtabekrvte* in dvr
Umnditat uiid in I'lierjiiTiuiti, Apchiv f. (iyn.. 1805, nlviii. 20l-2i5fl.
Gnindlattcii mir iVrothcrapiM do4 StnifitnkokkcnpuorpcmliicliiirK. ZciUchr. f. (M>.
u. Qyn.. 1904. li. 400 MB.
Walthakd u. ItciiEJL Ucilni^ tur KounlniA dar Xatiu" u. klin. Bodoutunf; dtv
Vaxuialstrvptokokken. Zntochr. f. Gob. ■■, Gyu., 190G, Uv, 3(H-t42.
Wblcm. .Morbid CanditionK atuwid by Bacilliu AerogeriiMi OapMlatoa. Booton lied.
and ^urg. Jour, 1900, <-xliil. 73-«7.
WKTHXttai,. Tlie Rntiooul TrmlBienl ot Puerperal lafwllon. AiDor. Jmir. Obat.
1903, xlvii. AS0-M)8.
WiBAi. I^tiide ^ir I'infeplion )Aiur|>^i^l^' Thi*e ■]• Purin, ItffW. .
lofwliuu piicqM^mlc ot phlcgmnab Bibu dolonn. Gui!, ile» Hop., 1888, 565. '
Wii.i:i«)ia, .1, W. Puurpuml Iiilvrlioii <-oti«i(icrod from ii ltaclcriu)i>giml INunl of V'iow,
n4Lli SpfiTiul Itrfcivnix! to tliu IjOLiitUin of .^itU>-in[<Krtt»ii. Ainer. .Intir. Mrd.
Hricnrau. July, ^fm.
Tliu CnuDO of tlie CVHiltictiiig StutvniciiU coiireming tliu BacleiinI (.'unlciiUi nf the
Vn^nul .Svtivlian i^f the Prvgnont Woman. .\Rief. Jmir. Obat., I8U8, xvKviii, MfT-
817.
PUERPERAL I.VFECTION S97
WiLLiAMK, J. W. Tbe Bacteria of the Vagina and thuir Praclirul SigiiilicaJin;, based
upon tbe Bactoriologirat Examination of the Vaginal Secretion in Ninoty-lwo
Pregnant Women. Anier. Jour. Obst., 1^8, xxxviii, 449-483.
l>iphtberia of the Vulva. Amcr. Jour. Obst., 1898, xxxviii, ISO-iai.
Kin Fall von puerpemler Infektlon, bei dem rich Typhu^Mcillen in dun IxKhien
fandcn. Zentnlbl. f. Gyn., 1898, xxii, Nr. 34.
Piicrpcral Diphtheria. Atner. Jour. Obst,, Auguat, 1898.
Williams, Pryoh, Fky, and REVNOLoa. The Value of AntUtreptococcic Serum in toe
Treatment of Puerperal Infection. Trans. Amer. Uyn. Soc., 1899, xxiv, 80-126.
WiNTRK. Die Mikroorganismen im Ucnitalkaoal der gesunden Fraueo. ZcitHchr. f.
(Job. u. <;>'n., 1888, xiv, 443.
WiTTE. BakteriologiiK'he UntereuchunKshcfunde bci path. Zustanden im weibl. (^li-
talapparat, niit beaonderer BeriickHichtiguiig der Eiteremger. Zettschr. f, Uob, u,
Gyn., 1892, xxv, 1-30.
Wood. Puerperal Infection caused by tbe Bacillus Acrogenos CapmiUtus. Med. Kec.,
April 15, 1899.
CHAPTER XIJV
DIHKASKS .LVi> ABSOitMAUTtHS OF THK PVKRPKMVM
Wb have alr^ndv (Iimu^^ in dctait the moro tvjiicdl iii^Uncc-^ nf put^r-
pcrnl iiifivtioii. W<! sluill irnvr fjikt- ii]> ccruiii alvpical vurielii-.s — ^tittHnUK,
phlc^miuua allia doIeiiH, and cystitiH — and xhall theii pnxvcd to consider
cprtHiii "llirr ili]^(»iH« mid ii1>n<iniMilitit-c wliich iiinv In- f-uiiiiimfn-d in tli«
|im-rjH-riiuit. but which are not due to ihe inlrwliiction of infwtive material
into tli« gt-nildl tnic-l, Thu». wo i^IihII liiid llinl 1w<t a^wxiutwl with
ivmiiLitutioQid diHturliancis \» not lnfrc<|uenily met with at* llie iviiult of
patholoffical conditions io the bri>a«t«, dittorden of tliv int<»li>iHl trat-t, and
ill V1.TV rnrc ini^tanw* «f oinolioiud eJiuMii. Mureiner, it must l»e n'lni-iii-
bered that Nature has not rendereil the piit'r|HTal woman excnij)! from tite
varioii* di*ordor» from which she nii)dit suffer at other liuMw.
Tetanus. — The untioulited development of tetantis durinj; the pnerpe-
riajn, although a ven- rare occurrence, lia* bwn fully estahliiOiHri by the
nsfflrchcs of Chaiitrnivsne iiiid Wiiial. Ilfvsp. liiiVH^ka, and others, who
haw isolated the i-liHriu-tciisiic baeilli from the uterine lochia. The infec-
tion ufiuolly follows gross errors in aseptic tvchuiquc. capocially during
openitivi- pmot'd tires. Thu*. in wvcral of the n*ported casft*, it is f««rded
that the ojwrator (ilatrd tin- foiccjis iijwn the dirty floor by the side of the
Iml. and Hfteruard carried it directly to the genital tract of the patirut.
Decasjonally, liowi-ver, such nu explunalion cauiiot be mhluced, as in an
epidemic in the I'ra^^e l.r)n|f>in Hosj)itaI, the disease, in one inataor^, at
Ii-ast, rtccurn-d xn a woniiin who hud not even In-en exaniim'd inlvmidly.
The disiBse fallows abortion lunre fre<|iieaily than full-term laljonr,
and a» a rule giv-e^e rii^e to untoward manifestations tielwcen thf t\\\\\ and
tenth days of the puer^K'rruiii, and i^onictintM later, tliou^li in rare in-
iTanct* the lin-t symptom has heen known to appear liefore the conipletiou
of lalMur. The prfijiiioxi" i« vtrry grave. All of the ^(i patienl" ni<-ntion<i]
by Rubct-ka feuccumbeil, while Vinay reports a similar rcstilt in !>-l out of
the lOti ca^s jnchuii-d in his statistics.
Beyond affordinjf m<wns for Innporariiy i.-onlrollin); the aymptoma,
tlierapcittic measures are valuel^s, and thus far the results obtained from
the employment of iinti-tetanus serum have not been eneoiirapng. altlmUKh
it* pmphvlactie empioyment hiiA Urn atlj'nded by e.vi-ellenl results. In
viey of the hopeliv^nei^ of nther lines of treatment, Pawlik and RiilKvka
ri'iiin^-rd the utcTU.-^ in sevi-ml of tlii-ir ciisi!'. but without avail.
Thromboiit of the Veiseli of the Lower Extremities. — Thrombosis oc-
curriug in the crural, popliteal, or «ipheooua vein* — phlegmatia ntha doUns
THROUbUSlS OF THE V&HI-X8 UF THE U)m!:K HXTUKJUTJfcii 8^9
— in uxually n iiianir«i.t»ti<iii of infection, nnd foII«W(t the direct esliMt^ioil
of a thrombotic procew from tlie pelvic veins, aillinu^U (Mwasionally it
n'»iiiu fmm « lwjiliw.il phlclHlin or {HTiphk-bilic. The lumiiui of Uic Inrgu
veins rarely imdergo complete obliteration, no that thfi circnlation, while
tnariicdiy interftinl with, it not complvtsly »lniL off.
Ryniptomn of pfiliikcma-nia i]o not UAualh' make their apjieaninci- until
the latter part of the [itvond week of the puerperimn or oven later. In
miiKt ciiM-j* thv firKt mtinifo'tHtion i* juiin in one li-^ vxtt-iidin^ a)nii); |}iu
coiimc of one of the Ur^r vcinx; thiA i^ Hoon followet) by iHleuia, which
tuuilly bi-^ng in the foot and extends upward, althouf^i occu^ioniilly it
appears first in ihc ni-if;hl)"itrli<aid of the jtmin. Tlio log noon be<^>meii
much ('vollen, the hkin t^'in^ lightly xtrt^lched ami prei^enting a jjluiH-d
ajipitiram-e, aiwt nt nR>1 pittinj; cun )>c dii-iU'd only nfliT [irolongui) prvH-
Bun- with the finger-tip. If tW crural vein is implicated, a mrd-likc
atrttrlure, which t* very wii*itive to pnwurv. oan oftni be {wlpuiH ju^t
bvneath l'oui>art'« linainent and for a certain itistanco down the thiph.
Tin* inllHiTimiitorv <-liaii};i-» are uounlly ulU-nitcd by i^ome ch-va(ion of
temperature, the pulse )>ein^ more or lens accderatcd. High fever and it
very ni])t<] ac-tion of the licHrt usually indicBte thai a similar process is
taking place in otlicr portions of the body, and that the patient is HulTer-
iiig from a general infection or pyniiiia. The pain, swelling, ami tem-
perature continue for »evenil wcekn, and then gradually sulfide, (hough
orcasioually ntonths elapse before the patient regains th« full use of
the leg.
Ordiaarity, tho procewi ia limited to one aid«, more rarely botli «%•
trrmilie* an- affwtcil. an interval of a wwk or tt-n days clapping licfore Ihc
second h^ lM%oniei> implicated. If properly treated, mottl cases undergo
spontaneous cure, the condition being dangerous only when it forms part of
a gi-noridtxiil inftx-lion. or w)M-n (he lhrouibu;i und<>rgi>n« Huppuration and
softening, so that infected partiela^ are carried to other parts, giving rise
to rni^taslHtio nlut'Csmw oud oocafii<mally to suddm death from pnlmonary
emboli em.
TrMtrHi-nl. — PiTfecl rest is abwhitcly essential. The lower part of the
leg should 1* elevated. «n<l the r-ntire metiiber eni-ased in ulworlH-nt (titton
and pmtMU'd from the weight of tlic bedclothes by a suitable contrivance.
If tlw jiain i» severe morphine may be required, thongli ordinarily the appli-
cation aloitg the course of the throniboocd rein of cloths maied in lead
watw and opium is followiil by marked relief. Kxcellcnt n^xults have bwn
reported fn»m juiinting the leg with a l.V or 20-per-eent solution of ichthyol.
(hi account of the dungi-r of di-tiu-hing puMtons of tlte thrombus, the
leg nliould nerer be roblied. llie patient should be kept in a horii^ntal
position for at least a week after the pain has disappeared and the tempera-
ture nuUidcd. ami after Wing allowed to get up sJie nhould be cautioned
against making sudden moTemenls.
Small Tarico§e veins of the lower extremities sometimes utHlergo llirom-
hww during pn^«nc>'. but more often daring the first weeks of the piKr-
perium. In pregnancy this occiirTcnr^ is favoured by tlw interfervnce with
tlte circulation due to tlie pn>»wun- exerted bv the uterus upon the veaaeU
n
goo
OHSTtn-RICS
retiirainp fr«m tlie extreiiiitieti. Uiiring the puerpcriuiii its (Ki-elopiiient in
occasiiiii«lly f«v«iirwl bv pix^sfUR- cxwrti-d uiMiit tlic iiitrnpt-lvk- vein* bv
in flam ma lory t'SiiKUtc-i. io atuaW v«ini Uit< thrombosis i:t usunUv uimUciultMl
by MTDptniu!:. iiltlioiigb iiow and acnin the ctev«lopm«nt of a localixed phl^
bitw or [ii'Hphk'hiri* iiiiiy cause puin, and uxoeptionaUy t.-vt'iitutttc in the
fonna!i"ii if n siiuill aburps*.
Gftngrene of the ExtremitJet. — In vtry rare iiK^tJincw, as the rc«alt
of extenxive tbroniboeis of the venotiH channels or of emboUHin of the
artiTi«». U)(- circulation En the <-.xtn-mitit> may bo»>iiic so iiiipHJrctl that
ganffrpne n-siilu. Thin a<*idcnt. first dwcriViiKl hy ('hurohill and studi<nl
more pnrlifiilnrly hy Wornisrr an<l Biirckhard. if s most serious complica-
tion, aad uHUally cuds fatally. Wornitter, in tlMM, colietted 80 ca-iesi from
Hk litiTaturu, U of which irrrc appamitly exaoiploti of RnynatidV diMasP.
while til) of the rcinaiuiug li cai»>d occrurred in piK>r])cral, &» mniipAred
iriUi 6 ill prf'giiiinl women. The procwB usoally invnivpe om or both feet,
although the hand^ and forearm may occasionally lie implicatMl. Sixty-
two pi-r ct-iit of thu '.a patients nKintioiicd In Tjiifond's thesJK died, in spite
of the fact that in iM>Teral instanoeit amputation waA rcsorlml to in onlvr
to ch"li IIk- fiirtlii-r di'vi-lopnicnt of the process.
Diieases of the TTritiary Tract. — A fi/ftitui occ-tirrtnj^ during tlto pncr-
periiim is usually the result of infection following catheterization, durin;;
whioh the ndw iif nitep*!*! have not l»«i ccniiiulou-ily followed. TW occor-
lenee of the randition is favoured by the presence of filif;ht lesions of the
TeE^ti'iil mueui<ii which friijucntly lu'cimipuny ea.->y and e{iontaiieou^ labours,
and are almost univiTsiaily a.-isocia(eil with diifieult deliTeries,
In view of the impossibility of thoroughly disinfei-ting the vulva and
urethral oriliw, cystitis will occasionally occur, despite the most ripid pre-
cautions. For this reason catheteriKatioii shoidd be restricted In the gTeat-
cst posnihle extt-til, and i-ni|)loyiii only in those cshgh in which tb.- patient
is unable to evacuate her bladder after being ptac^rl in a sitting position
In rare inslnrKy-s, the aGTet-tion n>siilts from the direct exteoaion of arm*
of inilttmmation about the urctbrnl orillce and vulva.
As the pTTirf-vt deummls a certain period of incubation, symplnni* do t>ot
usually appear for socral days. The patient lir't experiences a fr«]HenI
desire to miclunile, but iiusseii only a Kmttl) quantity of urine at one tini<-.
tiie act beinfi accompanied by a burning sensation in the urethra and ■
tendency to tent-smus after rach evacuation. .\t the Mme time, the hlndd<-r
and the urethra become sensitive on pressure. The urine is UNually clouds,
and upon micmscuptc examination is found to Ih) limded with mucus, hii-
oocytes, epithelial cells, and bacteria. Occasionally it contains a large pro-
portion of blood. Tlie acid reaction is usually retained, although, more
especially when the process ia prolonjped, the secretion may heeomc alkaline,
and very offeticivc in ixlnur.
Now imd iijtnin <-ii.-x-r> «ii- enroimterrtl in which tlie infi-etion is so severe
that 1ar;^r or smaller portion-' of tlio mueiwa Iteeomc exfoliatetl and are an^
olT with (he urine, tlieir CJipul!<ion lioing asiiociated with eramp-likc paii^|
In these vii-nlent types, and also in the milder hut obstinate procees!^|
ike dI)«Hu>c tends to est4-Dd up Uiv nreten and to iavolve tlw iK.-UiH oftfefl
a«MUimUA(iES DirRINti THE PUHKPERIUU
001
kidnev. giving; rit* to a figelo-nephrosix or even a pgelo-ntphrilu, thoil^^
st^'cnJ wuvk* am UHiially n-quiixid for thv dordopmcnt of thcM: Utter i.-oiidi-
tions. Thus, in <wtu« caset, the paiicnt who luM prertoiwly lud a ejsti^
but has Tcooverfd «uti»fiictorily from the puerperiiiiii, may siiditiMily expe-
mticv inU-ii>^- piiiii in oni^ n>iial rcginn, a.4:Miciitlo<) wiDi iIk* tlevi-Iopnu-nt of
3 temperature cliaractoriKttI \>y ii)ark<>it remiMtiotiK anil the pa8t^Hg<> of largVi
(]iuinlitu-» or nriiur laJt-a with |m«. The i>rindi1ioD not infn-(|uouily npptti^
ently pa^ece off, to recur Oj^ia wlicn Iraiit e.\pect«d.
Ill mihl caKcv of OKtili* lliv tnvjtmrnt coiinisl;^ in thu in^^lioii of Uim
ijuantitiiy of tluid, |iarlit.'nlnrly milk and th^* rarlH^mtltxl and alkalinA'
walen. The v<-hi<-al irritahtlily is oftm satisfactorily ailayod by the admin*
btralion of u-^iraiD captmle^ of «aloJ or urotntpiD repeated every fnur to
six honn. Ordinarily, *imple treatment lnid« to rveover)' in a compara*
tively fhort time, but if the proeesii dra^ on, daily irrifjation of the bladder
with a 2-)K-rKviit iioliition of hone acid or a 1- to- till .OIK) or S't.UOO stJuttOD
of bichloride xhuiild be pracli^.
ilo*t viutx of p«'l<»-Dephm#i« xeeover Hpontaneoudly after rwt in b«d
and the aditiiniotration of largie quantitiex of fltiidti and the ti^tnal renal
antifvptioi: but wheni'>er a py.-Io-iK'iihnlie develop* and is accompanied by^
prolnn^M fi'l>rib- luanifetitalions, drainage and oecaaionally ejkliqtation
the orfran bcvomm nceciHMir}'.
Hflrntion uf ('rinf.—Xu Chapter XVI, tip^m theeJtre of lite patient dur-
ing the pn«r7>Frium, refervnce wag made to the retention of urine, which
freqwnlly nniM>!* annoyanoe dnring the first few days of that period.
JnroHtintnee of fViW. — In multiparoiis vomen. for the first few Aaj^
of Ihp piierprriain. c<'>ii);)iing, snei^ing, or other factors Iradin^ to a Htidd
incNHHe in the inira-abdomiDal preacure, often produce an involuntary diii-
char]gn of a Nmall ipiantily of urine. Ilie eondiiioo uMiiallr pa»*(v off iipon-
taneoufly, t>iit cure a sometimes hafitetied by the administration of ^
grain of strychnia every tin hour«.
Uore marked iDeonlinence at this time \* usually the renult of Icaioos
about IIk- ncek of the bladder following opt^'ralive deliver}-, thoujth whon
tlte condition does not manifest it»elf mitil tlie end of the flri^t week it i:i
Qsnaliy the fir*t ^ign of the di-vclopnienl of a i'mwv). r.iy ina/ fistula. In
tlie majority of »ue)t eaaes serupuloiu attention lo deanline^ will be fol*
lowed by fiponlnneouH r^corery; but when the ttotulous openin;; is etteasive,
a CTirt- t^R l>e I'fTccled only by of*rative proeeihin>i at a later period.
HsBmorrhftges during the Paerperium. — Ordinarily, if tliere ha« been no
^erioiw )o# of blood during llw HtvL boar or lioiir and a half following
delivery, it may Iw asunmed that tllo danger of po^il-partum hemorrhage
han prartie4illy ptt>v4<(l, and that the only iowt of blood for the next few daya
will be repre*#nied by the loebial diseliarKe,
Occaiiionaily. howfver. in the hitler part of the firxt we«4. and more
often utill later in iIk> pnerperium, more or \fM severe uterine lueraor-
HiafTe-s arc encounten-d. They arw nearly alway due In the retention of
pnriirmi' of a pla(«-nlal ontvleiinn or of a Kiienntiiriate lobule which may
not have l>een discorered at the time of labour in spite of the mo«t rigii
procautioiu ; although the preaeneu of large portions of placenta can bardi
902
OBSfTETRKS
bt- overlookeci unlew Uio olj&u-trician U gro«flIy n<";;lif;enl. If the retaineu
tiiMue !!< Dot <^asl oiT t^pontaui-'ously or rL-iiior«d. it uudi>rgoe« gradual aecro-
eis, while at the eauio time tibrin bct-oiut-e deposited about lU jMrripher}',
givtug ri«r to it polypoid growlli of varying fiK — placental polgp — -a certain
amount of ha^iiiorrha)^, ahhou^h iiot enough to cause slartii, contiDuing
< as long a« it mnaius in thv utvniK.
' Lftrge pnrlifiiti' of (litt fn'tnl meiiit>rano« retained in t\w uterino «i?itj
rarely pivo rise to serious hemorrhage, as the tiasuea gradually disiutegraUi
and are cast uft with ihi; lochial dtxehnr^. The pres«ncc of a remnant wf
1 decidua of any consideralilc size whieh has failed to undergo the usual
n^KMivfi changw, may act n* an irriUiit upon tlii! rcgtimTnting cndome-
trioin, giving riw to a hyperplasia which is usually aissociated with moi
or leM lueinorrhage. TIiim eon(lili»D U d^vignati-d m fiidomHrilvi pnst^
turn or post-aborfion. according as it followB full-term labour or abortjoi
The diagnosis of tin; n-lciiliou of a plminilnl remnant or the exii«ton'
of a polyp can onlv \ie veritied liy the senw? of touch. Therefore, whenever
a pattoJit sulTcrv from an acute lo«^ of blood during lliv puvrpcriuni. lh«
interior of the uterus shotild be carefully palpated, and any abnormal sub-
Btance found in it »houM bv promptly rcmovitl by ommii^ of llie finger or
curvite.
The tnwtmcut of itic flight hsetuorrhngv following retroflexion and sul>-
iandution of the ulcruii has been referred t« wntler tha« headingi*. Tlie
t.lon of blood a>»(>ciu(cd with an endometritis poi-t-partum also demands
curettage. If the patient does not begin to bleei.1 until late in the puer-
pcriuni. and more particularly after the o.vpulriion of an hydatidiform mole,
(lie piirsibiliiy of the ■■xi>li-iK-« of a ctuiri*>-iiiith(!iioma ifhould alwayif be
considered. In *uch cases the uterus should be curetted, and the tisanes
m oblaintil Mibmiltcd to microxi^ipical exurnination, Hinue in thi^ way one
receive^ timelv warning of the existence of any sorious process,
PiierprmI I/miiithinid. — A tmncfactioii resulting from tlie cecape of
Mood into the connective tissue lieneatli the vaginal mncoti'a or the rJci
covering tho external genitalia is known as a vaginal or vuliiil hamaio.
This condition, first stiidit-d in detail by Denewx, in 1830, is a rare coi
plJcHtiou of labour and the pucrperium, occurring about once in 1,500 or
3,000 cast's. The condition occasionally originati^ during pregnancy, and
may attain such proportions as to interfere with the descent of the child-
Less frei[\ienrly fatal hainol-rhage may follow its rupture at the time of
labour, nn in tlie ca«>s reported by Kiinzig and others. More often it fol-
lows injury lo a lilood-ix-jucl during the uct of lalmur wilhuui Inct-ration
of the siiperlicial tissues. Xow and again it does not occur until later, and
is then attributable to the «1oughing of a vcj^el which ha« become necrotJc
as the result of prolonged pressure,
Tlie site at which tlie hictnaloTna develops varies according as the lorn
vessel lies beneath or alwre the pelvic fascia. In the former cue the
tumefaction involves thu lower part of tbi^ vagina or the ^nilva and perineal
region, while in the latter it prolnidci^ into the upper portion of the vagiiul
canal, and as it increiws in »i7<> «eparate» Ihi- p'ritnnifiim fmir H— imditf^
lying tJ««ueH, so that at times the effused blood pec^s otT t in
I of
Jcil^l
PUERPERAL H.FJJATOMA
903
covering the iliac (oMtv. grwluallj' iiivadtw the n<uiil n-gton and prentaftll)'
reaches the lowvr inargui of the diaphragm.
Vulval liKtnaluniHtn nf ui<.>dpralB 6iz« art.- usually ali.-«>rl>nl HjMiDtanfi- ,
ouiilv. In other cawCM llw- IUiik.% vowring tlif linimur may undergo pressure '
n«cro6is and give way, profuse hwuioirhage resulting, or the cimieata may
Ik* diM'h«rgt<d in Utv form of large clotw. In eitlicr event the interior of
the lismaloma U Tcry prone to litvonie infri-ted, tlie condition <*<>mettin<t«
tiiding falally. If the tumour is larj^, it not only c-auscti di«eoDifort by its
mere size, but gives ri.-e to great ^utTi-Hng, which Iwwitmm more intenMt
the more rapidly it i» fornu-d, as the result of the tearing and ctretching
of thu tissues.. In rare inritanetw it nuiy »>nt»tn nueh large i(iiauiitic« of
blo<»d that the patient snlleM from acute ann'mia, and may even die from
lwiiK>rr)uig(> Milhriul rupture.
In tJi« Eulpj-rit'iutiil variety, immeiiBe quantitiw of blood may be effused
beneath the pentona-iim ami rnpidly 1cjid ta dc4>th from acute aua-mia. la
otiwr cawe a fatal issue fallottH liecondary rupture into the peritoneal cav-
it)'. and many e*M» iiiK-oumh to infK-1i»n. In 33 cmnc* of this (.-haracter
which 1 collected in 1!M(4, tlw mortality u-aa Mi per cent. It U intensilng
to i»i>te tluit more than fin pt-r cent o( tW ctfc* ixi-unxnl iu primipara; and
*1 per cent after spoulaneous labour. In my patient the hiemnrrfiage came
from u vnwl at thv ba*« of thu bladder, which liad become torn through
during the course of labour.
A valval h«.'maioiiiii i" n-mlily dinjrn"'"''' I'V the KudiU-n apiwarancc at
the vuUa of a teswe, elastic, tiiictuating, aixl .-M-'naitive tumour of varying
aiie, corered by the difcoloured skin. When tlie mass dei,'elopt> in the
vagina it niay e>4>ape dt<tF<otion for a time, but pre^urc ttytuptomit aoan
ensue, and on a vapnal examinatiim one di»«ver» a round, fluetuant tumour
which enenMchOK up<in the lunifn. On l)ie othi-r hand. wlH-n the Winatoma
extends upward between the folds of the broad ligament, it is liable to escape
defection, nnlcM eymptnmti of ana-mia or infM-tion appear. In my caae
the uterufl wa§ markeilly displaced upward by the effused blowl. and on
bimanual examination a largi' Ihictuant tumour oiuld bi- pMl|>iii>tl In-neath '
it; although if tl>e patient were not seen until after infection bad occurred,
the differential diognotiiH betmH-i) nuch a i-oiidiliuu and a pelvic inllamma-
lory maits might become ver>' difRcnlt.
Tlic prognoKin i* ui^ually favourable, thnugh very largt- hivmalomata occa*]
#iona)ly lead to death from haemorrhage, uht^reaa in rare (-a->-^ tlie ffttal]
termination U the result of inff?etion.
Trratmmt. — Small luematumala nhould 1)6 left alone, «k «pontaneoua
resorption nsually takes place, provided the part* be kept clean and infection
avoidod. On the otlter hand, itim-« a xteady incrvafe in the f\M of th«,
swelling iodicatefl a continuance of hemorrliage, the tumour in such casea
should be laid widely opm and packnl with gauze, which uinally effectually
controlii the Iom of blood. The strictest antt.4epti4: precautions are impera-
tive, inasmuch as infection is a frequent complication. In large subperi-
toneal luematomata. aerompanie'l by acnte uiia'mia. laparotomy ^hnutd be
promptly perfornied, the blood clofci removed, and the baemor^hl^^' con-
trolhil by ligBtun- nr hy packing the cavity with gauxe.
004
(jBSTETHICS
Diteasts and AbBonnalities of the Vteraa-Suhinpolulion. — lliis term
ie uwtl lo di-wrilii! iiii nrn-st nr n'iiin!atif>n «f llif pwK^ss o( inrulution, bjf
wlik'h the puerjteriil 'iili^rui! liluHittl Ik: gratltiullj' nvUtrf^ In its original pnt
portioUH.
Xomial inTolutioQ is to Ije attributed to utrophj of the Uidividiial iniiii-
cle cells ralhcr lliun to fully Jt^p-nerHlioii. u* «iw formerly AuppottiKl. It*
pTOKimnie eauw i^ to bo wuKlit in the swldeti and marked diminution of
the blof-d supply to llw nt«nis; aitd. a* liii* cun b« bnmglit iilw>ul only by
]Mili.->riii'l»ry lontractiiin and rftrnolion uf tlie »ri,'an, it i.-< apparent that any
interfereDoe with tbp pfoccsii may ba followetl by subinvolution.
Among the most fni^iK'nl a-liolojcicAl fanlont in it* production are
imperfect exfoliation of the decidua, retention of portions of the after-
birth, !iiflnTnmut<iry hwiim* of tbi- t-ndonn-lrium. lliir presenw of m\'omatnuif
nodules in the uterine wall, abnormalilie* of circulation which frequently
Bccompauy displowinente of tlie uteriu;, the existence of pelvic inflamma-
tor; Ifsionii, and imiufficient nvl during i\v- pnerfieriuni. Tn other wordji,
subinvolution is practioully always the re^iuh of loral conditions and not
of roniiTitiitional di»iintiTs, and ai'conlinjily cantfiil iiiviT^ligution will n-viial
the underlying cau«e, and approprialc treatment, if mulertaki'n t^iiffiiicnily
early, will leml lo it* inirt*.
The existence of aubinvoliition is manifeiitod by a prolongation of tin:
lochial diMliargv- iK-yotul ihi- ti>uiil prrnMl, its cvssalion being followed by
pvTsirient leucorTh<ea with pains in ihi' back, a general fet-liii^; nf draggi-
neva, and a delayed rt-turn lo pvrfcct health. Similar symptoms accom-
pany uterine dinplaecnicnt?, but in all probability are in great part iac lo
the coinrideut subinvolution.
The dia^o&i* i« eHlal)li.->hi-d by bimanual exAminnlion. tlic uterus being
found lo \te larger, softer, and more sueciilent than it fthoutd be at a given
time following delivi'r)-, Normally the (iinduif i^)iould have descondcd to
the Ie*el of the upper iimrgin of the symphysis by the tenth day, ahhongh
Die organ dot;* nut regain it« original *ixk for »ix wekt or more after
deli very,
InHKUiuch as subinvoliitioii is dependent mainly upon local conditions,
very little nan be esjiocted from medicinal treatment, allhongh thv ndmin-
ixtralion of 30 drops of Ihe Hiiid extract of ergot every three or four
bonrs for several day* i* .■«)mu-I i nn-a ffillowrtl liv inipn)V<-mciit. l^x-al mcas-
nres afford much belkr results. If the uterus is displaced it Hhonlii he
put in proper position by bimanual manipulation and held in position by a
suitably fitting pessary. When disease of the endometrium or retention
of portions of the after-birth arc nT^ponsible. prompi nireltngi' olTor* llw
most ellicictit method of treatment. On the other hand, procrastination
may lead to seriou.* results, as the subinvolntion may become permanent,
and prove a constant source of irritation.
Laclation Atn/phy of the Vffrua. — Occasionally, in womeo who suckle
their children, the uterus may undergo exci^^ive involntion. beeoming
smaller thiin in the virginal state. This condition, which \i*uaI1y l«yv>m«
most marked during the third or fourth month after delivm-, is attributed
to rellex irritation emanating from the breast* and ineident to lactation
DISEASES AND ABNORMALITIES OF THE UTERUS 905
and nnrsinfr. It usually (lisn)>|viir:! simnliim-HXisly iifirr wfaniiig, tlioii^li
when lli(> child is niirst'd for a Inii^^-r |>LTiod (hiiii iisiiiil the uterus may
befrin to iiK'n-asc in sizi! bi'f<ire the end iif a year, even though laetatioa
t)e continued, it is priilialile llial the ccsi^tion of lucn.-^trualioit, which is
usually observed during lactation, should be partly attributed to this form
of atrophy.
The condition was first definitely deecribed by Jacquet, in 1871, and
since the publication of hie paper has been carefully studied by numerous
investigators, particularly Thorn, Uoltschalk, Doderlein. and Vineberg.
In rare instances the atrophy may persist after weaning and become
permanent, the uterine cavity sometimes measuring only a few centimetres
in length. This abnormality, first described by Chiari, Braun, and Spaeth,
in 1855, was later designated by Simpson as superinvolution. It is prob-
able that it may occasionBlIy be the causative factor in the unusually early
appearance of the menopause.
Displacements of the Uterus. — Immediately following the birth of the
child, the lower uterine segment and cervix are represented by a flabby,
collapsed structure which is freely movable upon the rest of the organ {see
Fig. 3'i'i). Under these circumstances a comparatively trivial cause, such
as a slight increase in the intra-abdominal pressure or distention of the
rectum, may lead to a bending over of the upper part — anteflexion of the
uterus. The condition is usually without significance, but occasionally the
angle formed between the upper and lower portions of the organ may be so
acute as to occlude the cervical canal and lead to the retention of the lochial
<liseharge — lockiometra. As a rule, the retention, when it occurs, is only
transitory, but if it be prolonged the lochia may undergo putrefactive
changes which are accompanied by the formation of toxines, the a))sorp-
tion of which may give rise to constitutional symptoms. The eomplicatioD
is readily overcome by allowing the retained discharge to drain away
through a douche-tube, after which the uterine cavity should be irrigated
with sterile salt solution.
So long as the body of the uterus lies above the promontor>' of the
aaemm, retrodisplacement cannot occur, as the falling backward of the
enlarged fundus is prevented by the convex surface offered by the lumbar
vertebrae. But as soon as the organ has descended iiilo the pelvic cavity
a retroflexion or retroversion immediately becomes possible. Their develop-
ment is occasionally favoured by the use of an abdominal binder which
may cause the abdominal contents to exert pressure upon the fundus of the
nterus, forcing it downward and backward. ^lore often the retrofiexion
merely represents a recurrence of a similar condition existing prior to preg-
nancy, while in other case* it may be the result of extreme distention of
the bladder. Sot uncommonly its mode of production is ditricult to un-
derstand, although it is probably connected with excessive relaxation of
Bome of the stnictures about the base of the broad ligaments.
Bacleviard displacements of the nterus rarely give rise to symptoms bo
long as the patient remains in bed, but as soon a;; she begins to move about
their presence is apt to cause more or less inconvenience. The earliest
and most characteristic manifestation is a marked increase in the amount
906
OBSTETBKS
of liH'tiiitl tli^-liargp or the renftpfaTaiifi- of lliv Knv if it hta alreaiW oeas^l.
SoDietimeB liMf patienl enffvr* Iron) pain in the ttack and lower abdnmeD.
allliou):)) JM nth4T i-Nsi-;! t\v nutv <»t\\ Ik- fmvinu^ that «hi' w iiut riigKiDtlig
her :<tr('(igtU as ra|iiilly as clu' hnd ^-xjuvlwl.
The preeeiioe of lhi-*o *vni[ili>ms hIkiuIiI aiwaya sngjii'si the eiistenw of
a retrnflexioii, aiihou^ii they are sometiuK-s iJui- to ^ubiiiroliihon prodatrtl
by other cauMs. A poMlivL* diatzinMU mn alwayti be made upon rnginal
L^iKinination.
^ The n«toration of tlw ulerui' to itit normal po«iti«n by biniftnuiil maiiip-
ulatioii.", and the intrixiuttinn of a [iroperlv fittinj; pessarv, as a nile
vill afford prompt rvlk-i. and on rrinoval of the [luiMary mme months
later Et will usually be found that a permanent cure haa resulted. <>n
the otlier hand, if it* ciTiployin<-iit i« postponed too long much \e*i^ favour-
able n'-iulln an- obtainod. Thin fact M-T\'t-s again to einphadize the nt-ceM*
BJty for niakinK a 6nal examination before discharging the puerperal
jMtiiiit. AVlii-n tlw! patient liiw ^ufTi-n^l from nMroflmion before prvji-
naocy, an examinalion made at the end of the wroiid week of the pner-
perinm will iisimllv nhov,- Itiat the uIitiik ban n'turntK) to itit abnormal
position. In Hiich eHHes it should he replaceil and a fKirsary at onee tnlro-
ducnl.
I ItelaxiUion of (he Vaifina! Outlet am! frulapit of thf Vttru*. — Rffer-
^eDOC hait ainwdy bn-ti iiiiide to tho fraiuenl oixiim-nrv of perinval lai,vratioa«
at the time nf lalxiur and the coasccjuont relaxation of the vaginal outlet
whii-h f<illouB nvglitrt to repair Ibeni.
SloreoviT, tho ohangew following rhild bearing prttlispoM to the oceur-
rence of prolapse of the utrrtts, and an esacerbation should Iw e):pC4rU«l
during the piii-riwriwm in wonit-n wlw have proK-nlid mixlerale degree* of
desoenjius uleri in-fore labtmr. In onier to obtain the lit^t rt^iiiu, and to
prevent serious diMiliiJity. an early operation is imperative, since the diffi-
culty of rectifying ihc condition ib-jjcnilo largiely upon Che cxlral of the
prolapse- and llx- lrti<.'lli of time that it hal^ lieen allowed to «xt8t.
Obstetrical Paralyses. -Puralyitc (tindiiiom' may di-tvlop in either
mother or child during the puerperiiim. Tliat liranchft* of the sacral
plexus Nunetimoit itiilTer from pn-^^urc during lalxmr is flvmunstrated hy
the faet that many patients complain of inti*n.-<e nenraljtiia or of (rramp-ltk«
painn exlending down otic or holh leg* ae smm a» the head l>cgins to de^^'nd
into the pelvic canal. As a rule, of codrse, llitt <t>inpr>»^ion i* ruMy M-v.-n-
enough to gi\o riw to grave li-^ion*. In some itu^tancefl, howerer, tin- pain
cotitinueti after delivery, and is aii.i»m[wni<til by tltu development of pataly-
sJR in lh« muwle* supplied by the extemul popliteal in-rve — the flexnry of
the ankle.4 and the t<.vtejisor< of thv toi-* — the gluteal musdn* occasionally
becoming afFivteil to a lesser extent.
The Kuhjcct lirtH bMHi t-arefuliy Mudicd by Utinermann, ]]. U. Thomas
and UiiiMlin. The investigations of tV' former MUpplivd a vury aati^faeton'
explanation of tlio common localization of the |iaralyrtitt hy showing tlial
th« cxtcmiil jioplili'ul nerve receives fibres from tlie fourth and fifth liimlHir
roolri, and that tlicsi- nn their way downward to join the Mieral plexus pass
over the brim of the pelvLfi. where they are e.\pm»d In dangur ftx>m torn-
OBSTETTRICAL I'AllALYSKS
907
■
prpsiion. wliPrea* tSc low«r rotrts wliich li« upon the pyrifannU mnsclc nre
ninn* prolwHsl.
Iluncrniann coiuidcr^ that tln^ t-hanvw of injurioiiii prvwurv htv grvat-
fHt when.' the pelvis U Renerally contra<:t«]. and lesH so in tlie rhAchitic
vam-ticfi. inufiOiiKrh a^ i\w projcctiiif; pronmntop,' in ihu laltpr tpnd« to pre-
V(-rI IIh: h<-jul fmm cninitig i>i contiicl with llii' m-rvi^. In thi^ iiiaJnHtv of
iiues the injury is the result of direct prcwhurt' excited by the child's brad.
and onlv cxn-ptioRaliy i« eatimd by 1\k furc<-p».
In view of the fact that only one oblique diameter of the tmperior strait
is ocfupifd by tlw greatest diaim-trr of tlK- head, it i« r>-<ulily iindervtood
why the iiaralvi'iii >n u^iiaUy Itniiicit to one le>;, Th»ina!<'i< ruse being tlie
only i&Htance on record in which t>oth lege wvre alTM-t«l. The paralytic
■lyinpioiii* usiudly ftpjn^ar immediaiely afii-r delivery, and may Ux^tnie per*
manent unless <>uilalile thenipeutie measures, muru particuhirly the UM of
eirt'tririly, an' Jinimpllv iiiiititutH.
In other caiics paralytic symptoms accompanied hy inteii>e neuralgic
pain* following the toiirM; of lh« »cialic ncMf. follow {iclvic inflammatory
tronblfti. The condition it luimciiiiieH due to the development of a neuritis
affivting certain braiichtw of the »arral plr\u». whik- in oilier vauvh pressure
exerted hy an inilainninlory exudate in rvHiHin^-iblc 1 have neen a nw of
the latter character which piTsicled for yearn in epite of continuous treat-
ment, and which diMip^n-ared »» if hy magic after lapanitomy and iIm' repa-
ration of lite adherent appendages from the posterior and lateral portions
of the pelvic wall.
WiuM-heid has direct«'d particular alt«-ntton to the nrc cai^M of ntttnfw
which follow delivery. The inflamnialion may be general or localised. lo
the Utter, only one or two nrrvi-s an; affi-i-twi— thv molian, ulnar, or cniral
— and atrophic »yinploms eoon make their appearance. In tlie former,
since a nnmher of ncr\*e» an implicate*! iiimullaneou«ly. eomciimee ercn
those of the face not escaping, the itymptomM may lie manifold nnd the
condition bvcome ni'i«t 6criou«. In either event we are ignorant concerning
the m<>dt' of prmltti'Tton of the m-r^e hi'ionf, thougli they arc »uppomd to
be due to tosic intiucneei-. The prognosis is fair for the localized but
poor for the gencrBliwd variety.
It iM also important to bear in mind that s«}>aration of the ^lymphyoia
pubi», or of one or other Mcro-iliac synch ondro»ii> during labour, may be
followed by pain ami so marktii tin interferem^ with Ineonioiion :l- at fin<t
sight to suggest the existence of paralysis. Moreover, the disturbances in
th<.> function of tliv puMus muMleK and the ndductoK of the thigh, wliicli so
frniuently aocompany tlie early stages of osteomalacia, might readily lead
to a similar error.
A« A rcull of a dilTK-iill laU>iir, and exceptionally after an eaity one, the
diild is sometimes bom preiwnting an affection of the arm which in com-
monly known as Dachtnnt'x parulfftu. In th.it form, paralysis of the del-
toid. infraiipinntuK, and the flexor muM-hv of the forearm cntL»c« the entire
arm to fall cIom- to ibe side of lii« boaly, and at the same time lo rotate
inward, while the fon-ami lnvotnua vAleiMkxl upon the arm. Tlie motility
uf the fingers U usually relnineil.
Krli {Hiiiik-d nul Ihiit siit-li ti pttMlvi* imiW U- rim? nnly to a li^ion
iuvtilving Die liflii iiud iii\lli rooB n{ the brachial picxua, and bbowed
that electrical stimutatioii «1 a poiol from S to 3 ecntiinvtras above the
vlarifli- niiJ rn fronl at l!io tnuisvt-rsi' processt of the sixth curTJcal %'ortebra
— now known as p>b's point— prixlutf!! contrai-t ion^ of Iho niuwlt^ in-
volvwi. lie couBiilcrwl llml l\w ]>nTaW*i* tKH\nfM\y follows compression of
l\uy pb'xii* b_v llirt c-Iavicle in the Pragiie nielhoil of extraclion, more i>ar-
ticularly wtit>n the anns haro become t-xIiinUtl over ibi? hiwl. In ullicr
i-iWN^s lis priMliiftion Is attributed to traction with the fingers in the axilla
of the child, and occa?^ ion ally to the iiw? of forci'iM.
That <'oirijirt-*«ion niav lie PxerlwJ during the employraent of either of
llie tirst two of tbcsc roanueuvres is at ouce cridvnt from a coiiKidcralion of
till! annlomioil n^lnttons. On llic other bAml, the experiments of SInlper
show that the 'plexus cannot possibly bo compressed by the tips of the for-
cqw w> ioiig «* tlti; child pRwerils by the vortcji, althou^i jl may oit-iir in
faee or hn.>w presentations.
Carter, in l^O'J. nas tho Sr^t to direct utiention to tite fact that lh«
comlilion is due to stretching of tbe upper roots of th« brachial plexus
more frwpicntly than to at-normiil presti\ire. llii? re'iittB were ct;>nfirra«l
' by the expentiientJil work "f Kieux. SeboeniBker, and Slolper, nil of whom
demonstrated Ibat the plexus was readily subjected to extreme tension as
a result of pullinjiobliqiK-ly upon ihf hcjid. tbu» sharply ftvxing it toward*
one or other shoulder. As traction in lbi.-> direction is fn<|uently employed
ill order to cffwl delivery of the thoulder* in vertex presentations, it ta
readily «!Wi that Ducbwiue's puraly!<i» might follow couiparativety simplo
or even spontaneous labours. In view of tbpse consideralioOA, therefore,
, in exlracltiig the i^lioublers can- should bu luken not to brinf; nl>oii| loo
gnaX lateral llcxion of the neck. Moreover, in br<w<'h extnielioiw llie
PrHgiic niHiio-nvre *b(nil<l bo eiupbiyed only wiien_ahsoluleIy nocewary, and
particular atietilion should be dcvolcd to pre>'enting Uie exlensirm of tlw
arms over the bead, an il not only inulcnally couiplieales deliverT, but adda
considerably to tbe dauKor of infanlile paralysis.
The pr»/ijnn.-is if usually fair, tbe majority of the children recowrlng.
Occasionally, however, a eoso may n-sisi nil trt-ntmt^nt and tbe child may
remain hopelc^ly paralyzed. All of tbe instances which 1 have persomilly
observitl eiuled in r^Tovery, but in iioinu of tiicm prolonged treatment wa*
neci'ssiiry. In this fonn of paralysis tbe children should l>e promptly pflt
iiiidcf I III' i-aro of n rom|>eleiJl neiinili>^i>l, as the intelligetlt U!« of ibo
electrical current is frequently the only means by which degei)cnii>t<'
cbang(« in the ncrve-« and niusele« ran be ohriatoil, and ncgtect in this
leotard may result in the condition lieeominn: permanent.
Abnormalities and I>)teM«> of the Breasti.^ — t'ompb'te ahsi-nrr »/* lialh
brftutu i^ one of rlic r;iii'>i aii"rniilie!i nf dcvi-lopuieut, while the absence of
one and the normal deinelopmenl of Ibc other breast has been noted in a fi-w
isolated iiimw.
Ilitjitrlr'ifthy of the hreimh is more often ol»erv«sl, hal i« nir\i-rt)io-
Ii-bji jiti infri'iiiteDt iKTurn-iHT. In n large pro|Ktrtion of lite n\N>rdiHt en.-«e«
the coodittOD de%'el<>])ed rapidly iii young unmarried uouivti, both bn?asl«
UISKASE8 ASU ABNORMAUTIBS UF THE BREAtfFS 909
bt-iiig ittiiilkaU'd and occartionally attaining such iiniiiciisu i»roi«irtions Ihat
amputation iMK'ame niicessary. Cauea have been reported in which a single
hreadt weighed more than 50 pounds. The hypertrophy sometimes recedes
during lactation, so that the abnormality does not always afford an absolute
contra-indicalion to suckling the child. Overdevelopment of the mammae is
sometimes observed in men, a number of cases having been collected by
Laurent.
Supernumerary Breasts. — Probably one in every few hundred women
ha.s one or more accessory breasts — polymastia. Reference to 262 such cases
are to be found in Goldberger's article.
The supernumerary breasts rarely attain any considerable size, and oc-
caMonally arc so minute as to be mistaken for small pigmented moles. They
are often provided with distinct nipples. They are most commonly situ-
ated upon the anterior thoracic or abdominal walla, usually near the mam-
mary line; less frequently they are found in the axitlse, and occasionally
upon other portions of the body — the shoulder, flank, or groin, and in rare
instances the thigh. They vary greatly in number, Xeugehaucr having
descril)od a patient with 10 breasts.
The condition is usually regarded as an atavistic reversion, though it
is not associated with an increased tendency towards multiple pregnancy.
In not a few instances an apparent hereditary influence can be traced. Not
all observers, however, accept this view, Ahlfcld holding that the distribu-
tion of the mammary tissue is to be attributed to the transference at an
early period of development by means of the amnion ot some of the cells,
which onlinarily go to form the breasts, to other portions of the bo<ly.
The condition has no obstetrical significance, though occasionally the en-
largement of supernumerary breasts occupying the axille may result in
considerable discomfort to the patient.
Ahnormalitifs of the Hippies, — The typii-a! nipple is cylindrical in shape
and projects well bcvfmd the general surface of the breast, its exterior
Nnng slightly nodular but free from fissurtv, A'ariations from tlie normal,
however, are not nncimimon, some of them being so pronounced as to inter-
fere seriously with the act of suckling.
In f'Ctnw women the lactiferous ducts open directly into an area which
forms a depression at the centre of the areola. In pronounci-d instances of
this so-called (/p/wMxcd nipplr, nursing is out of the question, although
when the depression is not very deep the breast may occasionally be made
availalilc by the employment of a nipple-shield.
More frtHjUcnlly, although not depressed, the nipple is so stuntcsl that
it hardly projects above the surface of the breast, and in consequence can
l(e Seidell bv the child's mouth only with the greatest diHicultv. In the
presence of this anotnaly daily attempts should be made during Ihe last few
months of |>regnfincy to draw the nipple out by traction with tln> fingers,
and a wooden nijiitle-.-^hieid should l>c constnnily worn in the Iiojh' that by
rxertiuf; pressuri- upon llic jHTi[hlu'ry of tlie jiriiilii Ihe nipple il^elf may
be gradililllv m:t<\r Ui ))rolrudc |1h'oii;;Ii II |ii'iiiii;r of lln- sliii'ld (*i-a
Kig. I!l>).
.\gain, it soim'liiiies bapgiens that nippU's which arc iioriiinl iu sliupi;
910
UBSTETRICS
anil siw may present *a liiuurM] or nodular a surface &e to be especially
suKrt'p tittle 111 injury from Iht- child's moulli iluriu); tliv not of iiurting. In
!>uoh rases i^mall rracks or /ijuHrf.« niiiio-'>1 iuevilably a[>pc«r, anil reDdesd
nursing t^o painful Ihsl tlw mother dreatU the approach of the child, anal
the mcutal di»ti«»s so induced oftvn has * deleterious influence upon the
secrotory fiiuplimi. Slnrwiver. nuoh injuries are still more serious in tliat
ihey olTiT a wmveiiieiit portal of entry for pyop-iiic tiartvriii which arw liable
to invade ihe bri'aiol mid ^ive rise to a iiiaHtitis.
Ahnormalifies in the Mammfiry Sfcrrtion. — Marked Individual varia-
tions exiiit in the miiounl of milk seer»teil, many of which are depemlcnt
not upon the );eiieral health and appearance of the iixlividual, but upon
the degree of devi-lnprifiil of the gliiiiiUilar portioitx of tlw bri.'*:'!]^. Thu*
wc often find that a woman who passee.'*eti large, well-formed brca^tA, and
who apparently "hunld l«^^ an cxtvlicnt milk-privlncer, woretw only n small
(juantity; while, on tho other lund, one is often AiirpriMHJ at the nliundnnt
supply pn>duccd by another whoi^o manitiia- are ^niall and (Int. It is a
matter of common ok-x'rvation that .iloul umntin with vrell-forniitl hut re-
dundant brcni^ts usually have n very deficient secretion, the bulk of the organ
being made tip of fatly liKKtiv while (hr glandular element* are j>oorly devel-
oped. Deficient secretion is likewiiie fretjuently nottnl in very young women
and in elderly primipane. In the fonner. the defect is to be attributed to
imperfect development; in ihe latter, to regressive and atrophic chimgctf to
the breasts.
In rciy rare inslnncoH there is au uhsoliito lack of mammary ftecretion— ^^1
agaUtfia. As a rule, however, the defect is uot abNoIuIe, as tl \^ neartj^H
alwari^ poi<vible I" cjiuso at leuet a small amount to exude from the nipplfi
on the third or fourth day of the puerperium, On the otlM'r hand, rela-
tive deficiency is fri'^^uently observed, a large number of women tuH-reltng
an iiiiKiiinl of milk quite iiuuffieient for Ihe nutrition of the child. Tn
(.'hapter XVII reference was made to the variations in the <iuantitv of the
milk (IS wc-ll as the various factors which may he connrmed in their pro-
duction.
pecHsioiinlly tlie niHiiniuiry sccretioo is excessive — polygalana^-ajxA may
even be so abundant that milk is constantly esoiping from tlie nipples.
This latter condition, which is known as githdnrrkim. sometimes continues
for yi'ars after Ihe birth of the child, and is extremely intraclablu to tmt-
ment. Nothing is known as to its cause. Although in rare inslAnccK tlw
health of the woman may ntmnin unimpaired, m » rule sIh' soon begins to
show evidences of the continuous drain Upon her system, l)ecoming irritable,
i|iicnilouB. and cveiitiudly developing .symptoms of cailicxia.
(taliii'torrlKva is best treated by the application of tight bandages aou
iho inteinal ndminist ratlin of fairly large doecs of potassium iodide. Go«id
I'rtcc't* are also said to hiive Imi-ii obtaintnl from the use of chloral. Id a
eerfain numlicr of case_i Ihe iimditiDn is i-ondHniHl uiih atrophy of the
uterus, and several obsenTrs have reported improvement following pn>
eedunw whieli Uiul In bring nlioiit an increase in siae of thw nierua, such
as the use of the vaginal d'>iu-he, local applications to tl»o cerrii. or the
employment of ckvtrinlt.
DISEASES AND ABNORMALtTTBS OP THE BREAfTTS 9U
Duraxrn of the Sipplr^. — Hie mode tif jirmliu-tion an<l tivatnivnt of fis-
sures <>r Ihv nipples hsK alrcnilv txr-n i-oii^iiU-n-'I i» (t<-luil in f'luiplcr XVII.
Hnt/iirgiMtent of the Strrimlx, — F"r ihi- lirsl Iw<-inv-four or fnrty-eight
hours following Iha devclopmeiil of the Uoieal »ecre(ian, it U not unimtsl
for th« broaxt* to booome immoii«>t_v (list«D<li-d. and to olftrr on ]Mi1pat!on s
Tinti, lUKliilar rosiHijimv. 'VXw ronditiiin. which !■> (>nmiiK>nl>' known «h
" caked brtasl^' nfit'n ;'ives rise to a criiiAidrmMp flrprty? of pnin. tind in fn"-
qiii'iitlj aroom|)aiiinl l>v n Kli^irlit vU*i'Hli»n of tt<tii|)(Tiiiiin>. Wilhin n day
or so the engorgement usually pasws off spontaneously or n* the rwult of
appropriate trcMitmt'nt, (hough in wmi> t-aot* it pcntii'l« in Mpitc of all that
can be done, and may W a for*n»nnor of the di'velopnienl of a nianimary
abaeme. It is prohalilp tttnt tlR> vxtn-KsiTf distant inn of ihi- (>lan<)uUr por-
tion of lite hreaiit lentLi to iilt)(ht tix^ue ettan^J. thereby olTorini; a locus
tninoris resistenti^ for inruAion by baetvria. which an- uxtiully prvMiit iu
tlie luitiferonii duot^.
WlH-Qt-ver the breast becomes markevlly ^n^rp<d, immediate Ktepa
xhouM Ik* tak4-n to nOit'rv ihv conililion. TIiih i* most roadily awoniT
plisbed by drawing the breasts lirmly a^net the thorax by meam of a tight
l>inil4T, uml if mi^w»ary giving { grain of i-odia. whit-h may lie rejxiited
in three hours if necessary. I'snally this will relieve the eondilion uithin
twenty-fimr hqim. and tht- physicinn is caiiiioniil not lo !>■■ too hai^ty in
resorting to other measure*. If the engorjifenienl does not show signs of
Eubetding nithin this period, and particularly when the child la unubte
to draw off a sutHrient (juantity of milk, an Rnglisli breast-pump should be
eniployod ti> r*?move the excess. Sometimes this procedure ]>rovcs ineffee-
tual. and relief can bv obtained only by proper niaN^ge. Tlie uur^ baring
anointtnl iIk' palmar nurfaccs of her haiidn with olive-oil, mixed with
oqual parts of laudanum If the breasts are very sensilire. makes strok-
ing n>ov«>nien1s, iH-ginning at thi- p-riph^-rv of the bn-MKC aiu) grailually
approaching the nipple. At first liie manipulations should tie made very
gently, bm ii« the juilicnt twcimes aecuxtomed to them more force may be
employeil, which will soon cause the milk to eynde from (lie nipple, .\fler
tlin brtMUit has been emptied, tlie bandage should be reapplied, as it not only
relieves pain by prerejiting the overloaded organ from sagging downward,
but at the fanw time mttck to diminish the amount of secretion bv dimin-
ishing the blo<H] augiply. Judging from my ''ifHTiiiiii-, the breai^l-pamp
and ma^^ge will be less and less frequently tiiwd. as one learnK to apply the
baixlugi* properly un<| apprrciuttv iIr' fact that the engorgement is usually
transient. In many instances 1 believe tliat Ihe u."!- of iIh-^w mt^a«ure$ often
defeats the rery purpose for which they are employt^I, as they uliniiilate
ratlwr tlian diminiith lite MtTCtory activity of the brwsta.
Occasionally thu engorgement persist!) in spile of all (hat can be dune.
In inich caf«8. if fte\-eral da>-s of persistent effort prove nnavailing. the
inlenwis of iIm; patit-nl will U- bt-st sub^erw-d by dmng up Ihe breasts. a»
a continuance of the condition is alma^t sure lo eventuate in alwi^* for-
mation.
Drying up Ihr Brtaxht. — In rare e»K* of ubHlinatv engorgement, but
more fretiuenily after Ihe death of the child, or in cases in whicli for one
012
OBSTETUICS
n?itM>p or aitollMT tlio cnnlinuance of ItK^tation U tbniit^tt amlo.'^iftiMc^ rit{t*
iiittft Im! Iiikcn for dipckiiig itin iHrtc-til MiL-n^tioit. or " (trvin^; up iIig milk.''
a* it U Bnually (Ivwigimtivl, rmiinTly tliU »«-■< wcomiilislinl liy llii- us«
of the biodvr. Lilt* aiiptit^alinn of Iji^llaiionna ointuieiit, sntl (lie eiiiployinent
[if ilio )irt>asl<pump and ma»i8)^ vrlicn th? eni:nr);iMni-iit bocanie pronounood.
TIti' proo^ss was fri'ipn'iillv vt-rv piiinftd In 1h« [Hi(i<>iit, vt-rv l-n"il>l«»">inw
ti> the Dume, nnd usually hud to be einployod for a week or ten dava or
r»-»>n InnjKT bt-foro Mh' ilt«irwl ri'-*u]l w«« otiliiimsl.
In I9ti-l. Dr. K. II. Levis of WcMcHy. II. 1.. told me that Auch truat>
incnt was wnjiewwMiry. mid tliiil iinifh imiro MHisf<wtory ixwiilti- cniild l»e
ohiHitiiil by thft ail miuisl ration of 2*1 graina of {toianxium aivlato evt-ry
six tiouis. ] iinnM.-dialoly put hiit suggMlian into prdctico. and found tiiat
tlii; briiH*l» driiHi up in the cownto of two to four days without olhgr ttvtii-
mont. KiirtbiT iiivvKiigutiouh', however, showed thai tho ]»las«inni aivtato
waf of no vahx^ as eiiually satiKfaobiry n.-!>iilts follow if dni^ »n- not iim^I.
Acpordiiigly, whwi it is dc-xired to " dry up " the breai^ts, no binder or
applicttlion of any tmrt it em^^oyed, but Ihv bnui^tic are li^fl nWilulvIy alunv.
In the TOurse of twenty-four hours they lierame more or less enjjorjrcd.
and soint-liuKV v<-rv guiinful. If l)iv guin iif lU'^vrv, } grain of ivkU'Io i^
adininiisten^j, and repeated if neoetmary, but the breast-pump or utH.-uia^M
i« not vmph>T<^i]. Williin a few houni the ongorgemont bi-pns to oubsido
gpnntaneouiily and the amount of iws^retion to deereai>ft, su> thai t\w brvaflu
become soft and pnink^s by the end of another tvrcnty-four hour?*. With
each !tuat^'<lin^ day tho milk liceomt--'' tt^w and li^** al>iiudiml, and Klmovt
entirely disappears in the eonrse of five or sis days.
Since 1 have employed thi» mt-thod in my clinic^ the use of l>ellni1onaa
ointmi'ni, thi» breaHt-ptiinp and nva^<>a^- luij< bcten iMilircly abantlniuil, iw
well as ihe tight breast binder, though when the breasts are lar^ and pon-
dulouii, lli<>y iiiay la: hehl in posiiion by a louwe liauda^.
H. J, Storrs, in inUT, publislied a report of i?] cases 90 treated in
my clinic, and vtaled thai iho nvulis wt're iiionI «atiitfactory, as not a
single bi-east abscess had dereloptii, and that less than one wunian in
Nil cornplaint-d of »ul1iciciit paiu to nvwmitato (he adminixtrutton of a
setlative.
Inflammalion of the Jtrtvuts — MastitU. — Parwichymatous inflammation
of the tnaminary inlands is a not infrequent complication of the puer|HTinni.
The symptoms hardly ever appear before the end of the first week, and as
a rul« not until (HmHidt^rably tiiter. Marked en^irgemcnl uxnally prfcodi-;'
tlie inHamuiatory trouble, the first sign of which is aiTorded by diilly iva-
«attoDH or an actual rigor, which t* «<x>n follovrvd by a constderablo rise in
temperature an<l an inerea^e in the rate of the pulse. The hn-iust twvomu*
hard, its surface is reddened, and the patient complains of acute pain. In
many instami*, by ihe end of twenty-four houw the condition disappear*
spontaneously ailhout treatment, lieing often favourably inlluenoeil by tlie
application of a tightly fitting bandagvi. But if the s^taptoms permst for
long<?r than fnrty-eight honn<, ."Uppurallon is lo (»• expt-cled. The proee^s
may remain limited to a single lobe if the first altsce^ is o]>enMl promptly;
hilt if left to itself the breast is liable to become undermined in all direc-
DISEASES AND ABXORMAI.ITIES OF THE BREASTS 913
tions, and, as a result, ^he destruction of tissue is extensive, antl the exter-
nal surface may Ih- it'ft riddle^l with niimcrDus fistuliiiis tract*.
In some cases llie constitulional symptoms altciidin^ a rnaitiinnry al>s(x;s<j
are very marked, and sometimes lead to a fatal terminulion, whereas the
local manifestations may be so slight as to escape observation. Such cases
are usually mistaken for puerperal infection, and give rise to nn lillle
anxiety until the examination of cultures from the uterine cavity harf
demonstrated the absence of bacteria. On llie other hand, a certain nuiiilMT
of cases pursue a subacute or almost chronic course, the breast tn-ing some-
what harder than usual and more or less painful, but constitutional symp-
toms are either lacking or very slight. Under such circumstances the first
indication of the true state of alTaira is often atTord<^d by the detection of
fluctuation.
etiology. — Ma«titia is always the result of infection, pathogenic bac-
teria from outside gaining access to the breast through fissured nipples
by way of the lymphatics; or else some of those already present in the
lactiferous ducts meet with conditions which enable them to invade the
tissues. The researches of Bumm, IJiinigmann, Kocstlin, and others, have
demonstrated that Staphylococcus albus is present in 80 to ;i4 per cent of
all breasts. Ordinarily, this micro-organism lives in the milk as a harm-
less parasite, but when the tissues are seriously altered as the result of en-
gorgement, it is possible for it to become pathogenic. That this occurs,
however, in only a small proportion of cases has lieen shown by the re-
searches of Rubcska, who reported the following Imcteriological findings
in ll> case.s of mammary abscess:
Stapby]ocoGcu« aureui 9 c«aea
Staphylococcus BUreUB and albus !) "
Staphylococcua albus .1 "
Streptococcus 1 case
Exceptionally, other bacteria are causative agents, Sarfcrt having demon-
strated the gonococcus, Chassot the bacillus pyocyancus, und liittlc the gas
bacillus.
When the infection occurs through fissured nipples, the inflammation
is usually phlegmonous in character. In some cases it involves only the
connective tissue beneath the breast, a large collection of pus Iw-ing formed
between it and the thoracic wall — retromammary abscess. Again, the infec-
tion may be limited to the areola, beneath which small abscesses, rarely
exceeding 1.5 centimetre in diameter, may develop — subareolar mastUls.
Id rare instances the affection may be erysipelatous in character, and be
limited to the superficial tissues.
According to Winckel, 67. ti per cent of all cases of mastitis occur in
primiparffi. but its actual incidence varies acinrdiiig to the care given the
patients during pregnancy and the puerperium. Thus, the statistics of
Rubeska show a frequency of 0.54 to 4.1 per I'ont in the various fleniian
clinics. Generally speaking, it may l>e said thai the occurrence of mastitis
in more than 1 per cent of a large series of eases is indicative of neglwt on
the part of (he physician or nurse.
914
OBSTKTRICS
Trealiiifnl. — Tire orcum-iicH' of tnni>titi'< y«ii Ik* prpv4'nlrd in i;rcat part
lijr )'tin4il)k- pr'>|>livlai'li(- mcjisuns, wliiih rimiii1_v [imHi!<l in )>n-vcnliiix D"?
devclopnieot of fii^urnl iiipptcs or trualiiig thum properly after Uk'j liare
appuun-d.
Th« itn»*t suitable measures for hardeniog the nipples during pregnaor-y
so aK to enable (li<:[ii to bittlur wilhxUiK) ll»^ ilraiii i>f iiiirxiii);. hitvu atrt.fiily
bccD mviilitHivd iii ('hapliT XVII. When lactation becxtmee establii«h<H]
the .^Iricledt cleanliDe§« t^tould be ob^iirvMl mikI lliv nipples watclHtl ino«t
carefully. As soon as a tissurc bc^iiif to dtivetop a nipple-iiliivlrl lilwnild hi>
cmployi-d, Ihe child ii')t Ihho;; allowed to apply the mouth diropth to tlio
nipple until healing has taken place. In the intenals between Ihe fe^xlin^
the sore nipple should Iw covered wilh a piiri? of absurlMait ootton )U)«k«il
in a iiaturated xolution of boric aeid. The various applications which
are usually recommended, however good in lheiiiH.'lvcs, wiil provi- prac-
tically valurlewi unloiw the nijipie can he j>la<i-d at comparative resl,
ffbich U best afforded by the iLse of a suitable aippte-sliield. If tlic con-
dition becomes worse after some days' trial nf this treatment. H U od*
Tisable to wean the child rather than take the risk of infection, whicli is
so pni;u- to follow if the deeply fissured nipple be uw'd for any length of
time. Finally, it may hi" said that ton ^reat xtretu cannot lie laid upon
prompt attention to enj^or^roent of the breasts, as its prolongetl jwrsbt-
ence i* nearly always f<ill«wi'd by abscess formation.
On the first symptom of mammary infection, the breast should he put at
rest a8 far as possible by not allowing the child to uurw^ it. and wilhitniwin^'
the milk, if tHYCjiiarY, l>y mean» of a brcast-pttmp. .After being emptied
the breast should be thickly covered with cotton, and by means of a tiglitty
filling lumduge subjected to the greatest possible pressure ponjiistenl with
the comfort of the patient. In many cases such Ireatment apparently cuts
»ihort the proiTK--^. ihe symptoms disappearing within twenty-four hours,
after which the patient ih able to resume xuckling Iter child. Fanally.
however, the process sooner or later eventuates in abscess formation. In
such oaseji the brea.*l« iihould be carefully walcliiil and inciiwJ a:" *oon as
the slightest evidence of fluctuation can be olitaimii. In early cases Hicr
rejiorls eurlient n^ults following Ihe use of his method of artiGoial liyiwr-
semia. Pmcrasti nation is not ])ermi«<ihlc, d^ay boing «ynonyinoufl villi
exIeiiKion of Ihe pnx-ess. which frc<|ueiitly leads to such extensive destnie-
tion of lissue as to deeitroy penuitiienlly the physiological function of the
organ.
The inetttion* nhoiild Ite made radially, extending from near 1l»P areolar
margin towards the periphery of the glaud. in onlcr to avoid injury to the
iHctiferous duels. In early cases, a single incision over the most ilependent
portion of ihe an-a of fluctuation is usually sulRcient. but when multiple
abscesses are present sewral incisions may be n^iuin-d. The operation
should always be done under anaesthesia, and the obstetrician should not
consider Ihat it has In'en completed until he has introduced a (ing";T through
the incision and carefully explored Ihe inU'rior of the breast, breaking down
the partition walls Iwtween the various pockets of pus. so Ihat only a singlft
abscess cavity is left to be dealt witli. This should llicn be looixyly packed
PUERPERAL INSANITY 915
with gBtizo, which ia removed at tlie end of twenly-foiir hours and tlic oavily
waahc<l out with Kterile salt solution or a !i-|>cr-ccnt iHiric-acid solution.
after which another pack is inserted. If Ihe pus has inx-n Ihoroughlv evaeu-
ated the ahsec»s cavity heeomes obliterated uitli u rapidity wliich is some-
times surprising.
Gaiactocete. — Very exceptionally, as the result of clogging of a milk duct
by inspissated secretion, an accumulation of milk may take place in one or
more IoImis of the hreast. Ordinarily, this is limitf<l in amount, but may
lK*oriic exee.isivc and form a fluctuant tumour which may pive rise to
pressure .-iyiuplouis. In many instances, massage and the application of a
tight bandage will cause it to disappear, while in others the structure may
attain such a size that puncture becomes imperative.
Paeiperal PiychOKi. — Reference has already been made to the altera-
tions in the mental condition which may accompany pregnancy. These
vary from slight changes in disposition to actual insanity, though fortu-
nately the latter is of relatively rare occurrence.
The insanity of pregnancy is usually a manifestation of auto-intoxica-
tion, and may lie accompanied by melancholic or maniacal svmptoma. It
usually persists throughout the remainder of gestation, hut disappears
shortly after lal>our, unless thp patient has an hereditary tendency to mental
derangement.
I'uerpiral insanity, on the other hand, is much more common, and
according to the statistics compiled by Berkley and Jones is noted once in
every (ilti and 1,100 labours, respectively, though my experience would lead
me to believe it less frecjuent. In former times it was a comparatively eoin-
mon coniplicQlion of the puerperium, and it would seem that the intro-
duction of aseptic nielhods into midwifery is responsible for a reduction
by one half in its incidence.
The affection usually makes its appearance within tlio first two weeks
following delivery. When it occurs at a later period it is designated as
iactationnl imtunitij.
Puerperal psychoses may be due to one of three causes: infection, auto-
into.xicalion. or direct lability of the nervous systotu. Of these, infection
is by far the most iinportant. This fact has long Iiwh rccogni.ied, but it
is only of hile that the liiu-tcria concerned have Iteen identilieii, and then
only in n sniiill pn>j>ortion of the cases. In 'i of (he :( instancrs which
have eiuiic undiT riiy ohservalion, Ihe infeelion was dm- to Ihe stn^jilococcus.
and in Ilie third to the streptococcus and colon bacillus. Ilerkley likewise
reporls a case due to Ihe organism first rnenlioned.
.Vulo-inloxicalinn is also a fref|uent a'tiohigiial fai-lor, and it is probable
that the vast majorily of mental derangements following eclampsia are due
to this condition. Ordinarily, insanity is regardcil as a rare complication
of eclampsia, though Olshausen observed it in (1 per cent of his 515 cases.
Acconling to Hansen, and Picqu^. infection and auto- intoxication are re-
sponsible for more than 80 per cent of all cases, while the remainder are to
be attributed to other causes, occurring particularly in women afflicted with
hereditary tendencies, the exciting cause of the insanity being shock.
extreme mental depression, or the rapid loss of a large quantity of blood.
M
916
OBSTETRICS
Till! pucrpi-nil |iKVclu>i'v« an> tisiunlly diiiraotcriaed \>y gnml Kiicitvnw:nt
ihifmg ihv Rml hv ilnys, DiuuM-Mlml willi all nnrU nf h9illui-inatinii>. I^Iit
Iho ninniiiciil ^viii|il<iiii> fltKitppi'ur. ami ifif jintiTrnl paiMw iM" a titiiditi'in "f
ilepr<*.-ioii, aii'l frxijiicnlU- cxIhImIh ^^ihi'kIhI IciHk'ticii'M,
Thf pnigiic'i' i» iii'i»l finmirnliK- in tin- tiisc* follovtinf; wlMm;i>'iii. tln^
iiriijiiritv «r llitwi- [iHlii-JitH «?ciivurin^. (In the otliur hand, thnge foliowirig
inrectinu are very ttHliniH. and 80 to 40 per ct*iil of the vnnuit fail to tvcruiii
llK-ir nifiilnl upiililiriiiiit. It ik not iinu:>iml for the itifiilal di'mtiji^i'tiiciit
In ItiHl hr friiin tlirw l<i #i-\ nionth«, allliou).'li tlu" pro-pwl fur r»v"v<"ry ia
poor if tlic IttKiT jkt(imJ is oMi\iliii, ll U giinTnlW »liil«i timl frnm .'t to
III por ("Mit of lilt' paticDtti afHUted with puerperal inttanjlv di«-. this high
mortality ralu U-ing due, of counu, 1o tW i:iid<*rlyinjr iufvrlton and not to
llio mental dcrnnKi-niont iti^lf.
In caiiP'' followinfr infection, the treatinciit n^hotild fii*t bo directed to the
underlying oniidtlifin. and the diri'diiiiw de.-nrilieil in ['Itaplvr XLIII rigor-
ouhIv followed. The acute iiianiacat t-yinptoms f^hotild lie met tiy thu uduiiu-
(oiration of i»>daliviv, and llie piitieiit xliotild bo w«telM>(l nioKt enrffully
tUrniij-hout hiT enlire illno^-i, more |iartieidarly diirinj; llie iM-rifxIi* of de-
pre-vtoi), tliiriii); nliii-h *\n- *hoidd nevt.T be left bIhik- fiir fear timl .ilie may
do an injury to Jierwlf. If prompt iinproTt-ment does not follow the dis-
appearanw of ibt; ^yiiiplomt awrilmlile 1» tnfwlion. lite [lulieiit nhoiitd be
plared in oharf!e of a eonipetent psychiatrist.
Typhoid Fever. — lliii; i« not an infrtiim-ril (viinpltcalion of IIr- pncr-
[lerhim. IIt> ciiiirse, howerer, varies but Utile from that ob»er«'d uniler
otii^r mnditionfl, allhou;rli the progno§is is necessarily somewhat intlueneed
by the faet timt ilii- patient i.* aln-iiily deliilttalwl by tbo strain incidi-nt In
labour. The dia;;nosi« should never be made unleivs a delinile Widiil reai-
tion ejiii Ih- ilenuin-ilrulti!, inusmin'h n« all the other fvinptom-i of the dis-
ease may lie a.-wnciateii wilh a pinlonged puerperal infeetion, eH|>«eially wliitn
tiie mdoeariHuni is invuUed. Furthermore, llic »i-calli>d typhoid eondi-
liiKi (> iifli-i[ I'lii'Kunit'nil in varion.i fonrin of jtra-iiiin.
Malarial Fever. — In eerttiin districts the puerperium U not infreqnenilj
eonipliiuli'il hy nialHriid infn-lion. .Mlliough the rourH" of the diwaw i'
not materially indueneed by the fact that the |)alieut has reoenily given
birth to a eliild. it i* iuUrreHling to note that lalKiur. no less than i^urg'tml
prnwdures. sfTini* lo preili^ijHisc to a reerudoru'enit? of the disorder in women
u'liii iiavc nin-iidv >n irci'ii! frntn it. the typii.'al plienoniena ofirn appearing
tliiriiifc the fimt few days of the puerperium.
Too miuiy »ins of otnisKion mid coMiiniKsion on the purl of the otelulri'
fian have undoubleilly been cloaked under the dia^oaiA nf " nialuris." At
the prewnt day. whenever a patient presents a temperahire ohamelehW
hy marked remUaions and possibly by ehilU, puerpenil inbirtion slwjuld I"*
sii»p<-eU<d. and tl,ic e.xistenee of tnalarial fever »l)Ould never be acrinuKly
entertained unles.4 all other poK^ibilitie!! have Ixi^n praelirally elimiiwlvil
and the c-haraet eristic pam^iites ha^x- been foum! in tlie blom).
,\i* .ioi>n a.* a positive diagnnsis hii* Ixvn Hiwle. tptiniiK- i^hould lie -fiitu
in flullieientiy large doses to break tip Ihft altaek, «» it e\ert« no apprf-
ciahle infliwniT upon Ibe niarnmflrv s<,>crotion or the weU-being of the cliild.
Di8F.A8E8 UF THE PUERPEnil'U
Pneumonia. — Croti|muH ]>tK-uin<>iiiii Sh a nrp ntinpticiitiiiii of the gtucr-
]M'i-al -liilc. unkis- tliu (li>««iH.- h«t< pxiiilcd \x-low Um' oftM*! of lalmur. Ilin
oiiiliMik It xlwa>> hrnmi<^.
TIk' Miiiliir vHriHv, i>r l)rr>tu-tf>-}>iii-iitii<iiiiu, is nfU-ii n ItTiiiiiml pnio-wi,
nnc] ii> <iii« of the iixwl foi»in<in cjiumw iif dciilh id pali^'nlit who utuMnintb
within a fi-it da.VTs followinjt an pclainplic attack. The trcalnicDt dw^ not
iliffiT ■■sM-iitiallv from lluil nnpl"_v<-d at otht-r tinM>«.
Scarlet Perer. — Alilmiixh uoarloi fovt-r is rarely eiKount*r««d during the
ptwrpcrium. iti' nti-iirTrnt^- lias given nn: to a gn^t dt-al of iliMruN'toti and n
very (vuiKitiernUli' lit(Tiiturt>. Tlic inUTc^it ntanifc^ied in the disease h
targply to be accountetl for bv the fact that a (trartatinifortn ra^li is ocn>
Kionalty oliM-r\'i-<l during tbi' roiiriio of n [iiHT|H-ral iriforlion, M that in
many caii'^H a difffrfntial diagmxiiH booomt'K rtfry difliciilt.
Kpidvnii<^s of iirarli'l frier in ihu j>uiT(MTitiiii bavi- txicn reported by
BoAall, Mevor. Aldfeld. and otliers. NevtrtheloKS. it would ap|>ear that
tlic piicr{K-ral nonian i>^ to a t-crtain cxirni itnmuiK' fruTn Iht; diH-nM?. iaa»-
iniwh an staiL-"lic-i jro to uliow that only a wmaH pro|>nrli"n of those expoited
to the contagion boivnu.' iiifwItJ. Thus, Meyer found tin- rnle of ni'irbidiiy
to be about t per MMit anton^ hi« patients.
It is gt'Derally «tat4.>d that infection may occur in llie usual innnner as
well ax hv thf (-nirancc of ibi? niMiifio iMtinon ibr>nij|[h wounds aUmt tli<- geni-
talia. The belief in the possibility of the latter evenlunlity i^ lia^^t'd upon
tlw fuvl that tiMt ra^b wnuionally 8p|H>an< fir>t in the iivigblioiirhixNl of ihe
rulva, and tbt^noe .ipreadu to oth»T portionii of the liody. Moreovf r, the fre-
quent KHiux-ialion of pelrie inflninmalory troubles, and tbe occasional Im'uli-
zalion of dipblhcrilii' palrbex in iho vulva or vagina. iii:<lMi(l of in ihf throat,
are advan»i) in support of the view. Modern baeteriological iiivt-sligation.
however, hail di'Tilroyed tin- forev of ihix la*l argunit^nt, nini'O it Itaa iihovn
that the w>-(-alled diphtheritic deposila oceurring in the throat in scsrlot
fc»*i'r an- dm* to a miiH-iib-nt Ktri-plmiM-cir iiifiieliou, Moniiver, nini-e Aurh
conditionii bIjouI the ^'enitalia nitiialls have a similar origin, it uoujd appear
ilillicult to diffen-ntiale Ix-twi'en llwisc- nunplicating scarlvl fever and the
rarietiea occurring during the eour>« of piit-rptra) infection. It is also
urged that the ap|iuirunee of tbe diHeasi- on ttw tbini or fourth day of the
puerperium Npeaka in favour of traDAiniiMiau of contagion through the
g«-nilalia.
In fnink cunwo, ibe diagnosio i* n'mlily iiuuli! from l)u> exiMUnce of a
elm fact eristic rash, which is later followed by desquamation. Moreover, the
^trawlK-rry tongue, tbti developitvi-iit of pM-iido-dipbilnTitie patches in the
pbarvni. I)h' apiK-aranee of albumen in tbe urine, together with a hip^or}'
of exposure to possible contagion, usually remove all doubt. On the other
hand, in llie aWnre of chAravlerixtii: niunif««t«tion>L. llic diagno«t« cannot
br made, it being often impoit§ible to differentiate lietween warlet ferrr
and puerjicral infwiinn, even when a disiinel biniorj- of exjwwure to conta-
gion can be elicited.
Tito prognosis is largely tbe same as under other eircunutaiMcs. mild
forms, a* a mh*, iixling in rccovwy, whvrvaH patient:! affKrted with tbe
liiemorrhagic variety usually die. The puerperium appears to exert little
918 OBSTETRICS
ctrect upon (he cniiriic' of the diwoasc. tiie tk'Hth-ralf! nnt Iwinff higher than
uiidiT nriliiiiirv iiindilintis. TIr' child iiiiiv or iriav not !»■ i ii fdrtcnl.
Mi-itxli's anil xiiuill-/Hu- (uras ion ally occur tliiriiig llu- jiui7r]K.Tiuin. but
Ihcir oiursi.' dix's not differ maUTiaJIv from (hat observed in woniL'ti who
have not recently given birth to children.
Diphtheria. — True diphtheritic patches, in which the Klebs-Ijoeffler ba-
cillus can lie dcmonHtratcd, occasionally occur upon denuded portions of
the vulva and vagina. They may be due to a primary genital infection,
or be nierelv pari of a procerus primarily localized in the throat. Ino-iiuuch
as pseudo-diphtheritic patches in the genital tract during the course of
puerperal infection are of frequent occurrence, the presence of n fibrinnns
exudate about the vagina or vulva should lead to a diagnosis of diphtheria
only in thoi*c cases in which the characteristic bacilli can l)e demonstrated.
If the process is limited to the genital tract, the constitutional symptoms
are not severe, and the disease usually pursuesi a benign course, readily
yielding to the employment of the anti-diphtheritic scrum.
LITERATURE
Ahlfeld. Spaltung der AnUge der Brustdriiae. Polymastie. Die Misabildiing ilea Meu-
Bchen. Leipzig, 18S0, 110-113.
Uetwr Exantheme im Wochentiette, etc. Zeitscbr. f. CJeb, u. Gyn., 1893, xxv, .^1-44.
Berklev. The Inaaoities of ths Puerperal Period. A Treatise on Mental IHse&aeit.
1900. 307-328.
BoXALL. Scarlatina during Pregnancy and in the Puerperal State. Trans. Lond.
Obst. Soc., 1889, XXI, 11-77; 126-154.
BuMM. Zur Aetiologie der puerperalea Mastitis. Archiv f. Oyn., 188fi, xxvii. 4fiO— i»4.
BuHCKHARD. Gangraii tier unteren Extreniitiiton ini Wocheiibetl*. ZentnUbl. f. ( [yii.,
1900, xviv. 1381-1384.
Cahteh. Obstetrical Paralysis, etc. Boston Meil. and SurR. Jour., May 4, 189.3.
Chantemes.sk ct WiiiAi.. Uechercbes aiir I'etiologie du t^tamis. I« hull, mM., 1889,
No. 74.
Chassot. .Seplicpinie hCniorrhagique fi la Hiiite d'unc ntaftitc puerp^rale causae par le
ntaphylorcHjuc et le bacille pyocyanii|oe. Unit, do la soc d'olwit. de I'arii, 1904,
vii, 100-170.
Ckiahi, Bhaum iind Spaeth. Ap<|iiirirte Volumsnbnahme (ica l'teni«ki)ri)tTs. Klinik
derl^eb.. 1854, 371-372.
Denkux. McHioiro siir Ioh tumeurs saiipiines c!e In vulvc ul (In vagiii. Paris, l&to.
niJiiEiiLEiN. Die Atropha uteri. VeitV Handlmih der (Jyii.. I8il7. ii. 3!M -WL*.
DucFtEVNE. I'uraiysie" obst^trioiiles in fun tilts dii menilirc .-iiijii'rirur. i>e Telecl risu-
tioii loculisiJe. Pari,s, 187-2. 3]ne »ki., ;t.'.7.
FiEtix. I)e la patliog(5nie iIuh paralysiuK br.irhiult.s chez le noiivean-ntj, Amuilcs de
gyn. ot il'olist., 1897, xlvii, .'12-04.
(IijLDBEKiJEn. Ein scltcner Kill von Pobiuastie. .\rrhiv i. Gyii., ISO.'i, xtix, 27'J-277.
GoTTscHALK. BeitraR zur Lehre von der .\trophia uteri. Volkmann's SamiiilunR klin.
Vortriige, N. F., Nr. 49.
Hansen. Ueber daa Verhaltnis.s zwisrhen der piierperalen (ieisteskrankheit ii. cier
puerperaleiL Iiifeition. Zeitschr. f. Geb. u. Gj-n., 1888, xv, 60-127.
Heyse. Uelter Tetanus puerperalia. Deutsche med. Wochenschr., 1893, Nr. 14, 318.
HovidMANN. BakteriiJogiHche Untereuchungen illier Frouenmiich. D. I., Breslau,
1803.
DlHlvASia AND ABXOIIMALITIES OF THE Pt'KUri-JUUM 919
HuHMiiiN. Ucber puriphere SchwangerschaflxlahniunEeD. Miiiicbetier iiieil. Wwbeu-
schr., 190.5, Sr. U.
llr.NEKMANN. Ueber Nervenlahmung im G«biete dcs Nervus JHchiadims infolgc von
tjitbiiidungen. Archiv f. (iyn., 1900, xlii, 489-512.
Jacuubt. Ueber Atrophia uteri. Berliner Beitriige lur (Jeli. u. (iyn., 1873, ii, 1-11.
JoNBs. I'lierperal Inmaity. Jour. Obrt. and Gyn. Brit. Emp., 1906. iii, 109-13.5.
Kbktma.nn. TeUiDUs puerperaJiii. Monatsschr. (. (iet>. u. (Iyn., 1900, xi, 527-539.
KiJHTUtN. Beitragc lur Fragc dcs KeimgcfaaltCH der t'rauen milch u. lUr Aetinlogie der
Mastitis. Arrhiv f. Uyn., 1897, liii, 201-277.
KUxziu. Ueber das Hatmatom der Vulva in der Vagina. D. 1., Tijbingen, 189-').
Lafonu. De la gangrene des niembtes inf&ieurs dans les suites de couches. TbAae dc
Bordeaux, 1901.
Laukent. Ijynakoiiiaxtie, etc. Bibliothek fur Social wissenachaft. Leipiig, I89ft, vl.
Meyer. L'eber tScharlach bei Wiwhnerinnen. Zeitachr. 1. Geb. u. (iyn., 1B88, xiv,
389-3.'il.
XiovuEBAUER. Riiie bisher einiig dastebende Beobochtung von Polyniastie iiiit 10
Brustwanen. Zentralbl. f. Cjti., 1886, x, 729-736.
Olhhausi^n. Beitrag lu den piierperalen Psychoscn, speciell den nach Eklainpsie auf-
Iretenden. Zeitschr. f. <leb. u. Oyn., I8S1, xxi, 371-38.'i.
E'u'<4Ut:. Oonsidf'rationa aur lea psycboses post partuni. Bull, de la hut. d'obat. de
PariH 190.1, viii, 19-38.
KiruKHKA. Beitriige »mn Tetanus puerperolis. Archiv f. (Iyn., 1897, liv, 1-12.
Zur Behondlung von wunden Warieo und Maatitiden im Wocbenbett. Arrhiv f. (iyn.,
1899, Iviii, 177-184.
Sakfeiit. Diplokukkcn im Eiter bei Mastitis. Deutsche nied. Wochunschr., 1894,
Nr. 8.
HcHiiEMAKEK. Teller djc Actiologje dcr £)iitbindungslabniungen, et<'. Zgitschr. (. (ieb.
0. (;>-n., 1899, xli. 33-.W.
SriiT.rEK. Ueber Entbindungiilahniungen. MonstaBchr, f. (ieb. u. (iyn.. 1901, xiv,
49-6.5.
Stokhh. Drying up the Breasts. Bull. Johns Hopkins Hnapital, 1907, xviii.
Thumah. Obstetrical Paralysis, Infantile and Maternal. Bulletin Johns Hopkins Hos-
pital, 1900, n, 379.
Thuhn. Deitrag xur Lehrc von der Atrophia uteri. Zeitachr. f. (ieb. u. (iyn., 1880,
xvi. .57-10.5.
VisAv. rhi tetanus puerperal. Archives de tocologie, 1892, xix, 179.
ViKEBERii. A Further Contribution to the Study and Practical Stgnifiisjice of lactation
Atrophy of the L-terus. Amer. (iyn., 1902, i, .\o. 2.
\\'tLUAMH. Subperitoneal Hii'matoma following Laliour, not asHOcialed wttb [.esions
nt the Uterus. Trails. Am. (iyn. Soc.. 1904. xxix, 186-2a5.
W'iNCKEi,. Fntiiindung des BrustdriiaenparenchjTiiH, etc. Die Pathologic u. Thcrapiu
du« Wochenlierts. HI. Aull.. 1878, 428-439.
W:sH(-HF,ii). -Neuritis gravidarum und Neuritis puepperalis. (iiaufe'sSammlung zwang-
Irwcr .^bhandlungen auf dem Ciebtcte der Fruuenhcilkunde tind Geb., 1898, iii,
Heft 8.
WiiKusKit. \ochniuU zur puerpcralen (iangnin der unterun Kxlreiiiiliil«n. Zentralbl.
f. (Iyn.. 1901. x\v. 110-112.
l'cl>er puerp. Oangran der Extremitaten. tt'icner klin. Kundachau, 1904, Xr. 5
u. 6.
I N I) K X
AlMliiiii>-n. (LIxi-iiltiratL'iu itt, la itrogDIDCj,
1711.
pnlirgpnifat ••(. during pregnaDi-y. 1S4.
■fd'Ui, pnrHOtmJ. r«uw ut ilyiitofl», 7Uj.
pf DduloUK. IHt^
Ktrip i>f. In pregnancy, 170.
Abdumlnal hinder. 341.
imJIcle. Hi. 11-1.
prvKnanry. H43.
wall. changeR In. durlnx pregnancr. 170.
during pucrperliim. XAj.
emphj-Bema of, N.17.
rnnnliiD or, during labuUr. T£2,
Aixinlon. Ull.
iMlnlogj- of, 1111.
t'haugeri In f«ptuH In. dl6.
rllnlral hlHUiry of. G17.
nimpkle. KIT.
(Tlmlnal, 374.
■'urpltagr In. 474. «J{I.
ppldeoilr. Ill.t.
ciddiig I'auivK of. tll.1.
(r*niieoi*y of. Oil.
In Pholera. 481.
In rp(r»fleim] prPKnaol uterun, 557.
In typbcild fever. 482.
Inromplete. ai7.
Indui-tliin of. fiir •iinlrailed pelrel. 37.1,
for dineaiH^ of ovum. :I74,
fr>r mallflnanl grmvtha, 37r>.
fur mliwed abortion, ^(TTi.
for ovarian tiimouni, 37ri.
for pemlrloUH vomiting of pregnancy.
515.
fur renal loBumHenry. 374,
for retrttflpxed pregnant utpruH. ^IT4.
for tiibcrriiloitiK, 37.1.
for uterine hemorrhage. IIT.'i.
for uterine myomata. :IT.~>.
fcir vomlUnK of prrgnaniy, .■[74.
melhiHiri of, 3741.
ll1lioL>mIli>n In, 1117.
memlinniii. retention of. lu. 0'2t).
mlKrarrlagp. HI I.
miMied, n:;o.
molp, tiirmatliin of. In, Hit),
neglected, fl:;fi.
Iiaiholrigy of. ni:<.
prrdlapOHlng I'aowx of, 01.1.
pniphylailH of, 1114,
repeated. <II4.
rii[^ure of uterux In. H31I.
threatened. 617.
treatment of, GIN.
tubal, 637.
Abm-e™, In pueriM'rnl fever. Niir.,
of Harihollu'H gland. ^'>2-
uf breaat. 0\2.
meUMallc, »&'>.
pelvic. S63. 88N.
reiro- roam Diary, 013.
Absolute IndlcBtlun for fvurean Heitlon,
443.
Acaathopelja. TS8.
Arardlacua, 363, ^71)3.
ArireaKiry fontanellr. 1S3.
Acceiaory oatlum of tube. 58.
Acceaaory tubea, 58.
Aceldental favmorrhage. Si 17,
Aocldenta during pregnani'y, TiiH-
Accumnioilatlon theory aa to produitlcin of
preaenlatlons, :!11.
Aci'ourhement forf^, 383.
for hemorrhage due to premature Meitara-
tlon of placenta. S<>S.
In eclampsia, 54.1.
In placenta pr»vla, RIO.
In pre-eclamptlc loiemla, 51^^,
verxua poat-mortem t^marean Hectlon. 451.
Are pha Ileus, 7»3.
Ai-etoniiria during pregnaney. 176.
during pnerpiTliim, 331 >.
Action drop Ian la, 71.'>, T4II.
Aiiirmua, 71)3.
A'Tomlu-lllac preaenlallunn, (See l^ana.
Term I'reaentadoDa. i
Ai'llve moTemeDKi of fipluB, 183.
Acute Inferlloui dlii*aneH la liregnamy. 48U,
cpdema of cervli, ,'t63.
yellow atrophy of liver, 515.
Adherent placenta, nwi.
Adhealonx. amnlotli'. TMl.
AdlpiK-ere, 644,
Afler-comlng heail, forn^iis to. 41'i.
In contracted pelves*. 411».
Iierforallon of, 4115.
Afterpalna, 337. 341.
Agalacia, tllC),
Age of fiWuB. calcnialliin i-f. 147.
Air. enlrancp of. Info velnn. 830.
enlrani'e of. Inlo uterine alnuaen. 8.'i0.
Infection. 868.
Alhuglnea. 01.
Album I no meter. Falach'a. .'.liO.
Alhuminiirla, ibangea In iilac-entn In, '-m.
during prejmancy, 174, .V.iii.
during puerperlnm. 330.
In eclam|w1a, 3^.
relation 1o premature KetiaralloD of pla-
centa, 806.
921
92-2
INDEX
Allmiiiliiiirli* n-tliitUs. Ti^n.
Allmeulallun, niliil. lu liyiici-vim-MlN. ^iiiTi.
Allain.Jl.- vi-BtdP. 13S.
AllHI]t<ll!<. IIJ.
AmaunmlM during fr^gnBTii)'. 411M. .'ijs.
AmpDorrhiPH. fini-eptinii duriDg. ISH.
Ammonia (v-cfllcleLit, 3l>l>.
Amnion. in:>.
RdlieHlunB of, MO.
rystK ut. 587.
d^rmoldh of. SKT-
dlB^HKPX of. [>8t.
dropKy of. r>Sl.
fluid of. lie.
tormBdiin uf. in Imt. UHl.
In rhlckrn. 10::.
in K'llnva |)1k. )<>:i.
IL man. inn.
Iti nniiikf'y. ion.
InflamniBllim of, 5NT.
Rtrut'Mii'p. IIG.
Amnln(l<- adheflonit. .'jHii.
(■■rnnclpn. Sftr..
fluid. fiinc'iliin» 1,1. ^:•U,
Infection of, 47^1,
origin of. 1S8. r>81.
AmurphiiB. 71>.^,
Ampulla of ttitw. .~>il.
Ampullar jtrejrnan'^y. <i:ui.
of leg. effefl niMm |>pIvIh, 7NU.
Ampntatlon. Inlra-iilerlnp. oNil.
Anipmla, piTnloloiiK. 4118.
Anaprohlp bacteria lu |iiierifi'a1 liifk-rilim.
SriT.
AntpxdiPHla, nul.
coc'alQC. :!-j;i.
In hear! dlni^as". 4n«.
In li'i'e^iilnr paltli of Ili'Ht sliittt', dill.'.
In normnl iHlmiir. :<:;i.
In pillnflll iHlmnr. (HiL'.
Id pre^'lpliat*' lalH»ur, liii:^.
lumbar. ;l::;1.
s<-opB Limine, n'2A.
AnencpplislllR, Ti'lt,
Annular detarhOH'nt <if ™rvli, S;iO.
AntPfli'^lon. In 4'>mtrarl»'<1 (rflvcx, 7-».
of pregnant utk^rnii. r».'>7-
of piii'nii'va] oleriis, !M»r».
Anlp-pnnum rilnrapKla. ."ii;".
Ilfrmorrlifliri'. Hfiri.
AnIevprsUm of prpKtmnl nti-rus. r>Ti7.
Antbrni diirhiK pri'iinaNiy. ■•"■I.
Anllslrfpioi-oi-i'li- wTTim. 8>i;>.
AntllPtaniin Kt-i^iim. Mils.
Anns. Ia(cratl"n of sphlnrier of. 'AM.
leslim^ of. during liklionr. '2Tt'2.
Apopleiy diirinw ]>rPK"anoy. -I'lK,
In Prlflnipsln. fi-'N.
of plnn'nla. Tilil,
Apppndlrltis diirlnjc prt^jEnanry, r>02.
Apron. HoKPnloi. ]1H.
Arbor vltip uierlnn. 41.
Area, pmhryonic, IHl.
J^prmlnnllva, IM.K
opftra. (in.
]>pllM<-ldji. ',>'.>,
Aivula. KiaudH of Munteouicry in. 171.
uf preunant)!. 171.
aei'ondary, 171.
Arterln. {tire Uluad-TemwlH.)
arterial presBurr. TI^j.
Artlflclal feMllng. ;tr<7.
re*plratlon. (Use Asphyxia NconBtiinim.i
AaclteB. of fstua. obatrurtlQK labour. ')l7i,
■linulatlag pregnancy. lliJ.
Aaphjila. from ruinure of vaMt previa. uUT.
iDIra-uterlne, 844.
II V Ida. 845.
neoaatorum. S4S.
pallida. 843.
rpBuai-ltatloD from. 84(1.
IrepanatloD for. 848.
Assimilation pelTla. 750.
Astbma during pregaanry. -I81I, '<ti;.
AatriDgpnlH In post-partum brmorrbage,
822.
Atony of uwrua. 308. S'M.
Atresia of cervli. ftliS.
folUmlar. 77, l«U.
of vagina. na6.
of vulva, UUB.
Attitude of fu-tUH. 2<i-~i.
Allien Itl on. ubalptrlial. IMI. 210.
prr.ira In, 2H1.
fiptal ht^art. 181.
fu'iai hpart murmni'H. 182.
funic souine. 182.
Baa In maternal iutesilupK. 1m;!.
In multiple pivgnani'y. 3i>i>.
movempnlB of fiMal diaphragm. IHtt.
placental siniinp. 18^.
nterlnp aonllle. 182.
Auto-lnfpc'tlon, 8i;8.
Aiito-lntoxlratlon. Inlpntlnal, r'4ii. H7!>.
of piTgnani-y. 0117. .">4(l,
I'Platlon of. to prlainprtla, TtiUu
to Inrianlly. 1^5.
.Vutolyfllq of uterurt, n.ftl.
Auls of |ielvin. 10,
Alls tracllon fon-pps, 415.
llavlMuH nerogenpH cap^uladifi. i-aiKp of pm-
pbyHpma of abclomlnnl vnlls. K;t7.
Infpftlcm n'ltli, cause of firta] dyndM^la.
lar,.
lufpc'tloo Hlth. Klniiilallui; ulr puiliolism,
Hr,i\ n:,i;.
In pucrppral Infpcllon. XMI.
Itaclliiis coll commune, in inipvpi^rnl iiifi'i--
Hon. 8ri4,
In tyni|ianiti>H nrerl. 8rt4.
llacllUia diphtlierla* in iiuprpt^rn I infi-ctlon,
an:,.
ItAi-llliis 1yi>bi>MU4 In pnfr|HH-nl liiffi-tlnn.
Sr.fi,
BnrlcrlBl orieln of cilampsln. ri'-XTi.
iiactpri.iioiiy of lochia. Xm. sriT.
of pupriH'rnl lnfpctl<m. sr.7.
of vaiflnal spcretlon. 870,
Ung of BBtprs. ■.•2(1. 24-"i. rtoS. «r.l».
llallotipmenl. 18:1.
Ilandl's rluR. ISpe ContrarlloD Ring. I
INDEX
*m
llarncK'K llildic-liai:. .Im::.
Itartbollo'it j^IhdiIk, tut.
L n flam mat hin of. dining prejpiaui-j, 35'J.
IIbuI plate ot <lri'l<lua. l;lt.
KBHllj'st. 4UT.
ItaKlotrlbc. 4<17.
Kath. raid, lu |iiipr]ieral fevrr. S8T.
during JalKiur. 307.
uf npm-lieirn clilld. :HH.
riwrat. In et-lsmpHlB. r>54.
lUtllediire iilaceuta. QUO.
UaiitliKtlpl. i:em.
Kaiidrlui-iiurH (-v|ilial<jtrlbe. -titU.
diameter, >iM(l.
■ •elvlmcter. UMU.
lied. |ir>'|'B''alluD of, 31^.
Blchlurldt' pulanulnit Irom lntra-ut*rln»
diiuc'IiP. 474. HSa.
UlivrnuAio ulpruH. t'auiie uf dyntui'la, l>^11.
bpFDla of, rilI4.
|iregnaii<-y In. Ti'iri.
nipturi^ of, &5II.
lllrdiT. imp of. diirlnu |iiii'r|M'rium, :hi.
Itltfcjlar vfrxlim, 434.
Illaddi-r. c-liaaKi'it Id, durlnjc prvguaufj', 17:1-
•'ali'iiluH uf. 077.
pftopla nf. 7."i7.
(OmgrfiH^ of. Jiw.
ruiilurp <it. 5lHI.
lumijiir <tf. romplit-atlnK lalxMir. 077.
Illaslodprniic vpali'lp. 07.
IIH>i«rd'ii sIki of malufltj' of fcttuii. 14H.
BlHMllDK In i-i'lampsla. r>44.
BIihm]. i^hanffPH In. during menBtratton, 81-
durlnfE presiiaiK'r, 171^.
during puerperliim. 337,
frPrilDR polnl of, ir>il.
m(il«i, 61 fl-
prvMiii'p In prrgnanc-j. 171^.
Hpnim. loxLrlty of. la ei^lampnla, ^36,
Ulaud-vMju'lH ot ctlturia, 1*9,
of otaripK. CI.
ot iilai-fnta. 133.
of utprua. 40.
of raelDa. 37-
pudlr. !;40.
umlilllral. KIT. 347. r.li6.
WKiltinlar Imltu. 1:11.
Illol H ■•rrforalor, 4114.
Illiinl IXKik. 4:1::. 411:1.
lluul'B dilator. 3NII.
BoiikI.'. f'>r Indiii-tlon of [KTmaliin- lalioiir.
3MI ; Iti-BHlK dilator, 3Mtl.
Itob-i-lH In jir''Bn»ncy\ t^tfii.
Itrai hyi'ardlfl diirlns piiPrperlum. 3311.
Bfaln. rhnriKPf fn. In pclamjiBlB. 534.
Braija'H hliiiiT hmik, 4ni>.
cranlorlBsi. 4lin.
Blgn of iiFcgnanr-.v. I8II.
(ri^iian. 4fir..
Braiion 1lli'k*s mvtlnKl of vmlun. 4:14. 4:10.
Ml.-,,
Ulan of pirji'iani)'. |nT.
IlrHSMIi. alijceno*- at. IHiK.
Hnalouiy of. :1.M.
armiln of. 171.
Un'aslB. i'uki*d. ■>ll.
rare of, during DiirBlug. 343. 3.~iri.
In pregnBnt'3'. ^11.
rliange» In. durln); prPBnsnry. 171, 188.
drying up wiTPtlon of, 3.'7. Oil.
pngurgpnipnt ot. till.
hypenropliy of, OUN.
InflaiDUiallon of. 01:!.
BU|ierniiairrary. UtKI.
Itnvi-h jireBpniatlcmH. '^m.
anphyila In. ::no.
Iilunt huc)k In. 43l'.
bringing down finit In frank, ■^•,»l.
rauRatl'in of. 2H*i.
wphallc vpi'Blon In. ::KD. 433.
compllcalpd by i-ontrailvd pelveB. 740.
dlagnonia of. 'JKT,.
pitrartlon of, 43i.
nilpt In, 43L'.
forrepB In, 410. 4:;!!, 43L'.
frecjuency of, :!K5.
In hydrin-i'iilialiix. 7o4.
lll>«rRilnn of arniH In, 4:14,
tnechanlxm of. :^87.
lirognoHlri In. l^HO.
prolapKp of nint In. M4L*.
trfBlniPnl of, dnrlng lalxxir. 2'.n<.
during pregnancy, -JWI.
Ilrlgbt'H dlHpaBr. (Sep Npt'lirlll". I
llrlm of pplvlx. (Hh I'cIvIh,)
Broad llganienE, 47,
hematoma of. 003.
pregnanry, 041.
Bronrbo-pupiimonla in pniTiHral InfeHlim,
87H,
If row prpHentAiliinx. '2X-
r-auBat1on r»f. 2K^.
(•onHgurailon of hi'nd In. :.'><:l.
mnvpt-Bloti of. Into fac-e iir vorteii. ;;H4-
freqnenry of, "JWl!.
mechanlHni ot. JM3.
proKnoxIs In. :;83.
p.viDphyKe'ilomy In, 1:84.
trpatment of, ^84.
version In. 284.
Bruit, ulerlnp. IHL'. -
»ud1n"« pplvlniftrr. liHJ,
llnlli ventOnilar. :«>.
llyil.-lil'H iieirlmpliT. IW^.
llyrd'H niPthod of r**HOHi'lljiIloii. J*47,
t^pHAVean Bpr-tlon, i-lip<'k1ng lifpiuorrliatft- In.
44H.
liinaervBtlve. 44L'.
rontra-lDdli'Hllonx for. 445.
eitrapprlloneal. 448.
following vagi ntt-HiHt Ion, fl7'J.
vpntro-flxat1i>n. *i70-
for t-ari'lnoma i»f t-ei'vii. 441. ."»"p:i,
(Tf rei-liim. 1177.
ff»r oontrai'ti'd iM-lveh. 44-1. 734,
for myoma of iiierim. 444. Ii'7'2.
for old ekirn uti-rlne pregnanr'y. Old.
for ovarian oiinonr, dTH.
for iilai-pnta pnrvla. 4 14. Mt7.
hlHtory of. 441.
^^^^^^ ^^^^^^^^^B
q
('■raaiviiii ■••-lluii. Iijini^m't'iiii) iini-r. H'i.
ivifU. iimiw" (11. iliiiiiiK iHi-iiif. :;;i."
*1H.
ilurllitf |ir*i;iiHncy. lAT.
^^H
iDillnUnBn rur. 449.
iliitInK piivrirvrlum. n3<.
^^H
la TClanipolM. 444, irj.
clrciilur ilvudimciu ■>(. K.1U.
V
InMWnd ef tDdUclloa or prrmaiurt latwur,
iiiudlltxli "f. In iHIIvr iiart iif pn-RnaDi'jr, J
741.
33S.
^^M
In miuvcnr iimmutlon*, 8UX.
illlniHiloii nf. dutliu; talHMr, 242.
^^H
I-orro'ii iitxTiitliin. 44^. 447.
mnniiiil. :1H1.
^^^M
IHUI-UlOtU-ni, 4."V1
wlllx l.nll.-Jii, sn:..
^^^M
l>ruKnuil> i.f, 441'.
vlth rtoKnl'ii tlllHi'ir. IIKO.
^^^M
n-|>t«lnl. 4'il.
wllh fcrtvin, .111".
^^H
■irrltldnH |ia(l*nl« ■rtcr. 4IU.
tllivraHi'H i>r, illirInK Ifit^uuiirj. 4ltn_
^^H
*u|>ta (roP^T*™!. ^'''•
ci'lmpJoD lit, tS.
^^H
tvrlinliillM iif. 44n.
rilumal UK, 40.
^^H
TBttniil. 3Mit.
Itiinillun of. S3.
^^B
('•Ii-lflinilon i.r tir^uiL «4I.
RlBIIlU of. 41.
V
of |OAf'>-nfh, MKk
hyiHTiniiilijr af mpr^YtLttiuni iHarllun
■lur- 1
rmlJiin rormmloD. rffpii u|mn itrlrlii, nv
tns prpsnimrT. .ViX.
1
(-■iim. n-cili'Dl. 41. 2Sli, 2*2.
Iiic'liiliin i.f. sua.
^^M
of Si.'li. it,. VS.
InfraTHMlnnl iHirtlan n(. 40.
^^^M
(-anallud dbrln. 130, S|ll>.
1u iiorinai labour. 220. ^4<i.
^^^M
C*artr. I^r l**rrliinniii.>
iTitrrnat ok. 41.
^^^M
lllMUlar aiPiiil)r4np. CSI.
Irdaiia of. durlDK lalmiir. ^U.
^^^M
t'iil«i( mic-n-ilnni'iim. :;i4, tlTl. 7an.
mnc'uui lit. 41.
^^^M
<^«rhiinih- ii<J<], rrlHtlon w trliinijtHlji. i^iU^
niroinn "f. *IS.
^^^M
('■rbolif nirM polwDlac Iruui Inti'anlvrlnc
rlRldKr "f. «a9.
^^^M
<1i>iii-l>i>. 474.
■IhiiuhIh of, ttRS.
^^^M
Carbou itlotld'. Iiirnvv of. In lilncid. miar
■trl«t<irr of. SU!^
^^^M
of Uboiir. Slfi.
■ii|>r«TaKlnal pnnluli, M>.
^^^M
L'^rrlnttniti nf t^rvli. 4'auiiiviin tu^i'llHii for.
U«n< of. «aa
^^^M
4:.».
lailonl poriloa. («.
^^H
i-->iii|illi-nlliu( iirviciiNiifr. 4AX.
rha4Klt-k'K iiljtn At [irrcnam-)'. IKti.
^^H
r.f ivi^iim. •'■iiT ff dyntoi^lii. tlTT-
rhamlvttiin rnn-ri'*. ;iiW
^^^
CArrjIlixIlll »jllf\Ll»k. r."«.
rhaiutH-il'T <1>- KI1h'*'» MIIiuib, axi.
:IH3. 1
Canllni- WiUni^ In prrcniini-i'. 4S".
Changrt In iii'ma Oiirltitt •-AnKactlnaiK,
•no. ■
r«ni(wn> molch 'illi.
Child. iKw Vpw barn i'hlld,>
1
('■riilirlltir inyrtirnniuti. ^3. Rnik
(?lilll. ilni'liii: t'liiTiiiirliiiu. n:U.
^^M
■ '■ruiirlr* (if amiilon. aun.
fullnwiiiii iiorninl ivtxiiir. :t:iri.
^^H
uf |>ln<'rntn. .*>».*•.
In iniiTtfL-ral liiroctlon. HT>^.
^^H
rmlirti'rtnlltin diirltijc pui*i'itf*rtiinit n4>.
t'lilnniroriM 111 iHliiiiir. A2I.
^^B
rmil. -JIT.
Cholera vomplUntlne pncoauiv. 4HI.
1
I'miHHllon of UtHiiir. 21ft,
Chr>iidt'iKl)rHti'i)iiian f'lMnlln. 7I.V T(1>. TTMI. |
tVII InjriT <if •'iKirlnii. 110.
dioiidripdynt miilili- divarf prIiU. TSO.
■
mimi, iDleriial. Wi.
Churi'n. ,'isii.
^^B
1 ikhIaii, lan, l.tl).
dtirliiK |iri-|[iinni'y. 4t4T
^^^1
Otiallili In imorpr-rnl InfTtrlliia. 803,
Chnrlu aiiirl'iuia of plairvaua. StM.
^^^1
reiiitnl iilai'i-nii) [jui'vIii. Nun,
{rbotiv>-v|iltli''ll<>nia. Hit, Hit.
^^^1
tvnr lit }irtUio'im. ^IVT.
(-h'li'lon. Il>-.'
^^^M
('■■iif rnpifliiip. 117.
Dl»ir1l'm. frifin dJaraae uf. ItlS.
^^^M
i'i'|i)mlriti:lfl. iliirliiti |>ii-i: ■■«'!• ')^. I)ii>.
niiKli>ni]i '«f. .Mi4.
^^^M
' iU Ilin-HEitllr'rl IS' In miwlH, ^1^.
• unalliod llltrln uf. VM\ Xfi.
^^^M
Ci'Iilinllr vrrnl.in. -JSU. i:ia.
.-fll layer i-f. Ilil,
^^^M
ludknllunu for. 4!(:i,
rlllN i>f. IIA
^^^M
Illl-Illixlv llf. J.1«
ij'rtif dcKmi-railon iit, STl.
^^H
ri'iihnl^inji'Trt. Tllfi,
d-ndtial Ulan.lH nt. 114, 143.
^^^1
1 VliliD I'll rl lie. inii.
■ll<Tiii>» ni)rii>nia of, SSI.
^^^1
IVrvknl t.-airiilii>ii, hH, Ids.
<Vnl". Y.-MiTil fliitula. »39.
illu-avn nf. :i7l.
^^^1
plilthflluma "f. S7«>-
^^^M
(■■•rrls, :<H. 1(1.
■■[.lilirlliini of. Iia. lilt, inx
^^^M
mill.- iiili'iuH .if. .".IKI.
fniitFiili]]! t'KII at. IIS,
^^^M
mifktiaiiiy nf, 4n.
fiirinniloM <>r. In Hilrkni. MI3.
^^^M
niiiiiilflr drill clunpiil of. iMli.
ill niiiii, |ii;i.
^^^M
nri|mr»ii.l NlmrlMiltii nf. In itrvenmirj. vMil.
fnmil-Miim. ItT: fj».
^^^M
Hi'lv-r rltr iitrilui, 41.
■lant r«l1i> of. 114.
^^^M
airrda of, «at.
In-vr. ir.. }ia.
^^^1
pivrcliiiiiiiii -ir, .'i^a.
IjiiiEhana'k laftr of, lilt. ISV.
J
INDEX
025
rtiiprlrm. i»i-iuliriiiii- 'if. 1i:k
Diyioma niiruHuni vt, Ml.
mrxDiD* iif. KTI,
lifanmodlum or, 116.
stroma of. 60. IIW.
atructurp vt, 1 13.
ByDrrlliim of. 110. 132.
trophoblaiit of. 1118. 1.13.
villi of, ion. 11.1, 1.11.
ZellDThlrbt of. 116. 1.11!.
Cborlutilc villi. IH<« Villi rhurlciDlr.l
mfmbranp, lia,
rplthpllum. 11.1.
cpltholloma. 570.
<'bruino8om?B. Dumber of. 04 ; reductloa of.
92.
t'lUa of ova r lea. 6T.
of lubeH. nS.
at utprna. 44.
Circular alnua of planntH. 139.
dplachment of rrrvli. 836.
CIrculatluD Id fiplua. 1S4.
Id Dew-hnrD i-hlld. 346.
clrc-umrlnlnD. girl, -'0.
(.'ImmTallBlP ptacenlA. 504.
CleldotoDi;. '02.
f lllorldpitoDiy, 20.
CJltorla. 20.
ampuoilon uf. 29.
aaatomy of. 39.
prppu<¥ of. 28.
Clnaama. 174. SOO.
ClnalDg plalv of decldua. 1.11.
Clotblug during pregDaar;. 200.
(.'lub-fool. eir*rt upoD pplTln. T8T.
('of-alDp anrathnla Id labour. 323-
c'otTygpus Diua^rl**, 247.
forty I. 2.
rivlome. 101.
Coffw (round vomit, Sll.
Cofflu blrtb. 8r>l.
C'ohn*B Diplhiid iif Indurlng labour. 3H2.
CnillDg of <vrd, 137. 310. n08.
ColiDi dDrIng preKDaDry. 200.
Coltapap durlni labour. 840.
CollanC'l In piiprppra] lofrtttoD. 801.
Collni'a law. 48T. tcio.
Colllalon of twlDm 360.
(■"loKtnim, 171. 331.
<MirpU[M'lpn. ^t,"!.
I 'oliiaporrhrxlx. 820.
4'olpeurynter In ImluriloD of pn-Diatiire
labour. 381.
Tolpo-hypprplaBlB rjratlra. 352.
<'nlumDa of vagi Da. 36.
Coma la puerpprlum. ,%45.
Combined pregnancy. 646.
piamlnalloD. 21.1.
ConiplPte abonliin. 617.
CompouDd prearnlatlon. 803.
rono-Bled ha- mo rr ha If. 807. 810.
Conn-pilon. da(i> of. H8. 105.
durlni BDirnurrbo'a. IR«.
C'lndiK-t of normal labour. ^103.
ronflnemenl. eKtImallon of ilatp of, 105.
ConEenllBl i-yoilc kIdni-.VH. 706.
CoDgPDltal ectropion. 4o.
<'onglomerate glandular Uxly. 'H.
CongluIlDatlo orlflcU riterDl. WUt.
CoDjugata dlagunallH, 6.
eMeraa. 68u.
Tera. 6.
Conjugate, analomlial. 6.
Baudelocijuea UHU. 686.
diagonal. 60<l.
eiiemat. ttHii.
Meyer's. 1>.
normal. 0.
oblique. 0. UHO.
obBletrlcal. 6.
□r outlet. 605.
true. SOI.
CoDaervatNe Ccaarean aectlon. 445-
Cooatlpallon dDrlDg pregDaDcy. 173, 200,
491.
during pnerperlum. 343.
CoDstrictar raglDK. 249.
Contracted pelves, feaarean aectlon Id. 443,
734.
rauae of dIRIcult labour. 670.
i-taulflratlon of. 607.
congenlUl. T04. 716.
eourae of labour In. 728.
craniotomy In, 739.
dlagnoala of. 682.
due to abnormal malleability of bonea,
702.
to bilateral tamenesv. 786.
to dlHeaaea of the vertebral eoluiun. 766.
to generallEed and Hymmetrlcal anoma-
llea Id development. 746.
In locallaed and aajmmetrlcal anoma.
Ilea Id developDient. 751.
to localized and Bjmmetrlcal anoma-
llea In development. 756.
to lumoura. etc., T8H.
to unilateral laoienem. 7X4.
elTwt of. upoD coune of pregnancy, 722.
frequency of. 680,
history of, 670,
In new-bom child. 704. 716.
iDdurtlon of abortion In. 375, 742.
uf premature tabotir for. 377, 742.
mei-hanliim of lalHiur In, 724.
|ielvlui.-iry In, 683.
protnioxlK of labour In. T.TJ.
kIxi> tif fii-(uH In. 72;i.
(n'Btmeul <if lalHiur iHHiipllcad-iJ liy. 734.
X rayH In dlagnonlH of. iiWi-
I'ontrBi'ilon. cTuire for uterine, 221.
hourglBBB. of uterua, 664.
palnleMi. 1H7. 223.
uterine. 222. 240.
ring. 213. 2.17. H3.1.
CHUHe ,tf dyrttorla. 6*!4,
In d.vritiH'la. due In *^iuirBHi-fl pelvea,
7 28.
In Ihrenli-ni'il ruHiiri' of ulcruH, 738,
KOI.
ConverHlim In Utii* prefienlallona. 284.
In face prenentatlonh, 281.
ConvulalooB. (See KclBmpnli. )
926
INDliX
Oiril, rS.v luililll.'Hl Ciiril.j
l^iruua *>t uteriM. <1N, ZtTtii.
I'ortmfll Fiiitiirp. lo-.
Coriiiili'Di'c HluiulBtlng i)r)q{uiiiit'y. i'-<'J.
Curims BlWioriM. 7j.
niirosuin, Tj.
tiiituni, T:{. IGO.
rjftic 7«.
r)*Bt« fn clinrlo-epltlu'llijina. "iTH.
i)'BlJi III Uj'dal 1(1 L flit ro Dmlf, ."iT:i.
ralw. 77.
Itilprnal ecirelluD uf. li'J. T7.
of mpusiruatloti, 78.
of p]'e>;iian<:y. 7H.
Htrunurr of. 74.
Irup. 77.
I'orroBlvr HulilltDntc. (Se* HlrhJurldv of
.Mi-i-fury.)
t'ortt*! of uvfiry. HI.
Cotylvdiills of iilHirntn. i:<4.
CuialRla, THH,
(^oxartliri^liritlietli' iietvlH. Too.
I'raiiliM'lni'l. 4im.
I'miilniia^iiH. 70:;.
I'ranlutiiiDy. 4n:i,
clanRprH itT. 4fl8.
fur oLd extra- uteri DO prej^nHncy. 047.
Id mill Nil III uf twin*. :<iil).
In contrarlPd pj'lveii. 7.11'.
Id ficp. pr^RentatloDH, cJiId puHterlor,
:;81.
In 1i3'dro(-e|ilialiiri. 71>r>.
In nii^itrp ••( iiIituh. 838.
liiJIi-ailiiii- fcir. 4im.
]»rti^nciHlH of. 408.
roi-overy from, 408.
(i'rlilili|i"' cif. 4114,
iipiili BflcniiniUie lii'Bil, 4(i."i,
C'Tiiiiliiiii. iSoi* lli'fld. Ko'taT.i
CrAvliif!;* In i^'epiianry, H>o,
('rfdf'n iiipihod of exjH'eiuilnK iilacpiila. U'l'K.
olnlmnnt, 801,
Cretin iliA'arf fielvix, 75(1,
rrlnilnal altorTlim, '^I't,
Crotiliol. 4:iJ
t'lllliiiir', :jiki,
('tiI-'l''rMiti\ liirlHloii 111 |)iioi-]ieriil liift'rtliili,
ns.s.
of ]h^u}.'|]m. :L"i,
I'liiniiru^ ihipliitnis, 00,
riiri'llJHO, 474.
diilihr''rH >jf, 47o,
in nlKinloii, Oltl,
indli'iiliiins for. 474.
In imiTiB-rnl InfHctlnn, Mr,.
Cystli- il.'K<'m'inllini i.r I'liorloii, .'Tl.
ryHTlils, iliirliiM jitb'Koanr'y, ,1^10,
diirliiL: iMU'i'iit-rintii, rt42, OOO.
I'yrttiH-olc, romiillrilEUlE Irtiiour, 077.
I'yfltJi <i( iinihLllriil i-oi'd. r)ftl>,
of ^-^ii-lrNil wrills ■>bKtriif'tlii^ liihoiir, OON.
C.vtolVHln. Ti'M.
aniiilitn, r>MT.
of <'or[Mi,'J liil'Miiii. 78. r»T:[, .'(TO,
i'l'tulyiilH <tl ovary, (vmiilli'allne <llaBiiin>lK
ot iirtgnancj, lul,
of iilaceuta, 503.
Iiate of oonOaemeDt. extlmatlou of. iti.V
iieath of fiptna durlnfc pregnanc-y, Mtli.
of motber dirrlng labonr, 848.
during pr«gnaary, 4S1,
llfc'aiiUatlon. 4tl9.
In lucked iwlna, SHI).
la trBa§Terae preaeDtatlonM. 80^.
I)p<v|>sulatlun of kidney a. 040.
IleiLdua. no.
baeterla Id. 507.
haaal plate of. 131.
baaallB. 121,
capNularlH. 121.
i*H« of. i:!l,
{■ervlral. 120. SKI.
cbangea In. <-aiij4e uf laf>oiir, Jilt.
In abortion. Ol.t,
i-1o9lng platr ut. 1.11.
lomiiacl layer of. 121.
develojtineat of. uutalde of uli'niis 124-
dlffuHC formatLon of, 124,
tblvkenlDK of. otto.
rtlKPHBeH of, .".04,
fatly defeneration of. 210.
glabt reJlH of. 12(1,
glBDdnlar hyiierplaxla of. OUtt.
layer of, 121,
goDococ'i'l In. .'lO',
hyrierplaala of. ^fl.'i.
Id blfornuate olerua. n*>0.
In eitra-iilerlne pregnanry. «20. ii:!2.
In non-LJre)rDant tube In Intra-llterlur prt'u-
nancy. 100,
111 ovnrlen. 124,
Ml perUoniruni, 124.
InOaniniudori of. oU7,
Islandr* of. 114,
mi-nntriiai, 84.
orljtlu of. 12-'i.
polyiiosa. ."iflU. 013.
I»«'u(lo-reOe:ia, 1134,
ri'lleia. 124,
rp|tai'Hrlon of. In |i(teriiei-liini, ;13:[
Herolliin, 120.
i4|>orlKy layer of, I'JI,
Mlillllls of, (i04,
liilieroiiH ^iilic'luirlal l>irnint,>ii<Li nr ikio
vei'a. 121.
l>e<'ldiial rsKt In cxlra-ijlerlne pr(*Kiiani-*
030.
.ellH. 121.
I'ndoineli-lrlri. (8ee r]ndomf-tr1t1». >
iHlHndx, 111. 1:10.
ri-ni-tlon In tnlieK, 021. 032.
>-ur<"oinn, .170,
IX'c-ldiioina niallgnuni. r>70.
In pxtrfl-uiorliii- preKnaney. ((44.
ln-fofnied pelvi-n. fSee I'ontrni'ted IVIvew.i
llellvery. nurmBl. 314.
ptost- mortem, srd,
]>eniol <'arles dorlng prei^nancy. 402.
INDEX
927
]N>[M>rlailiin <ir <^hi>rinDk vlHt In nJauiiiKln.
iHTniillllK lii-nx'tifiiriulH. ~>IHI,
Ih»H>¥iit i'f fu'IUN, <'atiHPH of, ^4Q.
lu bren^ti iiri'trniatlttnii, JDT.
In tiruw |ir>w^aUt1ooii. ;:83.
In facf [>rvi«pnt»tlcin«. L!7M,
In v^rtt-1 ]>reH^Dtatlon}t, 'irtH.
lN*u(<iplflrim, Tl'.
lipvHr>|jin>-nl cif allnnlnlH. 1l\;.
lit naiuUin. HfJ.
«if i-hcirLijn, IOl*.
i>r ••iiiiiriK. :;<),
iif <-(jrd, i:tH.
cif fti-ltl', 144.
itt hym4>n. ;il.
of (ivsrli-ii. on.
ijf civuni. f»7.
of |h-IvIh. it.
of ijlaccnta. 1^8.
of iuIh-h. I>n.
of utrrus, sa.
of viiKlna. :t7.
of vulva. :ii.
DlihriFH (liirlDK prritnaiK')'. :i8li. -lil.t.
durlnii piirr[>erlum. .130.
phtiirldiln. ISD.
DlBii^noKlii. diircrenilal. of prrRnanrj. (See
of life ur deatb of fcplua. 193.
uf pr'Knanc'jr. (See I'recnaocy.k
of piVK^DIallOD (it frptuH. ^11.
of nfi durlnff pregnancy. 18S-
Dlanipt4-rit of bpad, iri3.
■»r pp[vln. 4.
|i|i!<tnHlK of rrn\ mnHrLM In preKnancy. 1"*'.
.'itl4.
In |>iier|>eriiiin. AnS.
UlrpphaliiK. TllL'.
Dli'klnann'K Mga of prejn)an<'r, 181.
Ijlef during prctnianry, ^1M>.
fliirlnfc ]nifr[wrlum. 342.
Dlirvrenllal diagnoilB of preifnanry. Mni,
Iillslailon of i-rrv)i. anllli-lal. .1f)4,
In aoriiial labour. 2*-.
IilpaciiK, i«L'.
Iil|)liilipr1n. diirlntc piiprpvrlnm. fllf*.
|iiieri>pral. hr,:,. R.-il».
Iilphth^rUli' Hlri-r of Tiilvn, finn.
IHfiroHijfiori. T'>-.
l>lri-i-IlniiK for oliHtrlrli'Ri iiiinip. nri4.
for luHlfiirn dlirlnjr pn'Knancy, ^02.
lilA-iM proJIiTHniK. 1*11. 72.
Itlm-BKPH <^tmirl1riiHnK prffTnanrj, 4flO.
rompMi'itlnK piii-rperliim. SfM.
Iilainfi't'ilon i>r handH, nOA.
of tiilva. ;ilii,
I i1)t[iln<-4>mi>ntn. iHe^ T'ltrna.)
IilHilrinlon bcin-pcn flrKt and aiilMennenl
ftn^ffnan^'leii. 111-.
nivertl'iila fr-im (ubeii, r>N.
iHiTlne ravlty. !-Ti7.
l>fill<-lL4i-i^]ihaMi' head, cauae of fare preaen-
(ailoD. 27.'>.
I>ollclio.|[)'ni>-platf-iipoiiil]'lua, TT8.
I 1 t'lri'iiiiiEi'a iireometer. ^20.
I Lhtiilde Nat'f^le pelvln, T.'iU.
utrniK. jM.
l>ou<-he. Intra -lite Hue. 4j:i.
prophjln.-tlr, 471'.
vaginal. 472.
Itouglas'a nil-dr-anr. 35.
perforBtliid of. 8.'{n.
liropii}' of nmalon. (Kec ElydraniiiloH.)
iif fii'tuK, GOn. 71>.'i.
of ovum. 621.
Dry la I mil r. 220. tt'tS.
I>r,vlnj[ ii|i lireaHiK, (111.
tJiiebenae^K iiaralyiilH. HUT.
liiii'lH. lai'ilfeniiiH. .irii.
Milllerlan. Hit.
para-iireihr-al. 30.
itkpne'x. 30,
W'uiman. 30. 04.
Iiuctii* artprliiHUH. 1."i.
veniHuin. I.'i.*}.
l>1l1intiien'K rervlcal Inc-lxlnnfl. 3K0.
IMinr^n'H merbanlHin In ext.riinlon of ]da-
eenla. 204.
Duration of lalioiir, 2.11.
preKnanoT. 103.
I>uverney*H KtandH. .10.
l>warf. 740.
jielylB. 740.
l>jBpnipa during pregoanrj. 400.
Iiyatciela due to abnormal It I e»( of oerrljc. Uf>S.
due to abnormal 11 lea of (he eiinilHlve
ror««. O.'iR.
of fiFtua, 780.
to almormalklee of vagina. Otiil.
10 abnormalltlpH of riilva. <>ti<l.
to mnlracled pelves, T22.
lo rontrsdlon of Bandt'n rlnc. 'Min.
to kvator an! muarle, tUiS,
to old extra-uterlue prefinaney. 047.
to lumoura of birth ranal. IIT".
to uterine diKplareraentd. iliiK.
follcrwlnn vagi nollxat Ion, 00!*.
follon-lng ventro Illation. 070.
Uyaiiria from Ineareeraied preKnant nternn.
r>oo.
1-I<-hlnij(-oc'ciiR cyKtH rompllrallug lalxinr. 077.
l'>lainF>»la. a<T<ini'hemenl foni'' In. :IM|. :•(:<.
irtlology of. ri3.'i.
nllinmlnnria In, r>21l.
I'arterlal origin of. .'i3-'i.
IiN'hIIiik in. -'•44.
Mliidntvx ncTompanylng. .'>2H.
Tii-riarean Heedfin In. 444. .'i43.
pllnli-al blutory of. Tt'J'i.
frequency of, r>24.
lu extrauterine pregnancy. ri2n. 044.
Id neiv-lKim rhlld. r>31i,
mania following. r>2N, !il.~>.
liatboiogy of. r.:Mi.
progncjHla of. r»41.
(reatnieat of, .'>41.
urine In. ri20.
veneaertlon In. .144.
without «iDval«loa*i &20.
^M 92g ^^^^^f ^^^^^^^H
^^M KftiHknn. lol.
KpUepnf dnrlns prfxnaoi-r. iml. ^^H
^^1 Kiti>|>lr iirvKUaiiry. t!^' Kitr* niTlnp
Jiiiliiir pij>-riH'rliitii. illT.
^^B I'tlWIM »•■)'. I
r:pl|ihyu-h LiL iifiihlll*^ ^t-2.
^^H llrti>|tlKi-<niln. Hil.
■I'luiiiiiliiii lit. iliirlflK I'ltniTttun. VJ».
^^B l>iro|ilim. ivnRfiilliil, -13,
MpNlot y. :IIH.
^H h^Ki: iii'Mi. «l.
l'l|KHiplifhri-ii» 4t.
^^M innilk Htxiiinw !■ OMrmn wvli>in. AM.
Krb'a farnljiilii. IHIS.
^^M KIdcrlj prlmlparB-. :::il.
KtKot III |HH>l-|iBiI<itii liaqflnnhaiii-. k'SI,
^^H I':ii-i'tFl''liy In vilra-iltvrlnv iin-Kimiir)'. Illtl.
nar of. In laliaur. 5:t. Iitl ^^1
^^H llli'T'linnllnaln mniirtilTii dxIIiii. '■•■li.
Kryalitrlan In |in-inii>n<'y. tK. ^^^
^^M Kiii>H>ll>m, ":•••.
rtlali'in of. in |iiirr]>rnii inr<'i-ik>n, "id. ^^B
^^^1 fliirliiif pri'iEiiAiK'y. 4Mtt.
irumnluloii to f<i-i(i>. wi:i. 1
^^H imltDiinury. dui'lnK IkIh-iii'. KIN. XMI,
Rutmrh'B alliuiiiluiiui>-l*r. .'•::i> 1
^^H
10ic'U(rl»>on, I'll. 1
^^H iiniit"iii)r N4.
Knilniotli.u o( date »f ■wnnni-uiuM. 1!>5. ^^M
^^^1 J^VpI'ipmi^Dl of. HT-
^^M
^^H iii>iirl>liuii-iil of. IM.
ICUBtaclilan »Itt. lAri. ^^H
^^F I'linbry-iuli- vrpii. III).
RriiKriadiin. 4n|i. ^^H
^H ■lilfM,
Rvi>lHlJit1l» H|hllirNIIKp11«. MNI, ^^^1
^^H [viitliryilDmy, idn.
fliioilnnilun. mmblnril. -iM, ^^1
^^H ICrnfxIh In vtri-jcimury, 1H», r»rM.
Anal. :i4» 1
^^H I'^nipliju'ina n-nipll'-nilni: i-tfgnanry. IM.
invllnilnntr. durlug |ir<Wianr;. Zii'i. 'Ma. 1
^^H flii-lBl. i'Hu>liiii dyu-Hin. TliT.
rafflnal. duilue labour. Sll. 1
^^H of KlMlnmlnal imllt MlnKhig nipluiv of
|iri'|fiiBiM^>. -rt4, ^^J
^^H iii<ni«. MCT-
KiBDIlipinuni 111 piviiiancT. inn. ^^H
^^H lliicii|ilinl<>i«li>. 4lin.
ICirrrliu) iliiiinic pn'Knanrr. I<MI. |^^|
^^H t':arliondt'idia of ih-ItIh, 7KH.
I<:i<mIiiiiIh. |>rin]iirlin[ iii-lrti- ilvforailllr*. TSU^^^
^^H Hilda rWrltii. ■■omiivnMlar)'. ilrirliiit piin--
l^lpn-iulou ot iilaiTnta. SON. 1
^^^P (H^rlirm. ^^l-l
HtlDwimloD. llllui'n'ii iiifili-iil lit. .tiT, (tin. 1
^^B^ KndiirvrdliU diiiiiiE [irvRniini^y. *ho.
Ktpukliiii It) brci-li i>rrvniatlnnii. SMT. 1
^^K ti'UKii'rriiMi. 4H.1. >in4.
In ttcc pmnDtatluiiiL :!T!>- ^^M
^^H li'.nil-n-rrtlcltU, nnS,
In vrrtrx timnila 1 lima. '.^ilV. ^^H
^^^B I'^nditnK'ti'^ILii. Hr^iif dcHiliiaL ^T.
l^ilmcloii In Tarv iin-n-iitalliniia. Hit*. ^^H
^^^m Mvii\thW iJfrUhinJ. ^t57
In tvni-x t>rrJU^Iiliiiaa. 34U, ^^H
^^^^ t'Uliiw of nlx^jllcJkT f13.
Kilrraol iP-npratU-r nrcaiii. :HI. ^^H
^^H caiini' »r |j|iie'>-ii<ii (irwIn, Kll.
Kilrrnal m. (0. ^^m
^^H I'niiMi- iif iir-'IIIBIIiiv lU'lilil-nllfiti nt |>lan>li(n.
Kilfrnal mill Inn tn bfMvh pivwtitAiUuiii, 1
"I4T ^^^^1
En ffn-f pri*Hi>iiiNilfiiiik -Tl' ^^^|
^^H Jrc'Idun rymlcB. T-iIT,
III I'r^ni't prmirntNtbina. '.J^i'. 2iu>. ^^|
^^V Kl anil II la flu. nfltl.
Rilrmal vrnliiD. '2S0, UtS- ^^M
^^1 lll|llltll>Tlll<', 8MI.
Kllnli-tleill, ^^H
^^B Id prpiinaai^y. ^'tS,
111 brooi-li piTVfriiatloaa, 4»- ^^^|
^^H iHiHt-nlHiriiiiii, Wi.
ludlmileiiia 4'JU, ^^U
^^H |HUii-[inni>ni, H02.
III rriiiik liri-fi^h prpwnlatknift. 4ni>. ^^H
^^H |>UFr]H-ral, S.'-U.
MnMrlci^afi'ii man^f^ntn' r<>r. 4:;it. ^^^|
^^B
i'ruK iniii»vuvn> tut, 4'^f<- ^^^M
^^1 M-llllc.
I'^tlm iii'rIiH- |<rfV'i>n'jr. *l'i3. ^^H
^^H 1(T4tlnr^l n(. SIIB.
114.1. ^^^
^^H Kndcimi'tMiiiu. *3,
iiKii'iioii ((.in. ^^1
^^H 111 ajf. -I.'i.
iPiioioEj of. C2n. ^^H
^^M In j-nime I'tihd. 41t.
fliinlDiu)' or. flSI. ^^H
^^H i'r«TnPP«ll»n of. arUT nirfiUBi>, 4.'t,
nmirlati'd wllh lnlni-nliTln*>, lUR. ^^^|
^^H ()iM'1i>)i |iiii>r]H'rliiin. :ill^
nt'arhair'nt of uviiiB Hi. ItXI. ^^^|
^^H iTtlcllliim or. 4f:
lljtaini'ni. 041. ^^^|
^^H iinmiKP of.
<-aii<v of dpMiH'la. 1140. ^^^1
^^B ICiiiiaKvniaiit. PXlrainnllDii. 7-J'.
cborin i-pUbi'lloma M. 6(4- ^^^|
^^H In iTcprh prcariiialloiia. 'Ml.
• lauini'Hlloii at. it^, ^^H
^^H In brnn iiri'innUllonM. 2^^,
ilorldoai TTSitlnn In. KM, flS2. ^^^|
^^H In rai* iin-wnlallnn*. 27^
il!ivii«>i» or. 047. ^^H
^^H In Tr>ni>i pmrniiBlloiiH. Il.'-n.
nrlBiRpnla la. B29. «4*, ^^«
^^H Knitrciri'Io, ii>iii|ill<-a||nK Ighoiir, UTT,
eVrrit iip»n aubarqiunt ■'bllilhrarliiK, RtQ, 1
^^H ■'»iii|>ll'-atlna prt'Enani-)'. niVI,
fnir lit t'Mnn In. (UX j^^l
^^B ICntrrnploili ilnrlnx |>tvi:naiii-y, 4113.
fiirouilloo of dprldva In. im. ^^H
^^H Kntiidi-nn. 11)1,
plfli^ula in, iklS. ^^H
^^M Kniraiirp nf sir Inlo utrrlnr i>li«i>'>. ii^<i.
frwiiiHnrjr a(, 033. ^^^|
INDEX
920
Kxtm niri'Inp prpgnBDry. Iiirmitunia iikiIi-
111, tm.
Il:l-IIIHIiH-i-li' hi, 1i4.'i.
liyrliiiliLir<iriti uKiki' Lri» liH-
liyilrjLiiiiiliH III, IU4.
liittTBIItlnl. tinil.
Jltliii|Hi*dli>n form at km In, 044,
niLjrratL«ia cif ovum In. dJ-'i.
miilliiilr, 640.
iiiiiiiimllli-alldD In. U44.
iilHrlail. <iJS.
filiii-'-nia 111. O^-'i.
I'HtH-Blltl. U4<t.
ru]>liin' i>r. OHO.
HyiM[iiiini»' of, 044.
iprniliiBiliinH of. «M,
irrmnii'iit of, 04H.
IiiIihI. IU(i>.
iiiiTlDi' Oirldus In, ono.
Kyi's <if • lilM. :i41i.
Fbit ]»rrHi-ii1atlfinri. 207. L'74.
almiTmnl niPi'lifluliiD In. ^70.
■ aiinmii.n nf. l'ts.
c-iimplLi-BiiMl liy (-rmtraf'fi'<l jihIvch. 74fi.
c-onvprslim iif. Into ven4>i. 2H1. .
iTiDliiinmy In. LiS-'.
iIIaK<ii»'I'< of, ^T4.
riirrpiiB [u. L'Hl, 418.
frftjupnrj iif. 274.
ni4*<-liBnlrini of. 27M.
nitMlaki-n for hrwch. L'80,
IHTf.irtili.ii In. 2HI.
pr<j|fl|»K' i.f curd In. 84J.
IKibldtiiniy In, -H^-
Mymi>hyiHH»1oniy In. 'iSI.
in-alni<'nl r>r. i^Nn.
viTFiLcm In. Jfl2.
I-'hi-1bI tJBVBlyKlK fiilliiwlnfc forr**!!!!, 4:M.
FunvK vt Infant. ^r»ll.
Kal1<i[ilBD liibrK, .V'l.
acreniHiry. ,'jS-
[TimlnB of, -'>A.
<iritlum of. -'8. <i'2'i.
BtiBlniny at. Tm.
■'hanHi'H In. during pri^jEnnni'y. 101>.
'41lBry ■-iiTrt'nt In. '>8.
dft'liliia In. 124.
illvcrtli'iila of. T,S. 0::4.
Klanili of. r>R.
In iirt-frnanry. 100.
r.il!<i' InlHMir. 040.
I'ii]iu> iiriimontory. 70n. T<12.
I''a<u-la prlvk. 'J41I.
fiprlnoBl. 2411.
l-'SHti-nlnn villi. 120.
Kflt In abdiimlnBl wallii Hlmiilallns pttk-
nanry. I OS,
Kaily dr-gt-aprallnn nf ptaccDUi. r-li1.
l-VninilBlion. XH. H4.
K-H'illnx. anlQplat. .').'i7.
Ki-mali- prctnurleiiK, 04,
tVnllb.Bilon nf nvnm. 114.
IVnT tn wlampFla. r>4l.
In lalMiiir. OOn. 72n, N7«.
lu ptierpt-rliim. 342.
Ki
"lliro-mjomata of mrrim. ii imp Ilia line In-
Ikiui'. 072.
■■Ilh'l. i:i2,
'lEiilirIn ipvarlra, .~p7
'luilirlaliMl fxtrt-iiilty oT 1mIh\ .'iO.
iBKiin- lit ni|.|ik. ■.t:iTi. imi.
lat. ni-nrliaitiltli' ih-IvIm, 702.
rhai-hlilr pelvln. 7i>7.
Imhy moK (Mil.
Ipxion Id l-iwch prcm'ntalliitii'. 217.
In lirow pTi-Hp mat Ions. 2H''>.
In faiT piiwu-nlatliina. 27!i.
In uTi.'i iHTwnlalUina. 2r.!i.
liiatlnK klilnpy iltirluK inrKiiani'j-. 4!>ri.
iplivn. 4110.
'ii'lal rlri'ulatliin. l.'>4.
dlM-aN^B. OO.'t,
ilrupay. 71*^.
ilyxtoi'la, 7<H).
h.-Brl t>fBt. 1R1.
kuki'mla. 400.
membranPH. ii2. 1.'tO.
monHtroaltLpH, 702.
pprltonltlK. 711.'.
syphlllH. r.OO,
cHiuii, aOnornialUli-H i.f. ..liBthinHnB lalmir.
702.
B<-tlvi- muvPaienlK iif. IH:i.
an>-iirliim ut. TOO.
BKrlti-H of. 705.
nt fall lerai. 1.12.
aullndt' iif, 2lh^
liladdrr. dlKtt>ntloD of. 70il.
■'BlHa<-B>liin of. 017. 044.
• ardlBr Iraliinii In, 1f<2.
rlri'ulatlon of, I.'i4.
c'cimprcNHiiH. 3n.'i.
I'unRpnllal hydriHi'plialnH nf. 704.
cranium nf, l-'il.
cyadr kldnejK of. 70r>.
ilcatti nf. inn.
(lefonnlilPH of. 70:i.
dui- to Bmnliillr adhPKlonn. .'i^Iif.
diif to ollfr<j-hydramn1oH. ,'iNft.
dPVPlopmpnt of. 144,
dlampttTH of hrad of. l.".n.
dlPt. pffpol upon hIxi- of. 2IIJI-
dlfc^'i'tlve funrllonfi of. Iliil.
dlKpawH of. lUi.'t.
dNxiliitO.n of. 010,
distention 'if bladder nf. 'i»l.
■■niphyKenia of. 707.
r-nlarKf nt of alHlom f. 7:i'>.
rstlniadon of mice irf. 1 47.
enTnnlve dpvelopmpnt of. 701*.
eirmmlTply laritP. 1411. 7!i".
eWrai-tlon of. 4'J2.
Bpni-ral drii|)jiy of. 0115. 70.5.
hanlliiBl dealh of. 3B<I.
liablluH of. 21>.'i.
bead of. 1S1.
hPBdkKK. THn.
Iipart-bral of. INI.
bean anundx of. la HH|ibyila. X45.
In ptT^anrj. 1H2,
hydrocejihalnH of, 7tl4.
930
IN'DEX
FiMlHM, Infpilliin «t. «lih Itnc'llliix nfniiti'n'Ti
caiiriiilBtiis, TIMi^
(It [•I'lll. T!Mi.
lanu^ of. 117.
length ot. 147.
tealuDB of. In cclampHla, [i;lll.
QwerHtloD of. BUO. Gill.
uiBlCormBtlans of. 702.
lupcnnlum of. :ir,().
metalMjllmn of. iri4.
miivpmi'ntH ot, la prvKniini'y. MtX.
inummlflratloD of. lUWt, tn7.
iiCKro. 1 4S.
nutrUlon uT, iri4.
civer-dPTPlopnipnt of. 1411. TO".
r>apyrar«tiii. 30.1. <ll~.
liSHSive movvmmtH uf. 1x:i.
[*r1tonltl9 of. 7!>."..
phyalotogy of, 1 r.l .
pOBltlOD of. SOT.
piwntBllon of, 2flS.
preBHure markTi on hi^nil of. 7^1.
r*np1 ration of. Ull'.
HanirilnulpntiiH. <tlll,
aXgnu of malilrlly iif. HH.
slip of. In contrartMl ijcIv^b. ":;;I.
Id various muutha. 14T.
Bjphin* of. sun.
tunuiurH of body of. 71*7.
tumour of t^sllrlp uf. TIHl.
of llv»r of, 796.
orlne of. ISO. SM.
T^rplx rflseoBB of, 14A.
warmth of. IIUI.
wplpht of. 147.
Folllrlr. (Irniillaii. iffv f-rnnllnii ro11IHt'.>
FitlNc-iildr' nlri'xlA. 11M».
«pUbP!Utin, tllL
Fontanpllps. 1 TiL*.
t\>otlln>r prpBi'nmtlon. L*n7.
ForampD ovRlp. ir>."i.
Fr.rippK. :i»2.
aiiiilli'inli.ii nf. 4i">.
ax illlator of rprvli. n't7.
11^1^ trailloD. 4iri.
(pplmllr nr'iil'faiiim or. jni.
riiiimbTleirf. it'ir..
I'liotrp of. X"~.
rnnilUloiis ii'-i'i'HMiry f-n- npjilLi'iLTIoii of.
.1!1H.
c'oiilriislril vvlili vi'tvli,ii. T-IO.
rt*'11vpry 111 I'hlliiiK -'Ipllip |ii*.Hl,'rior |",s|.
lion. 4ii!i.
wUli lu-iul iir iMlvn. 4"",
with hltiii. 414.
ollh mid. 4117.
with 0''i-l|illt III lii.llow <if Kiln-iilEi. 4<IIL.
dpsprlpllon of. 3!>L'.
failol paralysis fnllon Ini-. j^ii,
fnni-lloiin of. ."^7.
lileh. 4011,
htHli.ry of, 3M.
In lirMVli prPKpntuIlimfl. 4111.
In hroi^' proxpntntlonx. l.*>*4.
In r.illi-<lon of twins. HfiO,
In coDlrnrtfd pplvi^s. 7ai), 741),
'orr*ppa Lu I'i'lampitlB. rr4't.
Ill fare prpxpntatloQs. liHl, JIM.
In rrank brifrh pn'HpatattoUH. 4in.
In li<-art dlwaae, 307, 488.
\u ctr-<-lpllO'|KiBtprlor (ireapiitallvtiii. 411.
Id prolapfl? at L'otA, 843.
In protracted srroDd stage of Isbniir, M:
In rupture of uterus, 838.
IndlcatlonH for, 307.
I*vrpf8. aiKl.
lona. :ti«i.
low. 41X1.
mill. 4iH).
ovum. 'ill).
i'aJoiH manipuvrp. 417.
tiplvlr opplirailon of, 40:{.
[HTlnpBl ti-am dnp to, 4111.
lireparallonH tor oppratlon. arm.
lirnjcnoidB of. 41l>.
Saxrori>h'H mann-iivrp. 4111.
Si*nxoura mHn<Piivr(>. 41:;.
short, ano.
Simpmin'H, ^1):;.
Smplllp'x. 31)0.
TarnlerX 417.
lo aftcrromlne hPad. 4111.
upon flosrlng head. 4IHI.
orppR oi>npprnpd In lalxiiir, 24."i,
'oi-mallD iDjprtlotix In iniprix-rni Inf^ilnB
Sl)1.
ornli. vaiflnal. 3.">,
rnptnrp of. diirliiK InlHtnr. ^:;i>.
'oRsa navl^nilarlH. .'to.
oTsrlpa. fill.
'i.nrPhWte. :;8.
'in«^iiii-Hs of-i"'lvlj*. TS:i,
of xkiill. ISpp Kkiill.l
'rppzlng point of Itlotxl. Kiii.
rpiiilllliu rlKiprldis. :;>1,
ronml siiMiri'. I.-pi.'.
'liiidal lni4xloii In i':i'^nri'xn Kn-rhtu. 441;.
'nnlp soiillle, IHJ.
iinlx. (Mpp Iniiillkiil I'l'i-il.!
'iiiinfl-xlui|iPil |ifh is. Il;ii;. 7ii1.
llnla^'toi'i'lp, 1I1.V
I :.1 liK-toi^ni^urs. tiX':
t'•>^\a''^l^^ri^^l•a. UIH.
iiiiniiHon. c-rivlinl, :
i:xi]j;r<p|i4' or hiw^-T I
pi-1'1 '.Il'ii.
■ ■r pkipi-pt'i-iil nli'i
<ijl-^ fmrilllis. I S*T
i'ii]i>ii1ji[iii.i
iljisxi'i-lnn foiiinnp'ITpv ir...
■ ^■'ni'i'jil nu'tiibollsin In |n'rirn:in>'y. 17."i.
\(l
■inliiiw .liirliic Ti'iPr
IIS.
>^i;i.
UiH'llliM .Vi-riii;.>m-
*;< nt'rilllj- i-ittilrUiti'd. Hjii, rluic lihl
711.
(■(HiTriirti'il [K'lvW. 7 U\
I'lilurj^i'il |»'Jvls. 7^^^-
<*<|Mnfl.v >iiiUrrt'-Tr(l ihurhliE^^ jh*!*-!
0<'rmlnal <-|jktM'lliiiii, fl4.
sjtoi. 7:^,
vcj^Lrft*, 7:^.
frt'lvlfl
7 1 -J.
INDFX
9:ii
<>lBni cplla nf di'ililiia. I'Jii.
••I plBrenta la Iiiiikh, -'i:i4.
plawQlBl. mi
<ilnKlv&tlri In i»roifimnc'.T, WJ.
UlntldCB, oritan uf. 47.
(ilaodii. Danhulln'M, Ml.
rervkal, -I-,
decidual, Vi'i.
liuvprni'y'o. ;iii.
nmminttr.v. ITl. :l.-l. WS.
Miintjfoniery'a. ITl.
HSllvary, rliangPH of. In iirptEnnni-y. 4ft-2.
Ihyr'ild. i'aiifl« oT fare preiteniatlon. -Tri.
chaap-Fi of, In pi-lamiHilA. TiJO.
In iiregnXK'y- ^^3.
fcetal, I'HiiM' tif d^'Htucla. T1HI.
tabal. oM.
uterine. 45.
TkKlnal. 30.
veatlbular. 30.
Tulval, 30.
Globulin, iurreaae of. In erlBmnKla. ^W.
UIOTea, rubber, use of. 3II1>.
Glycerine, use of. In Inrtui'lng labour. 3S2.
Glycosuria during preitnaiuy. 403,
during ]>ueri>erluni, 33U.
Goitre In pregoancy. 40H.
GoQococcuH In Kartbolln'H jilandB. [>n-.>.
Id endomi'trHLn deildiia. Til'.
Id roamniary ahm^psn. H13.
In ophtbajmla neonatornm. 340.
In puerperal Infection, ti'ti.
GonorrlKPB In presnanc-y. AH:i.
In puerperlum, 834-
Gonorrlwpal pndomelrlila. 88 T.
ophibainiia, :n:i.
(ioodeira cervical dilator. 370.
Graafian rollldc tlS. 70.
alreala of, I'lU.
degeneration of. T7.
rnptore of, 7.1,
Gravllsllon flicory bk to produ<t1on of
pre^^entBtlon. 2IO,
Cjreater Contflnelle. l.'f*.
Gufrln's line. Hul,
f^umma oT plBcenta. 004,
Gut. primitive, in:i.
Gyna^coaiArilla. IM1D,
IlBbHiiol di-Bth of fiplim, ;ttlO.
ElirmBto-lcolpon. 41',
llvmaliirele. dllTuKe. G.tO, 045.
pelvic. 04.",
■olltary. 114 o,
t re simian I of. Cin,
Ilrinaionin mole, Olfi, (144.
of altdumlnal wallx. 'tiXK
of Iroad Ugamr'nl, 041. 003.
of dei'Idua. 010,
of liver. In eclBnipola. 5:14.
of plai^pola, .'"lO'J,
of Hterno ckldo ma«tiild rouaclea, 4W.
of nmlilllcal cord, ."iO!i.
of vattlna, !»rj.
of vulva. 00:;.
puerperal, IMJ'.;,
Ill
llB'nialoma mole. Hubiierlionenl. S4N. liiill.
llpmatoHBlpltix. ii:i!i,
llipmalnrlfl dorliig pri-i^TiHUcy. 404.
Iliemopbllla dnring pregnnm >'. 400.
Ilicmurrbage. ucddenlal. Ni'.'i. Ni>7.
ante -pa num. »Oj.
concealed. 807.
cnretta)[e In. 01*0. 004,
<lue lo aluny of iilerua. Mix,
to hnmapbllla, 499,
to Invention of uterilH. AL:.t,
Ut parBlyrila of tlip ]»lrtcenlBl Klre, SIO.
to placenta prrvla. KOO.
to premalure separation nf normally
Implanted placenta. 805.
to retention of plBt*nta. 818.
to rnplare uf umbilical cord. SIH.
during normal labour, ^.W,
puerperlum. SOI,
ergot In. 8J1*.
from velamentoua liiHertloo of cord. Ml,
In abortion. 017,
Id cholera. 481,
In InOueaia. 483,
In multiple pregnancy. 308,
Intraperitoneal. (1.10, 04.'5. 830.
Intra uterine douche In. 47:t. S'24.
pack In. 477. 8L'4.
manual removal of placenia for. 47S. Sl'3.
tJOHi-partum, 81 S-
una voidable, )t07.
use of salt solution In, 8-J2.
Hemorrhagic hepaillls, !iK.
Hair of pubis. 28.
Hallatereala, 717,
Hand dlBlnfecllon, 30H.
llarrla'a method of illlatlnK llie i-ervii. 384.
Head. f<etat, changes In shape of. In brow
preaentatlons. 28.3,
In vertex preaenlBtlonK. 270,
Id face presentations, 27n.
clrouroferencea of. l."!:!.
diameters of. iri.1.
eatlmallon of alze of, 7.15,
fontanellCB of. 152.
of new-born cblld. 1.M-
ac-Blp tumour on. IKei^ i^aput Kncceda-
Deum,»
t^ntores of, 152.
Headache In eclam!>Hla. 51M.
In pregnancy, 400.
Head folds. lOO,
lever In face presenlallons. 270.
1n vertex presenlatlonH, 250,
Heart, dlrit^asei* of. In |>rcgnBncy. 370. 487,
fatal. 181,
mean' of dlaEUoKlni; fpi. 182,
palpation of, 1H'2.
hypertrophy of. In pregnancy. 172.
Heboiomy, 450,
Heiwateotomy. 4."i«.
Ilegar'a algn of pregnancy. ISO,
Hemianopsia following eclampnla. 528.
IlemlcpphaluH. 205. 703,
Hepalliailon nf pla.-enia. 501.
Ilepato-toiffmla. WI7. .-|34. .'.30.
032
IM»M\
lleredJIy, pxpLflDBtloo of. {>ri,
llprmuaa'ri ttivcvpt*. 411-
Ilern]H[ilii''»lttl'<[n. Ji>,
llernlH. i-^iiK'nltBl. "( firliiB. -'■!IT.
IngiiJnat, .'iti^l.
tif iirejfnant ntfniK, ^iiit,
uuiL'lllial. TiU-l.
TBRlDSl. U7T.
Elcrpm gPHtatloDPH, SOO.
lllrkN'a Hlgn ol prcxiiBni'j'. 1S7.
MiKh forceim. dan|tprn iif, JL'ii, 7-tn.
IILIitm of ovary. G1>.
lllmt'H p^lTimctpr, 001.
1liidjf<-'H liif'lln^ plane of ppli'ln, 3»
llodfec'V paratipl planPK. H.
Hook. IjlilDt. 460.
Iloiir-K^a^^ coQtrai'itop of ntfriiH. (Ui^l.
Hubert's forrepH. 417.
Ilyalla In OTBry, 73.
Hydatldlform molr. 380. r>7l.
bcnlgp, R73.
deatruotlvp. G7r».
In €ilra-iitprlae prrgnaiK')'. 044.
malign ant. 57S.
ovarlPB In, 673.
palholoKy of. n72.
relation of. to drilitiinma mallKDiim. TilTi.
treatmPDt of. S76.
lljdrffmlB of prp>^Bacy, 17'1.
tlydntiDDlos, .<t8(>. SHI.
acute, CHI,
eclampala In, [>2n.
Id doublp-OTum tvlna, .1^4. nS.t.
In eitrs-ulPrlDp i>n>jtnaary, 044.
llydrocpphaliia, 7U4.
(Tanlolomy la. 4^4.
TeraloD In. 4!A*\.
Ilydrorrliira grBvldaniiii. !ilii\.
Hydrosaiplni, 58.
Ilyglpne of pregnnni^y. ( Si*p l*rpcnanry,
Manngi'm^nt itt.)
Hyrofn. .11,
aht4eni-e of Injury af c-hl]dl>paTln>r. 't^-
snnularlB. .tl.
atresia of. 4'2. flOfi.
ranini-ula' nij"Hif"rmefl, .'l.'t.
nrafllstpncy of, iU.
dpnilculBIe. 31.
dovelcijimi^nt of. ;U,
flmlirlat-ed. ■it.
ImpprtorBlp. ;il. 4-J.
cnuxe nf dilHi'iiii tnliimr. IMC.
Injurlep at I'oltiix. .'IJ.
InliirlPH folliiwln^ flilldlH-ni'lne, :i:t.
oporatlcmx U|h>d, .12.
aemlliinarlfl. ,tl.
neiitBIP. ni.
Htrurturc of. Rl.
llyppr^'DipBlrt gravldni'iim. HOS,
IlypprplBBla nf clinrl.mlr villi. .".HI. .-p'M,
llyppi'lrojililn oloiigat !*>□ vt oprvli durlhff
pipgiianry. nfl;t.
H.vpprtrophy of uterus dtii-Inf; j>re|Eiianpy.
1G4,
llypnollHm In lalioiir. ^-4.
llypopUynU cerpbrl, 171.
Hypoplaalk ditarf pelvis. 7^1.
Hyntpreiiiuny diiplnj; prcKnani-.v. tJ74.
for rhorlo-eplIliellomB, 5H1.
for myomalB. U74.
fr>r puerperal Infei-tlun. 88R.
siipraraKlnal. after rmmreBu M>>tloD. 448.
total, after I'eeiiareBn nectlun, 448.
Hyaterla, eavee of nauapft ot pregnanrj, MKt.
In pregD&nry, 4]>7.
IlyBlprotomy. vaginal, 38 A.
Ire. uae of. In bwrnorrbagp, k-2-2.
litpruB of rhild. :<r>[>.
during prpgiianfy, 4i»l, 'il.'t.
gravl*. ."il."i.
1 llo-[ipi'tlneal line. iKee l.lnea TeriDlnalliLI
Ilium, :<.
lleUB due to retrollpxed pregnaut uteru*.
560.
Imaginary pregnanry, IBl.
Impetigo tip rped form Ib, 4nft.
Implantation of ovnni. KIH. I2«. (1.11.
Impregnation. 8H. 114.
Inrarceratlon of prolapHefl pregnnnt ut^nu^
56-2.
of retroflexed pregnnnt utenia, r>.'i1i.
Inclslocs ot cerTl*. deep. 38ti.
Inrllnatlun of pelvis, 8,
InroraplPte abortion, HIT.
Indigestion during jirpgnnnty, 4A1.
Induction of abortion, i See AlHirtlon, Id-
duetlon of. )
of premBturp labour. ISpe I'retnaluiv lA.
hour, Indnrtlon of.)
Inertia uteri, O.'il).
Inevitable alxirihm. <117.
Infant. (Sep New b;iru Child. I
Infantile paralyuls, plT"<i iipou pelvlH. TSfi.
pel via. 7411.
InfarctB of plac-enta. WM^
InfeotloiiB dlneaHeH t-imi [ill rating pregiianrv,
480,
Inferior strait, (1. r.'lL",
4"ontrB<'tl(i!iM of. IVJ'^r
I nil III) la (Ion. '^S.
lllducnia during pr.'giinury, 482.
InfundUmlo pelvli' llt:i nt. (ill.
Infiindlbuhim, -Ml.
Injuries to lilrtli luniil, si'n.
lulet, pelvh-, 4,
lonervatlcku of uipi^ufi, ,'p^..
lunfjmlnate l»tur, -O.
Intwnlty In pre^ciiiinr.v-, ill,'.
lartntlonnl, IU,'i.
puerperal. 111,'.
Insertlo vt-laineni'tHn, ~iiS(i.
Insulllatlon of liinK" I" asphyxia neonato-
rum, 84fi.
Inierglsndiilnr tissue of ulenis. 4.1.
Inlermlttent ronlrui'tlons of uterus. Ih7.
Internal n'll ruJIns, |IH.
Internal geiuTHtli'e orj^aus, ^H.
t*alloi>lnu lubrri. rtTi.
ovaries. IMi.
uterus, .IS.
Internnl Miailon, 2."!>.
WOEX
im
Intrmkt rolallon. oauMlIon of. SHI.
In tm*<li jirpiirnlHIIunii. :;h7.
In brim' proBentBiJcinB, aB.I.
\n ffli*? prem^DtatloDB. 2T1I.
In vertex i>reBenlaU(>nH. linn. :>HT,
latFrnRl iwervlli>ii nr ovarliii. H^t.
tnlernal tpphIoii. 1X7.
Interatldal prrjfnanry. 6^0.
IntfrTllloun blrux) upai^B. i:>8. i:iii.
IntMtlpBl DbBtraclIon. !ii>2.
Idtra-iwrliitn erlampitla. ri-jH.
\nlenUm. «fi3. 72ft. HTM.
Inlra-tubat rupture, IWT.
Inin iilirlnp diiuihc. 47:1. KNri.
indlcatlonii for, 4T'L.
In p«il-i>nrliini hmnrrliam'. 47^, S:;4.
Id puEriirral iDrectlon, 47:i. HS.'i.
pack, 477.
pmuiurp, 223,
lUTemlon ut ^rm layeni, 99, 103,
of uterus. 823.
Involution i>r ulerun, XfJ.
laolilo-pavernoBUii. L'4I>.
Isphlopaj^x. 7^12.
Tacblo-publotomy. ITtTr.
l«i-blo-r«cta] tOKiit, L'4n.
Iirblum. 3.
■pines of, 3-
Istbmlc preffnai'-j. 030.
Iitlitaus of tubp. riTi.
Janndlpp of rblld. 3.'<n.
of motber. 4fll. .'ilTi.
Joints, mc)!)!!!!]? nf, during prptcnaa^'T. 11,
pflTlf. in.
pubk, 10,
relaiatlon of. durlni; prpKnam^, TiOI.
rnptiire of, duriiiK lAl>oiir, 'i'2iK
HITO-lllai', II.
jQato-maJor pelrlx. T-IA.
JufiEo-mlnor pelvln, 746.
Kidne)-. cliaiiKeB In, diiMoit pivRnanPT. '73.
Ip prlarupBla. ri^il.
fJBtIc-, of flMllS, 71111.
dlBlucBlliin of. during prcKnapr;. 4flri.
dlBlooatpd. nuDpUrailnit InlHiiir. <17T.
BoatlliK- ilurltiK jirpKUBDry, 41l.~i.
of prrgnancy, IT.l, .">IS.
removal of, 406.
tumour of, rompllratlnK LalHiiir. 40.'i.
KUen'a pelvlmelpr. Cfltl. 7(14.
Knee preHenlHtInn, 207. 2H4.
Knot! or umhiiical <rurd. r.nu.
Krairae^H methiid of ludui'lnc lalKMir, 3HI.
Kjpho-rbHr-bltlo peWln. 77~J-
Krpho-Biiiltn-rhai'hltlc' iwIvIb, 775.
KyphO-BiMillnllr JjelvlK. 77ri.
KTpboHlx. T'lll.
Kyphotic |>elvlH, 71111.
Ijiblum maJiiB. 27.
cmnlnlnHiireH of. 27.
develnpmeni of, 2M.
hernia Inro. 2M.
irdema nf, 41hi.
I^blam minus, 28.
fotma navlcnlarlH. no.
fourcbette. :!B.
frenulum I'lltnrldlB. 2H.
laborlum. 2H.
Innhulatlou. 2H.
Dymphr, JH.
prcputlnm cllIorlB. 28.
■•aborde's methiid of resasrltatlnn. 84H.
labour, abdominal ponlrartloDH diirlnic. 2411.
action of expellenl forrea In. ^40.
anPStbeKla diirlnic, .321.
arterial preaaur* In. 225.
BHppala In. 214. Sot.
bed. preparation of, for, 312,
caput Buccedapenm. 271.
caunt- of oniiet of, 21 H.
changea In arterial leDRlOD daring. 172,
223.
In perlnpum during, 251.
In pulBe during, 225.
in rectum during. 232.
Id reapiratloo during. 221. 325.
In shape of head In. STO.
In temperature during. 225.
Id uterus during Brat stage of, 240.
In uterus dnrlnx aecond atage of. 244,
Id vagina and pelvic floor during, 247.
chill after, 335.
clinical rourati of, 229,
cocaine aDtealheila during. 323.
collapw after, 848.
complicated hy bony (umoora of pelTta.
788.
by rumpound prtaentatlon at firtna, TDK.
by concealed brmorrhage. 803.
by coialglc pelvis. TBS.
by deformities of fcatua. 793.
by eclampsia. 542.
by enlargement of abdomen of ftptds.
7»5.
by pireKslve alie of cbtld. 790.
by fo-Ul monstrnBllleB. 792.
by flat pelvis. 702. 727.
by funnel pelvis. Tfll,
by generally eonlracled pelvis; 746.
by generally eontraeted. Hat, rbaehltte
pelves. Til
by generally enlarged pelTla. 746.
by bydrocephalus, 794.
by Injurle* lu cervix. 830,
by Injuries to vagina. 828-
by Intrauterine aspbyxlB. 944.
by Invention of uterus. 823.
by kyphotic pelvln, 760.
by myoma of uterus, 672.
by N'aegete pelvis. 751.
by osteomalacic pelvea, 716.
by ovarian tumour, 674.
by paraplegia, 222. 224.
by pelfia sptnoaa, 7S8.
by placenta previa, 813.
by post-partum hemorrhage. 810,
by premature separation of placenta,
805.
by prnlapsc of placenta, ROT.
M4
INDEX
Ijilhiiii'. t-oni|>IU-nr«Mt hy iircilapw of nmhllb-
• iil inirl, H I:;.
Ii>- rliarhUIr (H-lvK 7i'4.
by Krilwrt ir'IvIr. T.iii.
by rupture of tbe iilenjH, H'Mi.
by HpJit pelvla, 7Ii7.
ty BpoadfloJlBtbetlr iwlvts, T7n.
bj tranMverse jirewBIBili'ii i-f fii'tiiB.
798.
iiy tunn'iira ot fiptun. 7!l".
by tumours of pelvlH, 7HK.
tonflupl of, 7117.
Hrat BUge of. 307.
■eivDd Btage of. 312.
tblrd Btase of, 325.
contrAcl&OQ of uterine llffBTnentJi during.
48. 213.
cour»e of. In rooliSfted pi'lvpK. 724,
dealli during. 84N.
deliver; of xhouLderH. 31ii.
dlLatatloQ of cerrii. 242.
dry, 22(1. ur.l).
duration of. 231.
«nlrapife of air Into uterine bIuubph dui^-
luK. HM1.
eplHlolomj Id. 318.
ergot during. .124. HOl.
eiamlDBtloD in, 313.
falBP. 646.
flrsl nUlge of. 22(1.
force exerted during, 22.1.
forces eoDcerned In, 23.'i. 24-'j.
formation of conlracClon ring diirlns- 238.
245, 802. 832.
of low^r uterine itegmeut. 2rL(l.
hsmorrtaage during. 230.
hand dialnfocllon la. 30H.
hypnotism In. 324.
In elderly iiplnilpnrie. 2;!l.
in yiiimg fii'lmlparie. 232.
Inlra-u^r-rtni^ pi'rssure durln};. 223.
laceration of [lerlnirum during. 314, 4lli,
Diei^hanlHm of. In breei'h presentations, 2S7.
In brow p rem' nl a I Ions. 2s.'l.
In face pii^wnlHltons. 27*(,
Id vertex prefteniatlonn, 2.'i-l.
nils»i>d. (j(l4,
moulding of bead In. 2711.
metabolism in, 22(>.
nervciin 1n[luen<'es diirlni;. 222,
normal. 22."i, 3i);!.
ohrtlrin^fed ( See 1 »y,''1"c1n, i
jiBlnful. (ir.S.
painless. 223.
I)alns of, 222.
palT'Btlon In, 2.">. 2iiil.
fierlneal tear? In. 31(1.
pliennmeiia. cllnlral. of. 22.'p,
pb,VNlral rhantes clnrhij.' iili'rlne 'mhIi'iih-.
tlons. 224,
pbyil'iloKv of. 2IS.
preclpltale. 0(13,
prediction of dat'- of. i;ir.,
lii'ematnrc. Oil.
jirefiaralbms for, on imi't i»f itiiUcnl niiO
nurse, 303.
Labour. preparationB for. on part of iibysi
I'iaii. :i«0.
profound uiinil:il dtpresHlon during, m\*r
prolonged, (ijK.
prote<'tbin of llic perlnipnm In. :st(>.
pulmonary embolism during. ti.'VO.
repair of perineal tears. 32.''i.
respiratory excbange. 221.
rubber glov^es. use i»r. during, .30t>.
rupture of membranes In, 22fl. 313.
setimd stage of, 22(1.
shriek during. 848.
stages of. 226.
»yn(roti« during, 840.
tardy. floS.
temperature In, <lfl3. T29, B7S.
tliird stage of. 22)1. 2H2.
time uf, 232.
tying ot cord In. 320.
vaginal examination during. 311.
l.acUIlon, 3M.
Biropby uf uterus. 004.
l.a(>tRiional Insanity. 015.
Lactiferous duns, .3r>7.
l.actofluria during pregnanrj. 4!>r^
during piierperlum. 330.
Tjlmbdold suture. 152.
I.BUgbaus^s layer of cborlrm. HIT. 132.
l^iniigo. 146.
l.Bparo-elytrotomy, 4M.
Laparotomy, for coliMiiiorrheiis, S2fi,
for de^'p cervical tears, 832.
for pueriMTBl Infertlnn, SS!I.
for rupture of uterus. 838,
In e\tra-nierine j-n-gtianij-. iHO,
lb tri'atim'iit of i'<'li-ode7ii.tl pregnnrU
uterus, .'■fll.
[.ntcraJ curvnlun' ot spine, 773.
di>.]ilaci'mi-iit of picgnaiit uterus, .*ii:i.
Jlc^Iun 1[i lir -b presentations. 2^*7.
placciiia pru-via. KilO.
plane prcscniti tlons. tSee Trnusvi^rrie
l*ri'MetUrttloii. h
T.aiailvi's In riucrpirlnin. 343.
Lead iMtlsoMliig ilnring pre*;naM*-4. 4110.
1 .eg- bolder, 3; HI.
Li'opold'h ovnm. 1 11.
T.eKBer foEitaiit'llc. 152.
JjCllc.K'ytiNSIs In [Oil. r perl urn. 172. 337. M^M.
Lcncoinalncs In ct-lampr^ln. 7i'^K
I.eiikieinlQ .luT-UiK prci;iuin< y. 4'Hl,
LevHtor nnl muscle. 247,
flvrilocln line to, IKi^.
injurl.'s to. diiiloE ItiUiiiir. S'j<i.
I.cvrt'fs forceps, ."nt..
Life. ISll.
Iicrieptlim of, laiK
l.l<:anicMis. brotid, 47.
cgirdliinl. of lii.cks, 4s.
llio-wi. inl. 21.
Idrilllilliilll.. pelvic. -JT. C.M.
of iircriiv. 47.
oiaihio. till.
redo uterine, 4S.
pilfiic, HI.
r<iijiid. 4s.
INhKX
935
LIx^DWDtH. Hiii.'r»-Bciaii>'. il.
HUHiienHorj'. uf *iviir3', 47h I'iI*,
uteni-iiacral. 48.
LJgampDluai. RviialuDi publH. lii.
latum. 47.
ovarii. 60.
Urea. 48.
traD«TiTiuilp colli. 4N.
LIdh terroliiallK. 2.
■.tqnor ■mull, 1 10.
roiiiruii. no.
l.ltbup»dloa. 617. 641.
I.ltllF'a lurhlil lube. KM.
L>lv«r. aru(i> jrllim- »tn>iili.v nf. diirliik' iiri'K-
DBQCf. 'll.'l.
chanjfi'ii In. In I't'lniniiHlii. TiiEU'.
Id peril li'luiiH riinilllrit:, .M'l.
r^Klli-. In fii'liiH. Til".
■ypbllltli- I'lrrhoHlH, nf, mil.
I^H'lila. :t::7.
lia<1<-rlB In. 3;!S.
Iiacterliiln^h^flj f-iiiiiiliuLtUpii nT. .^TiT. Mhl.
Id impriHTBl Infi'i-tli'ii. »m1,
rFlrntliiD nt. NTH.
IjK-hlanii-irH. H*ii.
tiiH'kPd iwluK. :tiKi.
lJ>ntrlafCH In iti'^iihti'-.v. \'J^t.
I>HipH In iilulilllral <-<>nl. -Vis.
IdU'a dllaiiir. :<ki'>,
l^wpr nli-Tliip wtcnipiil. J-!i>.
diirlag i>ii4-r|ii>Thiiu. •i'-l-r.
blRtury i>r. -JXr,.
nam re nf. :::<)<.
palpallon of. L'Kl.
LumtMir aomitliPHla. .i:;:t.
panilurp In (M-lRni|tHU. ri-l.'t.
LanffH, ohauEPfi In. tlui'lnt i>rf'iEiiiini'y. 17.L.
IvalnUH ft. In filaiujiuln. :<:<4.
I.QtpIn 1*I1», 71. 7:.. Tii.
LaKatl<ta n( f'-nmr. '-fT'-fX nin'ii |>"Ix-Ih. IXTi.
Lymjihalli ^ nf i.vui-1i-«, lii'.
of lubp. ."i8,
of UtPniFi. 41*. .'iL'.
of vagina, M.
LTrnjibuld nodutt-^ In t-nilomi^Trliim. 4.~p.
Maoprallon ■<{ fn'iiH. (iim. inii.
Uanila rmhryimHllM. H^.
Uaiar''»tt<-i»n dliu'Brip, TIT.
Uataria during ;>ri'>:nHn'^y. is,".
In pnerpiTl 11111. sxo. »]•:.
iraiiHiulMHiiin i<r. in I'hilil. isr..
Male ]>r<irLMi-JiMi:', liii.
MannniF. iSp.- ]iri']LKi>s.i
MaDasemrtit ••< in'i-tinxni i. lii'.V
Mania. iSi-i- ln>iiiiliy.i
Manual r«-ru<ivAl .if iiIuh'TjIji, '•',"[. 477. s::t.
Martcinal In-.Tiiiin nF iiMrt, .v,ii).
placi'iiia iini'vlii. *^"'.'-
3tfarg<> plaifutip, Tilfl.
MarkKiriinui'. 'i:;.
Martina |u-UlniriPT. ip"1.
Maiu-nlliii' t"'lvls. 7 \'.*.
MbkiIiIk. Ill:;
MaliirKII'in ••< I'Mim. ',>J.
Maliirlly ■.! Fir'Ui^, ^Ik-ii-^ -t. lis.
.MaiirktBiia manieiiTrp. 4-'ri.
MeaiileB during iirpgaaut-y. 4)tl.
during pueriwrlum. U18.
urinary. 30.
MpatuB. urinary, 3U.
MribanlKm of labour, nimpllialed liy f<rlal
moDMi'rjNKIfH. 711:;.
In breach iir^wnlallonK, ^l^T.
In brow pri'M-niailona. 1:8.1.
In ri>ntrartp<] pi-lvptf. 7^4.
Itl rat"? proHpntatlunH, U'78.
In nc'c-1j»ltu-pciaterli>r prpH-nlatlotiH, i;6fi.
In tranaviTM prrspnlalliiDH. TIHI.
In viTtfi pre Bfntat IcinK. L'j-1,
Mi'i'lLel'ii diverticulum. lltU,
MwonliiQi. ajo.
Mi^ulla iif uvary, dl.
.M<>du]laTy i^nJK, llli.
mroi've, lUU.
rld«p». HH).
tli-iubrann Kranulmui. i>l>. Tl.
Mi-nibrmivH. (yial. u:;, latl,
uK'tliud -it rupliirlDg. ;I1X
niiriui'i' of. ^44,
liii'liiature. 1^-6.
ill ^'o 11 tract I -d |vlvpx. TJH.
.Mi'UilirauiiiiH plaii-nla, Mm.
Mi-mory. Iush uf. Iii fi'lamiiHla, rt-7,
Mi'iiiipauKti, 81.
Alfti»«'H, i>-fl>4all4>n i»r. In pri^iialiry, 188.
rieritlMtc-nn- uf. In pri'guani'y, 188.
Mpnnlrual lyi-lt, 8a.
drcldiia, »4.
IHTVe, M5.
wave, 8r>.
Mi-nHlriiBl1on, 81.
arirr rivarluiumy. Hi
amiiuni iif bicitid loM In, 8L'.
analoDili-al c-liaoffeH In, 8i!.
i-HMKalliin i>f. 8:<.
<-i-wtat1iui of. In pregiianry. INK.
In Inreniii, 81.
panli'ipiiilon in. by iiibi-, 8^
IfprKlHii-iii. 81.
[irii'iirhiiiH. 81.
tvlatlun ft. tu uvulBilun. 8:t.
Mi-ntal and pmotlcmal change during preg-
nancy, lao.
deprpfsloD during lahutir. 8-1 U.
drningempnt tiiU'iKlBg FilBUipiila, ,'>J8.
In pregiianoy. 5111.
Mt-ntit-IUar preMenlBtluri. i.<pi> Ka<-c i'ri'B-
PDlalbiuH. I
Mercurial j-plwiinlng rmin Inlra-iiterluF
dnucbe. 474.
MHrtleiM'w iiviiiu. 111.
MpiKililaKtlc Hoiultex, 101.
Mcsralfrra, liil.
M-'Hiiih-riuli' area. PH.
MpKcisRljiIni, 47. <H1,
M-'inl-ilIsm III lime nt la1«>i>r. 2'Jii.
l(»-ncrnl. in r^ripgnaacy, 17.'>.
In pii.-ri.iTliiin. -f-W.
McriPiviirliiiii. lUk.
Mi'irlll'' ilfolrnim. 8111.
Ill jtri-xiiBiicy, OOH,
H 936 ^^^^H ^^H
^U Mclrttl*. Iiucrprral. SIM.
Mjtonu of •itvniih Omnvii hniIub Ui |Wt^^|
^H MTfTI''' nWJllKIK''- 0
nanry. lal. 3»V. ^H
^M Mlchaplli'i tiicaibold. «WI.
U)aiui>i'i»iu) during pivEiianry, S74. ^^H
^H Ulsmlliiii or uvum. tH, tt'ii.
MjvinFirliioi. i«, ^^^^^t
^H Ullk. BDDlIOIDJt ot. Xi'i.
Miriumii Til aril. ^^^^^|
^H vur|iuarln* uC, SiS,
ntifoauiD iiianruM, 5a«. ^^^^|
^H <ow'«. 3ST.
^^^^H
^H dfjilnR up, 3i(T.
Kabotblan r»llU'lwi, 4S. ^^^H
^1 human. ^6S.
Xa*xelc> obllqullf, SS, ':». ^^^H
^H madlllod. 3 ST.
NHi-gi'W |wIv1h. TM. *^^^^^|
^B rorrr. »3a. HTU.
Nauam nnd T'>mlllna In prrKnaory. IXIint^^H
^^^ Icfl^ ll^rv I'blr^niiihtR Alt'* litiliTUh.)
Xricrii fiulUH, i-liaioiTirrlKtln of. 1 It). ^^H
^^^B Uliearrliier. «IJ.
Nfpbrltla. cbruntr, diiilDit prfxnaitry. IT^^|
^^^P UhMd •Iwitlon. 02».
(OS. SIT. ^H
^^^^ IB boil r.
Id arut' )*ll<Ha alniiili;, Sid. ^^M
^H M<K]in~<i milk. an?.
In rrlnmi'da. S^l. ^^M
^M MoIp. ItKi.
In tuiB>niU' vinnltlnK. Sll. ^^M
^H blood. Bill.
.\>rvpt of flltoHK Sn. ^H
^^1 cani<H)ii4. tnit-
uf iivarli-a. «2. ^H
^H doalrurllvp, r>TS.
of iiiprna. AH. ^^|
^1 (Ifiby, HID.
XpiToua axaltiD tn prtvnaDcjr. tTt. ^^|
^H hvnialnmii, llll(. M*.
\runilt[la durinc prBKnanry. IM. ^^M
^M lvd«(ldltorm. S't.
Nnirtnlvrli- nsal, 11'.;. ^H
^H liilial. Ailll.
XVurlila dortnc picsnanrj. 3TV, 4DS. -i^^H
^H uwrln*. Kill.
piitfrpml, fN»7. ^^H
^H lluleralar rum.'viilniUaD ul lilmnl. US.
Ni-urotic voniltlnB of prrxnan'')'. liWi. ^^M
^■' Mi'lllilu »»>liiiii. TI7.
.\i>w-biini Flilld. nnltlrtol fpnJIUR uf, iUI.^H
^H ModAtra. 'tf:t.
aqibfila ot, >m, ^^M
^H lIuD* rrnfTU. Ilk
ran al. Sta. ^H
^H MvniRnniT)-'* (InndK. ITt.
i-yn of. ^^1
^H JIanlfi'a forrcps. 417.
rtroulntury rhaDB« ■>. UI*. ^^^^|
^H .MiirnInK uli'kai-ui. 1MI.
dRi*Iii>i Hrtrrbuniii of. Utik ^^^^^|
^H Morula. l>T.
frrdlDB ^^^^^1
^H ItlnvoRiPnta <>f fiviiia durlnjc prvsnaniry, 193.
forainnii lU, 3ML ^^^^^|
^H MultHTrgr niBH. II'.
hi-ad ^^^^M
^H Ullllrrliui diirt*. &3.
Irtr-nw of. 320. ^^^^H
^H MIIHi-r'ii nii'tliiiil nf Imiiruutmi ut hrad. 7Sd.
Jaundlio ^^^^H
^1 Mnilrr-n riDiE. ^^11.
iMIRIb ^^^^1
^H Multl|>li' iilHCPiiIH In kllielr pr*KlullicT. 38S.
Inu of wriehl uf, 850. ^^^^|
^1 Miilllpk prf icm iiry. :IU(>.
noralnu of, itiA. ^^^^^H
^H ninrdia In, 'MS. 71111,
niibthalmlB ot, 349. ^^^^^|
^H coiiriii- itf ImIh»iii- In, HUT.
Hfi ^^^^1
^H dilEnoilh of. :I4II.
Hool* ^^^^1
^1 H'Koiiie; lit. swK
iimblllral I'ord of. :MT, ^^^^^|
^H pclflriipnlii In, A^23,
tirttii- ^^^^1
^H rtrlun jiupynfcua In, Wi.
TK-lgbl ^^^H
^H tr*i|U>'ni')' f>r. MO,
Xlp|il»«(, nl'ii'irnmllikii of. nOB. ^^^^H
^H hirnii-rrbiicr In. 3t>8.
(■arc nf, <1oHi>i; pr>'|ciiaD<*y. 'JHl, ^^H
^H by dramnio* In. 3U4.
duTine pucTpcrlum. 333, ^^^^^t
^H 111 Ii]lx-i>, «4tl.
^^^^U
^H mummin cation ot tmtaa In. :l>n.
drprrmrnl, tluS, ^^^^|
^1 rtlallan ot plan-nia and mcinbraon (a.
nuurvH ^^^^1
^1 nao.
Mppir im. .tM. ^^^^1
■ ilBc of cblldnn la. 3U1.
Mimiionouii lurtlllop of nrlnr. MO. SXO^^^|
^1 liaalmvnt of, SSI.
.Vonipn«laliir« uf prvBfntnOuu. :!OT ^H
^H Uu«c1« DlirFU of prfjcoant iitprui. Itl.'i.
Noloi-horil, 102. ^H
^H rhumboidx of uiciiix. IHT-
Nuchal prrwnlBllou. MM. ^^M
^H MuKdilar ronlini'lun-i In (idrumklacla. "III.
Niu-h. cannl of. :!!). ^^M
^H palilea Id oatr&milni-la. Tt9.
S'uclvln. till' -if. In piiatytml iDftctlon. 8^^|
^H Mna Pill Blur* at ncxi |irf||niint iit'm^ IS.
Nurtritn. tPsmcnlallonk Mt. ^^M
^V ut prTtfnaot tilTiin. IRS.
NiininK, r^sn. ^H
^H of lubr. .%'.
Nyniphir. 'J*>, ^^^^H
^B .M]Fui.ar(ll(1ii ditrliiv |>rfKrinn<7. IMii
^^^^^1
^H Mviimir of IKcrua. tV'««-Dn ■frll-iti tii, 441.
tll>Rc|iic1y rotitl'N<'t''l talVbi. 7M. ^^^^|
■
iib«i>trlcnl niiltll. 3(HI. ^^^^^
^m rcrniiillratlnu tatnur. «TS.
liamlyalii, <H'^ I-anly«K <MH«MrlrnL{^H
INDEX
937
I ilMtvirli'Hl HurgFry. (liee i)ivralli>Dii. iih-
Hietrli'dtj
ohrttrui'U'd Labour. (See Dyvtovla.t
llcdliHo-aDtfrlur prt'wnUlioDB. ISee Ver-
Iri rrfHCDtatluD. I
Kftllilio-iHimerlcir prewDUtlona. i»« Ver-
Irx rrPMPBlallrin. I
(Kdi-nia iif iTrvli, ariiti-, 5«.'l.
In |>rrj(n»nij, IT". 4Wi.
f iLlfc<i-byriramnL<rH, 7j>i^.
niB[)halo-me»eiit#rk' Teiiaelj4» 1^"-
OiHjlf. 04.
I iiigpneslH. U4.
(luKunU. U4.
• lo|>h<>rltlH, pncrppral. 885.
Iipvratluna. ubBtetrliil, ;I7I.
ai'ciitii'hfin^Tit torc^. ;iH3.
t'SHarpan sfrtlun. 441.
i-ervLt'al LarlnLaan, Sfiti^
<' ran lot limy. 44L;1.
<'Ur<'llai;>'. 474.
[IriajilUiloa. 400.
dourlip. 41 'J.
fuUirynXinDj. 4tLD.
I'viHiTratlon. 460.
I'M TBI I Inn In bn'Rt-b )nviH>utalloiia. 4:;::.
fon-(-|w. Ii^t2-
lip|H>ioni>', 4-'ii».
Indiiitl'ia of Blionlon. X';t.
Iirpmature Jabiiiir, 3TT.
Iniia-iiicrlne iiark. 477.
iHiiaro-fljlnjtonij'. 4.">1.
inanual ri'moval or pra<«D(a, 47T.
Iireparailonfi for. ^Tl.
l.nliliitiini.v, 4.'>6.
KurKlinl lu pr^gnaDi'y. Sill,
■)iii|ihyiifotijmy. 45:;.
lariipim. 47A.
- vanlaal I'vimirta set-tlon. 38H.
ophihalnila. 3M.
nftinarriFum. 340.
I'ritBn of (Jlralden, 47.
lit llowmUller. 47.
Oh riivrDuin. 4ii.
inniiminaiuDi. \i.
lutToum. 411.
IIS ilnrr, 41).
i>iulrl>'atliin of ppItIh. 17,
'iHliM'i'boDdrltiB 8j-(ihlihlrB. Oil:!.
omtsinialai'La. rllnlial hlmnry of, 717.
fiatholoKy of. 717.
IH'IvIh In. 71!>.
'latmnialai'lc prlrlB. 717.
llBllsiplijtr. 174.
iiuik'i of pelvlB, H.
i'iiDlra<'(loiis ot. (192.
iiva, Parly liunian. 108. 111.
Ovarian aUm-eiui. N88.
arliry. 40,
i-jililn-lluni, 04.
niulirla. r>7-
■ ■rficnanry. IVJH.
IMmi^HrH. riPHari^an w^-llnn In. 444,
■■•pmpllcallnK pn-Knanry. IWi. 37"i. .Itfl,
074.
Uvarlei, Wl.
arctfaaory, HIJ,
analuniy of. Ou.
ibenges In. In pregnanvy. IKS.
cuTjim luteum of, 73.
(.■yatB of, 37A. ri7D.
dprldual eeUg Id, 1:14.
develop mt'Dt of. 63.
vpltbvlliin] of. OU.
iTwIlllly of, 01.
gaogUuD uF, *i'i,
CraaBan follicle, «8.
hllum of, 00.
in [Hit?omalBc:la. 718,
lDt«rDal secretion uf. 03.
In ynuDK rhild. OS.
llBBmeDt of, 60,
mnlullary mrda ot, 62.
njkroai'opli- etruclure uf, 07.
peritoneum. relaHuna of, to, 61.
IKiBltlon of, In pre^anoy, 100,
relation of. to Wolfflan body, 64.
removal of. pregnaary after, So.
reie of. o\;,
tranHplanladon of, tl3,
iivarloiomy during pregnancy, 674,
ovale pelvis. 571.
1 1 vep- rotation In breei-li prenentailon, 'JS8,
Oviila Nabothl. 4:^,
Ovulation, »3.
during pregnancy, tOO.
relalloD uf. to meustruatlun, 03.
Ovum. Tl.
at>domlnBl pedlile, 113.
allanlule vpalcle, 112.
allanlola of. 112,
amnion of. 102.
area »pa<'a of, 09.
area peMui'IdB of. DO.
Daucbxllel of. 112,
blaKladermIe veilde. 07.
cenlriiHome of, 67.
cborlun of. 10^.
cbromoKomea of. 03.
cleavage of, 07.
cfplome of. 101.
deutoplaam of, 72,
development of, 07.
dlsi'tiarge of. from ovary, 7.1, 83,
diiieaaea and abnormallllea of, 375, 571.
dropaleal. 621,
eetoderm of, 101.
ectoplflcenta of, 104.
embry<inLo area of, 00,
embryonic ribleld of, 09.
entoderm of, lOI.
female prunurleua of. 04.
rertllliallim of. 04.
germinal Hpol. 7!!.
germinal veBlile. 72.
head roliN of. IIMI,
llynlx DM.
Imptanlalliin of. ION. 12(1.
Impregnation of. A8,
Internal i-ell maHK of, OH.
In iraDHll ibrfiugb lobe, !>K,
93S
INDEX
Leiipolil'Fi, 111.
mat'ula pmbryuDitllB uf. OS-
male iiroJiucLpua of, Ud.
maturulloa of, !>2.
mature. 7;;.
m«lul1ary grojivp of. liH'.
mpduUary riUgen of, H'U.
MeritpDH'ii, III.
meflohlaritlc si'IoUph of. 101.
mpBodermlr art's uf. UU.
mrsod^rm of, llll.
mlRratlon of, Hj, U:;o.
extei^oaL 87.
Inlemal. S7.
monils of, 1)7.
neiirfDlerlc- i-anal uf, 113.
notocliurcJ, ItllJ.
parietal zone of, IIH.
parthpniigpnlslH uf. llll.
I'elerH's. liis.
liliygtulugy uf. Ba, O^.
plai:« of mepllDg v\ih x]H-riiijll0£0il, KS.
IHitar hodlvs of. 04.
premature eniulKion of, i Sii' A()ortloi].i
prlmar.v HPsroi'Uin of, llll.
primitive fulda of. Km.
primUlve aireak of. ltH>.
lirlmorillal, 1)4.
proQui-IeiiB. D4.
lirotovertebrw of, ml.
Helcbert'H. tlS.
segmental layer of. llll,
aegmeatatiuD niii-lvuH of, ST.
seamen tall oil of, M. fi7.
8PI of. 101.
size of. 72.
Bomntoiileoie of. lin,
Spees, III.
splanrhDopI'Mirp of. 101.
Irophoblast of, 108.
tiibi'r^iiloj'uiii, mn.
umhltli'al vpxli'le of, I I -J. l.'tll.
vlielllae memUrane of, 7-,
will) iliiiible Qiirlel. U^, ;il>l.
yolk of, 7-'.
yolk-sao of. IIIO. 112. 13!!.
Timtk pelluolda ft. 7'.'.
Oiylorli'B, iDdliatlons for use of. (itll.
raik, I See Taui[)on, i
l^Blnlei<4 labour, L!:^:i.
raj<it"s manujnvie. 417.
I'alfyn'B ton-epH, aiiri.
FalpailoD. -'11.
In anterior oci'lplto prem-utatlonH, 'JTij.
In breerli prpBenlallons. icri.
In Ijrow prexpTitallon^ 2HJ.
In fare prpwenTBTl'ins, JT.'t.
Ill |>or<terlor oi-pli)lto pre^nlatlons, 2til&.
of iM"plmll'- pronilneiirt'. 211.
of foiilrai'tlon riliE. 211.
of frplal ln'on hi>ni. IS2.
of Wtwer MhTlne rteKmeiil, 21:1.
of olIIIIneH of f.ptiiB. I«:i,
of round llt;ameittH. 21^.
I'alpalluu of abouMer, 213,
tbroiigb perlnenm, 314.
Palper ine&aurateilr, 736,
Tamplnlform pleitia. SI.
I'BradoikBl iDcoDtlncDPe, .'itK).
i'aralyBls, Ducheone'a, OUT.
during pregna^iry, 498,
dui'InK puerperlum. SOK.
facial, following forceps, 420.
obatetrlral. 429. fiO«.
of placental site, 81 U.
ParametritlB. 8t!3.
I'aranietrluni, 48.
I'araplegla cumplleatlnR labour, 222. -
during prfgnaDcy. 4l'U.
I'aralbyrolds In d-UmpsIa, 340, S44.
I'ara-urelbral duels. 30.
l-arletal layer. 101.
I'arletal preBeutatlon, 124.
I'armiphi'ron. 47.
I'arovarluiu, 47.
rartbpno>!pncHlfl, Htl.
I'artlBl placenta prs-vla, Kinl.
I'arturltlon. (See Ijilioiir.l
I'artUB eondupUcaln corimrp. Sill.
I'aKKlve movpineniH of fu'tuB. 183.
Patbologr of labour. U:>8.
of pregnancy, 4 HO.
of puerperliini. 8r.2,
I'elvlc abacesB, SS3. 888.
a lis, 10.
cBTlty, 3,
idlullIlH following puerperal lufectlun,
8«3.
fascia, 241).
floor, 247.
anaioiny of. 247,
changen In, during lalKkur, 250.
hffmatocele, fJ4."i.
Joints. rPlanatlon of. lu prpgiian.-y. ITit.
lierltoDltlfl following puerperal lnfe<tloii,
877.
relvlgraph. 6M1.
I'elvlmetry, by use of X ray, liOU,
eiternal. flM4.
In pregnancy. 203. U82.
Inlernal. HUB.
of outlel. 0S2.
Pelvis. 1,
acanihopeljB, 788,
aaatomlcnl conjugate. 6.
analomy of, l.
articulations *it. 10.
asalm Nation, 750,
ails of, 10,
ravliy of, a,
rhangpn In ^l/.f of, II.
c lion d rod y Atrophic dwarf. 7.'0,
iflccyx, 2,
comparlhitt) of. 12.
coi:ijLiKaTH cllauonaJIs, IpIm).
rtinjugain v^-ra. OIH ,
t-onlrai'U'd. < Si'p roiiiracit.d Ivivls.j
■■-imlglc. 7K4.
*4>]raril)rolWibPilc, T.'i.">.
I crelln dwarf. 7.'0.
INDEX
939
IVlvla, drvpluiUDflit irt, 17.
dlHnii-t<>rif 41 r. 4.
<l<'Ji.'I<'>|-vlll.', lii.
diiillili' liiistliiii >i[ ffUurB. TKH.
(Ii'iiliti^ XBtgfle, TJB.
dwarf. T-10.
enrhondrcijnH of. 7SH.
pioHlonlri of. THft.
pxterDaJ ntDJUKBfo of. liH6.
raliv. .1.
Hat ncinrhHi'liiili-, 7Ul;.
nai rhartiUlr-, Til".
rnciiiri'K ijf, 7H8.
fiiniK-l *liB|)i'd, till::. ;ni.
gi-nprBll): c-.intraciiHi. 74tl.
Sst rha.-hlfl.-, Tf>7.
fr4*QprB 1 13' enLB rgfd, 74<k
gpDerally niualLy c.'uiitrai.'li^ rhacbUlr.
Ti;;.
hlftiiry iif, 1
hyi>u|)La«tLi- dwarf, 1T,\,
Incllnrttli'ii <if. K.
InfanHI-. 17. 7J1I.
JIBTBlyKlH. THII.
Inftrliir Mralt. <IO:f.
lnli-( ut. i.
Ino-iinlnnti- line. 3.
iKi-lilal Nfiliii'H, 3.
Ixchliim. ^i.
JolDlH of. to.
JiiKti.niaJ'T. 74«.
}tjritr>-iiilaur. T4IL
kMiU« rhB<-i>ui<'. tt:;.
kMiliii Hi'ollo rliarbitli'. 7'S.
liyi)liiiMi)ll<>Ilc 775.
k.v|iliiitlr. Toil.
lluariii'iitH of. 1 1.
Mora <<>rniiDBlla. '2.
rynli-, la.
nmif'iilLnr. T41).
iiii'Halli)*^!!!^. Iti.
luiiTrim-iilH uf. In JiiInU, 11, SOI.
uiiIMrliii 'it, :;47,
Nfli-H>'lp. 7jL
□ ann. 7.'>o.
niiDlx jiarva. 748.
normal i^tnJiipBip of. [i.
otilli|i)i- ritnJIijCHI** '>f. B.
<tlillijiii'1V «-<mlra«'ti-d. Tr>1.
■iliHimrli'Bl riinJiijcBIe of, 0.
iilnnlB. Till).
<if ni'W'lri,i-n rhlld. 17.
iwkIHi'BIIiiu i>r. 17.
'thtf'tnijilnrl'-. 710.
iiiitli-1 I'f. 0. H'.iL".
iiva'v. ri71.
phiiin lK-v'rii1i>rl- 711'.;.
■ ■Iiinn <,^li',,[kmhiii,-a, 710.
JillliM' >'t jif-aii-^t Tt*'lvlt- dlm^nHl'in. 7.
1*lBih' lit l^nrtr ]H-]vh' dImcnHriin. H.
Hanr-!. i.f. 4.
|.lilt>l"-ll1i-- 10.
Jtsi-Milo iHHii'nIiinlikrI''. 71-,
imlils. 4.
ifli-lnl OirTi'i'i-nren In, 1*1,
S3
1 l-elvlH, rhai-bltlc. 704.
dwarf. TGI.
Kc>l«-rt. 7ri(L
Mcru-i'oiyluld dlamelpr of, 0.
Kai'ro-Ular HyDCbondrHHlH, II.
iiB<Tuni, 3.
Brullo-rliBi'hlilc. 773.
BiciJlolk, 77S.
Bi-ciind jArallcl of, 8.
Beparatlon uf. durlnf lahDur, 1.
H*lual dllTerenrea la. 13.
Dimple nat. 702,
Butt jiaris (if. 1'47,
Bplniina, Til, TS8,
Bpnt, T57.
niwudyllitoiP. 770,
8]Hindyl<'lli>tb«llc, 7T5,
Mralta uf. 4.
HuperlirT rilrall of, 4.
113-miibyHls. abaenrf of. 7S7.
ayoipbj'ils of. retaiatluD In, IMII.
nympbyxli piiblB, II,
termlnBl, Icnmb of, :!0. 710, Tin.
trannformatlon uf firlal Inlu adull. 10.
iraniiTeriH-lj' cuptrarted, 750.
true, 3.
oimjiijcale uf, G.
dwarf, 750.
(iiinuorH of, 7HS.
iiaLlatprai liixallon of frmiir. 775.
vHrlatliinB In. 11!.
VpII'h main plane of. R.
nitb Imperfect develnpmeDt of narrum,
758,
I'endulouB abdomen, BHU. T2i:.
lyrfurallon. <t!ee t'ranlqliimy.)
of l>i>iiglaii'« cul-ili'^ior, ^40.
of uteruH. 830.
reriupal fascia. :i4U.
gmipr, ;!51.
mai^i-lefi. ;;41k.
lean, after I real me at of, T2».
rentral, 327.
(rwim-ncj of. 310.
mode or produi-tlon of, ;tlO. 703.
preTeatlon of. 317.
Impair of. 325.
IWIniriim, analomj' of. 247.
rbanKiv In, dnrlnff labonr, 251.
lai'prationn of. 31«. 4111.
protwiinn of, 317.
rl)tld. lUll.
I'erltonlilM. fipinl. 700.
pUelT-TBl. 804. 877,
1'prl iilprlni^ iDOaminaflon In pregnanry. SOA.
IVr I vitelline Hpai-e, 72.
IVrnli'lonK anu'mla during prejcnaoi'y, 380,
I J 118,
I vomlilnK of prpgnaniT. .'>oS.
I I'liieaty In I real men t of n-trofleied preg-
imni iiieriiH. -Vll.
IVterw'K ovum, HIK.
I'lliiili-r's liii'ls, in,
I'liunfofri rinii'iiii'o In tMairnoHlH of preg-
nanry, l'.y-.
rlilelililH. feniurnl. Mi.'i.
940
INDEX
I'hIvblllK. uterine. HUU.
rhltfWtoojy Itl pclniupRlB, 544.
FhlvKiaaHlH alUa Juleas, 4S0, SUS, H'lS.
avs.
fblurldilu tlUbetea. l&O.
PbttilslH u>t placi-BtA, 5t>l.
eumpLlcallDg prfgnsncy, 483,
i'bysluLog; of labour, 21ii.
I'liyKonn-ira. 7iiU.
l*lgmen[at1uD, phaDgeij In. during pri^gnaDry.
1T4. 5()f).
In ne^ro babj. 148.
1u pregDan<^y. 189.
riaceata, 134.
Rbnorma titles In alz« of. aST,
abaurmalltlPH In welgbt ot, Sas.
■dlipreni. :iul. SOO.
anatomy of. 131.
anffloma of, &04.
annular, SS7.
Biwpleiy of, ^Ul.
artlfldal Ki-imratlon ut, 4TT.
at lull ttrni, 134.
Btruphj of. 5U1.
banal plate of. l'A'2.
battledore. !>II6.
bi part II a. :iHS.
bruit iif, lH)i.
ralcllli'atlna of, :i95.
canalized flbrlD of, 130,
cell oodeH of. 120. i;i(l.
chancre la. In eclampsia, 534.
cborlo-anKloma of, 5U4.
circular slnua of. 130-
clTciimvallHla. MHi,
closing plate of. 131.
cot J I "do tm of. 134.
cy»tn ill. .'il)3.
di'<'ldiiaL Islands of. 13U.
d*-velo[nncnl of. 1"H-
dlagnosis of poHltlim of, hy pulnatlon ot
round MgnnicnLs, i;]3.
dlmldiata, :-»x.
dlH.'BSl-» lit. 5ft 7.
dnj.lci. 5«!t,
cpltliclliim of. 132.
e.tiire.iKlon of, :;!>N.
by Huilioi'^s nii>tliod. ;iiir>.
Iiy CriKlf's nuHhiHl, \i:>n.
ex[iulxlou cif. i>y Purican'u method. '2^4-
by S.huKw'B mctliod. :;!>4.
tally Ui'Kt'ti^railon of. r>!>l.
fciicslrntn. r>8K.
riliroma of. r.l)4.
tiiiic'iioris i>f, in;;, ir.n.
Blniit r-i-lls of, i,t;i,
^nnmid of, tin.].
|]--parl7.jitlon of, 511 1,
In albuminuria. 501.
Ill extrn-utrrlno jiri'^mnnny, r.3,'>.
In iBiter lialf of precnancy. 131.
In miilHiih' jircBnanr)-. 363.
Ill plAi-iMirn. 5ri4-
In MV|>hills, IlilL'
lufnrrts lit, .'illl.
Inllaminalion of, 5!)5.
ria<«nla, iDtervllluua blood spaces at. I'M,
laj.
manual removal of, 301, 4TT. H'2l.
marglnata, 50U, 5U1,
margo. 5B1,
mecbanlam ut aeparatloD of, '2U-2.
■uetubrBnacea, 5H0.
membranes of. 136.
mode of delivery of. 2&3,
mode of extrualoD of. 29-.
multiple, In alngle pregnancy. 586,
myxoma fibroHum ot. 594.
new growths iQ. 594.
tpdema of. 5SS.
Dsmollc pressure Id, 156.
pblhlBis at. GDI,
polyp at. 90a.
prffiTla, 444. 501, 809.
Bccaufbemeni toi'c^ In. 815.
stlology of. Sll.
Csesarean svrtlon In. 81 T.
developed from n-flfxa placvnla. 811.
diagnosis of. 814.
fre(|Ufnry of, 8111.
Induction ot premature labour, 816.
podallc version In, 810.
progQoHls of. 814.
symptoms of, 813.
treatment of. 815.
vaginal paclc In. 4TQ. 8ltl.
liremalure separalloti of, :;81l. 81)5,
prolapse of, 807.
redeiB. 812.
retention of. cause of baiioorrhagp. 3<)0,
81B.
sarcoma of, 59.'t.
schlrruH nf. 5111.
secretion of. HI.
senility of, 502-
seiituptex, 5811,
site ot, puKt iiarlum. 333,
Hliuatlon i>t. In uIto. 202,
spuria. 51MI.
siicccnturlala, 500-
syncytlum i>f. 132.
KJphllls ot, 002.
transmission of Hubstani-es ibrouitli. I.'iG.
trlpkx, 080,
Iropliolilaut of, 132.
tnilTI, 5112,
Iiilh-rr-iilorilri i>r, -^ll>5-
tumfiurs ut, ,'M14,
vela men (oiiTi. 51 Kt,
ve.sseln of, 131.
vli'lous Inscrllon of, 810,
vim of. fastening, 120.
welEhl of, 1211, 134,
E'lacental fiirccps. 376.
tTnnsmls,Hlon, 156.
perlcMl. 220.
amount of blood Inst during, 208,
clinical picture nt. 206,
bfpmorrhacTf during. 301,
management ot. 202, 298,
mechanism of tieparatlon ot placenta
202.
INDEX
941
Doi'^'nlAl |filo*]. inrKli* tit f-iii-uitlitn nt ikLa-
'I'llTH. J1*J.
Euii'iiial rilliialU>ii o{ iilaifnta fu uti't-tt,
HmirHi'. IHL>.
risrpDikln, 511 'i.
l'tan>>ii tt pelvis. 4.
ria»ruiKjluni. rLorluDlo, I ill.
I'li'Tirlny in pupriierat Intertlon, STN.
Iiaraplniriirm. CI.
rjicir pnlniKta^p 41.
I'Di-iimoiila allia. ilill.
iliiring prrmiaury. 4S3.
iliirlRK i>ii<T|ierluni, SIT,
r<nl»lli; viTRliin. 4;!r>.
In brow preiipn (sill inn. JH.**.
La Thiv prpHeatatliinH. V-iTi.
In •Hvlpllu-pimliTlnr pn>WDI*tlunii, 4X1,
liiillcalJunR fur. 4X~i.
tpi'biiUpii' of. 43T.
I'lilar iJ-idy. Il-J.
(■■>l)'ea)a<'lR. 1>I0.
■ ■iiJymaxlla, MHI.
■■iilypiiK. rHirlDoiiH. rauHlnic hicnmrrbnici'. IM>2.
rr»rr<i <'ii-Narpan ■wtilitn. 447-
I'cinl" vsKlnallB »( itrvli, 40.
I'liKtiliin of fn'liiH. '-'07.
of UtHrilX. i'*.
]*«mLiIvp Hignti of prpfCQani'j, 1)40.
rtwtnuirtpni ('■•luiri'an nciiloD, 4r.l.
drlLvi^py. fl.'il.
roHtpartiim pclampula. ."i^l.
hPniorrhBKP. AIM.
PtlolxK}' of. NIS.
cilnlcal hlHlciry of, Rin.
[r^Btm<'ni of. M21.
I'o«urf. In flrnt Ktajie of labour. 220. 312.
In HPi'iiml M»Kv lit lalnur. 227. SIS.
rrauiii' inan'riivrp. 4J8.
Tiwlpllalp iHlMiur, GG.'',
I 're -4H^] a in 14 k loxpmla, 51fl.
I'n'KnHni'y. 104.
fllHl»ni<n«l. 04.1.
enlaT>renii>nI ilurlnn. 1^4.
altnornialllli-fi of pl^fmentallnD In. GOO,
Hiarflln In mul1lpli>. :t<13. T»3.
nr-r'<il<<iil>< diirlnic, '•('}.
Bi'iiip podomi-lrliln during. .167.
aiiiip Infwtl.mii iIJw>awa In. 370. 4H0.
ariiii- iiilrma of rervli dnrlnjr. ■'tft.t.
anirp yi-1]ow atrophy or llv^r In. .MTi.
atii-r rpmoval of kldn^r. 400,
nfii^r rfmifval of ovarleii, 85.
nihil ni Inn ria dorLoff, ni8.
Bllnimlnnri^ n-tlnltlii. ^28.
amAMi-iiHlii In, 4^4N,
ami-nnrrhiTa diirlnjc. 81. 188.
nniTmllHr, 0.ir>.
nnn-mln, pten>U'loi*H. In. 408.
annmnMM nnd iIIwbkpk of nviim. STl.
nnfpOi'Tlon of iifi^rnR ^iirlnfl. TtliT.
nnii'v*THlnii of iii4'riiti ilnrlns. .'>57.
niillirin Ml, 41.1,
niK.j.kij- In. 41IH.
rrrjtnanr}', ap|irndl<-ltlH In, rill2.
ureeila In. 171, IHH.
B^tliuin III. 4S1I.
Htroyhit pDdomi'trltla din-ldua during. oVT,
HiilO'lntoxli'alloD In. Ml.
halluItPDirnt In. 18:j.
blacliliT and rvriuni. vtiangea In. 173.
hliHid I'bauKPii Id, 172.
bluud prt'nKun- In. 172.
iMWPli In. 201).
itraitnn lllrki'a sign of. 187.
hreaatn. can' of. during. 201.
broad llgBment, 041.
changra In. during. lOO,
I'arrinoma of r-prvix during. nr>3.
••ardlac Ii'iIudh In. 3TII. 487.
ppptaalsliila In. 408, ril8.
1-rrvli In. ^;{5.
I'liadvilik'H Klgn nf. 180.
rhanKPH In abdomlual wall during. ITO.
bladder dnrlng. 171).
Mood iliirlnit. 172.
brpaxiH during. 171. 188.
rervli during. 187. 2Xi.
general mptabiillam. 17S.
Iivart during. 172.
kldnf.vs during. 17.t.
llrtT during. 17.1.
lungH during. 172.
maternal organliini during. 104.
mrvoiiH nympD) during. 174.
ovarian dnrlng, IflO,
plgmpnlatlon during. IHI), IMIO.
alie. nbaite, and conalateDry of utertift
during. 107, IST,.
Kkr Irion during. 174.
akin during. 1T4.
(byrold during. 17.1, &40, S44.
^uh^n during. 100.
utPrim dMrlng. 104.
vagina during, 100.
wi'lgbt dnrlng, IT.^i.
I'hnkra In, 481.
rborca In, 380. 407.
ihronlc Infei-tlimB dlacSAifH In. 48.1.
i-lironU' nfpbrlllH In. 40.3.
cloanma In. r>00,
i-lolhing during. 200.
c'l'kuH In. 2110.
rol]Hi'by|it>rplialB ryatlra dnrlng. TiTtS.
riiniOlnrd. S4n.
ntniiilpBtlon during. 2O0. 401.
i-on(raclnJ pt^lven during, .177.
i-orpufl.luti'um of, 78.
cravlngB during. 100.
cyKtllla In. 40n.
cytol.K'lH. n37.
dvalh of fiptuR during. 103.
drrlduB pulypoHa during. frOO.
d.'niBi rarb'i. In, 40U.
dt'pri'Kiird nlpplm In. !^1.
dprmatlil* hrrpetlfrirmln In. r>00.
dlfllH-ifn In, riHO. 4Ii:i.
dlBEniml" of. 180,
dlntruoHlM. dllfprrnilal. of. 100.
of dpalh nf r<p(n8 In, 103.
942
INDEX
I'regnaiii';. dlagnonls ol multiple, 3(10.
dinnlflrilH itf ri'cl] muMcleH durLug, ^H4.
AWl duilnB, lilKI.
dllTuBr lUlrkeDlDg u[ d«cldua during. S05,
dlnrtlnna fur iiailents during. l:OS.
diRc'ilciratlitn <»f min'oiiH membranij In, INIt.
dltieawK o( allmentBi-jr iract BUd liver lii,
401.
or blood In, 498.
of cervli during, rȣ3.
of rlrculBtorj' and respirator; sfBtems
Id. 4ftT.
ot derldua during. 564.
of kldneya and urinary trart Id, 403.
of nervous Bjstera In, 4H0.
nr DViim during. 375.
of skin In. 41)11.
of TulvB and vnglna diirlog. 5^12.
dlHlncBtlon of kidney In, *aii.
dlsplBi'enientB of uteruB during. -'i,'>T.
dlntlnrtluD livtireen Hrst and xiiliapiiupnl,
192.
dlBlurbanr¥H of vlxlon In, 2U2. 498.
duration uf, lO.t.
dyapnrea In. 49(1.
eelamiialB In, ri24.
ertoplc. (Rw Kxtra- III trine PreeuBui'y.)
fmcRlH in, IgD. ATS. RUS.
pmphyaema durlni;. 481).
eadorardltls In, 4811.
endometrlllB ilei-ldua cyHtIca during, 6B6.
«iidunivirltl!i during. ntLI.
enteroptoBls In, 49^.
epilepaj In. 4I>T.
erjslpelBfi In, 482.
esilmatloii of date of citnll Dement. JD.'k.
esllniBll'in of diirnilnii of. Iil.'i.
cxamlnailiiii, pr-niniluai-.v, during, 21)2.
exanlhenintn during, 4M't.
esen-lse during, lf>!).
eilra-iK'rUon*'a I, f>42.
eitraiitPilnP. (Sw Kilraiitprlne I'ren
nnnej, i
lloating sjiii'on In, 4111-
kldnpy In, 4!l.'i.
fii'iBl li-'flrl In. IMl.
fiirniatlon oT Ifiwer uterine Rpgment, 2-10.
fitnlr siiuine in. iM2.
gInglvltlH In, 4'.I2.
glandular hyiH'rplasIa of dprldua during.
,-iO<i,
glyc-oHuriii In. 4!f.t.
goitre In, 41tS,
gono[^rlto-n In, 4K:i, .M^T.
bn'iiintouia of nlKloinUuil wrIIm In, 50ii.
liii'inaiurin in. 40-I.
hrrnioKlohln cinrlni,;. 172.
Iin'niniililllii In. 41111.
hi'art, liyi>Hi-(riiph,v of, in, 172.
l[pi:nr'« nlcu i.f, isii.
hnpato-lojn'min In, ,"ill7. r..t4,
h'TNln dnrlnc. M:t.
lii'rpt'x ffrsriiiioiils In. ."tOO.
Iiyilnlliliroini uinli< In. :is^i>, r>71.
li.vclnt-nilii in, 172.
liydiauiuion in, :is<i. ."isi.
I'regnaney, hydroplaBmla In, 17ri.
bydrorrbii-n Krovldarum during. nUG,
by men In. HI, (jiili.
hyperempslfl in. fiOS.
byperlropliir elongation of cervix during,
iiyiifrtropliy of cervix In. I8T.
1iy[)ol)b>'Bls cerebri In, 174,
hysteria In. 4S7.
Icterus Id, 491, 61S.
luiBglnary. 191.
Impetigo hprpetlfornila In, 409.
incaroeratloQ of uterus during, r>50.
ineoQtlnenpf uf urine la. SttO.
Indlgesllon In. 4B1.
Indurtlon of abortion In. -ITri.
In dlverllrula from uterine cavity, TtTi'.
Inferllon of uterine ooatenla during. IUI3.
7211, H78.
InflammBtlon of Rartholln's glandn dur-
ing, .'.r.2.
Influenza in, 482.
ingainal liirnlB during, fifllt.
In nidlmemary born of double uterus,
5."i4.
Insanity during. Til!!. OlS.
inlermlttcnt coatrB<'tlons of uteruH during,
187,
Inlersllllnl. ma.
Intefitlnal obstruction In, 502.
In uterus Mcornls. fiol).
In uteruB uulroralH, 5r>6,
Islhmlr. n.lf).
kidney of. 173, ni8.
lactosurla In. 493.
iBpBrolomy during. Tilll. G49, 838.
Ipfld pulNonlRK In. 499,
leukicmia In. .'IKII, 4im.
lopnllzed tiilc-kpnlng of decidun durin§c.
r.60.
lower utPrlne apgmpnt In. 23(1.
mnlnrin in, ixr-,
mamniip In. 171. ISH, 201.
niBUBgeTnent of, lllil.
mapping nut fu'liis In, 1S3.
marital relatinnu In. 20').
nieaslc'K In. 4S1.
mensPB, cpKsntlon of, during, 1S8.
pprKlHteiicc of, during. 188,
mental and emotional pbBn>;eH In. I'.iti.
menlnl derangpments In, Tjlil. 528,
mrlJiboTlfim In. ]7ri.
m<>lr1tls doHHlcnuK. 4iht.
during, .'ifiS.
milk in, IHfl, ari2.
mlnapd nlmrtlon In, 37r., fi2n.
morning iili'knpSR in, I8P.
movpmpnts of fiptus during, 1S3,
multlrilp. ^Spp Multiple r'regnnncy-^
myoiordHls In, 48!).
nnii'iPB and vomiting during, IHii. TiiXi.
nephritic toiipmlB In. r.17.
nppbrltla In, 371). 4!)3.
nervou:! Irritability In, 174.
npurnlgin In. 4011.
neuritis In, 49G.
INDEX
943
rrocnancj. amrotlc TomltliiK Id, tiV^,
ailviDB In, 41M).
uprratloni during, SOI.
oMmphyte. 17-1.
iinrUn, O'JH.
c'j'i't iiimpllrallnK. 1l>l. ;<T.'>, 3N0.
uvulntlun durlnir, 160.
paliiitlcin diirlDf;. Z03, 311,
af fipiBl hpsn In. Wl.
pKraduiloal Ini'ontLnence of orlop durliiK,
r>eo.
panilyslH In. 4na.
Iiarapti-Kia Id. 4M.
p«ihoiogr of. 480.
prlrlnietr; diiriRK, 203.
penduloDH abdomrn In. in4. ntt3. 7(12.
pprl-utvrlDP iDflammallnD dnrlns. QG8.
pernlc'lquM nnipmla In, 3H0, 498.
TO m It Inn of. !>IJ8.
ppttHBry la. Stt1.
pblrtciaBalB In. 480.
|ihfHlulciK7 of. 104.
phlliliilH In. 483.
plfTDi-niailoD In. 180.
pLBCi*D1s prapvla In, 380,
plarrntal tmiillle In. IS'J.
pliifntltlH In. r.o.'i.
pDFiimuDla In. 482.
poHltlrf fllgDH of. 181.
pre-Pi'lamptk (oiipmla la. Stfl.
prPHumpllVi' ultniH »f. 188.
prefiumablP tuxvnilaii. !nr>.
prubahLe algaa of, 184.
prolapiip itf ulcruH during, GUI,
priilongi^. 1)»4. THl.
Tinirltiiii In. .'lOO.
pwilil'M'j™!". 101.
|»vihuK«i diirlnit. 54.1.
pulmonary pmbollum In, 480.
I>iiliu- In. X30.
I>y<>IU'Di'pbrltlH In, .180. 4D4.
q>il<-k<-ninK In. 1811,
rolapKing f^rer In. l.'iT.
rplaxadon of ]>p|vlr Jolnla dariag, 001-
nf VBKlnal niitliH diirinx. n53.
renal Influfllplpni-y during, 375.
rpfplrallon In. 17ti.
rent, effo<^ ttf. on. 10.1.
retrodeiUm of utpnia durlnfr. -175. ■'>rt7.
rptn>vcnilon nf ulPrnn during, r»ri8.
nipiuri' r>f uli^niH during. SS2.
piari'ulalinD of ntvrua In, 101, TiSO.
Hatlrallon In. 402.
Hoarltn fi-yer la. 481.
«*|isln in. 482.
H-iiial Intt'n-ourw during. 200.
KignH of. 1811.
kIkdh of pri^vloiiM. 102.
■Ill' nf uii'MiH In. ifl4. inn.
MniAirpoi In. 4HO.
kouIHi'. riinlp. In. 182.
Mpnrliini'. 101.
wlrin- of. I«!l.
HUfipr^^ixlon of ni»m«''* In. 188.
Hur>:lr]il o|XTni1oDK ilurlng. riOI.
Hynl[i1<ini4 i>f. tHi>.
rrncnaDPT. Hfphllls in. 4S.'>.
tai-byi'arilla In, 481).
tamo, pprreralona of. Id. 174.
Ipelh. 174.
trrmlnntlun of, 11)3.
tvlanuH In. 483.
letanj' In. 407.
thyroid In. 173. r>40.
toolharlie In. 4U2.
tomloD of cord Id. SOS.
toia'mlaK of. .170, S07.
Iranitnilaflliin- of barterla from molber in
fietaa. 157.
lubal, 630.
InberouloalH In, 37^, 371). 483.
(ubo abdrimlnal, C30. tl4'.'.
tnlHi.uvarlan. 043.
lubuutrrlnr. 042.
lumoiini (-amputating, 568.
lyphold fevpr In. 482.
umblllral hernia during. 504.
umbilicus in. 100. 504.
UTva. amouDt of, during. 170.
urinary dlaLurbant-pfl during. 18i).
urlnalloD durlog, 176.
urine, eiamlnatlon of. during, 2<il.
urln« Id. 170.
utrrlnc diHplaivmpntB Id. 5.';7. 000.
hemorrhage during. 3i5.
myomata during. 37ri, 380.
■oufne la. 182.
ulvrn abdominal. 8.13.
ulerua la. 104. 185. 222. 235.
Tacf- 1 nation in, 481.
Taglna la, ISO, 247. 000.
vaginal eoleroeele durlag. TiM.
Piamlaallon during. 204.
vaglnlllH during, 5A2.
valvular lenlona of heart In. 487.
varleea In. 400. r>r>2.
varlrow vpina in. 4IM). 1152.
variola In. 481).
vomiting of. 375, .'i<l8.
weight in, 170.
rreiiuilnary examination during pregnancy,
202.
I'remalure labour. Oil.
In rhrcjnle nepbrUlii. 4!)3. 517.
In heart dlKpaxe. 488.
In infpfllouK dlseatieH. 370.
In lead poisoning. 490.
In leiikriDla. 41>n.
In malaria. 485,
la iivarian luniourn. 074.
Id [■neumoiiia. 482.
In xyphillii. 4811. r,00.
treaiiiii-ni of. )il7.
rreuialnre iniritur. Indui-Ilon of, 377.
for neiKe nepliriMa. 37f)-
for cardiae leKlonx. 37^.
for ihorea. 3H"I. 407.
for rcmlra'-li'd peiven. 377. 741.
for dinbeK'H. IIHil.
for cu'es-lvc sii" of .■(lild. .170. 701.
for bniiliiinl di-nih of fieiu*. .180.
for heart dim^rtHe. 4H8.
944
INDEX
l*rfmaluiv LbIkjuf, for hydatldlform mule,
MSI),
ror hydramntoa, 380.
fur peiirltlH, 3T».
for old eitra -uterine pregnaacj, 047
tor ovarian tumijurs, 3>H\, 674,
for perolcloiiB anvmlB. 380, 408.
lor placenta previa, 380, 815.
for pyelo.oeiJbrllls, 3T0, 4a3,
for loiKinla of preipianrj, 379, 522.
for luberniloBls. STfl. 485,
for ulerlDe mynmata, 3S0, rf72,
methods of. 381,
{■reoiatnre BeparatloD of normally Implanled
plBcpQta, 2S1>, 805.
rreparallonH for lalKiur. 303.
PreiHi™ of c'lltiirlB, ;;i>,
PresentBtloD, ^l>5,
acromion la r. ISee Trapsverse I'retieata-
tlon,)
anlvrtor parietal. T21.
brppcti, 3U5, ^u7, 284.
brow. 200. 282,
rauRatlon of. 200.
cephalic. 205,
compound, 798.
dlngnoais of, 211.
ear. 724,
face, 200. 274.
fool. 2(17,
frank breei'h. 207.
frequency of the apveral varletlea of. 200.
funic. 842,
bead, 20S,
knee. 207,
lateral plane. 71)8.
mcnlo.Ulac. (t^ce Face Presentation,)
nomenclature of. 207.
nui-hal. K04,
occl|>li(i-i[lac, (See Vertex rreseniatlon,)
pelvic, 207, 284,
pijsterl.ir parlclal. 72r>.
reasuTiH fitr pj'Cflonilnnnce of liend. 200,
BHcrci lilac, (Mec Breecli I'rcscutnllims, )
■ lion I ill- r. 2ori, 7118,
Hliirlijltnl. 20l>,
trnrnverw, 20.">. 708.
vcrlci. ^.'j4,
Preaciilatloli and poKillon, :;05.
dIaffiioalH iif, 21 1.
fregupncj- iif, 200,
In conTrai'li'd pclvca, 723,
uoniPnclBUire of. 207,
rrcMi.nilHu pan. i;o.">,
PresLiniaOlc titi^H'EiOn^. rt4,^,
I'rcriiiuiiitlve slK'"* of prcflrinncy, 1S8,
IVInmry sc^iui-iitn, loi,
rrlmliinnc, elderly, :;31,
y<Min^, 2:t2,
rrlmlilvc foiils. 100.
troiivc, 100.
slrenk, mo.
rrimiinllnl fullicli'. 04. 00.
JViiha^ilc sl^s of [u-ci;nnucy. 184.
Prolapse ot placcuta. 807,
I'rulapae of pregoant uterns, 5St.
nf puerperal uterna. 1H)G.
of umbilical cord, 307, 730, 842.
Pr«lon«ed labour. 838.
preguancy, !04.
promontory, aacral, 3.'
Pronucleua, teniale, 94.
male. 06.
Fropbylacik douehe, 472. 873, 884.
veraloQ, 741.
rrutovertebrs, tOl.
Pruritus during pregnaDcjr, 500,
TUPPK, 500.
I'aeudoeyeBiB, 191.
I'seudo-oaleomalaile rbaehlllc pelvis, 712.
I'seudo-refleia. 631,
Paychoseg durlag preguaocy, ri41i.
puerperal. 915.
1'iiblototny. 456.
blatury of. 456.
in brow preaentatlonR. 284.
In contrai-led pelves. 4.'iO. 7.19.
In face preaentatioaH. 282. 459.
indications for. 459.
prognoHlK of. 4riO.
technique of. 450.
Pubis. 4,
arch of. 4.
palliation of, 004.
symphysis, 3,
Pudendum. 26.
Puerperal Infection, 8S2.
aetiology of, 866,
anllatreptocorclc ivrum In. 889.
Buto.infeetlon, cause of, 8G8.
bacteriological examination of lochlA to.
881,
bacteriology of. a."i2,
curelln(!C In. 47.'i. 885.
dIagnoKlH of. 878,
freipieney of, 874,
bystcrec'loray for. 888,
Intra -iitcrlne doiirhc In. 885.
opcrnilve treatment of. 888.
ftHtliolii^Ira! anatomy of. 858.
pya-nila In, 804. 877,
sapra'Uila In. 8.">8.
aeptliiemlB In, S.")8,
sewer pas In, 868,
ayinplonis of, 87."i,
treatment of. 88.1,
Piierperlum, 3.12,
abdominal wall during. 335.
ncotonurla during, .130.
after, paliiv in. 332. 341.
album inn ria during. 310,
anatomical changes In, 132,
anteflexion of uterns during. OOn.
atrophy of iiterua diirine. 332. »n4.
binder In. 141,
brcBMts, diseases of, during. OOS.
lare iif patient during, 140,
catheterliallnn during, 342.
i-crvli during, 114.
changes In blood during. 337.
in lower uterine Beemebt during. 332.
INUIiX
946
l'ucr)irrliini. ihanKPB In uterine TeawlH diir-
Idk. .'i:<».
cbill iliirlnK. :ia.'>.
•'llnliiil HKiwrlK »r. 3»5.
.Tiilli" iliirlnK. (KM*.
ilcnlb diirlnK. H4S.
dlalK'leH durlDit, Xm.
dkl durlUR. 342.
dlphHiiTln during. SIR.
pmtKiiism in. SK. Sno.
«adBrti>rltli< In, n:i4, IHVJ.
ergiil In, :vj-i. flrtl. M:"2.
I'lB ml nation durlog. 343.
KiDRrene uf luwer eilr^inltlfn durinK.
IMM).
tcenrral fiinc-tlonn during, 3<1^-
glj'oniiDTlH dnrlng. .'^31>.
hipmaloniA during. IMt2,
liirniiirrhagi- dnrlng. Wil.
InninllncniY of nrlne during. W)!.
InriTtlon during. KTi'J,
Innanli^ during. iHo.
InvolufloD fit nlpruri during, 332.
laiioKiirla during. 3-tl>.
laxBllvH Id. .'<43.
Irnnii-.vtiiKlK dnrlng. 172. 337, SUI.
tiic'bli during. 3.17.
IfK-hlnnielra during, Hltl.
UtKH nt weight during. 340.
malaria] fpviT during. SM, Die.
managi-ni'nl of. 3.15.
niBHtlilH during. 1)12.
meaxli'rt during. SIH.
□iptalk'tlism during. 339.
milk r^ver In. 3:<IS. S7U.
nPurlllB during. WJ7.
nuTKlng In. 3.'i3-
(ivarlan (unKium In. 674.
[MralyHlH during. IHKI.
tiprlionpum dur1n)(. 3STi.
peHHarjr during. IHKI.
ItblegmaHla allia diilenn during, 89S.
pneumonia during. 1117.
pnilaime i>f ntprnx during. DOS.
Ii!iyilii>ii«i during. Hlj.
pulw during. 3a«.
liyplci-neiilirij*!" during, IM'l.
rpgenpratlon iil endomolrlum during. 333.
rplenll'm •>( urine during. .3311. 1HI1.
rclrorieiiun <it ulenii during, iMiri.
m'srlel ferer dnrlng. 017.
Kmall |Hii (luring, OIS.
HuUlnvi>lu(i<in 'if uieruH during. W>4.
Kwi'atliig In. ;!3>i.
Hynii^|v In, H4!i.
leniix'rnture during, .t.'llt, 342.
(eunuB during. k!iS.
1hri»mlH>KlFi during. 80S.
Ilnie fur gplllng up. 343,
typhiild fPver during, SSO. (11(1.
urlnatliin during, 342.
urlnp lu. .1311.
ulerlni' m.v.imaia In. r.74.
nilvnf ri.lM during. 340.
*'-!tllt. I"s>i at, during, 340.
I'ulmonarr pmbolUni. (See ?;mliollsm. 1*01-
miinary. i
I'ultip during pueriwrlam. 336,
i'yipmla. Mil4, 877.
i'j'elUlM. 173.
I")el...nepbrltl«. 3811. 1K11.
during iirvgnanc-jr, 173, 404.
pupriierlnm, 0"l.
I'.i'gfipagiiH. 7Lt2.
Tyrlformla muHcle. 247.
Ijnadruplet iiregnani'j, (See Uutl|iie I'reg-
nanry.i
Quickening, 181).
Quinine as an uijlocle. 081,
Quintuplet pregnaary. ISpe Multiple I'ref-
nanc)'. I
" Rapport ami u rill UP." "30.
lipt-exHai'uluni HpmlniK, 8]).
HectoreJe romplleatlng lalK>ur, 877,
Itectii' vagina I Ilstula, 721>.
Be|iiuin. 35.
Kectum, carrlnoma uf. rcini|>lkatlDg iirex-
nauiy, 077,
In latxfur, 2.'i2.
Red Infan^Iri r>f plai-pnia. 501.
Iti-ductltin [it retroQvled pregnant uteruii,
000.
Rpflpi vomlllng iif prrgnancy. 503,
Rplehert'B ovum. 08.
Relapxlng fever in pregnancy. I.'i7,
Kelatlve Indlcatlnnii fur I'leiiarenn iie<-tl<m,
443,
Relaiatlrin of ih-IvIc Jolnis In prpgnanr-jr.
170. 174. .".Ol.
of vaginal nutlet after ialiour, 828.
nf vaginal ouili-t during pregnaniy, S52.
Renal decapHulallon, o-l.'i.
Insumrlenry. 374.
ItPppatrd iVnarean Henlnn, 4S1.
tnlial i>regnani'y, 0411.
RepoKltur (or prcilapaed umbilical curd, N43.
KenplratloD. artlOi'lBl, 840.
Id [iregnanry, 176.
tnira-utprlnp, K44.
Kent cure, 5l."i.
elTpct of, upiin prpgnaopy, 105.
ReHlllutlim. (Sep l-:ilprDal Rntallon.)
Retained plai-enla. 3IMI, 477. 818,
KetP (ivarli. fl2.
Retpntlim of urinp, 342.
In (<rluH, 71H>.
KelU-uliim ft endometrium. 48.
Kellnllix, albumlnurli'. .528,
llelra.-tli-n ring. lS.-p I'ontrartion Ring,)
Retrai-rorPH uLprl. 48.
Uelroflpilon. eaUFU- of abnrtlnn. 013,
due li» ('onlrai'letl fiplviH, 722.
r>f lileomuatp uteruK, .'>50.
ot prpgnnnl uterux. .17."». S-IT.
of ]urer[rHrnl utprux. 1H).'i.
Retro-uinniinary ahHi-eax, 01.1.
iCetn>.|H-rltnnpj|] plilpgmon. 8tl3.
Rliai'hilli' dwarf pi'lvlx. 7r,l.
Itbaihillx. dlagnofllx of, 71.1.
946
INDKX
K bach Ills, rn-lal, T1o, TMi.
uuide uf [ii'iMiuctlun i>f iwJTlc deFurmlt; Id,
7U.
]lBthul«K; of. TUS.
|]flvLH IiIh 7(t7.
IttaumlMld ut MlfhaellH, 6m.
lUniR piidcudL, -li,
itlDK i>r Baudl. (ttM CuntrarUon Ring.)
ot Minifr. L'U5.
RKgpD'B metliod of expresBloD. 317, 4KB.
Robrrt pelvlH, 7-">H.
Ri>eat^n raj Id dpiprmlnlns bIic of p«Jv1h,
n<HI.
RoaenmlUtcr, orRaD of, 47.
Rotation with forcepn, 411.
ItiiUDd llfnuncniH. Of.
function of, during labour, 224.
palpation or, '21'^.
Rubber kIovpx. iik» of. 3UD.
RnRie Tselnal. 36.
Itnptiii* oC rimatlaD toUlcle. 73.
»f p*lvli- jDlDtM. 7-'a.
of lirbal prfKnancy. ti-'IO.
of umbllli-al mril. S98.
of UlPillK. 8.'!-'.
ffllolojty of. 8:(3.
u( lime ot labiiiir. S:t3.
durlOK prrKiiBtiv.v, S3'2.
in ftinlracted |irlvpK. 7'J8.
Id nFElei-tHi tranHVrrae prvspntatloan.
7»e. 834.
In prefniani-y In bircirniiatp uieniH. .~>r»H.
In Hf-ar folJowlnR rfHHi'rau qertlon, 4.~il.
repeated. f*^^i.
fljmptomB of. S.tti.
trcalmi'Dt of, 83H.
SacfUlatlon of utcnw, 1!H, 551).
Knc-ro Itlflc synt-h<in(lr4trtls. 11.
rupture of. In lalmltr, T"Jft.
aynofHimU of, 7-''l-
Shcto-j'cIbiI'- noli'h, ;i.
Sar'i'nm. 3.
aKslmllallon >»f. to vorti*brnl i'tplumti. 7."iJI-
lni|H.'rfc<"t develoi'mettt "f. To^l, 7^»8-
ttnt a ki'j'Ktono. 4.
primiiinlory of. 3.
Sa»:litHl fiinianelle, I'lS.
j*iitiin*. I."n2.
Snllv]ilti]» In pri'eimncy. 4!>"J.
Salptnclils. fdillc'iilnr, raiirw of tiilial
lin'pnniivy. liLiii.
jincrpi^rnl, Kill,
Hull Hiilutliin III eclninpsin. .'i44.
In hirniorrhiijfe. H'J:l.
sapriPinin, sriii.
SarcMlmilr n<ld In cHnmiJ^ln, !>J0.
Sflrciinin iUitI diiMii" r..lltilQn>, r.78.
Sailorpb'w mamviivrc. 4IH,
Sraii^onTH miuKi'iivre. 4IL',
Wi'flrbn Si^yri' III |M'i'i;naH*'y. 4H1.
In pnerpi^rlinn, !ilT.
liitrn iiliTlil". -ISI.
r>'lnTl(m of. In |iiit'r|n*rnl liirf,-M'iii. ^117.
S<'linlj: nii'thod i.f cdnviTJ-li'i). -Xi.
S4'h*'f*le's iU4-thnd <tf IimIiii-Iiik InlmiTr. '18L
SchlrruH of plaeenta, SOI.
£4chult£e^a meolinnlhm of extrusloa of pla-
ceDla. 'M4,
method at resuM-IiatloD, 84T.
Scollo.rbarbltU pel via. T73.
SrolloHls. 773.
SehoMotle pelvlfl. 77^.
Sropa lorn Inc. aDRatbeala, 334.
Seal -worms, SOD.
Segmental layer, 101.
I'BTlty. B7.
Segmentation nucleus, 1>6.
of ovum. Ofi.
Spmeu. 04.
SrjiHjj loudrauanlr. 858.
In pregnancy. 48^.
SepClcvmlB. puerperal, S.'^2.
Sewer gas In puerperal Infectlim, S68.
8ei. drier minatlon ot, 160. 182.
dlagnoalii by heart-beat, 182.
Sexual Intereourae In pregnancy. 21)0.
organs, abnormalities of. r>53, 666.
Rho<-k during labour, 848.
Khorleiilng of (*ryli. apjwrent. In prefc-
nani-y. :13^.
Shoulder iireaeatalloD. tSee Transverse
rreseutatlnn. )
delivery of. 3]».
Rtiow, 2:;6.
SIgnB of pregnancy. 180.
Simple flat petvlB. 71)2.
Simpson's basil yst. 467.
i.ianl(iclaKl, 46(1.
forceps, 302.
Sincipital preaentatlon. 206.
Skull, oinllcuralion of, ~S0.
depreRBlon of, 732,
fracture of, 421). 731,
preBHiii'c markr^ on, 731.
SkutHch's iH-lvlmeter, 601.
Slow ]iulse (hiring puer|>er1)im. 336,
Small-iKix during ^ircpnanry. 4811,
during piierp-'rliim, OIB.
Intra -iitiTlni', 157. 480,
Rmellle'fl rorcepn. 306,
sclssorH, 4ti4,
So ma to pic II re. IDl,
Souffle, funic. 1S2.
placental, 182.
uterine. 182.
Spee'rt ovum. 111.
Spcimallrt. tij,
WpiTmHtocyte. 05.
S|>ernifttogeneslH, 05-
Sperniadiiiia. 88. 1)4.
entrani*e Into ovum, 04,
li^flucnce uiKm Hei. 101.
modi' of entry Into uterus. 88.
niimher of. 88,
Sr)li1ncter vaglnie. 37-
Splrocba-te. 486. (11)3.
Siilnnchnopleure, ini.
Spleen, enlargeil. complirating labour, (177,
Split pelvis. "o7.
SponifyllK^me. 77 1).
SpiiTKlylollslhCHl^. 775.
INDEX
m
Simndylolyalii. 778,
t^poQlBneoUB amputfttJuD by Bmnlotlc adbe-
eUina. ~>8U.
vvulutlun, ttu<>.
vitbIud. mw.
S^liurlouii ]>reKDftut'3'. 11^1,
KtagTB lit labour. L':;5.
Sia|ih3'tui'i>ci'UH Id |jiier]Hfral lalptltou, 8^3,
Stein's pelvimeter, HMU.
Sti'miKlH iiF iimbDIral veiwelH, jS2,
KterlllzAIiuD i>r patient after fmresTi AVC-
Ilon. 4411.
Xterno-i'leldiLinaRtuld muacleii. Iupmaluma
<it. 4JII.
Iiill/ma I'lllii-uli. 71.
Straltn of pfivlH. 4.
t<irppi<io<i<'<-uH Id mauiinarj aLutivim, II Kl.
Id puer|>pral iDfe<tIirn. UTtH,
Id iKiiTiH'ral lasaalty. I>ir>.
«Ifl»> uf [jpeKiianrj . ITi), ISll.
Kuharpi.lar raaMltlH. 111:!.
Sulilnvithitlim 'if iiti^rfjii, W*i-
i-urr^'ttajci- In. 4Tr>, 1ti>4.
Hubp4>rlt'inpal liiprnatnma. 1MK(.
SiH'i'BinrlBie ]>lBri'nta. .'iim,
HiiddPn d>'alli durliiK lalxxir. x^S.
HuKir In iiriaF. :{;il>, :ifU), ■tm.
t<MiH^rrp<-iinda11i>n, 3tlD,
Siipcrfii'lalliin, Mt:).
Superior Ktralt, 4.
Siipra^hympliyrieal C'ipiiarpan nei-tlon. 448.
SuTElcat iipiTHiluns during pregDSDry. 001.
Su(ur<-ji {if head, lyj-
tiiT perineal repair, X2H.
Symphyseotomy, hlxtory uf, 452.
Id hmu- preaeDtatlona. 'M4.
In ninlrai-led pelves. 739.
in faiv prem-D tall una, :^A1-
In NaeEele pel^ia. TTtTt.
In HiHindylollHthetle pelTla. 781.
iDdlc-ailDDH for. 453,
pro^uxlB of. 4.'>4-
teehnUiue of. 453.
Kymphyrilx, publa. 1!, 1U.
absence itt. 757.
rupture of. {a labour. 7^tf.
tiepa.'atlon of. during laboof, 1.
Kynrhonilrosls. Hacro-lllac, 10.
Sjiiclytlwm. L'50.
Hyoci'ije durlnx labour, 840.
Synryiolyiln. 537.
Syncylliinia mallKDum. 57»,
Syn<-y<lum. 1 tl<.
in erlanifMila, 5.17.
In hin£s. Ln eclampala. -'S.ll.
Sypbllls. bune lesions Id. 002.
diirlnfc prejfDanry. 48-'f.
fiptal, 5tl0.
palholoiiy of. 01X1.
pincenlal lesions In. 602.
poBt-roni-eiitlonal, 48fi.
iranKmldslon of, to fiptua, 480,
Syphllllii' 'iMiMii-boDdrlils, ivr>.
'rn''li7rardla In preirnanry, 4S1>.
Tampr.n, 47ri,
Taui]>on lu aboriLun, 47tl.
In plac'piila prfvla, 47u. Mil.
Id iHist-partum liemorrtiaicr, 477, 822.
Id rupture of uterus, fitm.
Tardy labour, 058.
Ta ruler's banlotrlbe. 407,
fepbalotribe. 4«0,
excllateur ulPrln. 382.
foreepH, 417-
Temperature durlDS labour. :i;<tl. W,l, 720,
(*78.
duriuK ]>uer|ierluiu. 330. 342.
Tem^xtral fontanelle, 152.
Teratoma of teatlele. .'iHil,
produc-tloD uf, 94,
Terminal len^tb of pelvis. JO.
'iVtaDle mntrat'tlon of uterus. U03.
TeiUDUa durlDg prftmaDry. 483,
of newly tHirn child, ^47.
In puerjterlum. 808.
uteri. BI];i.
Tetany Id i}reffDan<'y, 4911.
Tli.i-a roilii'ull. 71.
Third slBue o( lalmur. iSi^c riari'iiinl Tr-
rliMl I
ThurHii^pagUK. TO J.
Threali'ned aliortloD. 017.
Thrill Id uterine artery diirlDu iin'i:nuucy.
183.
ThrtimboslH of uterine vesHels, 3,13.
of vessels of lower extremities, 80S.
Thyroid, cause of dystocia. 7tKl.
rause of faci' prcsenlatlon", 275.
(ouFDila of presnancy, 173.
ehauKes In, during pregnancy. 173.
Id eelampslB. 540. 544.
Toolbache Id preftn'Dey. 4U2.
Torsion of cord. 598.
of menu, 1«»,
Touch, vaginal, during lal>uur, 311.
Ln pregDancy, 212.
Toiienila of pregnanry, 370. Si>7, 518.
relation of. lo eclampsia. 519. 523,
trealmeDt of, 510.
urlDe In. 520.
Toivmlc vomltlDg of pregnBDcy. 500.
Tracbelorhekter, 471.
Trannfualnn of salt soUiIlon In eclampsia.
544.
In eilra-uterine pregnancy. fl."iO.
Id poHt'partum hemorrhage, fi'llV
Transit of ovum, 08.
Transplnntatlon of ovaries, U3.
Transportation of chorionic villi. 5:i7. 575,
835.
Transverse presentation B. 708.
I'eiihalic version in, 433, 802.
I'ourse of labour In. 700.
decapiiBllon In. 409. 803.
diagnosis of. 7119.
podalb' version In. 435, 802.
Trannversely iMntrartcd pelvis. 750.
Ttnns^-ersiis pcrlncl. 241».
TrepsnaMnn for nsphyxin ni'onaloiiiiM. 848.
Triplet prcgnanvy. t Sec Multiple Tren-
nancy. I
948
INDEX
Tri>|i bub last, im, 631.
True dwarf p*lvla, 750.
TubaL abortion. 63T.
pregQSDty, 030.
TubercuJoslti during pregnane)'. 3T5, 370,
4H3.
puprperlum. 880.
of Tilsfenia. 4N4, 305.
IranamlnaloQ of, to ftctas. lo7. 4m.
TuberouB aubehorlal hprnatoma v( di-ddua,
eiu.
Tub«B. FalJuplan. (See Kalloplaa TubcH.I
Tumours, abdominal, dlagnoalB of. In preg-
nancy, 101),
compll rating pregnancy, S6S-
flbrold, of uterus. 672.
of fiptus. 707,
of [k\v\b. ISS.
of plarenta. 504.
of umblllral rord. 500.
oaaeoue, deforming pelvla. 785,
ovarian, 100, GT4.
pbanlum. dllferentlatloi] of, from pregnan-
cy. 102.
BPalp. •m. 2--1, 730.
vagina]. 067,
Tualea eilerna of t^raafian follicle, Tl.
Imerna, 71.
Turning. (See Version, |
Twin pregnancy, (!r\ee Multiple l*reg-
□aacy, I
Tu-lns. collision of. 3S9.
locked, 300,
Tytopanla ulerl. 854.
Tympanliea uteri. TIIB. 854.
Typliold bai'llll. traDsmlsslon to fictUH. 158.
Typbuld fi'ver during prcKUancy, 48^.
la pucriHTium. SMO, 018.
Typhoid ii'ierus, 515.
Vlcer. i^uerpeial. X58,
rmbllkal arUTlea, 137. 155.
bernta. 504.
lufpciton, 3411,
reside, 13SI,
relalloQ to vplamenlons insertion of
rord, 51>7-
Uml.lltcol .-ord, 137.
abnormalities of, 506,
battledore. Insertion of, .^00,
care of, 347.
colls of, about neck of cblld. 310.
compresslitn of. In breech j>reBentBtlon,
:;ei>.
cyms of, 500,
dermoid of. 500.
developmpot of, 138,
tortnaltoD of, 138,
bipmatoniB of, 500
bprnin of, T,m.
Infpctliin nf, 347,
InllnmniiiUiio nf, r,m. (104.
kiiotK of, .V,1S,
incr^rallipo cif, 507. .508.
Ilgntlon of. :ioo. 340,
loopM of. 5!)8.
Umbilical cord, marglaal luBenlua of. 5U0,
myxoma of, 590,
ipdema of. 500.
prolapse of, 30". 730. 842.
reposition of, S42.
rupture of, 508.
sarcoma of, 50]f-
shortenlng of, 508.
aoulBe In. 18:^.
stalk, 138. 130.
steD09l8 of vessels of. 58:;.
BtrangulatloQ of, by smnlotli.' adbealuns,
586,
sypbllla of. 604,
CetapuB of, 348.
torsion or, 508,
tumours of, 500.
tying of, 330, 348.
variations In length of. 507.
varices of, 500.
velamentous Ipscrtlon of. 5t>6.
vesicle, 130,
I' oa voidable hemorrhage. SOT,
L'riemlB, 517,
in retrotleilon of pregnant uterns, SOO.
Urea la eclampsia. 5',;0.
Id preiniaacy. 176.
I'reometet, Doremua's, o-'O,
L'reler, compreBsloD of, cause of eilauiiwla.
53:;.
Urethra, 30,
Urethral opening. 30,
Urinary dlstuibaaceg In pregnancy. 180,
Urine, ammonia co-eMcleut of. 514,
eiaminailon of, during pregnancy, ■Jtil.
Incontinence of, 901.
Id acute yellon atrophy, 517.
la pclampNia, 5^'0.
la pregnani'y, 1T0,
la puerperliim, 338,
In lOKtemla of pregnancy. 510,
In vomiting of pregnancy. 513.
•i! fiptus. 158. 58,^. 705,
nltrogenouH partition of, 510,
retention of. during ]>uerperlum, 34'..*.
Uterine atony, 818,
bruit. 18;;,
glands. 45.
Inertia, 650,
Insuftlclenry, 650.
milk. 133,
parulynl". SIO,
Bouflle, 182.
I'teroaacral llgamealB, 48,
Uterus. aon-]i regnant, 38,
anatomy of, 38,
. bloodveBKela of. 40,
cervli of. 3R.
roraua of. 38,
developmeal of, 53.
tlgnmcntF4 of, 47.
lymphatliN of, 52,
mucosa of, 4,'!,
lUMsctilntiiri' of, ill.
nerves of, Ti'.i.
poalllon of, 40, m
INDEX
949
I'tcrug. non-prPttnant. Ki>l|{l>t i<f. -i". I>H-
Llenin. imnurlem. action o(. Id laljour. :i4ii.
BDtelli^iluii i>r. UUti.
t'ontraciltind tif, -'--.
faulty <i>[ilnictluu or. 7^.
btur-glBKK contraction ot^ 4tti4.
iDcrtiB "I. 6.">0.
niyomfl fjf, ILT'J.
D4>rvi' riupplf of. 221^
p«rruralli>ii nf. m:I9.
rPlroBfiloQ i>f. film.
rupture nf, 7:i8. 83a.
nrriilitlon of. .I'lO, 8flO.
IfUnUK cif. ««:i, 7^8.
I'terua. prcKnant. Bbncirmalltlea of, 6iJ8.
BUleflpilna iif. .'57. 116! I.
anlvviTKlrm of. .'•.'> 7.
atrophy of dpcldua cBUilnft ahortlon. Oia.
atrophy of dniduB caualo^ placenta pre-
via. 81.;.
VterUH, prvKnBnt. bloom la. 5541.
cari'lDoina of. UTi.
cbanffK In c-?rTli. 23:i.
cbangeft In. dnrlnie ritntraotlimfi. 240.
chanjcf' In nl^e and ahape uf, 107. 185.
conBlKiPory of. IB.!,
ninrrflc-tlonpi of. 187-
develiipm^nlsl flbnormalltiea of. 3'>3.
dlrertlrula of. r.r.7.
doulilp. with rnillmeDtary born. 554.
duplex. .'jfiC.
hTpertr-iphy of. I«4.
iDrarrfralton of relrnflpied. 559,
Involution of. :i3-J.
iacfrBtl..n of ■-.rvli of. -J^n, 3B5. B18. 830.
lateral dlHplarementa of. .'iHI.
Inver nlerlne aegnient nf, 236.
ma I forma 1 1 on H of. ."in.
munrlf layprit of. lllo.
myoma of, 67:;.
nerve nupply of. 221.
perforation of. 8311.
prolapse of. 672.
pneudodldelphyB, 5.".4.
retrofleilon of. tl'Tr. 557. flOO.
retroveralon nf. 558.
sacculation of. 5511, 660.
Khape of. 164.
alnklnK of. 1»6.
■uapenKlon of. lauae of dyatorla. 668.
tomlon of, niK.
tumouTK of. <-oaipllcatlaK preKQaocy. 672.
Ilnliornl", .'>."pll,
■ i-lKht of. im,
rterUH. pueriieral. anlellexloii of. 1HI5.
endarteritis of. :n4.
gangrene of. k«4.
hourxlai'i' coniracilon of. 664.
Inversion or. **-^.
Invoiuiiiin of. ;i:i2. WM.
lac^fnrlon Atrophy of. iHH.
pBrnly<tls of. 8l1i.
|>ri>la|i-a- of, !MK[.
reKen<riiii..ii of, ::::?..
remfivnl •■{. nttvr tV"ari-Bn iuvtlon. 448.
after rupture. 8.18.
I'terui, ]iuerp«ra1. removal uf, for Infection,
888.
relroflexlon of. nt>5.
■ubinvolutlOD of. 475, 004.
welgbt of, 332.
Vaii'IniB, 481.
Vagina. :t:i.
atreala of. 666.
rbann^ii of. In lalHiur. 247.
la pregnaDcy. 16!i.
In puerperlmn, 3Xj.
closer of. 37.
colour nf. In preKnancy. 189.
development of. 37.
diphtheria of. 859.
double. 557, 667.
forali of. S.V
functlona of. 35.
glands of, 36,
hematoma of, 668, 902,
Inlurlea of, during labour, 828.
larerallon of. during labour. 828.
niu<Miia of. 3fi.
neoplaama of, 668.
prolapae of. In pregnancy, 552.
rcladoDB of. 33.
ruge of. 36.
aei'retloo of. 37.
septa In. 667.
■pblDCtcr uf. 37.
alenusU of, 667.
thrombus of, 902.
tumours of. 667.
ulcer of. 85D.
Vaginal I'leKareaa section. 386.
dnurb«. 472, 884.
enterocele. .'i67. 677.
examination during pregnancy. 2i>4.
In eclampala. 544.
In placenta prKvls, 818.
In preeclamptic tolvnila. 522.
Id premature aeparatlon of ptaivnta. 898.
opening, 31.
outlet, relaxation of, during pregnancy,
,152, 828.
secretion, 37. 17(1.
In pregnancy. 179. 870.
In puerperlum. 33S.
tou<-li during lalxiur. 311.
In pregnancy. 212.
VaglnlxmuH. 668.
Viuilnltis, o.~>2.
puerperal. 858-
^'aglno-fliailon, cauae of dystocia. 660.
Vagltus uterlnus. 815
Varicose reins lu pregnancy. 400, 552.
Variety of presentation. 207.
Va«a pr»TlH. S97,
Velnn. <See RIood vessels.)
Vell'K main plane, 8.
VelamentouH lUM-rllnn of mrd. !iM.
Vetiesedlon In ef-lnm|Mila. 544.
In heart dliiea>e. 4HN.
Veniro Hiallon. iflune of d.vstorla. 660.
Veralrum virlde In eilampKla. ri45.
ftW
INDliX
Vernli rasMSB. 148.
VerBloD, 433,
bipolar. IRee Bliwlar Version.)
ceilhaHc. (See I'epMlIc Version.)
ciim blued. 430.
eiteroBl. tUfn Kiternal V«r«lua.)
Id ooniraded pel veil. "40.
Id t ran averse presentalloDa. &02.
Ii.iflflll. s,'-- I'odallo VenloD.)
prophylaclk, 741. '
BpontaneoiiH, 800.
VerTpbrit. [frliultlvr-. 1*>1.
Vertei [ireiieo tat Ions. -00, '-154.
(■ausBilon of. 209.
dla^DOBlH of. '2b4,
tiecpienry of, 254.
ijn'.-Uaiilfm iif. 2r>4.
ui'fliitii prj«t«^rlor, "ftll.
Veiili-al vnloiiliis ci>inpll<'«lt>8 iabuur, UGT.
Vesicle. blB.'<ii>fI>Tmii-. 07.
umbilk'Hl. l;t'.i.
VeBJcii-ciTvlfHl figliila, 7:.1).
Vfslni vnL-lrm (tstiila. 7^0. 800.
sepiiita, ;i,"j,
Veakular mote. r»71.
Vestlbulnr InilbB. :!<).
Vestibule. ;10.
elaiidiiln' vi'HillmlareK mijorea, 30.
inlniir<'T<. Uii-
Vlbvliin sepili]iif>. t<7i7i.
Villi, chortonk-. 13, 131.
hyperplasia of, SSI. 504.
melBHtBB^ii from, 573.
f.rjililluk' i'hnii);i'>i la. «l>3.
trQnxpurlallvn ot, 537. 373. 035.
Visceral arcbes, 143.
clefts. 145.
Vision, dlatiirbRni'Ca of, d u r I dk pregnane}', 41iH,
In eclam]>0lH. Ti-N,
Vitelline nienibrnne. 7l',
Vomiting of pre^oancy. 1'8U, 373,
Vulva. :;«.
atre^ila of, HIW.
clitoris, ;;ii.
Vulva, cnmuilsBiir? of. :;7.
dIpbtheriB of. 83».
dlphtberltlc uloer oC, 838.
fourcbelte of, 1!8.
rr<?uvjliLm ^'i. "J.s.
bsmaloma ot, 666, 90^,
hjmeD, 31.
Injuries u(, during labour, 838.
lahls niQj'.tra, -7.
minora. 28.
tp<lema of, 400,
prurltii>i i.^r. i>n.
toilet of. during pnerperluui. :U<i.
uretbral opening. 30.
VBSlna] olienlpg, 31.
varlcea of, 5j-.
vestibular liulba, 30.
vestibular glands. 30.
vestibule, 3U.
Wal'-lier'a poature. II,
la rontrarted pelves. T3K.
Wegner'a bone disease, <MH .
Wrljihi. -liiiiii-r.i. In. during iirvKunniy. 17:
loss of, itiu loi.' 'lie iiiieriHTluni. .'140.
ot fu'tns at various months. 147.
of newly iK.ni liilld. 14M.
Wharton's Jelly. i;i7.
Wlilic' liiriu-cis of placenta, ortl.
«"l[liHmsi MLitlw pelvluietei, l>04.
Wolfflau body, 61*. 64.
ducts. 62,
X ray In determining size of pelvia, 6116.
Yolk, 72.
Yolk-sac. 1311.
Young prImlpnrA-. la hour lu, -;i:2.
Zellscblcbt of I'lKirlon, 1 1(i.
Zwelfel's pi'h'l meter. 002.
trarbelorliekiM. 4TU.
Zona pelluL'lda, "i^.
1 .
m
THE END
r
0124 -iiUlimSfJ.r. 8284
>.j^B^ 'rrZ4 Obstetrics ^
1308 ^
cop . 1 MAMS
DATS M
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